0:00

and welcome to Ways to Change the

0:02

World. I'm Krishnaguru Murthy and this

0:04

is the podcast in which we talk

0:06

to extraordinary people about the big

0:08

ideas in their lives and the events

0:10

that have helped shape them. My

0:12

guest this week is Joanna Moncrief. Now

0:14

Joanna is a psychiatrist and is

0:16

perhaps the leading sceptical voice in the

0:18

use of antidepressants to treat depression.

0:21

She has written... and she's appeared on

0:23

a lot of media and she's

0:25

a controversial figure and her latest book

0:27

is called chemically imbalanced the making

0:29

and unmaking of the

0:31

serotonin myth

0:33

Joanna how would you change

0:35

the world? I would radically

0:38

demedicalize our understanding and treatment

0:40

of mental health problems. I think

0:42

that understanding things like depression,

0:44

anxiety, ADHD, et cetera, as if

0:46

they are medical problems that

0:48

arise from the brain is harmful

0:50

to the individuals themselves. I

0:52

don't think it leads to good

0:54

outcomes. And I think it's

0:57

harmful to society because it distracts

0:59

our attention from what is

1:01

actually making people unhappy and stressed

1:03

in the first place. And

1:05

so I would relocate. help for

1:07

people with mental health problems out

1:09

of medical facilities, out of GP

1:11

surgeries, probably to somewhere like social

1:13

services, where they wouldn't be treated

1:15

for their diagnosis, for their label,

1:17

but actually helped to deal with

1:19

the problems that had made them

1:21

unhappy or anxious or stressed in

1:24

the first place. So you're not

1:26

talking about just

1:28

replacing drugs with therapy.

1:30

You're talking about tackling the

1:32

underlying causes of... depression. Yes,

1:34

absolutely. I mean, I do think therapy

1:36

is helpful for some people in some

1:38

situations, but I don't think it's a

1:40

panacea. And I think the main problem

1:42

is that we think of people who

1:44

are depressed as having this thing called

1:46

depression, and we treat the depression rather

1:48

than helping the individual with their individual

1:50

difficulties. I mean, there are between eight and

1:52

nine million people, we think, being

1:54

treated for depression with antidepressants in

1:57

Britain at the moment. And it's

1:59

thought to be a growing diagnosis post

2:01

-pandemic. big increase

2:03

in mental health

2:05

treatment. And what

2:08

you're saying is there's nothing

2:10

biologically wrong? Yes, I

2:12

am saying that we haven't

2:14

found evidence that there is

2:16

a biological process that causes

2:18

this condition, if we want to

2:20

call it a condition. What is the

2:22

serotonin myth that you think you're correcting? One

2:25

of the... theories of

2:27

depression that was proposed several decades

2:29

back now was the idea that

2:31

depression is due to a deficiency

2:33

of certain brain chemicals. And serotonin

2:35

was one of the brain chemicals

2:37

that was suggested to be relevant

2:39

in depression in particular. So

2:42

this is referred to as

2:44

the serotonin theory of depression.

2:46

It was articulated by medical

2:48

researchers back in the 1960s.

