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[00:00:00.720 --> 00:00:08.800] We've set up this expectation in society that there is this thing called depression and it's a medical condition and you should go and see your doctor about it.
[00:00:08.800 --> 00:00:17.120] But I would say that depression is a natural human emotion and emotions are reactions to the events in our lives.
[00:00:17.120 --> 00:00:19.840] Emotion is a meaningful response.
[00:00:19.840 --> 00:00:27.200] It's a reflection of our values and it's a way of expressing, you know, we don't like this situation.
[00:00:27.200 --> 00:00:28.960] Hey guys, how are you doing?
[00:00:28.960 --> 00:00:31.040] Hope you're having a good week so far.
[00:00:31.040 --> 00:00:32.000] My name is Dr.
[00:00:32.000 --> 00:00:38.240] Rongan Chatterjee and this is my podcast, Feel Better, Live More.
[00:00:39.840 --> 00:00:48.560] I want to start by saying that this may be one of the most important conversations I have ever had on this podcast.
[00:00:48.560 --> 00:00:50.960] And I don't say that lightly.
[00:00:51.280 --> 00:00:59.840] Did you know that nearly one in five UK adults and almost one in four women are currently taking antidepressants?
[00:00:59.840 --> 00:01:01.520] Does that strike you as normal?
[00:01:01.520 --> 00:01:04.800] Is that something we should regard as okay?
[00:01:05.120 --> 00:01:13.760] And if so, what does this tell us about our culture and what does it say about the way we treat mental health disorders?
[00:01:13.760 --> 00:01:21.680] Do one in five of us really have chemical imbalances that can only be fixed by pharmaceutical medication?
[00:01:21.680 --> 00:01:24.240] Well, this week, my guest is Dr.
[00:01:24.240 --> 00:01:26.400] Joanna Moncrief.
[00:01:26.400 --> 00:01:45.200] Joanna is professor of critical and social psychiatry at University College London, a consultant psychiatrist for the NHS, and the author of the groundbreaking book, Chemically Imbalanced, the Making and Unmaking of the Serotonin Myth.
[00:01:45.200 --> 00:02:11.960] In our truly thought-provoking and wide-ranging conversation, Joanna explains how the diagnosis of depression itself is subjective and based on criteria that she describes as completely made up, and how the widely accepted belief that depression is caused by a chemical imbalance or serotonin deficiency has very little scientific evidence to support it.
[00:02:11.960 --> 00:02:52.840] You'll also hear about the research showing that there is very little difference between antidepressants and placebo, how pharmaceutical marketing campaigns fundamentally changed our cultural understanding of depression, why withdrawal from antidepressants can be extremely challenging and is not actually something that doctors are trained to do, and the concerning side effects of SSRIs, a type of so-called antidepressant like Prozac and Citalopram, including emotional numbness, sexual dysfunction, and an increase in suicidal thoughts.
[00:02:52.840 --> 00:03:15.640] We also discuss the actual causes of what we term depression, how alternatives like exercise, mindfulness, and addressing underlying life issues might be more effective than drugs, and whether visiting a healthcare professional should really be our first option when experiencing low mood symptoms.
[00:03:15.640 --> 00:03:27.480] Joanna and I both believe that we've been disempowering people by teaching them that negative emotions represent a deficiency rather than a natural human experience.
[00:03:27.480 --> 00:03:38.760] And this conversation encourages all to view our emotional responses as meaningful signals rather than medical disorders that need chemical correction.
[00:03:38.760 --> 00:03:52.400] If you or someone you know has ever taken antidepressants or been diagnosed with depression, this conversation offers a perspective that could fundamentally change the way you see things.
[00:03:56.880 --> 00:04:02.480] You have been a practicing psychiatrist for over three decades.
[00:04:02.480 --> 00:04:04.640] Let's start off with the elephant in the room.
[00:04:04.640 --> 00:04:20.640] Okay, 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?
[00:04:20.960 --> 00:04:23.920] So that's a very good question.
[00:04:23.920 --> 00:04:31.280] And the answer primarily is because of the efforts of the pharmaceutical industry from the 1990s onwards.
[00:04:31.280 --> 00:04:50.640] So the chemical imbalance theory of depression was first constructed in the 1960s by psychiatrists and researchers who were experimenting with various drug treatments for depression and trying to come up with a justification for using drug treatment in this situation.
[00:04:50.960 --> 00:04:55.520] But it wasn't an enormously well-known or popular theory at that time.
[00:04:55.520 --> 00:05:04.160] 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.
[00:05:04.160 --> 00:05:06.480] That didn't come up with anything.
[00:05:07.120 --> 00:05:09.840] So, you know, the theory wasn't really getting anywhere.
[00:05:09.840 --> 00:05:23.520] 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.
[00:05:23.520 --> 00:05:34.600] And so there were massive advertising campaigns that told people that depression was caused by a chemical imbalance, or sometimes they'd say it might be caused by a chemical imbalance.
[00:05:34.840 --> 00:05:40.360] But this was repeated so many times that basically people became convinced it was true.
[00:05:40.360 --> 00:05:41.080] Yeah.
[00:05:41.400 --> 00:05:54.680] 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.
[00:05:54.680 --> 00:05:55.560] Absolutely, absolutely.
[00:05:55.800 --> 00:05:57.720] It's not just, oh, that's a theory.
[00:05:57.720 --> 00:06:03.000] I think the general public, or much of the general public, believe this to be true.
[00:06:03.000 --> 00:06:24.920] And so your work for many years, including your brand new book, Chemically Imbalance, 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.
[00:06:24.920 --> 00:06:28.440] But I think what you've done is give people the evidence for that.
[00:06:28.440 --> 00:06:30.520] Yeah, or I should say the lack of evidence for that.
[00:06:30.680 --> 00:06:31.400] Yeah, yeah.
[00:06:31.400 --> 00:06:43.240] 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.
[00:06:43.240 --> 00:06:45.240] They think it's proven.
[00:06:45.240 --> 00:06:52.360] 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.
[00:06:52.360 --> 00:06:59.560] So that's why I thought, right, we need to look at the evidence properly, set it out, get it published and see what it says.
[00:06:59.560 --> 00:07:15.680] 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.
[00:07:14.760 --> 00:07:16.400] Yeah, it's interesting.
[00:07:16.560 --> 00:07:24.720] 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.
[00:07:24.720 --> 00:07:30.160] And the resident GP said on that segment, Well, why does it matter?
[00:07:30.160 --> 00:07:30.480] Right?
[00:07:30.480 --> 00:07:31.360] Why does it matter?
[00:07:31.360 --> 00:07:32.480] We know that they work.
[00:07:32.480 --> 00:07:35.120] It doesn't really matter why they work.
[00:07:35.120 --> 00:07:39.680] Now, it was quite shocking for me to read that, to go, it doesn't really matter why they work.
[00:07:39.680 --> 00:07:40.720] Hold on a minute.
[00:07:40.720 --> 00:07:46.640] There are a ton of side effects to these drugs, right?
[00:07:46.960 --> 00:07:55.440] So if the whole principle upon which they're prescribed is built on sand, we kind of need to know about it, right?
[00:07:55.440 --> 00:07:55.760] Absolutely.
[00:07:55.840 --> 00:07:56.880] So what is your take on that?
[00:07:56.880 --> 00:08:11.440] And what are, 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?
[00:08:11.760 --> 00:08:28.880] Yeah, so just to say first, 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 other leading doctors to say it doesn't matter, it doesn't matter how they work.
[00:08:28.880 --> 00:08:31.840] And I think that is absolutely shocking.
[00:08:31.840 --> 00:08:34.240] I think it matters a lot how they work.
[00:08:34.240 --> 00:08:47.440] And it is absolutely essential that we discuss this with the public 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.
[00:08:47.440 --> 00:08:57.360] So, SSRIs, the idea was that they would work by correcting an underlying serotonin deficiency.
[00:08:57.360 --> 00:09:06.520] And it turns out that actually the evidence for that is weak, inconsistent, and not compelling, and certainly not proven.
[00:09:07.400 --> 00:09:09.800] But they are, you know, they are drugs.
[00:09:09.800 --> 00:09:14.120] They do change the normal state of your brain chemistry.
[00:09:14.120 --> 00:09:17.400] They do modify our biology in some way.
[00:09:17.880 --> 00:09:25.560] And we know that they cause, you know, that they change people's thinking and feeling processes.
[00:09:25.560 --> 00:09:31.000] And one of the common effects they have, for example, is that they cause a state of emotional numbing.
[00:09:31.000 --> 00:09:39.400] So people often say that they can't, you know, they may not feel quite so sad anymore, but also they can't feel happy anymore and they can't cry.
[00:09:39.400 --> 00:09:51.480] And some people might welcome that effect, but some people, a lot of people report that it's actually quite unpleasant and, you know, they don't feel like themselves anymore when they're in that sort of state.
[00:09:51.480 --> 00:09:52.280] Yeah, it's interesting.
[00:09:52.280 --> 00:10:02.840] As I was reading your book and diving into your work, Joanna, I reflected a lot on my own practice over the years as a medical doctor.
[00:10:03.160 --> 00:10:11.080] 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.
[00:10:11.080 --> 00:10:27.640] 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.
[00:10:27.640 --> 00:10:33.240] And I remember early in my days as a GP, there was one patient.
[00:10:33.240 --> 00:10:36.040] I don't think I started an SSRI on her.
[00:10:36.360 --> 00:10:42.600] I think she'd been started it by a colleague of mine, but she came in for her four-weekly review, right?
[00:10:43.240 --> 00:10:46.880] And she was a young lady, I think she's about 23 years old.
[00:10:46.880 --> 00:11:00.480] 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.
[00:11:00.480 --> 00:11:01.520] I don't feel high.
[00:11:01.520 --> 00:11:02.640] I don't feel joy.
[00:11:02.640 --> 00:11:04.160] I feel nothing.
[00:11:04.160 --> 00:11:06.240] So I always remember that so well.
[00:11:06.240 --> 00:11:08.560] I thought, that's really interesting.
[00:11:08.560 --> 00:11:12.640] She's potentially having what you're calling this emotional numbness or emotional blunting.
[00:11:12.640 --> 00:11:14.880] And I thought, well, how is that helpful?
[00:11:14.880 --> 00:11:25.440] 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?
[00:11:25.600 --> 00:11:29.920] So that's one case I really remember super, super well.
[00:11:30.880 --> 00:11:48.160] And the other case I remember really, really well is without going 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 hear in order to make the diagnosis of depression.
