potential harm

Blowing a raspberry

Imagine there is a door in front of you. There is a person standing next to the door:

"Hey there, pudgy, do you want to be thin and beautiful without having to do any exercise at all? All you have to do is hand me some cash and step through that door there."

This person goes on to explain that if you step through the magic door, you will step out of the other side with a perfect, slim figure. You won't need to change your diet or do any exercise. You just need to walk through the door. They show you some glossy before and after pictures. There are pictures of beautiful, smiling people holding out the waistbands of their old elasticated tracksuit bottoms, so you can see just how much more skinny they are now.

There is a slight rumble from behind the door. You ask what is behind it.

"Oh, we don't know. But honestly, it'll work." 
"But is it safe?" you ask. 

"Oh yes, its perfectly safe" is the reply. "All you need to do is go through that door, and you will definitely lose all of that stubborn weight and absolutely nothing bad will happen to you whatsoever. Now if you'll just hand me your money there, that'll be great."   

Sounds great, right? You excitedly take a step towards the door.

But before you step through the door, you take a moment to consider what might be behind it.  You don't know, and the person telling you to go through the door doesn't know what's in there either. No one has studied what's behind the door. There are no photos and  no videos of what's in there. All you have is this person's word that it is safe, and it will work. 

Broadly speaking, there are three possibilities of what's behind the door:

  1. Nothing. Its just a room. You go through the door, and nothing happens. You don't lose any weight, but you have lost your money. 
  2.  It works. You step through the door and emerge as a smiling, happy, beautiful, skinnier you. You quickly run home to find some horrible grey tracksuit so you can smugly show everyone how marvellous you are now you're skinny.
  3.  Something harmful is in there. Maybe there is a big pile of dog poo right behind the door, and you are destined to step in it, which will be mildly unpleasant for you. Or the door could be perched on top of a cliff, below which is a mesh of razor blades that will cut you into little pieces. Worse than that, perhaps Piers Morgan is through there.

Do you step through the door? 

Now, I really do want to lose weight. But I also don't like being deceived, and I really don't like being harmed. I also really don't like Piers Morgan. 

All of which brings me nicely on to this season's most fashionable weight- loss aid, Raspberry ketone. Its the chemical contained in raspberries that makes them smell nice. Its widely used as a flavouring and fragrance agent in foods, which begs the question: if its so effective, why don't we already lose weight when we eat food that it is in?

You've probably heard about it already. By which I mean that you've probably seen someone on Twitter tweeting about how they lost 3000 kg using raspberry ketone, along with a handy link to a website where you can buy it. You've also then probably seen the follow up tweets, that go something along the lines of "Urgh, my account has been hacked. I've changed my password now, sorry."

And there's the first warning sign. People who make real medicines which work don't tend to need to resort to hacking people's social media accounts in a desperate bid to get people to buy their wares. You don't see Pfizer or Glaxo, for all their faults, hacking into random peoples' accounts and mass tweeting "My cancer is in remission thanks to Drug X. Buy it here!!!!". Its not a particularly ethical way to sell healthcare products.

Putting all of that aside, is there any evidence that raspberry ketones work as a weight loss aid?

In short: no, except for 18 mice and a difference of about 5 grams at most. Which also means there is no evidence that it is safe. There are no human studies out there at all. All of this hype about it is based on the fact that its chemical structure looks a bit like two other chemicals (capsaicin and synephrine) which might have some effects on weight loss.

That's a bit of a stretch. Human bodies are complicated things, and we can't always predict how they will react to medicines. Even when we theoretically think that something might work for good, plausible reasons, there's no guarantee that it will (COX-2 inhibitors come to mind as an example). Marketing raspberry ketone as a foolproof weight loss aid just because it looks a bit like some other chemicals is like finding a random key on a street and expecting it to work without fail on your front door, just because it looks a bit similar to your front door key. 

If you were to decide to take raspberry ketone, you would essentially be walking through that door. You might lose a bit of weight, or you might not. You might be harmed, or you might not. There's just no way of knowing right now.

Hxxx


To self-monitor blood glucose, or not?

Today's news greets us with a story about "rationing" of diabetes glucose test strips. Diabetes UK, in a survey of about 2,200 people, found that 39% of people with diabetes have had their prescriptions refused or restricted. Meanwhile, politicians are wading in stating that restrictions are unacceptable. 

Now, this sounds bad. But when you start applying some skeptical principles to this area, it all becomes slightly less clear. Here are some brief points to consider about self monitoring of blood glucose (SMBG) to put today's news into context:
 

Test strips are expensive. 

Spending on test strips in the UK is pretty high, and has been rising year on year since 2008. In 2010/2011, a whopping £158.4 million was spent on testing in England alone. These things are expensive, and a lot of them are being prescribed. Historically, they have been over-prescribed, and this has been a priority area for the NHS to attempt to prescribe more rationally. (NB: rationally does not necessarily mean rationing, it just means using resources more effectively.)

The UK Guidelines are clear that SMBG has an established place in the management of diabetes controlled by insulin, whether this is type one or type two. Its also accepted in the guidelines that it is useful for patients with type 2 diabetes who are at risk of hypoglycaemia. Reports such as this one from the NHS Diabetes Working Group are also clear that rationing should not be undertaken in patients who are deriving benefit from SMBG. 
 

SMBG doesn't actually do anything to control diabetes.

 It isn't an intervention, it's a testing tool. The only way it can have a positive impact on diabetes treatment is if the results are used to guide treatment or behavioural choices. So its useful for insulin dosing, for example, as it is variable and needs to be responsive to what you have eaten that day. However, if you take a twice daily dose of metformin 500mg, say, SMBG isn't going to really help anything. I think this point isn't quite as clear as it should be to some patients, carers, and even healthcare professionals.  

It only gives you a result for one pinpoint in time. It doesn't tell you anything at all about more long term control. This limits how useful it is in assessing lifestyle changes, such as exercise and longer term changes in diet.


Studies have found that some patients are not using SMBG to guide treatment changes or choices

...so they are essentially testing for no gain at all. If this is the case, then it is clear that the SMBG can be discontinued with no impact on the patient's overall care- in fact its an all-round win situation, as the NHS saves some cash and the patient no longer has to bother doing a painful test.

Its not a no risk option. Apart from the obvious discomfort of testing, there is some (although limited) evidence that some patients can feel more depressed, anxious, and even obsessive if they are using SMBG.
 