2:50

There was a big project to try

2:53

and detect abnormalities in serotonin and

2:55

other brain chemicals that were proposed in

2:57

the 1970s and 80s. They

2:59

didn't find anything. The

3:01

theory sort of fell out of favor

3:03

in the... 1980s,

3:05

but then it was recruited

3:07

by the pharmaceutical industry when

3:09

they released the SSRIs in

3:12

the late 1980s and early

3:14

1990s to help to market

3:16

that range of drugs. And

3:18

that's when this idea that

3:20

depression is caused by a

3:22

chemical imbalance became really widely

3:24

known by the general public

3:26

and featured in advertisements and

3:29

on pharmaceutical industry websites and

3:31

that sort of thing. an

3:34

explanation that

3:36

is used now for

3:39

depression or for prescribing

3:41

SSRIs. But you're

3:43

saying that's still a common

3:45

misunderstanding? Well,

3:47

I think the question has

3:49

to be, if antidepressants are

3:51

not correcting a serotonin deficiency or

3:54

some other chemical imbalance, as they

3:56

were initially said to be doing,

3:58

then what are they doing? That's

4:00

a slightly different question. What

4:03

I'm trying to tackle and get into

4:05

what you think is wrong with the way

4:07

things are prescribed at the moment is,

4:09

do you think people who go on to

4:11

antidepressants still think that this is the

4:13

reason? And what's your evidence for that? I

4:15

think there's an assumption. by the

4:18

medical profession as well as by

4:20

patients, that antidepressants work

4:22

by targeting some underlying

4:24

biological abnormality. And

4:26

yet that has not been demonstrated. And

4:28

there is another way that antidepressants work,

4:30

which is not presented to patients and

4:32

not widely acknowledged. So, I mean, are

4:34

you saying that SSRIs are a bit

4:36

like alcohol? Absolutely. They change

4:39

the way you feel. Absolutely.

4:41

Antidepressants are mind -altering brain and

4:43

mind -altering drugs like alcohol, like

4:45

cannabis, etc. That doesn't mean that

4:47

the effects that they produce

4:49

are exactly the same as the

4:51

effects that alcohol produces. But

4:53

in principle, they do the same

4:55

thing. They change our mental

4:57

states quite subtly in the case

4:59

of many antidepressants. But nevertheless,

5:02

they do produce these changes, particularly

5:04

this characteristic emotional numbing. Isn't

5:06

there something? bigger here, though, about

5:08

our whole approach to medicine,

5:10

which is that too many people

5:12

think that scientists really understand

5:14

how medicines work. You know, we've

5:16

got very used to just

5:18

taking pills to make things better.

5:20

And the truth is that

5:22

a lot of it is just

5:25

trial and error. We don't

5:27

really know. Yeah,

5:29

I do think we put

5:31

far too much it. We didn't

5:34

know how penicillin worked for

5:36

decades. I think we can put

5:38

too much faith in medical

5:40

pronouncements or the pronouncements of medical

5:42

research or neuroscience findings, and

5:44

those can be over -interpreted. But

5:47

I think that taking something,

5:49

for example, for pain, people

5:51

often cite the fact that

5:53

we don't know exactly how

5:55

paracetamol works, is different from...

5:57

taking something that is changing

5:59

your mental state, like alcohol,

6:02

as you say, and therefore

6:04

changing your thoughts and feelings

6:06

by changing your brain chemistry. We

6:09

do that, like you say, we

6:11

do it with alcohol. We recognize

6:13

that, you know, if you take

6:16

a lot of alcohol, you'll probably

6:18

temporarily feel better, feel less depressed

6:20

or less anxious. But we don't

6:22

regard that as a sensible long

6:24

-term solution to feeling, you know,

6:26

to feeling low or fearful or

6:28

something like that. And

6:30

so, you know, I think

6:32

that that way that antidepressants are

6:34

working, those effects that they

6:37

have need to be clearly explained

6:39

to people so that they

6:41

can make properly informed decisions about

6:43

whether they want to take

6:45

brain and mind -altering substances to

6:47

address their emotional problems. So you

6:49

think there is no use

6:51

for antidepressants, is that right? So

6:54

I think that the

6:57

evidence base for antidepressants

6:59

shows that they are

7:01

probably not beneficial. They

7:04

are minimally different from a placebo.

7:06

And that difference is probably explained by

7:08

the fact that people in these

7:10

randomized control trials who are meant to

7:13

not know whether they get the

7:15

placebo or the antidepressant probably do know

7:17

in a lot of cases. And

7:19

that gives them an amplified, that gives

7:21

the people who are taking the

7:23

antidepressant an amplified placebo effect. So

7:26

I think that's probably what explains the

7:28

small difference between antidepressants and placebo, but

7:30

it's very small anyway. I mean, just

7:32

to be clear on that, I mean,

7:34

the evidence is that there is an

7:36

improved outcome for people on antidepressants, isn't

7:38

there? There is a slight better than

7:41

if you're just on a placebo. It's

7:43

slightly better. Yes. And your hypothesis is

7:45

that people somehow know. I

7:47

mean, what's that based on? So

7:49

there are trials where people have

7:51

asked the participants to guess whether

7:53

they're taking the antidepressant or the

7:56

placebo. In most of those, not

7:58

all, but in most of those,

8:00

people can guess more accurately than

8:02

would be predicted by chance what

8:04

they're taking. And then we also

8:06

know from some studies that what

8:09

you guess you're taking has really

8:11

quite a strong impact on outcome.

