Mad in America: Rethinking Mental Health

In this second interview in our Science and Pseudoscience of Mental Health series, Dr. Sharna Olfman interviews Dr. Darcia Narvaez. In 1955, Erich Fromm published a book called The Sane Society. The basic premise is that cultures that support our existential needs for love, community, autonomy, creative expression, purpose, meaning, and communion with nature, enable us to become fully actualized, sane human, beings. Cultures that fail to do so, engender mental illness. Darcia Narvaez,1 a Professor of Psychology at the University of Notre Dame, has taken up the mantle of Fromm's quest to identify and promote sane cultural practices that foster mental health. A prolific multidisciplinary scholar, her recent books include Neurobiology and the Development of Human Morality: Evolution, Culture and Wisdom (2014) and Basic Needs, Wellbeing and Morality: Fulfilling Human Potential (2018). To read more about Dr. Narvaez' work, visit this link: https://www.madinamerica.com/2018/12/reclaiming-humanity-dawn/ © Mad in America 2018

When we discuss the issue of forced treatment, coercive mental health interventions like involuntary commitment, forced drugging, and electroconvulsive therapy usually come to mind. But force and coercion can be much more subtle. Many researchers and thought leaders have argued that our society mandates us to be happy and perform well-being at all times through cultural norms, media depictions, and workplace and school regulations. This week on MIA Radio we interview Will Davies, Reader in Political Economy at Goldsmiths University of London, and author of The Happiness Industry, a book that explores the rapidly growing culture of mandated happiness and well-being surveillance. In this interview, we discuss the increasing pressure people face to be happy and think positive, and how this pressure serves the interests of the corporate elite and the State. In this episode we discuss: What the "happiness industry" is and the history of its development How the notion that happiness can be quantified or measured, as well as advancements in neuroscience and medicalized frameworks of depression, have influenced our culture How employees are increasingly pressured to be happy or perform happiness within the workplace How people receiving welfare or government benefits are required to engage in positive thinking programs or cognitive behavioral therapy That holding individuals responsible for attaining their own happiness relieves responsibility from structural and institutional determinants of well-being The coercive and forceful aspects of the "happiness industry," including surveillance in workplaces and mandatory self-help programs in schools The role that positive thinking and self-help culture play in upholding neoliberalism and capitalism Relevant Links: Dr. Will Davies The Happiness Industry: How the Government and Big Business Sold Us Well-Being The Managed Heart: Commercialization of Human Feeling The Power Thinker: Why Foucault's Work on Power is More Important than Ever The Weariness of the Self: Diagnosing the History of Depression in the Contemporary Age Dr. Davies' next book, Nervous States: Democracy and the Decline of Reason will be published by Norton in early 2019. © Mad in America 2018

This week on MIA Radio, we interview Dr. Sandy Steingard. Dr. Steingard is Medical Director at Howard Center, a community mental health center where she has worked for the past 21 years. She is also Clinical Associate Professor of Psychiatry at the College of Medicine of the University of Vermont. For more than 25 years, her clinical practice has primarily included patients who have experienced psychotic states. Dr. Steingard serves as Board Chair of the Foundation for Excellence in Mental Health Care. She was named to Best Doctors in America in 2003 and writes regularly for Mad in America. She is editor of the book Critical Psychiatry, Controversies and Clinical Implications due in 2019. In this episode we discuss: What led Sandy to her career in psychiatry and her particular interest in the critical aspects of psychiatry and psychology. That Sandy's initial interest was in biomedical explanations of psychotic experiences. How, in the late 80s, the advent of new antipsychotic drugs caused an initial excitement because of the promises made about safety and efficacy, but that Sandy came to realise the problems with the drugs. How she witnessed the over-promotion of the drugs and that the promotion was markedly different to the results of studies and her observations of patients that were taking them. How a series of disappointments and recognition of some inherent flaws in psychiatry led Sandy to her interest in alternatives. That the book, The Truth About the Drug Companies by Marcia Angel MD, had