Around one in eight adults in England – or 8.3 million people – is on antidepressants, a figure that has risen by over 20 per cent in the past five years. Many would say the medication has eased their suffering; Joanna Moncrieff, a professor of social psychiatry at University College London and an NHS psychiatrist, believes they have been sold a lie.
Her work made headlines last summer when she published a review in Molecular Psychiatry concluding there is “no evidence” that depression is caused by low serotonin levels. Moncrieff had identified a gulf between professional and public understanding – around 80 per cent of people believe depression is caused by a chemical imbalance – but she also wanted to make a bigger and more controversial point about how antidepressants do, and don’t, work.
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She argues that, given how little we know about the biology of mental illness, there are no targeted, disease-specific drugs; antidepressants are closer in nature to alcohol. They do not rectify an underlying brain malfunction, but rather change how you think or feel. “Those changes are superimposed onto whatever someone is thinking and feeling at the time. We even have an expression for this with alcohol: we talk about ‘drowning your sorrows’,” Moncrieff said, when we met in her spartan shared office at UCL. “If you recognise that’s what the drugs are doing, then it immediately becomes obvious they are not going to be a long-term solution and they might be harmful.”
Moncrieff is a leading figure in critical psychiatry, a movement that rejects mainstream psychiatrists’ medical approach to mental illness. Her books The Myth of the Chemical Cure (2007) and The Bitterest Pills (2013) argue that faulty science and corporate greed have led to psychopharmaceuticals being mis-sold and massively overprescribed, and are central texts in the movement.
When she sees her patients, she does sometimes prescribe drugs. In the short term, she finds sedatives can help those who are agitated and can’t sleep, and antipsychotics can be useful too. “But I’m not convinced that antidepressants have any use,” Moncrieff told me.
She said clinical trials have shown the effectiveness of antidepressants over placebos is so small as to be clinically insignificant. Even this, she argued, can be explained by an enhanced placebo effect, since the side-effects from antidepressants (drowsiness, nausea, loss of libido) mean subjects can tell when they are in the treatment group. Most trials run for a few months, and can miss the longer-term aspects of antidepressant use, like withdrawal symptoms or the fact that depression often improves within six months without intervention.
Does she acknowledge that her views could seem dismissive to the millions who believe antidepressants help them? “Just because something’s painful and scary doesn’t mean you should keep information from people,” she said. “Also, there’s nothing to be ashamed of if you had a placebo response… It’s not because people are gullible or stupid.” She emphasised that anyone considering stopping antidepressants do so only with the support and guidance of a doctor.
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Moncrieff is 57, a slight figure with a mop of wild curls. She drank peppermint tea and spoke softly, but she was unequivocal in her views. Does it matter how these drugs work? If a placebo helps people feel better, why not give it to them? “The problem is the placebo effect is good for the short term, but believing a pill got you better is probably not good for the long term,” she said: it prevents people from recognising the changes in their life or outlook that played a role in their recovery.
“I think what [Moncrieff] is doing is very important, to challenge the evidence and ask questions that are key for clinical practice,” Andrea Cipriani, a psychiatrist at Oxford University, told me when I phoned him for his perspective. In 2018 Cipriani led the largest ever review of antidepressant effectiveness, which found all 21 drugs it included were more effective than placebos. “My interpretation is the effect of the active ingredient of the antidepressant, as opposed to a sugar pill, is not big – I agree,” he said, but it is clinically significant: on average 55-60 per cent of people respond to antidepressants (experiencing a significant reduction in their symptoms), while 35-40 per cent respond to placebos. He emphasised there is huge individual variation: the challenge for psychiatrists is to get better at identifying who will benefit, and from which drugs.
Cipriani challenged the view that antidepressants don’t work long term, pointing to a 2021 study in the New England Journal of Medicine which found that patients who gradually come off the pills after taking them for a long time are more likely to relapse than those who remain on the medication. He said we need more nuanced conversations about psychiatric treatments, in part because the debate over their effectiveness has become so ideological – and so heated. After the 2018 review, he received threats against him and his family.
Moncrieff is used to strong criticism from colleagues, but says she’s seen a shift in recent years. A critic of the Covid vaccine mandates (she was sceptical of the trial data and opposed to coercive measures), she believes the pandemic created a new atmosphere of intolerance for scientists with heterodox views. “It became OK to cancel scientists. Scientists who weren’t toeing the line were attacked and vilified,” she said. She noticed a similar climate in the wake of her serotonin study. “Some of the articles were putting forward the view that it’s off [limits] to criticise antidepressants, that this is an area of scientific debate that shouldn’t be allowed to be had,” she said. “I think Covid enabled people to say that.”
Moncrieff has been a dissenter her entire career. As a student in the Nineties she felt greater affinity with earlier figures such as RD Laing and Thomas Szasz, who saw mental illness as a political and social construct, than with colleagues who believed that advances in brain science would yield new cures. While working for the Institute of Psychiatry in London she joined a reading group with like-minded peers – “We were all quite left-wing and a bit rebellious” – that in 1999 merged with a group in Bradford to become the Critical Psychiatry Network. The network, of which Moncrieff is co-chair, now has over 400 members.
“The pharmaceutical industry and the medical profession have coached the population for decades that there is a medical solution to various crises in life – and I think we need to uncage people because that’s simply not true,” Moncrieff said. “We need to find more non-medical ways of supporting people through crises.” Rather than viewing depression as an illness, she wants people to see it as a “mood state”: “Mood states are related to emotions, and moods and emotions are the way that human beings, which are complex, intelligent organisms, respond to events in their environment. Depression is by definition a reaction to a state that someone doesn’t want to be in, to something that’s gone wrong in someone’s life, or a stressful situation.”
Moncrieff’s critics point out that her views are popular with the American far right and Scientologists. “That’s life, isn’t it? Sometimes you share views on some things with people whose views on other things you don’t agree with,” Moncrieff said. “Just because the Scientologists… have these views about mental health doesn’t mean I should drop them.”
Another group with whom her views resonate is the growing community of people who say they have been harmed by psychiatry and are agitating for change. Their perspective is more “powerful” than hers, she said, and she was “hopeful” for the future. “But,” she added, “there needs to be a political move to demedicalise the whole mental health arena and that’s going to be very, very difficult.”
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This article appears in the 03 May 2023 issue of the New Statesman, Beneath the Crown