8:13

It can improve your depression scores

8:15

by quite a bit more than

8:17

the difference between the drug and

8:19

the placebo. Isn't there a bit

8:21

of a problem with surmising that

8:24

because people are correctly guessing that

8:26

they're on the drug rather than

8:28

the placebo, that the drug doesn't

8:30

work? They are

8:32

probably guessing that because they're feeling

8:34

better. Yeah, absolutely. So that's been

8:36

proposed by people. The trouble is

8:38

it's also been shown in negative

8:41

trials where there's no difference between

8:43

the drug and placebo, that people

8:45

who guess they're on the active

8:47

drug do better than people who

8:49

guess they're on the placebo, regardless

8:51

of what they're actually taking. But

8:53

I suppose the summary position for

8:55

you is that you don't think

8:57

that the medical trial outcome, which

8:59

shows that... people are better off

9:02

taking antidepressants than not, is sufficiently

9:04

good for it to be scientifically

9:06

sound. I don't think that it

9:08

justifies the mass prescribing of antidepressants.

9:10

But another really important point is

9:12

that we've assumed that what antidepressants

9:14

are doing is correcting some underlying

9:16

biological process that leads to the

9:18

symptoms of depression. We don't

9:20

have evidence of that. The

9:23

paper that I did on

9:25

the serotonin hypothesis was what

9:27

sparked me writing the book.

9:30

And there's another way that

9:32

antidepressants might be working or

9:34

might be having their effects

9:36

when people take them for

9:38

depression. And that is that

9:40

they are... not inert. They

9:42

are drugs that change our

9:45

normal brain chemistry and by

9:47

doing so change our normal

9:49

mental states, our normal feelings,

9:51

thought processes, et cetera. They're

9:54

not massively strong drugs in

9:56

this respect, most of the antidepressants

9:58

that we use nowadays, but

10:00

they do induce feelings of emotional

10:02

numbing. They numb people's... positive

10:04

and negative emotions. And they have

10:06

been shown to do this

10:08

in volunteers as well as people

10:10

with depression. And of course,

10:12

if you give people with depression

10:14

a drug that numbs them

10:16

a bit, that may be what's

10:19

reducing their depression scores compared

10:21

to placebo, as well as this

10:23

amplified placebo effect. So I'm

10:25

not saying that, so it's possible

10:27

that it might be that

10:29

effect too. But I think that

10:31

the decisions that people make

10:33

about whether they want to take

10:35

a drug for depression, if

10:37

it's presented to them as something

10:39

that changes their normal brain

10:41

chemistry and their normal mental states

10:43

will be different from if

10:45

it's presented to them as something

10:47

that's going to target and

10:49

correct some underlying abnormality. Because

10:52

one of the criticisms around

10:54

your work is that you've

10:56

created a straw man, an

10:59

imaginary myth, which is that... explanation

11:01

around brain chemistry. When if you

11:03

go on the NHS website or

11:05

if you look up any of

11:07

the charity websites, they're pretty clear.

