Antidepressants and the myth of the "chemical imbalance"

Psychiatrist Dr Joanna Moncrieff says “often there are better ways to deal with things” than taking drugs.

IT IS ONLY AFTER AFEW SECONDS into my conversation with Dr Joanna Moncrieff, a psychiatrist based in London, UK, when her fresh perspective on psychiatry strikes me.

“I think mental illnesses are more like aspects of our personality than they are illnesses that come over us. People can struggle with their feelings and behaviour, but usually they can learn ways to manage and deal with them. Sometimes that might involve taking drugs, but often there are better ways to deal with things.”

The British psychiatrist is a leading figure in what is known, broadly speaking, as the critical psychiatry movement. As the author of several books including The Myth of the Chemical Cure, Dr Moncrieff is a prominent critic of the modern “psychopharmacological” approach to treating mental health challenges.

Dr Joanna Moncrief

She is in Vancouver next month as the keynote speaker at a conference for BC physicians and pharmacists, and agreed to speak with me in advance of her trip. Our wide-ranging discussion delved into how society uses an array of psychiatric drugs including antipsychotics, drugs for ADHD, and antidepressants.

It is the latter class of drugs—antidepressants—that I want to focus on, particularly because I want to try to understand one simple fact: why are so many of us taking them? A study released this August found that 8.8 percent of Canadians between the ages of 40 and 79 took an antidepressant in the last month. In the US, that number is 15.4 percent. When you tease apart the utilization data on these drugs, you find women are twice as likely as men to be on an antidepressant. In British Columbia, close to 20 percent of women between ages 19 and 55 are taking an antidepressant. Canadian data from 2016 found that 60 percent of seniors in long-term care are on antidepressants (compared with 19 percent of seniors living in the community). With a bit of census data and some quick math, I roughly calculate that in Greater Victoria alone, there are close to 30,000 women under 65 who are taking an antidepressant.

Let’s be clear, depression can be serious and debilitating, and there should be no stigma associated with taking an antidepressant or on any drug that is helpful; yet at the same time, these kinds of statistics raise many questions. If one in five women in Victoria are on an antidepressant, why? Is depression really as widespread as the drug stats might indicate? Does this really indicate that a lot of people are medically sick and receiving an effective treatment, or are we medicalizing the ordinary difficulties of life? To be fair, antidepressants are prescribed for a variety of things, including anxiety, obsessive compulsive behaviour, premenstrual symptoms, and panic disorder, among others. But most of their use would likely be linked to persistent sadness and hopelessness.

I asked Dr Moncrieff how we arrived at this point. She quickly pointed to a number of factors, particularly that taking mood-altering drugs is not a new phenomenon. For nearly half a century, women especially have been plied with drugs such as benzodiazepines or barbiturates for anxiety and depression. One way to explain this, she said, is that “women might be more likely to internalize their distress. Men are more likely to get angry and drink. Men are likely to blame outwardly.”

As for the statistics, she’s as astonished as I am: “It’s extraordinary, isn’t it? It’s an indicator of a number of factors—there are a pool of people whose lives are miserable, who go to the doctor looking for a solution; years ago they would have been put on a benzo, or a barbiturate, and so on.” She noted some people do seek a chemical solution to their problems—but, she added, “this view reflects the huge marketing efforts that happened in the 1990s.” This coincided with the first Selective Serotonin Reuptake Inhibitor (SSRI) type of antidepressant, Prozac, coming into use. In her estimation, when it became apparent that benzodiazepines like Ativan, Valium or Xanax “were being handed out like sweets, that’s when the drug industry came up with this idea of the chemical imbalance, in association with launching the new SSRI antidepressants.” Prozac was followed by other drugs intended to alter serotonin in the brain, like Zoloft, Paxil, Effexor and others.

The “chemical imbalance” theory is one of the biggest controversies in psychiatry; it is often hauled out to explain a person’s depressed mood, and how a drug which tweaks the level of serotonin in the brain might actually help. The problem is that there is little, if any, proof to support such a theory. “The evidence for a link between serotonin and mental illness is all over the place,” said Dr Moncrieff. “The idea that psychiatric drugs are tweaking some underlying abnormality is completely misleading,” yet this hasn’t stopped these drugs from becoming the mainstay treatment for depression.

The automatic prescribing of antidepressants, in Moncrieff’s opinion, is fraught with problems. “If you tell a person going through depression that they need a drug, you are giving them a message that they are biologically abnormal. Not only are drugs chemicals that interfere with normal biological responses,” she says, “the ‘chemical imbalance’ idea is also disabling. It often ends up with the patient trying one, then another, then another different drug. They just end up being on a cocktail, because none of them actually work,” she said.

