This Psychiatrist Says Chemical Imbalance is a LIE

For decades, patients were told their sadness was caused by a chemical imbalance, and a pill could fix it. Depression may be related to an imbalance of natural chemicals between nerve cells in the brain. Prescription Zoloft works to correct this imbalance.

But today, I'm speaking with the psychiatrist who dared to say that story was never true. This is Dr. Joanna Monreef, an academic who risked her career, her reputation, and the approval of her own colleagues to expose the truth behind psychiatry's most popular myth. What she reveals in this interview should worry us all. The pressure to stay silent, the fear of losing professional standing, and the human cost of telling patients a comforting lie. We talk about what happens when a doctor stops believing the scripts and starts asking deeper questions. Why are millions still being prescribed drugs we know don't fix any known brain abnormalities? Why do so few speak out? This isn't just about science. It's about ethics, power, and what happens when medicine forgets its first promise to do no harm.

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Dr. Joanna Monreef, thank you so much for agreeing to come on and speak with our audience.

It's a pleasure, Joseph. It's lovely to talk to you.

So, yeah. So, to jump right into this, you've recently come out with a book, a great book, Chemically Imbalanced Here, and it made um a lot of waves in the media, and it was talking about how um essentially the serotonin theory of depression really didn't hold water. And I guess my question to you about this would be, you know, if this chemical imbalance theory of depression has been, I guess, discredited or that it doesn't hold any weight, why are medications still prescribed to millions of people each year as if they correct a brain defect?

Great question. Great question. And it's a particularly good question because the medical profession, at least the sort of academic part of it, have known for a long time that that there's no evidence of a or no compelling evidence um of a serotonin abnormality or of any other chemical abnormality in people with depression. And therefore that anti-depressants can't be correcting correcting said abnormality. Um, and so why do they why do they keep on prescribing them? And they would they would say it's because they work. I would say it's because that uh it's because the use of drugs like anti-depressants satisfies various interests. Obviously, one of the interests it satisfies is that of the pharmaceutical industry to make money, to make profit, but it also satisfies the interests or maybe I should say the needs of the psychiatric profession to feel like they are real medical doctors and have a real medical treatment, a sophisticated targeted treatment to offer for one of the common problems that that they are faced with. And then of course people uh you know the public in general um are uh often you know often attracted by the idea that there might be a simple chemical solution for the you know the feelings of distress and discomfort that they're going through. So it it has some sort of popular appeal as well. Although on that note I should say that actually in the past people used to be cautious about using um about using chemicals to manage their emotions and the pharmaceutical industry uh launched campaigns in the 1990s deliberately aimed at changing people's minds at whittling down that natural caution that people had about the use of chemicals that affect the brain. brain. So I think it's I I think the reasons why anti-depressants have continued to be prescribed is because of this combination of factors because they satisfy these these various interests and therefore and therefore any uh research that that's that contradicts the idea that they might be useful or beneficial is resisted or ignored for as long as it can.

What I want to ask you about is something you said right at the beginning. This has been dismissed by the medical community for quite some time. I have to say that's not the experience that I've heard uh from the patients coming to me. In fact, most of them u would say, you know, my doctors told me that, you know, this is genetic or you know, there's some biochemical problem in here. Um and so it doesn't seem like that's the case. you know, how could it be two things at the same time, dismissed by the medical community, but every week people are coming to me saying believing that they have a essentially a chemical imbalance or a genetic brain problem. So, so does that make sense?

So, no, you're absolutely right and that's a really good point. So I I believe that people have been continued to be told that depression is due to a chemical imbalance and that anti-depressants correct that imbalance. Often explicitly, but sometimes it will be an implicit message. You know, oh dear, yes, you know, this must be a medical condition and you need a drug treatment for it and no other explan if if no other explanation is given. Um but people are told that they will generally assume given all the propaganda that there has been over the years um that you know that this drug is is being given them to correct a chemical imbalance. But many people have been told that explicitly by their doctors. But the point I was trying to make is that the research community, the academic community have known that there is no there is no good evidence to support this idea for a long time. Um in fact in 2005 uh to to academics published a paper quoting a whole load of medical medical experts who acknowledged that there was no evidence to support the serotonin theory of depression. Um and and and that made some uh uh caused some attention grabbed some attention from the media at the time and uh leaders of the psychiatric establishment at that time um commented that oh yes of course you know we know there's no evidence for this at the moment but we assume that something like this must be the case and therefore um one of them said it is a useful metaphor. or that we tell to patients and subsequently um leading psychiatrists such as Ronald Peas in the US have written several times um that that the chemical the idea of a chemical imbalance is has not been demonstrated but is but may be something that is told to patients as a useful shorthand for explaining what he thinks doctors believe is the case with anti-depressants even if it's not been proven or demonstrated. So, this of course is enormously dishonest. You know, this is really leaders of the psychiatric profession saying that it's okay to mislead patients. You know, we we we believe that depression has has some biological roots. Therefore, we assume that they'll be discovered eventually. Therefore, we're just going to let our patients believe that they have been established already. That's that's basically what they're saying. And I think that's what you know and and because those people haven't stood up and said publicly no actually you know this this theory that depression is caused by a chemical imbalance has not been established has not been proven because they've not said that outright um in in public. Many um doctors as well as patients have continued to believe that actually this this is proven and therefore you know practicing doctors pass this this idea on to their patients.

How does something like this happen? Well, actually, you know, I I think I came, you know, I went through when I was going through school um to become a psychiatrist. What I heard a lot about was BDNF. You know, there's no chemical imbalance, but maybe there's something about these anti-depressants that are fixing BDNF. It's brain derived neurotrophic factor or some other biological agent or we've identified circuits in the brain um that that are, you know, may be involved in depression. Are you saying that there's no, you know, just to put aside the, you know, this the serotonin thing, um, that there is no other targets there, you know, that that have been shown to be, um, abnormal in people who have depression, whether it's brain circuits or other chemicals like BDNF.