[00:11:48.160 --> 00:11:50.160] And I remember looking in the BNF.
[00:11:50.160 --> 00:11:54.240] So for people listening to the show all around the world, so the British National Formulary.
[00:11:54.240 --> 00:12:01.200] So our kind of byball of drugs and the consequences, what the indications are, what the side effects are.
[00:12:01.200 --> 00:12:05.200] And I remember looking through it, and I knew this anyway, but I was just looking through it.
[00:12:05.200 --> 00:12:15.200] 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.
[00:12:15.520 --> 00:12:18.240] And I thought, this doesn't make any sense to me.
[00:12:18.240 --> 00:12:21.280] I've got someone in front of me with low moods.
[00:12:21.280 --> 00:12:28.880] And I'm potentially going to be putting her on a drug that, yes, it might be a small risk that may increase her risk of suicidal thoughts.
[00:12:28.880 --> 00:12:32.200] And I thought, this doesn't kind of make any sense.
[00:12:32.200 --> 00:12:34.200] So, any comments on what I've just said, Joanna?
[00:12:34.200 --> 00:12:35.640] Yeah, yeah, no, absolutely.
[00:12:29.440 --> 00:12:43.240] I mean, so it comes back to there being, you know, two very different ways of understanding what these drugs might be doing.
[00:12:43.240 --> 00:12:52.120] And if you understand that they are correcting an underlying abnormality, an underlying deficiency, then it sounds like a good idea to take them.
[00:12:52.120 --> 00:13:01.320] And you might take a small, you know, a small increased risk of something if you're correcting, you know, an underlying biological disease that you have.
[00:13:01.640 --> 00:13:21.320] Yeah, so just on that, so if you have an infection, for example, which is, you know, a pneumonia, right, which is 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, right?
[00:13:21.320 --> 00:13:23.480] So I'm just trying to draw the analogy, that sort of thing.
[00:13:23.480 --> 00:13:23.720] Exactly.
[00:13:23.880 --> 00:13:26.760] But you think that the benefits outweigh the risks.
[00:13:27.000 --> 00:13:28.280] Yes, exactly.
[00:13:28.280 --> 00:14:02.360] But if it's not the case that there's an underlying abnormality, and that's what we've shown, and you are taking something that changes your normal, the normal state of your brain and your normal feelings and thoughts and behaviors because of that, 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, including positive emotions, blunted, you might feel lethargic a lot of the time.
[00:14:03.400 --> 00:14:08.960] You are very likely to have sexual dysfunction, at least while you're taking the drug, possibly afterwards.
[00:14:09.360 --> 00:14:11.880] Then all these things actually become much more important.
[00:14:11.880 --> 00:14:13.920] They're not just incidental.
[00:14:13.560 --> 00:14:18.560] They're part of weighing up whether actually this is a good idea.
[00:14:18.960 --> 00:14:25.040] Yeah, going back to your TV segment where the other doctor said, well, it doesn't matter.
[00:14:25.040 --> 00:14:25.760] It doesn't matter.
[00:14:25.760 --> 00:14:26.720] If they work, they work.
[00:14:26.720 --> 00:14:28.160] We don't need to know the reasons.
[00:14:28.160 --> 00:14:30.800] Well, these are pretty significant side effects.
[00:14:30.800 --> 00:14:33.920] Of course, we need to know the reasons before we put people on them.
[00:14:34.080 --> 00:14:35.280] Absolutely, absolutely.
[00:14:35.280 --> 00:14:57.360] And I think, 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 having a, you know, like having a drink of alcohol or something like that will numb you temporarily.
[00:14:58.240 --> 00:15:01.600] Many people, I think, will decide actually, no, I don't want that.
[00:15:01.760 --> 00:15:03.680] You know, I can get through this myself.
[00:15:03.680 --> 00:15:04.880] I don't want to be numbed.
[00:15:04.880 --> 00:15:06.480] I don't want to be drugged.
[00:15:06.480 --> 00:15:10.240] Do you know how common it is in the UK?
[00:15:10.240 --> 00:15:14.400] You know, how prevalent is the prescriptions of antidepressants?
[00:15:14.400 --> 00:15:16.960] Or do you know how many people are on them currently in the UK?
[00:15:17.280 --> 00:15:24.480] So the estimate is about 17% or a little bit more of the population.
[00:15:24.480 --> 00:15:27.600] So almost one in five are taking them at the moment.
[00:15:27.920 --> 00:15:30.080] Those are figures from about 2017.
[00:15:30.560 --> 00:15:37.680] That's including, I think that's, yeah, I think that's the population of over 18s.
[00:15:37.680 --> 00:15:43.120] So over 18, so maybe one in five adults in the UK are on some form of antidepressants.
[00:15:43.280 --> 00:15:44.720] And it's more for women.
[00:15:44.720 --> 00:15:47.200] So 23% of women take them.
[00:15:47.200 --> 00:15:49.840] So almost one in four women are taking an antidepressant.
[00:15:50.080 --> 00:15:52.880] Do we know under the age of 18 how common it is?
[00:15:52.880 --> 00:15:58.480] Because I understand that more and more adolescents are being prescribed these things.
[00:15:58.480 --> 00:16:02.680] Yeah, yeah, I don't have precise figures for younger people, but you're absolutely right.
[00:15:59.840 --> 00:16:04.840] The rates of prescribing are rising.
[00:16:05.160 --> 00:16:16.840] I feel like when I'm talking to my children and their friends, that a lot of their group are on antidepressants, sometimes other sorts of medication, but a lot of them are taking antidepressants.
[00:16:16.840 --> 00:16:17.800] It's really interesting to me.
[00:16:17.800 --> 00:16:35.960] Last week, Susanna O'Sullivan was here in the studio and she's written another very important book, The Age of Diagnosis, where she questions many things to do with how many people are being diagnosed with a variety of different conditions, including depression.
[00:16:36.600 --> 00:16:40.680] It's kind of interesting how these books are coming out in, you know, at similar times.
[00:16:40.680 --> 00:16:41.320] Yeah, yeah.
[00:16:41.320 --> 00:16:41.640] Right.
[00:16:41.640 --> 00:16:51.080] 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.
[00:16:51.080 --> 00:17:04.440] 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.
[00:17:04.440 --> 00:17:08.840] Good feelings, bad feelings, struggles, positive emotions, negative emotions.
[00:17:08.840 --> 00:17:12.360] These things are part of the human condition.
[00:17:12.360 --> 00:17:14.840] Yeah, yeah, no, I absolutely agree.
[00:17:14.840 --> 00:17:20.520] And the ways it's negative is there are a number of ways.
[00:17:21.000 --> 00:17:33.480] When you give someone a label, a diagnostic label, you often cease to see the individual and their individual problems, and you're then treating the label.
[00:17:34.040 --> 00:17:40.440] And actually, what we need to do is see people as individuals, and people, you know, people do struggle with their emotions.
[00:17:40.440 --> 00:17:56.160] I think sometimes we're, you know, maybe unnecessarily medicating people who are having 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.
[00:17:56.160 --> 00:18:11.280] But nevertheless, I don't think it helps to say, you know, to treat this as a diagnosis, to label everyone, because then you don't actually uncover what the real problems are that need to be addressed.
[00:18:11.280 --> 00:18:14.160] We've mentioned this term SSRI quite a bit.
[00:18:14.160 --> 00:18:27.440] Okay, so first of all, I'd love you to expand upon, 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.
[00:18:27.440 --> 00:18:33.360] And then, if possible, John, it would be really good to understand what did the trials actually show?
[00:18:33.360 --> 00:18:54.080] Okay, because you're saying that this serotonin chemical imbalance theory is got minimal evidence to support it, but nonetheless, one in five of the UK population, at least probably, and because that was 2017, mental health has got a lot worse in the last few years.
[00:18:54.080 --> 00:18:55.920] There was COVID, there was lockdowns, right?
[00:18:55.920 --> 00:18:57.920] So it could well be more than that now.
[00:18:59.520 --> 00:19:06.400] On what evidence was the prescription of these drugs even based upon in the first place?
[00:19:07.680 --> 00:19:12.960] So, yes, so this comes down to the clinical trials that have been done.
[00:19:14.160 --> 00:19:40.120] So, the justification for the use of antidepressants, apart from this idea of the chemical imbalance, is these trials that show that antidepressants perform a little bit better than a placebo tablet if you randomize people and allocate them either to take the placebo or the antidepressant, and then you measure their mood using these mood scales.
[00:19:40.120 --> 00:19:49.320] Now, there are lots of problems with these studies, including that measuring mood is a very artificial thing to do and questionable at best.
[00:19:49.640 --> 00:19:59.160] But even if you just put that aside for a minute, the difference between the antidepressant and the placebo in these trials is very small.
[00:19:59.480 --> 00:20:18.680] And it's not large enough to actually register as a clinically significant difference if you use other ways of measuring people's function, like something called the clinical global rating scale, which is a sort of general impression of how someone is doing, for example.
[00:20:19.880 --> 00:20:25.640] And there are various other ways of sort of judging the clinical relevance of a difference.
[00:20:25.640 --> 00:20:27.640] So it's very small.
[00:20:27.640 --> 00:20:36.360] And it may well not be a pharmacological effect anyway, because we know that a lot of these trials are not fully double-blind.
[00:20:36.360 --> 00:20:47.880] People can guess whether they've got the actual antidepressant or the placebo because of some of the side effects they get, particularly if people have been on antidepressants before, which many of them have.
[00:20:48.200 --> 00:20:55.480] And we know that what you think you're taking has a significant impact on your outcome in the short term.
[00:20:55.480 --> 00:21:03.320] 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.
[00:21:03.320 --> 00:21:03.960] Yeah.
[00:21:04.280 --> 00:21:05.640] There's quite a few things there, Joanna.
[00:21:05.600 --> 00:21:06.760] If we can we just unpack a few questions?
[00:21:06.840 --> 00:21:07.560] Yeah, of course, yeah, yeah.
[00:21:08.120 --> 00:21:14.760] So, um, first of all, you mentioned how one is diagnosed with depression in the first place.
[00:21:15.360 --> 00:21:18.560] Now, we're both medical doctors, okay?
[00:21:18.560 --> 00:21:27.520] But for the general public who are listening, they may not be aware of the subtleties and the subjective nature of diagnosis like this.
[00:21:27.520 --> 00:21:28.640] So, can you break it down?
[00:21:28.880 --> 00:21:29.920] What are these scales?
[00:21:29.920 --> 00:21:31.920] What sort of questions do they ask?
[00:21:31.920 --> 00:21:36.560] Because I think that would help people understand that this is kind of, I wouldn't say it's flimsy.
[00:21:36.560 --> 00:21:40.320] Well, I would actually, it's a little bit flimsy how we diagnose these conditions in the first place.
