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Psychopharmacology
Joanna Moncrieff on The Myth of the Chemical Cure
On the future of mental health.
Posted February 12, 2016 Reviewed by Ekua Hagan
The following interview is part of a “future of mental health” interview series that will be running for 100+ days. This series presents different points of view about what helps a person in distress. I’ve aimed to be ecumenical and included many points of view different from my own. I hope you enjoy it. As with every service and resource in the mental health field, please do your due diligence. If you’d like to learn more about these philosophies, services, and organizations mentioned, follow the links provided.
Interview With Joanna Moncrieff
Joanna Moncrieff makes a clear distinction between a disease-centred model of drug action, where actual diseases exist and are being treated, and a drug-centred model of drug action, where chemicals with powerful effects are employed to produce certain effects (as often negative as positive). She argues that the former is what the current, dominant paradigm purports to be engaged in and that the latter is what is actually going on, much to the detriment of many of “medication” for “mental disorders.” Here is Joanna Moncrieff on this important subject.
EM: Your first book was The Myth of the Chemical Cure. Can you tell us a little bit about its top points or findings?
JM: There is an assumption that the drugs prescribed for mental health problems work by targeting and reversing an underlying chemical imbalance (or some other brain abnormality). What I wanted to tell people in this book is that there is no evidence that this is the case, and that there is an alternative way of understanding what drugs do which is much more plausible.
I called these two ideas the "disease-centred" and "drug-centred" model of drug action. The disease-centred model is the idea that the drugs target an underlying disease or abnormality; the drug-centred model is the idea that drugs exert psychoactive (or mind-altering) effects in everyone regardless of whether or not they have a psychiatric diagnosis. These effects can interact with the symptoms of mental distress. For example, antipsychotic drugs dampen down thinking processes and emotions because they have a generalised inhibiting effect on the nervous system. This is what appears to reduce psychotic symptoms, not the targeted reversal of underlying chemical imbalances.
In this book, I look at the history of the disease-centred model of drug action and how its development was driven by the vested interests of the psychiatric profession, the pharmaceutical industry, and the State. I demonstrate the lack of evidence for this model for every major class of psychiatric medication, including antipsychotics, antidepressants, "mood stabilisers" and stimulants. I flesh out the nature of the mind-altering effects of these different drugs and the implications for their use in clinical practice.
EM: Another of your books is The Bitterest Pills: The Troubling Story of Antipsychotic Drugs. How does that differ from The Myth of the Chemical Cure, and what top points from it would you like folks to know?
JM: In The Bitterest Pills, I look at the history of antipsychotic drugs, from their "discovery" and introduction into psychiatry in the 1950s, to the massive expansion in prescribing that has occurred over the last 10 years. In the 1950s, antipsychotics were regarded as special sorts of tranquilisers, drugs that worked by inhibiting and restricting the nervous system. This idea gradually got forgotten, however, and got replaced by the view that they are sophisticated treatments that target an underlying brain disease. In other words, they came to be understood according to the disease-centred model of drug action, although there was never an evidence base to support this.
This way of understanding antipsychotics has produced a rosy-tinted view of their effects. Evidence of serious adverse effects, including tardive dyskinesia (a neurological abnormality), brain shrinkage, and diabetes, has been suppressed or glossed over. On the other hand, evidence of their benefits, especially for long-term treatment and early intervention has been over-stated. The book also describes the recent epidemic of prescribing antipsychotics for bipolar disorder and looks at the role of the pharmaceutical industry in driving this expansion. Concerns are raised about the level of adverse effects this pattern of prescribing is likely to produce in the future.
EM: You are a practicing psychiatrist. How would you like to see psychiatry change?
JM: Firstly, I think psychiatry is trying to address problems which it has no hope of helping. The misery that is caused by social problems, poverty, unemployment, difficult relationships, and social isolation cannot be helped by drug treatment, like antidepressants. National governments and local communities need to address these problems, and people need to understand that they are not illnesses, and will not be magicked away by medication.
For more severe mental conditions like psychosis, what I would like to see is facilities and services that can provide alternatives to drug treatment so that people have more choice. Drug treatment can be useful when someone is acutely unwell, but even then, some people will recover without it, if they are in a supportive environment. I am particularly concerned about long-term medication, however. I would like people to have the option to try without it, if they want, with the support of mental health services, rather than feeling obliged to take it forever.
EM: What are your thoughts on the current dominant paradigm of “diagnosing and treating mental disorders?"
JM: The idea of diagnosis is misleading. The DSM and ICD are classification systems, not diagnostic systems. They are attempts to organise the myriad of mental health "symptoms" or problems into categories, based on our experience of the sort of patterns that people manifest. Classifications do not indicate the causes of conditions; they are merely a way of organising experience, and they are highly subjective. Mental health problems are highly individual, so there is no universally valid or useful way of classifying them. Pre-determined categories do not capture the essence of a particular individual’s problems, and rarely tell you much that is useful.
The problem with our current approach to treatment is that it is presented as targeting a putative underlying brain disease or abnormality. It is based on a presumption that drugs act according to the disease-centred model of drug action. Therefore we have ignored the psychoactive (mind-altering) properties of the drugs we use. We should have a greater knowledge of all the alterations that drugs produce in body and mind. The psychoactive properties of some drugs may be useful in some situations, but they can also be unpleasant and disabling, and this is not recognised widely enough.
EM: If you had a loved one in emotional or mental distress, what would you suggest that he or she do or try?
JM: It completely depends on the nature of the problems. I do not think it is useful to have a blanket approach to mental health problems, or even to single disorders or diagnoses. Everyone with a diagnosis of depression will have a different set of problems, for example, and a different story leading up to those problems. It is the individual’s unique problems, and not a diagnostic label, that should determine what sort of help will be useful. That help may involve practical support to address social and interpersonal difficulties, it may include therapy to help the individual identify the origins of their feelings and develop strategies for managing them better, and it may sometimes include drug treatment to reduce the intensity of pre-occupying thoughts or feelings of distress.
Joanna Moncrieff is a Senior Lecturer at University College London and also works as a consultant psychiatrist in the NHS in London. Her academic work consists of a critical appraisal of drug treatment for mental health problems, as well as work on the history, philosophy, and politics of psychiatry and mental health. For information on and/or to purchase The Future of Mental Health, visit here.
To see the complete roster of 100 interview guests, please visit here.