I I absolutely am saying that the probably okay the um there there are many theories about possible biological um biological factors that might give rise to depression um such as a serotonin imbalance or a deficiency of some other brain chemical like noradrenaline but also as you say something to do with BDNF or um or neural circuitry Uh there are there are hormonal hypotheses. There are all sorts of different theories or hypotheses. And the serot the reason that looking at the serotonin theory was important is because that's one of the theories that has been most thoroughly researched and we didn't find consistent evidence of uh that of a link between serot serotonin imbalance and depression. None of these other theories have been established either. There may be one or two positive studies. There are often also one or two negative studies. Um there there is no other theory that that no no other biological factor has been definitively linked with depression. And and I think this I think what you were saying illustrates a really important point that that this the psychiatric establishment seems to be obsessed by this idea of that that that anti-depressants and and other drugs of this sort must target some underlying biological abnormality. They just must do that. And therefore there's this endless quest to look for something that might be the target of their effects. And because they're so focused on this completely mistaken presumption and completely unevidenced presumption, they are ignoring the fact that these are drugs that change our normal brain chemistry that change the normal state of the brain. And I know you've discussed my drug and disease centered models of drug action in in previous podcasts, but I think this this just really nicely illustrates that because the psychiatric establishment is so wedded to the disease centered model of drug action. That's all it can think of. All it can think of is trying to find the biological substrates of of depression. And therefore, it is completely ignored. It is completely neglected to research what anti-depressants actually do, how they actually change the brain, change the normal state of the brain, and what the consequences are of doing that.

So, uh, just to recap, um, for for new listeners here, uh, what Joanna's talking about is there's two different lenses that you could look at the at at how psychiatric drugs work. One is that they work on some underlying biological deficit and they're fix and they're fixing something and then the downstream effects of that result in you know improved mood or or symptoms. And the other side is a drug- centered model where they mask symptoms that people are experiencing and that's how they deliver their therapeutic effect with the distinction being you know one is getting at a root cause presumably underlying problems and the other one is essentially masking symptoms and and she's talked a lot about you know the the the best lens to view these medication that medications through the most accurate and correct is a drug- centered model and so and just just to add to that maybe Joseph can I can just add to that.

So I I think it's important to say so the drug centered model as you say is this idea that drugs may occasionally because sometimes I don't even think they they do that but may occasionally mask symptoms because of the mental alterations they produce and that they but the important thing to recognize is they produce these mental alterations in anyone who takes them um because of the way that they alter the normal state of the brain. So it's just like having a drink of alcohol. You know, alcohol changes our normal mental states and those changes can occasionally can can be superimposed onto our underlying feelings. So that if we're very unhappy and go out and get drunk, we may temporarily forget our unhappiness. And we have a phrase in English, you know, um, called drowning our sorrows to express that situation. So I'm not saying that all psychiatric drugs are exactly of the same sort as alcohol. Obviously they're uh lots they they consist of lots of different sort of chemical compounds which have different sorts of effects on the brain and therefore they produce different sorts of mental alterations. um but uh but many of them will uh dampen down and numb emotions to one degree or another and therefore will often as you say mask the mask people's underlying feelings of distress.

Coming back to what you said before you said the psychiatric establishment is obsessed with um finding these underlying biological imbalances. Um why though? Why why not just take on a drug- centered model and just say yes we're using these drugs you know to to to to cover these symptoms or mask these symptoms why are they so obsessed with just looking at it through one lens.

Yeah. So another good question because because when I when I go and talk to groups of psychiatrists I try to say to them look this is a perfectly respectable way of looking at what the drugs that we prescribe are doing. And it doesn't mean that you should never use them. There are I believe there are situations where some psychiatric drugs can be very useful. Um but a and it actually requires us to know more about the drugs we use than we currently know. It requires us to understand exactly what sort of alterations they're they they produce in the brain and the rest of the body and how those impact on people. And I don't think at the moment we we have very good information about that. I don't think we're very knowledgeable about that at all. Certainly not as knowledgeable as we should be. So I think we could work in that way. Why is there resistance to it? I think it's because I think it's it's this idea of doctors of psychiatrists wanting to compete with what they perceive as being sexier medical specialties where people have have proper targeted treatments and you know even cures although there may be many there are many treatments in medicine that target underlying symptom mechanisms but are not necessarily cures but I think that's I I think that's what it comes comes down to I think it's it's um uh you know particular biologically inclined um academic psychiatrists who who are trying to compete with sexier medical specialties and and you know wanting to present themselves as uh you know feeling that that this sort of that if they could find a biological basis to depression and could prove that that's how anti-depressants were working that would give them more credibility as as doctors. As I say, I I I talked to lots of um you know, practicing psychiatrists. Some some of them I think some of them feel a bit threatened by this way of thinking and and you know, prefer for them it's just sort of simpler to feel that they're diagnosing an illness and then they have a treatment to offer. I and I suppose that's part of it that that if you use the drug- centered model, we're not really treating illness. Then what we're doing is we're using mindaltering chemicals to alter people's mental states and behavior. And that's a bit of a different sort of activity from treating a disease, treating an underlying disease. It's, as I say, I think psychiatric drugs can be useful and I think it's a it is a useful and necessary thing to do in some situations, but it's something you need to do very carefully. And not only do you need to have all that medical, you know, and pharmacological knowledge, you need to have a good ethical grounding to be thinking about using drugs in that way, to be using them to modify feelings and behavior. Um, and I think there are some doctors who are uncomfortable with that idea.

