Before I go on, I should stress that I am not against the use of drugs for mental health problems per se. I believe some psychiatric drugs can be useful in some situations, but the way these drugs are presented both to the public and among the psychiatric community is, in my view, fundamentally misleading. This means we have not been using them carefully enough, and crucially, that people have not been able to make properly informed decisions about them.
Depression is not the same as pain or other bodily symptoms. While biology is involved in all human activity and experience, it is not self-evident that manipulating the brain with drugs is the most useful level at which to deal with emotions. This may be something akin to soldering the hard drive to fix a problem with the software.
We normally think of moods and emotions as being personal reactions to the things going on in our lives, which are shaped by our individual history and predispositions (including our genes), and are intimately related to our personal values and inclinations.
Models of Drug Action
The idea that psychiatric drugs might work by reversing an underlying brain abnormality is what I have called the ‘disease-centred’ model of drug action. It was first proposed in the 1960s when the serotonin theory of depression and other similar theories were advanced. Before this, drugs were implicitly understood to work differently, in what I have called a ‘drug-centred’ model of drug action.In the early 20th century, it was recognised that drugs prescribed to people with mental disorders produce alterations to normal mental processes and states of consciousness, which are superimposed onto the individual’s preexisting thoughts and feelings.
This is much the same as we understand the effects of alcohol and other recreational drugs. We recognise that these can temporarily override unpleasant feelings. Although many psychiatric drugs, including antidepressants, are not enjoyable to take like alcohol, they do produce more or less subtle mental alterations that are relevant to their use.
This is different from how drugs work in the rest of medicine. Although only a minority of medical drugs target the ultimate underlying cause of a disease, they work by targeting the physiological processes that produce the symptoms of a condition in a disease-centred way.
Painkillers, for example, work by targeting the underlying biological mechanisms that produce pain. But opiate painkillers may work in a drug-centred way too, because, unlike other painkillers, they have mind-altering properties. One of their effects is to numb emotions, and people who have taken opiates for pain often say they still have some pain, but they do not care about it anymore.
In contrast, paracetamol (so often cited by those defending the idea that it does not matter how antidepressants work) does not have mind-altering properties, and therefore although we may not fully understand its mechanism of action, we can safely presume it works on pain mechanisms, because there is no other way for it to work.
Influences
In my book, “The Myth of the Chemical Cure,” I show how this ‘drug-centred’ view of psychiatric drugs was gradually replaced by the disease-centred view during the 1960s and ’70s. The older view was erased so completely that it seemed people simply forgot that psychiatric drugs have mind-changing properties.This switch did not occur because of scientific evidence. It occurred because psychiatry wanted to present itself as a modern medical enterprise, whose treatments were the same as other medical treatments. From the 1990s, the pharmaceutical industry also started to promote this view, and the two forces combined to insert this idea into the minds of the general public in what has to go down as one of the most successful marketing campaigns in history.
As well as wanting to align with the rest of medicine, in the 1960s the psychiatric profession needed to distance its treatments from the recreational drug scene. Best-selling prescription drugs of the period, amphetamines and barbiturates, were being widely diverted onto the street (the popular ‘purple hearts’ were a mixture of the two). So it was important to emphasise that psychiatric drugs were targeting an underlying disease, and to gloss over how they might be changing people’s ordinary state of mind.
So when the pharmaceutical industry developed its next set of misery pills, it needed to present them not as new ways of ‘drowning one’s sorrows,’ but as proper medical treatments that worked by rectifying an underlying physical abnormality. So Pharma launched a massive campaign to persuade people that depression was caused by a lack of serotonin that could be corrected by the new SSRI antidepressants.
Psychiatric and medical associations helped out, including the message in their information for patients on official websites. Although marketing has died down with most antidepressants no longer on patent, the idea that depression is caused by low serotonin is still widely disseminated on pharmaceutical websites and doctors are still telling people that it is the case (two doctors have said this on national TV and radio in the UK in the last few months).
We haven’t worked out what those mechanisms are yet, they admit, but we have plenty of research that suggests this or that possibility. They do not want to contemplate that there might be other explanations for what drugs like antidepressants are actually doing, and they do not want the public to do so either.
Replacing the serotonin theory with vague assurances that more complex biological mechanisms can explain drug action only continues the obfuscation, and enables the marketing of other psychiatric drugs on equally spurious grounds.
The serotonin hypothesis was inspired by the desire of the psychiatric profession to regard its treatments as proper medical treatments and the need of the pharmaceutical industry to distinguish its new drugs from the benzodiazepines that, by the late 1980s, had brought the medicating of misery into disrepute.
It exemplifies the way that psychiatric drugs have been misunderstood and misrepresented in the interests of profit and professional status. It is time to let people know not only that the serotonin story is a myth, but that antidepressants change the normal state of the body, brain, and mind in ways that may occasionally be experienced as useful, but may be harmful too.