Joanna Moncrieff

Efficacy of antidepressants in adults

Most people with depression are initially treated with antidepressants. But how well do the data support their use, and should we reconsider our strategy?

Trends in prescriptions and costs of drugs for mental disorders in England, 1998–2010

BACKGROUND Increasing rates of prescriptions for antidepressants, antipsychotics and stimulants have been reported from various countries. AIMS To examine trends in prescriptions and the costs of all classes of psychiatric medication in England. METHOD Data from the Prescription Cost Analysis 1998-2010 was examined, using linear regression analysis to examine trends. RESULTS Prescriptions of drugs used for mental disorders increased by 6.8% (95% CI 6.3-7.4) per year on average, in line with other drugs, but made up an increasing proportion of all prescription drug costs (P = 0.001). There were rising trends in prescriptions of all classes of psychiatric drugs, except anxiolytics and hypnotics (which did not change). Antidepressant prescriptions increased by 10% (95% CI 9.0-11) per year on average, and antipsychotics by 5.1% (95% CI 4.3-5.9). Antipsychotics overtook antidepressants as the most costly class of psychiatric medication, with costs rising 22% (95% CI 17-27) per year. CONCLUSIONS Rising prescriptions may be partly explained by longer-term treatment and increasing population. Nevertheless, it appears that psychiatric drugs make an increasing contribution to total prescription drug costs, with antipsychotics becoming the most costly. Low-dose prescribing of some antipsychotics is consistent with other evidence that their use may not be restricted to those with severe mental illness.

Do antidepressants cure or create abnormal brain states

Moncrieff and Cohen argue that psychotropic drugs create abnormal states that may co-incidentally relieve symptoms of mental illness.

Rethinking Models of Psychotropic Drug Action

Theoretical assumptions about how psychotropic drugs ‘work’ are rarely discussed explicitly. In a ‘disease-centred model,’ drugs are believed to work by acting on a disease process. In contrast, in a ‘drug-centred model,’ the characteristic physiological, behavioural and subjective effects of drugs are used to define drug action. The therapeutic value of a drug stems from the usefulness of these effects in clinical situations. The disease-centred model appears dominant but has weaknesses: (1) it cannot logically justify the use of drugs since major pathophysiological hypotheses were derived from selectively observed actions of drugs; (2) comparisons between drugs believed to have specific effects in certain conditions and drugs thought to have non-specific effects fail to support it; (3) outcome measures for various disorders include items responsive to non-specific drug effects; (4) studies with healthy volunteers describe characteristic drug-induced states independently of a psychiatric diagnosis; (5) animal tests show effects with agents not usually thought of as specific treatments for the conditions modelled by tests. This article offers suggestions to develop a drug-centred model and discusses its potential impact on clinical practice.

A Critique of the Dopamine Hypothesis of Schizophrenia and Psychosis

The dopamine hypothesis of schizophrenia and psychosis originated from observations of the dopamine-blocking actions of early neuroleptic drugs. These results support the dopamine hypothesis, however, only on the assumption that the drugs act by reversing an underlying disease mechanism (or part of it). An alternative explanation is that the drugs work by inducing a state of neurological suppression that reduces the intensity of symptoms. Although stimulant drugs are known to induce episodes of psychosis, the mechanism for stimulant-induced psychosis has not been clarified, and stimulants are known to affect many neurotransmitters other than dopamine. Recent imaging studies suggest that there may be increased dopamine release in response to amphetamine administration compared to controls. Some studies indicate increased uptake of L-dopa in parts of the striatum, but some do not. The potential confounding effects of factors associated with dopamine release--such as movement, arousal, attention, stress, and smoking--have rarely been examined, and prior medication use may also have influenced results in some studies. Comparable research on other psychiatric conditions associated with increased arousal, stress, and physical activity is sparse. Research on dopamine concentrations in postmortem brain tissue, on homovanillic acid concentrations, and on dopamine receptors has been negative or inconclusive. Therefore, the idea that the symptoms of psychosis or schizophrenia are caused by the overactivity of dopamine is not supported by current evidence.