a big impact on Sandy's view of the drugs during the 2000s. Other influential books were The Daily Meds by Melody Petersen and Side Effects by Alison Bass. That reading Anatomy of an Epidemic and particularly the problematic aspects of the long-term use of antipsychotic drugs caused Sandy to question how she was practising. That she found colleagues were sometimes angry at the conclusion that antipsychotic drugs might not be safe or lead to better outcomes for patients. That this led to the investigation of alternatives such as Open Dialog, training with Mary Olsen at the Institute of Dialogic Practice and discovering the Critical Psychiatry Network and the work of Dr. Joanna Moncreiff. How Sandy approaches practising from a critical perspective, particularly when expectations are in line with the dominant biomedical narrative. Her book, Critical Psychiatry, due in 2019 which aims to help clinicians apply transformational strategies in their clinical practices. That psychiatrists would be well served by welcoming lived experience input to their daily practice. Why informed consent should be viewed as an ongoing process rather than a one-time agreement. The problems that arise in clinical studies where experience is translated into a numerical form. Relevant links: Critical Psychiatry, Controversies and Clinical Implications (due 2019) How Well Do Neuroleptics Work? What We Are Talking About When We Talk About Community Mental Health The Truth About The Drug Companies by Marcia Angel MD (video) The Daily Meds by Melody Petersen (review) Side Effects by Alison Bass Open Dialog The Institute for Dialogic Practice Critical Psychiatry Network

This week, MIA Radio presents the fourth in a series of interviews on the topic of the global "mental health" movement." This series is being developed through a UMASS Boston initiative supported by a grant from the Open Society Foundation. The interviews are being led by UMASS PhD students who also comprise the Mad in America research news team. Over the past three weeks, we have published interviews with many of the leading voices in this debate. Immediately following the release of the report and the beginning of the Summit, on World Mental Health Day, psychiatric epidemiologist, Dr. Melissa Raven, was on the MIA podcast. She questioned the evidence base of the movement, pointing to statistical issues in the prevalence rates of mental disorders internationally, and called for a focus on addressing barriers to health rather than on individualized treatment. Mental health service-user activists, Jhilmil Breckinridge, of the Bhor Foundation in India, and Dr. Bhargavi Davar, of Transforming Communities for Inclusion (TCI) Asia Pacific were also on the podcast. Each discussed the lack of involvement of service-user and disability rights groups in the UK Summit and Lancet report and laid out alternative frameworks for addressing distress in ways that are sensitive to culture and social context. Next, Dr. China Mills, a critical psychologist and author of Decolonizing Global Mental Health, spoke to my colleague, Zenobia Morrill, about her experience attending the UK summit and the lack of attention that has been given to the ways in which austerity policies in Britain have contributed to the increased demand for mental health interventions. You can find these earlier interviews at the links below: 10/10/18 - Interview with Dr. Melissa Raven, psychiatric epidemiologist - The Global 'Mental Health' Movement – Cause For Concern 10/20/18 – Interviews with mental health service-user/psychosocial disability rights activists Jhilmil Breckenridge and Dr. Bhargavi Davar - Global Mental Health: An Old System Wearing New Clothes 10/24/18 – Interview by MIA research news editor Zenobia Morrill with Dr. China Mills, a critical psychologist and prominent critic of the global mental health movement – Coloniality, Austerity, and Global Mental Health Today I am very pleased to announce that we are joined by Dr. Derek Summerfield. Dr. Summerfield is an honorary senior lecturer at the Institute of Psychiatry in London and former Research Associate at the Refugee Studies Centre at the University of Oxford and consultant and Oxfam. He was born in South Africa and trained in medicine and psychiatry at St. Mary's Hospital Medical School in London. Dr. Summerfield has published hundreds of articles in medicine and social science and has contributed widely to understanding the impact of war-related trauma and torture on people around the world. He has been an outspoken critic of the global mental health movement for several years, criticizing the medicalization of trauma through PTSD, the exaggerated prevalence rates in the epidemiological data, and the lack of awareness of the different cultural experiences and understandings of distress.