[00:21:41.200 --> 00:21:46.720] Well, so, I mean, I mean, we diagnose depression in practice, don't we?
[00:21:46.720 --> 00:21:53.920] Because someone comes and says they, you know, they don't feel well, they're feeling low, they've lost interest in things.
[00:21:54.240 --> 00:22:08.320] But then there are official criteria for making a diagnosis, which include that you have to have had a low mood for two weeks at least and some other symptoms, which might include difficulties sleeping or loss of appetite.
[00:22:08.320 --> 00:22:14.000] But of course, you know, whether or not you've had a low mood for two weeks or not is completely subjective.
[00:22:16.160 --> 00:22:26.240] 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.
[00:22:26.720 --> 00:22:28.640] That's just completely made up.
[00:22:28.640 --> 00:22:35.520] It's just what psychiatrists drawing up these manuals have decided is a reasonable criteria.
[00:22:35.520 --> 00:22:48.560] 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.
[00:22:48.880 --> 00:22:55.040] And I really noticed this when I worked in a practice in Alden where there was a huge ethnic variety in the practice.
[00:22:55.040 --> 00:23:08.680] 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.
[00:23:08.680 --> 00:23:18.200] Like, so pain, for example, and, you know, without going down a rabbit hole, you know, even the way we ask that question, have you had a low mood?
[00:23:18.200 --> 00:23:20.760] Well, to 10 different people, that means 10 different things.
[00:23:20.760 --> 00:23:21.480] Yes, doesn't it?
[00:23:21.480 --> 00:23:27.720] So there's an inherent bias, even within the question, as to whether someone even answers yes or no to that.
[00:23:27.720 --> 00:23:28.600] Yeah, yeah, absolutely.
[00:23:28.600 --> 00:23:29.160] Yeah.
[00:23:29.160 --> 00:23:50.920] And the way that low mood is judged with one of these commonly used 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 just have some of the symptoms.
[00:23:50.920 --> 00:23:53.960] So the language you use will actually influence your score.
[00:23:54.280 --> 00:23:55.240] Exactly, exactly.
[00:23:55.640 --> 00:23:56.760] Which is ridiculous.
[00:23:56.760 --> 00:23:58.200] And also the way that you present.
[00:23:58.200 --> 00:24:12.040] So if you're someone that 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 subdued, stoical, more restrained.
[00:24:12.040 --> 00:24:16.120] Okay, so the diagnosis in and of itself is very subjective.
[00:24:16.600 --> 00:24:18.440] And I think this is a point to really hammer home.
[00:24:18.440 --> 00:24:23.640] We're not doing a blood test for depression and going, oh, yeah, you know, your blood test is in this range.
[00:24:23.640 --> 00:24:24.520] We can say you're depressed.
[00:24:24.520 --> 00:24:25.320] We're not doing that.
[00:24:25.320 --> 00:24:25.720] Okay.
[00:24:25.880 --> 00:24:29.160] We're doing it on a questionnaire, which is open to interpretation.
[00:24:29.160 --> 00:24:37.720] Let's assume the questionnaire accurately diagnoses depression, okay, which, of course, we're questioning in the first place.
[00:24:39.320 --> 00:24:52.800] My understanding from the paper you published in 2022, that sort of game-changing paper, I think, which I think is, if you could tell us about the impact that paper has had, how many times it's been cited and shared, which is really profound.
[00:24:53.120 --> 00:25:07.040] But also my understanding is that actually all the trials have shown on average is that taking an antidepressant improves your score by just a two-point difference?
[00:25:07.040 --> 00:25:08.400] Could you just elaborate on that?
[00:25:08.480 --> 00:25:08.720] Yes.
[00:25:08.720 --> 00:25:23.360] So the difference between taking an antidepressant and taking a placebo in these placebo-control trials is two points on this common depression rating scale, which has a maximum score of 54 points.
[00:25:23.360 --> 00:25:25.680] So it's a very small difference.
[00:25:25.680 --> 00:25:36.880] So as you've concluded and other people have as well, that actually most of the benefit, if any, is from placebo.
[00:25:37.520 --> 00:25:40.960] But also, as you said before, it's not only placebo, is it?
[00:25:40.960 --> 00:25:53.840] Because these drugs, these so-called antidepressants, and I want to question even why we call them antidepressants in the first place, if there's no evidence for it actually helping this imbalance theory, shouldn't we even be calling them antidepressants?
[00:25:54.080 --> 00:25:54.560] Good question.
[00:25:54.800 --> 00:25:57.440] We should probably say we're talking about SSRIs here, right?
[00:25:59.040 --> 00:26:06.800] But these drugs, because they have side effects, you may already know when you're on it.
[00:26:06.800 --> 00:26:10.800] And therefore, it's, is it almost like a heightened placebo effect?
[00:26:10.800 --> 00:26:11.200] Exactly.
[00:26:11.200 --> 00:26:20.400] So people get an amplified placebo effect, the people who are taking the real drug, because they get some signs that indicate they're on the real drug rather than the placebo.
[00:26:20.400 --> 00:26:30.000] And equally, people who are on the placebo may be able to guess that they haven't got the real drug and therefore may get a negative placebo effect.
[00:26:30.520 --> 00:26:50.200] And it's been shown in one study that the effect of guessing, of thinking you were taking the antidepressant, the difference between thinking you were taking the antidepressant and people who thought they were taking the placebo in terms of the depression rating scale was five or six points.
[00:26:52.440 --> 00:27:04.600] So the effect of thinking that you were taking the real drug versus the placebo was much bigger than the effect of actually getting the drug in, if you look across all the different trials.
[00:27:04.600 --> 00:27:21.240] John, it's pretty remarkable to think that if the evidence supports, or if the evidence says that there is a two-point difference on this 54-point scale, and a two-point difference can be accounted for in a multitude of different ways.
[00:27:21.560 --> 00:27:23.640] Again, I come back to my initial question.
[00:27:23.960 --> 00:27:33.560] How did this industry, how did it become so common where one in five of the adult population of the UK are on these drugs?
[00:27:33.560 --> 00:27:37.320] I mean, it seems utterly remarkable, does it not?
[00:27:37.320 --> 00:27:38.680] Absolutely, absolutely.
[00:27:39.000 --> 00:27:40.600] Is this the power of marketing?
[00:27:41.400 --> 00:27:42.680] I think it's partly that.
[00:27:42.680 --> 00:27:45.640] I mean, I think it's a confluence of interests.
[00:27:45.640 --> 00:28:02.600] And the main driver has undoubtedly been the pharmaceutical industry and the big marketing campaigns that they did that persuaded people that taking an antidepressant was correcting a chemical imbalance, that antidepressants weren't addictive and were safe and basically, persuaded people to take them.
[00:28:02.600 --> 00:28:11.880] But the medical profession, particularly psychiatrists, have also had an interest in medicalizing depression for many decades.
[00:28:12.680 --> 00:28:24.480] And then, of course, you know, people in general like the idea of, you know, of there being a simple solution to complicated life problems.
[00:28:24.960 --> 00:28:28.400] I mean, in a way, if there was, of course, we'd all like that.
[00:28:28.640 --> 00:28:34.960] It's just unlikely, in my view, that there is going to be a chemical solution for life problems.
[00:28:34.960 --> 00:28:35.600] Yeah.
[00:28:36.480 --> 00:28:38.880] A few weeks ago, I spoke to Camilla Nord.
[00:28:39.120 --> 00:28:41.600] She's a neuroscientist at Cambridge University.
[00:28:41.600 --> 00:28:45.440] And, you know, she studies the neuroscience of mental health.
[00:28:45.440 --> 00:28:57.120] And one of the things she told me in my conversation with her on the show, she even said in psychedelic trials, there is some evidence of the power of the placebo effect.
[00:28:57.200 --> 00:29:08.960] So if you think you're taking a psychedelic, right, and this is mind-blowing for people, you can still have some of the hallucinations of some of these things that you, you know, even if you're taking the placebo.
[00:29:09.280 --> 00:29:22.960] And I think there's a wider point here, isn't there, that we've really undervalued the importance of placebo and the power of placebo, I would say beyond just depression and mental health, I think across the whole of medicine.
[00:29:22.960 --> 00:29:24.560] Yes, I agree.
[00:29:25.280 --> 00:29:30.560] But I would just caveat that with I think there are some negative effects of giving people a placebo.
[00:29:30.560 --> 00:29:30.880] Oh, yes.
[00:29:31.120 --> 00:29:35.440] So I think it's sort of how we harness those effects, isn't it, that's important.
[00:29:35.440 --> 00:29:45.920] So there's good evidence that giving someone a placebo tablet temporarily elevates them, you know, elevates their mood.
[00:29:47.120 --> 00:30:12.200] But in the long run, I think people's beliefs that they need a tablet in order to get better, to feel better, might actually undermine their improvement in the long run and undermine all the sort of all the strategies that actually might help people to improve their mood and stay well and stay happy.
[00:30:12.360 --> 00:30:20.040] The trials that did show a two-point improvement on placebo, how long were they conducted for?
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[00:33:30.920 --> 00:33:34.360] So, most of them are conducted for eight weeks or less.
[00:33:34.360 --> 00:33:42.440] There are very few studies that have been conducted more than three months, very small handful that have lasted about six to nine months.
[00:33:42.440 --> 00:33:53.560] Which again is truly remarkable because the amount of people who start off on these things, and before you know it, 18 months has passed and they've been giving repeat prescriptions, right?
[00:33:53.560 --> 00:34:06.680] And you know, we'll talk about the system and how doctors currently work and how the reality is, if you've got a busy clinic, the easiest thing in the world to do is to continue a repeat prescription.
[00:34:06.920 --> 00:34:10.040] It is, and that's not having to go at any individual doctor.
[00:34:10.040 --> 00:34:14.200] The system is almost, as you said, there's a confluence of factors, right?
[00:34:14.200 --> 00:34:24.440] The way, you know, having a 10-minute appointment with your GP to try and deal with these complex life problems, it's quite easy to prescribe something because that sort of closes the consultation down.
[00:34:24.440 --> 00:34:28.680] Yeah, and the patient feels as though they got something, the doctor feels like they've done something, right?
[00:34:28.680 --> 00:34:40.920] So, I get all that, but there's a wider point here because I know in the book sometimes you make the case that mental health is fundamentally different from physical health in a variety of ways, okay?
