Joanna Moncrieff, The Myth of the Chemical Cure

In a recent post offering some suggestions for readings in psychiatry, skepticism, and social justice, I mentioned that the next book on my list on the topic was Joanna Moncrieff’s (2008) The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment.

Having now finished it, I think it deserves a post of its own. (I’d also recommend moving it up in the reading queue to second - just after Mad in America - which additionally makes sense chronologically.)

We all come to a contentious issue like this with our own skeptical biases, and many people are less likely to engage, or engage openly, with highly critical works about psychiatry by nonpsychiatrists, especially if they make some speculative arguments. So, for instance, people might not be inclined to take up the books by Whitaker or Kirsch, a journalist and a psychologist, suspecting a lack of expertise in psychiatry, professional rivalry, a muckraking agenda, or what have you.

I believe many of these fears would be dispelled if people read the introductory chapters of these books. More generally, though, I think that while this skeptical attitude makes sense, it can sometimes be counterproductive. My approach, if I have reason to believe a book contains some sound and original arguments but might have some major weaknesses or make claims it doesn’t support, is generally to read it with a critical eye, be attentive to criticisms, and try to sift out the better-substantiated points.

But I recognize that it’s partially a question of temperament and mood. Some people aren’t inclined to do this sifting, and prefer a more focused scholarly treatment by someone in the field. For them, I recommend this book. Moncrieff, Senior Clinical Lecturer in the Department of Mental Health Sciences at University College London and co-founder of the Critical Psychiatry Network, is an established psychiatrist and academic researcher. But it’s the book itself that should assuage the concerns of even the most skeptical reader looking for expert analysis of the scientific literature. It’s thorough, reasoned, and fair.* And so well organized it brings joy to my heart.

Moncrieff considers in turn each category of psychiatric drugs – neuroleptics, “antidepressants,” stimulants for ADHD, and “mood stabilizers.” For each class of drugs (she rightly argues that these should be classified according to their real action and effects rather than their assigned place in the brain-disease model), she structures the section in the same way. So, for example, the chapters dealing with neuroleptic (“antipsychotic”) drugs are “The Birth of the Idea of an ‘Antipsychotic,” “Are Neuroleptics Effective and Specific? A Review of the Evidence,” and “What Do Neuroleptics Really Do? A Drug-Centred Account.” The review of the evidence for disease-specific action of neuroleptics concludes with a summary of the evidence, answering the following questions:

(1) Is there a demonstrable pathological basis to psychosis/schizophrenia from which the action of ‘antipsychotic’ drugs can be understood?

(2) Do rating scales for acute psychosis or schizophrenia reliably measure the manifestations of a particular disease process?

(3) Do animal models of psychosis select antipsychotic drugs reliably?

(4) Are drugs considered to have non-specific actions inferior?

(5) Do studies with healthy volunteers show different or absent effects?

(6) Is the outcome of psychosis/schizophrenia improved by the use of antipsychotic drugs?

This pattern is repeated for the other three categories. For each group, Moncrieff describes the history of the particular brain-disease model involved and the belief that the drugs act on disease in a specific way. She then examines the existing evidence for these claims, with attention to methodological problems and the distorted reporting of findings. Finally, she considers the drugs’ effects from a drug-centered, rather than a disease-centered, perspective. Her comprehensive approach is necessary to assessing the value of the disease-centered model and the drugs.

Moncrieff argues for the embrace of a drug-centered approach, in which these drugs are evaluated not on the basis of the unfounded assumption that they treat brain diseases but on the basis of their actual effects and risks in comparison to other drugs and approaches. Adopting this reasonable approach wouldn’t necessarily mean the end of all use of these drugs (though this would decrease drastically, and several drugs she advises scrapping for these uses altogether). But uprooting the brain-disease myths, as she recognizes, would mean a radical transformation of psychiatry, greatly reducing the institutional power of psychiatrists and involving a cooperative relationship between people suffering from mental distress and those seeking to help them. Although it’s not her focus in this book, Moncrieff does discuss the psychological and political harms of the disease-centered model, and views her proposed approach as progressive and democratic.

At the beginning of her concluding chapter, she states:

The disease-centred model of understanding psychiatric drug action can be viewed as an ideology…in the Marxist sense. Like other forms of ideology, it presents itself as an objective impartial body of knowledge determined only by the facts of the world, whereas it actually conveys a partial view of human experience and activities that are motivated by particular interests. The institution of psychiatry, aided and abetted by the pharmaceutical industry and ultimately backed by the state, has constructed a system of false knowledge about the nature of psychiatric drugs.

For those with a tendency to reject such strong, politically inflected claims out of hand, please note that this is a conclusion based on a thorough review of the evidence. I challenge you to read the 236 pages preceding this bold statement and then casually reject it.

*My only significant criticisms, in fact, concern the physical book itself. There’s a lot of tiny text packed into its 244 pages, with insufficient spacing between lines; the binding is shoddy, and some pages have already fallen out; and the cover design is uninspired.