Beyond the “Chemical Imbalance” theory: An interview with Prof. Joanna Moncrieff

From Psychology Today/Justin Garson, PhD: “I talked with Prof. Moncrieff about her history of advocacy, the future of mental health, and a report that rattled the medical establishment.

. . . Justin Garson (JG): The initial reactions to your paper ranged from, ‘we already knew that the serotonin theory was false,’ to ‘serotonin is one small part of the puzzle but not the whole thing,’ to ‘your paper is harming suffering patients.’ Which of the reactions to your paper most surprised you, if any?

Joanna Moncrieff (JM): I was surprised, first of all, by the level of public interest and then by the defensiveness of the profession. I probably wasn’t surprised by them saying, ‘oh, yes, we already knew that.’ And I wasn’t surprised by people saying, ‘oh, it’s all more complicated,’ because everything’s always more complicated [laughs].

I guess none of that was really a surprise, but the level of defensiveness was extraordinary, and the fact that the profession found it quite impossible to be honest with people, that actually these results have major implications for how we think about antidepressants and whether you should be using them.

. . . JG: One common response to your paper has been: look, we always knew serotonin abnormalities were one small part of a larger puzzle, probably involving a complex relation between serotonin and other brain chemicals and adverse life experiences. Aren’t you just presenting a caricature of what a compelling theory would look like?

JM: Saying that depression is caused by serotonin, but also caused by everything else is not a theory [laughs]. That’s the first thing. You need a hypothesis to test. And the serotonin hypothesis was a testable hypothesis.

Prior to the 1990s, people generally thought of depression, in particular, as a reaction to life events. And they thought that taking drugs to modify your mood was generally not a good idea. The pharmaceutical industry set out to change that mindset when they were marketing the SSRIs and SNRIs, with campaigns that told people depression was caused by a chemical imbalance.

My point is, in order to change people’s natural inclination to understand moods as a response to what happens to us, it was necessary to tell people that something had been proved or to give the impression that the science was certain or settled.

. . . JG: In the 1980s, psychiatry came under the grips of a disease-centered paradigm that it hasn’t yet broken free from. In my view, part of psychiatry’s breaking free from that paradigm will involve presenting a compelling alternative vision of mental health and healing. In a few words, what’s your alternative vision?

JM: I think we’ve got to thoroughly demedicalize the whole enterprise of mental health, because I think it does a lot of damage to persuade people that they have a brain abnormality and that they need some chemical or physical intervention to put that right. Which is not to say that I don’t think that sometimes when people are acutely psychotic, for example, chemicals can’t be helpful in some ways. But telling people they have a brain abnormality, or some physical medical problem, is profoundly disempowering. So, I think we’ve got to get away from that.”

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