Doctors Won't Tell You This! - Dark Truth About Antidepressants & How Big Pharma Fooled Everyone

1. 0:00 – 3:10

   Why the serotonin “chemical imbalance” story took over depression care

   1. RCDr. Rangan Chatterjee0:00

      If there is no evidence to support the chemical imbalance theory of depression and a serotonin deficiency, why is it that so many people think that there is? And why are so many people on these drugs?

   2. JMJoanna Moncrieff0:15

      So that's, that's a very good question, and the answer primarily is because of the efforts of the pharmaceutical industry in the-- from the 1990s onwards. So the chemical imbalance theory of depression was first constructed in the 1960s by psychiatrists and researchers who were, um, who were experimenting with various drug treatments for depression and trying to come up with a justification for, for using drug treatment in this situation. But it wasn't an enormously well-known or popular theory at that time. There was a big project set up to test whether there were any differences in people's brain chemicals, people who had depression versus people who didn't in the 1980s. That didn't come up with anything. So, you know, the theory wasn't really getting anywhere. But then in the 1990s when the pharmaceutical industry wanted to promote their new range of drugs for emotional problems, that is the SSRIs, they picked up this theory and widely promoted it. And so there were massive, um, advertising campaigns that, that told people that depression was caused by a chemical imbalance, or sometimes they'd say it might be caused by a chemical imbalance. But this was repeated so many times that basically people became convinced it was true.

   3. RCDr. Rangan Chatterjee1:35

      Yeah. This idea that depression is caused by a chemical imbalance, I think that idea has become so widespread that it's now taken as fact.

   4. JMJoanna Moncrieff1:49

      Absolutely. Absolutely, yes.

   5. RCDr. Rangan Chatterjee1:50

      It's not just, "Oh, that's a theory."

   6. JMJoanna Moncrieff1:52

      Yeah. Yeah.

   7. RCDr. Rangan Chatterjee1:52

      I think the general public-

   8. JMJoanna Moncrieff1:54

      Yeah

   9. RCDr. Rangan Chatterjee1:54

      ... or much of the general public believe this to be true. And so your work for many years, including your brand-new book, Chemically Imbalanced: The Making and Unmaking of the Serotonin Myth, I think is really helpful, not only for the public, but also for professionals like me, other medical professionals who potentially have felt intuitively there's something not quite right here. But I think what you've done is give people the evidence for that.

   10. JMJoanna Moncrieff2:23

       Yeah, absolutely.

   11. RCDr. Rangan Chatterjee2:23

       Or I should say the lack of evidence for that.

   12. JMJoanna Moncrieff2:25

       Yeah, yeah. So this is exactly why we set out to do the serotonin review because I became aware that most of the general public think that the link between serotonin and depression is an established fact. They think it's, it's pr- proven. They don't realize that it's a speculation, a theory that, you know, that there may be a bit of evidence for and a bit of evidence against. So that's why I thought, right, we need to look at the evidence properly, set it out, get it published, and, and see what it says. And, and I think, as you say, that actually a lot of clinicians had been persuaded that maybe this was true too, even though there was, you know, there was no convincing body of evidence ever put together to say, you know, "Yes, this is definitively the case."

2. 3:10 – 5:46

   Why mechanism matters: prescribing on a shaky theory has real consequences

   1. RCDr. Rangan Chatterjee3:10

      Yeah. It's interesting. In one of your chapters of this book, you write about your appearance on, I think, This Morning, the UK television show, to talk about this, and the resident GP said on that segment, "Well, why does it matter?" Right? "Why does it matter? We know that they work. It doesn't really matter why they work." Now, it was quite shocking for me to read that, to go, it doesn't really matter why they work. Hold on a minute. There are a ton of side effects-

   2. JMJoanna Moncrieff3:38

      Yeah, yeah

   3. RCDr. Rangan Chatterjee3:38

      ... to these drugs, right? So if the whole principle on- upon which they're prescribed is built on sand, we kinda need to know about it, right?

   4. JMJoanna Moncrieff3:50

      Absolutely.

   5. RCDr. Rangan Chatterjee3:50

      So what is your take on that?

   6. JMJoanna Moncrieff3:51

      Yeah.

   7. RCDr. Rangan Chatterjee3:51

      And what are-- for, for anyone who's listening who perhaps is on an antidepressant at the moment or an SSRI, selective serotonin reuptake inhibitor, what are some of the signs that might indicate they're having some problems on them?

   8. JMJoanna Moncrieff4:06

      Yeah, so, so just to say first, um, the-- it was a very common reaction to when we first published the serotonin paper and also since I've published the book for psychiatrists and, and other leading doctors to say, "It doesn't matter. It doesn't matter how they work." And I think that is absolutely shocking. I think it matters a lot how they work, and it is absolutely essential that we discuss this with the public and, and so that people are able to evaluate what they might be doing to them if they're thinking about taking one of these drugs. So SSRIs, the idea was that they would work by correcting an underlying serotonin deficiency, and it turns out that actually the evidence for that is, is weak, inconsistent, and not compelling, and certainly not proven. Um, but they are dr- you know, they are drugs. They do change your, the normal state of your brain chemistry. They do modify our biology in some way. Um, and we know that they cause, you know, th- they, they change people's thinking and feeling processes. And s- and one of the common effects they have, for example, is that they cause a state of emotional numbing. So people often say that they can't, um, you know, they may not feel quite so sad anymore, but also they can't feel happy anymore, and they can't cry. And, and some people might welcome that effect, but some people, a lot of people report that it's actually quite unpleasant and-

   9. RCDr. Rangan Chatterjee5:40

      Yeah

   10. JMJoanna Moncrieff5:40

       ... and, you know, uh, they don't feel like themselves anymore when they're, when they're in that sort of state.

3. 5:46 – 11:01

   Emotional blunting, suicidality risk, and the ethics of risk–benefit tradeoffs

   1. RCDr. Rangan Chatterjee5:46

      Yeah. It's interesting. As I was reading your book and, and diving into your work, Joanna, I reflected a lot on my own practice over the years as a medical doctor. And I've always believed that one of the most important things that a doctor can give a patient is a sense of agency and autonomy, and I feel that by overly labeling people and making them think that they can only get better if they're dependent on a medication which they can't then stop-I've always had a deep, I guess, an ethical issue with that. And I remember early in my days as a GP, there was one patient, I don't think I started an SSRI on her. I think she'd been started it by a colleague of mine. But she came in for her four weekly review, right? And she was a young lady, I think she was about 23 years old. And I remember her saying to me something to the effect of, "Well, yeah, I don't feel as low as I did four weeks ago, but I feel nothing anymore. I don't feel high. I don't feel joy. I feel nothing." So I always remember that so well. I thought, "That's really interesting. She's potentially having what you're calling this emotional numbness or emotional blunting." And I thought, "Well, how is that helpful?" Yeah, you could argue we've removed the really low moods, but if you can't experience pleasure or joy or hope or whatever it might be, I thought, "How is this helpful?"

   2. JMJoanna Moncrieff7:20

      Yeah.

   3. RCDr. Rangan Chatterjee7:20

      So that was, that's one case I really remember super, super well. Um, and the other case I remember really, really well is, without going into, into the young lady's history, I remember seeing someone and I thought, "Yeah, you know, these symptoms are consistent with what we get told we need to hit in order to make the diagnosis of depression" And I remember looking in the BNF, so for the people listening to the show all around the world, so the British National Formulary. So our kind of bible of, uh, drugs and the consequences, what the indications are, what the side effects are. And I remember looking through it, and I knew this anyway, but I was just looking through it, and although it's documented as a rare side effect, I was looking at it going, "Oh, there's an increased risk of suicidal ideation" And I thought, "This doesn't make any sense to me. I've got someone in front of me with low moods, and I'm potentially gonna be putting her on a drug that, yes, it might be a small risk, that may increase her risk of suicidal thoughts" And I thought, "This doesn't kinda make any sense." So any comments-

   4. JMJoanna Moncrieff8:27

      Yeah, yeah

   5. RCDr. Rangan Chatterjee8:27

      ... on what I've just said, Joanna?

