In this podcast (episode #383) and blog, I talk to psychiatrist, researcher, professor and best-selling author Dr. Joanna Moncrieff about critical psychiatry, the difference between a drug-centered and disease-centered approach in the field of mental health, the history of psychiatry, withdrawal from psychotropic drugs, the dangers of medicalizing misery, the myth of chemical imbalance, the potential downsides of using psychedelics to treat mental health, and so much more!
Joanna calls herself a critical psychiatrist. This means that she doesn’t sign on to the mainstream view of psychiatry, which claims that all mental disorders are the same as brain diseases that need to be treated with drugs, ECT and other interventions that focus on physiological or biochemical symptoms.
Human beings come in all shapes and sizes—we are all different. This means we have a huge range of assets, but also a huge range of problems and difficulties. It is not helpful to just call these issues a disease or think of them in solely medical terms, unless we are convinced, by a good body of evidence, that there are specific abnormal brain issues present. Everything we do is reflected in our brains. We need to distinguish brain activity that goes along with everything we do from a neurological disease like a brain tumor. But we are also more than just our biology; everyone’s mental health issue is unique to them on a social, spiritual, biological, psychological and spiritual level.
Of course, saying a mental health issue is not a neurological disease doesn’t mean that there is nothing happening in the brain. It also doesn’t mean that we do not influence what happens in the brain by both what we do and how we live and, sometimes, by taking certain drugs.
Joanna discusses this difference in depth in her book The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment. As Joanna points out, the current disease-centered approach claims that symptoms of depression are caused by a brain chemical abnormality, and psychotropics like anti-depressants help rectify this abnormality and improve mental health symptoms. This hypothesis currently dominates the field of mental health, yet we have no evidence that it is the best way to understand mental issues. First, there is no strong evidence that depression, for example, is 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.
Joanna takes a different approach—what she calls the “drug-centered” model. This centers around understanding what prescribed psychiatric medication is doing in the brain and body, and how it is changing the state of the brain like a substance such as alcohol does. We need to understand the kind of alterations these drugs make and factor them out of the equation—we cannot simply say that they are targeting and “correcting” a hypothetical biochemical imbalance.
For example, benzodiazepines are currently used to treat anxiety. These drugs, when given to someone in a high state of arousal, can help calm down the brain and body. Yet they also do the same for someone who is not anxious—they alter the brain by reducing brain activity. There is no strong evidence that these psychoactive drugs are “curing” anxiety.
To understand psychoactive drugs and their use in mental healthcare, we first need to understand their general effects in people, including individuals who do not have anxiety or symptoms of another mental issue.
Yes, some people may see these mind-altering effects as an improvement, but not everyone. It is also important to consider the negative outcomes that often occur when a person comes off these drugs—withdrawal symptoms can be incredibly traumatic and last for a long period of time.
Unfortunately, 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. For instance, research done on brain abnormalities in people diagnosed with schizophrenia has often been used to “prove” that schizophrenia “shrinks” people’s brains. Yet it has been shown that the antipsychotic drugs individuals diagnosed with schizophrenia take to treat also affect brain volume and function. Based on this new research, 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.
Additionally, it is important to point out that the trials that supposedly establish the “fact” that psychiatric drugs are effective acute treatments are placebo-controlled trials. This means that psychoactive drugs are compared to an inert placebo tablet that doesn’t have any noticeable mind or brain effects. Researchers are not distinguishing whether the drug hypothetically “cures” the purported underlying basis of the disorder or is having specific mind-altering and brain-altering effects (the drug-centered model mentioned above).
These trials show the psychoactive drug does something different to the placebo, a feeling which can be enhanced when people in the trials realize they are taking a psychoactive drug. People’s expectations of what treatment they get can have a powerful effect on their outcomes, which is something we do not often consider when it comes to psychiatric medications. These placebo trials are not properly double-blinded, and as such we should not be placing so much trust in the interpretations of the results and any healthcare treatments based on these interpretations.
In fact, even when these trials show a positive effect when the drug is taken, this is not significant in the long term. In a large 2018 meta analysis, for example, the difference between taking an anti-depressant and placebo was incredibly small, and of doubtful clinical value.
There are also many issues surrounding the research on psychiatric drug withdrawal, as Joanna discusses in detail in her book A Straight Talking Introduction to Psychiatric Drugs: The truth about how they work and how to come off them. People usually don’t take these psychoactive drugs for a few days or weeks. They generally take them for months or years, often based on research done on the long-term effects of psychiatric drugs like anti-depressants, called “relapse prevention trials”. These trials look as if they are examining the benefits of long-term treatment, but what they are actually doing is enrolling people that have already been using these drugs for years, then randomizing them to either continue the treatment or be weaned off (usually very quickly) onto the placebo. The latter group often experience intense withdrawal effects, since these drugs alter brain function and chemistry. However, in the trials, these withdrawal effects are often assumed to be because of the “brain disease”. This can make someone feel terrible or believe that there is something intrinsically wrong with them, even though what these research studies are actually studying is not the benefit of long term treatment but the adverse effects of withdrawing from these psychoactive medications quickly. Very few studies try to wean people off these drugs gradually, and even these still have a risk of significant withdrawal effects that bias the clinical data.
The longer someone is on these drugs, the greater chance that their withdrawal effects will be more significant and last longer. In Joanna’s blogs, she points out that this is why it is so important to understand how these drugs affect the mind and brain, so that you are more empowered to know what choice will be best for you and your unique circumstances. 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.
There are ways to withdraw from psychiatric drugs, although this is best done under the guidance of an appropriate medical professional. 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. It is important to take a flexible approach, and avoid switching between certain drugs, especially anti-depressants, as much as possible. (Anti-depressants are often quite different from each other.)
Joanna uses these methods in her London clinic, which she is hoping to expand into other areas of the UK and perhaps the world. Joanna and her team also want to try to set up a peer-support group to help other people trying to withdraw and find hope. Thankfully, there are also great sites like Mad in America, Rxisk, ISEPP and other patient-run websites that seek to provide people with helpful information and address all parts of the human experience, not just our biology.
For more on psychiatry, withdrawal and managing mental health, listen to my podcast with Joanna (episode #383), and check out her amazing work. If you enjoy listening to my podcast, please consider leaving a 5-star review and subscribing. And keep sharing episodes with friends and family and on social media. (Don’t forget to tag me so I can see your posts!).
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2:40 Joanna’s incredible work
3:11 What critical psychiatry means & why Joanna calls herself a critical psychiatrist
5:36 Everything we do is reflected in our brains
6:30 The difference between a drug-centered & disease-centered approach to psychiatry
14:05 Research bias & common misconceptions in mental healthcare
16:00 Mental disorders are not associated with specific or identified brain abnormalities or processes
16:40 The failures of psychiatric drug trials
18:00 The power of the placebo effect & people’s expectations
19:45 The issues surrounding psychiatric drug withdrawal research
29:00 Withdrawing from psychiatric drugs
33:10 How the science is changing
35:00 Joanna’s NIH clinic for withdrawal
38:20 Methods to withdraw from psychiatric drugs
52:30 WHO studies on schizophrenia outcomes in different countries around the world
55:30 Why we need to re-evaluate at how we understand mental health
58:40 Psychedelics & mental health
This podcast and blog is for educational purposes only and is not intended as medical advice. We always encourage each person to make the decision that seems best for their situation with the guidance of a medical professional.
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