While some sorts of psychiatric drugs can help some people some of the time, Moncrieff believes other factors are likely leading to society’s over-reliance on antidepressants. As Jiddu Krishnamurti famously said: “It is no measure of health to be well-adjusted to a profoundly sick society.” There is no shortage of adverse societal influences causing many of us to feel anguish and despair. Dr Moncrieff’s UK perspective includes “things such as austerity, following the financial crash in 2008—and a general income drop in the last few years—that has likely created a genuine large amount of distress and misery.” And let’s not forget more recently that her country has been dealing with the deep uncertainty caused by Brexit, undoubtedly adding anxiety to peoples’ lives.

While it might be understandable why so many people are initially put on antidepressants, the question arises, how come so many people stay on them for the long haul? Part of this has to do with dependence. As Joanna Moncrieff says, “Some antidepressants are very difficult to get off—many people don’t realize they have withdrawal symptoms. They try to stop, and they think they have a relapse, and it confirms their status as a patient.”

Moncrieff agreed the very mention of “withdrawal symptoms” associated with SSRIs is controversial. Earlier this year, a newsletter produced for BC doctors and pharmacists by the Therapeutics Initiative was attacked by a vocal Vancouver psychiatrist who dismissed the seriousness of the withdrawal effects of SSRI antidepressants.

Yet the notion of dependency is gaining traction. Moncrieff cited a recent high-profile example published earlier this year in the medical journal The Lancet. Author Mark Horowitz wrote: “All classes of drug that are prescribed to treat depression are associated with withdrawal syndromes. SSRI withdrawal syndrome occurs often and can be severe, and might compel patients to recommence their medication.” Patients have reported such symptoms as nausea, headache, dizziness, chills, body aches, paresthesias, insomnia, electric-shock-like sensations, panic attacks, dramatic mood swings, suicidal thoughts, and exhaustion. Horowitz’s coauthor, David Taylor, the director of pharmacy and pathology at a London hospital, described his own withdrawal from Effexor as a “strange and frightening and torturous” experience that lasted six weeks in a recent New Yorker article. Instead of denying the existence of withdrawal symptoms, these two authors make a strong case for tapering antidepressants very slowly.

Among the known side effects of antidepressants are those affecting sexual function. Dr David Healy, a psychiatrist from Wales, runs a website that tracks the effects of SSRI antidepressants (RxISK.org) and other drugs. For many years, he has been collecting data from real-world patients who reported losing their sexual function even after stopping their antidepressant. Healy has used these data to petition the European Medicines Agency to put a warning about persistent sexual dysfunction on these drugs. Moncrieff, who is very familiar with this literature, reminded me that often the studies on antidepressants are simply too short to detect the effects such as long-term sexual dysfunction.

In terms of SSRIs’ effectiveness on depression, Moncrieff said, “sometimes [patients] feel better, sometimes they don’t.” With her own patients, she said, “I couldn’t convince myself that antidepressants were having any significant effect. Some have said they’re basically active placebos.”

A large meta-analysis (a summary of a large number of studies in the same area) published last year was reported extensively in the media with the message “antidepressants do work!” But Dr Moncrieff found many flaws. “They looked at response rates which inflate the actual effects, [whereas] if the results are looked at in the usual way, the analysis showed a very small and clinically irrelevant effect.” Moreover, she pointed out, in this meta-analysis, “an awful lot of those studies were withdrawal studies.” They studied people who were on antidepressants, comparing those who continued on their regimen to those who were switched to a placebo. So instead of measuring the effects of the SSRIs, they were finding that those switched to the placebo were doing worse—probably because they were suffering withdrawal symptoms.

Moncrieff has a different approach to mental illness and its treatments than many other physicians. She spends a lot of time helping patients get off psychiatric drugs, but also trying to avoid putting patients on them in the first place. She told me most cases of depression “are responses to things that happen in people’s lives—and we need to figure out ways to help people to manage or address their problems—it’s dealing with the causes.” She mentioned a number of options—CBT (cognitive behavioural therapy), exercise, and mindfulness training, among them—that enable people to manage their mood or anxiety in a non-drug way.

When a patient says, “I’ve done all those things and nothing works,” she recommends physicians discuss with those patients the evidence on antidepressants, how there is little to support their effectiveness, as well as the pros and cons of medication. She said that if antidepressant medication is prescribed, it should be viewed as a short-term measure, one which needs constant review and a willingness to stop.

This is the evidence-based message she’ll be bringing to BC doctors in Vancouver on October 5 at a conference sponsored by the Therapeutics Initiative (see www.ti.ubc.ca).

Alan Cassels is a drug policy researcher in Victoria.