The passing of each year brings further evidence of the dangers and failings of psychiatric drug treatments. Peter Breggin, David Cohen, David Healy, Bob Whitaker and Joanna Moncrieff have all made substantial contributions to unmasking the shameful deceits and pseudoscience that masquerade as theory and evidence as far as psychiatric treatment is concerned. Yet despite this, drugs continue to dominate psychiatric practice.
If the blimp that is psychiatric treatment were a passenger aircraft, the authorities would have grounded it many years ago, but still it continues to inflict harm on countless thousands of people. I read Joanna Moncrieff’s latest book with a growing sense of anger and shame. The roots of drug treatment in psychiatry are thoroughly rotten. They sustain the decaying trunk of psychiatric theory and practice through misrepresentations and untruths; it is snake oil peddled by quackery.
She picks up the narrative she started in The Myth of the Chemical Cure (Moncrieff, 2008), but The Bitterest Pills is concerned primarily with neuroleptic drugs. She describes in detail how they came to be seen as a ‘specific’ treatment for schizophrenia and, increasingly, other psychoses. Starting with the transformation of chlorpromazine into psychiatry’s first wonder drug, she describes the origins of the dopamine theory of schizophrenia as a post-hoc rationalisation, based in the observation that the drug, which appeared to damp down acute psychosis, was subsequently discovered to block dopamine transmission in the brain. She dismantles the evidence for the effectiveness of these drugs with the precision of a Swiss watchmaker. As she points out in chapter six; despite all the claims made for the effectiveness of neuroleptics in schizophrenia, no placebo-controlled study of their use in first-episode psychosis has ever been conducted.
In her earlier work (Moncrieff and Cohen, 2005; Moncrieff, 2008) Joanna Moncrieff has set out the distinction between drug-centred and disease-centred models of psychotropic drug action. The latter holds that neuroleptics are effective because they have the specific property of rectifying a biochemical ‘abnormality’ (an excess of dopamine activity in certain brain areas) believed to be responsible for the symptoms of acute schizophrenia. The difficulty, as she indicates in chapter four, is that there is no evidence to link excessive dopamine activity to schizophrenia. In contrast, the drug-centred model maintains that psychotropic drugs may help some people because they induce abnormal brain states. In the case of neuroleptics this arises through the complex effects they have on consciousness (inducing indifference) and motor activity (reducing it).
I found that one of the most significant achievements of her book is the light it casts on why the disease-centred model is so attractive to psychiatrists. Chlorpromazine was introduced barely ten years after penicillin revolutionised the treatment of infections, saving countless lives in the Second World War. In the guise of Largactil it became psychiatry’s ‘magic bullet’, reaffirming its medical credentials just as the medical profession more generally was becoming increasingly identified with drug treatment.
This appeal to a medical identity also helps us to understand why so many psychiatrists are reluctant to face up to the implications of serious critiques of the scientific basis of psychiatric practice. To accept these critiques would result in a crisis of legitimacy for the role of doctors in mental health. I have a different view of this. Dr Moncrieff’s work is a threat to the role of the doctor if you believe that the medical role is restricted to prescribing medication and checking for concurrent physical illness. I don’t subscribe to that view, and have more to say about how doctors can work without drugs and physical treatments, with people who experience madness and distress, in my forthcoming book about the future of psychiatry.
Chapter seven deals with the subjective experiences reported by people who take neuroleptics, which has potential as the starting point for a systematic investigation of the drug-centred model. Most of the evidence here comes from people who use psychiatric services, but I must confess a personal interest. Some years ago I was one of the subjects in David Healy’s study of droperidol referred to by Joanna Moncrieff. This experience served the purpose of reinforcing my determination to help as many of my patients as possible to reduce or come off these drugs. The coercive use of medication is the subject of chapter eight. In it she contrasts patients’ experiences of coercion, described as humiliating and degrading, with the presentation of coercion in the psychiatric literature (on the rare occasions it is addressed) as ‘therapeutic’.
Chapter nine examines the relationship between long-term neuroleptic use and brain atrophy. For years cerebral atrophy has been presented as an intrinsic part of the disease process of schizophrenia. The evidence implicating neuroleptics in this has met with indifference or denial in the profession. Indeed, her account of how the profession and the pharmaceutical industry have played down these serious consequences of long-term neuroleptic drug treatment is a shameful spectacle.