The evidence that SMBG works is very limited, 

and is confounded by lots of different factors. You can find more detailed information on the evidence base in this Medicines Q&A. The technology of SMBG was welcomed with open arms by patients and healthcare professionals alike, and it was widely accepted before there was robust evidence that it worked to improve outcomes. In these sorts of situations, where people are used to using a technology or drug etc, it becomes quite difficult to start being rational about it, without people feeling that they are having something taken away from them. If you really want to have a good look at the evidence, you can have a look at this Health Technology Asessment by Clar et al. It's only 156 pages long (!) but it is a really good quality summary of the evidence. 
 

The evidence that SMBG is cost effective is even more limited.

We simply don't know if it represents good value for money for the NHS. Meanwhile, there are interventions which we do know are cost-effective. So doesn't it make sense to limit spending on the unknown, and to put funds into the interventions that we know work instead?

Its a real shame if these sorts of issues have been ignored in favour of rationing. Rationing test strips for patients who are insulin treated isn't rational prescribing, its just daft. But there is a serious issue of overuse and over dependence on SMBG, which blanket rationing makes more difficult to address. The UK guidance makes a lot of sense given the state of the evidence we have access to at the moment, and I would be very sorry to see it being misused in some patients, whilst others are fruitlessly undertaking a needless task at a potential cost to their quality of life and the NHS. 

Hxxx

Nelson's: Suggesting that your kids need mood stabilisers from two years old.

You know of Rescue Remedy, right? You probably had an aunt who would constantly swig a drop for her nerves, or might have even taken some before a driving test or exam.

Rescue Remedy has become a pretty well known brand- so well known, in fact, that most people don't bother finding out whats in it, or what principles its based on. You wouldn't want to know the recipe of Coca-Cola before you take a refreshing swig- you'd just assume that because its a well known brand, its probably going to work.

Rescue Remedy is, however, a whole load of woo nonsense. Sorry, but there's no other way of putting it. Some dude called Edward Bach decided- apropos of nothing- a good few years ago that some flowers, if left out in the sun and dissolved in alcohol,  will be able to balance physical and emotional distress. This is interesting, really, given that its taken the entire fields of neuroscience, psychiatry, and psychology many, many years to get to a point where there are still a vast amount of unknowns regarding mood disorders.

Science is getting there- slowly- when it comes to understanding things like depression. It's a vastly complicated subject. There's no perfect cure-all drug out there for treating such things- mainly because we don't yet understand it that well yet. So forgive me if I am skeptical that some random guy years ago has just randomly (without any basis in science) decided that, for example, mustard flower:

 "is the remedy for deep gloom and depression that descends for no apparent reason out of a clear blue sky. People in this state often list all the reasons they have to feel happy and contented, but still everything looks black and hopeless to them. The remedy helps to dispel the clouds so that we can once again appreciate the joy and peace in our lives."

Rescue Remedy is a blend of some of Dr Bach's made up flower remedies, diluted in brandy. You're supposed to reach for it in times of anxiety, as a soother. Funnily enough, brandy, being alcohol and all, it might make you feel a little bit better, but similarly to homeopathic remedies, they are dilutes such that very little or no levels of active ingredient are likely to remain. So even if Dr Bach were right about the flowers (despite evidence and science suggesting otherwise), there wouldnt be enough flower-stuff in a drop of it anyway to make a difference.

I can't quite get away from the fact that this is a cynical product which Dr Bach made up in an attempt to target wealthy women ("ooh! pretty flowers!") in the days where women were considered "hysterical" and many were labelled as having "problems with their nerves" based entirely on their sex.

Anyway, why am I on about Nelsons, and why am I on about children? Well, because the Bach Rescue Remedy brand- in all of its many, varying, and just-as-cynically money-grabbing-as-Big-Pharma- forms- is sold via Nelson's homeopathic brand. That's Nelson's who the FDA discovered weren't putting magic woo water in all of their magic woo water pills, but were happy enough to put particles of glass in there. That's Nelson's who are all "ooh, we care about you and your healthcare unlike those big meanie pharmaceutical companies who only care about money" all the time.

Well, I happened to stumble across this product of theirs today. Rescue Remedy Gummy Stars- aimed at children from 2 years and onwards. According to Nelsons:


"The first day back at school is a big day so parents should have a secret weapon against tiny tears on standby in the school run bag. RESCUE® Gummy stars - The latest addition to the RESCUE brand come in fun star shapes to help turn a frown upside down at the school gates and each Gummy Star contains four drops of RESCUE, the famous soothing combination of five flower essences."

What's wrong with that? The fact the Nelsons are attempting to medicalise a perfectly normal part of childhood purely for their profit, that's what. Being nervous on your first day of school is entirely normal, especially for a little one. What they need to do is to develop normal coping mechanisms to deal with their anxiety. What they don't need to feel is that their anxiety is abnormal and something which only a medicine can fix.

When encountering the world of complementary or alternative medicine, I often like to stop for a moment and replace the names of the companies with those of Big Pharma. It gives a good indication of whether or not there really is a difference in practices between the two camps, and whether people's reactions would be different

"The first day back at school is a big day so parents should have a secret weapon against tiny tears on standby in the school run bag. PROZAC® Gummy stars - The latest addition to the PROZAC brand come in fun star shapes to help turn a frown upside down at the school gates and each Gummy Star contains 10mg of PROZAC, the famous soothing antidepressant fluoxetine."

Icky, right?

Hxxx

Customer walks into a pharmacy...

...and chooses what medicine they want to buy, before taking it to the pharmacy counter. Yes, that's right folks, instead of telling a daft joke, I'm going to witter on yet again about the self-selection of P-meds. This time I want to think about it from a patient's perspective. Some of these considerations may seem small and petty, but i just want to put my thoughts down on virtual paper and you can see what you think.

When I walk into a shop, I can be pretty easily intimidated. I'm shy, and I don't like to bother people. I also hate that uncomfortable feeling when you walk into a shop and you feel like you're being watched by someone and then you feel terrible about not buying something. I can get anxious about the smallest of things, in particular not quite knowing what you're supposed to do in a shop- if I can't find the til, or there's an empty box and i don't know who to ask, or if I can't find something, for example.Of course this is worse when I am feeling a bit poorly and I can be particularly skittish- im likely to go home without buying anything, even if i need it, because i can't be bothered to have to work out what I'm supposed to do. This brings me onto my first point about self selection

1. It could be different everywhere.

 Not all pharmacies will take up the self-selection option, so I'll need to ask at the counter as i am used to. But in some pharmacies, the packs may be out on the shelves, whilst in others, they might be in security packs or might be empty packs that I need to take to the counter, like an early nineties video rental shop. It sounds daft, but this sort of thing could be quite off-putting.
 