   6. JMJoanna Moncrieff8:28

      Yeah, yeah. No, absolutely. I mean, s- so it, it comes back to there being, you know, two very different ways of understanding what these drugs might be doing. And, and if you understand that they are correcting an underlying abnormality, an underlying deficiency, then it sounds like a good idea to take them. And you might take a small, you know, a small increased risk of something if you're correcting, you know, uh, an underlying biological disease that you have. But-

   7. RCDr. Rangan Chatterjee8:56

      Yeah. So, so just on that.

   8. JMJoanna Moncrieff8:57

      Yeah.

   9. RCDr. Rangan Chatterjee8:57

      So if you have an infection, for example, you... Which is, you know, a pneumonia, right? Which is, are really, really bad and you can't get over it, fevers, productive sputum, you know, all this kind of stuff. You may decide to take an antibiotic knowing that you may get side effects.

   10. JMJoanna Moncrieff9:15

       Yeah.

   11. RCDr. Rangan Chatterjee9:15

       Right?

   12. JMJoanna Moncrieff9:16

       Yeah.

   13. RCDr. Rangan Chatterjee9:16

       So I'm just trying to draw the analogy.

   14. JMJoanna Moncrieff9:17

       Yeah, yeah.

   15. RCDr. Rangan Chatterjee9:17

       That sort of thing.

   16. JMJoanna Moncrieff9:18

       Exactly. Exactly.

   17. RCDr. Rangan Chatterjee9:18

       But you think that the benefits outweigh-

   18. JMJoanna Moncrieff9:21

       Yes

   19. RCDr. Rangan Chatterjee9:21

       ... the risks.

   20. JMJoanna Moncrieff9:21

       Yes, exactly. But if it's not the case that there's an underlying abnormality, and that's what we've shown, um, and you are taking something that changes your normal, the, the normal state of your brain and your normal feelings and thoughts and behaviors because of that, then, th- then the i- y- you know, then the idea that actually some of these changes might be quite negative, like you might get some suicidal thoughts, you might have your emotions, you know, including positive emotions blunted. Um, you might feel lethargic a lot of the time. Um, y- you w- you are very likely to have sexual dysfunction, at least while you're taking the drug, possibly afterwards. Then, then all these things actually become much more important. They're not just incidental. They're y- you know, they're part of the, of weighing up whether actually this is a good idea, really.

   21. RCDr. Rangan Chatterjee10:13

       Yeah. And g- going back to your TV segment where the other doctor said, "Well, it doesn't matter."

   22. JMJoanna Moncrieff10:19

       Yeah.

   23. RCDr. Rangan Chatterjee10:19

       "It doesn't matter. If they work, they work. We don't need to know the reasons."

   24. JMJoanna Moncrieff10:22

       Yeah. Yeah.

   25. RCDr. Rangan Chatterjee10:22

       Well, these are pretty significant side effects.

   26. JMJoanna Moncrieff10:25

       Yes. Yes.

   27. RCDr. Rangan Chatterjee10:25

       Of course, we need to know the reasons-

   28. JMJoanna Moncrieff10:27

       Yes

   29. RCDr. Rangan Chatterjee10:27

       ... before we put people on them.

   30. JMJoanna Moncrieff10:28

       A- absolutely. Absolutely. And I think y- you know, I think people will make, many people will make a different decision if they're presented with something that's supposed to, you know, correct your serotonin deficiency, or they're presented with something that's going to numb you a bit, like li- like having a, you know, like having a drink of alcohol or something like that, numb you temporarily. Um, many people, I think, will decide, "Actually, no, I don't want that. I, you know, I, I can get through this myself. I don't want to be numbed. I don't want to be drugged."

4. 11:01 – 14:06

   How common are antidepressants—and what it suggests about medicalizing distress

   1. RCDr. Rangan Chatterjee11:01

      Do you know how common it is in the UK, you know, h- how prevalent is the prescriptions of antidepressants? Or do you know how many people are on them currently in the UK?

   2. JMJoanna Moncrieff11:12

      So, so the estimate is about, um, about 17% or, or a little bit more of the population, so almost one in five are taking them at the moment. Those-

   3. RCDr. Rangan Chatterjee11:22

      Adults

   4. JMJoanna Moncrieff11:22

      ... those are figures from about 2017. That's, that's including... I, I think that's, uh, the... Yeah, yeah, I think that's the population of over 18s.

   5. RCDr. Rangan Chatterjee11:32

      So over 18, so maybe one in five adults in the UK-

   6. JMJoanna Moncrieff11:36

      Yeah

   7. RCDr. Rangan Chatterjee11:36

      ... are on some form of antidepressant.

   8. JMJoanna Moncrieff11:37

      And, and, and more, it's more for women, so 23% of women take them, so almost one in four women are taking an antidepressant.

   9. RCDr. Rangan Chatterjee11:44

      And do we know under the age of 18 how common it is? 'Cause I understand that more and more, um, adolescents-

   10. JMJoanna Moncrieff11:51

       Yeah

   11. RCDr. Rangan Chatterjee11:51

       ... are being prescribed these things.

   12. JMJoanna Moncrieff11:53

       Yeah, yeah. I d- I don't have precise figures for-

   13. RCDr. Rangan Chatterjee11:55

       Yeah

   14. JMJoanna Moncrieff11:55

       ... for younger people, but you're absolutely right. The, the rates of prescribing are rising. I feel like when I'm talking to m- my children and, and their friends that, you know, a lot of their group are on antidepressants, sometimes other sorts of medication, but a lot of them are taking antidepressants.

   15. RCDr. Rangan Chatterjee12:11

       It, it's really interesting to me. Last week, Suzanne O'Sullivan, uh, was here in the studio, and she's written, um, you know, a, a, another very important book, The Age of Diagnosis-

   16. JMJoanna Moncrieff12:20

       Mm

   17. RCDr. Rangan Chatterjee12:20

       ... where she questions many things to do with how many people are being diagnosed with a variety of different conditions-... including depression. Um, it's kind of interesting how these books are coming out in, you know, at similar times.

   18. JMJoanna Moncrieff12:35

       Yeah, yeah.

   19. RCDr. Rangan Chatterjee12:36

       Right?

   20. JMJoanna Moncrieff12:36

       Yeah.

   21. RCDr. Rangan Chatterjee12:36

       I feel that there's a sense within society, certainly within the medical profession, that, wait a minute, something we're doing isn't working very well. And, and my feeling is that we're trying to medicalize a lot of, frankly, you know, normal or the variety of symptoms that people experience in their day-to-day life, good feelings, bad feelings, struggles-

   22. JMJoanna Moncrieff13:01

       Yeah, yeah

   23. RCDr. Rangan Chatterjee13:01

       ... positive emotions, negative emotions.

   24. JMJoanna Moncrieff13:03

       Yeah, yeah.

   25. RCDr. Rangan Chatterjee13:03

       These things are, are part of the human condition.

   26. JMJoanna Moncrieff13:07

       Yeah, yeah. No, I, I absolutely agree. And, and, uh, the ways it's, it's negative is, uh, y- there are a number of ways. When you, when you l- give someone a label, a diagnostic label, you, y- you, you often cease to see the individual and their individual problems, and you're then treating the label. Um, and actually, what we need to do is see people as individuals. And, and people, you know, people do struggle with their emotions. I think sometimes we're, you know, maybe unnecessarily medicating people who are having, you know, fairly normal reactions. But people vary in their reactions, and some people will react to difficult circumstances more extremely than other people and will struggle with that. But nevertheless, I don't think it helps to say, you know, to, to treat this as a, as a diagnosis, to, to label everyone, because then you don't actually uncover what the, what the real problems are that need to be addressed.