11:10

They don't actually say that. They

11:12

don't say there's a problem with

11:14

your serotonin, therefore go on one

11:16

of the... many common antidepressants that

11:18

people know about. So lots and

11:20

lots of medical websites have told

11:23

people that there's a problem in

11:25

their brain chemistry historically. They have

11:27

started to correct that over the

11:29

last few years and some have

11:31

corrected it since we published the

11:34

paper on serotonin and depression. But

11:36

the thing is if you... If

11:38

you don't tell people this other

11:40

explanation, that these drugs are altering

11:42

your brain chemistry and thereby altering

11:44

your normal mental states, then people

11:47

will assume, I think, particularly after

11:49

all the promotion that's come from

11:51

the pharmaceutical industry, persuading people that

11:53

depression was a chemical imbalance, that

11:55

the drugs are targeting some underlying

11:57

abnormality. So they're being

12:00

fixed? Yes, exactly. So I think

12:02

that unless people are explicitly told

12:04

that, no, we don't have evidence

12:06

that... is what the drugs are

12:08

doing, then that's what they will

12:10

assume that they are doing. I

12:12

mean, at the moment, antidepressants are

12:14

doled out very, very easily by

12:16

GPs who are not psychiatrists. How

12:20

have we got into that situation? Well,

12:23

that's a really good question. I

12:25

think we've... I think there are

12:27

a number of factors. I mean, the

12:29

first is that the pharmaceutical industry

12:31

has promoted antidepressants very heavily since the

12:34

release of SSRIs in the early

12:36

1990s. So, you know, GPs

12:39

and psychiatrists have been deluged

12:41

with advertising and promotional material. So

12:43

that's one of the reasons. I

12:45

think that another reason is

12:47

that doctors want to be able

12:50

to help people. And what

12:52

does a doctor usually do? They

12:54

give you a pill, they

12:56

give you a prescription. And

12:58

psychiatrists in particular want

13:00

to feel that they have

13:02

a medical solution for

13:05

a common mental health complaint,

13:07

that is depression. And

13:09

people themselves have, of course,

13:11

the idea that you

13:13

could get rid of really

13:15

troubling feelings with a

13:17

pill is appealing. And so

13:19

people have also... persuaded

13:21

by that message that originally

13:23

came from the pharmaceutical

13:25

industry. Because actually, prior to

13:27

the pharmaceutical industry's really

13:29

strong campaigns of the 1990s,

13:31

people were reluctant to

13:33

take medication for depression. And

13:36

they it was really scary medication, lithium

13:38

and that kind of thing. Well, it

13:40

was... Partly because the benzodiazepines were so

13:42

widely prescribed at that time, and it

13:44

was becoming clear that they were dependence

13:47

-inducing. So it was partly because of

13:49

fears about dependence. But also people, I

13:51

think, just felt that actually dealing with

13:53

emotional problems with drugs wasn't the right

13:55

route, and that depression was something that

13:57

was a reaction to life circumstances, and

13:59

so there should be other ways to

14:02

deal with it. I mean, patients ask

14:04

for SSRIs, don't they? You know, people,

14:06

they don't go to the doctor and

14:08

say, can I, you know, what can

14:10

I do? They'll say, I think I

14:12

need to take antidepressants. What should doctors

14:14

be doing in that situation? So I

14:17

think there are some patients that come

14:19

to doctors like that, but I think

14:21

there are also many patients that come

14:23

to doctors and are not sure really

14:25

whether they should be taking a drug

14:27

or not. And so I do think

14:30

that the encounter with a doctor is

14:32

an opportunity to... demedicalize the situation and

14:34

try and suggest other approaches to people

14:36

and i'm sure that lots of doctors

14:38

do do that um of course you

14:40

know often people are coming to their

14:42

doctors at a time of crisis and

14:45

wanting something to be done and the

14:47

doctor doesn't want to send people away

14:49

without anything so there are all these

14:51

pressures i think that do and our

14:53

mental health services are on their knees

14:55

anyway so So queues for treatment are

14:57

extremely long. And GPs are trying to

15:00

deal with a lot of distress that

15:02

mental health services won't take on. Yes,

15:04

absolutely. So there is always going to

15:06

be a temptation to say, OK, we'll

15:08

try this. There is. I

15:10

mean, we do have a national therapy service

15:12

now in the UK, and we're unique to

15:14

have one, I think, in the world, one

15:16

of the few countries in the world that

15:18

has that. There are

15:21

other options. I know therapy doesn't

15:23

necessarily start immediately, but people

15:25

can be referred for therapy straight

15:27

away. It will start within

15:29

a few weeks, the basic level

15:31

of the NHS talking therapy service that's

15:33

available. But therapy often doesn't work,

15:35

does it? People

15:38

try it and it just doesn't help.

15:40

No, not always. But I

15:42

don't think that antidepressants help either.

15:44

Well, that's the problem, though, isn't it?

15:46

Because billions of people are taking

15:48

them. And presumably a lot of

15:50

them feel that they are being helped, you

15:53

know, that it's working. And

15:55

they don't know why and they don't

15:57

really care why. They just know

15:59

that it's making them feel better. Otherwise,

16:01

they wouldn't carry on taking them.

