The myth of the chemical cure

Book review published in Journal of the Society for Existential Analysis, July 2008.

‘The Myth of the Chemical Cure’ by Joanna Moncrieff. 2007. Palgrave Macmillan, £50.00 hb, ISBN978-0-230-57431-1

Subtitled ‘A Critique of Psychiatric Drug Treatment’, Moncrieff’s book explores the widely held view that depression and other ‘mental illnesses'(note 1) are caused by chemical imbalances in the brain and that psychiatric drugs can correct these imbalances. She traces how this has come about, carefully delineating fact from fiction to expose how much of what is claimed is based on skewed, partial and dubious evidence and that in reality these psychoactive (note 2) drugs are administered ‘on the basis of a huge collective myth’.

Moncrieff is an academic and practising psychiatrist. She examines what is wrong with current practice and suggests how it could be made better. She acknowledges the contribution of Peter Breggin and others in the critical psychiatry movement for identifying how psychiatric drugs can impair brain functioning but she does not go as far as Breggin who claims there are no justifiable uses for them. This is a sober and thoughtful book. I found it very engaging and worth the effort to be better informed about a subject that affects many of our clients and impinges on our professional lives as therapists.

Moncrieff describes how the action of psychoactive drugs is currently understood and researched within the ‘disease-centred model of drug action'(note 3). She argues that this is fundamentally mistaken. Psychoactive drugs do not have a disease specific action, they do not act on any known neurological causes. Instead they exert similar effects on anyone who takes them by acting on the nervous system to produce a state of altered consciousness. Like recreational drugs such as alcohol and cannabis, they intoxicate us. The main difference being the effects they produce are often experienced as unpleasant. While they may bring some relief (as with recreational drugs) they also bring side effects, some very serious.

Belief in the ‘chemical imbalance model of psychiatric disorder’ is also exposed as a myth. Doctors and the public talk about an imbalance of serotonin being the cause of depression and how anti-depressants will cure this although there is no conclusive evidence that this is the case. Moncrieff says these myths have been promoted by the pharmaceutical industry ‘with the psychiatric profession in tow’ and with the blessing of governments eager to offload the costs of in-patient care onto the community.

This situation has resulted in burgeoning prescriptions and costs for (potentially dangerous) drugs although there is minimal and contradictory evidence that they are beneficial. Moncrieff provides many examples of the hyperbole, and sometimes downright deceit, in the drug companies’ promotional materials. She claims that typically only drug trials that show the desired result have been published whereas when meta analyses are done to include negative outcome studies the results look very different. The remedy she argues for is greater openness and honesty about the real nature of these drugs, and for a change from a disease-centred model to a drug-centred model for understanding, researching and prescribing of psychoactive drugs.

Moncrieff outlines the history of treatments for mental illness and how we have arrived where we are. With the appearance of new psychoactive drugs in the 1950s ‘psychiatry was lifted out of the doldrums of the large asylum era’ and into the arena of physical medicine and outpatient treatment. The perception of drugs for mental illness changed from ‘crude but useful restraints to cures for specific illnesses’.

She explores in detail the main classes of psychoactive drugs in current use -antipsychotics, antidepressants and mood stabilisers – describing their actions, effectiveness for the conditions they purport to remedy and side effects. Her painstaking analysis which forms the bulk of her book, I will summarise as follows.

Some psychoactive drugs are no more effective than placebo or no treatment at all and the cost in terms of impact on the patient makes their use questionable. The effects of many so called specific drugs such as lithium and antipsychotics are not easily indistinguishable from those of non specific sedatives. In some studies hospital readmission rates appear to be lower following placebo than active drugs. Long term treatment may produce the problems it was prescribed to remedy.

Some studies suggest drug treatment makes recovery more protracted and outcomes worse. Although outcomes for manic depression are not better now than before the introduction of lithium and other mood stabilisers lithium’s efficacy is ‘regarded as unquestionable’ even though it has not been shown to be superior to alternative, less toxic drugs. There appear to be withdrawal problems with all classes of psychoactive drugs which are often mistakenly assumed to indicate that the ‘illness’ is still present but may be evidence of bodily adaptation and even permanent brain damage. There are significant side effects from all psychoactive drugs such as Parkinson’s disease-like symptoms, cardiovascular damage, impotence, cognitive impairment and severe agitation which may lead to violence or suicide.

Moncrieff examines the ‘dopamine hypothesis of schizophrenia and psychosis’, lampooning the tautological arguments underpinning this and showing how other valid lines of enquiry have been overlooked. She takes a similar line with the monoamine / serotonin theory of depression for which there is little evidence and which has encouraged a widespread belief that taking pills to smooth out the ordinary ups and downs of life is normal and OK. She suggests their ready availability undermines the sense of self-efficacy that could be gained by facing adversity without drugs.

In support of her call for change, Moncrieff exposes how the hegemony of the disease-centred model has led to many important areas of research being neglected. Adoption of a drug-centred model would clarify the therapeutic value of a psychiatric drug according to its chemical nature, interaction with the brain and the particular quality of the abnormal state it produces. It would establish the range of global effects associated with different drugs including ‘side effects’ and other currently unquantified impacts such as the possibility of developing dependence or tolerance or permanent brain damage. It would provide a platform from which to weigh up the pros and cons of using psychoactive drugs and what role they should play in psychiatric treatment.

She bemoans the trend towards medicalising problems of living and believing our emotional problems originate in abnormal biological processes. She especially deplores the ‘problematisation of childhood’ where damage is likely to be much worse in a developing brain and personality. Invoking the work of Foucault, Szasz, Laing and other writers, she argues for understanding difficult behaviour, madness and distress in a broader, social context as meaningful responses to the challenges of being alive. She claims a drug-centred framework is suited to this approach as it allows the use of drugs to relieve psychological torment without having to attribute the problems to brain disease.

Being truthful about the nature of these drugs and adopting a more consultative approach with patients and their families would enable them to make an informed choice. Unless someone’s behaviour is seriously anti-social or criminal, they should be allowed to decide for themselves which is more tolerable – the effects of the drugs or their symptoms.

Moncrieff lays out the issues clearly and suggests constructive ways to make things better. I admire what she has done but I imagine it could seem idealistic and threatening to some sections of its target audience. If change comes at all it is likely to be slow given the vested interests involved. But maybe not, while writing this review I have heard of two new studies claiming that drugs for depression are mostly no more effective than placebo. The interesting and unexplored phenomenon here is the placebo effect.

I started reading this book with an open mind. I had not previously taken a position on the issue of psychoactive drugs but this book has convinced me that the next drug related scandal may be just around the corner.

1 Moncrieff uses various terms in common usage, while not accepting all their connotations, to avoid long winded descriptions or terms not easily understood. For similar reasons I have used her nomenclature.
2 psychoactive : possessing the ability to alter mood, anxiety, behaviour, cognitive processes, or mental tension; usually applied to pharmacologic agents.
3 the disease-centred model of drug action has been imported to psychiatry from general medicine, where most drug action can be appropriately understood in this way, a paradigm example being the use of insulin to correct diabetes