In this podcast (episode #439) and blog, I talk to clinical researcher and fellow at University College London Dr. Mark Horowitz, best-selling author, journalist and mental health advocate Robert Whitaker, and psychiatrist, researcher, professor and best-selling author Dr. Joanna Moncrieff about the serotonin myth of depression, the dangers of chronic anti-psychotic drug use, schizophrenia as a contract, the neurobiological mental health rabbit hole, what MRI and other types of brain scans can't tell us, creating a new mental health narrative, and so much more!
As mentioned in previous podcast interviews, Mark and Joanna are the leading authors of the groundbreaking study on the serotonin depression myth that recently made headlines around the world. As mentioned in my interview with Robert, my recent interview with Mark and my interview with Joanna, the chemical imbalance theory has been around for a long time. From the 1970s, drug companies and many mental health professionals have largely marketed psychiatric drugs as anti-psychotic, anti-depressive, or anxiolytic (anti-anxiety) — cures combating a particular disease, notwithstanding the lack of evidence for chemical imbalances or other pathologies related to mental illness.
As Joanna, Mark and their team note in their incredible systematic review in the journal Molecular Psychiatry on the serotonin theory of depression (alongside many other mental health professionals and advocates), the chemical imbalance approach is shaped by the assumption that symptoms of depression and other mental health issues are caused by a brain chemical abnormality, and that psychotropics like anti-depressants help rectify this abnormality and improve mental health.
Even though this hypothesis dominates the way we think about mental health, we have no evidence that it is the best way to understand mental issues, as Mark and his team point out. First, there is no strong evidence that mental struggles like depression, for example, are associated with any particular biochemical abnormality. Moreover, we do not know if the drugs we use work in this way, i.e. correcting biochemical imbalances. This is due to the fact that the mental health drugs we use are psychoactive. They cross the blood-brain barrier and change the normal state of the brain, which means they can change our feelings, thoughts, perceptions and even behaviors, just in the same way a substance like alcohol can (as Joanna discussed in our recent interview).
As the authors of the study point out, “the main areas of serotonin research provide no consistent evidence of there being an association between serotonin and depression, and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations”. If we do not have good evidence that psychiatric medications like antidepressants work by correcting or reversing a chemical imbalance in the brain that causes depression, it is important that we review the way we use these drugs, many of which may even cause chemical imbalances in the brain, and can have many negative side effects (like the ones Mark himself experienced) that, unfortunately, are often just assumed to be the result of the mental condition returning.
This chemical imbalance approach shaped by the assumption that symptoms of depression and other mental health issues are caused by a brain chemical abnormality, and psychotropics like anti-depressants help rectify this abnormality and improve mental health.
Although this hypothesis currently dominates the field of mental health and the public’s imagination, we have no evidence that it is the best way to understand mental issues and psychiatric drugs, as Robert writes about this in his books Mad in America and Anatomy of an Epidemic, and as Joanna talks about in her books The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment and A Straight Talking Introduction to Psychiatric Drugs: The truth about how they work and how to come off them.
We need to look no further than the chemical imbalance myth to see the need for changing the way we understand mental illness. Why? Many mental health professionals, including the American Psychiatric Association, in concert with pharmaceutical companies, have promoted the low-serotonin theory to the public long after it had been found to be without merit, despite knowing that “a long line of research [has] failed to find evidence supporting the low-serotonin theory of depression”, which Robert believes is valid basis for a class action lawsuit.
The fact that the chemical imbalance theory has long been shown as inadequate and is still promoted in mental health settings is unacceptable. As Robert points out in a recent article, “surveys in recent years found that 85% to 90% of the public believed that low serotonin was the cause of depression, and that antidepressants helped fix that imbalance”, which is a sign of mass deception in the field of mental health—this is medical fraud. It is not okay to lie to psychiatric patients for decades and just push this information aside as nothing important. It is the duty of doctors and other health professionals to let the public know the truth, and to stop spreading the myth of the chemical imbalance theory—we ought to be giving people enough information to make fully-informed decisions on whether or not to take these drugs for their mental wellbeing.