16:03

Yes, which is why we need to

16:05

look at the randomized control trials

16:07

and try and understand the results of

16:09

those and recognize that actually most

16:11

of the effect of the antidepressant is

16:13

a placebo effect. And a

16:15

placebo effect, of course, is about

16:17

having some hope that you will get

16:20

better. It's not just about being

16:22

duped that you're taking something that doesn't

16:24

really work. It is the hope

16:26

that people get. The trouble is that

16:28

I think antidepressants are giving people

16:30

false hope. And a lot of people

16:32

may feel better initially, but actually

16:34

there will come a point when... realise

16:36

that the antidepressant isn't working anymore

16:38

or they've still got problems. And

16:40

then they can often feel even worse

16:43

because they feel, oh gosh, you know,

16:45

I've had the treatment that's supposed to

16:47

work. It's not working for me. I

16:49

must be, you know, a really specially

16:51

severe case. You know, what on earth

16:53

am I going to do? And that can put people

16:55

in an even worse place. Even

16:57

if it was, let's say it's

16:59

75 % placebo, why does

17:01

that matter if it's not

17:03

harming them? Because it's reaffirming this

17:05

idea that the problem is

17:07

in your brain and that you

17:09

need a drug to fix

17:11

it. And we know that people

17:13

who have that idea actually

17:15

have worse outcomes than people who

17:17

don't have that idea, who

17:19

think that depression is a reaction

17:21

to circumstances. People who

17:23

view depression in that way have

17:25

a stronger belief that they can

17:27

do something to help themselves and

17:29

affect their circumstances. But why

17:32

do you think it's better to tell somebody

17:34

that the problem isn't your brain, the problem is

17:36

your mind, which is an even more amorphous,

17:38

difficult thing to try and understand, and nobody really

17:40

understands it? That

17:42

really can feel hopeless, can't

17:44

it? I suppose it gives people

17:47

more agency. If you locate

17:49

the problem in the brain, then

17:51

you need a medical, biological

17:53

intervention to deal with it. If

17:55

it's to do with you

17:57

and your life and your circumstances...

18:00

then there are ways to change those.

18:02

But a lot of people don't

18:04

feel they can change their circumstances. That's

18:06

often the cause of depression, isn't

18:08

it? Yes, yes it is. And some

18:10

people are in circumstances that are

18:12

very difficult to change. I still don't

18:14

think we have evidence that antidepressants

18:17

help in that situation. And

18:19

so you don't think the evidence

18:21

that so many people are taking it

18:23

for so long is evidence that

18:25

they are helpful? I think it's evidence

18:27

that they're unhelpful. Just explain

18:29

that. I think most people would

18:31

say, well, look, you've got eight or nine million

18:33

people taking it. They're taking it for a long

18:35

time. Most of them will say, well, they think

18:37

they're feeling better as a result, which is why they

18:39

carry on going back for repeat prescriptions and carry

18:41

on taking the drugs. Isn't

18:43

that effectively a massive clinical trial?

18:45

So what happens is people

18:48

take antidepressants for a bit. Maybe

18:50

you think that they... are

18:52

doing a bit better. And often

18:54

when people start an antidepressant, I should say

18:56

that, you know, that they're at their lowest point.

18:58

They feel they've got to do something about

19:00

it. They go and see their doctor and then

19:02

they feel they have done something. So there's

19:04

all those sort of factors operating that I think

19:07

can help people improve when they first go

19:09

on to an antidepressant. But

19:11

so people will take an antidepressant,

19:13

feel a bit better, think that the

19:15

antidepressant has helped them, come off

19:17

it. And then the next time that

19:19

they get into difficulties, they will

19:21

assume that they need a drug again.

19:23

So they'll go back to their

19:25

doctor. They'll get back onto the antidepressant.

19:27

They might stay on it a

19:29

bit longer this time. And when they

19:31

try and come off it, they

19:33

might experience some withdrawal symptoms, which can

19:35

include anxiety, low

19:37

mood, changeable mood, tearfulness.