5. 14:06 – 17:02

   What evidence were SSRIs approved and adopted on? Small trial effects and weak clinical meaning

   1. RCDr. Rangan Chatterjee14:06

      We've mentioned this term SSRI quite a bit. Okay. So first of all, I'd love you to expand upon, um, you know, the common names that people, or the drug names that people may be taking or may have heard of which fall under that category. And then if possible, Joanna, it'd be really good to understand what did the trials actually show? Okay? Because you're saying that, that this serotonin chemical imbalance theory is, is, um, got minimal evidence to support it. But nonetheless, one in five of the UK population, at least probably, and because that was 2017.

   2. JMJoanna Moncrieff14:46

      Yeah, yeah.

   3. RCDr. Rangan Chatterjee14:46

      Mental health-

   4. JMJoanna Moncrieff14:47

      Yeah

   5. RCDr. Rangan Chatterjee14:47

      ... has got a lot worse in the last few years.

   6. JMJoanna Moncrieff14:48

      Yes.

   7. RCDr. Rangan Chatterjee14:48

      There was COVID, there was lockdowns, right? So it could well be more than that now.

   8. JMJoanna Moncrieff14:52

      Yes, yes.

   9. RCDr. Rangan Chatterjee14:53

      Um, on what evidence was the prescription of these drugs even based upon in the first place?

   10. JMJoanna Moncrieff15:02

       So yes. So this comes down to the, the clinical trials that have been done. Um, so the, the justification for the use of antidepressants, uh, apart from this idea of the chemical imbalance, is the, uh, these trials that show that antidepressants perform a little bit better than a placebo tablet, um, if you randomize people and, and allocate them either to take the, the placebo or the, uh, or the antidepressant, and then you measure their mood using these mood scales. Now, there are lots of problems with these studies, including, you know, that measuring mood is a very artificial thing to do and, you know, questionable at best. But, but even if you, y- just put that aside for a minute, the difference between the antidepressant and the placebo in these trials is very small, uh, and it doesn't... It's not large enough to actually register as a clinically significant difference if you use other ways of measuring people's function like, um, something called the Clinical Global Rating scale, um, which is a, just a sort of general, general impression of how someone is doing, for example. Um, or... And there are various other, other ways of sort of judging the clinical relevance of a, of a difference. So it's, it's very small, and it may well not be a pharmacological effect anyway because we know that a lot of these trials are not fully double blind. People can guess whether they've got the actual antidepressant or the placebo, um, because of some of the side effects they get, particularly if people have been on antidepressants before, which many of them have. And we know that what you think you're taking has a significant impact on your outcome in the short term. So people who guess they're on antidepressants do better than people who guess they're on the placebo regardless of what they're actually taking.

   11. RCDr. Rangan Chatterjee16:58

       Yeah. There, there's quite a few things there, Joanna. If we... Can we just unpack a few of them?

   12. JMJoanna Moncrieff17:01

       Yeah, of course.

   13. RCDr. Rangan Chatterjee17:01

       Right. Okay.

   14. JMJoanna Moncrieff17:02

       Yeah, yeah, yeah.

6. 17:02 – 28:53

   The diagnosis problem: subjective criteria, rating scales, and cultural/language bias

   1. RCDr. Rangan Chatterjee17:02

      So, um, first of all, you mentioned how one is diagnosed with depression in the first place. Now, we're both medical doctors, okay? But for the general public who are listening, they may not be aware of the subtleties and the subjective nature-

   2. JMJoanna Moncrieff17:20

      Yeah

   3. RCDr. Rangan Chatterjee17:21

      ... of diagnosis like this. So can you break it down? What, what are these scales? What sort of questions do they ask? 'Cause I think that would help people understand that this is kind of, I wouldn't say it's flimsy. Well, like, well, actually, it's a little bit flimsy how we diagnose-

   4. JMJoanna Moncrieff17:34

      Yeah

   5. RCDr. Rangan Chatterjee17:34

      ... these conditions in the first place.

   6. JMJoanna Moncrieff17:35

      Yeah, yeah, yeah. Well, so, I mean, I mean, we diagnose depression in, in, in practice, don't we? Because someone comes and says they, you know, they don't feel well. They're, they're, they're feeling low. They've, you know, lost interest in things. But then there are official, uh, criteria for making a diagnosis, which include that you have to have had a low mood for, you know, two weeks at least and, and some other symptoms, which might include difficulties sleeping or loss of appetite. But of course, you know, whether or not you've had a low mood for two weeks or not is, is completely subjective. There's no, um, there's, there's no evidence that people who've been in a low mood state for more than two weeks have a medical clinical condition and people who've been in a low mood state for less than two weeks don't. That's, that's just completely made up. It's just what psychiatrists drawing up these manuals have decided is a reasonable criteria.

   7. RCDr. Rangan Chatterjee18:30

      Yeah. Can I also say on that point, something I'm really passionate about is this idea that-The way we ask questions as doctors, we assume that a patient knows what we mean by that question. And I really noticed this when I worked in a practice in Oldham where there was a huge, uh, ethnic variety in the practice and I thought, "Oh, if I ask questions in the way I was taught to at medical school, for example," well, certain cultures, certain demographics don't think about their health using those terms. Like, so pain, for example, and, you know, uh, without going down a rabbit hole, you know, even the way we ask that question, "Have you had a low mood?"

   8. JMJoanna Moncrieff19:12

      Mm.

   9. RCDr. Rangan Chatterjee19:12

      Well, to 10 different people-

   10. JMJoanna Moncrieff19:14

       Yeah

   11. RCDr. Rangan Chatterjee19:14

       ... that means 10 different things-

   12. JMJoanna Moncrieff19:15

       Different things, yes

   13. RCDr. Rangan Chatterjee19:15

       ... doesn't it?

   14. JMJoanna Moncrieff19:16

       Yes. Yes.

   15. RCDr. Rangan Chatterjee19:16

       So there's an inherent-

   16. JMJoanna Moncrieff19:17

       Yes

   17. RCDr. Rangan Chatterjee19:17

       ... bias even within the question as to whether someone even answers yes or no to that.

   18. JMJoanna Moncrieff19:22

       Yeah, yeah, absolutely. Yeah. And, and the way that low mood is judged with one of these commonly used, uh, depression rating scales is that if you come across as being depressed and you say that you're depressed, you're rated as being more depressed than if you don't explicitly say you're depressed, but, you know, just have some of the symptoms.

   19. RCDr. Rangan Chatterjee19:45

       So the language you use will actually-

   20. JMJoanna Moncrieff19:47

       Will, will influence-

   21. RCDr. Rangan Chatterjee19:48

       ... influence your score.

   22. JMJoanna Moncrieff19:48

       Exactly. Exactly. And also-

   23. RCDr. Rangan Chatterjee19:50

       Which is ridiculous. [laughs]

   24. JMJoanna Moncrieff19:51

       And also the way that you present. So if you're someone that, you know, is very expressive and is maybe tearful during the appointment, you're more likely to be scored as having a severe depression than if you're someone who is more, you know, subdued, stoical, more restrained.

   25. RCDr. Rangan Chatterjee20:06

       Okay, so the diagnosis in and of itself is very subjective. You know, and I think this is a point to really hammer home. We're not doing a blood test for depression and going-

   26. JMJoanna Moncrieff20:16

       Yeah

   27. RCDr. Rangan Chatterjee20:16

       ... "Oh, yeah, you know, your blood test is in this range. We can say you're depressed." We're not doing that, okay?

   28. JMJoanna Moncrieff20:20

       No.

   29. RCDr. Rangan Chatterjee20:20

       We're doing it on a questionnaire, which is open to interpretation. Let's assume the questionnaire, um, accurately diagnoses depression, okay, which w- of course, we're questioning in the first place. What... My understanding from, uh, the paper you published in 2022, that sort of game-changing paper, I think, which I think is... In fact, you could tell us about the impact that paper has had, how many times it's been cited and shared, which is really profound. But also my understanding is that actually all the trials have shown on average is that taking an antidepressant improves your score by, is it by just a two-point difference? Could you just elaborate on that?

