Joanna Moncrief is, at once, one of the most radical and conservative thinkers in the field of psychiatry.
She is a Professor of Critical and Social Psychiatry at UCL and, in 1999, she co-founded the Critical Psychiatry Network - an advocacy group of psychiatrists seeking reform of the current treatment of mental illness. Her books - The Myth of the Chemical Cure and The Bitterest Pills - have since become foundational texts of the movement.
Her latest, Chemically Balanced: The Building and Unbuilding Of the Serotonin Myth, was released last year.
Why did we invite her on?
In 2022, she (along with fellow psychiatrist Dr Mark Horowitz) undertook her most significant project to date, seeking to answer what is arguably the most consequential, pervasive psychological problem of our time: where does ‘depression’ come from? Does it even ‘come from’ anywhere?
For decades, the consensus read that depression was merely a “chemical imbalance” - an insufficiency of serotonin. With the right diet of drugs, it could be remedied. Joanna and Mark’s umbrella review, drawing upon a wealth of research, found that there was no such relationship. In their words, "there is no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activity".
So, what does that mean? Can depression be treated? Is it even real?
History is littered with explanations for mental illness that we now, in enlightened times, find baffling. Demonic possession, Saturn’s influence, an imbalance of the humours, too much black bile - all easily dealt with via exorcism, inhaling pleasant smells, or having a hole bored in your skull.
These beliefs are, thankfully, at no risk of making a comeback. Trouble is, that’s no guarantee that we don’t have misguided beliefs of our own. Beliefs that, through the infrastructure of the billion-limbed pharma industry, have become so entrenched, so endorsed for profit, that they may prove difficult to disentangle. If Joanna’s claim is correct, millions have been lied to.
As soon as we read Chemically Imbalanced, we knew she would make for a perfect guest.
What did we learn?
”We treat depression like cancer; we think we can treat everyone the same way. And that’s what we do. We give them antidepressants, cognitive behavioural therapy. These might work, but I think we should see it differently.”
Some may read into Joanna’s words a contempt for modern psychiatry. This would be false. Rather, she’s suspicious of the practice’s one-size-fits-all approach - treating the symptoms rather than the underlying problems. In Chemically Imbalanced, she strives to take the totality of research and derive the solution from that. It turns out, there is much more contradiction than we’ve been led to believe.
For decades, the average person has been fed the line that depression can be reduced to a lack of the right chemicals in one’s brain. A disharmony of the glands. If they can be righted, the symptoms will go away and hey presto, no more depression.
Some studies support this hypothesis. Some. The truth is much more complicated.
”There are thousands of studies. Some of them find a link between serotonin and depression, that it’s a bit lower in people who have it. Some find that there is no relationship, some even find that serotonin is higher in people with depression. So, taken all together, overall, there is no consistent evidence of an abnormality either way.”
While it may feel like an unchallenged, axiomatic truth now, Joanna is keen to stress this wasn’t always the case. That we all now believe it is no accident - it was the deliberate, and expensive, work of a billion-dollar industry that got us to this point.
”The idea that depression was caused an abnormality of the brain or a chemical imbalance has been around for a long time, but it wasn’t widely accepted among the general public. In the ‘90s, the pharmaceutical industry launched campaigns to spread this idea. They did it to sell more drugs.”
And it worked. For all the campaigning that’s been done to raise awareness of mental health troubles, millions of people are quietly dependent on these drugs. Someone you know has likely revealed to you that they take them. Dozens you know have not.
”8.7 million in England take SSRIs. That works out at 15-17% of the adult population. It’s absolutely staggering.”
For just shy of 9 million people to be using something, it must work in some way. These receipients have to be getting something out of it, otherwise why would they bother? Why wouldn’t they go back to their medical professional and report that the drugs had had no effect?
Joanna corrects us: they are having an effect. It’s not disputed that antidepressants can alter one’s mood. The query is why, and at what cost.
”The mainstream view is that these drugs are targeted some kind of underlying abnormality. Drugs that enter the brain are going to change our normal feeling states. Think of alcohol; you can be feeling very depressed, have a shed load of alcohol and feel better. It’s not solving anything except in the moment. Most antidepressants have an emotionally numbing effect. People on them often can’t cry, or feel overjoyed. They might not feel as intensely sad as they once did, but whether that effect is beneficial is questionable.”
There is one thing that serotonin is credibly connected to. Unfortunately, though phonetically similar, it’s not happiness.
”There has been research into what serotonin levels [actually] effect. The only thing where there seems to be a meaningful correlation is sexual function, and it’s bad for it. The more serotonin you have, the less likely you are to want sex, or for your sexual organs to work properly.”
Depression, however unpleasant, may not be a bad thing. In the same way that the suffering one feels when they burn their hand on the stove isn’t ‘bad’. It’s your body’s way of conveying crucial information. One can look at someone who has recently been made redundant, or undergone a painful breakup, or received other terrible news, and the ensuing depression is no surprise. In fact, it’s probably a good thing they have that response - it demonstrates a sensitivity to their circumstances. Proves that they’re tuned into their own life.
In cases like that, depression might be, on some level, desirable. If nothing else, it inspires the patient to act. But what about cases where depression is not so easily explained? Where, on the face of it, the patient’s life is one of prosperity, security and pleasure?
This kind is often called ‘clinical depression’ - a condition more serious, less coherent than merely ‘being depressed’. One that requires medical intervention.
Even among those who are sceptical of medications, ‘clinical depression’ is frequently given a carve-out, treated as an exception to the rule.
Now, we find ourselves asking: does it even exist?