Many professionals, however, say that it doesn’t matter that the imbalance theory of depression is not true. As Joanna wrote about on her blog in response to the comments made when the systematic review was published, “many people, including many doctors and researchers, assume that the only way drugs can ‘work’ or affect people with mental health problems is by correcting an underlying abnormality- whether that abnormality is a chemical imbalance or something more complex. But there are other explanations for how drugs affect people.”
As Joanna discussed in depth in our recent interview and in her blog, “it’s important to remember that the majority of the effect of an antidepressant is due to a combination of the natural course of our moods and placebo (a pill that contains no active ingredient) effects. Randomized controlled trials that compare antidepressants and placebo are the basis for the use of antidepressants. It is evidence from these trials that regulating bodies like the United States FDA (Food and Drug Administration) and the United Kingdom’s MHRA (Medicines and Healthcare products Regulatory Agency) look at when they license a drug. It is what institutions like NICE (the National Institute for health and social Care Excellence) considers when it produces its guidelines and recommendations about how to treat depression. When you get all these trials together (as in this meta-analysis paper) they show that antidepressants are a little bit better than a placebo (an inactive sugar pill), but not much. People who take the placebo do almost as well. In fact, it is not certain that there is much difference at all, because there are methodological problems with these studies that may explain this small difference between drugs and placebo. These include the possibility that people on antidepressants have an enhanced placebo effect because some of them identify that they got the real drug due to side effects or other subtle changes, and this induces optimism, which helps with recovery. Read more about these concerns with antidepressant trials in this paper and this one.” Joanna also points out: “Other important points are that these trials are almost all conducted by drug companies, and the vast majority of them last only a few weeks. Many people end up taking antidepressants for months and frequently years, however, but there are very few studies of long-term use.”
Moreover, as mentioned above, these mental health drugs are psychoactive. This means that they cross the blood-brain barrier and change the normal state of the brain, which, in turn, means they can change our feelings, thoughts, perceptions and even behaviors, just in the same way a substance like alcohol can. You can read more about this here, here, here, and in Joanna’s amazing books The Myth of the Chemical Cure and A Straight Talking Introduction to Psychiatric Drugs.
As Joanna notes on her blog, “in the short-term, some [psychotropic] drugs may produce effects that are experienced as useful for people who in a state of acute distress or anxiety. Taking a drug that numbs emotions may provide short-term relief for someone who is deeply unhappy, fearful or confused”. However, “in the long-term, taking a drug that alters normal brain chemistry may have harmful effects. In fact, we know that antidepressants cause physical dependence. The brain alters to try and counteract the effects of the drug, and then when people miss a dose or stop taking the drug they experience withdrawal effects which are a consequence of the brain changes no longer being opposed by the drug. These can be severe and prolonged, especially if people have used the drugs for a long time and are of course well known in society in connection with alcohol use and other recreational drugs.” Joanna also points out that “long-term use of drugs that numb emotions may also have harmful psychological consequences because it may prevent people from finding other, potentially more lasting ways of managing their emotions. It may also prevent people from identifying and addressing the problems that made them depressed in the first place”.
We need to understand that the chemical imbalance theory is about more than just someone’s brain chemistry. It impacts their sense of self: how they see themselves. It tells someone that the problem mainly resides in their brain, and that there is something intrinsically wrong with their biology, which is a great burden to put on someone who is suffering, especially since there is no scientific evidence to support this hypothesis. This kind of mindset is also less likely to make someone think that their own efforts or anything besides medication can affect their recovery, which can impact their healing in the short and long term. Some people may find these drugs very beneficial in the short term; however, it is important to understand how these drugs can be dependence-forming in the long term.
It is important to understand that mental issues like depression are not as simple as a “brain disease”. Human brains and bodies are way more complicated than that. Of course, things are going on in the brain when people are feeling depressed. Everything we do is mediated by our brains, whether we are walking, working, feeling, eating, exercising and so on. This does not mean that we can fully understand depression at the level of the brain. Issues like depression are, at their core, an emotional reaction that is affected by our history, personal inclinations, and so on. It is, at its heart, a reaction to life circumstances mediated by our uniqueness. This means that, to understand mental issues like depression, we need to understand both the circumstances it is a reaction to and the individual’s personality, history and development (everything that has happened to them). One of the most important things we can do to help people who are depressed or battling with other mental issues is to find ways to empower them to address their unique life circumstances, not just give them a drug and send them on their way.