   30. JMJoanna Moncrieff21:02

       Uh, yes, yes. So the difference between taking an antidepressant and taking a placebo in these placebo-controlled trials is two points on this o- on, on this common depression rating scale, which is a, which has a maximum score of 54 points. So it's a very small difference.
7. 28:53 – 31:11

   Placebo, hope, and natural recovery: why people may feel better after starting SSRIs

   1. RCDr. Rangan Chatterjee28:53

      I wanna go into withdrawal in a minute. Um, let's just finish off this placebo piece. Right. So what I'm thinking of is someone who's listening to this going, "Okay, Joanna, I get that you are a well-esteemed, very well-respected [laughs] clinical psychiatrist. You work in a very prestigious hospital. You've been working for over three decades in psychiatry. You're telling me that there's no evidence or, or not very convincing evidence that there is a chemical imbalance in depression." Yet they might be thinking, "Well, yeah, I'm hearing you, but when I started taking Prozac, let's say, or citalopram, I started to feel better." What would you say to that person?

   2. JMJoanna Moncrieff29:37

      Yeah, yeah. That's, that's a really important point to make. So two things. One is that, um, most, most, uh, people with depression will start to feel better naturally at some point anyway, and often people come and see the doctor at a low point, um, and, and therefore will, you know, gradually improve after that. And there's also, I think, something about coming to the doctor itself, which sometimes is a sort of wake-up call for people. You know, "Oh my goodness, it's really got this bad."

   3. RCDr. Rangan Chatterjee30:08

      Yeah.

   4. JMJoanna Moncrieff30:08

      You know, "I've got to do, I've got to do something now." And I... And, you know, and, and often it will, um, uh, galvanize friends and family to come and be supportive.

   5. RCDr. Rangan Chatterjee30:18

      Of course.

   6. JMJoanna Moncrieff30:19

      Make people, you know, really reflect on, you know, "Do I really wanna carry on in this job that's got me into this state?" And people make other changes in their lives. So people often do improve after they start taking an antidepressant. Um, but we know from the clinical trials that people of- also improve, uh, after they've st- started taking a placebo.

   7. RCDr. Rangan Chatterjee30:38

      Yeah.

   8. JMJoanna Moncrieff30:39

      So some of the effect is-Um, it's, some of the effect is, is what would naturally occur anyway. It's making changes in your life, and some of it is due to believing that you're taking a tablet that's going to help you.

   9. RCDr. Rangan Chatterjee30:51

      Yeah.

   10. JMJoanna Moncrieff30:51

       That's-

   11. RCDr. Rangan Chatterjee30:51

       And the sense of hope.

   12. JMJoanna Moncrieff30:52

       Yeah, exactly.

   13. RCDr. Rangan Chatterjee30:53

       That-

   14. JMJoanna Moncrieff30:53

       Yes, yes

   15. RCDr. Rangan Chatterjee30:53

       ... oh, I didn't, um-

   16. JMJoanna Moncrieff30:54

       Yes

   17. RCDr. Rangan Chatterjee30:55

       ... yeah, I knew there was something wrong with me, and now the doctor's told me-

   18. JMJoanna Moncrieff30:57

       Yes

   19. RCDr. Rangan Chatterjee30:57

       ... I've got a chemical imbalance, and that, you know, I'm gonna take this pill, and it's gonna-

   20. JMJoanna Moncrieff31:01

       Yes

   21. RCDr. Rangan Chatterjee31:01

       ... correct it.

   22. JMJoanna Moncrieff31:02

       Yes.

   23. RCDr. Rangan Chatterjee31:02

       So you're going out with that belief that, oh, man, my life's-

   24. JMJoanna Moncrieff31:06

       Yes

   25. RCDr. Rangan Chatterjee31:06

       ... gonna change now, right?

   26. JMJoanna Moncrieff31:07

       Absolutely. Hope is the, I think is the key thing. That's, that's what you're giving people.

8. 31:11 – 42:35

   Sponsor break (wellness products and wearables)

   1. RCDr. Rangan Chatterjee31:11

      Do you sometimes find it difficult to find time to fit wellness into your life? I know many of us do. We feel our lives are too busy. BON CHARGE are a wellness brand who have a fantastic range of products to help you feel better, sleep better, and live better. And I've been using many of their products for well over five years now, and what I love the most is that they don't require me to find extra time in my life. I think their blue light-blocking glasses are some of the highest quality out there. I've been wearing them for years in the evening, also when I go traveling. I also love their infrared sauna blanket, which is much cheaper and more accessible than having a sauna in your own house. It's really easy to set up, and you can have a quick 30-minute session whilst relaxing, reading, or watching television. And this sauna blanket is gonna help you with recovery, relaxation, and sleep. BON CHARGE are giving my audience an incredible 20% off everything on their website. All you have to do is go to boncharge.com/livemore and use the coupon code LIVEMORE to get your 20% off or just click on the link in the description box below. I've been wearing this WHOOP band for about a year now, and it's had a transformative effect on my health and wellbeing. I've gained so many insights, how different types of exercise and life stress affect my recovery, how different evening routines affect my sleep quality, and I would say that wearing this WHOOP band has helped me understand my body much better. WHOOP is the only wearable that turns your health and fitness data into personalized guidance, and I'm pleased to announce that the all-new WHOOP is now available. 7% smaller and with 14-plus days battery life. Now, I've been a doctor for over 20 years, and I honestly don't think that health wearables are for everyone. Some people get overly obsessed with the data, and they can of course exacerbate health anxiety. But for some people, like me, they can be absolutely game-changing. The all-new WHOOP now includes Heart Screener with on-demand ECG readings that you can share with your doctor, and Health Span, a new feature that shows you how your daily habits impact your pace of aging. So if you want to improve your performance, longevity, and overall health, get the all-new WHOOP at join.whoop.com/livemore or click on the link in the description box below. But you can also give hope as a doctor without giving a pill.

   2. JMJoanna Moncrieff33:53

      Uh, no, I, I agree.

   3. RCDr. Rangan Chatterjee33:53

      And, and for-

   4. JMJoanna Moncrieff33:54

      Yeah

   5. RCDr. Rangan Chatterjee33:54

      ... a variety of different conditions, and it goes back to that sense of agency, autonomy. What can we give that person? How can we give them hope without necessarily giving them a pill that may have all these potential side effects?

   6. JMJoanna Moncrieff34:07

      I think giving people a pill i- in this situation is giving them false hope.

   7. RCDr. Rangan Chatterjee34:11

      Yeah.

   8. JMJoanna Moncrieff34:11

      Um, and I think-

   9. RCDr. Rangan Chatterjee34:11

      There's a real cost to it

   10. JMJoanna Moncrieff34:12

       ... y- yes, absolutely. And, you know, people may feel better for a bit, but then people, you know, many people will tell you, you know, "Then actually it stopped working."

   11. RCDr. Rangan Chatterjee34:22

       It stops.

   12. JMJoanna Moncrieff34:22

       "I didn't feel great again. You know, the sort of initial, initial stimulus I got, you know, wore off, and then I felt really awful, even worse than before because I thought, 'Oh, my goodness, this, this thing that was supposed to make me better isn't working.'"

   13. RCDr. Rangan Chatterjee34:35

       Yeah. It's, um, it, it's, it, it's really profound. I mean, I'm pausing on these points because I really want us to land these points for people, given how prevalent this belief is. 'Cause there will be people pushing back.

   14. JMJoanna Moncrieff34:51

       Yeah.

