Last week, a study went viral that was widely promoted as proof positive that everything we know about antidepressants is wrong. Helmed by lead author Joanna Moncrieff, a professor of psychiatry at University College London, the study was an umbrella review of research into selective serotonin reuptake inhibitors (SSRIs), one of the primary medications prescribed to people diagnosed with depression. Though most lay people believe that SSRIs work by increasing serotonin levels in the brain, thereby relieving symptoms of depression, the review of 50 years of studies concluded that there is “no clear evidence” that low serotonin levels cause depression to begin with.
The paper was widely picked up by media outlets in the United Kingdom, with some citing the study as evidence that SSRIs don’t work. It was shared and discussed by Pizzagate promoter Jack Posobiec on his podcast, as well as promoted extensively by far-right commentator and professional transphobe Matt Walsh, who tweeted, “Big Pharma has made billions prescribing wonder drugs to treat depression but there was never any solid scientific evidence that the drugs would work. Now we know that the whole thing was built on a myth.” Tucker Carlson spoke about the study on his show, characterizing it as a rejoinder against taking SSRIs in general. “First we were told that SSRIs would save lives. Now we learn they don’t actually work as intended. In fact, the whole idea behind the drug was completely wrong. And yet, and here is the best part, people are ignoring this news and the drugs are still being prescribed.”
Contrary to what Carlson claimed, the review wasn’t explicitly a condemnation of antidepressants; rather, it was an interrogation into the mechanism by which SSRIs are thought to work. “We have shown that the main hypothesis for how antidepressants might act on the biological mechanisms of depression is not supported by evidence,” Moncrieff tells Rolling Stone via email. “I see our research as linked with the way we understand and evaluate antidepressants, and it logically follows from my other work on the nature of drug action.”
“The paper is not coming in a vacuum,” says one psychiatric researcher.
Yet it is not at all surprising that the paper was received the way it has been. Moncrieff has spent years actively questioning the efficacy of SSRIs and the nature of mental illness in general, as well as promoting widely disputed beliefs about the dangers of various mental health interventions such as antidepressants or alternative forms of treatment. “The paper is not coming in a vacuum,” says Awais Aftab, clinical assistant professor of psychiatry at Case Western University who has previously interviewed Moncrieff for a 2020 Psychiatric Times article. “It’s coming with two decades of work in which Moncrieff has consistently challenged the characterization of depression as a mental illness. If someone is not familiar with this prior background, it may not be obvious to them. It’s not an accident the discussion went in that direction.”
Within the medical community, the paper’s conclusions were nothing new. David Hellerstein, professor of clinical psychiatry at Columbia University Medical Center and director of Columbia’s Depression Evaluation Service, explains that the serotonin hypothesis — i.e., the idea that depression is caused by low serotonin levels — is a “quaint and oversimplified shorthand that has been superseded by other explanations in clinical practice for a decade or more.” He says that the review was largely met with yawns from the psychiatric community. “In reading it, I was kinda thinking, ‘Wow, next she’ll tackle the discrediting of the black bile theory of depression,” he tells Rolling Stone. Several U.K. researchers and psychiatrists, as well as a spokesperson for the Royal College of Psychiatry, criticized the paper, questioning why an umbrella review of outdated studies was even needed. That prompted Moncrieff and her co-author to issue a rebuttal.
So where is Moncrieff coming from? She is one of the co-founders and chairperson of the Critical Psychiatry Network, a group of British psychiatrists that, according to its website, aims to “[mount] a scientific challenge to claims about the nature and causes of mental disorder and the effects of psychiatric interventions.” This perspective is not unusual in the United Kingdom, where care providers are largely trained to believe that psychotherapy, not medication, should be the first form of intervention, versus American practitioners, who are quicker to prescribe medications, according to clinical prescribing and medical psychologist Joseph Comaty. What is somewhat unusual is that Moncrieff’s work is frequently promoted by an organization called Citizens Commission on Human Rights (CCHR), which touts itself as a “mental health industry watchdog” and was established by the Church of Scientology, which is virulently opposed to psychiatry and medical interventions for mental illness.
Moncrieff has devoted much of her career to criticism of virtually all mental health care interventions, including psychedelics like esketamine and transcranial magnetic stimulation (TMS), inaccurately linking the latter method to an increased risk of cognitive impairment. She has aggressively championed the idea that SSRIs can cause lasting structural damage to the brain, authoring multiple papers to that effect. On her blog and in her research, she has promoted the idea that withdrawing from SSRIs can cause long-term mania or psychotic symptoms (this is a documented side effect, but an extremely rare one; the most common side effects of withdrawal, such as dizziness or gastrointestinal distress, are uncomfortable yet short-lived) as well as the belief that SSRIs are linked to aggressive behavior, a fringe view that has recently been adopted by the right in the wake of national calls for increased gun control to prevent mass shootings.
“Although I am concerned about our findings being used to argue against gun control, I do not think this means that we should not be talking about them,” says Moncrieff.
When asked whether she believes there is a link between SSRIs and aggression, Moncrieff points to a 2016 meta-analysis in the British Medical Journal indicating that antidepressants can cause aggression in younger people. “But it is rare, and I would not say that means you can blame them for school shootings, which are obviously much more complex,” she tells Rolling Stone. “Being from the U.K., I am very much in favor of gun control, so I don’t like people using anything as an argument against that.” She added in a follow-up: “Although I am concerned about our findings being used to argue against gun control, I do not think this means that we should not be talking about them.”
