Are we overprescribing antidepressants?

Antidepressants play a large role in a lot of medical settings. But they are not without their critics. Dr Joanna Moncrieff is one of Mark Horowitz’s colleagues at UCL and has some concerns about the widespread use of antidepressants.

Joanna - First of all, I just want to correct some things that Hamish McAllister Williams mentioned earlier. He gave the wrong impression that depression has been shown to be a brain disease, that abnormalities in the brain have been demonstrated in people with depression. That is simply not true. There are lots of theories about the biological basis of depression, and of course there are some studies that show some differences between people with depression and people without. But there are other ways of explaining those differences. And there really isn't convincing evidence that there is any sort of biological abnormality in people with depression. Just let me take one example, inflammation, that he mentioned. Yes, there are studies showing that people with depression have different inflammatory markers than people without depression, but we know that inflammatory markers are influenced by many things that can explain that difference. For example, the level of exercise that people get, people's weight, people's sleep, people's social class, stress, adverse life events, all these things can easily explain the abnormalities that are shown in inflammatory markers. So we don't have evidence that depression is caused by a brain abnormality.

Chris - It's very real though. To the people who suffer from it, it's very intrusive on their life. So they would argue that regardless of whether their brain is different, something is very different about the way their brain is working for them at that moment in time.

Joanna - People can be suffering. That doesn't mean that the cause of that suffering is in the brain. And the question we have to ask is, if there's nothing wrong with the brain, then what are antidepressants doing to the brain? If they're not correcting an underlying abnormality - it's not just a little bit uncertain - it is completely uncertain exactly what antidepressants are doing. They are actually creating an abnormality in the brain. They're changing the normal state of brain chemistry. And that is what leads to the sort of side effects that Mark Horowitz described. The lethargy, the tiredness, the memory problems and, of course, the withdrawal problems that people have when they're trying to get off these drugs because the body has adapted to the presence of this extraneous chemical and is trying to counteract its modifying effects.

Chris - So why do we carry on using them if this is the case?

Joanna - So there was a very concerted campaign starting in the 1990s to change people's common sense views about the nature of depression. And this was led by the pharmaceutical industry, but the medical profession jumped on board, and it basically set out to convince people that depression is a biological brain condition, that it's not some sort of understandable emotional reaction to life, but it's something that's biological in the brain and needs to be treated with medical treatments. Of course, drugs were the main thing that the pharmaceutical industry was pushing at that time, and that was a very deliberate campaign, and that's why many people have come to believe this idea that depression is a medical problem, that you need to take antidepressants, that antidepressants will rectify the underlying abnormality. It was the deliberate aim of these campaigns to make people think in this way.

Chris - Are there any exceptions to this situation? Are there any people for whom you would say that taking antidepressants is a good idea?

Joanna - First of all, I think we need to understand the effects of antidepressants differently. They are not reversing an underlying abnormality. They create an abnormal mental state in more or less subtle ways. Some of them have quite subtle effects on our mental activities. Some of them have more dramatic effects, make people drowsy and a bit foggy. And they all have this emotional numbing effect. And it may be the case that some people find that emotional numbing effect helpful when they're feeling very distressed. But I think it's really important to appreciate if that is useful, it's not because the drug is rectifying an underlying abnormality. It's because it is actually inducing an artificial state, which may temporarily relieve underlying feelings of distress. In the same way that if we had a drink of alcohol, we would feel different, and we might temporarily come out of our sadness. And, again, making the comparison to alcohol, it's not usually a good idea to do that on a long term basis. It may be okay. In the short term it may be helpful but, in the long term, it's not usually helpful either psychologically or physically.