There is a much to admire about Joanna Moncrieff’s book, but treading the path of a critical psychiatrist can at times be a fine balancing act. If her message is to get through to the profession, its tone and positioning are of utmost importance. If the message is too strident the wagons will circle and the cowboys will start to let the Indians have it with everything they’ve got. This is how the profession responded to the attacks of so-called antipsychiatrists in the 1960s. For this reason I suspect that some may find her arguments too cautious, possibly to the point of ambivalence. There is evidence, however, that her carefully articulated tone is having an impact within the academic elites. The prominent British psychiatrist Robin Murray was very supportive of her systematic review written with Jonathan Leo about the effects of neuroleptics on brain volume, published in Psychological Medicine (Moncrieff and Leo, 2010)
There are two main criticisms I would make of this book. Given all that she has to say about the problems associated with the long-term use of neuroleptics, there is little in the way of practical guidance to psychiatrists about how these drugs might be used to help people in the short-term, whilst minimising their potential for harm. There is also little advice or guidance about reducing or coming off neuroleptics for those who are taking them.
True, there is a chapter on this topic in her short book about psychiatric drugs (Moncrieff, 2009), but perhaps more advice on the topic would have been valuable. That said, perhaps the greatest impact of her work is that it creates spaces for voices that are usually excluded from psychiatric discourse about drugs; those of service users/survivors and families. One important source of evidence about coping with coming off neuroleptics is to be found in the stories and testimony of service users and survivors. This can be seen in the recent post by Sera Davidow, Laura Delano and Sean Donovan on Moving Beyond the Medical Model. Here in England, Rachel Waddingham, Rob Allison, Adam Jughroo and I are in the early stages of collecting fifty stories of people’s experiences of reducing or coming off neuroleptics. Stories, whether in video or text, have the power to set free by opening up new possibilities for those who otherwise might never have countenanced the idea of coming off.
My other criticism concerns the prospect of mapping the subjective experiences of neuroleptics, and for that matter other psychiatric drugs, on to particular neurochemical mechanisms (chapter seven). This is another version of the problems of neuroscience in accounting for consciousness (see my earlier blog Why Neuroscience Cannot Explain Madness). The subjective experiences we have when we take a drug that affects consciousness arise not only from the effects of the drug on the central nervous system and the physical body. It is also the product of a wide range of contextual factors. Take as an example the consumption of alcohol. When I was a young man the subjective effects I experienced from alcohol when out drinking with friends after playing cricket depended amongst other things on the outcome of the game. Our excitement at winning, especially if I had taken a few wickets, would become elation fuelled and released by alcohol. In contrast two or three pints of beer tipped downheartedness at defeat into a miserable silence. The subjective effects of drugs, legal, illegal or therapeutic are contents of consciousness that are embodied and encultured, and thus saturated with meaning and values. For this reason I have serious doubts about the ability of neuroscience and psychopharmacology to generate anything like a comprehensive account of these aspects of consciousness, let alone one that might have some limited utility in psychiatry.
These minor quibbles should not mar the valuable contribution I hope this book will make towards a more rational, transparent and ethical approach to the use of neuroleptic drugs. By implication it also offers up a strong argument for much wider choice for people in crisis, particularly the provision of minimal drug/drug-free systems of help and support, such as Soteria-type facilities and Open Dialogue. It is a must-read for all psychiatrists and mental health professionals, and its accessibility means that many survivors/service users and carers will find it a valuable ally in their fight for more humane and less harmful alternatives to psychiatric drug treatment.
References
Moncrieff, J. & Cohen, D. (2005) Rethinking models of psychotropic drug action. Psychotherapy and Psychosomatics 74, 145 – 153.
Moncrieff, J. (2008) The Myth of the Chemical Cure. Basingstoke, Palgrave Macmillan.
Moncrieff, J. (2009) A Straight Talking Introduction to Psychiatric Drugs. Ross-on-Wye, PCCS Books.
Moncrieff, J. & Leo, J. (2010) A systematic review of the effects of antipsychotic drugs on brain volume. Psychological Medicine. 10, 1 – 14.