19:40

So often people will think

19:42

that they're getting depressed again. put

19:45

themselves back onto the drug and not realize

19:47

that what they were going through is withdrawal.

19:50

And so people end up taking

19:52

these drugs for long periods

19:54

of time. I think that's evidence,

19:57

first of all, that they're not working, but

19:59

also that people are becoming dependent on them

20:01

and finding it difficult to get off them. But

20:04

I mean, again, the retort to

20:06

that for a lot of people is

20:08

going to be, well, whatever works.

20:10

And if that works and gives me

20:12

some sort of instant relief in

20:14

a way that talking therapies don't, because

20:16

they're very hit and miss. What's

20:20

wrong with that? You

20:23

know, I can see your sort

20:25

of, your principled objection to it,

20:27

but I, you know, practically, we're

20:29

in a world where the NHS

20:31

health services are not good enough

20:33

to cope with the demand. I

20:35

mean, I suppose I'm saying it

20:37

doesn't work. I mean, there's not...

20:40

There aren't a lot of studies on the long -term

20:43

outcome of long -term use of antidepressants, but the

20:45

ones that there are don't suggest that people who

20:47

are taking these drugs long -term are doing better than

20:49

people who aren't. And

20:51

we know that there are lots of what

20:53

we might call side effects or adverse effects

20:55

of antidepressants that I think are probably going

20:57

to be reducing the quality of life of

20:59

people who are taking them long -term. things

21:03

like lethargy, insomnia, difficulty

21:06

concentrating, sexual

21:08

dysfunction, which is widely

21:11

recognized. And then, of

21:13

course, these problems with

21:16

with trying to get off the drugs if

21:18

people want to try and come off them. A

21:21

lot of people do experience withdrawal symptoms.

21:23

For some people, these can be severe

21:25

and really debilitating and can go on

21:27

for long periods of time. And the

21:29

sexual dysfunction can also persist for some

21:31

people after they've come off the medication.

21:33

This is something that's just come to

21:35

light over the last few years, really.

21:38

So why do you think there are

21:40

so many more cases of... mental health

21:42

crises being reported now and people saying

21:44

that they are depressed? So good question. And

21:47

I don't have all the answers.

21:50

I mean, first of all, the

21:52

public have been educated for

21:54

decades now that negative emotions are

21:56

medical problems and they should

21:58

go and see their doctors about

22:00

them. So I think it's

22:02

partly that and that education has

22:04

come from medical institutions, but

22:06

also been sponsored by the pharmaceutical

22:08

industry partly. And

22:10

I think I think it's

22:12

also to do with factors in

22:14

society. We've become a very competitive

22:17

society, I think increasingly so over

22:19

the last few decades. I think

22:21

that's particularly affected young people so

22:23

that people are constantly comparing themselves

22:25

to other people and worried that

22:27

they're not living up to standards.

22:30

That can lead to demoralization if

22:32

people feel that they're not succeeding

22:34

as they should be. It can

22:36

lead to anxiety and stress, clearly.

22:41

And for many people, life has got,

22:43

of course, we've got a cost

22:45

of living crisis. You know, so life

22:47

has become financially more difficult. Employment

22:50

has become less secure and

22:52

precarious. Housing, of course, is a

22:55

huge problem. So there are

22:57

lots and lots of social factors

22:59

that I think give rise

23:01

to stress among adults and younger

23:03

people. And do you think

23:05

people want the diagnosis? You

23:07

know, do people like being

23:09

told? Yes, you've got depression and

23:11

you need to be treated.

23:13

I think some people have come

23:15

to believe that they have

23:17

a medical problem and that a

23:19

medical label would be helpful

23:21

for them, whether it's depression or

23:23

anxiety or ADHD or various

23:25

other labels that people... come

23:29

to their doctors thinking that they might

23:31

have nowadays. Of course, social media is

23:33

playing a role in that. People look

23:35

on social media at people doing videos

23:37

saying, I've got this, I've got that,

23:39

and think, oh, yes, that might be

23:41

me. So I think that's

23:43

playing a role. I think people

23:45

are desperately looking for explanations. And

23:48

I think that's a reflection

23:50

of people, of feelings of

23:53

insecurity. People feel that they're

23:55

not performing at the level

23:57

that... is expected by someone.