[00:34:41.240 --> 00:34:47.720] But actually, I have a slightly different perspective in the sense that, and we'll maybe talk about that throughout this conversation.
[00:34:48.040 --> 00:34:52.840] But let's take those trials, very few of them have been done over eight weeks.
[00:34:52.840 --> 00:34:58.040] Whereas many people, dare I say, the majority of people on SSRIs are taking them for more than eight weeks.
[00:34:58.040 --> 00:35:01.320] So, there's no trials showing you that you should be doing that.
[00:35:01.320 --> 00:35:04.040] It's the same with PPIs, like proton pump inhibitors.
[00:35:04.040 --> 00:35:08.000] Most of those trials were done for four to six weeks, yeah, yeah.
[00:35:08.000 --> 00:35:08.360] Right?
[00:35:08.360 --> 00:35:19.760] Yeah, you've got patients who are literally on a five-year repeat prescription, and then the similarity is when they try and come off it, they've had their acid production suppressed for five years.
[00:35:20.080 --> 00:35:23.360] Of course, when they try and come off it, they have a rebound side effect.
[00:35:23.360 --> 00:35:27.920] But the belief is, oh, I need to stay on the medication.
[00:35:27.920 --> 00:35:28.400] Yeah, yeah.
[00:35:28.480 --> 00:35:29.280] That's quite similar.
[00:35:29.280 --> 00:35:31.520] That's a physical issue, right?
[00:35:31.520 --> 00:35:35.200] But that's not dissimilar to what happens when people try and stop the antidepressants, is it?
[00:35:35.200 --> 00:35:36.880] Oh, yeah, no, I agree with you.
[00:35:36.880 --> 00:35:45.600] And, you know, I mean, I think all sorts of drugs can lead to physical adaptations and withdrawal effects when you stop them.
[00:35:45.600 --> 00:36:02.880] And stopping antidepressants is, you know, is helping people come off antidepressants, enabling them not to remain on them for long periods of time is difficult for both for, you know, because of those, because of physical dependence, but also for all sorts of psychological reasons.
[00:36:03.200 --> 00:36:09.760] You know, people might get some withdrawal symptoms and then assume that they're relapsing or the doctor thinks they're relapsing.
[00:36:09.760 --> 00:36:12.000] I want to go into withdrawal in a minute.
[00:36:12.560 --> 00:36:15.120] Let's just finish off this placebo piece.
[00:36:15.120 --> 00:36:15.600] Right.
[00:36:15.840 --> 00:36:25.520] 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 clinical psychiatrist.
[00:36:25.520 --> 00:36:28.080] You work in a very prestigious hospital.
[00:36:28.080 --> 00:36:31.200] You've been working for over three decades in psychiatry.
[00:36:31.200 --> 00:36:40.560] You're telling me that there's no evidence or not very convincing evidence that there is a chemical imbalance in depression.
[00:36:40.560 --> 00:36:44.400] Yet they might be thinking, well, yeah, I'm hearing you.
[00:36:44.400 --> 00:36:51.840] But when I started taking Prozac, let's say, or citalopram, I started to feel better.
[00:36:52.160 --> 00:36:52.920] What would you say to that person?
[00:36:53.200 --> 00:36:55.920] Yeah, yeah, that's that's a really important point to make.
[00:36:55.920 --> 00:36:57.760] So, two things.
[00:36:57.760 --> 00:37:06.680] One is that most people with depression will start to feel better naturally at some point, anyway.
[00:37:07.000 --> 00:37:14.360] And often, people come and see the doctor at a low point and therefore will gradually improve after that.
[00:37:14.680 --> 00:37:21.560] And there's also, I think, something about coming to the doctor itself, which sometimes is a sort of wake-up call for people.
[00:37:21.560 --> 00:37:24.760] You know, oh my goodness, it's really got this bad.
[00:37:24.760 --> 00:37:27.960] You know, I've got to do something now.
[00:37:27.960 --> 00:37:34.600] And, you know, and often it will galvanize friends and family to come and be supportive.
[00:37:34.600 --> 00:37:35.000] Of course.
[00:37:35.160 --> 00:37:40.760] Make people, you know, really reflect on, you know, do I really want to carry on in this job that's got me into this state?
[00:37:40.760 --> 00:37:43.320] And people make other changes in their lives.
[00:37:43.320 --> 00:37:48.040] So people often do improve after they start taking an antidepressant.
[00:37:48.440 --> 00:37:54.920] But we know from the clinical trials that people also improve after they've started taking a placebo.
[00:37:55.240 --> 00:38:00.920] So some of the effect is some of the effect is what would naturally occur anyway.
[00:38:00.920 --> 00:38:02.920] It's making changes in your life.
[00:38:02.920 --> 00:38:07.400] And some of it is due to believing that you're taking a tablet that's going to help you.
[00:38:07.640 --> 00:38:08.920] And the sense of hope.
[00:38:08.920 --> 00:38:09.560] Yeah, exactly.
[00:38:09.880 --> 00:38:12.520] Oh, I just, I knew there was something wrong with me.
[00:38:12.520 --> 00:38:18.600] And now the doctor's told me I've got a chemical imbalance and that, you know, I'm going to take this pill and it's going to correct it.
[00:38:18.600 --> 00:38:23.400] So you're going out with that belief that, oh man, my life's going to change now.
[00:38:23.400 --> 00:38:23.960] Absolutely.
[00:38:23.960 --> 00:38:25.560] Hope is the, I think, is the key thing.
[00:38:25.560 --> 00:38:27.560] That's that's what you're giving people.
[00:38:27.560 --> 00:38:30.840] Yeah, but you can also give hope as a doctor without giving a pill.
[00:38:30.840 --> 00:38:31.720] No, I agree.
[00:38:31.720 --> 00:38:35.880] And for a variety of different conditions, and it goes back to that sense of agency, autonomy.
[00:38:35.880 --> 00:38:37.640] What can we give that person?
[00:38:37.960 --> 00:38:44.760] How can we give them hope without necessarily giving them a pill that may have all these potential side effects?
[00:38:45.120 --> 00:38:48.960] I think giving people a pill in this situation is giving them false hope.
[00:38:48.960 --> 00:38:49.280] Yeah.
[00:38:49.680 --> 00:38:50.720] There's a real cost to it.
[00:38:51.040 --> 00:38:51.920] Yes, absolutely.
[00:38:51.920 --> 00:38:59.520] 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.
[00:38:59.840 --> 00:39:01.360] I didn't feel great again.
[00:39:01.360 --> 00:39:06.080] You know, the sort of initial stimulus I got, you know, wore off.
[00:39:06.080 --> 00:39:13.040] And then I felt really awful, even worse than before, because I thought, oh my goodness, this thing that was supposed to make me better isn't working.
[00:39:13.040 --> 00:39:13.600] Yeah.
[00:39:13.920 --> 00:39:18.720] It's really profound.
[00:39:18.720 --> 00:39:28.800] 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, because there will be people pushing back.
[00:39:28.800 --> 00:39:29.280] Yeah.
[00:39:29.840 --> 00:39:30.640] What are you talking about?
[00:39:30.640 --> 00:39:32.560] You know, of course, there's a chemical imbalance.
[00:39:32.560 --> 00:39:34.320] I've been hearing about this for two decades.
[00:39:34.320 --> 00:39:41.360] You know, I learned it at medical school, but this whole thing that, you know, someone might be thinking, well, I got better when I started taking it.
[00:39:41.360 --> 00:39:43.360] Look at it through another lens, right?
[00:39:44.000 --> 00:39:51.120] Again, I think this pattern is common and prevalent in medicine, both with doctors and with patients' beliefs.
[00:39:51.120 --> 00:39:56.320] So, for example, let's say you've had a really bad cold for weeks, right?
[00:39:56.320 --> 00:39:57.280] And this is very common.
[00:39:57.280 --> 00:40:01.920] All general practitioners will have been in this position before where you know something is viral.
[00:40:01.920 --> 00:40:03.680] You know that the patient is coming in.
[00:40:03.680 --> 00:40:11.200] There's no symptoms to just a bacterial infection, which, again, for anyone who doesn't know, antibiotics treat bacterial infections.
[00:40:11.200 --> 00:40:13.760] They don't treat viral infections.
[00:40:13.760 --> 00:40:18.880] But, you know, if someone's coming and they're getting annoyed, saying, Look, I've been off work for three weeks.
[00:40:18.880 --> 00:40:20.640] And you're like, yeah, there's no fever here.
[00:40:20.640 --> 00:40:22.000] There's no product disputum.
[00:40:22.000 --> 00:40:23.200] This is just one of those things.
[00:40:23.200 --> 00:40:27.920] You prescribe an antibiotic because it's easier to do so.
[00:40:27.920 --> 00:40:32.920] They may well get better that week, but they probably would have got better anyway.
[00:40:33.240 --> 00:40:34.760] They'd already had it for four weeks, right?
[00:40:29.840 --> 00:40:37.320] And the natural course of the infection is, oh, I'm going to get better.
[00:40:37.640 --> 00:40:48.520] Now, I can't say that in every case, but then and the real problem with that is then the patient goes out with the belief, oh, the antibiotic is what made me better.
[00:40:48.520 --> 00:40:49.240] What does that mean?
[00:40:49.240 --> 00:40:56.600] It means in 12 months' time, when you get another infection, you've got this ingrained belief that you need that pill.
[00:40:56.600 --> 00:40:58.680] We can draw that same analogy in depression.
[00:40:58.680 --> 00:40:59.960] Yeah, that's a really good analogy.
[00:41:00.280 --> 00:41:00.520] Are we?
[00:41:01.240 --> 00:41:01.480] Absolutely.
[00:41:02.280 --> 00:41:05.800] If it comes back to you in three years' time, oh, I know what it is.
[00:41:05.800 --> 00:41:08.520] It's that old chemical that I need to make sure I get an antidepressant again.
[00:41:08.680 --> 00:41:10.280] Yes, absolutely, absolutely.
[00:41:10.280 --> 00:41:22.520] And people haven't learned a very important lesson that depression will get better on its own and that there are things that you can do about it to help yourself because they've invested their beliefs in the pill.
[00:41:22.520 --> 00:41:24.760] Even that term depression, okay.
[00:41:25.080 --> 00:41:30.040] I always struggled even with the concepts of clinical depression as a thing.
[00:41:30.040 --> 00:41:32.040] I'm like, what does that mean?
[00:41:33.080 --> 00:41:39.000] What does it mean where these emotions now are, oh, it's now clinical depression, whereas that isn't?
[00:41:39.320 --> 00:41:43.320] So, help me understand your perspective on that, because I think that's another thing that people think about.
[00:41:43.320 --> 00:41:45.160] Oh, you've got some symptoms of low mood.
[00:41:45.160 --> 00:41:47.000] Yeah, but is it clinical depression or not?
[00:41:47.000 --> 00:41:48.280] Well, what is clinical depression?
[00:41:48.280 --> 00:41:49.720] Yeah, yeah, it's a good question.
[00:41:49.720 --> 00:42:04.920] And it also, I think, um, touches on what you were saying earlier about the you know, the difficulty of sitting there with someone in your consulting room and wanting to feel that you're able to give them something.
[00:42:04.920 --> 00:42:14.600] Um, so we've, you know, we've set up this expectation in society that there is this thing called depression and it's a medical condition, and you should go and see your doctor about it.
[00:42:15.760 --> 00:42:20.560] And this is actually not how people used to think about depression.
