"Chemically Imbalanced": An Interview With Joanna Moncrieff

Close to one-in-six American adults is currently prescribed an antidepressant. A serotonin, or “chemical,” imbalance hypothesis remains one of the key justifications for antidepressant use. But many are now questioning whether the term chemical imbalance is sufficiently explanatory, asking whether antidepressants resolve a chemical imbalance or risk creating one. I recently spoke to Joanna Moncrieff, author of Chemically Imbalanced, about avoiding neuro-reductionism and thinking about mental states in ways that aren’t disempowering.

Chris Lane: Recent surveys you’ve quoted indicate that 85-90 percent of the American public believes low serotonin or a chemical imbalance causes depression and other mental states; the percentages are strikingly similar in Australia and the United Kingdom. Not unrelated, though spiked by the pandemic, antidepressant prescribing in the United States increased by 34.8 percent over six years, reaching 83.4 million in 2021-22. Why do you think the chemical imbalance metaphor has been so popular and resilient, even as its supporting evidence was always quite flimsy?

Joanna Moncrieff: I would credit the massive marketing campaigns of the 1990s and 2000s, undertaken by the pharmaceutical industry, and aided and abetted by the psychiatric profession. The chemical imbalance message is particularly useful because it suggests that people with depression need a chemical intervention. So it helped overcome people’s natural caution about using drugs to manage emotional problems. The message also had intrinsic appeal because it seems to provide a simple explanation and solution for complex and varied problems. As the saying goes, “For every complicated question, there is an answer that is clear, simple, and wrong” (H. L. Mencken).

CL: The systematic umbrella review you led in Molecular Psychiatry has drawn more than a million reads; yet, in a recent article about it, you’re quoted as saying: “I am perplexed at why this story has been taken up by the right-wing media more than the left.” You and I are just a few months apart and grew up in a Britain where the Left dominated the medicalization debate by tying it to empirical problems with diagnosis and overprescribing, to adverse events and withdrawal problems from polypharmacy. These days, some corners of the Left are more likely to accuse you of “pill-shaming” them. What accounts for that shift, and how might we address it?

JM: It’s complicated. Partly, the Left is responding to the fact that many more people are embracing the identity of “having a mental health condition,” and it sees its job as championing the rights of people with minority identities. Also, as the Establishment (at least in the United Kingdom) has become more left-leaning, the Left (or parts of it) no longer sees itself as challenging the status quo, but as defending it.

CL: What do you think right-wing media discovered in the results that, for years, the same outlets on both sides of the Atlantic managed more or less completely to ignore?

Source: Courtesy of Flint Books

JM: The Left’s embrace of what I might call “extreme identity politics”—including the medicalization of emotional problems—left a vacuum for critique that the Right has stepped into. When I was studying, it was the Left that led the charge against medicalization. The Left highlighted how the personal, emotional consequences of capitalism were neutralized by medicalization. There were right-wing critics, too, such as Thomas Szasz, who, like contemporary right-wing critics, argued that Western states create and reward dependency by labeling it as sickness. But they were the minority.

The public embrace of the medical identity is a strange mirroring of traditional medicalization. In the latter, the problem is regarded as a “pathology” that medical “treatment” is intended to correct. The new attitude to mental health, spearheaded by the neurodiversity movement, suggests that though the problem is neurological in origin and therefore beyond the individual’s capacity to change, it is not something that necessarily needs to be corrected. It is something that other people need to adjust to.

CL: That’s fascinating. If blanket opposition to the medicalization of emotional problems has licensed the Right to critique overprescribing, what’s a comparable remedy for a progressive approach?

JM: I think the solution is to go back to basics, to clarify what “mental health problems” actually are. They are not diseases; they are patterns of behavior that make life difficult for the person affected and the people around them. When we recognize this and stop obsessing over brains, we may appreciate more fully the social and political implications of what we call “mental illness” or “disordered” behavior. Judgments about behavior depend inherently on context. Hyperactivity is problematic in the classroom but might be advantageous on the football pitch. The conservative response is to send depressed people to the doctor and medicate children into passivity. The radical response: to try to change the school system so that everyone can flourish. Depression is almost always a reaction to depressing circumstances, whether that is poverty, abuse, or lack of meaning.

CL: The importance of invigorated agency returns at the end of Chemically Imbalanced, in that avoiding neuro-reductionism provides space to think about depression, anxiety, and other mental states in ways that aren’t disempowering—as a reaction, as you say, to adverse circumstances, tied to environment, poverty and financial stress, family and relationship dysfunction, social dynamics, and a host of other factors. Some of your colleagues view this as insufficient—as failing to grapple with the biological complexity at stake. What’s your response to those who imply that you’re conflating being depressed with feeling stymied or trapped?

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JM: My response is that no biological mechanism has been established to underpin any sort of depression, whether that is very severe depression or more recognizable and relatable low mood. And that even cases of severe depression, as occur most typically in the elderly (and used to be called “involutional melancholia”), are usually reactions to loss or hardship such as bereavement, retirement, or loneliness. As you say, viewing depression as a meaningful reaction to life circumstances highlights how people can use the experience to adjust their lives in positive ways and to become more resilient.