Yet Moncrieff’s views more clearly align with the right on other matters. For instance, much of her work has focused on the question of preserving personal bodily autonomy over the health and welfare of the general populace, as evidenced by one 2014 paper she wrote on the work of the late Thomas Szasz, a controversial psychiatrist who questioned the institution of psychiatry and eventually co-founded the CCHR. (Szasz himself was not a Scientologist). In the paper, Moncrieff cites pediatric vaccine mandates in the United States as an example of the “paternalism” of public health interventions, and frames mental health care interventions — as well as mental illness as a diagnostic category — as an effort on behalf of the state to exert mind control tactics over individuals who refuse to conform to societal standards, referring to psychiatry as “the arena in which the conflict between freedom and health comes most sharply into focus.”
More recently, she has used her platform to publicly question mandatory Covid vaccines for health care workers in the U.K.. Last year, she was one of the signatories of an open letter from health care professionals opposed to the mandates, which, while acknowledging that they can be helpful for some people, maintained “there is considerable uncertainty about the effectiveness of the Covid vaccines.” In the past, she has also compared Covid vaccine mandates to forced psychiatric care. “Forced treatment in psychiatry is rightly controversial and limited, but now we are forcing thousands to have Covid jab,” she tweeted last December.
When asked about her views on vaccine mandates, Moncrieff doubled down. “I believed and still believe that forcing people to take a vaccine that was not well tested… that would have minimal benefits for many of the people taking it, and very importantly, has not been shown to reduce transmission, was not ethically justified,” she tells Rolling Stone. (Vaccines have been widely shown to reduce transmission of some variants as well as the risk of hospitalization and severe illness from Covid-19.)
On at least one occasion, she inaccurately connected severe Covid-19 symptoms to antidepressant or antipsychotic use (in fact, data from an observational study suggests that taking SSRIs may actually reduce a person’s risk of dying from Covid). When asked for further evidence to support this view, Moncrieff demurred, saying, “I have not been following this story recently, so can’t give you any more recent information on this.”
In speaking about the dangers of SSRIs, Moncrieff has dabbled in the same vein of light conspiratorial thinking that characterizes her views on vaccines. “I have been asked whether I think this is evidence of a conspiracy by drug companies to suppress evidence of the dangers of their products,” she wrote in a 2016 post on SSRIs, suicidality, and aggression. “It may be, but it is also evidence of a more systemic failing.” She then goes on to question whether Big Pharma may play a role in covering up potential side effects, writing: “Why the reluctance to investigate this matter properly? Financial conflicts of interest is one answer.” She also wrote that “[o]ther factors include psychiatrists’ professional insecurity, and doctors’ perceived need to have something to offer the people who queue up daily in the hope of a remedy for their distress.”
Even critics of the paper believe that the meat of the conclusions it draws — i.e., that the serotonin hypothesis is potentially inaccurate — is reasonable.
While Aftab may believe it is not an accident that the paper was embraced by the right, Moncrieff is somewhat perturbed by the segment of the U.S. media currently championing her research. “I am perplexed at why this story has been taken up by the right-wing media more than the left,” she says. She believes that treating mental illness with medication constitutes “inappropriately medicalising distress and thereby obscuring the effects of social injustice, poverty, inequality, racism, child abuse etc, [which] should be a major concern for the left.”
Ultimately, even critics of the paper believe that the meat of the conclusions it draws — i.e., that the serotonin hypothesis is potentially inaccurate — is reasonable, if not somewhat well-trod territory. Their real issue is whether those with preexisting views that all pharmaceuticals are inherently bad, or who deny the existence of mental illness in general, may use it to further their own ends. Aftab places the blame on a long-promoted narrative about depression and mental illness that he classifies as “quite impoverished.”
“People have heard myriad buzzwords about chemical balance, serotonin deficiency, or talk about brain disorders. That’s the message that has been coming from medical and psychiatric associations, which has been linked to this idea about medications correcting chemical imbalance,” Aftab says. “When most people think of depression, they think in these terms — there’s some sort of chemical imbalance and the medication is correcting it. But the scientific reality has been very removed from this commonplace understanding. Things are much more complex and messy.” Still, Aftab believes the onus also lies with the study authors, to some degree, for “playing on this public perception that these questions of serotonin imbalance causing depression and SSRI efficacy are linked,” he says, adding, “so it’s sort of a sneaky hit job.”
To read Moncrieff’s paper and conclude that antidepressants do not work, as many on the right have, is the wrong message to take away from the study. “[The paper] doesn’t undermine the efficacy of antidepressants for those people for whom they work,” says Comaty. “But we just don’t know the biochemical theory of depression.” Such ambiguity may be unwelcome to those looking for definitive answers one way or the other about SSRIs. Uncertainty is an inevitable aspect of the scientific process, Comaty says, and one that should be welcomed rather than cited as evidence of psychiatric medication’s uselessness, as some on the right have done.
“People should expect there will be many more of these types of these articles which theoretically debunk what has previously been understood,” says Comaty. “But that isn’t the takeaway. As we learn more about mental illness, yeah, things will change. If what we once believed is no longer tenable, then yeah, we’ll move along and come up with a new one. I don’t see this as a bad thing. I see this as the process of scientific inquiry.”
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