Go into that a little bit um about how because I do think that's very interesting. I mean because if if you do take a drug uh sorry a drug centered model of looking at it um I mean it essentially means that there someone is unhappy or someone's having symptoms. You don't know where they're coming from and the way we're deciding to treat them as as medical professionals is essentially to to mask them. um share more about the the the the the ethics of that or the moral implications of a of a society or a a medical group that uses drugs in that way.

So we're we're using drugs to mask feelings and seeing as our feelings are such a you know an essent essential and integral part of who we are we are using drugs to change people's personality. I think that's an important thing to acknowledge because you know then it it does start to sound a little bit um a little bit of a dubious activity which I think it is and I think it's something we do need to think very carefully about and be very clearsighted about. Um now now people do try and change their personality in lots of different ways. Therapy you know psychological therapy is about changing your personality. Um but obviously it's quite explicit there and and people are are you know are setting themselves goals and making changes that they want to make. And this is one of the one of the reasons that I think this chemical imbalance idea is so insidious and so harmful is that it is basically masking not only individual people's feelings but the fact that what we are doing when we prescribe these drugs is changing people's personality. If we're going to use drugs in that way we need to be really upfront about it. We need to say this is you know this is what this is about. Um, and you know, changing your personality using chemicals is is a big deal and you need to think very carefully about about whether you think that's really a useful or desirable thing to do. And and also when we think about changing your personality with drugs, unlike with therapy, you're not really changing your personality to be a different sort of more functional personality. You're actually inhibiting parts of your personality. you know, you're you're suppressing your feelings or cutting yourself off in in some way because drugs don't have the ability to suddenly transform us into into different people. They're they're very crude instruments. You know, they can numb us a bit, they can sedate us a bit, they can arouse us a bit. Um, but they don't have the ability to make us um, you know, better people, more intelligent people, more emotionally intelligent people, or any of those sorts of things.

You know what I think is interesting? I mean there's there's a part in your book where you talk about uh people used to be weary and you even said this earlier on. They used to be weary about the idea of taking drugs essentially to mask problems. Um, and I actually still think people would be wary about that today, even though we have, you know, probably I think in the US probably around 15 or 16% of people taking these meds and something around 20% of women. Um, and to me it makes a lot of sense that if you if you were suffering and you saw the symptoms of that suffering as as being meaningful, you know, signs that something's was going on with you either medically or or spiritually or psychologically. You wouldn't think that the the best way to solve that problem was to mask those signs um, you know, with a drug. I I still think that people would find that intuitively a bad plan moving forward. Uh especially when you think about the drugs being essentially you can get tolerance to them. And so you know in a way I wonder you know in a in a way I think that this chemical imbalance theory allows doctors to sidestep that or the medical profession to sidestep that that intuitive response.

Absolutely. I mean, what would you say about that?

Yeah. No, absolutely it does. I mean, this was this I believe this was the explicit aim of the pharmaceutical campaigns in the early 1990s was to overcome people's caution about using mindaltering drugs by persuading them that they had an underlying chemical imbalance. Um, so, um, there's, um, I I came across this survey that was done in the early 1990s about people's attitudes to depression and anti-depressants, and the majority of people thought depression was a reaction to things like divorce or unemployment or loneliness or child abuse. Um, and felt that taking drugs to deal with depression was not helpful and just a way of numbing your feelings. and the and and that survey was set up to inform a campaign that was meant to re-educate people to teach people that depression was a proper medical condition. Uh and therefore that the drugs that that were prescribed for it were proper medical treatments. It didn't the campaign that was organized after that survey, the defeat depression campaign, didn't explicitly tell people that depression was caused by a chemical imbalance. But of course there was lots of that information circulating anyway um from the pharmaceutical industry at that time. So I I completely agree with you and I I think I I think that if you don't I if you are honest and don't mislead people into believing that they have an underlying chemical imbalance, people will be naturally cautious about taking a chemical that changes the normal state of their brain and through doing that may numb their feelings to some degree. Some people, my experience suggests that some people will still want to take drugs, whether that's whether that's because, you know, our culture has just become so saturated with this idea um that there's a chemical imbalance that our feelings are, you know, sort of not necessarily an intrinsic part of us, but due to some brain event that can be corrected or adjusted in some way that even when you tell them that actually it's not like that, they can't quite might get past that idea. I don't know. But certainly I think that um you know if you set it out clearly to people far fewer people are going to just want to be prescribed an anti-depressant than is currently the case.

So, it makes a lot of sense to me that the pharmaceutical industry may want to do something like that to to essentially boost sales and, you know, sidestep the the ethical and moral implications of using drugs in that way. But we've got, you know, these academic institutions. We've got government organizations. We have um essentially a whole a whole group of doctors who are meant to see through this and have the public's best interest in mind and and to speak out against, you know, these types of um misrepresentations of the science. right now it seems to be just you and a and a small group of other doctors who who are outspoken about this. Why why why haven't more independent doctors and academics and government you know psychiatrists stood up and and shared well well actually you know we're we're just you know we're using these drugs to mask symptoms because because then it seems like you're you're on the fringe. Um um so what's what's going on there?

Yeah, I mean, it's it's totally true what you say. There are, you know, the majority of the medical profession, medical regulatory agencies, uh, academic journal editors, everyone is going along with this story as well as the pharmaceutical industry that anti-depressants are beneficial. um uh you know work in some sort of targeted way even if we don't quite know what that what that is at the moment. Um and many of them will go further. You know they they save lives. They're you know amazingly beneficial for some people um even though we don't have good evidence that they uh that they save lives or are even very beneficial if at all.

