A Straight Talking Introduction to Psychiatric Drugs

by Joanna Moncrieff, Pete Sanders (Editor), Richard P. Bentall (Editor)

Psychiatric drugs and their use are amongst the most hotly debated issues in the 21st century. How they work, whether they are effective, how to understand the evidence, and explanations of the major categories of psychiatric drugs are all covered in this clearly written guide. The competing theories of drug action are also explained in easy-to-understand terms.

Genres: Psychology, Mental Health, Psychiatry, Nonfiction, Health, Drugs, Medicine

155 pages, Paperback

First published October 1, 2009

Reviews

[Tim Capps · Rating 5 out of 5]

Straight Talk Indeed

This little book is aimed at the large percentage of the population who have been prescribed antidepressants, tranquilizers, mood stabilizers, so-called antipsychotics, and stimulants. It is not an anti-psychiatry tract, and the author recognizes that in some cases the advantages of a drug may outweigh the disadvantages.

However, the author also points out that the research into these powerful drugs is likely to be flawed for many reasons. Even the “gold standard” double-blind random controlled tests have pitfalls. They are conducted by the very companies wishing to bring them to a lucrative market. Unfavorable studies may simply remain unpublished. Also, it doesn’t seem to have occurred to researchers that it isn’t difficult for those getting the real drug, and the control group getting a dummy pill, or placebo, to figure out which they’re getting. This produces “unblinding” which knocks out one of the supposed main strengths of such studies.

This means the evidence that mood fluctuations and other “mental illnesses” are really caused by “an imbalance in brain chemicals” that can be corrected, that is, restored to a natural state by drugs, is practically nonexistent. That is why drug companies qualify their pitches with “it is believed that.” It is also why your doctor comparing an antidepressant to insulin is disingenuous. We know exactly what causes diabetes and we know just how to compensate with insulin and nothing has to be “believed” because we know all the scientific facts.

I can check my blood sugar anytime I want with a simple finger stick. In all my years under psychiatric care, I have never seen a “serotonin level,” probably because they would have to get it directly from my brain: an expensive and unpleasant experience for non-cadavers.

So what accounts for any improvements in symptoms? This is the most interesting part of the book.

The book states the obvious: drugs do stuff to you. They change the way your brain works. The provocative question is this: are they really “correcting a disease-specific imbalance,” or are they just doping you up so you are exchanging whatever symptoms you have for drug side effects such as sedation and loss of interest in things?

If you take an opioid painkiller, you’re going to feel super whether you’re in pain or not. If you take Valium, you’re going to chill whether you suffer from anxiety or not. And if you take an antidepressant, you’re going to experience effects, whether you are depressed or not (except not so pleasant). The author says this “drug-centered model” is the right description for what is going on when your doctor prescribes any psychotropic drug. It is not correcting some imaginary chemical imbalance. It is just a drug doing its thing on any human brain.

This book says psychiatry purports to treat “diseases” but its drugs simply change how anyone who takes them feels—usually by deactivating them to one degree or another. Now, this may be a good thing for people suffering severe symptoms. If you’re psychotic or manic, you are probably better off with a drug-impaired brain, at least for a while. Most of us shouldn’t need our lives bubble wrapped.

This book arms the patient and family members with an easy-to-understand perspective they will not get from their doctor. In the end, it’s pretty obvious: these drugs do powerful stuff to your brain, which is one of the more important organs in your body. Maybe you really need that. Most people don’t. There are reasons to make your own informed choice, and not taking psychotropic drugs—especially for the rest of your life—may be better in the long run.

[J.A. Carter-Winward · Rating 5 out of 5]

Straight Introduction to Psychiatric Drugs by Joanna Moncrieff: A Review.

When I read the negative reviews of critical psychiatry books, it's reminiscent of when I left my religion. I no longer believed, so, therefore, I was evil. So, allow me to state this caveat here, as absurd as it is.