Today, we bring you the third in our series of podcasts on the topic of the global mental health movement. Part one of the series featured Dr Melissa Raven and part two featured Jhilmil Breckenridge and Dr Bhargavi Davar. These interviews are led by our Mad in America research news team. In this episode, we interview Dr China Mills. China participated in organizing the open letter in response to The Lancet Commission on Global Mental Health and Sustainable Development. In this interview, China shares her concerns and reactions to the Lancet's proposal, elaborating on deeper issues related to the framing of global mental health as a "burden" and the underlying implications of coloniality, technology, and medicalization. In addition, China tells us about her insider perspectives after attending the Global Mental Health Ministerial Summit hosted by the UK government. In her recent piece for Mad in Asia about the summit, she writes: "It was ironic to listen to a range of UK Government minsters talk about the importance of mental health whilst sat in a room just over the river from Westminster, where governmental decisions to cut welfare, and sanction and impoverish disabled welfare claimants has so detrimentally impacted people's mental health and led to suicide. It felt like arrogance on the part of the UK Government to position themselves as world leaders in mental health when in 2016, the UN found that the Government's austerity policies had enacted 'grave' and 'systematic violations of the rights of persons with disabilities' . It was equally jarring, given the cuts to social security under austerity, to be transported by boat about 2 minutes away, to an evening drinks reception at the Tate gallery." China Mills is a Lecturer in the School of Education, University of Sheffield, UK. Her research develops the framework of psychopolitics to examine the way mental health gets framed as a global health priority. In 2014, she published the book 'Decolonizing Global Mental Health' and has since published widely on a range of topics including: the inclusion of mental health in the sustainable development goals; the quantification of mental health and its construction as a technological problem; welfare-reform, austerity and suicide; and the intersections of psychology, security and curriculum. She is Principal Investigator on two British Academy funded projects researching the social life of algorithmic diagnosis and psy-technologies. China is a member of the editorial collective for Asylum magazine and for the journal, Critical Social Policy; and she is a Fellow of the Sheffield Institute for International Development (SIID).

Today, we bring you the second in our series of podcasts on the topic of the global mental health movement. These interviews are led by our Mad in America research news team. On October 9th and 10th, 2018, World Mental Health Day, the UK government hosted a Global Mental Health Ministerial Summit with the intention of laying out a course of action to implement mental health policies globally. In the same week, The Lancet Commission on Global Mental Health and Sustainable Development published a report outlining a proposal for "scaling up" mental health care globally. In response, a coalition of mental health activists and service-users have organized an open letter detailing their concerns with the summit and report. The response has attracted the support of policy-makers, psychologists, psychiatrists, and researchers. In our last episode, we were joined by Dr Melissa Raven, a critical psychologist and epidemiologist, who discussed problems with the scientific evidence base used by the global mental health movement. She also emphasized the need to consider responses to the distress and suffering of people globally that address the social determinants of mental health, including poverty, education, and healthcare. Today we turn our focus to the concerns raised by mental health activists in response to the UK summit and the Lancet report. To discuss these issues, we are joined first by Jhilmil Breckenridge, a poet, writer and mental health activist and later by social science researcher Dr Bhargavi Davar. Jhilmil is the Founder of Bhor Foundation, an Indian charity, which is active in mental health advocacy, the trauma-informed approach, and enabling other choices to heal apart from the biomedical model. Jhilmil also heads a team leading Mad in Asia Pacific; this is an online webzine working for better rights, justice and inclusion for people with psychosocial disability in the Asia Pacific region. She is currently working on a PhD in Creative Writing in the UK and, for the last three years, she has also been leading an online poetry as therapy group for women recovering from domestic violence. She is working on a few initiatives, both in the UK and India, taking this approach into prisons and asylums. Her debut poetry collection, Reclamation Song, was published in May 2018. For our second interview, we are joined by Dr Bhargavi Davar. She identifies as a childhood survivor of psychiatric institutions in India. She went on to train as a philosopher and social science researcher at the Indian Institute of Technology in Bombay and has published and co-edited several books, including Psychoanalysis as a Human Science, Mental Health of Indian Women, and Gendering Mental Health, while also producing collections of poems and short stories. Dr Davar is an international trainer in the Convention on the Rights of Persons with Disabilities (CRPD) and the founder of the Bapu Trust for Research on Mind and Discourse in Pune, India. This organization aims to give visibility to user/survivor-centred mental health advocacy and studies traditional healing systems in India.