2. How the hell am I supposed to know what to buy?

 I tend to acknowledge people who know more than I do about a subject and listen to their opinion. If I go to the hairdressers, for example I tend to ask them what style they think would best suit my hair type and face. After all, they've done some training in cutting hair whilst I am utterly clueless about it. If I walk into a pharmacy, therefore I don't expect to have to do all the hard work of product selection myself. My product selection process for most things usually goes like this:

Its either that, or I stand around reading every single box of every single product. This would take me bloody ages, and would be pretty inconvenient.

3. What If Its The Wrong Thing?

 After I have found the shiniest product, I take it to the counter, where I am then told that I've picked up the wrong thing and I'm not allowed to buy it. This, frankly, pisses me off and adds even more inconvenience o the whole affair. I've chosen the product, and now some jobsworth glorified shop assistant is saying that I've chosen the wrong thing? how dare they! (I've lost count of the number of times I've been called a glorified shop assistant by patients-and on occasion non-pharmacist managers over the years, by the way). You know like when you're in a hurry, and you've picked something up in a shop and you take it to the counter, and they tell you that its on buy one get one free, but there is a huge queue behind and you're going to be late for your train so you just say "oh its fine, I'll just take that one". I suspect that would end up happening quite a bit as well.

4. Advice Isn't Quite So Forthcoming.

 When I ask for a specific product in a pharmacy, the counselling and advice I am given tends to be minimal (if at all), whereas if I ask what they would recommend for a particualr symptom (not that I usually have to bother doing that myself, but you know), I tend to be given fuller, more rounded advice as part of the product selection process- I've written about this before. If I want to know something about a product, I have to ask about it, and I might feel a bit stupid doing that when I'm supposed to have picked the product myself. In addition, I might not actually know that I need to ask for advice unless it is offered. With self-selection, I fear that offering routine advice would become the exception rather than the norm, and instead of being proactive in giving advice, we would instead get into a pattern of waiting to be asked.

5. Medicines Are Commodities And Its My Right To Buy Them.

 I've written before about the paracetamol problem- its so widely available that people think its safe and innocuous, and they can take extra or dismiss it because they've sort of forgotten that its a medicine. I think this may become a wider problem. If medicines are available on the shop floor for me to handle and choose myself, I assume that they're either not very good medicines, or they are so safe that I can use them how *I* like. If I want to take three times the amount of antihistamines that it says on the pack, then I can do, just like how if I want to eat peanut butter out of  a jar with a tablespoon then I should be allowed to, because its my choice to buy it and who is anyone else to judge me and tell me otherwise? this is going to be particularly problematic with codeine-containing medicines and similar.

Anyway, those are a few thoughts for now. I may add to them as time goes on. What do you think?

Hxxx 

The Vaper Verdict

I seem to have gotten myself a bit of a reputation as a Vaper-hater. In truth, I'm actually really not.

I even once owned a disposable e-cigar. It was a good few years back now. Although I consider myself a non-smoker, I do smoke the odd cigar, but about one a week and only when the weather is nice (so about 4 days a year then) and only when someone has brought me some back from their holidays probably does not constitute a habit, or would be considered the world's most pathetic addiction. I would never dream of smoking indoors, and somebody thought it would make a nice stocking filler for me one year.

I used it a few times, and it was alright, in the same way that a Pot Noodle is mildly enjoyable in its own right, but bears no resemblance to a steaming hot bowl of freshly cooked spicy Szechuan chicken in udon noodles (no 69. on the menu at Nudo, my favourite restaurant in Newcastle. Its always giggle-worthy ordering it). E-cigarettes are the Smash mashed potato of the smoking world, a Cup-A-Soup to a home-made broth.

I can see how it would be good to have something vaguely resembling a cigarette if you're trying to give up smoking, and I can certainly see how a nicotine delivery method that avoids all the tar, chemicals and other gunk that smoking dumps in your lungs is more healthy.

My reservations are thus:

  1. If they're unregulated, you have no idea what's in them. It might say on the pack that it contains x mg of nicotine and chemicals y and z but there is no guarantee of this. Some have been found to contain toxic chemicals like ethylene glycol, for example. Its undoubtedly likely that they still contain less dangerous chemicals that cigarettes, but it would be very nice to have that guaranteed.

  2. There's no long term safety data. We literally don't know what the long term effects of these things are. For all we know, the seemingly safe-at-first ingredients could actually prove to be carcinogenic, say, when inhaled in this way in the long term. Admittedly its unlikely the products would be as bad or worse than smoking, but without the studies we just don't know. Theoretically they may seem like they're going to be harmless, but without the data there to back it up we just cannot make that assumption- its that sort of reasoning that lead to the thalidomide disaster, for instance. Unknown does not mean safe.

  3. There's evidence that products are often do not contain what it says on the label (if they even have a label at all). A study in the BMJ's Tobacco Control found that products contained variable and potentially dangerous amounts of nicotine- most often the product contained less than was stated. Now, if I'm paying for a product that says it contains 72mg/ml of nicotine, I expect that product to contain 72mg/ml of nicotine, just as I would expect a 500mg paracetamol tablet to contain 500mg paracetamol. If it contains less than this, I'm essentially being ripped off. The other available nicotine replacement products- patches, gums, inhalators etc- all have a license, and I don't really see why these electronic cigarettes should be any different.

  4. In smoking cessation, using a product which looks like a cigarette might be helpful in the short term, but it doesn't help to address the habits of smoking rituals, and in my experience of helping people quit, that's half the battle.

  5. The risk of serious accidental nicotine poisoning in both adults and children. 

  6. There is a risk that the ease of use of the products and ability to use them indoors might actually increase nicotine intake in some people.

  7. Even if nicotine itself were entirely safe (which it isn't), its still an addictive substance. Any addiction can lead to harmful effects in a person. For evidence of this, try speaking to me on a day when I have not had any caffeine. If I added up all the time and money I have spent in my life engaging in drug-seeking behaviour to feed my addiction (mainly desperately trying to find the nearest kettle or coffee shop), I suspect it would be very upsetting.

Today there has been, in my opinion, some good news. The MHRA have decided to start . This decision essentially eliminates concerns number 1, 3 and 5 and starts us on the road to also ruling out concerns 2,4 and 6. The BMA have responded enthusiastically to the news, stating:

“We can now build on this and press for good research which looks at the efficacy and health implications of e-cigarettes. It’s really important that we find out if the hand to mouth use of e-cigarettes either breaks or reinforces smoking behaviours. We need to know if e-cigarettes actually help smokers quit."