[00:42:20.880 --> 00:42:29.760] But now we've got so used to thinking about depression as clinical depression, as a clinical condition, that it's even got difficult to use that word, I think.
[00:42:29.760 --> 00:42:39.520] But, you know, I would say that depression is a natural human emotion, and emotions are reactions to the events in our lives.
[00:42:39.520 --> 00:42:47.600] They're coloured by everything that's happened to us, by our personal history, and probably a bit by our genes and our biology, too.
[00:42:47.920 --> 00:42:59.520] And those things will mean that some people are more vulnerable to, you know, reacting extremely to things than others, might get more anxious or more depressed when things go wrong than other people.
[00:42:59.520 --> 00:43:01.760] Of course, there's individual variation.
[00:43:01.760 --> 00:43:06.400] But nevertheless, emotion is a meaningful response.
[00:43:06.400 --> 00:43:13.520] It's a reflection of our values, and it's a way of expressing, you know, we don't like this situation.
[00:43:13.520 --> 00:43:16.800] There's something about this that, you know, is getting me down.
[00:43:17.120 --> 00:43:21.200] Should it even be a clinical or medical diagnosis?
[00:43:21.520 --> 00:43:33.600] So that's what I was driving at: by suggesting that when we've got to the stage with someone sitting in front of a doctor, expecting a diagnosis and expecting a treatment, there's a problem.
[00:43:33.600 --> 00:43:37.840] And I think we need to roll back from that situation.
[00:43:37.840 --> 00:43:41.520] I think we need to demedicalize depression radically.
[00:43:42.480 --> 00:43:53.360] And instead of treating depression, we need to help people who are depressed in whatever ways they need help with.
[00:43:53.360 --> 00:43:59.600] And that will be a great variety of ways because people are depressed for a myriad of different reasons.
[00:43:59.800 --> 00:44:10.040] Which leads to the natural question for me at least: is going to see your doctor the best place to go when you have symptoms consistent with depression?
[00:44:10.040 --> 00:44:22.680] I've often thought if you do have symptoms consistent with low mood and your particular medical doctor or your GP is very much in that what's the diagnosis, how do I treat model?
[00:44:23.320 --> 00:44:33.640] It may be that, I don't know, a life coach or a psychologist or someone else might be better for you than a medical professional for that particular condition.
[00:44:33.640 --> 00:44:38.760] Not in every case, but I think in some cases we have to acknowledge that that may well be a possibility.
[00:44:38.760 --> 00:44:39.480] Absolutely.
[00:44:39.480 --> 00:44:56.600] So when we first published the serotonin paper, one of the criticisms of us was that we would stop, you know, if we were publicizing this and raising questions in people's minds about the necessity or benefits of antidepressants, that would stop people seeking medical help.
[00:44:56.600 --> 00:45:09.080] Now, one of the important responses to that is that this whole idea of people seeking medical help for depression, there's very little evidence that this is doing people any good in the long term.
[00:45:09.080 --> 00:45:19.080] Actually, if you look at the long-term outcomes of people with depression who've had medical treatment and people who haven't had medical treatment, the people who haven't had medical treatment are doing much better.
[00:45:19.080 --> 00:45:25.800] Now, that's probably partly because they may well have less severe problems than the people who get medical treatment.
[00:45:25.800 --> 00:45:34.360] But even the studies that control for the severity to some extent are still showing that the people who don't have treatment are doing better.
[00:45:34.360 --> 00:45:41.000] And certainly, there's no good evidence that in the long run, the people who have medical treatment do better.
[00:45:41.000 --> 00:46:05.040] And if we just look at some of the sort of objective indicators of how well this strategy is working, the mass treatment of depression with antidepressants, such as the numbers of people on disability benefits with depression and anxiety, these have been going up and up dramatically since the 1990s, at the same time that the use of antidepressants has been going up.
[00:46:05.600 --> 00:46:13.440] So the widespread treatment, medical treatment of depression, is not helping people to get back to work.
[00:46:13.440 --> 00:46:15.600] Yeah, it's got unintended consequences.
[00:46:15.600 --> 00:46:18.000] You know, it's disempowering for many people.
[00:46:18.000 --> 00:46:19.280] Oh, I've got this thing.
[00:46:19.280 --> 00:46:21.600] There's nothing I can do about it.
[00:46:21.920 --> 00:46:27.520] That criticism that, well, some people may not seek medical advice then for there.
[00:46:27.520 --> 00:46:29.840] I have a real issue with that as a critique, right?
[00:46:29.840 --> 00:46:40.720] Because that's predicated on the belief that, you know, that humans are incapable and we're really fragile.
[00:46:40.720 --> 00:46:45.440] And when we have difficult scenarios in our life, oh, we must go and see a doctor.
[00:46:45.440 --> 00:46:47.360] And I don't believe that, right?
[00:46:47.360 --> 00:46:49.920] Yes, we're living more isolated lives now.
[00:46:49.920 --> 00:46:54.560] There's been a fragmentation of communities and people often don't have the support that they need.
[00:46:54.560 --> 00:46:56.160] I accept all of that.
[00:46:56.160 --> 00:47:05.840] We're living in a capitalist culture where lots of people have been driven to work long hours and jobs that they can't stand and they don't have access to, you know, cheap, good quality food.
[00:47:05.840 --> 00:47:07.040] They're sleep deprived.
[00:47:07.040 --> 00:47:08.880] I get all of those things.
[00:47:08.880 --> 00:47:13.040] It doesn't mean, though, that medicine is the solution to this.
[00:47:13.360 --> 00:47:19.920] 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.
[00:47:19.920 --> 00:47:21.840] And it wasn't always this way.
[00:47:21.840 --> 00:47:27.680] There's many cultures around the world who still don't believe that depression is a medical thing, right?
[00:47:27.680 --> 00:47:28.640] There's some cultures around the world.
[00:47:28.640 --> 00:47:31.960] I think the Hadza tribe don't even have a word for depression, right?
[00:47:31.960 --> 00:47:39.720] They naturally see these things as, oh, this is a signal that there is something that we need to address.
[00:47:39.720 --> 00:47:51.560] And 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, we need to give you a treatment.
[00:47:51.560 --> 00:47:53.640] It's like the question is, why?
[00:47:53.640 --> 00:47:57.000] What's going on in this person's life that means that they're feeling like that?
[00:47:57.480 --> 00:48:05.240] But these viewpoints are quite antithetical to the way modern Western medicine looks at condition like depression.
[00:48:05.240 --> 00:48:05.880] Yeah, yeah.
[00:48:05.880 --> 00:48:12.600] It just reminds me of a really interesting anthropological study of the introduction of depression into Japan.
[00:48:12.600 --> 00:48:20.680] So in the 1990s, up until the 1990s, depression wasn't something that was commonly diagnosed in Japan.
[00:48:20.680 --> 00:48:30.040] And like you're saying about Indian culture, it wasn't really, it certainly wasn't a sort of recognized medical condition.
[00:48:30.680 --> 00:48:34.680] And therefore, there weren't many antidepressants being prescribed in Japan.
[00:48:34.680 --> 00:48:39.880] And the pharmaceutical industry recognized this was potentially an untapped market.
[00:48:41.400 --> 00:48:42.440] Yes, yes.
[00:48:43.080 --> 00:48:49.640] So they set out to introduce depression into Japan and to increase the sales of antidepressants.
[00:48:49.640 --> 00:49:07.480] And we know about this because they employed a well-known anthropologist, Lawrence Kirkmayer, who's written up his experience of being involved in this strategy of the pharmaceutical industry to persuade the Japanese that they were depressed.
[00:49:07.800 --> 00:49:16.400] So they employed him as an anthropologist to tell them about the culture of Japan and why it was that people didn't consider themselves to be depressed.
[00:49:16.400 --> 00:49:26.160] And that was partly because depression was understood as a meaningful reaction to things, not seen as a clinical disease.
[00:49:26.160 --> 00:49:46.640] And so they came up, just as the pharmaceutical industry did in this country, actually, they came up with ways of overriding the cultural norms and people's sort of intuitions about what depression was in order to persuade them that it was a medical condition and it was very successful.
[00:49:46.640 --> 00:49:51.200] And the rate of prescribing of antidepressants, you know, escalated as a consequence.
[00:49:51.200 --> 00:49:52.800] So that's actually a case study.
[00:49:52.800 --> 00:49:54.160] And it goes very interesting.
[00:49:54.800 --> 00:50:05.120] We smile and we laugh, but actually, underlying that laughter is a real disturbing truth here.
[00:50:05.120 --> 00:50:17.760] 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?
[00:50:17.920 --> 00:50:18.800] So let's go into that.
[00:50:19.040 --> 00:50:19.600] So we're doing that.
[00:50:19.600 --> 00:50:22.960] And we are also changing people's sense of self, aren't we?
[00:50:22.960 --> 00:50:44.720] We're changing people's idea 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 at times, are a disease that can be eradicated somehow, not something that they would previously have understood as a part of themselves that they need to manage and integrate.
[00:50:44.800 --> 00:50:46.840] And address, this is this is okay.
[00:50:46.840 --> 00:50:53.120] Maybe this might come across as a glib example, but I'm going to share it anyway because I think it's relevant to what you just said.
[00:50:53.120 --> 00:50:53.680] Okay.
[00:50:54.240 --> 00:51:01.160] So I'm normally a pretty upbeat, calm, optimistic human, I would say.
[00:51:01.160 --> 00:51:03.960] I've just come to the end of an extremely busy period.
[00:50:59.840 --> 00:51:07.320] Okay, so my new book came out earlier in the year.
[00:51:07.640 --> 00:51:13.880] 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.
[00:51:13.880 --> 00:51:17.960] And I went straight from that into my first national theater tour.
[00:51:17.960 --> 00:51:22.280] So I created a two and a half hour show on what it means to thrive.
[00:51:22.280 --> 00:51:31.240] 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.
[00:51:31.240 --> 00:51:34.600] Okay, so I've not had a weekend off for six weeks.
[00:51:34.600 --> 00:51:36.600] And I'm not, I'm not bragging about this, to be clear.
[00:51:36.600 --> 00:51:38.600] I'm not saying this is a good thing, right?
[00:51:39.720 --> 00:51:44.040] And I tried to balance that by what I was doing in the week, right?
[00:51:44.040 --> 00:51:46.120] But it didn't work so well.
[00:51:46.120 --> 00:51:51.320] Okay, so I was getting progressively more and more tired because I normally go to bed at nine and I wake up at five.