This week, we present the first in a series of interviews on the topic of the global 'mental health' movement. These interviews will be led by our Mad in America research news team and today's interview is hosted by our lead research news editor, Justin Karter. In this episode, Justin interviews Dr Melissa Raven, who is a psychiatric epidemiologist, policy analyst and postdoctoral research fellow in the Critical and Ethical Mental Health research group at the University of Adelaide, South Australia. Originally qualified as a clinical psychologist, she then worked as a lecturer and researcher in public health and primary health care. Her current mental health research and advocacy is informed by a strong social determinants perspective and a strong critical orientation, which she applies to a range of topics, including suicide prevention, workplace mental health, (over)diagnosis, (inappropriate) prescribing, and conflicts of interest in mental health and the broader health/welfare arena. On October 10th, 2018, World Mental Health Day, The Lancet Commission on Global Mental Health and Sustainable Development published a report outlining a proposal to "scale up" mental health care globally. At the same time, the UK government is hosting a Global Mental Health Ministerial Summit with the intention of laying out a course of action to implement these mental health policies globally. In response, a coalition of mental health activists and service-users have organized an open letter detailing their concerns with the summit and report. The response has attracted the support of critical professionals, psychologists, psychiatrists, and researchers.

Sharna Olfman Ph.D interviews Zach Bush MD One of the few triple board-certified physicians in the country, with expertise in Internal Medicine, Endocrinology and Metabolism, and Hospice/Palliative care, Dr. Zach Bush abandoned his prestigious academic career in cancer research, and his conventional medical practice a decade ago, after coming to terms with the fact that not only were his pharmaceutically based research and treatment protocols ineffectual; they were making his patients sicker. He then opened a clinic in the middle of a food desert in rural Virginia, where he swapped out pharmaceutical interventions for the medicinal properties of plants. Now based in Charlottesville, Dr. Bush has assembled an outstanding group of scientists and clinicians who are at the forefront of research on the microbiome and epigenetics. He has developed an impactful approach to healthcare which directly challenges 'big farming, 'big pharma' and conventional medicine. https://www.madinamerica.com/2018/10/healthy-planethealthy-mind-zach-bush-md/

This week on MIA Radio we turn our attention to Electroconvulsive Therapy (ECT) or Electroshock as it's known in the US. On Wednesday, September 19th, this emotive and controversial intervention was discussed at the 57th Maudsley debate, held at Kings College London. The motion proposed was: "This house believes that ECT has no place in modern medicine". Supporting the motion were Professor John Read who has undertaken several scientific reviews of the literature supporting the use of ECT and Dr Sue Cunliffe. Dr Cunliffe was a paediatrician until she herself underwent ECT, after which she became cognitively impaired and found herself unable to continue working. She now campaigns for the risks of ECT to be made more explicit and to directly address the professional denial of the damage that ECT can cause. Speaking against the motion were Professor Declan McLoughlin and Dr Sameer Jauhar. Both John and Sue took time out to talk about the debate and the wider issues surrounding ECT. Professor Read kindly shared his debate notes, which are provided below. Thank you to the Institute for bringing us all together. Let us first remind ourselves tha thistory is littered with procedures which people believed in- just as strongly as some psychiatrists believe, today, in electrocuting people's brains to cause seizures - but which turned out to be ineffective or damaging. The list includes spinning chairs, surprise baths, standing people next to cannons, and, more recently, lobotomies. It was 80 years ago, in 1938, that Ugo Cerletti administered the first ECT, to a homeless man in Rome. After the first shock the man called out 'Not another – it will kill me'. The theory back then was that people with epilepsy didn't have schizophrenia so the cure for schizophrenia was to cause epilepsy. So Cerletti was driven by the genuine belief that causing convulsions by shocking the brain really might help people, by the genuine hope that we might finally have come up with an effective treatment. The story of ECT illustrates, yet again, however, what happens when our beliefs and good intentions are not tempered with good science. ECT quickly spread from Rome across Europe and America. Finally, an effective treatment! People who received it were discharged earlier….