I'm also enthusiastic about this step. Whilst it may lead to decreased availability and choice of these products, it will hopefully lead to a smaller number of better quality products being legitimized and incorporated more formally into smoking cessation or harm reduction schemes- if they are proven to work in robust clinical trials. This is yet another case where, instead of waiting until we have good, robust data that a product works and is safe, it has been widely sold and adopted by users in lieu of risk or efficacy information. There will no doubt be an outcry from users and manufacturers, and wails that the MHRA have banned e-cigarette sales, that its a Big Pharma conspiracy to give everyone cancer so they can sell more drugs, that big evil corporations are trying to trample the little guys down, when all they are trying to do is save some lives. But none of this regulation means that.

All a manufacturer of e-cigarettes would need to do to continue selling their product is to prove its safety, efficacy and quality. It will take money and time, but if they have been already producing their wares safely and in accordance with Good Manufacturing Practice guidelines, they're already some of the way there. Gaining a license will of course cost time and money, but if these manufacturers are genuinely interested in saving lives- and not just unscrupulously making profit- they would see the value in the licensing process, and the opportunities available for a licensed product in the long run.

So here's to what could be start of a new dawn of smoking cessation or harm reduction. I really hope so, but will reserve judgement until the evidence starts piling in.

Hxxx

e-cigarettes: accidents waiting to happen

We all know smoking is bad for us, and we all know that giving it up is a good idea. E-cigarettes have been around for a good few years now, and they seem to be the answer to a lot of our prayers to some people: That lovely nicotine hit, without having to traipse outside, and without any of the nasty tar or other chemicals that makes smoking bad for you.

There's currently a bit of a kerfuffle going on about them as the EU look into tighter regulation of them. A quick search on Twitter reveals lots of folk stating that they save thousands of lives, are much safer than other pharmacological smoking cessation methods, and are totally safe, therefore shouldn't be banned by the EU. Others have covered the fact that e-cigarettes are unregulated, that they may actually contain chemicals and ingredients which can be carcinogenic, that they might have adverse safety effects so I'm not going to cover all of those potential issues here. .But there is one aspect of their use which I think is easily forgotten about, but has the potential to be very worrying.

It seems that e-cigarettes come in a variety of forms- none of which are regulated. Some are disposable, some have refillable cartridges, and some require refilling with a liquid. There are even some sites which encourage mixing your own nicotine liquid: a complicated process requiring mixing a nicotine concentrate with a flavouring and a diluent using a dropper.

Now, as a fairly young pharmacist (or so I keep telling myself), it has been a long time since I compounded any medicines myself, but I do remember doing so in university and I have a pretty good idea of how to work out and produce mixtures. I'm a keen baker, so used to following recipes which can be complex at times. And yet a quick glance at some of the mixing guides for nicotine liquids makes me worried. They look complicated enough for a pharmacist like me to follow, never mind anyone else. Milligrams, drops, milliliters, colours, parts etc are all terms used on the same instruction sheet, and the medicines safety part of me is crumpled and crying in a corner, wailing "HIGH RISK COMPOUNDING PROCEDURE!" loudly to anyone who will listen. And yet, because these things aren't considered a medicine, anyone can sell this stuff, and anyone can buy it. There are risks at every step of producing these mixes: not understanding the instructions, not accurately measuring amounts, mixing up the different liquids, storage of the liquids, spillages etc etc. Some sites even suggest using a syringe- complete with needle- to inject the nicotine solution into devices. A little bit of me is dying inside. 

Even the ready made liquids are problematic enough. They come in little eye-dropper type bottles, and are often pleasantly flavoured. In short, they're probably rather attractive to children. 

In my day job, which partly involves advising on poisoning cases, I have come across quite a few cases where nicotine liquid intended for use in e-cigarettes has been accidentally ingested. A lot of people don't know that nicotine itself can be horribly toxic, particularly for children. It only takes a small amount orally to get some pretty nasty, potentially fatal effects. And yet, freely available to buy without any regulation at all, a variety of attractively flavoured and packaged -and really highly concentrated- nicotine liquids are sitting ready to be bought by eager punters. You can even buy multi-packs of large bottles of highly, highly concentrated nicotine liquid. They don't even have child-resistant tops on them- and why should they, as they're not even considered a medicine? The websites selling these things aren't particularly clear about the dangers of them- again, why should they be, when they're trying to sell them as a safe alternative to smoking?

I've had a quick look around the medical literature and as of yet there is very little information published on this aspect of e-cigarette usage. And that's part of the problem: the technology has been widely adopted without a thorough understanding of all the different aspects of its safety. Even if they were tightly regulated and highly safe, this aspect of accidents with refills will still remain, and in my opinion it is only a matter of time until there are some very serious accidents of this nature. 

So, whilst e-cigarettes might be a useful ally in giving up smoking for some people, we really need to put some thought into the safety issues surrounding them, and not just the obvious ones which might affect the person using them.

All of this is without even considering the fact that using them can sometimes make you look a bit daft, especially the ones that light up at the end like a pretend-y cigarette. Others, frankly, look like "discreet" vibrating devices for ladies. You'd be better off with those yummy candy cigarettes from the eighties, if you ask me- they look more like an actual cigarette than most of the e-cigs and they're a whole lot cheaper too. 

Hxxx 
 


Minor Update (2nd May 2015): Some time has passed since I wrote this, and I think my fears have started to be borne out in the evidence. Poisons Centres around the world are starting to report evidence of toxicity. Deaths in both humans and animals are being reported. Its a real shame that it came to this, but hopefully with proper regulation the safety of e-cigarettes can be improved. 

Some thoughts on quality and quantity

The sad news about Iain Banks has gotten me thinking today. 

I'll be honest here and say I've never read any of his books (so many books in the world, so little time!). I know nothing at all about him. Yet when I read his statement at work this afternoon, I had tears in my eyes. His words were so dignified, so stoical, and so noble that they really touched my heart. The ability to have humour at such a time is something I admire hugely.

I'm sure his words are the tip of the iceberg. I really can't even begin to understand what a lengthy, horrific process it must be to come to terms with such news. But what struck me most of all was his plans to spend his remaining time with his family, friends and loved ones. Isn't that, when it comes down to it, what we would all want? And yet it seems to me that cases such as his appear to be in the minority of those that are reported in the media. 

