Joanna Moncrieff is an eminent British psychiatrist, a founding member of the Critical Psychiatry Network, and the author of several papers and books, including The Myth of the Chemical Cure and Bitterest Pills. I have discussed both of these books on this website, and I recommend them highly. Dr. Moncrieff speaks out clearly and fearlessly about the concepts and practices that drive modern psychiatry.
In both of the books mentioned above, Dr. Moncrieff advocates a shift from a disease-centered model of drug action to a drug-centered model.
On November 21, she opened her own website (joannamoncrieff.com), including a tab to her blog, where you can see her first post. It’s called Models of drug action. In this article Dr. Moncrieff briefly outlines the essential features of the two models.
“The disease-centred model suggests that psychiatric drugs work because they reverse, or partially reverse, the disease or abnormality that gives rise to the symptoms of a particular psychiatric disorder.”
“…the ‘drug-centred’ model suggests that far from correcting an abnormal state, as the disease model suggests, psychiatric drugs induce an abnormal or altered state. Psychiatric drugs are psychoactive substances, like alcohol and heroin. Psychoactive substances modify the way the brain functions and by doing so produce alterations in thinking, feeling and behaviour.”
“The drug-centred model suggests that the psychoactive effects produced by some drugs can be useful therapeutically in some situations. They don’t do this in the way the disease-centred model suggests by normalising brain function. They do it by creating an abnormal or altered brain state that suppresses or replaces the manifestations of mental and behavioural problems.”
“There was not then, and is not now, convincing evidence that any class of psychiatric drugs has a disease centred or disease-specific action.”
Dr. Moncrieff concludes the article by expressing the belief that the drug-centered perspective is the more accurate way to conceptualize the matter, and that:
“The drug-centred model focuses our attention on the impact that drugs have on the body and the brain, and on all the possible consequences that drug-induced alterations can have on how people think, feel and behave. It is a necessary starting point for the sensible, cautious and safe use of drugs in mental health services.”
Obviously I have no quibble with the facts that Dr. Moncrieff has laid out in this article. Psycho-pharmaceutical products are essentially on a par with alcohol, nicotine, and street drugs. They are toxic to the brain, and to other organs, and they cause altered states of feeling, thinking, and behaving. In particular, they do not treat illnesses.
Where I have nagging doubts and concerns, however, is in the notion that psychiatry can be rehabilitated by switching from the fallacious disease-centered model of drug action to a drug-centered model.
What’s being proposed here, if I understand it correctly, is that psychiatrists would continue to prescribe these pharmaceutical products, but without the pretense that the individual has an illness which the drugs are treating. Instead, the practitioner and the client would collaborate on identifying the problem – anxiety, say, or perhaps anxiety in certain specific situations. The psychiatrist would explain what kind of drugs might be helpful, including pointing out that the drug is not a medicine, but rather a chemical that induces a feeling of relaxation, and would point out the potential adverse effects. It would then be up to the client to accept the prescription or not. (I acknowledge that this is an over-simplification of Dr. Moncrieff’s position, but I think it does give the gist of the matter.)
I find myself torn on this issue. On the one hand, I respect completely each individual’s right to ingest whatever he/she chooses. I’ve written on this subject here. I’m not advocating the use of drugs. They’re destructive of organs and of relationships. This is true of street drugs and pharmaceutical products. But if people choose to use them, I don’t think we have the right to stop them. I think the profit motive should be regulated, and some safeguards maintained, and I have discussed these issues in the article linked above. But if people choose to use street drugs or psycho-pharmaceutical products, I believe they should be allowed to do so.
What I struggle with, however, is the notion of medical practitioners being involved in the distribution process.
Obviously I exclude from these considerations situations in which these drugs are being used in a genuinely medical context. There are various medical procedures, for instance, in which an anxiolytic can make things a great deal easier for everybody, and obviously this is, and should be, a matter for the physician to decide in consultation with the patient.
But situations which do not involve a genuine medical issue are, in my view, more problematic. My primary concern is that regardless of what the physician says, the fact that the drug is being prescribed by a medical practitioner will inevitably communicate the notion that somehow it is a medicine, and that the problem is medical in nature. I can also readily imagine that psychiatrists would – again inevitably – begin to truncate the caveats, and in some cases might dispense with them altogether.
To sum up, I have two questions:
1. Is there any legitimate use for psycho-pharmaceutical products other than the obviously medical uses mentioned above.
2. If the answer to question number 1 is yes, is there a legitimate role for the medical profession in the sale and distribution of these products.
Interestingly, in her second post, Why there’s no such thing as an ‘antidepressant’, Dr. Moncrieff addresses the same questions:
“This raises all sorts of thorny questions, of course, about why some psychoactive drugs are legal and others illegal, about what sort of drug use society approves of and what it doesn’t, and why the legal dispensation of many drugs is restricted to doctors: subjects for many future blogs!”
These questions, which are obviously complex and intertwined, get touched on from time to time in the general debate, but I haven’t seen them explored in depth. One occasionally encounters arguments on both sides. It is sometimes said, for instance, that if a person is clearly out of control, then an injection of a tranquilizing agent is warranted to prevent injury to self or others. On the other hand, it is pointed out that the police routinely subdue extremely out-of-control individuals without recourse to tranquilizing agents. And so on.
Although Dr. Moncrieff effectively demolishes the disease theory in her various writings, the debate is by no means over. There is an ongoing need for us to continue gathering data and presenting evidence in this area. But I think we should begin addressing the above questions also.
I’m grateful to Dr. Moncrieff for opening her website, and I look forward to reading future articles. I hope that they will stimulate fruitful discussion and debate.