… by the doctors who gave it. But there were no studies for 13 years, by which time everyone just knew it worked, and their belief may have been very helpful to some patients. The first study on depression (which became the main target for ECT), in 1951, found that those who had ECT fared worse than those who had not had it. It made no difference. I have co-authored four reviews of the ECT research, most recently last year. There are only ten depression studies comparing ECT and placebo; placebo meaning the general anaesthetic is given but the electric shock is withheld. Five of those 10 found no difference between the two groups. The other five found, compared to placebo, a temporary lift in mood during the treatment period, among about a third of the patients. One of these five found that this temporary improvement was perceived only by the psychiatrists, but not by the nurses or the patients. Most reviews and meta-analyses assert, on the basis of these temporary gains in a minority of patients, that 'ECT IS EFFECTIVE' But none of them have ever identified a single study that found any difference between ECT and placebo after the end of the treatment period. There is just no evidence to support the belief that ECT has lasting benefits, after 80 years of looking for it. Similarly, there are no placebo studies to support another genuinely held belief: that ECT prevents suicide. There is nothing wrong with treatments working because of hopes and expectations. But passing 150 volts through brain cells designed for a tiny fraction of one volt causes brain damage. Indeed, autopsies quickly led to a new theory about how ECT works. In a 1941 article entitled 'Brain damaging therapeutics', the man who introduced ECT to the USA, wrote 'Maybe mentally ill patients can think more clearly with less brain in actual operation'. In 1974 the head of Neuropsychology at Stanford wrote: 'I'd rather have a small lobotomy than a series of ECT….I know what the brain looks like after a series of shock'. All ECT recipients experience some difficulties laying down new memories and in recalling past events. What is disputed is how many have long-lasting or permanent memory dysfunction, which might reasonably be called brain damage. Findings range from one in eight to just over half. A review of studies that actually asked the patients, conducted here at the Institute, found 'persistent or permanent memory loss' in 29 to 55%. Yet another belief is that ECT used to cause brain damage, in the bad old days, but not any more. But a recent study found one in eight with 'marked and persistent' memory loss, ….. and also found much higher rates among the two groups who receive it most often, women and older people. The same study also found that the memory loss was not related to severity of depression. This is important because another belief about ECT is that the memory loss is caused by the depression, not the electricity. Psychiatric bodies in the UK and USA recite the belief that only 'one in 10,000' will die from having ECT, without producing a single study to support that belief. Our reviews document large-scale studies with mortality rates between one in 1400 and one in 700, several times higher than the official claims, typically – unsurprisingly - involving cardiovascular failure. ECT in England has declined, from 50,000 a year in the 1970s to about 2,500. The number of psychiatrists who still believe, despite all the evidence, is dwindling fast. It may have been understandable for the psychiatrists of the 1940s to believe that ECT worked and was safe. They didn't know any better. But if psychiatry wants to be an evidence-based discipline, to be part of modern medicine, it must acknowledge that, despite all its honourable intentions, it has got this one, like lobotomies, woefully wrong. Thank you. Links and Further Information To watch the debate on YouTube, click here. To read a report on the first ever Maudsley Debate, held in January 2000, which also discussed ECT, click here. ECT Accreditation Service (ECTAS) MECTA The effectiveness of electroconvulsive therapy: A literature review, John Read and Richard Bentall Is electroconvulsive therapy for depression more effective than placebo? A systematic review of studies since 2009

