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The Myth of the Chemical Cure. A Critique of Psychiatric Drug Treatment By Joanna Moncrieff. Palgrave Macmillan. 2009. £18.99 (pb). 320pp. ISBN: 9780230574328

  • David Taylor (a1)
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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The Myth of the Chemical Cure. A Critique of Psychiatric Drug Treatment By Joanna Moncrieff. Palgrave Macmillan. 2009. £18.99 (pb). 320pp. ISBN: 9780230574328

  • David Taylor (a1)
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Author's response

Joanna Moncrieff, psychiatrist
03 August 2010

As the author of the Myth of the Chemical Cure, I would like to respond to some of the points raised in David Taylor’s review. I am grateful to David for attempting to summarise my models of drug action, but I felt he did not clarify how these models informed my assessments of the evidence concerning different classes of psychiatric drugs. For example, with antipsychotics, I am suggesting that the drugs produce a drug-induced state, in which thought, emotion and movement are dampened down and psychotic symptoms are non-selectively suppressed. Some of the newer antipsychotics like olanzapine and clozapine appear to induce a slightly different state, which is also characterised by emotional indifference, but is not associated with the physical restriction or Parkinsonism of the older drugs, although it appears to be related insteadto metabolic disturbances (1). Antidepressants come from a wide range of chemical classes, and produce a corresponding variety of drug-induced effects. Some of these effects, such as sedation, may lead to apparent improvement as measured by rating scales, which contain items relating to sleep disruption, anxiety and agitation, but this does not indicate any specific “antidepressant” effect. Other possible, although unconfirmed drug-induced effects like emotional suppression, could also effect rating scale scores. Similarly, I do not simply say that lithium does not work, but that it is a sedative drug, that suppresses nervous system function. As such, it is bound to reduce the signs of acute mania, but its utility is limited by its highly toxic effects and I can see no logical way in which it could prevent or ameliorate episodes of depression.

The point that I would like to emphasise is that almost no research has attempted to distinguish whether psychiatric drugs are having effects on an underlying disease process, or whether they are, according to my drug-centred model of drug action, inducing altered states that suppress the manifestations of mental disturbance or distress. On the basis of current evidence, we cannot claim that they act on disease processes, or reverse chemical imbalances or any other hypothetical underlying pathology.

In response to David’s specific criticisms, I am not sure why David thinks I misrepresent the CATIE study, and to say, as I do, that the newerantipsychotics are not clearly better than the older generation is hardly controversial now (2). The sentence that David uses to illustrate an unsubstantiated claim actually reads as follows: “As we shall see in the next chapter, neuroleptic drugs dampen down all spontaneous thought and action”. The sentence is not referenced where it stands, because much of the following chapter analyses the evidence that supports this claim. Similarly, in the same chapter, I discuss in some detail the unusual ability of antipsychotics to induce a state of mental and physical suppression or deactivation with co-existing signs of restlessness, tension and anxiety (akathisia). That the deactivating effects may reduce symptoms of anxiety does not contradict the fact that the drugs can also produce an anxiety-like effect. The pictures of imipramine and chlorpromazine were taken from another book on psychopharmacology (with permission), and I do not think that anyone disputes that they are structurally similar.

Finally, I do not advocate advising people with depression to take antidepressants, for the reason that the drug-induced effects of antidepressants, as far as we know them, are not likely to be useful in people with depression. Sedative drugs, including low dose tricyclic antidepressants, may be useful on a temporary basis for problems such as insomnia or agitation that may be helped by such effects. In the main, however, I believe that the treatment of depression should be non pharmacological, since we cannot claim that any drugs have specific effects.

Reference List

(1) Moncrieff J, Cohen D, Mason JP. The subjective experience of taking antipsychotic medication: a content analysis of Internet data. ActaPsychiatr Scand 2009 Feb 12.

(2) Tyrer P, Kendall T. The spurious advance of antipsychotic drug therapy. Lancet 2009 Jan 3;373(9657):4-5.
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Conflict of interest: None Declared

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