[00:51:51.320 --> 00:51:52.360] That's my rhythm.
[00:51:52.360 --> 00:51:57.560] But normally after a show, I wasn't really getting to bed till about one or 1.30 by the time I'd switched off.
[00:51:57.560 --> 00:52:00.520] But I was still waking up at five or six, right?
[00:52:01.800 --> 00:52:03.080] So I've just come to the end of that.
[00:52:03.080 --> 00:52:04.600] And it was a phenomenal experience.
[00:52:04.600 --> 00:52:05.960] I don't regret any of it.
[00:52:05.960 --> 00:52:10.840] But early on this week, I had a few days where I felt really low.
[00:52:10.840 --> 00:52:12.280] This is very unusual for me.
[00:52:12.280 --> 00:52:14.200] My outlook on life was quite negative.
[00:52:14.200 --> 00:52:16.200] I was being quite reactive.
[00:52:16.200 --> 00:52:18.840] Things that I'm not usually anymore.
[00:52:19.160 --> 00:52:19.800] Okay.
[00:52:19.800 --> 00:52:26.040] Now, again, I'm not saying that I necessarily met the criteria for a diagnosis.
[00:52:26.200 --> 00:52:27.640] I probably didn't.
[00:52:28.280 --> 00:52:35.000] But the principle that I'm trying to sort of get across is I didn't see this as a deficiency in me.
[00:52:35.000 --> 00:52:36.840] I thought, oh, this is interesting, Rongan.
[00:52:37.320 --> 00:52:41.880] This is a signal that you are overly tired.
[00:52:41.880 --> 00:52:42.840] You're overly stressed.
[00:52:42.840 --> 00:52:44.040] You need some relaxation.
[00:52:44.040 --> 00:52:45.920] You need some resetting, right?
[00:52:45.920 --> 00:52:49.360] So instead of going, oh my God, why am I feeling so low?
[00:52:49.360 --> 00:52:54.640] I saw these things as signals that, hey, Rongan, you need to make some changes at the moment.
[00:52:54.640 --> 00:52:56.240] You need to be really careful.
[00:52:56.240 --> 00:52:59.840] Make sure you've got some time off, all this kind of stuff.
[00:53:00.320 --> 00:53:04.880] And I, you know, within a couple of days, I'm back to my usual self, right?
[00:53:04.880 --> 00:53:08.880] It's not quite the same thing, but there's a kind of principle there, isn't there?
[00:53:08.880 --> 00:53:09.440] Definitely.
[00:53:10.240 --> 00:53:17.040] I think seeing emotions as signals is a really good way of putting it because that's what they are.
[00:53:17.040 --> 00:53:23.280] Your body and your mind is reacting to what's going on around you and saying, we don't like this.
[00:53:23.280 --> 00:53:23.680] Yeah.
[00:53:24.320 --> 00:53:37.440] 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.
[00:53:37.440 --> 00:53:44.880] 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.
[00:53:44.880 --> 00:53:48.560] You often have to take other medications to counter the side effects.
[00:53:48.560 --> 00:53:50.960] You can sometimes feel worse in the long run.
[00:53:50.960 --> 00:53:53.200] Your personality can change.
[00:53:53.520 --> 00:53:56.640] These are pretty significant and severe.
[00:53:56.640 --> 00:53:58.240] So, can we go through them one by one?
[00:53:58.240 --> 00:54:01.520] You know, you mentioned emotional numbness before.
[00:54:01.520 --> 00:54:02.000] Yeah.
[00:54:02.640 --> 00:54:03.680] Can you just expand on that?
[00:54:03.680 --> 00:54:04.160] What is that?
[00:54:04.160 --> 00:54:05.760] And why is that a problem?
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[00:58:40.760 --> 00:58:47.400] Yes, so this seems to be a pretty consistently reported effect of most antidepressants.
[00:58:47.400 --> 00:58:56.040] Um, that uh, it's like the intensity of your emotions is sort of dialed down or they're sort of suppressed or restricted in some way.
[00:58:56.200 --> 00:59:00.360] People will often say they can't cry when they're taking antidepressants.
[00:59:00.360 --> 00:59:08.680] Um, and most people find that pretty unpleasant, especially after the sort of first initial crisis has passed.
[00:59:08.680 --> 00:59:16.440] 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.
[00:59:16.440 --> 00:59:31.640] And that is connected with probably the evidence seems to suggest with the ability of most antidepressants to interfere with our sexual function to cause sexual dysfunction in various ways.
[00:59:31.640 --> 00:59:39.960] Um, and both of these things can, uh, it's been shown recently, can persist after people stop taking the drug.
[00:59:39.960 --> 00:59:45.000] So, that's really worrying and something that I really wanted to highlight in the book.
[00:59:45.760 --> 00:59:57.360] Because if that happens to you, if you've taken antidepressants 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, that's a catastrophe.
[00:59:57.360 --> 00:59:59.600] Okay, let's just sort of dive in there.
[00:59:59.600 --> 01:00:01.280] So, I think that's a really important point.
[01:00:01.280 --> 01:00:13.760] Okay, so if you're struggling with your mood, whether we want to label it depression or not, on some level, you're not able to experience pleasure or joy, right?
[01:00:14.080 --> 01:00:16.560] And you mentioned sexual dysfunction there.
[01:00:16.560 --> 01:00:26.160] As a psychiatrist, Joanna, how important is it for an individual to not have sexual dysfunction?
[01:00:26.160 --> 01:00:37.680] 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 well-being?
[01:00:37.680 --> 01:00:39.760] Yeah, well, I think it's hugely important.
[01:00:39.760 --> 01:00:45.680] It's a part of being human, being alive, being a living organism, isn't it?
[01:00:45.680 --> 01:00:58.960] And certainly, people who lose it or have it damaged feel very upset about that and feel that they're not, you know, living being their full selves anymore.
[01:00:58.960 --> 01:01:09.440] 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.
[01:01:09.760 --> 01:01:16.160] You're saying that actually, for some people, the sexual dysfunction continues after they've stopped the antidepressants.
[01:01:16.160 --> 01:01:29.360] 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 percent or more, sexual dysfunction while they're taking them.
[01:01:29.880 --> 01:01:37.960] Um, but what hasn't been recognized but has been emerging recently is that for some people this problem persists.
[01:01:37.960 --> 01:01:45.240] And another point that I think is important to make here is that, of course, when people are depressed, their libido you know can go down.
[01:01:45.720 --> 01:01:49.960] They as part of constellation exactly.
[01:01:49.960 --> 01:02:03.400] 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.
[01:02:03.400 --> 01:02:07.640] So it's not just the depression, the drugs have an additional um effect.
[01:02:07.640 --> 01:02:20.840] And one of the particular things they do, which is not characteristic of sexual dysfunction in depression, is they cause um anesthesia of the genitals, so they sort of dial down the sensitivity of the genitals.
[01:02:20.840 --> 01:02:25.960] Um, and that that seems to be this sort of parallel effect to numbing emotions.
[01:02:25.960 --> 01:02:40.040] There's this sort of dialing down of sensitivity, um, and that uh and and and that and other effects like reduced libido are what can persist when people stop taking the antidepressants.
[01:02:40.040 --> 01:03:01.480] This is and sorry, and just one more point that's very important: is um persistent sexual dysfunction has it's been reported by a lot of patients now, and there are several online um patient groups uh who have described it and are campaigning for more research on it and for you know people to research possible treatments.
[01:03:01.480 --> 01:03:12.720] Um, but there's also animal research that's shown that if you give animals um SSRIs, uh, that they will show reduced sexual activity after coming off them.
[01:03:13.680 --> 01:03:17.520] If you just take a step back from what you're saying, Joanna, right?
[01:03:18.480 --> 01:03:20.320] It's how things work in medicine often, right?
[01:03:14.920 --> 01:03:22.160] We're now looking at, well, let's get some more research into that.
[01:03:22.320 --> 01:03:23.920] Of course, we need that.
[01:03:23.920 --> 01:03:29.280] But if you step outside this for a minute and go, well, wait a minute.
[01:03:29.600 --> 01:03:31.280] We're trying to research stuff.
[01:03:31.280 --> 01:03:40.000] We're trying to research side effects to something which may have hardly any evidence to support it in the first place.
[01:03:40.000 --> 01:03:40.320] Right?
[01:03:41.520 --> 01:03:42.080] Yep.
[01:03:42.480 --> 01:03:50.160] I know it sounds obvious, but we're saying that maybe one in five of the adult population are taking drugs like this.
[01:03:50.160 --> 01:03:59.600] There's a reasonably high percentage of people having sexual dysfunction that happens while they're taking it and when they stop it.
[01:03:59.600 --> 01:04:02.880] And so we're downstream trying to go, well, let's have some more research here.
[01:04:02.880 --> 01:04:11.120] But we could just go upstream and go, we kind of need to make the case why we should even be starting anyone on this in the first place.
[01:04:11.120 --> 01:04:14.400] But we don't do that because there's a belief.
[01:04:14.400 --> 01:04:18.480] It's almost a truth now that actually there's a chemical imbalance.
[01:04:18.480 --> 01:04:19.920] That's why your book's so important.
[01:04:19.920 --> 01:04:22.080] That's why your 2022 paper is so important.
[01:04:22.080 --> 01:04:30.560] Because once you start to challenge the existing belief at the root cause of these, we may not need to study these downstream things.
[01:04:30.560 --> 01:04:37.120] We may just go upstream and go, well, let's be a lot more cautious before we start it in the first place.
[01:04:37.120 --> 01:04:37.840] Absolutely.
[01:04:38.080 --> 01:04:39.280] I mean, absolutely.
[01:04:39.280 --> 01:04:46.480] The emergence of this fact that they can cause persistent sexual dysfunction, I think, is, you know, it is so serious.
[01:04:46.480 --> 01:04:50.400] We don't know exactly how many people that will affect.
[01:04:50.360 --> 01:04:56.080] Um, but you know, there are certainly tens of thousands of people online reporting it.
[01:04:56.080 --> 01:04:59.520] Let's say they recover from their initial bout of depression.
[01:04:59.520 --> 01:05:03.320] If you do want to label it and call it a medical condition, right?
[01:05:05.560 --> 01:05:22.200] If our sexuality and our libido and our ability to, let's say, enjoy sex is a part of who we are as humans, as animals, what is the long-term effect of having sexual dysfunction, right?
[01:05:22.200 --> 01:05:24.200] It's not exactly going to help your moods.
[01:05:24.200 --> 01:05:25.560] No, exactly, exactly.
[01:05:25.640 --> 01:05:30.600] I mean, it's going to obviously interfere in our ability to have relationships.
[01:05:30.600 --> 01:05:40.200] Yeah, and relationships are part of what keeps us, you know, stable and happy and part of what is so rewarding about being a human being.
[01:05:40.200 --> 01:05:49.000] Could you just name-check some commonly prescribed SSRIs so people can maybe attach that term with things that they may be taking?
[01:05:49.000 --> 01:05:55.640] Yes, so the first SSRI that was commonly used was Proza

