Criticizing Moncrieff (and similar people) is complicated ... So many laypeople still believe in an extremely simplified chemical imbalance theory (need not be for depression only, but for everything psychiatric). Like some slightly updated version of the medieval humour theory - the four humours of serotonin, dopamin, and ... maybe adrenalin and oxytocin, must be balanced! The doctors job is to balance them.
This can be somewhat helpful for people who try to defend themselves from a constant barrage of "you wouldn't need those pills if you just exercised more or learnt to pull yourself together like the adult you are or ... (insert more blamey stuff)". I gather this is much more common among those on anti-depressants or ADHD-stimulants than if you're on anti-psychotics like I was, and I get that it sucks.
Also, if you ARE a schizo-something-psychosis patient, there's this constant message of "you're basically brain damaged already and if you have a relapse you're gonna get much more brain damage so you GOTTA TAKE YOUR PILLS" and then reading some Moncrieff stuff that questions this narrative really was like a breath of fresh air.
In general, this whole narrow biomedical framework is often pushed on people from clinicians, and it's great to find someone who questions that. (I think people who do research in addition to clinical work, like you do Awais, and who know many other smart people in the field, sometimes underestimate how common all kinds of simplified and/or uninformed bullshit is among both GPs and non-research psychiatrists.)
HOWEVER. Moncrieff is, as far as I know, not Mad herself. Just like traditional psychiatrists, she's got this favourite narrative that she pushes on those concerned. (And even if she were Mad, she shouldn't make sweeping generalizations based on her own case alone, and speak over those who can't make themselves heard in the same way).
She says, for instance, that anti-psychotics only numb people down, and don't actually have an anti-psychotic effect. I think this is intended to be a liberating message, and it might be for those psych patients who have this experience, but their doctors insist that the meds do much more than that and won't listen to what they say. But I did NOT have that experience with Haldol, and telling me that I can't understand my own experiences, but SHE does, is pretty damn disrespectful.
Actually testing this claim would be pretty hard, but it would probably involve something like gradually replacing the anti-psychotics with benzos for one group and not doing it with another, and then it should be double-blind. If people like me, who said they experienced an anti-psychotic effect, couldn't tell the difference between being on Haldol and being on Xanax in a blinded study, that would provide some evidence. But in the absence of evidence, the default position should be to take people's self-reports seriously (thus, taking seriously that the effects of those meds vary a lot between individuals). It should NOT be to assume that Moncrieff is right and everyone else is wrong.
This is a problem not just with Moncrieff, but with lots of critical psychiatrists or anti-psychiatrists. At the end of the day, it's more voices from up high who wants to push THEIR narrative on all the Madpeople, service users, patients, survivors (you do you re terminology) down there, regardless of whether they agree or not.
Wow what an excellent rebuttal of Dr Moncrieff, and of the unfortunate article that disseminates her misleading views! I echo Dr. Pies comment: You have taken on a Sisyphean task. It is Sisyphean, and it also reminds me of never-ending battles against zombies in horror movies. Denying the material basis of experience is a zombie idea that should be have been dead long ago - It is in fact dead - but it keeps getting up off the ground and lumbering towards us again and again. .I suspect that the temptation to deny materiality somehow motivates Dr Moncrieff and the journalist who interviewed her - a journalist who mindlessly got the ball and ran with it. Thanks for the detailed reasoning and evidence!
Thank you for taking on what is surely a Sisyphean task, Awais--pushing that boulder up a mountain of misunderstanding, misrepresentation, and misstatement! After 45 years in psychiatry, I am still amazed by the almost complete inability of "lay" journalists to grasp the relevant issues, arguments and conclusions in the endless debate over antidepressants. May I respectfully suggest to your readers the following source material, related to your posting:
To be clear: the above material--much of which Dr. George Dawson and I developed-- does not directly deal with the efficacy of antidepressants, which, as you note, is a separate and very complicated issue. To summarize a boatload of studies, I am of the view that these agents are modestly-to-moderately effective in the treatment of acute, non-bipolar depression, when compared with the placebo condition (which is not merely the provision of a "sugar pill", but involves a good deal of supportive professional contact).
Long-term or "maintenance" use of antidepressants for 2 or more years is less robustly supported by existing studies, but may be necessary for unipolar depressed patients with multiple (3 or more) episodes of severe, incapacitating depression. In my view, for mild-to-moderate depressive states, "talk therapy" alone is generally the treatment of first choice. The combination of psychotherapy and medication is probably the most effective treatment for many severely depressed patients.