This is not to say that there is no such thing as severe depression or that people with depression do not suffer greatly, or even that psychiatric drugs do not work for some people over a set period of time. But, unfortunately, we do not have any good evidence that even issues like severe depression respond well to psychiatric drugs or other interventions just at the level of the brain.
Indeed, even though there is very little specific biological evidence that distinguishes the brains of people diagnosed with mental disorders and people that are not, much of current mental healthcare research and treatments are biased in the direction of the disease-centered approach. Research has fallen short of finding “the genes” responsible for mental issues like schizophrenia, for example, but countless dollars are still invested in doing these kinds of studies. Likewise, although much of the research done on brain abnormalities in people diagnosed with schizophrenia are used to “prove” that schizophrenia “shrinks” people’s brains, it has recently been shown that the antipsychotic drugs individuals diagnosed with schizophrenia take to treat it also affect brain volume and function. We now think that this reduction in brain volume is significantly (if not wholly) due to the effects these drugs have as they cross the blood-brain barrier, not just the fact that these individuals have been diagnosed with schizophrenia.
However, it is important to understand that no one should stop using psychiatric medications overnight. Withdrawal should always be done under the supervision of a qualified professional. Take your time, process the information in this podcast and blog, speak to those you trust and the appropriate medical professional. Read articles like Joanna’s excellent blog on What you need to know before starting a drug for a mental health problem.
As mentioned above, these drugs can alter brain chemistry, and withdrawal can be an incredibly difficult process. The brain adapts to the presence of these drugs. Even if we do not feel a “high” from a drug, this does not mean we cannot become dependent on it.
Like Mark notes, “no one should stop their antidepressant medication abruptly—this can be dangerous and is known to cause withdrawal effects, which can be severe and long-lasting in some people, especially those using the medications long-term. If anyone is considering this choice…discuss it with your doctor and, if you go ahead, to undertake a gradual and supported reduction as advised by recent Royal College of Psychiatry guidance.”
There are ways to withdraw from psychiatric drugs safely, which Mark has written extensively about including in a recent paper about how to come off antidepressants, although this should always be done under the guidance of an appropriate medical professional.
When withdrawing, there are several key points to consider:
- Come off psychiatric medication SLOWLY under the guidance of a medical professional.
- Go down in SMALL AMOUNTS. It is very important to understand that very small amounts of any kind of psychiatric medication can have large effects on the brain.
- It is important to note that with psychiatric drugs you can reduce higher doses a lot quicker than lower doses. For lower levels, people often use tapering strips or liquids to reduce the drug by very small amounts over time. This is why it is important to make smaller and smaller reductions over time as you get down to lower doses (by proportion), based on the effect these doses have on the brain.
- It is necessary to take a flexible approach as everyone’s situation and past history is different, and avoid switching between certain drugs as much as possible.
- There are different ways to decrease doses, which should be done under the guidance of a medical professional. These include dividing tablets, using a liquid version of the drug and a syringe, and using compounding pharmacies to order smaller doses or tapering strips.
There are also great sources of information like Mad in America, Rxisk, ISEPP and other patient-run websites (like the kind Mark mentions) that seek to provide people with helpful information and address all parts of the human experience, not just our neurobiology.
For more on creating a new mental health narrative, listen to my podcast episode with Mark, Joanna and Robert (episode #439), and check out their incredible work.
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5:20, 31:40 The low serotonin myth of depression & the study that everyone is talking about
13:45 The origins of the chemical imbalance theory & why it became so popular
19:00, 21:35, 28:00 The great psychiatry fraud
22:30, 25:30 How psychiatric drugs affect our brain chemistry
23:50 Why pharmaceutical companies changed the drug narrative
25:40 What the pharmaceutical company trials do not tell us
39:40 What we aren’t told & why
42:20 It is not just “Big Pharma”: why the media should be criticized as well
50:00, 54:25 What we get wrong about schizophrenia
51:58 The myth that anti-psychotics correct an underlying chemical imbalance
1:02:00 The long-term impact of psychiatric medication
1:11:50 Why brain scans cannot diagnose mental disorders
1:16:20 How to safely withdraw from psychiatric drugs
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