24:00

I mean, it does feel a

24:02

little bit, I've been listening to you,

24:04

it feels a little bit like you are

24:06

basically saying it's all in your head

24:08

in a sort of academic -y kind of

24:10

way. So I'm saying that there are real

24:13

problems out there in society that make

24:15

people feel stressed and anxious and unhappy. And

24:17

we need to address those problems.

24:19

And I think actually the people

24:21

who are saying it's in your

24:23

brain are the people who... are

24:26

making it less likely that we're

24:28

going to resolve the problems that are

24:30

making people unhappy and distressed and

24:32

anxious in the first place. How realistic

24:34

is it then, do you think,

24:36

to try and treat eight, nine million

24:38

people a different way? It

24:40

would be tremendously intensive, wouldn't it,

24:42

for the NHS? Well, we have

24:44

radically changed the way that we

24:46

treat back pain, for example. We

24:48

used to tell people to go

24:50

to bed. um and rest up

24:53

and take time off work and

24:55

now the advice is you know

24:57

to to keep active and take

24:59

gentle exercise and the number of

25:01

people off sick for back pain

25:03

has plummeted so i think that

25:05

we can make large changes in

25:07

medicine actually and i think that

25:09

we we could take a different

25:11

approach to to depression and anxiety

25:13

and emotional emotional problems um in

25:15

fact it's already started we have

25:18

There's social prescribing now in

25:20

general practices, social prescribers who

25:22

try and link people up

25:24

with local social groups and

25:26

institutions that might help them

25:28

and support them with loneliness

25:30

and financial hardships and other

25:33

problems that may be leading

25:35

to mental health problems or

25:37

indeed physical health problems. So

25:39

we've actually have made a

25:41

start. And what I'm saying is

25:43

I think we need to

25:45

take that further. I think we

25:47

need to actually locate that

25:49

sort of help outside of the

25:51

NHS. Do you think it

25:54

means retraining GPs? I think we

25:56

need to support GPs to

25:58

be able to divert people away

26:00

from antidepressants, away from medical

26:02

solutions into social ones. Do you

26:04

think GPs are too influenced

26:06

by the pharmaceutical industry and the

26:08

literature that they're constantly sent? I

26:11

can't speak for GPs specifically, but I

26:13

know that the medical profession as a

26:15

whole is influenced by pharmaceutical industry, advertising.

26:18

I go to conferences and there are

26:20

pharmaceutical companies with stands up everywhere and

26:22

handing out leaflets and things like that.

26:24

It's actually better than it was a

26:26

couple of decades ago, I would say,

26:28

but the influence is still there. What

26:32

kind of reaction have you

26:34

had then over the years to

26:36

your work? I mean, you're

26:38

controversial, you're constantly criticised. Doctors,

26:41

but particularly psychiatrists, are very

26:43

reluctant to admit that their

26:45

drugs are not targeting underlying

26:47

biological processes, underlying mechanisms that

26:50

produce symptoms or disorders, because

26:52

they want to think that

26:54

these drugs are more sophisticated

26:56

than they are. There have

26:58

been psychiatrists who I think

27:00

want to shut down the

27:02

debate about about the serotonin

27:04

theory of depression, about the

27:06

biological origins of depression and

27:08

the fact that there isn't

27:10

really convincing evidence for them

27:13

in order to maintain this,

27:15

what I would say, misleading

27:17

view that antidepressants and other

27:19

drugs work in this targeted

27:21

and sophisticated way. You're also

27:23

taking on Big Pharma. How

27:25

do they respond? Well, I

27:27

haven't had any sort of

27:29

personal... personal contact with big

27:31

pharma. I mean, actually, I

27:34

think big pharma have largely

27:36

moved on from antidepressants. And

27:38

now the drugs that are

27:40

being marketed are mainly drugs

27:42

for ADHD. So

27:45

they probably don't care

27:47

that much, actually. Is that

27:49

your next crusade? It

27:51

might be. I mean,

27:53

why have you spent so much time on this?

27:56

Because this has been many years

27:58

you've been making this argument.