   15. RCDr. Rangan Chatterjee34:51

       Who go, "What you talking about? You know, of course there's a chemical imbalance. I've been hearing about this for two decades. You know, I learnt it at medical school." But this whole thing that, you know, someone might be thinking, "Well, I got better when I started taking it," look at it through another lens, right? Again, I think this pattern is common and prevalent in medicine, uh, both with doctors' and with patients' beliefs. So for example, let's say you've had a really bad cold for weeks, right? And this is very common. All general practitioners will have been in this position before where you know something is viral. You know that the patient is coming in. There's no symptoms suggest a bacterial infection, which again, for anyone who doesn't know, antibiotics treat bacterial infections. They don't treat viral infections. But, you know, if someone's coming, they're getting annoyed, saying, "Look, I've been off work for three weeks." And you're like, "Yeah, there's, there's no fever here. There's no productive sputum. This is just one of those things." You prescribe an antibiotic because it's easier to do so. They may well get better that week, but they probably would've got better anyway-

   16. JMJoanna Moncrieff35:55

       Yeah

   17. RCDr. Rangan Chatterjee35:55

       ... 'cause they'd already had it-

   18. JMJoanna Moncrieff35:56

       Yeah

   19. RCDr. Rangan Chatterjee35:56

       ... for four weeks, right? And the natural course of the infection is, oh, I'm gonna get better. Now, I can't say that in every case, but then... And, and the real problem with that is then the patient goes out with the belief, "Oh, the antibiotic is what made me better." What does that mean? It means in 12 months' time when you get another infection, you've got this ingrained belief that you need that pill. We can draw that same analogy in depression.

   20. JMJoanna Moncrieff36:20

       Yeah, that's a really good analogy. Yes.

   21. RCDr. Rangan Chatterjee36:22

       Can't we?

   22. JMJoanna Moncrieff36:22

       Yeah.

   23. RCDr. Rangan Chatterjee36:22

       Same thing.

   24. JMJoanna Moncrieff36:23

       Absolutely. Absolutely.

   25. RCDr. Rangan Chatterjee36:23

       Where if you, if it comes back to you-

   26. JMJoanna Moncrieff36:25

       Yeah

   27. RCDr. Rangan Chatterjee36:25

       ... in three years' time-

   28. JMJoanna Moncrieff36:26

       Yeah

   29. RCDr. Rangan Chatterjee36:26

       ... that, oh, I know what it is, it's that old chemical I need to, I need to make sure I get-

   30. JMJoanna Moncrieff36:29

       Yes
9. 42:35 – 45:26

   Depression across cultures: how markets can ‘introduce’ a diagnosis (Japan case study)

   1. RCDr. Rangan Chatterjee42:35

      And here's the other thing. You mentioned that now it's so commonly believed that it's a chemical imbalance, that the natural place to go is the doctor, and it wasn't always this way. There's many cultures around the world who still don't believe-... that depression is a medical thing, right?

   2. JMJoanna Moncrieff42:49

      Mm-hmm.

   3. RCDr. Rangan Chatterjee42:49

      There's some cultures around the world. I think the Hadza tribe don't even have a word for depression, right? They, they naturally see these things as, um, oh, this is a signal that there is something that we need to address. In my culture, you know, I'm growing up in an Indian family. In traditional Indian sort of Ayurveda medicine or traditional Chinese medicine, you know, you're not really making this as a, oh, this is a diagnosis. There needs to be a treatment. It's like the question is why? What's going on in this person's life-

   4. JMJoanna Moncrieff43:17

      Mm

   5. RCDr. Rangan Chatterjee43:17

      ... that means that they're feeling like that?

   6. JMJoanna Moncrieff43:19

      Yeah, yeah.

   7. RCDr. Rangan Chatterjee43:19

      But these viewpoints are quite antithetical to the way modern Western medicine looks at a condition like depression.

   8. JMJoanna Moncrieff43:27

      Yeah, yeah. It just reminds me of a really interesting anthropological study of the introduction of depression into Japan. So in the 1990s, uh, up until the 1990s, depression wasn't something that was commonly diagnosed in J- in Japan, and it, it, like you're saying about, um, Indian culture, it wasn't, wasn't really, it, it certainly wasn't, wasn't a sort of recognized medical condition. Um, and therefore, there weren't many antidepressants being prescribed in Japan, and the pharmaceutical industry recognized this was, uh, potentially an untapped market.

   9. RCDr. Rangan Chatterjee44:02

      An untapped market.

   10. JMJoanna Moncrieff44:02

       Exactly. Yes. [laughs] Yes.

   11. RCDr. Rangan Chatterjee44:04

       [laughs]

   12. JMJoanna Moncrieff44:05

       So they set out to introduce depression into Japan and to increase the sales of antidepressants. And we know about this because they employed, um, a well-known anthropologist, Lawrence Kirkmer, who's, who's written up his experience of, of, um, of being involved in this, i- in this strategy of the pharmaceutical industry to persuade the Japanese that they were depressed. So, so they employed him as an anthropologist to, to tell them about the culture of Japan and, and why it was that people didn't consider themselves to be depressed, and that was partly because, um, because depression was understood as a meaningful reaction to things-

   13. RCDr. Rangan Chatterjee44:45

       Mm

   14. JMJoanna Moncrieff44:45

       ... not seen as a, as a clinical disease. And so they came up... Just as the pharmaceutical industry did in, in this country, actually, they came up with ways of overriding the cultural norms and, um, people's sort of intuitions about what depression was in order to persuade them that it was, uh, that it was a medical condition, and it was very successful, and the rate of prescribing of antidepressants-

   15. RCDr. Rangan Chatterjee45:11

       Yeah

   16. JMJoanna Moncrieff45:11

       ... you know, escalated as a consequence. So, so that's actually a case study in that-

   17. RCDr. Rangan Chatterjee45:15

       There you go

   18. JMJoanna Moncrieff45:15

       ... which is very interesting.

   19. RCDr. Rangan Chatterjee45:16

       And it's-

   20. JMJoanna Moncrieff45:16

       Yeah

   21. RCDr. Rangan Chatterjee45:16

       ... you know, we, we smile and we laugh, but actually underlying that laughter is a real disturbing-

   22. JMJoanna Moncrieff45:25

       Yep

10. 45:26 – 1:08:05

    The ‘dark truth’ side effects: emotional numbing, sexual dysfunction, and persistence after stopping

    1. RCDr. Rangan Chatterjee45:26

       ... truth here. You know, we're putting frankly millions of people on drugs which may have limited evidence for their benefit and may have a huge ton of side effects, right? So let's go into some of them.

    2. JMJoanna Moncrieff45:41

       So, so we're doing that, and we are also changing people's sense of self, aren't we?

    3. RCDr. Rangan Chatterjee45:45

       Yeah.

    4. JMJoanna Moncrieff45:45

       We're changing people's idea about, about what it is to be a human being and persuading people that parts of themselves, some of these feelings that they have that might be a bit inconvenient ti- at times, are a disease that can be eradicated somehow, not something that they would previously unders- uh, have understood-

    5. RCDr. Rangan Chatterjee46:02

       Yeah

    6. JMJoanna Moncrieff46:03

       ... as a part of themselves that they need to manage and integrate in some way.

    7. RCDr. Rangan Chatterjee46:06

       And address. Like, this is, this is... Okay, maybe this might come across as a glib example, but I'm gonna share it anyway 'cause I think it's relevant to what you just said. Okay. So I'm normally a pretty upbeat, calm, optimistic human, I would say. I've just come to the end of an extremely busy period, okay? So my, uh, new book came out earlier in the year. I was doing a lot of interviews and travel to raise awareness, as you well know, what it's like when you have a book out. And I went straight from that into my first national theater tour. So I created a two-and-a-half-hour show on what it means to thrive, and I've done something I've never done before, which is every weekend for five weekends, I did three or four back-to-back nights.

    8. JMJoanna Moncrieff46:53

       Wow.

    9. RCDr. Rangan Chatterjee46:53

       Okay? So I've not had a weekend off for six weeks. And I'm not, I'm not bragging about this, to be clear. I'm not saying this is a good thing, right? Um, and I tried to, um, balance that by what I was doing in the week, right? But it, it, it didn't work so well, okay? So I was getting progressively more and more tired because I normally go to bed at 9:00, and I wake up at 5:00. That's my rhythm. But normally after a show, I wasn't really getting to bed till about 1:00 or 1:30 by the time I'd switched off, but I was still waking up at 5:00 or 6:00. Right. So I've just come to the end of that, and it was a phenomenal experience. I don't regret any of it, but early on this week, I had a few days where I felt really low. This is very unusual for me. I... My outlook on life was quite negative. I was being quite reactive, things that I'm not usually anymore. Okay. Now, again, I'm not saying that I necessarily met the criteria for a diagnosis. I, I probably didn't. But the principle that I'm trying to sort of get across is I didn't see this as a deficiency in me. I thought, "Oh, this is interesting, Rangan. This, th- this is a signal that you are overly tired. You're overly stressed. You need some relaxation. You need some resetting," right? So instead of going, "Oh, my God. Why am I feeling so low?" I saw these things as signals that, "Hey, Rangan, you need to make some changes at the moment. You need to be really careful. Make sure you've got some time off," all this kind of stuff in or... And I, you know, within a f- couple of days, I'm back to my usual self, right? It's not quite the same thing, but there's a kind of principle there, isn't there?