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Um, so why is that happening? I I I think as as I said earlier, you know, it's it's this combination of interests and this is this this this desire to medicalize life problems has been going on for a long time. It's been really ramped up by the pharmaceutical industry since the 1990s, since the advent of SSRIs, but it has been going on for a long time. Before the SSRIs, of course, the the benzoazipines were huge sellers, and then before that, we had the barbbiterates. And I think, you know, I think it's just partly inertia in the system. people people can't imagine a system in which people who were distressed were not were not presented with a medical solution to that distress. I mean I think the I think the answer to this situation is a a complete radical overhaul of what we call mental health care. taking it completely out of or most of it completely out of medicine and locating it in social services. So that the expectation is not that you deal with a mental health problem by going to see your doctor and getting a medical intervention, but that you deal with it by going to see a social worker or someone of that sort who helps you to fix the reasons why you've developed some symptoms and distress in the first place. And I I I think in order to to have a system like that, it needs to be really thoroughly demedicalized. And I think I I think part of the reason why that hasn't happened is it's just it's become so big. You know, we are just treating so many people with anti-depressants now. We're just medicalizing so many people, so many different situations. Uh it's it's difficult to contemplate changing that. And you know this is such a good point because an important point going back to the nice guidelines on depression in 2004 um myself and Irving Kersh wrote in a so the for people who don't know in the states NICE is the national institute for um health and care excellence it's now called and it's a UK organization that it's a bit like a licensing authority it it determines whether a drug is going is worthwhile to be used in the National Health Service in the UK. And so they did uh they did a a report and guidance on treatments for depression. I think their first one came out in 2004 and Irving Kersh and I put in some evidence to this in which we pointed out uh that the difference between anti-depressants and placebo is very small probably not clinically relevant and probably explained by things like the amplified placebo effect. And we also pointed out that NICE's own meta analysis actually found that for the majority of people there was no in fact for everyone there was no clinically relevant difference between the anti-depressants and the placebo for the very low margin of clinical relevance that they had set themselves. So it didn't even cross that margin. Um and um so we pointed this out in 2004 to a committee that um was led by a psychiatrist, quite a thoughtful psychiatrist, David Goldberg, done quite a lot of social research, not a not a sort of ardent biological fanatic um and uh other doctors and members of the public. And that committee not only ignored our um well it did it did give some replies to some of our points but it ignored the point that we made that what their own meta analysis analysis had found that there was no clinically relevant effect. So that's just to show that going back to 2004 authorities have known that anti-depressants are not worthwhile and have chosen to turn a blind eye to that. And as I say, I think part of the reason is this medicalization of misery has just got too big for people to be able to contemplate the radical radical overhaul that is needed and that the evidence suggests suggests is needed.

I'm going to take a different tack on this and speak a little bit about my experience and I'd like you to comment on it. Um and you know for people who may not have watched um may not know about me before so I uh I after becoming a a psychiatrist I worked for the FDA and also in a few pharmaceutical companies and um so I've had sort of I've rubbed rubbed shoulders with academics and the drug company and regulators and I had a lot of these questions and what I saw in the pharmaceutical industry was that there was almost this grooming Maybe that's a harsh word. This grooming of academics um te taking place um where well to to to give you some context where if if you're going to become an academic in America I imagine the same as in the UK or in other places um if you want to be a professor you need to show that you are um you know an authority in your space. you have to have a lot of public um you know you have a lot of publications. You you need to be giving like international talks and and really demonstrate that you are an expert in order to get that promotion. And what I often saw was that the best way to do that was was to partner with drug companies was was to run their clinical trials. Um they would generate publications for you. They would give you you you know we would give academic doctors the protocols. We would give them administrative support. we would give them payments um and and then we would fly them around the world and we would bring them out to you know um internal conferences and we would speak with them and it gave me this this insight into well maybe this is just happening on a mass scale when where now the leaders of these academic institutions because they've been given this leg up um because it's so much easier in the United States to get funding from a drug company than it is to go to the NIH. NIH grants are extremely competitive. um pharmaceutical grants um and and this is what you need to to maintain a career in academia. They're a lot easier and they're a lot more plentiful. um and so it made sense to me just from a career perspective that well a couple things. One, you know, these academics probably wouldn't want to say very negative things about the drugs because it could have some negative career effects um for them. And so they're just going to, you know, overlook that because they they um they want to guard those, you know, they want to maintain those relationships. um And two, you know, when you when you have these people in charge of these academic institutions, and this goes on to, I think, why doctors are so bought into this, just the rank and file doctors. when you have these biological psychiatrists who are running these clinical trials, you know, endowed chair at Harvard or Yale or Baylor where I was, you know, these are the the cream of the crop, you know, they're the most prestigious positions. I used to look up to them and I think most people do as wow, this person could only get to the top of his profession if if he knows something that I don't. He must have a better sense of psychiatry and medicine um and and must be more knowledgeable and and that sort of shattered to me. um after going through all of that where I said well these people they're not that clinically active and most of the time they're just running drug trials um and so I think I you know you get this very skewed education from these biologically oriented psychiatrists who who kind of have this ulterior motive just to kind of go along with things for their career and I think you also don't want to break with that eventually and and when I was at the FDA I saw the same thing. I saw a whole group of psychiatrists who were still biologically inclined. And most of the people that go into drug regulation. They are academics who are tired of the grant process. It, you know, it's exhausting. It's hard to get money. And then they say, I don't want to do this anymore, but I love research. I'm going into I'm going to go work for the government and review things. Those doctors, you know, they they have all been trained by the same academic leadership. um and they have the same ideas. And so I started to think of it as just this, you know, these incentives just just trickling down through academic medicine. And and I think that's the thing that people miss is just just how how the drug company can capture um medicine and an area of it just with with all of these incentives that the the main way doctors are are kind of influenced. It's not how I think a lot of people think by like drug rex reps coming in with sandwiches to their offices, which happens in the US a lot. I don't think it's that. I think it's because they've they've captured academia through through these incentives. I'd love to get your thoughts on on that.

