For almost half a century, psychiatry’s narrative has been that we have effective and safe drugs for depression that fix a chemical imbalance. Even though none of this is correct, and even though the false narrative is harmful for the patients, health professionals, drug agencies, medical journals and the media are doing their best to maintain it. I shall illustrate this with two recent examples.
False statements in package inserts about a chemical imbalance
In January 2025, I notified the UK drug regulator, the Medicines & Healthcare products Regulatory Agency (MHRA), that the package inserts for antidepressants — called patient information leaflets (PIL) — contain false statements about depression being caused by a chemical imbalance, and I called for the misleading messages to be removed.
Depression is almost always caused by depressing life events or living conditions. As a patient once said to his doctor, “I don’t want an antidepressant, I want a job!” However, most patients are told they are depressed because they have a chemical imbalance in their brain and are then prescribed a pill that is supposed to fix this problem. This lie is very harmful. When patients are told there is something wrong in their brain chemistry that a drug can fix, why should they ever stop? Most patients on depression pills take them for many years.
No reliable research has ever shown the existence of any chemical imbalance causing depression, and in 2022, a comprehensive literature review by psychiatrist Joanna Moncrieff and colleagues showed that there is no support for saying that depression is caused by a lack of serotonin in the brain.
As I have described on Mad in America, the MHRA refused to make any changes. The MHRA is primarily funded by the drug companies it is supposed to be regulating. We must insist they overcome this conflict of interest and change their false and harmful information.
With Joanna Moncrieff, Gabriel Symonds, and John Read, I sent the above information as a letter to four major UK newspapers, The Guardian, The Independent, The Times, and the Daily Mail. We also called upon the Royal College of Psychiatrists to support us and the patients by demanding of the MHRA that they don’t propagate untruthful statements in their information to patients. As the Royal College has no email address on their website, I used their contact form, enclosing our letter to The Guardian, with this message:
To the Royal College of Psychiatrists
Psychiatry’s biggest lie: “Your depression is caused by a chemical imbalance”
Please see attached letter, particularly its last sentence. We sent this letter to The Guardian today as our first try. You might not be able to see the hyperlinks.
We very much hope you will support us, thereby supporting hundred of thousands of patients who wrongly believe that their depression is caused by a chemical imbalance in the brain, which is one of the reasons why many patients stay on their drug for far too long, sometimes even for the rest of their lives.
We look forward to your reply.
None of the four newspapers or the Royal College had the courtesy to reply. The media and the leading psychiatrist organisation in the UK don’t seem to care that our drug regulators lie to the patients about psychiatric drugs, even though these drugs are so overprescribed and so harmful that they are the third leading cause of death.
In New Zealand, psychologist Giselle Bahr and other health professionals got nowhere when they approached MedSafe — the New Zealand drug regulator. They then contacted the drug companies and persuaded the suppliers of amitriptyline, citalopram, clomipramine, dosulepin, mirtazapine, and paroxetine to remove the chemical imbalance statement from their Consumer Medicine Information. The suppliers of escitalopram (Lundbeck) and imipramine (AFT Pharmaceuticals) refused to comply. And a government regulator, the Commerce Commission, refused to raise this matter with the companies.
What should we do? I don’t regret that I called my most recent book about psychiatry, “Is psychiatry a crime against humanity?” It surely is and those who can accomplish the much-needed changes, turn their back to the atrocities. The book can be downloaded for free here.
How to avoid weighing the benefits and harms of SSRIs in a Lancet editorial
On 10 May 2025, an anonymous editorial in The Lancet, “50 years of SSRIs: weighing benefits and harms,” did little of what its title promised. I submitted a comment (700 words allowed) where I tried to be as gentle as possible to increase my chance of having it published.
It was rejected right away and I was told I could submit a letter to the editor. You have to be really quick, as you must submit it within two weeks after the publication, and brief as well, as only 250 words and 5 references are allowed.
There was therefore no room for my pleasantries. My letter was rejected on 23 June after it was discussed with the Editor-in-Chief, Richard Horton, whom I assume wrote the editorial: “weighing it up against other submissions we have under consideration, I am sorry to say that we are unable to accept it for publication.”
I expected this outcome because my letter explains why the editorial is meaningless and seriously misleading. Here it is, but see also my additional points after the references:
The Lancet did not really weigh benefits and harms.1 The effect of SSRIs on depression is far below the least clinically relevant effect.2 And the patients don’t like the drugs, they prefer a placebo: 12% more patients dropped out for any reason while on drug than on placebo.3 And half the patients have their sex life disturbed or made impossible by the drugs.2
FDA’s 2004 black box warning was not about a “possible” increased risk of suicidality in young adults. It was real and documented in the placebo-controlled studies. Furthermore, the drugs double not only the risk of suicide, but also actual suicides, and not only in children, but also in adults.4
First-line treatment for severe depression should not include an antidepressant. In contrast to pills, psychotherapy has an enduring effect2 and a systematic review showed it halved the risk of new suicide attempts in people admitted to hospital after a suicide attempt.2 Moreover, the widespread belief that the drugs are more effective in severe depression is wrong. It is based on mathematical artefacts,2 and even if the bias is ignored, the drugs do not provide clinically relevant effects in very severe depression.2
The balance between benefits and harms is negative for depression drugs. It is noteworthy that the World Health Organisation has recently called for urgent transformation of mental health policies, with a psychosocial focus, informed consent, no coercion, and less drug use.5
Declaration of interests: I have no conflicts of interest.