I am not, nor have I ever been affiliated with Scientology. I do, in fact, believe in the scientific method and evidence-based medicine. I do not, nor have I ever believed that the earth was anything but spherical. I am up-to-date on all my vaccinations, and so are my cats. I do not, nor have I ever claimed to know who shot JFK. I am also not a school shooting or 9/11 denier.

Let's review the book now that we've established what I am not.

In this thorough explication of how psychiatric drugs work, how they don't work, and how damaging and dangerous they are when used long-term, Joanna Moncrieff carefully assesses and debunks the myth of the chemical imbalance theory, a theory that has been kicking around since the middle of the 20th century. This is when, contests the author, psychiatry made its successful power grab that resulted in its specialty being one of the most financially lucrative medical specialties in the world.

Moncrieff shifts the focus of the disease-centered model of psychiatric drugs and introduces us, or rather reacquaints us, with the drug-centered model of psychiatric drugs. She details the mechanisms of action in each drug class and acknowledges that neither doctors nor drug makers know how they work in a disease-specific way because they don't act on specific diseases. If you aren't aware, there are no identifiable biological markers for mental illnesses, not even in serious and disabling illnesses such as schizophrenia. There are barely any genetic markers.

And so, when we shift the focus from the serotonin or MAO theory of depression, for example, what we're left with is not a disease, but a complex illness that, to fully appreciate and understand the scope of it, must take more than theoretical biological crossed wires into account, which places depression into its proper category: a serious, disabling condition that warrants support, care, understanding, treatment* and education. (*In every healthcare arena, "treatment" equates to "medication." That is not what I refer to here.)

And THAT is how you "end the stigma." By treating human beings who are struggling with mental health concerns as whole human beings. Instead, we are disease-focused, and so the sufferer believes they have a biological imbalance that can be rectified with medication. This is untrue. By accepting the disease model, we are essentially engaged in victim-blaming masquerading as validation and "care."

When someone is medicated with an SSRI, for example, the drug does not act in a disease-specific way. Depression is not caused by too little (or too much) serotonin. SSRIs and other psychiatric drugs simply act on normal brain function and alter it. When people feel altered, they feel "cared for" and the placebo effect is strong. Until, of course, it isn't, and it's at this point when managing side effects becomes the goal of the patient and prescriber, as the silent lie of "chemical imbalance" hangs in the air.

If you are a medical prescriber, it is your duty to read this book. If you find yourself saying, "No way," understand that you are ignoring critical information that will make you a better clinician, but more troubling, by refusing to question the CPGs in place for medicating people presenting with psychiatric conditions, you will be directly responsible for the harm you cause due to your willful ignorance.

I would argue with believers about religion. I asked them to read my books since I'd read theirs and they said they would never read a book that didn't support their beliefs—they didn't need to, they had faith. I know why, now. They were afraid. When something frightens us, we avoid it. But when you are a medical professional, you don't get the luxury of fear when it comes to prescribing medications. You don't get the luxury of belief, either. The standard of evidence-based was set, and it's up to prescribers to do their due diligence whenever they prescribe psychoactive drugs. To ignore the plethora of information available today is to be in the thrall of blind belief, and that is the opposite of evidence-based medicine, professionalism, and care. That is dogmatic belief.

For those of you savvy enough to admit that the chemical imbalance theory of mental illness is incorrect, I ask you: why, then are psychoactive drugs said to "correct" a chemical imbalance still being prescribed?

I finished this book some time ago, but what has stayed with me is a more thorough understanding of how completely deluded we are about psychiatric drug treatments. If we can agree that psychiatric drugs are psychoactive in the same way tobacco, alcohol, and marijuana are psychoactive and that these effects are what we're seeking when we seek intervention, then we can at least begin the conversation of what it means to be in emotional pain, what it means to be human, and how we, as a society, must change how we view these universal experiences to better support one another.

But for now, we still believe "there's a pill for that." And I've got news for you. There isn't, not without a terrible cost. This book is a must-read whoever you are. Chances are, it's relevant to your life in some way.

[Marco · Rating 5 out of 5]

A more realistic view on psychiatric drugs than you'll get from mainstream authorities.

