Abstract
The current paper presents an analysis of the NICE guidelines on depression and attention deficit hyperactivity disorder (ADHD) from the perspective of the philosophy of science, guided particularly by Foucault's notion of the symbiosis of knowledge and power. It examines how data that challenged the orthodox position on the validity and drug treatment of these conditions was managed in the process of guideline development. The depression guideline briefly considered the complexity and heterogeneity of depression, and numerous methodological problems with evaluating treatments, including antidepressants. However, the guideline recommendations made no reference to these issues and ignored evidence that questioned the analysis of antidepressant trials. The guideline on ADHD reviewed validity, but did not consider evidence from the critical literature, and overlooked inconsistencies in the data. The guideline identified that drug trials have shown no long-term benefit in ADHD, but still recommended treatment with stimulant drugs for children with severe symptoms and for all adults claiming consensus for this position. Both guidelines demonstrate how contradictory data are managed so as not to jeopardise the currently predominant view that ADHD and depression are valid and un-contentious medical conditions that should be treated with drugs. The subjective nature of guideline formation that is revealed illustrates Foucault's suggestion that the authority of medicine operates to promote a technological view of the nature of certain human problems, which in turn strengthens medical hegemony over these areas.
Highlights
The National Institute for Health and Clinical Evidence (NICE) was set up by the government of the United Kingdom in 1999 with a remit to make evidence-based recommendations about particular medical conditions and their treatment
In sections dealing with the concept of depression, the NICE guideline acknowledges that there are some difficulties in defining the term, and in categorising severity, but these difficulties and their implications are not examined in depth and do not influence subsequent discussions or recommendations
Despite the uncertainty expressed in these quotations, the guideline did not consider any critical literature on the validity of the concept of depression, despite references being provided in the stakeholder submissions (Pilgrim and Bentall 1999; Dowrick 2004)
Summary
The NICE guideline on depression was first published in 2004 and updated in 2009 (National Institute for Health and Clinical Evidence 2004, 2009). It recommended that antidepressants should be prescribed in moderate to severe cases of depression, but that mild depression should be treated without medication, at least initially. Philosophers of science and knowledge have long questioned the idea of objective, value-free, scientific knowledge that is embodied in clinical guidelines They have pointed out that knowledge is shaped by local and historical circumstances (Kuhn 1970; Pickering 1992; Latour 1987), and that it reflects the moral and political values of the society in which it is produced, as well as the interests of particular groups within that society (Kuhn 1970; Feyerabend 1975; Proctor 1991). The analysis illustrates the way that psychiatric knowledge is shaped more by human interests and power dynamics than objective data
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