References
1 50 years of SSRIs: weighing benefits and harms. Lancet 2025;405:1641.
2 Gøtzsche PC. Critical psychiatry textbook. Copenhagen: Institute for Scientific Freedom; 2022. https://www.scientificfreedom.dk/books/ (freely available, accessed 13 May 2025).
3 Sharma T, Guski LS, Freund N, Meng DM, Gøtzsche PC. Drop-out rates in placebo-controlled trials of antidepressant drugs: A systematic review and meta-analysis based on clinical study reports. Int J Risk Saf Med 2019;30:217-32.
4 Hengartner MP, Plöderl M. Reply to the Letter to the Editor: “Newer-Generation Antidepressants and Suicide Risk: Thoughts on Hengartner and Plöderl’s ReAnalysis.” Psychother Psychosom 2019;88:373-4.
5 New WHO guidance calls for urgent transformation of mental health policies. WHO 2025; Mar 25. https://www.who.int/news/item/25-03-2025-new-who-guidance-calls-for-urgent-transformation-of-mental-health-policies (accessed 13 May 2025).
Additional points
I included some of the points below in my submitted comment. For example, I praised The Lancet for acknowledging the important work of Joanna Moncrieff and for acknowledging that SSRIs can cause a protracted withdrawal syndrome, necessitating a gradual tapering when they are stopped. This is essential to know, as psychiatrists and other doctors virtually always mistake withdrawal symptoms for relapse (see my Critical Psychiatry Textbook), which tends to keep the patients on drugs they don’t need for decades.
Lancet noted that, “For many, SSRIs have been profoundly helpful in managing their health and continue to have an important place in care.” This is the mantra the media always use. Where are all those “many”? We cannot see them, and, given that the drugs provide no meaningful benefit over placebo and have substantial harms, SSRIs are not profoundly helpful. People become better over time but this is the spontaneous improvement that would have occurred also without drugs.
Lancet misrepresented Joanna’s book Chemically Imbalanced. The editor referred to a 2002 meta-analysis she mentions, which concluded that the effects of SSRIs are clinically negligible compared with placebo. And then says that “other studies have shown effectiveness, including a 2018 meta-analysis in The Lancet, which concluded that all antidepressants are more efficacious than placebo in adults with a diagnosis of major depressive disorder, with odds ratios ranging between 2.23 and 1.37.”
This is extremely misleading. First, Lancet failed to note that Joanna, in her book, comprehensively deconstructed the Lancet 2018 meta-analysis by Cipriani and colleagues, and moreover, she doesn’t rest her case on a single meta-analysis from 2002.
Second, the 2018 meta-analysis is so flawed that I published the article, “Rewarding the companies that cheated the most in antidepressant trials” and my research group showed that the outcome data differed from the clinical study reports in 63% of the trials; that the effect of the drugs was higher in published than in unpublished trials; and that there was a high risk of bias in the trials.
Third, the effect in the Cipriani review is very similar to that estimated in other reviews and so small that it lacks any clinical relevance (effect size 0.30), which Joanna, I and others pointed out in a letter to the editor of The Lancet.
Fourth, it is highly misleading to dichotomise a ranking scale outcome, which we also pointed out. The odds ratio gives a false impression of the effect of the drugs.
According to Lancet, “Some psychiatrists have argued that delineating a clear mechanism of action is unimportant as long as the treatment is effective.” The trouble with this argument is that the drugs are ineffective.
We were also told that “fluoxetine transformed the treatment of depression and associated psychiatric conditions.” This was meant to be positive, but it isn’t. After its launch, fluoxetine quickly became the most complained-about drug, with hundreds of out-of-character suicides and homicides. And, as David Healy and I recently demonstrated, the two pivotal fluoxetine trials in children were fraudulent.
Lancet said that “First-line treatments for more severe depression should be individual cognitive therapy combined with an antidepressant.” However, in contrast to pills, psychotherapy has an enduring effect (see my Critical Psychiatry Textbook) and it can halve the risk of new suicide attempts in people admitted to hospital after a suicide attempt. Moreover, the widespread belief that the drugs are more effective in severe depression is wrong. It is based on two mathematical artefacts, and even if these biases are ignored, the drugs do not provide clinically relevant effects in very severe depression.
Lancet also argued that “many general practitioners are pressed for time and short on options. A pill, the reasoning goes, might be better than nothing.” It isn’t. Doing nothing is better than prescribing a pill, and psychotherapy is better than both options.
We need to change the false narrative. The balance between benefits and harms is negative for depression drugs, and we have a mental health crisis because the existing drug focused approaches are not working. The World Health Organization has recently called for urgent transformation of mental health policies, with a psychosocial focus and less drug use.
What the Lancet editorial illustrates is that we should regard traditional medical journals as more or less dead. This is not where we can expect to be informed in the most reliable way. Horton has himself stated that “Journals have devolved into information laundering operations for the pharmaceutical industry.” The Lancet is certainly no exception to this.