Great book, save the repetition toward the final chapters.

[Brenda · Rating 5 out of 5]

One of the central tenets of mainstream psychiatry is that drugs like “anti”-depressants or “anti”-psychotics work by reversing the biological mechanisms that cause, say, depression or psychosis. This view is completely false, and this book explains why.

A drug can be classified as acting in more of a “drug-centered” way or more of a “disease-centered” way. Drugs that act according to a disease-centered way “exert their therapeutic effects by reversing an underlying biological abnormality or disease” (24). In contrast, drugs that act according to a drug-centered way “cause general mental and behavioral alterations in anyone regardless of whether or not they have a psychiatric diagnosis” (24). Drug-centered drugs will “influence symptoms by changing the way the body and brain normally work” (24), while disease-centered drugs will bring the body closer to normal functioning.

Moncrieff provides the examples of painkillers like aspirin and opiates. Aspirin and opiates work by targeting and opposing the specific biological pathways in the body that lead a person to experience pain. This means these drugs should be viewed as disease-centered. However, opiates are also drug-centered drugs. This is because opiates also have a psychoactive effect as well, where a person taking an opiate feels out of it and cares less about the pain they are experiencing because their mental state has been altered. On the same note, people who are not experiencing pain who take opiates will still experience an effect — an altered state of mind or high. So while aspirin is a disease-centered drug, opiates are both disease-centered and drug-centered.

Alcohol, on the other hand, is a purely drug-centered drug. You could drink alcohol to deal with pain, or to treat anxiety or depression, but the effects of alcohol do not work to biochemically reverse the causes of pain, anxiety, or depression. Instead alcohol induces a mental clouding which alters the mental state of the drinker and can in addition numb or affect other functionalities and faculties.

There may be a fine line in some cases when determining if a drug is drug-centered or disease-centered (as we saw above, opiates could be classified as both). But in general, drug-centered drugs will cause rather than correct biochemical imbalances, will also affect healthy people in a similar way, and will mask symptoms rather than treating an underlying cause. Disease-centered drugs (like insulin for diabetics) will correct chemical imbalances or abnormalities, and should not have a significant effects on healthy people or cause significant side effects (though there could be exceptions here like e.g. chemotherapy).

This book explains why all psychiatric drugs in use today are better understood as drug-centered drugs, rather than as disease-centered drugs. This doesn’t mean psychiatric drugs are never useful or should never be used, but it does mean care should be taken when prescribing or taking these drugs, because they act by sedating or stimulating, not by addressing any root biological causes of mental illness.

This book also discusses how to safely come off of psychiatric drugs. Because psychiatric drugs do not fix biochemical imbalances but instead create them, if you take a psychiatric medication, the brain will over time adjust neurotransmitter receptor densities to try to correct the chemical imbalance the psychiatric drug has created. This means that a person attempting to stop a psychiatric drug after taking it for a long period of time will likely experience withdrawal effects caused by adaptations their brain has made while taking the drug. These withdrawal effects can be disabling, can be more severe or even unrelated to the original condition the patient was being treated for, and can last for months or even years. Protracted withdrawal is currently still denied by mainstream psychiatry but has been gaining greater and greater public acknowledgement because of the increasing numbers of former patients who have come forward with their experiences.

If you’re new to the world of critical psychiatry, reading Joanna Moncrieff is a great place to start as she is more measured and palatable to a newcomer than some of the other well-known and influential critical psychiatrists. Thomas Szasz was a human rights activist and a visionary, but sometimes comes across as too tied to ideology to be practical — and his claim that someone with schizophrenia is not mentally ill but merely viewing the world in a different way can be a hard sell for many (plus he has pesky and somewhat baffling ties to Scientology). Peter Breggin is a psychiatrist who has done incredible work exposing the harms of psychiatric drugs and written countless books, but recently he’s become a COVID truther and anti-vaxxer. Joanna Moncrieff is way more moderate in comparison — she won’t tell you mental illness is a myth, and in fact she won’t even tell you not to take drugs, she just wants to make sure you know that they are bad for you.