28:00

Yes. So because antidepressants... are by

28:03

far and away the most

28:05

commonly used psychiatric drug because this

28:07

idea that depression is caused

28:09

by chemical imbalance was widely believed

28:11

by most of the general

28:13

public to have been established, even

28:15

though most of the people

28:17

in the profession knew that it

28:19

hadn't really been established and

28:22

the research base was actually quite

28:24

weak. And because I believe

28:26

that that subscribing to

28:28

this view that depression is a chemical

28:30

imbalance is not helpful to people.

28:32

There's going to be a lot of

28:34

people listening who are on antidepressants. What

28:37

should they do? So

28:39

I think that people

28:41

should, if they want

28:43

to... If they want

28:45

to rethink being on antidepressants, if they

28:47

want to think about the possibility of

28:49

coming off them, do some reading, discuss

28:51

it with friends and family, and then

28:53

go and see their doctors and make

28:56

a plan to come off their antidepressants

28:58

slowly and carefully and at the right

29:00

time. So don't read your book and

29:02

just stop? No, don't read my book

29:04

and throw the drugs in the bin

29:06

because it's very important to say that

29:08

might make the withdrawal process a lot

29:10

worse. What sort of things

29:12

would happen? So withdrawal symptoms

29:15

can be quite severe for some

29:17

people and prolonged. And it

29:19

seems that if you come down

29:21

much more slowly, that's going

29:23

to make them milder and less

29:25

likely to be prolonged. And

29:27

in terms of the evidence base

29:29

for talking therapies and other

29:31

therapies, how good is that?

29:35

Because what you've done is sort

29:37

of undermine the evidence base for

29:40

antidepressants. The question

29:42

is, how good are the

29:44

alternatives? So the evidence is that

29:46

talking therapies are as good

29:48

as antidepressants. So not very

29:50

good at all, is what you're saying? They

29:52

don't work. So

29:56

I think that this idea

29:58

that we're treating a disease is

30:00

one of the problems. And

30:02

so it's very unlikely that there'll

30:04

be something that just works

30:06

in that sort of medical sense.

30:09

And therefore, I think we need to see

30:11

talking therapies as something that might be

30:13

useful for some people in certain situations, but

30:15

not in others. It's quite a bleak

30:17

outlook you're offering, isn't it? In some ways,

30:19

because you're basically saying there are some

30:21

people who are depressed who are just going

30:23

to be depressed. No, I'm really not

30:25

saying that. And I don't think it's a

30:27

bleak outlook. Most people will get better

30:29

from depression anyway. You lost your parents as

30:31

a child and you've had a terrible

30:33

life as a result. There isn't going to

30:35

be any. social group that the

30:37

GP can send you to or talking therapy

30:39

that's going to help you with that. But

30:41

giving people antidepressants is giving them

30:44

false hope because we really don't

30:46

have evidence that it might be

30:48

numbing the pain. It might be

30:50

numbing the pain, but it's not.

30:53

It's not providing a very satisfactory solution

30:55

to the problem, I would suggest.

30:57

And I think it's really important to

30:59

say most people recover from depression

31:01

spontaneously without antidepressants. And I think that

31:03

giving antidepressants to people is actually

31:05

making that less likely, certainly less likely

31:08

in the long run. So even

31:10

though it may be a difficult message

31:12

at the beginning to say, actually,

31:14

we don't have... a drug that's going

31:16

to solve the situation. In the

31:18

long term, I think it's actually a

31:21

much more hopeful message that you

31:23

actually have the resources in yourself to

31:25

deal with this problem. I mean,

31:27

that's really interesting if that's true, that

31:29

most people just feel better spontaneously. So

31:32

the best advice to a family

31:34

or friend who comes to you

31:36

saying they're feeling terrible is you

31:38

will feel better. It is to

31:40

stick it out and maybe you

31:42

need some support and some care

31:44

in the meantime. and

31:47

to try and work out

31:49

what it's a response to and

31:51

change that if it's possible. Joanna

31:53

Moncrief, thank you very much indeed. Thank you. Thank you

31:56

for joining us on Where to Change the World. You

31:58

can watch all of these interviews on the Channel 4

32:00

News channel. our producer is

32:02

Sylvia Until next time, bye -bye.