animal studies should be acknowledged, since some PBM has received payment for lectures or advisory board membership from reports11 have suggested that rimonabant might have AstraZeneca, Eli Lilly, GlaxoSmithKline, Janssen-Cilag, and Lundbeck in the past
3 years. MJM declares that she has no conﬂ ict of interest.
antidepressant or anxiolytic actions. Another obser-
Di Marzo V, Matias I. Endocannabinoid control of food intake and energy
vation that might provide an alternative physio logical
balance. Nat Neurosci
Cooke D, Bloom S. The obesity pipeline: current strategies in the development
basis for increased mood disorders seen with greatest
of anti-obesity drugs. Nat Rev Drug Disc
weight-loss comes from evidence that leptin, the 3
Curioni C, Andre C. Rimonabant for overweight or obesity. Cochrane Database
adipose-derived hor mone, had an antidepressant action 4 Padwal RS, Majumdar SR. Drug treatments for obesity: orlistat, sibutramine, after intrahippocampal but not hypothalamic injec tion.12
and rimonabant. Lancet
Christensen R, Kristensen PK, Bartels EM, Bliddal H, Astrup A. Eﬃ
However, direct clinical correlates are diﬃ
safety of the weight-loss drug rimonabant: a meta-analysis of randomised
What is the signiﬁ cance of the ﬁ ndings reported by
Onyike CU, Crum RM, Lee HB, et al. Is obesity associated with major
Christensen and colleagues? First, their meta-analysis has
depression? Results from the Third National Health and Nutrition
raised major questions about the safety of rimonabant
Examination Survey. Am J Epidemiol
Food and Drug Administration Endocrinologic and Metabolic Advisory.
in obese people, who are already at an increased risk of
June 13, 2007. Brieﬁ ng Information, NDA 21-888 ZIMULTI (rimonabant)—Sanoﬁ -Aventis. 2007. http://www.fda.gov/OHRMS/DOCKETS/AC/07/
sion, especially since the FDA review suggests
brieﬁ ng/2007-4306b1-00-index.htm (assessed Aug 6, 2007).
that the risk of suicide is increased by use of this agent. 8 Gobbi G, Bambico FR, Mangieri R, et al. Antidepressant-like activity and
modulation of brain monoaminergic transmission by blockade of
More over, at least four other companies have CB antag-
anandamide hydrolysis. Proc Natl Acad Sci USA
onists in phase II or III development. The ﬁ ndings of 9 Hill MN, Ho WS, Sinopoli KJ, et al. Involvement of the endocannabinoid
system in the ability of long-term tricyclic antidepressant treatment to
Christensen and colleagues’ meta-analysis suggest that
suppress stress-induced activation of the hypothalamic-pituitary-adrenal
phase III studies of such CB antagonists should monitor
10 Moreira FA, Kaiser N, Monory F, et al. Reduced anxiety-like behaviour induced
psychiatric complications very carefully. Second, the link
by genetic and pharmacological inhibition of the endocannabinoid-degrading enzyme fatty acid amide hydrolase (FAAH) is mediated by CB1 receptors.
between depression and this CB -receptor blocker raises
2007; published online July 19. DOI: 10.1016/j.neuropharm.
theoretical questions about a potential central role for
Griebel G, Stemmelin J, Scatton B. Eﬀ ects of the cannabinoid CB1 receptor
the endocannabinoid system in both normal and clinical
antagonist rimonabant in models of emotional reactivity in rodents.
12 Lu X-Y, Kim CS, Frazer A, et al. Leptin: a potential novel antidepressant.
Proc Natl Acad Sci USA
*Philip B Mitchell, Margaret J Morris
13 Vinod KY, Hungund BL. Role of the endocannibinoid system in depression
and suicide. Trends Pharmacol Sci
School of Psychiatry and School of Medical Sciences, University of New South Wales, Sydney, NSW 2052, Australiaphil.email@example.com
Beneﬁ ts and risks of homoeopathy
Five large meta-analyses of homoeopathy trials have
Similarly, modern medicine can oﬀ er little for conditions
been done. All have had the same result: after excluding such as many types of back pain, stress at work, medically methodo logically inadequate trials and accounting for unexplained fatigue, and most com mon colds. Going publication bias, homoeopathy produced no statistically through a theatre of medical treatment, and trying every signiﬁ cant beneﬁ t over placebo.1–5 And yet homoeopathy
drug in the book, will only elicit side-eﬀ ects. An inert pill
in these circumstances seems a sensible option.
During the cholera epidemic in the 19th century,
However, just as homoeopathy has unexpected
death rates at the London Homoeopathic Hospital beneﬁ ts, so it can have unexpected side-eﬀ ects. The very were three times lower than those at the Middlesex act of prescribing a pill carries its own risks: medicalisation,
Hospital.6 The reason for homoeopathy’s success in this reinforcement of counterproductive illness behaviours,
See Special Report
epidemic is even more interesting than the placebo and promotion of the idea that a pill is an appropriate eﬀ ect. At the time, nobody could treat cholera, and response to a social problem, or a modest viral illness.
while medical treatments such as blood-letting were
Similarly, when a health-care practitioner of any
actively harmful, the homoeopaths’ treatments were at
description prescribes a pill which they know is no more
eﬀ ective than placebo—without disclosing that fact to
www.thelancet.com Vol 370 November 17, 2007
their patient—then they disregard both informed consent
Every criticism I have made could be managed
and their patient’s autonomy. Some could argue that this with clear and open discussion of the problems. cost is accept able, but such old-fashioned paternalism can But homoeopaths have walled themselves oﬀ from ultimate ly undermine the doctor–patient relationship.