Various quotes:
“…it has become ever-more apparent how little we know about the dangers involved in the use of psychiatric drugs, and how uncertain we remain about any advantages they may confer. In particular, we lack decent research on the harmful consequences of taking these drugs for long periods, even though it is clear that many people use them for years on end. Without proper studies published in scientific journals, people’s suffering often goes unrecognized. Even when research is published, it is frequently ignored if it suggests something that people in power do not want to hear.” (1)

“Psychiatrists maintained that antidepressant withdrawal symptoms were ‘usually mild and self-limiting’ and lasted for no more than one to two weeks. This advice only changed after lobbying by professionals, academics, and those who had experienced withdrawal problems first-hand” (2)

“The psychiatric field has been slow to recognize the damaging effects associated with some psychiatric drugs. The brain-shrinking effects of antipsychotics were first pointed out by American psychiatrist and well-known critic of psychiatric drugs Peter Breggin, back in the 1980s. For decades, his view was ignored and the fact that people diagnosed with schizophrenia had visibly smaller brains and larger brain cavities, as demonstrated by brain scans, was interpreted as evidence of the condition itself… Animal research conducted in the early 2000s produced clear evidence that antipsychotics result in brain shrinkage, yet those findings received little attention. It was only in 2011, after the publication of a large study of patients… confirmed this finding, that opinion started to change.” (4)

“Viewing a mental disorder as a medical disease or condition suggests that it can be identified, quantified, and measured independently of the person who is experiencing the problem. This is the way we think about cancer of the liver, heart disease, or arthritis, for example… but measuring non-physical things like emotional experiences, beliefs and behavior is, many argue, inherently different.” (36)

“It has now been established beyond doubt that antipsychotics cause the brain to shrink. Two studies conducted with animals — one with macaque monkeys and one with rodents — found that animals who were given antipsychotic treatment for a few weeks or months showed a larger degree of brain shrinkage than animals who were given a placebo treatment… Studies of patients confirm that the amount of antipsychotic people receive predicts the amount of brain shrinkage they show. A randomized trial of olanzapine versus placebo for the treatment of psychotic depression also showed that olanzapine was associated with greater thinning of the tissue in the cortex of the brain (the largest and most important part of the human brain) compared with placebo.” (68)

“…trials in which antidepressants are compared with placebo are likely to become ‘unblinded.’ In other words, people will be able to detect whether they have been allocated to take the antidepressant or the placebo because of the drug-induced effects produced by antidepressants. For example, people taking tricyclic antidepressants rapidly become drowsy and sedated, and people taking SSRIs may notice drowsiness, sexual problems, or nausea. If people can improve by taking an inert placebo or dummy pill, through what is known as the ‘ordinary’ placebo effect… then people who are taking a drug that has noticeable side effects may have a stronger or ‘amplified’ placebo response.” (81)

Many studies that appear to show antidepressants providing greater benefit than placebos fail to account for the fact that many participants in antidepressant trials have already been on some other antidepressant, potentially for many years. When they are taken off of that antidepressant during a “washout” period (which is usually only a week) before putting them on a placebo or the new antidepressant being tested, these study participants often end up experiencing withdrawal. If the participant is randomized to take the new antidepressant, this can help ameliorate their withdrawal symptoms if it has pharmacologically similar action to the antidepressant they were taken off of, but if the participant is randomized to placebo, their withdrawal symptoms may be misinterpreted by the study as ‘relapse’. (81-82)

“It has recently become apparent that withdrawal symptoms following cessation of some antidepressants may be severe and prolonged. They may persist for weeks or months after the drug has been stopped, and sometimes even longer. Increasing numbers of people are reporting that withdrawing from these drugs can be extremely difficult and needs to be done very gradually and with extreme care.” (90)

“Implicit in our understanding of emotion is the idea that emotions are typically human reactions to something that has happened, is happening or might happen to someone… Understanding depression or anxiety therefore involves understanding an individual who is struggling with a unique set of circumstances. Labeling people with a pseudo-medical diagnosis obscures the individual’s particular story.” (93)