This week on MIA Radio, we discuss the UK Royal College of Psychiatrists representation on a Government-led review of Prescribed Drug Dependence. Professor Sami Timimi, a fellow of the Royal College of Psychiatry, and 30 other mental health experts, have formally asked the College to 'replace Professor David Baldwin as its representative on The Expert Reference Group of Public Health England's Review of Prescribed Medicines, with an RCPsych member who is not compromised by conflicts of interest with the pharmaceutical industry'. In this podcast, we hear from Professor Timimi, Psychiatrist Peter Gordon and campaigner Stevie Lewis. Both Peter and Stevie are people who have experienced withdrawal effects from antidepressant drugs. Conflicts of Interest Questioned in Royal College of Psychiatry's Participation in Government-Led Mental Health Medication Review August 17, 2018 From: James Moore, antidepressant withdrawal sufferer, on behalf of the 30 other signatories to today's letter. London, UK – A fellow of the Royal College of Psychiatry, and 30 other mental health experts, have today formally asked the College to 'replace Professor David Baldwin as its representative on The Expert Reference Group of Public Health England's Review of Prescribed Medicines, with an RCPsych member who is not compromised by conflicts of interest with the pharmaceutical industry'. The Public Health England review1 was set up to examine a growing problem with patients becoming dependent on psychiatric drugs including antidepressants. In the UK, four million people are long-term antidepressant users2, with many of those unable to come off their drugs without debilitating and protracted withdrawal symptoms. Signatories to the complaint include 10 people whose withdrawal experiences have lasted between one and ten years, plus 11 psychiatrists and 8 mental health professors. In the Public Health England (2018) document 'PMR ERG members declarations of interest', Prof­essor Baldwin reports having received 'personal honoraria for lecture engagements organised by AstraZeneca, Bristol-Myers Squibb, Eli Lilly Ltd, Glaxo-SmithKline, Janssen, H. Lundbeck A/S, Pharmacia, Pierre Fabre, Pfizer Ltd, Servier, and Wyeth Ltd'. In addition, he reports attendance at advisory boards of five companies and research funding from twelve. The signatories are worried that he could be unduly influenced by the large number of pharmaceutical manufacturers he has received income from. This concern is exacerbated by Professor Baldwin's having already publicly minimised the withdrawal effects of antidepressants (Times 24.2.18), which was described as 'misleading' the public in the House of Lords3and led to a formal complaint against him4. Lead author of the letter, psychiatrist Professor Sami Timimi, a fellow of the Royal College, said: "DESPITE THE INCREASED AWARENESS OF THE PERNICIOUS INFLUENCE OF THE PHARMACEUTICAL INDUSTRY IN ALL SPHERES OF MENTAL HEALTH, THE RCPSYCH DOES NOT APPEAR TROUBLED BY THE POTENTIAL FOR MISLEADING THE MEDICAL COMMUNITY AND THE PUBLIC AND SOILING THE GOOD NAME OF THE PROFESSION OF PSYCHIATRY. WE FEEL THE NEED TO MAKE PUBLIC OUR OPPOSITION TO SOMEONE SO CONNECTED WITH THE PHARMACEUTICAL INDUSTRY BEING THE RCPSYCH'S REPRESENTATIVE ON A PUBLIC BODY APPOINTED WITH THE TASK OF WORKING FOR THE PUBLIC GOOD." Another signatory, psychiatrist Dr Peter Gordon said: "EVIDENCE HAS REPEATEDLY FOUND THAT COMPETING FINANCIAL INTERESTS CAN LEAD TO DOCTORS RECOMMENDING WORSE TREATMENTS FOR PATIENTS5. IN THE UK, THE PHARMACEUTICAL INDUSTRY SPENDS OVER £40 MILLION A YEAR ON DOCTORS AND ACADEMICS WHO MARKET AND PROMOTE THEIR PRODUCTS6. I HAVE BEEN COMMUNICATING WITH MY COLLEGE FOR MANY YEARS ON THIS, YET IT REMAINS THE CASE THAT THE ROYAL COLLEGE OF PSYCHIATRISTS STILL HAS NO SINGLE, SEARCHABLE REGISTER THAT RECORDS FULL DETAILS OF INDUSTRY PAYMENTS MADE TO ITS MEMBERS. IT IS THEREFORE IMPOSSIBLE TO DETERMINE THE SCALE OF PAYMENTS THAT MAY HAVE BEEN MADE TO COLLEGE MEMBERS WHO ARE INVOLVED IN DEVELOPING POLICIES AND GUIDELINES OR EDUCATING ON THE PRESCRIBING OF PSYCHIATRIC MEDICATIONS." Antidepressant withdrawal sufferer James Moore, also a signatory, said: "THERE ARE MANY PEOPLE OUT THERE LIKE ME, WHO HAVE FOUND THEMSELVES IN SEVERE DIFFICULTY AFTER TRYING TO COME OFF PRESCRIBED ANTIDEPRESSANT DRUGS. IN ORDER TO PROPERLY INVESTIGATE THIS ISSUE, IT IS VITAL THAT THE INFLUENCE OF THE PHARMACEUTICAL MANUFACTURERS IS NOT ALLOWED TO CORRUPT AN EVIDENCE-BASED AND HONEST APPRAISAL OF A PROBLEM POTENTIALLY AFFECTING MILLIONS OF PSYCHIATRIC DRUG USERS." References 1. https://www.gov.uk/government/collections/prescribed-medicines-an-evidence-review 2. https://www.theguardian.com/society/2018/aug/10/four-million-people-in-england-are-long-term-users-of-antidepressants 3. http://bit.ly/2BgyzxX 4. https://www.madinamerica.com/2018/07/30-mental-health-experts-write-secretary-state-unprofessional-conduct-uk-royal-college-psychiatry/ 5. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000352 6. https://www.bmj.com/content/360/bmj.k1380 © Mad in America 2018