Monday, 3 November 2014

Review of 'The Bitterest Pills: The Troubling Story of Antipsychotic Drugs' Joanna Moncrieff in BJPsych by Duncan Double

'The Bitterest Pills: The Troubling Story of Antipsychotic Drugs' By Joanna Moncrieff, reviewed by Dr Duncan Double (@DBDouble), Consultant psychiatrist and honorary senior lecturer, Norfolk & Suffolk NHS Foundation Trust and University of East Anglia, in BJP November 2014 205:414:

"This is an important book. You might think I would say that as a member of the Critical Psychiatry Network, like the author, Joanna Moncrieff, senior clinical lecturer at University College London. However, I do think her critique has a sound academic grounding and engages with public concerns about antipsychotic medication.  

The book describes the extent to which the prescription of antipsychotics is marketing-based rather than evidence-based.  Chlorpromazine, of course, was the first drug seen as having a specific role in the treatment of mental illness. Moncrieff, instead, emphasises the non-specific nature of antipsychotic effects, which she frames by promoting a drug-centred rather than disease-centred model of their action. Nonetheless, she says that antipsychotics can ‘help individuals gain relief from intense and intrusive psychotic experiences or destructive emotional states’ (p. 18). 

By this she means more than their placebo effect and believes they can be of value as emotional suppressants. I would encourage you not to dismiss her approach as unbalanced. Despite what may seem like niggling overstatement at some points, she does present a genuine argument, with which I think it is important to engage.  She describes the wish-fulfilling nature of the dopamine theory of schizophrenia. She also makes a stronger case than even I was aware of for ventricular enlargement in schizophrenia being a drug-induced phenomenon. (bolding is mine)

Historically, as she points out, there has been denial in psychiatry about traditional antipsychotics causing tardive dyskinesia and atypical antipsychotics producing the metabolic syndrome. Her summary critique of the early intervention approach also seems to me to be one of the best available.  

I am sure this book will be too sceptical for most psychiatrists.  It may seem to undermine psychiatry’s cultural system.  Personally, I think psychiatry needs to face up to the truth about the psycho-pharmacological revolution, rather than continuing to rely on its aura of factuality.  Even the past editor of this Journal Professor Peter Tyrer agrees we should call an end to the post-chlorpromazine era. I hope Jo’s book makes a significant contribution to this debate."

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