Many moons ago, at university, I went to a lecture by Sir Michael Rawlins. He discussed the thorny issue of how NICE assess drugs, and he touched upon quality of life measures. I remember being utterly shocked when he said that the majority of terminal patients choose longevity over quality of life. That's always stuck with me, as it seems so starkly counter-intuitive to me that I genuinely can't get my head around it. I also know that's very easy for me to say, and that I have absolutely no idea what it must be like to have to face such decisions. A few years ago I did my Diploma in Therapeutics, and we had to try out some of the quality of life rating scales that are used at NICE. Believe me, this really gets you thinking about how difficult these sorts of choices are. I also remember a really brilliant workshop with Claud Regnard, a palliative care consultant and author of some highly-esteemed books in the field. I remember being bowled over by how positive and creative such a potentially depressing subject could be.

We're a nation (and potentially a planet) that are very medicalised. We hunt for a cure for everything, and a miracle pill to make us cleverer, slimmer, healthier. When given the choice between taking a tablet and changing our lifestyles, I think it's safe to say that most of us would rather opt for the former. This is fuelled by any number of things, but I think the media has a lot to do with it: there's always a story about how some new drug is going to cure Alzheimer's, or obesity, or heart disease, and there's story after story of families desperately searching for a cure or treatment that can cure their love ones.

And here's what I've been thinking about: when all the options have been explored, and there is no cure, practitioners of conventional medicine (by which I mean medicine which is proven to work) will usually tell you so. 

At this point, the quest for something else, perfectly understandably, kicks in. Of course you would grasp at any straws, any vestige of hope. And so, right at the time where people should be spending their days doing what they love with the people they love, as Iain Banks is doing, some of them turn to alternatives. 

It could be weird diets, it could be homeopathy, it could be a certain well-known quack's clinic in Texas, it doesn't matter. What all of these things do is sell hope when all else has failed. They're a very seductive prospect, and it may well seem perfectly logical that you'd spend every penny in trying them, and you'd leave no stone unturned trying to find the perfect treatment for you, or your loved one. 

Just at the time when you should be kicking back and enjoying your time as much as you can, you end up on a plane across the world, which is stressful enough for anyone at the best of times. Or you might end up on a strict diet regime, having to deprive yourself of the foods you love just when you should be enjoying them more than ever. You might end up a slave to a complex regime of megadose vitamins, enemas, pills and injections when you should be being made as comfortable as possible with palliative care. 

These people who sell false hope rob patients not only of their money, but of their precious time as well. And that, in my opinion, is the most evil and unforgivable of sins. 

I hope that, eventually, we get to a place where a quality life and death become the most important thing to anyone with a terminal illness. 

This is yet another blogpost where I feel the need to write "hope this all makes sense" at the end. I probably should just plan posts better, but I've always found I'm usually better at just writing as I think at times. My humble apologies also for any typos... I'm absolutely rubbish at touch screen typing


Hxxx

Homeopathic Harms Vol 5: Interactions

In February 2013, my friend @EBMScientist and I delivered a Newcastle Skeptics in the Pub talk entitled Homeopathy: Where's The Harm? As a follow up to this, we've decided to write a series of blog posts expanding on a number of points we covered in the talk.

In the next instalment of our series on the harms of homeopathy, I want to talk about interactions. I've covered this a bit in the past, but let's have a look at this area in a bit more detail.

We all hopefully know by now that homeopathic medicines pretty much have no trace of active ingredient in them by now. Do we need to worry about drug interactions with homeopathic remedies?
 

Can homeopathic medicines interact with conventional medicines?

The obvious answer is no. Magic Sugar Water Pills are highly unlikely to affect any conventional medicines. There's a lack of actual evidence to prove this, but I think it's pretty safe to rely on a theoretical basis here. So that's great, right, blog post over and see you later. If only it were that simple. 
 

Can homeopathic practitioners interact with conventional medicines?

Unfortunately, yes. very much so. It's pretty well known that homeopathic practitioners step over (and in some cases stomp over, then jump up and down repeatedly on) the boundaries between conventional and homeopathic medicines, just by the advice they give. One example would be vaccines- many homeopathic practitioners are against vaccines and therefore advise their patients to avoid them- Just look at the emails sent by pharmacist (and embarrassment to the profession) Tony Pinkus to an undercover BBC reporter. Little offhand remarks about the toxicity of conventional medicines, or big pharma conspiracies, or how conventional medicines might not work, all add up to the effect of harming the patient's relationship with their actual doctor. And how about the spectacular example of inappropriate advice in my previous post? 

Can conventional medicines interact with homeopathic medicines?


I'd like to say no here, because of course homeopathic medicines are inert and don't actually contain any medicine. It is the case, however, that homeopathic practitioners unfortunately think otherwise, which can lead to a huge amount of harm as patients discontinue their conventional medicine in favour of homeopathy.

I have in front of me a book called "Homeopathic Pharmacy", by Stephen Kayne. This is a book aimed at healthcare professionals, and indeed is a  recommended resource for medicines information pharmacists in the UK. (EDIT: This book no longer appears as a recommended source.) And yet, even this source, which we could consider to be one of the more balanced tomes (despite the ominous mention of Dana Ullman in the acknowledgements), contains a wealth of dangerous nonsense. This book tells me that, for example, "potent topical steroids are thought to negate the use of  homeopathy in the treatment of eczema and psoriasis" Now I know more than some that skin conditions such as this can be horrifically uncomfortable, not to mention their effects on your self-esteem. Stopping treatment that works in favour of a placebo is not, in my opinion, acceptable in any shape or form, especially given how vulnerable and desperate people can be because of skin conditions- don't forget that in some cases, dermatological conditions are terminal, as they can drive sufferers to suicide.  

There can, apparently, be interactions between oral steroids and homeopathy too. "the patient's symptoms tend to be masked, however, making an accurate choice of remedy much more difficult", we are told on page 205 of Homeopathic Pharmacy. Well, you could call it a masking of symptoms, or you could- as I prefer, refer to it as "working". So what is the average homeopath to do then, when presented with a patient who is taking steroids but seeking their help? It would seem that the obvious (but sadly not the ethical) solution would be to ask them to discontinue their steroids so that that the symptoms are "unmasked". This will obviously lead to an increase in symptoms for the patient, and lead to unnecessary suffering, but it can also precipitate acute adrenocortical insufficiency, which can in the worst case scenario be fatal. Patients should "ideally" discontinue their steroids for 6 weeks prior to initiating a homeopathic remedy- this is more than enough time to result in loss of control in their condition.  