    10. JMJoanna Moncrieff48:30

        Uh, definitely. I think, um, I think seeing emotions as signals is, is, is a really good way of putting it, um, because that's what they are. Your body and your mind is reacting to what's going on around you and, and saying, "We don't like this." [laughs]

    11. RCDr. Rangan Chatterjee48:45

        Yeah. Let's now go into antidepressants then and these potential negative effects or I guess some warning signs that people may-... be experiencing that help them understand that they may have a negative effect. And I mean, some of the ones I've written down from your book are you feel numb, sex drive gone, brain fog, you can't get off them. You often have to take other medications to counter the side effects. You can sometimes feel worse in the long run. Your personality can change. These are pretty significant and severe. So can we go through them one by one? You know, you mentioned, um, emotional numbness before.

    12. JMJoanna Moncrieff49:23

        Yeah.

    13. RCDr. Rangan Chatterjee49:24

        What-

    14. JMJoanna Moncrieff49:24

        Yeah

    15. RCDr. Rangan Chatterjee49:24

        ... can you just expand on that? What is that, and why is that a problem?

    16. JMJoanna Moncrieff49:27

        Yes. So, so this seems to be a pretty consistently reported effect of most antidepressants, um, that, uh, it- it's like the intensity of your emotions is sort of dialed down or, or, or they're sort of suppressed or restricted in some way. Or people will often say they can't cry when they're taking antidepressants. Um, and most people find that pretty unpleasant, especially after the sort of first initial crisis has passed. And there may be a period where actually it's a relief maybe not to feel anything, but, but after that, most people find it fairly unpleasant. And that is connected with, probably, the, the evidence seems to suggest, with the ability of most antidepressants to, um, interfere with our sexual function, to cause sexual dysfunction in various ways. Um, and both of these things can, uh, it- it's been shown recently, can persist after people stop taking the drug. So that's really worrying and some- something that I really wanted to highlight in the book, because if that happens to you, if you've taken antidepressants for a, for a period, you come off them, and you've still got sexual dysfunction, and it goes on for years, as some people report that it does-

    17. RCDr. Rangan Chatterjee50:42

        Yeah

    18. JMJoanna Moncrieff50:42

        ... that's a catastrophe.

    19. RCDr. Rangan Chatterjee50:43

        Okay. Let- let's just sort of dive in there. So I think that's a really important point. Okay. So, um, if you're struggling with your mood, whether we wanna label it depression or not, um, on some level, you're not able to experience pleasure or joy, right? And you mentioned sexual dysfunction there. As a psychiatrist, Joanna, um, how important is it for an individual to not have sexual dysfunction? I know this might seem like an obvious question, but just to really spell that out, how important is it to have a libido, to have that sense, whatever it might be, for your mental wellbeing?

    20. JMJoanna Moncrieff51:24

        Yeah. Well, I think it's hugely important. It's a part of being, being human, being, being alive, being a living organism, isn't it? And, um, and, and certainly people who lose it or have it damaged, um, feel, you know, very upset about that, uh, and, and feel that they're not, you know, living, being their full selves anymore.

    21. RCDr. Rangan Chatterjee51:45

        Yeah. And it's interesting you said that because there may be a common belief that, oh, when I'm taking this drug, I might get side effects. But if I don't like the side effects, I will stop it.

    22. JMJoanna Moncrieff51:55

        Yes.

    23. RCDr. Rangan Chatterjee51:56

        You're saying that actually for some people, the sexual dysfunction continues after they've stopped the antidepressants.

    24. JMJoanna Moncrieff52:02

        Yes. Yes, and that's a really important point because it's... So it's well recognized that antidepressants cause, um, quite a large proportion of people, maybe up to around 60% or more, sexual dysfunction while they're taking them. Um, but what hasn't been recognized but has been emerging recently is that for some people, this problem persists. And a- another point that I think it's important to make here is that, of course, when people are depressed, their libido, you know, can go down. Th- th- th- they-

    25. RCDr. Rangan Chatterjee52:32

        As part of the whole-

    26. JMJoanna Moncrieff52:34

        As part of feeling depressed

    27. RCDr. Rangan Chatterjee52:35

        ... constellation of symptoms. Yeah.

    28. JMJoanna Moncrieff52:35

        Exactly. Um, so, so we recognize that, but, but it's definitely the case that, that SSRIs in particular and, um, other related antidepressants, um, affect people's sexual function on top of that. So it's not just the depression. The drugs have an additional, um, effect. And one of the particular things they do, which is not characteristic of sexual dysfunction and depression, is they cause, um, anesthesia of the genitals. So they sort of dial down-

    29. RCDr. Rangan Chatterjee53:05

        Wow

    30. JMJoanna Moncrieff53:05

        ... the sensitivity of the genitals. Um, and that, that seems to be a, this, a sort of parallel effect to numbing emotions. There's this sort of dialing down of sensitivity. Um, and, and that, uh, and, and, and that and other effects like reduced libido are what can persist when people stop taking the antidepressants.
11. 1:08:05 – 1:19:50

    What SSRIs do biologically: transporter blockade, unknown long-term effects, and ‘mind-altering’ framing

    1. RCDr. Rangan Chatterjee1:08:05

       What do SSRIs actually do then? If they don't correct an underlying chemical imbalance, what do they do?

    2. JMJoanna Moncrieff1:08:15

       So SSRIs block the transporter protein that transports serotonin out of the gap between the nerve cells, that's called the synapse, where it has its action. So by, by stopping serotonin being taken out of the synapse, they increase the time it's available in the synapse, and therefore in theory, increase the activity of serotonin, um, or increase the activity of nerves that fire impulses where serotonin is the transmitter. Um, so, so that, so that's the theory, and they certainly do, um, interfere with this serotonin transporter protein, and they probably increase the activity of serotonin by doing that temporarily, at least. Although we're not very certain about that, and we're certainly not very certain about, um, the effects that they have in the long run, whether they're, whether in, if people keep taking them, whether they, uh, whether they keep increasing the activity of serotonin in the, in the synapse, or whether they might even reduce it. There's some evidence that, um, serotonin levels in the blood, for example, which may not reflect the levels in the brain, but probably gonna be, um, you know, reasonably consistent with them, um, are actually lower in people who are taking SSRIs on a, on a long-term basis. So it may be, may be the case that they even lower serotonin in the long run. I, I think, I think we're not very sure, but they do seem to disrupt normal serotonin transmission in one way or another, either increasing it or decreasing it.

    3. RCDr. Rangan Chatterjee1:09:54

       But, and what's the effect on our symptoms, though? So let's say-

    4. JMJoanna Moncrieff1:09:56

       Mm

    5. RCDr. Rangan Chatterjee1:09:56

       ... it is doing some of these things. It's, it's sort of altering serotonin and the serotonin pathway in some way. Um, what is that doing then to our brains? Like, wh- why is it that people can feel when they're on these things?

    6. JMJoanna Moncrieff1:10:12

       Yeah. So, so we don't, we don't know exactly how that translates into what people, what people feel, but we know that it is disrupting the serotonin system and, and probably many other neurochemical systems in the brain.