Prompt 2: Key Takeaways

Now please extract the key takeaways from the transcript content I provided.

Extract the most important key takeaways from this part of the conversation. Use a single sentence statement (the key takeaway) rather than milquetoast descriptions like "the hosts discuss...". 

Limit the key takeaways to a maximum of 3. The key takeaways should be insightful and knowledge-additive. 

IMPORTANT: Return ONLY valid JSON, no explanations or markdown. Ensure:
- All strings are properly quoted and escaped
- No trailing commas
- All braces and brackets are balanced
Format: {"key_takeaways": ["takeaway 1", "takeaway 2"]}

Prompt 3: Segments

Now identify 2-4 distinct topical segments from this part of the conversation.

For each segment, identify:
- Descriptive title (3-6 words)  
- START timestamp when this topic begins (HH:MM:SS format)
- Double check that the timestamp is accurate - a timestamp will NEVER be greater than the total length of the audio
- Most important Key takeaway from that segment. Key takeaway must be specific and knowledge-additive.
- Brief summary of the discussion

IMPORTANT: The timestamp should mark when the topic/segment STARTS, not a range. Look for topic transitions and conversation shifts.

Return ONLY valid JSON. Ensure all strings are properly quoted, no trailing commas:
{
  "segments": [
    {
      "segment_title": "Topic Discussion", 
      "timestamp": "01:15:30",
      "key_takeaway": "main point from this segment",
      "segment_summary": "brief description of what was discussed"
    }
  ]
}

Timestamp format: HH:MM:SS (e.g., 00:05:30, 01:22:45) marking the START of each segment.

Prompt 4: Media Mentions

Now scan the transcript content I provided for ACTUAL mentions of specific media titles:

Find explicit mentions of:
- Books (with specific titles)
- Movies (with specific titles)  
- TV Shows (with specific titles)
- Music/Songs (with specific titles)

DO NOT include:
- Websites, URLs, or web services
- Other podcasts or podcast names

IMPORTANT: 
- Only include items explicitly mentioned by name. Do not invent titles.
- Valid categories are: "Book", "Movie", "TV Show", "Music"
- Include the exact phrase where each item was mentioned
- Find the nearest proximate timestamp where it appears in the conversation
- THE TIMESTAMP OF THE MEDIA MENTION IS IMPORTANT - DO NOT INVENT TIMESTAMPS AND DO NOT MISATTRIBUTE TIMESTAMPS
- Double check that the timestamp is accurate - a timestamp will NEVER be greater than the total length of the audio
- Timestamps are given as ranges, e.g. 01:13:42.520 --> 01:13:46.720. Use the EARLIER of the 2 timestamps in the range.

Return ONLY valid JSON. Ensure all strings are properly quoted and escaped, no trailing commas:
{
  "media_mentions": [
    {
      "title": "Exact Title as Mentioned",
      "category": "Book",
      "author_artist": "N/A",
      "context": "Brief context of why it was mentioned",
      "context_phrase": "The exact sentence or phrase where it was mentioned",
      "timestamp": "estimated time like 01:15:30"
    }
  ]
}

If no media is mentioned, return: {"media_mentions": []}

Prompt 5: Context Setup

You are an expert data extractor tasked with analyzing a podcast transcript. 
I will provide you with part 2 of 2 from a podcast transcript. 
I will then ask you to extract different types of information from this content in subsequent messages. Please confirm you have received and understood the transcript content.