Well, that's absolutely fascinating to hear your insights, Joseph. I I also um I worked on a drug company trial when I was a junior researcher. I was I was employed at an academic institution, but it was a a drug company trial that was being run partly by this institution, which was also a very interesting insight into into how studies work. But the I think the point that you're making is really important that pharmaceutical money is basically setting the research agenda and and creating it. It it's responsible for so many publications for such a large proportion of the research literature. um and and that of course you know frames creates shapes the culture of of psychiatry for everyone you know from the top to the bottom. um I know I know how difficult it is to do a non-drug company funded study from from the beginning of trying to get the money through to actually trying to do the study often with you know really not enough resource to do it. um through to trying to get it published. um and so, you know, of course, if there's money coming from the pharmaceutical industry to do big studies, which are the things that journals want to publish, then we that's partly why we end up with so much literature that's uh that's come from the pharmaceutical industry. um and and it's increasingly it's not just difficult to get money to do other sorts of studies. It's it's increasingly difficult to get anything published that is you know that's at all critical of the mainstream biological agenda because because you know journals are often getting funding from ph the pharmaceutical industry as well. Everyone wants big studies with big numbers. Only the pharmaceutical industry, you know, can really fund that sort of thing. So there are just so many so many factors that as as you say lead to the domination of the literature and therefore of the culture by pharmaceutical industry funded research.

And I and I'm going to get really cynical here for a moment. May maybe maybe you can make me less cynical or add to it. I you know someone once said I think it was um might have been Thomas talking about the scientific revolutions. He said something about you know when there's you know when there's established like ideas about science and then something disrupts that and then we make this sort of leap forward and we go to this different space. It it doesn't happen when the idea comes out. um It's not like everyone just says, "Okay, that's a better idea. That makes more sense. Let's go along with it." He's a I think it was a historian and he looked at it and he says, "The science changes when the people die and um, you know, when the old guard dies and new people come in." Yeah. Yeah. And and when I look at it now, I I almost think I mean we have this whole, you know, echelon of of psychiatric leaders who have built their careers off these studies and of saying that these things are chemical imbalances that I mean they would lose I mean it would be damaging to their reputation and to perhaps the prestige to to go along with this. And so I guess my question to you is is there a more hopeful vista or or or is is there a reason to be cynical perhaps that we we kind of need to wait for an old guard to die off and more people to come in with with different ideas?

I mean from a UK perspective quite a lot of the people who've been challenging me recently and really trying to stick up for biological psychiatry um and you know trying to ensure that that publications that are critical of of biological psychiatry are that things that are publish that are critical of psych of psychiatry are not published or get a get a difficult ride um are often quite young. that they're not they're they're not the old guard. um they're younger psychiatrists who are maybe struggling with this situation of you know as you say that you know it's so difficult to get non-farmaceutical company money. I'm not saying they're all taking pharmaceutical money. They're not. um but you know they're they're in a in a situation of trying to forge an academic career where getting money is difficult and you know aligning yourself with biological psychiatry in one way or another is is going to be helpful because in fact it's it's not just um the pharmaceutical companies uh that fund biological research. There are, you know, there are other there are other big funders for biological research and generally more funders for biological research than there are for social research in mental health. um So I I don't think it's going to be as simple as just waiting for the old guard to die. um because because I I was reflecting on this I was reflecting on this recently actually and I think I say this in my book. I I feel and maybe it's just looking back through rose tinted glasses, but I mean I feel that psychiatry was more open-minded when I was younger and when I was training in the UK at least that, you know, that that psychiatry was seen as somewhere where debate was a good thing and part and parcel of it. um and you know that we we I don't suppose we read them in detail, but you know, we learned a little bit about the anti-csychiatrists like RD Lang and Thomas Saz. um and I feel that if anything there's there's less of that nowadays. There's there's more of a feeling of actually psychiatry is biological and if you question that, you need to be shut down. We're not, you know, we're not engaging in that debate. you just need to be shut up. um So I think probably other conditions need to change for there to be radical change. um and for people with different ideas like you and I and the many other people that we know who have, you know, different ideas about how mental health should be conducted to um be able to really influence mainstream practice practice and um maybe may maybe there's an opportunity in the US at the moment for for that to happen with with the new um with the new administration um which of course you know uh have have differences with um but but it seems to me that they they may be doing they may do some good things in in the health in the health arena.

Why do you think there's less I mean I think most people would agree it would be healthy to have a lot of you know discussion and differing viewpoints and and people to be more open to consider opposing points of view. Why do you think that's not happening anymore and that there's more pressure to just step in line?

So, so I think for a couple of reasons. I mean, the the the response I got from the psychiatric profession to the publication of the serotonin paper um was was so extraordinary and so extraordinarily defensive. um It really revealed how strongly wedded they are to this idea that depression and by implication other mental health problems are biological conditions and really found anything that got any publicity that was challenging that, you know, a threat. And I think that is partly a result of the influence of social media and the fact that um that an alternative viewpoint such as you and I articulate and other people is getting more airplay than it used to. I think maybe maybe one of the reasons psychiatry was comfortable with debate, you know, going back 20 or 30 years ago was because it didn't really leak out into the public domain that much. um and nowadays it does. You know there are large communities nowadays um on Twitter and you know all the sort of social media platforms of people who have different views about mental health and and large communities of people who have been harmed by the current approach by the current approach of the mass prescribing of anti-depressants and and other medications who've got into trouble with withdrawal symptoms um and experienced other you know really harmful and debilitating adverse effects. um So I think that I think that's perceived as a threat by by mainstream psychiatry and therefore they feel more insecure about their um uh about their approach and therefore less amanable to the idea of of debating and discussing it within the profession. That's one thought. I think also it's it's you know there has been this la you know biological turn since the 1990s um spearheaded by these pharmaceutical campaigns that uh you know that promoted Prozac and the SSRI back then and have continued since then. um and of course there had been pharmaceutical campaigns before then. um but I think they didn't quite align so well with the views of biological psychiatry before then. So the big you know the the big best sellers back in the 1950s60s and '7s were drugs like benzoazipines and barbiterates. It's difficult to pretend that they are targeted medical treatments. you know, that their their their mindaltering effects are so obvious um and and so, you know, so similar to alcohol, for example, that it's difficult to pretend that they're correcting a chemical imbalance and not just altering your mind and emotions in some way. um and so I think it's it's only then in the 1990s that the pharmaceuticals industry's aims and uh the interest of the psychiatric profession to present this biological model of the disorders and the action of the the drugs came together. Uh and and that really has you know helped to strengthen um the biological strain in psychiatry, the biological um uh area of psychiatry uh as against the as against social psychiatry and psychotherapy which you know have always been part and parcel of psychiatry but I would say have you know have become much less dominant partners since since the rise of biological psychiatry. really um took off on the wave of this pharmaceutical promotion, pharmaceutical industry promotion of anti-depressants.