    7. RCDr. Rangan Chatterjee1:10:25

       Well, it must be, 'cause if we're saying that you're gonna get, let's say, emotional numbness-

    8. JMJoanna Moncrieff1:10:29

       Yeah

    9. RCDr. Rangan Chatterjee1:10:30

       ... that must be-

    10. JMJoanna Moncrieff1:10:30

        Be-

    11. RCDr. Rangan Chatterjee1:10:30

        ... an effect of it. If you're gonna have-

    12. JMJoanna Moncrieff1:10:32

        Yeah

    13. RCDr. Rangan Chatterjee1:10:32

        ... sexual dysfunction or what did you say around the genitalia, the, um-

    14. JMJoanna Moncrieff1:10:37

        Genital anesthesia.

    15. RCDr. Rangan Chatterjee1:10:38

        Genital anesthesia.

    16. JMJoanna Moncrieff1:10:39

        Yes. Yeah. Yeah.

    17. RCDr. Rangan Chatterjee1:10:39

        Well, even if you assume that they are working on that narrow pathway that we're told they're, they're working on, well, it's pretty clear they're doing other things as well.

    18. JMJoanna Moncrieff1:10:48

        Yes. Yes. Absolutely. Absolutely.

    19. RCDr. Rangan Chatterjee1:10:49

        They don't just do one thing.

    20. JMJoanna Moncrieff1:10:50

        Yeah, yeah, yeah. Um, I mean, we don't know very much about serotonin overall. Probably the one thing we do know that it's involved with in, in terms of sort of mental or behavioral things is sexual function, and we know that, um, higher serotonin activity impairs your sexual functioning.

    21. RCDr. Rangan Chatterjee1:11:09

        Wow.

    22. JMJoanna Moncrieff1:11:10

        Um, reduces your lib- reduces your libido, reduces sexual activity in animals, for example. Um, and a- apart from that, we prob- we, we really don't know very much about what serotonin does. But as you say, what we do know is what these drugs do to people, what the... So they do something to the brain, and we know what the end result is, and we know that this is sexual dysfunction, emotional numbing, um, degree of lethargy. Agitation in some people, um, particularly young people after they start taking the drugs, that can happen, and that's probably related to the cases where they can lead to an increase in suicidal thoughts, um, which I think is, is probably rare, but has been shown to happen in, in clinical trials.

    23. RCDr. Rangan Chatterjee1:11:55

        Can I, can I [laughs] ... I know I've already mentioned this point, but I, I, I really think it's worth highlighting. I- if you came in fresh to this conversation or the, or, or, I don't know, I was gonna say the world, right? You, you're coming in fresh, right? You, you haven't ever heard of this chemical imbalance theory before. Let's say there's, there's someone out there who's never heard of this, and they were just hearing that part of our conversation. Someone might think, "Okay, Joanna, so you're talking to Rangan about people with, uh, low mood who are really struggling with their life, and you're also talking about giving them a drug that may increase their risk of suicidal thoughts, even though that's rare. Isn't that madness on one [laughs] level?"

    24. JMJoanna Moncrieff1:12:40

        Yeah.

    25. RCDr. Rangan Chatterjee1:12:40

        Is it... It's kind of, I don- we're so used to it, it's hard for us to say as medical doctors, but I think it's a bit ridiculous to even think about [laughs] what... Or, or even these other things-

    26. JMJoanna Moncrieff1:12:49

        Yeah

    27. RCDr. Rangan Chatterjee1:12:49

        ... right?

    28. JMJoanna Moncrieff1:12:50

        Yeah.

    29. RCDr. Rangan Chatterjee1:12:50

        Lethargy.

    30. JMJoanna Moncrieff1:12:51

        Yes.
12. 1:19:50 – 1:34:09

    Withdrawal and dependence: why stopping can mimic relapse and how to taper safely

    1. RCDr. Rangan Chatterjee1:19:50

       Could we draw an analogy to common drugs that people use that often they don't think about as drugs, alcohol and caffeine, right? So if you're feeling a bit anxious, right, um, you could drink alcohol, and that may reduce your anxiety, right? So it's a mind-altering substance. Caffeine is a psychoactive stimulant. Although many of us, uh, drink our tea or coffee, and we enjoy it, I, I very much do, we often don't appreciate this is a psychoactive stimulant. This... You can-

    2. JMJoanna Moncrieff1:20:26

       Yeah

    3. RCDr. Rangan Chatterjee1:20:26

       ... feel a bit low and are not quite with it in the morning, have a, a strong cup of coffee-

    4. JMJoanna Moncrieff1:20:31

       Mm, mm

    5. RCDr. Rangan Chatterjee1:20:31

       ... and you feel like you can take on the world, right? So it's-

    6. JMJoanna Moncrieff1:20:33

       Yeah, yeah, yeah

    7. RCDr. Rangan Chatterjee1:20:33

       ... mind-altering.

    8. JMJoanna Moncrieff1:20:34

       Yes.

    9. RCDr. Rangan Chatterjee1:20:35

       But with those things, let's say caffeine, for example, we know, don't we, like if you're, if you are a habitual caffeine drinker, anyone, anyone who's tried to give up coffee before as a regular drinker will know the withdrawal can be pretty severe. Mood swings, headache, like real fatigue. Like, you know, 'cause caffeine's legal, and we all-

    10. JMJoanna Moncrieff1:20:57

        Mm

    11. RCDr. Rangan Chatterjee1:20:57

        ... you know, we enjoy it-

    12. JMJoanna Moncrieff1:20:58

        Mm, mm, mm, mm

    13. RCDr. Rangan Chatterjee1:20:59

        ... so we don't see it like that. But we, what we don't believe, I don't think, is if, if you're stopping caffeine and you have withdrawals, you don't think, "Yeah. Oh, God, I needed the caffeine, don't I? You know, I've got this problem that caffeine solves." Now you understand that it's withdrawal, but we don't think about that-

    14. JMJoanna Moncrieff1:21:16

        Yeah

    15. RCDr. Rangan Chatterjee1:21:16

        ... with antidepressants.

    16. JMJoanna Moncrieff1:21:17

        Yes, yeah.

    17. RCDr. Rangan Chatterjee1:21:17

        We think, "Oh, this is a... Oh, you know, I need it for my condition." So can you help me? Do you think that's-

    18. JMJoanna Moncrieff1:21:23

        Yeah

    19. RCDr. Rangan Chatterjee1:21:23

        ... a reasonable analogy?

    20. JMJoanna Moncrieff1:21:24

        I, I think that's a very useful analogy. I think it's a, a useful analogy to think about the effects of antidepressants. And, and in a lot of my work, I, um, draw the analogy with alcohol that, that you drew because alcohol, you know, we recognize that it can be helpful if you're anxious. It... You know, if you go out and have a load to drink and you were feeling depressed, you may not feel depressed for a few hours while you're under the influence. We have a phrase for that. We call it drowning our sorrows. Um, so you know, we recognize that mind-altering drugs change the way that we feel temporarily while we're under the influence. But we also recognize that dealing with depression by getting drunk every day is probably not a good idea. Now, I'm not saying that the effects of antidepressants are exactly the same as the effects of alcohol, that they're, they're not. Ev- every, you know, chemical substance changes the brain in a different way and produces different, uh, different changes in our mental state and our feelings and things. Um, but the principle is the same, that it's, it's, it's changing the way that... You know, it's changing our normal feelings.

    21. RCDr. Rangan Chatterjee1:22:27

        And also, we know that alcohol is a depressant-

    22. JMJoanna Moncrieff1:22:30

        Yeah

    23. RCDr. Rangan Chatterjee1:22:30

        ... right? But again, it, it's funny how we use language. We don't go around talking about alcohol as, "Oh, you're gonna, oh, you're gonna consume more depressants tonight. Are you coming around to my party? Do you want some depressants?"

    24. JMJoanna Moncrieff1:22:41

        Yes, yes. [laughs]

    25. RCDr. Rangan Chatterjee1:22:41

        We, we don't, do we, right? But we're, we're like, yes, but w- we know that there actually a lot of people will know when they've had a few-

    26. JMJoanna Moncrieff1:22:46

        Mm, mm

    27. RCDr. Rangan Chatterjee1:22:46

        ... few drinks, the following day they feel pretty low.