Lithium has no specific, disease-centered actions against bipolar disorder, it’s just a sedative which also happens to be very toxic. (100)

“Although it used to be said that stimulants produce ‘paradoxical’ effects in people with ADHD — effects that are the opposite to the effects seen in other people — this is not, in fact, true. The altered state produced by low doses of stimulants involves characteristic effects on activity and concentration and these effects have been shown to occur in all children and adults, regardless of whether they have been diagnosed with ADHD or not (Arnsten, 2006; Rapoport et al, 1980).” (111)

“There is more to the effects of stimulants, however. Animal studies show that they inhibit spontaneous exploratory behavior, reduce an animal’s interest in its environment and reduce its social interactions with other animals.” (112)

“A recent study found that adults who were prescribed stimulants for ADHD were almost seven times more likely to develop Parkinson’s disease or a similar brain condition than similar people without an ADHD diagnosis… The association between taking stimulants and Parkinson’s disease is well established among people who take the drugs recreationally.” (118) No surprises here.

“The mainstream view is that ADHD is a brain disease, or at least that it is a mental disorder with specific biological origins. However, others argue that ADHD symptoms are part of the normal variability of behavior, and some evidence backs this up.” (120)

Benzodiazepines cause you to be more anxious in the long term because the brain adapts and overcorrects for the drug’s actions. (Chapter 8)

Psych drugs are bad for you and do not actually treat or correct supposed “chemical imbalance” causes of mental illness. But when patients try to come off of psych drugs after taking them for an extended period of time, they often experience withdrawal symptoms which are nearly always mistaken as relapse. (135)

“Because many psychiatric drugs suppress normal emotional reactions, people who have taken them for long periods have to relearn how to deal with normal emotions again. They may not have felt anger, embarrassment or anxiety for several years, for example. Suddenly, social situations that may provoke such emotions can become more challenging.” (141)

“Most of the commonly used psychiatric drugs reduce arousal in one way or another, which is associated with mental clouding or impairment.” (159)

“Psychiatric drugs do not reverse an underlying biological abnormality, as suggested by the orthodox ‘disease-centered’ view of what they do. In fact, psychiatric drugs create an abnormal biological state.” (171)

[Evan Micheals · Rating 4 out of 5]

This is a challenging book which contradicts a lot of what is promoted about Psychiatric Medication. Joanna Moncrieff writes a book that feels about right, based on my years of experience in the mental health field. I do not pretend to know or understand the science well enough to make an informed statement. I do have 30+ years of experience in the mental health industry. That the ‘science’ remains shadowy for someone as experienced and as well read as me is its own clue.

I wonder if the whole Psychopharmacological Industry is predicated on the Goebbels principle of telling the same lie over and over until people believe you. Moncrieff’s view is the science does not support the existing practice. Moncrieff describes what Wittgenstein would call a scaffolding problem with psychiatric medications. A lot of the current studies have their foundations in what would be considered today as shonky research. The new research is scaffolded onto these the past knowledge creating a knowledge base with shallow foundations and developed a misguided culture (of pharmacological cures of mental illness). She suggests there is no evidence that the long term use of psychiatric medications is beneficial to people. If it is useful it should only be used in an acute phase of someone becoming unwell.

Moncrieff talks about the difference in the disease centred/chemical imbalance focused approach (which is currently accepted) and what Moncrieff calls the drug-centred model where the drug creates an unbalance and moves the brain’s biochemistry away from what is natural in the same way substances such as alcohol do. A theme is that there is not much difference between the illicit psychoactive drugs that people take recreationaly and the psychoactive substances prescribed by GP’s and Psychiatrists that ‘the drugs produce a global state of mental suppression’. Most of the problems when ceasing drugs are withdrawal effects rather that relapse. A fundamental premise is Psychiatric drugs create a form of addiction, rather than correct an imbalance in brain chemistry. “The drugs used in psychiatry are psychoactive chemicals that cause an altered drug induced state, a state of intoxication, in other words (p 105)’.