It's not just drugs themselves that can be a problem, but the excipients (inactive ingredients used in the formulation of a medicine) too. Strong flavours used in syrups, for example. This could potentially discourage patients to take- or to give their child- antibiotic syrups, with the potential to worsen or prolong a patient's condition. 
 

Can foodstuffs interact with homeopathic medicines?

  
Yes, apparently so, though again there is no hard study evidence for this- why would there be, when there's no good hard study evidence that homeopathy works in the first place? Coffee, tea, cocoa, chocolate, and spicy foods are all to be avoided. Aside from being unnecessarily restrictive, and potentially causing a patient anxiety, this idea fills me with horror. Imagine a life without tea, chocolate, or spicy foods. I rely on all of these three things to get me through my daily life, and would inevitably become depressed if I had to avoid any of them.
 

Can homeopathy interact with homeopathy? 


I know, right? What a bizarre question, given that homeopathic remedies are sugar with specially shaken water sprinkled on. Can sugar interact with sugar? Well it seems that someone has decided that they can, based on a grand total of no evidence. Aromatic preparations, such as camphor, menthol, and peppermint, are supposed to inactivate other homeopathic medicines. Remember, though, that homeopathic camphor, menthol  or peppermint is highly unlikely to actually contain any molecules of camphor, menthol or peppermint, and we're left in a bit of a ridiculous situation based on nothing at all. 

It would seem that homeopaths utilize certain foods or remedies as "antidotes". Apparently, if a remedy isn't working, and they want to try something else, they might ask a patient to drink a cup of coffee, or take a remedy like camphor to "wash out" the previous remedy so that they can start again. I'll refer you again to "Homopathic Pharmacy"- with a reminder that this is one of the more reasonable texts:

"It is certainly not dangerous in life-threatening terms, but used injudiciously will interfere with the vibrational pattern of the vital force."

Vital force, vibrational energy, sugar as an antidote to sugar, and none of it- not a scrap- based on science, evidence, or even basic logic.

See you again soon for the next episode :)

Hxxx

Homeopathic Harms Vol 3: Poor Advice

And so begins the third installment in our Homeopathic Harms series, a collaboration between myself and @EBMScientist of the Evidence Based Skepticism blog. For this post, I have my lovely, wonderful friend @shandymarbles to thank for the idea and the action.

Indirect harms due to homeopathy can, as we're trying to cover in these posts, come in various different guises. In my opinion, there is none more dangerous than this: poor advice from homeopathic practitioners. 

To set yourself up as a homeopath in the UK, you don't need any medical background. You also don't need to register with any regulatory bodies or undergo any standardized training. Medical homeopaths, i.e. doctors who practice it on the side, are of course regulated by the GMC, but your common or garden variety homeopaths could basically be anyone.

And yet, they claim to practice medicine and give advice on your health. Scary stuff, in my eyes. And I can give you a specific example of how harmful this can be, because one of my good friends contacted a UK homeopath recently. This homeopath is, as is proudly declared on his website, an engineer by trade.

Under the pseudonym Stacey Slater (which apparently didn't appear to ring any alarm bells with the homeopath in question), my friend asked for help in treating bipolar disorder. She said she had stopped taking the medication prescribed for it because she was getting horrible side effects, and asked if there was anyway that homeopathic treatments could help her stay stable and avoid psychosis. There are a few things to note here: the question was very specifically asking if homeopathy could be used instead of conventional medicines, and was asking about avoiding psychosis- we're talking about serious symptoms here, not a vague sort of "could it help with me feeling a bit down" sort of question. The description of "horrible side effects" would immediately ring alarm bells to me- what sort of side effects, and how is she feeling at that time.

Here's the response I would have liked to have seen in a dream world filled with responsible homeopaths (actually, in my dream world there would be no homeopaths at all, but you know what I mean):

"Dear Stacey,
Thank you for your enquiry. I'm sorry that you've stopped talking your medication for bipolar disorder, and would like to advise you in the first place to speak to your GP first of all about the side effects you have been experiencing. You should also discuss with them your decision to discontinue your medicines, as stopping them suddenly may cause your symptoms to worsen.
Homeopathy may be a useful option to help treat some of your symptoms. However, I wouldn't recommend that it is used instead of your usual medicines, unless this is done with the agreement of your medical team. Once you have spoken to them, please do contact me again and I will be happy to discuss any homeopathic treatment with you then."

This response covers all bases. It makes sure that the primary outcome of patient safety is covered by referring them to their own healthcare provider, however its also helpful and leaves open the possibility of some homeopathic treatment as an adjunctive, complementary treatment. It does not suggest that homeopathy can be used instead of her usual medication.

Here, however, is the real-life response:

"To,
Dear Stacey Slater,
Yes I am happy to help you for your Bipolar Disorder and will try to restore your previous health. 
Recently, my grandmother has been treated for her 15 years long Bipolar disorder with only two weeks of homeopathic treatment. Now, my father-in law (Himself Medical Practishner) says she is 100% okay with homeopathic remedy and need not take any other medications. 
To help you, I need some more information, like; your physical, mental and spiritual condition.
1. Any skin diseases are you suffering from?
2. Do you have problem of thyroid dysfunction? hyper or hypo?
3. Diabetes?
4.High or low blood pressure?
5. Since how long are you suffering from Bipolar disorder?
6. Your family history, if any one in your blood relation have tuberculosis, diabetes, cancer or high blood pressure?
7. Your liking and disliking? Food,Drink, time and weather 
8. Your family life, etc..
Your detail will help me to prescribe best remedy.
Looking forward to your reply,"

There are a few things to note here, as I'm sure you can tell. This homeopath claims that they will "try to restore to previous health"- in other words, he is offering a cure to bipolar disorder. We've got some anecdotes in there, in lieu of actual clinical evidence, and an extraordinary claim that longstanding bipolar disorder can be cured with only two weeks of magic woo water therapy. Now, given that bipolar is, by its very nature (and name!) a relapsing-remitting disease of two extremes, there is no way that an anecdote could be used as evidence of successful treatment. Who’s to say his grandmother wasn't just going through a good period that just happened to coincide with taking a couple of week’s worth of homeopathic medicines. How do we know she wasn't using effective conventional medicines at the same time? Who's to say she even exists? I can't help but wonder about his grandmother's right to confidentiality as well- has she given consent to be used as an anecdote in his consultations with other patients?