To to me there seems like they could there's some oppressive element to it as well because I I think not I I get being defensive about this because you you know you're so you know we built a medical specialty essentially around around these ideas and these medications. But what I see being thrown around to kind of um silence people like you um is that you're dangerous. Is that you're scaring people away from life-saving medications. You're putting people at risk. You're you're stigmatizing the mentally ill. You know, you you're covertly suggesting that maybe people should just, you know, go to church, talk to their friends, pull themselves up by their bootstraps. And this is this this outdated outdated and maybe idealistic way of looking at things. What do you say to I mean what do you think about that? How how do you respond to to people who say that you are dangerous and that you're causing people to to commit suicide by scaring them away from drugs.

So, I was explicitly told after the serotonin paper came out that I should not talk to the press that that I that that um I should keep quiet because if I, you know, if we told the public that that this was all a a lie um that that depression, we don't know that depression is caused by a chemical imbalance, then people, you know, wouldn't come forward for psychiatric treatment. Of course, the the hidden assumption behind that is that psychiatric treatment must be so beneficial. And I would, you know, I think that overall our current approach is undoubtedly doing more harm than good. um you know medicalizing medicalizing people's emotional problems and putting people on long-term medication for those problems um you know just has so many negative consequences um that that I really think that actually people would be better off without that system um even if there was nothing to put in its place and I'm not suggesting for a minute that we don't put anything it in its place, but even if there wasn't, I think it's just doing so much harm that that it would be better we'd be better off without it. um Sorry, I know that wasn't the question you were asking me. You were asking me why why

No, but I'm going to pick up I'm I'm going to pick up on what you said because I think it's really interesting. um Most people assume these drugs are safe to take long term. And let's just put the whole chemical imbalance thing aside. For instance, let's say you've got someone and they fully recognize that they're just using a drug to essentially, you know, they're a nervous Nelly and they don't like being a nervous Nelly and when they take Prozac, uh, they're less ruminative and it helps them. Why is that such a bad thing to do long term? Are there problems with that?

So, there are a number of problems at a number of different levels. um But if someone really does find it helpful and they have considered very carefully all the pros and cons, I wouldn't necessarily say that it's, you know, always a bad thing to do. But the downsides are a number of things. um dependence. You know, if if unless someone's confident they want to take this forever, they we know that actually it can be very difficult to

Get off these drugs for many people, particularly if they've taken them for a number of years. Um, if people end up taking them for long periods of time, they cause osteoporosis, which can lead to fractures. Uh, we know that they cause uh falls in the in the elderly, which of course are problematic. Um, they probably have effects on the heart. Uh, there's some evidence that they that they're associated with um reduction of brain volume. Um, uh, they have um, they cause sexual dysfunction. I know you've highlighted this on on your podcast and I think it's so important. Um, it's well recognized that they cause sexual dysfunction while people are taking them. Um, but it's becoming increasingly apparent that for some people, this sexual dysfunction will persist after they've stopped taking the antidepressants. Obviously, a huge issue, particularly for for younger people, but for people of any age. Um, so, you know, there are all those physical potential physical complications um and and more that I haven't listed.

Uh, then then I think there's the I think it's also important to think about the psychological consequences. It's it's difficult, I think it's difficult to judge to really evaluate how a how a drug is changing you until while you're under its influence. And you really need to come off it and look back at how you were and reflect back on how you were to judge whether it really was helpful. And I will always remember um watching the playback of a morning chat show in the that took place in the UK shortly after Prozac was introduced and the um presenter went up to a woman who said exactly what you've said, really. You know, this this drug has changed my life. It's changed me for the better. I'm a better person. And I'm less, you know, sensitive and um, uh, you know, jumpy and reactive and, you know, more mellow and things and I think I'm a a better person and it's fantastic. Um, then there was a bit more discussion and input from other people. And then later in the program, the presenter went back to her husband, who was sitting next to her, and he said, "She's changed in fundamental ways that I feel uncomfortable about. She doesn't seem like herself anymore." Uh, so to him, it had been a negative change. And I just think that highlights that that that we may not appreciate the negative aspects of how drugs affect us when we are under their influence. And it may only be when we look back that we that we're really able to evaluate whether it was a good or a bad thing to take them.

Um, sort of um, I'm I'm describing what Pet the psychiatrist Peter Bregan describes as the um, oh gosh, now I'm going to forget. Spellbinding. Spellbinding. Thank you. The spellbinding effect. Yes. Yes. Exactly. Exactly that. Um, yeah. So, uh, so as I say, I'm not necessarily in principle opposed to people taking that approach and saying, "Okay, I just feel it it makes me, you know, it's better." As long as people have thought very carefully about all the pros and cons and preferably evaluated the changes, the positive changes they thought they experienced after they've come off the drug and are able to look back at at how they were and how how it had changed them and then, you know, make a a a considered judgment.