academic medicine, and critique has been all too often
There are also more concrete harms. A routine feature met with avoidance rather than argument. The Society
of homoeopaths’ marketing practices is to denigrate of Homeopaths (in Europe) has even threatened to sue mainstream medicine. One study found that half of all bloggers,15 and the university courses on alternative homoeo
paths who were approached advised patients medicine which I and others have approached have ﬂ atly
against the measles, mumps, and rubella vaccine for refused to provide basic information, such as what they their children.7 A television news investigation found teach and how.16 It is hard to think of anything more that almost all homoeopaths who were approached unhealthy.
recom mended ineﬀ ective homoeopathic prophylaxis for
To ban homoeopathy would be an over-reaction, as
malaria, undermined medical prophylaxis, and did not placebos could have a clinical role. However, whether the even give simple advice on bite prevention.8 Undermining
placebo eﬀ ect is best harnessed by homoeopaths will
medicine is a wise commercial decision for homoeopaths, remain questionable until these ethical issues and side-because survey data show that a disappointing exper ience eﬀ ects have been addressed. with mainstream medicine is one of the few feat ures to regularly correlate with a decision to use alter native Ben Goldacre
therapies. But it might not be a responsible choice.
Homoeopaths can undermine public-health campaigns;
leave their patients exposed to fatal diseases; and, in the I am a medical doctor who is also employed by the media as a commentator on
pseudoscience and the sociology of medicine.
extreme, miss or disregard fatal diagnoses. There have 1 Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. BMJ
1991; also been cases of patients who died after medically
Boissel JP, Cucherat M, Haugh M, Gauthier E. Critical literature review on the
trained homoeopaths advised them to stop medical
eﬀ ectiveness of homoeopathy: overview of data from homoeopathic
treatments for serious medical conditions.9,10
medicine trials. Brussels, Belgium: Homoeopathic Medicine Research Group. Report to the European Commission. 1996: 195–210.
All these problems have been exacerbated by 3 Linde K, Melchart D. Randomized controlled trials of individualized
society’s eagerness to endorse the healing claims of
homeopathy: a state-of-the-art review. J Alter Complement Med
homoeopaths, and by the lack of a culture of critical 4 Cucherat M, Haugh MC, Gooch M, Boissel JP. Evidence of clinical eﬃ cacy of
homeopathy: a meta-analysis of clinical trials. Eur J Clin Pharmacol
self-appraisal in alternative medicine. Publication bias
in alternative ther apy journals is high: in 2000, only 5% 5
Shang A, Huwiler-Müntener K, Nartey L, et al. Are the clinical eﬀ ects of homoeopathy placebo eﬀ ects? Comparative study of placebo-controlled
of studies published in complementary or alternative
trials of homoeopathy and allopathy. Lancet
health journals were negative.11 To my knowledge, the 6 Hempel S. The medical detective. London, UK: Granta Books, 2006.
Schmidt K, Ernst E. Aspects of MMR. BMJ
ethical issues of autonomy and placebo have never been 8 Jones M. Malaria advice ‘risks lives’. Newsnight
, BBC2 July 13, 2006. http://news.
discussed. Homoeopaths routinely respond to negative
bbc.co.uk/1/hi/programmes/newsnight/5178122.stm (accessed Nov 8, 2007).
General Medical Council Fitness To Practise Panel. Dr Marisa Viegas. 2007.
observational study,12 which amounts to little more than a
ftp_panel_viegas.asp (accessed Nov 8, 2007).
10 Sheldon T. Dutch doctor struck oﬀ for alternative care of actor dying of cancer.
customer-satisfaction survey, has been promoted13 as if it
trumps a string of randomised trials.
Schmidt K, Pittler M, Ernst E. Bias in alternative medicine is still rife but is
Homoeopaths can misrepresent scientiﬁ c evidence 12 Spence DS, Thompson EA, Barron SJ. Homeopathic treatment for
freely to an unsuspecting and scientiﬁ cally illiterate public,
chronic disease: a 6-year, university-hospital outpatient observational
study. J Altern Complement Med
but in doing so they undermine the public understanding 13 Grice E. Keep taking the arsenic. Daily Telegraph
Nov 25, 2005. of what it means to have an evidence base for a treatment.
http://www.telegraph.co.uk/health/main.jhtml?view=DETAILS&grid=P8&xml=/health/2005/11/25/hhomeo25.xml (accessed Nov 8, 2007).
This approach seems particularly egregious when 14 Evans I, Thornton H, Chalmers I. Testing treatments: better research for better
healthcare. London, UK: British Library, 2006.
academics are working harder than ever to engage the 15 Goldacre B. Threats, the homeopathic panacea. Guardian
Oct 20, 2007. wider public in a genuine understanding of research,14 and
http://www.guardian.co.uk/science/2007/oct/20/homeopathy (accessed Nov 6, 2007).
when most good doctors try to educate and involve their 16 Giles J. Degrees in homeopathy slated as unscientiﬁ c. Nature
2007; patients in the selection of treatment options.
www.thelancet.com Vol 370 November 17, 2007
Second report of the Egyptian Ornithological Rarities Committee – 2011 Egyptian Ornithological Rarities Committee: Frédéric Jiguet (chairman), Mindy Baha el Din, Sherif Baha el Din, Richard Bonser, Pierre-André Crochet, Andrew Grieve, Richard Hoath, Tomas Haraldsson, Ahmed Riad & Mary Megalli (secretary) Citation: Jiguet, F., Baha el Din, M., Baha el Din, S., Bonser, R., Crochet, P.-A
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