Who is this father-in-law mentioned? If he is so happy with the treatment, why isn't he happy to be named, and why is he even commenting on the grandmother's treatment? What relevance does this have to this homeopath's practice? The advice given that she "need not take any other medications" is a clear indication that this homeopath thinks that the homeopathy he advises can be used to "cure" bipolar disorder on its own, as an alternative to conventional medicine. By trying to make it seem like the advice has come from an actual medical practitioner, the homeopath is clearly trying to give this advice more credibility.

Lets have a think about the consequences of this advice: Our Stacey Slater is reassured that she doesn't have to continue on with her conventional medicines. She responds to the email above, goes on to have a consultation with the homeopath online (which costs £50 by the way- we're not talking pennies here. £50 for an email exchange!) She slips into psychosis, or mania, or a deep, deep depression. Eventually, she can't take anymore and she commits suicide. This homeopath has directly contributed to her death by not advising that she sees her medical team before discontinuing her medicines, and by claiming that she can be cured by inert sugar pills instead of continuing on with effective, evidence-based medication

The problem is, we can't gather robust evidence on this sort of thing, as it would be too unethical to do good, clinical studies. Maybe Stacey hasn't mentioned to anyone that she stopped taking her medicines and she was under the "care" of a homeopath- how would anyone know that the death was caused by him? And even if they did know, they're probably too upset and shocked at that point in time to think about raising a complaint. Who would write up a case report to publish in the medical literature? Certainly not the homeopath in question, he's not going to incriminate himself, and her medical team have probably had little contact with her since she's been advised not to bother with them anymore. And so homeopaths can continue to claim that their treatment is "safe", because we just don't know the scale of these sorts of cases. 

The only bright side here is that, of course, my friend will most definitely not be taking this shoddy advice. She's well aware that homeopathy is a whole load of nonsense and just contacted this guy to see what the response would be. However, we have to wonder how many other emails he's getting, from people who are genuinely seeking help. And we have to wonder what's happening to them, and whether they are safe.As an interesting, and rather creepy, aside the homeopath started following my friend on Google plus and Twitter a couple of hours after responding to her. This is at best weird and unprofessional, and at worst, really quite frightening. I can't think of any healthcare professionals who would do such a thing, just randomly looking up a patient on social media and then following them after one consultation- what about confidentiality? 

Hxxx

Homeopathic Harms Vol 2. Where's the Evidence?

Here's the next in our series of blog posts following on from our SITP talk about the harms of homeopathy. This is a guest post written by the marvellous @EBMScientist of Evidence-Based Skepticism fame. Now, I'm going to be a bit bossy here and insist that, if you haven't already bookmarked her blog, you do so right this minute. Future blog posts in this series will just be posted on our respective blogs, but we'll be sure to post links to all of them so you don't miss any instalments. so, without further ado, I shall hand you over to @EBMScientist:

We often harp on about the evidence for homeopathy working or otherwise, and I’m not going to touch on that here, because it’s been covered beautifully by many more eloquent writers than me.  What you don’t often see though, is comment on the evidence for homeopathy doing harm.  In the last post in this series the lovely @SparkleWildfire touched on medicalisation, an indirect harm that’s very real but tough to quantify; but what about direct harms?  I’m glad you asked…

In conventional medicine, randomised controlled trials are the best kind of study we can do of a drug to see if it works and if it it’s safe.  What maybe doesn’t mentioned quite so often is that there’s an even *better* form of evidence – the systematic review.  These are produced when someone sits down to do the very tough but remarkably important job of finding every single scrap of evidence they can on a given topic, and pooling it all together to try and get closer to the definitive answer.  The result is a document that represents the best evidence possible for how well a drug (or anything else, for that matter) works, and how safe it is.

One of the biggest and most respected sources of these systematic reviews is theCochrane Collaboration, who cover all areas of medicine.  Happily, they also have a few reviews related to homeopathy, and that seems as good a place to start as any.  The most recently published is:

Homeopathic Oscillococcinum® for preventing and treating influenza and influenza-like illness

The authors searched multiple databases of medical literature, covering a time period dating back to the mid-60s and all the way up until August 2012.  That’s a lot of literature.  Out of all the results they found six randomised, placebo-controlled trials of Oscillococcinum that were similar enough to be directly compared.  Since we’re not really interested in efficacy in this review, I’ll skip straight to the safety part: out of these six trials, including a total 1,523 people, there was one reported adverse event.  One. It happened to be a headache. Let’s stop and think about that for a moment.

A good quality randomised controlled trial collects every single adverse event that happens to every single patient.  And the use of the term “adverse event” is very deliberate, because it includes absolutely everything unexpected and unwelcome that happens (and here’s the key part) whether or not it’s likely to be related to taking the drug.  That might sound counter-intuitive, but the reason is simple – we want to pick up every possible side effect of drugs, and sometimes side effects are…weird.  So it might sound odd to include as an adverse event that someone got hit by a bus, but what if the drug they were taking made them dizzy, or confused, or clumsy?  It’s not unreasonable to suggest that any one of those things could end up in getting you involved in a traffic accident.  So every single little thing is recorded, and once the trials is over you do some sums to work out the key question – are these things *more likely to happen in the people who took the drug*? If 20 people broke a leg but they were equally spread out among the trial groups then nothing further needs to be said; if 19 of them were on the drug being studied then there might be something to worry about.  The flip side of that of course is that if 19 were in the placebo group, you might want to wonder if the drug is (perhaps unintentionally) promoting better balance and co-ordination, for example (or if everyone in the placebo group was a keen but inept snowboarder).

Is that one single adverse event out of over 1,500 people taking Oscillococcinum starting to look fishy yet?  What about if I drop in the snippet that some of the people involved (327, to be precise) took the remedy every day for four weeks, to see if it stopped them from getting flu in the first place?  How many times in four weeks would an average, healthy person experience something that you could call an adverse event – a headache, a tummy upset, indigestion, a strained ankle, a touch of insomnia?  I’ve had three of those things in the last 24 hours, and I wouldn’t say I’m a particularly remarkable individual.


So hopefully you can see from this that there’s simply a huge, yawning hole in the evidence about safety in homeopathy.  There are ways and means to address this (though they’re far from perfect), and I’ll address one of those in my next post in this series.

Teratology: an area where more critical thinking would be useful

(Teratology: Noun: The scientific study of congenital abnormalities and abnormal formations. From the Greek teras [meaning monster or marvel] and logos [meaning study])

"Hands up, who is afraid of advising someone takes a medicine in pregnancy?"