Finally, too much emphasis has been placed on the full-scale Hamilton Depression Scale as a measure of antidepressant efficacy, and too little on "quality of life" (QOL) for depressed patients. Most of the QOL studies--imperfect though they are--show the benefits of antidepressant treatment. For more on these issues, please see:
Pies RW. Antidepressants: Conundrums and Complexities of Efficacy Studies. J Clin Psychopharmacol. 2016 Feb;36(1):1-4. doi: 10.1097/JCP.0000000000000455. PMID: 26658086.
Thank you again, Dr. Aftab, for "fighting the good fight" in behalf of our patients and our profession!
"There is a good reason why one pharmaceutical company after another developed me-too serotonergic antidepressants." Yes, because the profit margins were staggering. The negative trials were buried, or distorted to be positive. Erick Turner showed that half the trials of SSRI were negative, but the drug companies selectively published them so that 15 times as many were positive as negative. How many MD's would have prescribed these pills if they knew the truth, that half the studies showed they were useless? How many MD's would have prescribed them if they knew inert placebos were used, and thus much of the improvement could be due to penetrating the blind by the presence of side-effects? There actually has never been a scientifically valid study of SSRI/SNRI, because active placebos have not been used.
Subsequent meta-analyses took the publication bias into account, so that's old news in the efficacy debate at this point. The Turner at al paper came out in 2008 and got a lot of coverage, but providers have not stopped using these meds.
Active placebo is what if. If someone conducts an adequate trial with active placebos, we can discuss and analyze the results. The available data from RCTs with regards to unblinding from side effects doesn't suggest that explains the efficacy. If you were to maintain that trials are only scientifically valid if there are fully blinded active placebos, you'd have to acknowledge that there has never been a "scientifically valid study" of psychotherapy because psychotherapy can't be blinded to begin with. (Plus clinical practice isn't blinded)
Criticizing Moncrieff (and similar people) is complicated ... So many laypeople still believe in an extremely simplified chemical imbalance theory (need not be for depression only, but for everything psychiatric). Like some slightly updated version of the medieval humour theory - the four humours of serotonin, dopamin, and ... maybe adrenalin and oxytocin, must be balanced! The doctors job is to balance them.
This can be somewhat helpful for people who try to defend themselves from a constant barrage of "you wouldn't need those pills if you just exercised more or learnt to pull yourself together like the adult you are or ... (insert more blamey stuff)". I gather this is much more common among those on anti-depressants or ADHD-stimulants than if you're on anti-psychotics like I was, and I get that it sucks.
Also, if you ARE a schizo-something-psychosis patient, there's this constant message of "you're basically brain damaged already and if you have a relapse you're gonna get much more brain damage so you GOTTA TAKE YOUR PILLS" and then reading some Moncrieff stuff that questions this narrative really was like a breath of fresh air.
In general, this whole narrow biomedical framework is often pushed on people from clinicians, and it's great to find someone who questions that. (I think people who do research in addition to clinical work, like you do Awais, and who know many other smart people in the field, sometimes underestimate how common all kinds of simplified and/or uninformed bullshit is among both GPs and non-research psychiatrists.)
HOWEVER. Moncrieff is, as far as I know, not Mad herself. Just like traditional psychiatrists, she's got this favourite narrative that she pushes on those concerned. (And even if she were Mad, she shouldn't make sweeping generalizations based on her own case alone, and speak over those who can't make themselves heard in the same way).
She says, for instance, that anti-psychotics only numb people down, and don't actually have an anti-psychotic effect. I think this is intended to be a liberating message, and it might be for those psych patients who have this experience, but their doctors insist that the meds do much more than that and won't listen to what they say. But I did NOT have that experience with Haldol, and telling me that I can't understand my own experiences, but SHE does, is pretty damn disrespectful.
Actually testing this claim would be pretty hard, but it would probably involve something like gradually replacing the anti-psychotics with benzos for one group and not doing it with another, and then it should be double-blind. If people like me, who said they experienced an anti-psychotic effect, couldn't tell the difference between being on Haldol and being on Xanax in a blinded study, that would provide some evidence. But in the absence of evidence, the default position should be to take people's self-reports seriously (thus, taking seriously that the effects of those meds vary a lot between individuals). It should NOT be to assume that Moncrieff is right and everyone else is wrong.