    28. JMJoanna Moncrieff1:22:49

        Mm, mm.

    29. RCDr. Rangan Chatterjee1:22:49

        Right? It is a depressant, but we don't... [laughs] It's interesting even the language we use. So okay. All right. So if you're on it-

    30. JMJoanna Moncrieff1:22:57

        Yes. And so, so the, the other analogy is, is very good as well that we know that, you know, if we think of mind-altering drugs, as you say, like caffeine or like heroin, we, we know that when people start taking these every day, they become... The body adapts to their presence. They become physically dependent on them, and therefore, when they stop, they get withdrawal symptoms. And those withdrawal symptoms, because the drugs have, you know, there've been adaptations in the brain as well as parts of the body, those withdrawal symptoms will include, um, you know, emotional symptoms. So people may become, when they're coming off, um, [lips smack] antidepressants, very anxious, for example, pro- probably partly because those emotions have been suppressed when you're under the drug, when you're under the influence of the drug, and then you take the drug away, and there's a sort of rebound reaction. So people can become very anxious and also emotionally labile, very, um, changeable and tearful. Um, and, and as you say, because there hasn't been widespread appreciation that antidepressants cause withdrawal symptoms in the same way that caffeine, alcohol, opiates cause withdrawal symptoms, people will often interpret them as the, you know, "Oh, goodness, my depression's coming back. I feel anxious again." Um, then if you ask people in more detail, it's, it's often apparent that actually it's not quite the same as their original symptoms.
13. 1:34:09 – 1:49:25

    What clinicians can do instead: NICE alternatives, shared decision-making, and practical advice for listeners

    1. RCDr. Rangan Chatterjee1:34:09

       But okay then. So for a doctor who, let's say, pre this conversation was prescribing a lot of SSRIs, as the guidelines were saying they were okay to do so, but let's say there's a doctor who's just heard this and a patient comes in to see them with symptoms consistent with a diagnosis of depression, where in the past they would've prescribed an SSRI. What would you ask that doctor to do?

    2. JMJoanna Moncrieff1:34:36

       So the recent NICE guidelines are quite helpful in this respect, in that they list a whole number, it's about eight or nine, um, alternative treatments for people with depression that you can give instead of giving an antidepressant. And they inclu- or... Treatments, inverted commas, because they include things like recommending exercise, um, mindfulness, problem-solving therapy, CBT, of course. Um, so they do include some... O- obviously, I know there's usually a waiting list for therapy, and that's, you know, that can be an issue if someone's, you know, feeling really desperate. But they do include some things that people could go off and do straightaway. So I think that, I think that doctors should be trying to guide patients towards these alternative ways of managing their depression.

    3. RCDr. Rangan Chatterjee1:35:21

       Yeah.

    4. JMJoanna Moncrieff1:35:21

       If people are very insistent and really feel that they want to try taking an antidepressant, my general approach is to try and make sure that they do that in an informed way. So to have this discussion that we've been talking about of, um, ensuring that they know exactly what the drug is, what we know about what it does, and what we don't know about what it does to the body and the brain, its effects on your mental state and physical functioning, a- and, and, and the, you know, common and, and important adverse effects.

    5. RCDr. Rangan Chatterjee1:35:54

       Yeah. It's, um, it's really interesting hearing you say what the NICE guidelines, uh, are now saying. Um, you know, my, my, my very first book was called The Four Pillar Plan, and it came out right at the end of 2017, and in that book, I make the case that 80 to 90% of what we see as doctors these days is in some way related to our collective modern lifestyles. And I, at that time, and I still subscribe to what was in that book, the, the four pillars of health that I say have the most impact on our wellbeing and that we have a degree of control over, although it's different for different people, are food, movement, sleep, and relaxation. And I break down those pillars, and I give people actionable advice that doesn't cost much for all of them. I can't tell you, Joanna, over the years, and that book's, what, been out now for what? Over seven years. I've had hundreds if not thousands of messages from people saying that that book has helped them with their depression. Now, I don't mention depression, a diagnosis in it, I don't mention, but I, I think there comes a fundamental, um... There's a fundamental conundrum which we have to wrestle with, right? Which is, do we believe that there are fundamental problems with the human body, right? There are deficiencies we're born with. There are these chemical imbalances that need correction with drugs. Or, or, and do we look at it as going, okay, there are various things, various inputs into our biology and our physiology as humans that haven't, um, have a consequence, right? Maybe with our mood. And if we can correct or improveWithin our capabilities, some of those things, like more exercise, better nutrition, s- prioritizing your sleep a little bit more than perhaps you were, doing... learning a few helpful stress management techniques. Well, that's kind of what I shared in that book, and actually, it means that for some people, of course not everyone, actually, some of their emotions and symptoms start to get better. Yes, probably because of the direct impacts of those behaviors, but also because the sense of agency-

    6. JMJoanna Moncrieff1:38:07

       Yeah, yeah. Yeah

    7. RCDr. Rangan Chatterjee1:38:07

       ... that they feel over their life.

    8. JMJoanna Moncrieff1:38:09

       Yeah, yeah.

    9. RCDr. Rangan Chatterjee1:38:09

       "I can do something that makes-

    10. JMJoanna Moncrieff1:38:10

        Yeah

    11. RCDr. Rangan Chatterjee1:38:10

        ... a difference." Do you have, do you have any comments on that?

    12. JMJoanna Moncrieff1:38:11

        Yeah. Uh, well, I think it's a really sensible approach for that reason, and I think what's nice about it is because you've broken it down into four different areas-

    13. RCDr. Rangan Chatterjee1:38:19

        Yeah

    14. JMJoanna Moncrieff1:38:19

        ... it's not quite so overwhelming as-

    15. RCDr. Rangan Chatterjee1:38:21

        No

    16. JMJoanna Moncrieff1:38:21

        ... you know, someone feeling, "Oh, my God, I've got to change everything." You know, they can focus on these, on these four things, make some adjustments, and as you say, get back, hopefully, a sense of, a sense of agency, a sense of empowerment.

    17. RCDr. Rangan Chatterjee1:38:34

        You tweeted recently or, or what do you call it now? You X'd.

    18. JMJoanna Moncrieff1:38:38

        Yes. [laughs]

    19. RCDr. Rangan Chatterjee1:38:39

        You, you, you made, you made a post on, on the platform formerly known as Twitter, um, and I think it was to do with Chris Palmer. Um, Chris Palmer's a Harvard psychiatrist. Chris has been on my show before, and he's doing some quite incredible work, and he's published research, um, showing that for some people with severe mental health problems, a ketogenic diet, so improving their metabolic health, can have a huge effect. And I seem to recall from your post that you were questioning some of that. So not questioning, but just saying you don't want us to fall into the same trap going it was all serotonin. I think what you were trying to say is-

    20. JMJoanna Moncrieff1:39:18

        Yeah

    21. RCDr. Rangan Chatterjee1:39:18

        ... we can't now say it's all metabolic.

    22. JMJoanna Moncrieff1:39:21

        Yeah.

    23. RCDr. Rangan Chatterjee1:39:21

        Could you just expand on that a little bit? 'Cause I found that really interesting.

    24. JMJoanna Moncrieff1:39:24

        Yes. I think I also probably said, you know, that I think having a healthy, balanced diet is, you know, a very important thing for-

    25. RCDr. Rangan Chatterjee1:39:30

        Yeah

    26. JMJoanna Moncrieff1:39:30

        ... having a healthy body and mind. Um, but I am slightly wary that there i- there are a group of people who want to replace the chemical imbalance with a metabolic imbalance-

    27. RCDr. Rangan Chatterjee1:39:41

        Yeah

    28. JMJoanna Moncrieff1:39:41

        ... model, um, and suggest that some metabolic, uh, abnormality is a sort of specific direct cause of depression, as people were suggesting that a serotonin abnormality was a specific and direct-

    29. RCDr. Rangan Chatterjee1:39:53

        Yeah

    30. JMJoanna Moncrieff1:39:53

        ... cause of depression.

Episode duration: 1:49:26