Any challenge to orthodox thinking is to be welcomed, particularly when orthodoxy has failed to provide highly efficacious and acceptable treatments. Such is the case with drugs used in psychiatry – doubts remain about their efficacy when compared with placebo and many drugs' tolerability is poor at best. Perhaps more importantly, psychiatry has a history of championing useless and harmful treatments, so critical examination of accepted practice is essential.
In her book, Moncrieff distinguishes between the current disease-centred model, whose foundation is that drugs correct an abnormal brain state, and her preferred drug-centred model, which supposes that drugs create an altered physical and mental state and that therapeutic effects arise as a consequence of this state. An example of the former would be the use of L-dopa in Parkinson's disease; an example of the latter, alcohol in social anxiety disorder. Moncrieff argues that there is no basis for our current view that psychotropic drugs somehow act so as to correct known ‘chemical imbalances’. Psychotropics are merely crude but sometimes useful.
In 14 well-constructed chapters, Moncrieff provides a history of the fairly haphazard process of psychotropic drug development and considers evidence relating to the effects of various groups of drugs. She claims that antipsychotics do not have specific antipsychotic action but simply induce various degrees of Parkinsonism which render the patient emotionally indifferent and hypokinetic. Further, antidepressants do not really work (and in any case, depression probably does not exist) and if they do work, it is because they induce non-specific states, such as sedation, which contribute to a perceived antidepressant effect. Lithium, Moncrieff opines, does not work at all in mania or as a prophylactic agent and nor does it prevent suicide. With all drug groups the illusion of acute effects is said to be partly brought about by the use of placebos which both prescriber and patient can usually detect and by (unspecified) withdrawal symptoms in those switched from active drugs to placebo at the start of the trial. These withdrawal symptoms are also cited as an explanation for the apparent benefit of continuing psychotropics in the longer term: those who stop an ‘active’ drug and are switched to placebo relapse because of the withdrawal effects they experience.
Those readers with George Orwell's ‘power of facing’ will have no trouble assimilating the potency of these arguments, nor with living with a stronger sense of doubt regarding what many of us hold to be true about psychiatric illness and psychotropic action. Others will feel compelled to reject out of hand this psychopharmacological blasphemy and pore over the text searching for weak points in the author's lines of reasoning. And they will find plenty of those. There is a tendency throughout the book not to challenge the findings of ancient underpowered studies as long as the outcome fits with the argument. There are numerous misrepresentations of study outcomes (such as CATIE, p. ); unsubstantiated claims: ‘(antipsychotic) drugs dampen down all spontaneous thought and action’ (p. ); contradictory statements: antipsychotics give rise to coexistent ‘deactivation and anxiety’ (p. ) but the deactivation effects of antipsychotics ‘are likely to… reduce agitation and anxiety’ (p. ). Further, the structures of chlorpromazine and imipramine are drawn side by side to emphasise their chemical similarities (and so stress their pharmacological near-equivalence), whereas each structure is drawn incorrectly and in any case, two-dimensional representations have almost no relevance to the real arrangement of atoms in three-dimensional molecules.
The author contends that we should advise patients to take an ‘antidepressant’ because it might help their ‘depression’ by mechanisms not yet fully understood, but it will give them adverse effects as well. This is in some contrast to current practice, where patients are told that the drug specifically corrects a known chemical imbalance. At this practical level Moncrieff will find many supporters. On a philosophical and scientific level there will be many more detractors to the views expressed in this book.