Um, and and then of course also, you know, this is where this whole issue about about the research on antidepressants comes into play because although people might feel that the drugs are useful, the research evidence really doesn't suggest that they are. You know, it suggests that the effect is principally a placebo effect, probably amplified a little bit by by getting some side effects and, you know, recognizing that you're you're on an active substance. So, you know, so even though people may feel that the drug is benefiting them, we don't have good evidence that it actually does benefit people.

Another another issue that I feel hasn't really had a lot of airtime is that there are a number of psychiatrists out there who actually wonder if antidepressants could actually make people more depressed in the long run. I know there there's I think there's I'll butcher the name, but there's a psychiatrist at the University of Kentucky. I think his name is Riff El Melik. He's done something with Alan Swan, a professor at Baylor who trained me. We also have people like Giovani Fava as well. And and so there's a lot of who I wouldn't necessarily call fringe psychiatrists, but just solid, quite middle of the road, respect, you know, respected within their profession doctors out there saying these drugs may actually make some people worse, maybe after being on the drugs for several years.

What can you sh I'm not sure how familiar you are. Yeah. No, no, I know I know it well. So this is the whole idea of tolerance, isn't it? That you know that you that that you get tolerance to the effects and then and then, you know, you may sort of overshoot that and get even worse. My my problem with these w with this view, so I I partially agree with it, I should say, but my problem with it is that I think some of these people at least assume that antidepressants are lifting people's mood initially, and I don't think they are. So I I don't think you get tolerant to a mood-elevating effect because I don't think there's any evidence that they have a mood-elevating effect. Um, do they make people worse in the long run? There's good evidence. Well, there's reasonable evidence. I would say it's difficult to get any really good evidence on people's long-term outcomes, but there's reasonable evidence that people who are on long-term antidepressants have worse outcomes than people who are not on long-term antidepressants. That may be partly because, you know, they're more severely depressed. There's var various confounding issues to consider. But there are some studies that have controlled for for um, you know, those confounders to some extent and still found that people who are on long antidepressant long-term antidepressants do worse. Um, why are they doing worse? Um, I think that may be partly due to the debilitating effects of taking a of taking a mind-altering drug on a long-term basis. Probably people with um who take long-term benzodiazepines can also become quite dysphoric and anxious in in with long-term use. Um, uh, and and I expect you could find that with other with other groups of people using long-term mind-altering drugs of various sorts.

So well, you you I mean, this is something that I that I think about, right? I mean, I mean, we know that some people who drink alcohol every day will develop Wernicke-Korsakoff. We know that people who use high-potency cannabis, especially at a young age, you know, not only do they go on to develop mania and psychosis to to almost look like they have bipolar and schizophrenia, they also have cognitive changes that are seen on scans. The same with methamphetamine. We know antipsychotics can cause permanent movement disorders and brain shrinkage in the long run. We know that some people on lithium can develop a condition called silent syndrome, which is irreversible cognitive damage. And so I I look at these things and think, wouldn't it be the norm that some people, when exposed to a chemical long-term, um, may actually develop some form of brain injury or or or cognitive damage from that?

Absolutely. Like you say, we we don't flinch when we talk about that that effect occurring after long-term use of recreational drugs, do we? We, you know, we think it's quite understandable that someone who drinks every day is likely to have some cognitive damage, some brain damage as a consequence. Um, and you know, the same with methamphetamine uses and and all the rest. Um, and so I I completely agree with you. I think it would be uh surprising if there wasn't some degree, and it may be very subtle, but some degree of brain injury occurring when people take uh a mind-altering a brain-altering drug day in day out for years on end, which is what people are doing when they take antidepressants for many years, as many many people do, many millions of people do nowadays. So I I completely agree with you and probably one of the consequences of that for some people at least is is, you know, a degree of of dysphoria or of, you know, that that injury will impact on people's emotions in in one way or another, probably negatively.

So I I have a lot of people who come to me now um describing things that appear fairly similar. You know, they'll talk about, you know, they'll be on medications for maybe 15 years, antidepressant, and they'll say that they have very low energy and that they feel quite flat. Um, and it's hard to to to feel motivated to do things. On top of that, they'll have usually moderate to high background anxiety that just is always there, and they describe some mild cognitive dysfunction. And I'm seeing a lot of people reporting these symptoms, and they say it's different than the reasons they got on the drug, just this just this feeling unwell and just very flat and low energy. Um, a lot of them end up getting diagnosed with treatment-resistant depression. Um, and by the time they've come to me, they they've been hit with anti they're on antipsychotics. They they've done TMS. They've been given e sometimes even ECT and then oftentimes ketamine. And so I also wonder whether, you know, we do a very poor job of talking about the long-term risks of antidepressants and and and in and causing things like treatment-resistant depression and and and maybe the the best thing for these people is to do a taper off these medications rather than to have more meds stacked on top of it.

I I mean, I'm sure it is. And you know, this idea of treatment-resistant depression and, you know, throwing all these different chemicals and ECT, you know, throwing all these different hits at the brain is, you know, is just horrifying, really, when we think of it like this. The likelihood is, as you say, that they've got some degree of brain injury caused by the drugs that they've already been taking. And what do we do? We fill them full of more or or batter their brain with ECT or TMS. I mean, you know, it's it, yeah, it beggars belief, really, doesn't it? And and of course, like you say, uh, people coming, you know, with with complaints of fatigue and cognitive, you know, mild cognitive impairment and, you know, a bit of anxiety and dysphoria are going to be diagnosed as, yeah, as relapsing, as having a psychiatric disorder rather than it being recognized that they may have a um may be suffering from adverse effects of long-term treatment. And and again, that just illustrates our very blinkered view, doesn't it, of, you know, that we're we're so focused on finding an underlying disease and and finding a cure for that that we that we haven't paid nearly enough attention to the harmful effects of the of the drugs that we're doing out.