In the couple of training sessions I've delivered, this has been my opening line. And many hands go up. I regularly give advice on medicines in pregnancy in my job, and it strikes me that it is an area which could hugely benefit from more critical thinking and a reliance on evidence in everyday medical practice. I'm thinking might do a little series of blog posts on this subject. 

So why are so many people afraid of giving advice? One word: thalidomide. You'll all probably know what went wrong in the thalidomide disaster- a drug that was commonly used for morning sickness which unfortunately causes limb malformations when used at the time of pregnancy when women get morning sickness. That, coupled with the lack of post-marketing regulation ad monitoring back in those days- led to a perfect teratogenic storm, with obvious impacts for those affected, but which also shook the medical profession to its core. The good thing is that it forced a rethink in medicines regulation and triggered interest in pharmacovigilance, with schemes like pregnancy registries, teratology information services, and the MHRA's Yellow Card scheme being introduced in its wake. It's also left a lasting, deep-rooted fear of the potential of medicines to cause harm in pregnancy in pharmaceutical companies, patients and medical professionals alike. 

Why is this fear a problem? Well, primarily because some pregnant women do still get ill, and do still need medical treatment. I've lost count of the number of times I've heard a doctor say to me "my patient has (insert life threatening disease) and she's found out she's pregnant, so I've stopped all of her meds. What harm will that have caused?" And my first response is "how is your patient?", along with having to try very hard to stop myself saying "what do you think is going to be more of a teratogen, whatever the drug is, or having a patient who is dead?!" Such decisions to stop treatments are often done without consulting any evidence first, and there is a clear potential for harm to patients and their pregnancies in such situations. 

Another harm is that, in the event of something going wrong in a pregnancy, there's a tendency to way something to blame. I think it must be truly awful to have to think that because you have taken medicines, it's all your fault, especially as in many, many cases there will be no clear causality. 

I think we can pretty safely say that, because of the things that have been put in place since thalidomide, that another similar disaster won't happen again. There are drugs which can undoubtedly cause harm in pregnancies but as with all things in medicine, we have to consider a benefit vs risk balance. And we have to take into account what evidence we have access to, think about its limitations, and apply it to each individual situation. Just stopping all medicines because a patient is pregnant is not going to be the least risky option in most cases (and indeed in all those aforementioned cases that I've discussed, the drugs the patient has been on have turned out to have some pretty reassuring data sets). I even know of a dr who panicked so much when he found out his patient was pregnant that he put a note through her door telling her to have an abortion because he had prescribe her some drugs which turned out to have a pretty robust safety record in pregnancy. Imagine the emotional harm this sort of thing could cause. 

I don't want to end up writing a hugely long blog post so I'm going to end this one here as I'll cover some more aspects in future posts.

Why St John's Wort scares me, even though it does probably work.

Hi all,

It's lovely for once to be able to write about something that works, instead of something which has little to no evidence of it working. However, I wanted to share with you some reasons why I would tend to steer people away from a "natural" remedy, despite the evidence being positive. Why St John's Wort today? Well, my RSS feed today popped up with:

31/12/2012
Daily Telegraph
By: Presswatch
GPs prefer herbal remedies to Prozac, says survey
A survey by Schwabe Pharma found that GPs are increasingly likely to prescribe herbal remedies such as St John's wort for depression rather than Prozac.(
(http://www.presswatch.com/health/index.php?d=2012-12-31#3)

I haven't been able to find the actual story, or the press release from Schwabe Pharma (who, incidentally, produce St John's Wort, so wouldn't be without bias), but it got me thinking anyway. 

Is it because of a big pharma conspiracy? Is it because I'm in cahoots with the evil drug companies and all I want is money? Is it because I'm just too close-minded to be able to accept anything other than conventional medicines? Is it because I love seeing patients suffer? Well, in short no.

I find herbal medicines really interesting. Unlike homeopathy, which has no theoretical possibility of working, herbal medicines contain plant material with high enough levels of chemical constituents to cause a pharmacological effect. There's something quite beautiful about the concept of using plants for medicinal purposes. The problem with them lies in the fact that there just aren't enough studies done for us to be able to say whether they work, or more importantly, whether they harm. Whilst herbal remedies have enough "medicine" in them to make them work, this also means they have enough in them to cause adverse reactions, to interact with other herbs, medication, illnesses and so on. Without Big Pharma funding, though, its not that likely that large, well designed trials will be undertaken on them, so using herbal medicines can be a bit like shooting in the dark. Even if we don't find any documented issues with a herb, this doesn't mean none exist, it may just mean that nobody has looked at (or published) any issues yet.

St John's Wort is different. There is now a pretty large body of evidence to suggest that it works, and that it works better than placebo and as well as conventional antidepressants like the SSRIs. We also know a fair bit about its interactions and its adverse drug reactions... So that's great then, yes? That means healthcare professionals should all consider it as a better choice than the conventional medicines, with all their nasty side effects etc, right? 

Well, in my opinion: not always. Whilst we know a fair amount about it, the problem here lies with production, and the inherent variability in herbal medicines. Because they're made from plant materials, there can be a huge amount of variability in what each tablet contains.. Even if you're using a product licensed under the Traditional Herbal Registration scheme, there can still be variability between each batch, depending on where the plant was grown, the time of year/ day it was harvested, and what it was treated after it was harvested. So, if you get stabilised on one batch of medicine, the next batch may contain differing amounts of active ingredients, which could mean a whole host of things might happen: it might work better, it might start interacting with your other meds, it might trigger a side effect etc. Then, just when you're getting used to that batch, the next one is different too, etc etc.

I've come across a few enquiries where a patient wants to use St John's Wort as add-on therapy along with their antidepressants. It maybe doesn't occur to the patient or their GP/pharmacist etc that it actually works in a very similar way to a conventional antidepressant. Combinations of antidepressants are usually only done under specialist care (with a few exceptions) because combining them increases the risk of some very severe side effects such as serotonin syndrome- the same applies to St John's Wort. The fact it's "natural" seems to blindside people into forgetting the usual principles of how medicines work. 

This is before we even get into the territory of risks associated with self-treatment of what can be a very, very serious disease. Would I exclude use of St John's Wort entirely, for everyone? No, because it does appear to work. But do I treat it with as much (if not more) caution than I would an SSRI? Yes, because there's still not that much information about its safety in the grand scheme of things. So this sort of negates the point of it, to be honest.

Hopefully that explains a bit about why I'm cautious about herbal medicines.

Have a lovely New Year's Eve folks, see you again in 2013.

Hxxx