Childhood trauma in bipolar disorder

Objective: There has been little investigation of early trauma in bipolar disorder despite evidence that stress impacts on the course of this illness. We aimed to compare the rates of childhood trauma in adults with bipolar disorder to a healthy control group, and to investigate the impact of childhood trauma on the clinical course of bipolar disorder. Methods: Retrospective assessment of childhood trauma was conducted using the Childhood Trauma Questionnaire (CTQ) in 60 outpatients with bipolar disorder being treated for a depressive episode and 55 control participants across two centres in north-east England and New Zealand. Results: Significantly higher rates of childhood trauma were observed in patients with bipolar I and bipolar II disorder compared to controls. Logistic regression, controlling for age and sex, identified emotional neglect to be the only significant CTQ subscale associated with a diagnosis of bipolar disorder. Childhood history of sexual abuse was not a significant predictor. Associations with clinical severity or course were less clear. Conclusions: Childhood emotional neglect appears to be significantly associated with bipolar disorder. Limitations include the relatively small sample size, which potentially increases the risk of type II errors. Replication of this study is required, with further investigation into the neurobiological consequences of childhood trauma, particularly emotional neglect.

The Myth of the Chemical Cure

The data surveyed in this book suggest that psychiatric drug treatment is currently administered on the basis of ahuge collective myth; the myth that psychiatric drugs act by correcting the biological basis of psychiatric symptoms or diseases. We have seen that for the three main classes of drugs used in psychiatrythere is no evidence to substantiate this view. Instead, the evidence suggests that these drugs induce characteristic abnormal states that can account for their so-called therapeutic effects. This book has been about how and why this myth of psychiatric drugs as ‘chemical cures’ was constructed and sustained.

How do psychiatric drugs work

Joanna Moncrieff and David Cohen argue that changing our view of the action of psychiatric drugs would help patients to become more involved with decisions about treatment

Drop the language of disorder

We may be on the cusp of a major paradigm shift in our thinking about psychiatric disorders. The proposed revision of the American Psychiatric Associations Diagnostic and Statistical Manual (DSM) of Mental Disorders franchise for the classification and diagnosis of human distress, which will lead to the 5th edition (DSM-V), has served as a catalyst for a wide range of criticism (most notably at www.ipetitions.com/petition/dsm5/). This has identified serious inadequacies in the specific proposed revisions, and has also highlighted scientific, philosophical, practical and humanitarian weaknesses in the diagnostic approach to psychological well-being, underpinning the DSM. This debate provides the opportunity to propose a more scientific grounded and clinically useful system. Diagnostic systems in psychiatry have always been criticised for their poor reliability, validity, utility, epistemology and humanity. With great effort, and standardised approaches, it is possible for reliable diagnoses to be generated. But such practices are rarely adopted in clinical settings, and as we know, it is entirely possible to reliably diagnose invalid diagnoses (the mere agreement between diagnosticians is no guarantee that diagnoses correspond to meaningful clusters of symptoms, with distinct pathophysiology and aetiology, which predict the effectiveness of particular treatments). The poor validity of psychiatric diagnoses—their inability to map onto any entity discernable in the real world—is demonstrated by their failure to predict course or indicate which treatment options are beneficial, and by the fact that they do not map neatly onto biological findings, which are often non-specific and cross diagnostic boundaries. For example, depression and anxiety disorders are so comorbid that it is often arbitrary which diagnosis is given to a patient; schizophrenia symptoms are usually accompanied by mood …

An investigation into the precedents of modern drug treatment in psychiatry.

This paper examines some of the factors associated with the introduction of a range of new drug treatments into psychiatry in the 1950s and 1960s. The nature of psychiatry in the United Kingdom in preceding decades is examined and a continuous emphasis on biological explanations and treatments of mental disorder is revealed. Physical treatment procedures such as insulin coma therapy and shock treatment received most attention. Older drug treatments, although widely used, excited little interest during this time. The new drug treatments by contrast received much attention and began to be regarded as having specific effects on different mental disorders. It is suggested that a combination of long standing professional concerns and commercial factors helped to account for the rapid acceptance and employment of the new drugs. In turn, these drugs helped to strengthen the hegemony of the medical approach to mental illness.