What Moncrieff argues for is a more honest conversation about Psychiatric Drugs and their effects. She also argues they should only be used for a short time whilst a person is in crisis, and then they be tapered down. She see’s the diabetes-insuline metaphor as disingenuous and manipulative. She is suspicious of the motives of Big Phrama and evidences their poor record in producing iatrogenic effects with their ‘medicines’. What she mostly encourages is honesty and caution in the use of these medications

My own feelings about Psychiatric Medications is that things would have to be dire before I take them myself or recommended a family member, a friend, or a patient consider them. I would want them to try all other options first (Time, Talk Therapy, and Lifestyle Changes). Yet, I have given them to others and recommended other discuss them with their GP or Psychiatrist. We do not lack for people who seem to be having a dire circumstances. The best argument for taking a medication is being a scientist and running an experiment for 3 months. If you life is better, continue. If it has not made a change, try something else. The drugs we give do not come for free, and you have to weigh up whether the treatment is worse that the cure or not.

This is a challenging book and I intend to read more from the Straight Talking series regarding mental health, as well as more work written by Joanna Moncrieff.

[Emma · Rating 5 out of 5]

I was recommended this book by my supervisor after discussing whether I needed to go back on anti depressants or not. It has been an internal battle for me as to whether I should take them long term or not/ wondering how effective they are and also being concerned about the long term impact.
I have to say reading this has been terrifying and eye opening, the general take away is that most drugs don’t do anything other than create an arousal or a sedative affect and that our body permanently strives to reach homeostasis so essentially renders all psychiatric medication useless or very minimally impactful eventually without changing dosages. It also suggest that most of the science behind anti depressants states that the only thing they do is create a drug induced state which distracts us/ creates a slightly sedated affect which creates distance from our difficulties which people then think is making them feel better when in actual fact it’s not doing anything about the underlying problems… essentially a plaster over a cut. There is also no hard evidence to back up that depression is caused by a chemical imbalance and withdrawal from anti depressants is often mistaken for another relapse or depressive episode. I would still take anti depressants if I felt I absolutely needed to but after reading this it does make me wonder whether the positive feelings associated are mainly placebo.

[Oliver Eike · Rating 2 out of 5]

The proper title for the book should be: An Agenda Talking Introduction to Psychiatric Drugs.

For while there is much to agree on in this book, it is also written with a very clear agenda to attack medicine within Psychiatry. While there are much to poke at there, the book also recklessly seems to recommend people to avoid medicine or stop taking it.

So if you are to read this book, focus on the chapter on Stimulants which i think was Chapter 5, and Chapter 11. Chapter 11 speaks on being skeptical to medicines and doctors, which is fair. It is important to be skeptical and ask questions of those who would claim to be an authority. And as such i am skeptical of Joanna Moncrieff and her agenda.

Because there are chances that people with violent psychosis read the book and decide to not take their meds, or their loved ones thinking it being safe to stop taking the meds. Even so, a doctor should always be consulted before stopping meds. Not to just try to just decide yourself to lower or up your doses as she hints at in Chapter 10.

So yeah, much good, but chapter 10 dragged it down a full star for me.

[Serotonin · Rating 5 out of 5]

Libro imprescindible para conocer la realidad de los psicofarmacos y sus mecanismos de acción, pues no todo es lo que explican las farmacéuticas. Recomendado para pacientes, familiares médicos, psicólogos, etcétera. Todo el mundo debería saber lo que explica este libro.

[Ceri Paterson · Rating 5 out of 5]

Loads of information & well written

[Seth · Rating 4 out of 5]

This book is one of the best available on this topic along with the Maudsley Deprescribing Guidelines. Its greatest strength is exploring how common psychiatric drugs work and are prescribed through the current model (disease-centric) and observed through her proposed model (drug-centric). In this way, it is particularly forward thinking, and goes beyond a simple guide by providing a corresponding mental framework while still being accessible to a wide audience.