Antipsychotic drugs have become some of the biggest blockbusters of the early 21st century, increasingly prescribed not just to people with schizophrenia or other severe forms of mental disturbance but for a range of more common psychological complaints. In this book Joanna Moncrieff challenges the accepted account that portrays antipsychotics as specific treatments that target an underlying brain disease and explores early views suggesting, in contrast, that antipsychotics achieve their effects by inducing a state of neurological suppression. Much of the book is a detailed and thorough unpicking of the troubled history of psychiatry and antipsychotic drugs, but this is far from a one sided story, writes Sally Brown.
The Bitterest Pills: The Troubling Story of Antipsychotic Drugs. Joanna Moncrieff. Palgrave Macmillan. September 2013.
Dr Joanna Moncrieff, senior lecturer at the Mental Health Sciences Unit, University College London, is well placed to write this challenging and troubling book. Her previous book, The Myth of the Chemical Cure, was shortlisted for the MIND Book of the Year Award 2009 and she is a practising consultant psychiatrist who has published widely in respected peer reviewed journals. This broad-ranging critique of the widespread use of antipsychotic (neuroleptic) drugs therefore has considerable professional expertise behind it.
Moncrieff usefully sets the scene by describing what antipsychotic drugs are, and what they do. Introduced initially into psychiatry in the 1950s, their purpose at that point was to treat severely mentally ill patients, particularly people with a diagnosis of schizophrenia, in such a way as to restore them to normal lives; in the context of the large Victorian asylums in which many of these people languished, a drug that could allow people to live normally in the outside world was heralded as a major breakthrough. At the time they were referred to as “wonder drugs”, acting as they did not to control agitated behaviour in the crude manner of the drugs that had preceded them, but rather to have a therapeutic effect by counteracting brain processes. Compared to some of the treatments that were on offer, which seemed reasonable then but now appear shocking and horrific (including deliberately putting people into comas, near-freezing them, shocking them either with chemicals or electrically, or lobotomising them), drugs were appealing both to the profession of psychiatry, giving it a more firmly “medical” basis, and to the patients.
Despite these seeming advances in the treatment of people with serious mental illnesses, the drawbacks, such as physical side-effects resembling Parkinson’s Disease, gradually became known to the psychiatrists prescribing these drugs; however, one of the more appalling aspects of the story that Moncrieff tells also becomes apparent with the unwillingness of some of those keenest on using the new drug therapies to admit that there could be anything wrong with them. She gives examples throughout the book of clinicians and researchers who found “unhelpful” results being ignored or minimised, for example the work on antipsychotics and brain size discussed in Chapter 9. A number of studies are discussed where it seems that lack of control groups, limited choice of comparison groups, and perhaps even selective reporting of results, have contributed to persistent beliefs that the brains of people with schizophrenia are different to “normal” brains, and that antipsychotics should not be implicated in findings about difference in brain volume. However, recent evidence from a small number of studies, though not widely known, seems to suggest that the smaller brains found in people with schizophrenia might be attributable to treatment with antipsychotics, and not be innate. As Moncrieff points out, it is hardly surprising that this is not widely discussed or accepted as it effectively removes one of the main planks of modern psychiatry, that schizophrenia is a straightforward brain disease.
Much of the book is a detailed and thorough unpicking of the troubled history of psychiatry and antipsychotic drugs, but this is far from a one sided story. In Chapter 7, Moncrieff presents some of the arguments from the patients’ viewpoint, and we hear about the potential benefits of using these drugs as well as the drawbacks. Drawing on patient surveys and an online site that allows people to tell their own stories (askapatient.com, a US based site aimed at users of all medicines, not just antipsychotics), it seems that many people regard the negative effects of the drugs as worse than the illness itself, leaving them feeling numb, zombified, and detached from the world around them. Some felt that it had suppressed their personality and flattened their emotions. However, although for some these effects mean the loss of feelings of creativity and imagination, for others the suppression of distressing thoughts and feelings is welcome. Relief from anxiety, paranoia, and suicidal thoughts is experienced as “wonderfully calming” and in terms of the balance of costs and benefits, the negative side-effects which some people report are a cost they are prepared to pay in order to benefit from suppression of the worst of their illness .The critical point, which Moncrieff makes so eloquently in this book, is that doctors and patients need much more information about the nature of psychiatric drugs and the effects they produce in order to decide, carefully and knowledgeably, whether taking antipsychotics is a good way to manage their problems.
Some of the most alarming elements of the book are saved to the end, although the arguments presented will not be new to readers familiar with critiques of psychiatry, drug treatments, or indeed the pharmaceutical industry. Chapter 11 highlights how effective the drug industry has been in expanding the uses of antipsychotics into areas where the costs far outweigh the benefits for the individuals taking them, at the same time as psychiatry has effectively expanded the definition of mental illness. In particular, “off label” prescribing, i.e. prescribing a drug for a condition for which is not licensed, has grown at a phenomenal rate, particularly in the USA, whilst the numbers of people being diagnosed as having bipolar disorder, and more alarmingly the numbers of children being diagnosed with a serious mental illness (in some cases as young as 3 years of age) has rocketed. Indeed, it could be argued that bipolar disorder has become as fashionable a diagnosis for the gifted yet troubled soul in the 21st century as consumption was for the romantic poet and artist in the early 20th century. The problem with this shift in thinking about diagnosis is that it risks diminishing the suffering of those with a very real mental illness, and labelling and treating some unnecessarily.
With this fascinating book, Joanna Moncrieff has shone a light into some dark corners of the history of medicine, but by highlighting some of the errors of the past (and not-so recent past at that) she has provided both a warning for where we can go wrong, and a plea, for more humanistic treatment of people with mental illnesses.
Sally Brown is a Research Fellow in the School of Medicine, Pharmacy and Health at Durham University. Her research interests include young people and sexual health, men’s health, and lay knowledge and understanding about diagnosis, risk and decision-making. Read more reviews by Sally.