Well, on that very pessimistic note, I'm going to turn to to some, you know, some of the final questions here, which is, and you've hinted to this, um, but I think it deserves a bit of time. What's the solution to to the problem, the problem that we've found ourselves in with psychiatry? We have a whole medical profession all over the world who who may be, I I think actually harming people, doing doing more harm than good. How do we get ourselves out of this mess?

So, as I said, I think we need a really radical overhaul. We need we need to um thoroughly demedicalize the the the our approach because because even if you say treatment, of course, that's still medical, isn't it? Our approach to mental health problems, which probably means renaming them for a start. And we need public as as well as relocating services, getting them out of of medical care, we need public campaigns to, you know, to to actually undo all the damage that those campaigns back in the 1990s did trying to persuade people that they had a c a chemical imbalance. We need public campaigns to tell people that the chemical imbalance was a load of nonsense, not supported at all. Uh, that having negative emotions is a normal thing. Um, that emotions are a natural reaction to life circumstances and that the best way of managing them is to try and identify what those circumstances are and how they can be changed. Um, so I I think that is, you know, a very radical overhaul of of the current system. Um, and, you know, nothing short of that.

But I mean, because we we've gone some way towards this in the UK. We have introduced social prescribing to try and divert people, not just with mental health problems, but people with physical health problems as well, um, away from sort of interventionist medical treatment to social activities, such as exercise and things that will be helpful. Uh, so that to me is a good start, but it's problematic that it's still it's called prescribing. It's still situated in in the medical system. So people still have to go and see their general practitioner to be referred to the social prescriber. Um, so it would be better if it was, you know, located somewhere else. Um, we have also started, which I know is also, you know, obviously you're an example of it, but we've started a bit of a deprescribing movement. So there are um there there are some some areas um in which psychiatrists are, you know, doing some deprescribing activity, helping people to come off medication, but the Royal College of, you know, put out some information to try and help people, but it's fairly minimal the activity that's being done in that area. But so we need a two-pronged approach to try and stop people getting inappropriately medicalized in the first place. That means radically overhauling our mental health services and relocating them outside of medicine at the same time as um as funneling our existing resources to help people who are victims of the current system to get off harmful medications in a safer way as possible.

What haven't I asked you about which you'd like to share with the audience before we wrap? What what haven't we covered which is important?

Um, I think I I think we've done a fairly thorough job, haven't we? Good. I can't think of anything anything else. Maybe just to say maybe just to say because I like like to say it is um that that David Healey had already debunked the chemical imbalance idea back in 1987. So, you know, we've we've known that this idea was nonsense for such a long time. And I think that just emphasizes the point you may made about um, you know, about saying we have to wait for people to die. I don't think it's quite waiting for people to die. We have to wait for the right circumstances, the right conditions for change um before change will come about.

Um, and do do you want to know another really pessimistic thought that I have? Um, is that it took it took um it took I'm I'm going ahead. I'm going to subject you to it. It it took Luke Montigue, you know, is essentially British royalty to to develop a condition for for government to pay attention. Yes. And um, it's what haps what has to happen in the US. I'm like um I know we're having a change now, but do we need a child of a president or a senator to to have this problem? It's it's we I think it's going to happen, but it but that also saddens me in in a way. I'm I'm so happy for for the role that he played and um how all of the change, but it also made me feel sad thinking about that. It's like um Betty Ford changed the situation over benzodiazepines. She was the wife of President Ford and she, you know, she had a problem and she really got benzodiazepine dependence on the map back in the 1970s, late 1970s, and changed things over benzodiazepines. And Luke has started the same path with antidepressants. And I do think I I do think there are opportunities. I do think there are opportunities, but we do need such a massive change because this this system that this whole approach is just so harmful and so pervasive. So pervasive. Yeah.

Well, I'm going to shamelessly promote you now and then I'm going to have um some PE and then I'll have you share where people can get in touch with you or learn more about your work. Um Chemically Imbalanced, amazing book talking about um Joanna's recent recent paper that I believe is the most one of the most cited papers of all times. But the books that she does go deeper than this. There's a probably a really great book, "The Myth of the Chemical Cure" is an excellent book. It was very um, you know, it was like a fundamental um piece of my learning when I was going through psychiatry. That's great. "The Bitterest Pill" as well is another one that Joanna has done. They are all awesome reads for people who want um a more in-depth look at um everything that we've been talking about today. And so I would highly recommend them. Uh, Joanna, where can people follow you if they're interested in in your work and and what you're doing?

Thank you. So I have a website which is joannamoncrieff.com, which I put blogs on occasionally. Um, and uh, I'm on Twitter, uh, sorry, X now, which is @JoannaMoncrieff, and also on B Sky B um with the same with the same name. Um, and I should also say that "Chemically Imbalanced," my new book, is not out in the States until September of 2025, but you can get uh an electronic copy, or you should be able to, from Amazon UK or other or other UK-based outlets. I don't know. How did I get this? I I guess I think we I think I think the publisher sent it over to you because we were doing a doing the podcast. So, so it can be sent over so so you can get it, but it has to be posted from the UK, I'm afraid, until it comes out in the space. Okay. Okay. Good, good, good. Okay.

Well, on that note, thank you so much and um thank you so much for coming on and speaking with my audience. I really appreciate it. It was a pleasure, Joseph. Thanks very much. If this conversation with Dr. Moncrieff struck a chord with you, I highly recommend you watch my interview with her colleague, Dr. Mark Horowitz. He was a psychiatry trainee, fully bought into the system until he tried to come off the drugs himself. What happened next forced him to question everything he'd been taught.