This is a problem not just with Moncrieff, but with lots of critical psychiatrists or anti-psychiatrists. At the end of the day, it's more voices from up high who wants to push THEIR narrative on all the Madpeople, service users, patients, survivors (you do you re terminology) down there, regardless of whether they agree or not.
Wow what an excellent rebuttal of Dr Moncrieff, and of the unfortunate article that disseminates her misleading views! I echo Dr. Pies comment: You have taken on a Sisyphean task. It is Sisyphean, and it also reminds me of never-ending battles against zombies in horror movies. Denying the material basis of experience is a zombie idea that should be have been dead long ago - It is in fact dead - but it keeps getting up off the ground and lumbering towards us again and again. .I suspect that the temptation to deny materiality somehow motivates Dr Moncrieff and the journalist who interviewed her - a journalist who mindlessly got the ball and ran with it. Thanks for the detailed reasoning and evidence!
Thank you for taking on what is surely a Sisyphean task, Awais--pushing that boulder up a mountain of misunderstanding, misrepresentation, and misstatement! After 45 years in psychiatry, I am still amazed by the almost complete inability of "lay" journalists to grasp the relevant issues, arguments and conclusions in the endless debate over antidepressants. May I respectfully suggest to your readers the following source material, related to your posting:
https://www.researchgate.net/publication/362455607_The_Serotonin_Fixation_Much_Ado_About_Nothing_New
https://www.psychiatrictimes.com/view/debunking-two-chemical-imbalance-myths-again
https://www.researchgate.net/publication/361537710_An_%27urban_legend%27_remains_an_%27urban_legend%27
https://www.psychiatrictimes.com/view/antidepressants-do-not-work-by-numbing-emotions
To be clear: the above material--much of which Dr. George Dawson and I developed-- does not directly deal with the efficacy of antidepressants, which, as you note, is a separate and very complicated issue. To summarize a boatload of studies, I am of the view that these agents are modestly-to-moderately effective in the treatment of acute, non-bipolar depression, when compared with the placebo condition (which is not merely the provision of a "sugar pill", but involves a good deal of supportive professional contact).
Long-term or "maintenance" use of antidepressants for 2 or more years is less robustly supported by existing studies, but may be necessary for unipolar depressed patients with multiple (3 or more) episodes of severe, incapacitating depression. In my view, for mild-to-moderate depressive states, "talk therapy" alone is generally the treatment of first choice. The combination of psychotherapy and medication is probably the most effective treatment for many severely depressed patients.
Finally, too much emphasis has been placed on the full-scale Hamilton Depression Scale as a measure of antidepressant efficacy, and too little on "quality of life" (QOL) for depressed patients. Most of the QOL studies--imperfect though they are--show the benefits of antidepressant treatment. For more on these issues, please see:
Pies RW. Antidepressants: Conundrums and Complexities of Efficacy Studies. J Clin Psychopharmacol. 2016 Feb;36(1):1-4. doi: 10.1097/JCP.0000000000000455. PMID: 26658086.
Thank you again, Dr. Aftab, for "fighting the good fight" in behalf of our patients and our profession!
Best regards,
Ron
Ronald W. Pies, MD
"There is a good reason why one pharmaceutical company after another developed me-too serotonergic antidepressants." Yes, because the profit margins were staggering. The negative trials were buried, or distorted to be positive. Erick Turner showed that half the trials of SSRI were negative, but the drug companies selectively published them so that 15 times as many were positive as negative. How many MD's would have prescribed these pills if they knew the truth, that half the studies showed they were useless? How many MD's would have prescribed them if they knew inert placebos were used, and thus much of the improvement could be due to penetrating the blind by the presence of side-effects? There actually has never been a scientifically valid study of SSRI/SNRI, because active placebos have not been used.
Subsequent meta-analyses took the publication bias into account, so that's old news in the efficacy debate at this point. The Turner at al paper came out in 2008 and got a lot of coverage, but providers have not stopped using these meds.
Active placebo is what if. If someone conducts an adequate trial with active placebos, we can discuss and analyze the results. The available data from RCTs with regards to unblinding from side effects doesn't suggest that explains the efficacy. If you were to maintain that trials are only scientifically valid if there are fully blinded active placebos, you'd have to acknowledge that there has never been a "scientifically valid study" of psychotherapy because psychotherapy can't be blinded to begin with. (Plus clinical practice isn't blinded)