Transcript section:
's a chemical imbalance.
[01:04:18.480 --> 01:04:19.920] That's why your book's so important.
[01:04:19.920 --> 01:04:22.080] That's why your 2022 paper is so important.
[01:04:22.080 --> 01:04:30.560] Because once you start to challenge the existing belief at the root cause of these, we may not need to study these downstream things.
[01:04:30.560 --> 01:04:37.120] We may just go upstream and go, well, let's be a lot more cautious before we start it in the first place.
[01:04:37.120 --> 01:04:37.840] Absolutely.
[01:04:38.080 --> 01:04:39.280] I mean, absolutely.
[01:04:39.280 --> 01:04:46.480] The emergence of this fact that they can cause persistent sexual dysfunction, I think, is, you know, it is so serious.
[01:04:46.480 --> 01:04:50.400] We don't know exactly how many people that will affect.
[01:04:50.360 --> 01:04:56.080] Um, but you know, there are certainly tens of thousands of people online reporting it.
[01:04:56.080 --> 01:04:59.520] Let's say they recover from their initial bout of depression.
[01:04:59.520 --> 01:05:03.320] If you do want to label it and call it a medical condition, right?
[01:05:05.560 --> 01:05:22.200] If our sexuality and our libido and our ability to, let's say, enjoy sex is a part of who we are as humans, as animals, what is the long-term effect of having sexual dysfunction, right?
[01:05:22.200 --> 01:05:24.200] It's not exactly going to help your moods.
[01:05:24.200 --> 01:05:25.560] No, exactly, exactly.
[01:05:25.640 --> 01:05:30.600] I mean, it's going to obviously interfere in our ability to have relationships.
[01:05:30.600 --> 01:05:40.200] Yeah, and relationships are part of what keeps us, you know, stable and happy and part of what is so rewarding about being a human being.
[01:05:40.200 --> 01:05:49.000] Could you just name-check some commonly prescribed SSRIs so people can maybe attach that term with things that they may be taking?
[01:05:49.000 --> 01:05:55.640] Yes, so the first SSRI that was commonly used was Prozac.
[01:05:55.640 --> 01:05:56.680] That's still prescribed.
[01:05:56.680 --> 01:05:59.240] Its other name is fluoxetine.
[01:05:59.800 --> 01:06:06.680] Sertraline is the most commonly prescribed SSRI and antidepressant at the moment.
[01:06:06.680 --> 01:06:08.200] Then the citalopram, of course.
[01:06:08.200 --> 01:06:12.520] And then cetaloprams, citalopram is quite widely prescribed.
[01:06:12.520 --> 01:06:15.640] And es-citalopram has also been prescribed.
[01:06:15.640 --> 01:06:21.720] Venlifaxine is something that's used quite widely within psychiatry, I think, a bit less so in general practice.
[01:06:22.280 --> 01:06:28.360] What's the implications of pharmaceutical advertising?
[01:06:28.360 --> 01:06:39.080] And I guess the reason that popped into my mind is, again, your work is making me think back to various points in my career that I'd kind of semi-forgotten about.
[01:06:39.080 --> 01:06:54.320] But I seem to recall a drug company lunch, maybe at one of the general practice surgeries I worked on, and they were telling me about acetalopram and the benefits for people who aren't getting better on citalopram.
[01:06:54.320 --> 01:07:03.040] And I can't quite remember it all, but I vaguely remember picking up my sandwich and actually at lunchtime just hearing them talk about this.
[01:07:03.040 --> 01:07:05.840] What is, you know, maybe that's a broader question.
[01:07:06.000 --> 01:07:12.640] What is the implication of pharmaceutical companies coming in and teaching doctors about the benefits of their new drugs?
[01:07:12.640 --> 01:07:14.320] What are the implications of that?
[01:07:14.960 --> 01:07:27.840] So I think it's worth saying that the pharmaceutical industry were incredibly active from the 1990s onwards, well, and before, but particularly over antidepressants from the 1990s.
[01:07:28.080 --> 01:07:32.480] And that means that they were, you know, they were advertising everywhere.
[01:07:32.480 --> 01:07:39.600] They were supplying doctors with mugs and pens with, you know, with their drug embossed on.
[01:07:39.760 --> 01:07:41.520] They were taking doctors out for meals.
[01:07:41.520 --> 01:07:43.200] They were providing lunches.
[01:07:43.200 --> 01:07:46.480] They were subsidizing lavish conferences.
[01:07:47.040 --> 01:07:54.640] And we know, even though individual doctors may feel that they're not influenced by this, we know that they are.
[01:07:54.640 --> 01:08:05.200] You know, there's been research that shows that actually if you've had contact with representatives from drug companies, you'll be more likely to prescribe their product.
[01:08:05.680 --> 01:08:14.800] So what it means is that this message that the pharmaceutical industry had, you know, picked up and wanted to disseminate became embedded within medicine.
[01:08:14.800 --> 01:08:32.120] And although most leading researchers knew way before we published our paper in 2022 that there wasn't good evidence for the serotonin hypothesis of depression, I think there were many, many doctors who still believe that there was.
[01:08:29.760 --> 01:08:35.720] And certainly there were doctors who were still telling patients that there were.
[01:08:36.680 --> 01:08:46.120] There was, you know, there were doctors on national radio telling people that depression was a chemical imbalance only a few months before our paper was published.
[01:08:46.120 --> 01:08:49.400] So, and that is a consequence of this marketing.
[01:08:49.400 --> 01:09:10.760] And another thing I wanted to just say that something you said about how you felt about depression reminded me that in the early days of these marketing campaigns, some of the medical royal colleges and medical institutions helped out the pharmaceutical industry and ran depression awareness campaigns.
[01:09:10.760 --> 01:09:23.240] And one of them was the Royal College of Psychiatrists Defeat Depression campaign that ran in the early 1990s and was partly funded by Eli Lilly, the makers of Prozac or fluoxetine.
[01:09:23.560 --> 01:09:41.640] And in the initial stages of that campaign, they did some market research and they found that most people at that time thought that depression was a reaction to getting divorced or being unemployed or being lonely or having been abused as a child.
[01:09:41.640 --> 01:09:42.600] What year was this?
[01:09:42.600 --> 01:09:44.280] This is about 1992.
[01:09:44.600 --> 01:09:46.760] So even in the early 90s, we thought...
[01:09:46.840 --> 01:09:47.240] Yeah.
[01:09:47.240 --> 01:09:47.720] Okay.
[01:09:48.040 --> 01:09:57.080] And then when they asked people what they thought about antidepressants or taking drugs for taking medication for depression, they said, we don't think that's a good idea.
[01:09:57.080 --> 01:10:03.320] We think that that's just going to numb the feelings and people might get addicted or dependent.
[01:10:03.320 --> 01:10:08.360] And the majority of the population, that was their underlying ideas about depression.
[01:10:08.360 --> 01:10:20.720] And the pharmaceutical industry set out to change those, to change people's minds, to stop people seeing depression in that intuitive way and replace it with this idea that it's a medical condition and that you need a depression.
[01:10:21.040 --> 01:10:23.280] You know, it's remarkable when I hear that.
[01:10:23.920 --> 01:10:42.720] It was only 33, 34, 35 years ago where we thought that depression or these symptoms of low mood and lack of pleasure and not experiencing joy were a meaningful response to life circumstance.
[01:10:44.160 --> 01:10:51.680] And it just shows you how easy it is to manipulate us and change our view with clever marketing.
[01:10:52.000 --> 01:10:52.480] Absolutely.
[01:10:52.480 --> 01:10:54.480] I mean, that is what marketing is, isn't it?
[01:10:54.480 --> 01:10:55.040] Exactly.
[01:10:55.040 --> 01:10:58.320] And all of us know, you know, we're all human, we're all susceptible.
[01:10:58.320 --> 01:11:01.520] I think, well, Johan Hari's coming to mind for a couple of reasons.
[01:11:01.520 --> 01:11:18.080] When he first came on my show about his book, Lost Connections, which again is quite relevant in the context of what you're talking about, I think he shared some research, or maybe this was for his book on the problems with, you know, the digital age and the constantly consuming contents.
[01:11:18.080 --> 01:11:25.440] I think he shared some research saying that even watching one advert, for a child to watch one advert, it pops up on YouTube.
[01:11:25.440 --> 01:11:29.200] It fundamentally changes your desires and what you want in life.
[01:11:29.200 --> 01:11:29.600] Right.
[01:11:29.600 --> 01:11:32.560] So none of us are immune to marketing.
[01:11:32.560 --> 01:11:37.440] But also another thing in Johan's book, Lost Connections, he shared this story with me.
[01:11:37.520 --> 01:11:42.320] I think it was a Cambodian rice farmer who'd had an injury.
[01:11:42.320 --> 01:11:44.560] He had a prosthetic limb.
[01:11:44.560 --> 01:11:47.200] And, you know, he was struggling with his moods.
[01:11:47.200 --> 01:11:51.040] And the solution where he lived was to give him a cow, right?
[01:11:51.200 --> 01:11:55.120] So, the sense of meaning, the sense that I can now do what I'm meant to do.
[01:11:55.120 --> 01:11:56.640] I have something to help me do that.
[01:11:56.640 --> 01:12:00.520] It wasn't, let me go on a pill, right?
[01:12:00.840 --> 01:12:05.560] And it's interesting, isn't it, when we think about this, how quickly it's changed.
[01:11:59.440 --> 01:12:06.120] Yes, yes.
[01:12:06.360 --> 01:12:14.360] So, that reminds me: I had some medical students from the Caribbean when I was first a consultant who came over and did an attachment with me.
[01:12:15.000 --> 01:12:19.240] I was actually working in a ward with people with quite severe mental illness.
[01:12:19.240 --> 01:12:26.440] And she said, and I thought it was such a good idea, you know, what would be really helpful here is if they had some pets.
[01:12:26.760 --> 01:12:31.720] And then, lo and behold, a stray dog appeared, and the ward adopted this dog.
[01:12:31.720 --> 01:12:39.960] And the patients loved it and were, you know, and it gave them a sense of purpose and a sense of being able to nurture something themselves.
[01:12:39.960 --> 01:12:44.920] And these were, you know, these were people who were who had sort of quite severe chronic mental health problems.
[01:12:45.480 --> 01:12:58.200] This sense of who we are, what's our meaning, what are we here for, is such an important aspect of who we are.
[01:12:58.200 --> 01:12:59.560] Are you valued somewhere?
[01:12:59.560 --> 01:13:01.080] Does that pet need you?
[01:13:01.080 --> 01:13:02.760] Are you needed?
[01:13:02.760 --> 01:13:03.320] Right?
[01:13:03.320 --> 01:13:15.480] And I also wonder-I mean, you said this from the 1990s, how much has the increase in depression and antidepressant prescription mirrored the loss of religion in society?
[01:13:15.480 --> 01:13:22.600] Like, I don't know if there's any studies on that, but it wouldn't surprise me for all the positives or perceived negatives that people may have on religion.
[01:13:22.600 --> 01:13:33.720] One thing I think it's fair to say is that these religious institutions, no matter what religion you belong to or you identify with, they helped foster a sense of community.
[01:13:33.720 --> 01:13:42.040] And these are the principles of what it means to live: be kind, don't do harm to others, you know, give to people, have charitable pursuits.
[01:13:42.040 --> 01:13:42.680] Do you know what I mean?
[01:13:42.680 --> 01:13:43.320] How do you know?
[01:13:43.320 --> 01:13:51.600] Is there any research to there's no sort of empirical research that I know of, but I think you're absolutely right.
[01:13:51.600 --> 01:13:55.840] I mean, religion and it gives people a sense of purpose and meaning, doesn't it?
[01:13:55.840 --> 01:13:58.880] I think that's you know really important for people too.
[01:13:59.360 --> 01:14:06.400] Or you feel sad or you feel low, you will go and talk about it with your congregation, your community.
[01:14:06.400 --> 01:14:10.240] There'll be, I don't know, there was a mechanism in society to do that.
[01:14:10.240 --> 01:14:14.560] Yes, and also, I think religions help people with acceptance.
[01:14:14.720 --> 01:14:30.960] They help people to accept that suffering is part of life and to and to get through that and to see it as something that we can all come together and sort of support people through rather than something that has to be completely eradicated and something that we can learn from.
[01:14:30.960 --> 01:14:48.400] And of course, the religious message might be, you know, it helps you get closer to God, which you might not subscribe to if you're not religious, but makes a more general point that you may be able to learn something through suffering and it may ultimately bring you some benefits and help development.
[01:14:48.720 --> 01:14:52.880] What do SSRIs actually do then?
[01:14:52.880 --> 01:14:59.200] If they don't correct an underlying chemical imbalance, what do they do?
[01:14:59.200 --> 01:15:12.720] 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.
[01:15:13.040 --> 01:15:31.400] So, 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 or increase the activity of nerves that fire impulses where serotonin is the transmitter.
[01:15:35.000 --> 01:16:05.800] So, that's the theory, and they certainly do 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 the effects that they have in the long run, whether if people keep taking them, whether they keep increasing the activity of serotonin in the synapse or whether they might even reduce it.
[01:16:05.800 --> 01:16:24.280] There's some evidence that serotonin levels in the blood, for example, which may not reflect the levels in the brain, but probably going to be reasonably consistent with them, are actually lower in people who are taking SSRIs on a long-term basis.
[01:16:24.280 --> 01:16:28.520] So, it may be the case that they even lower serotonin in the long run.
[01:16:29.400 --> 01:16:37.560] 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.
[01:16:38.040 --> 01:16:39.880] And what's the effect on our symptoms, though?
[01:16:39.880 --> 01:16:41.960] So, let's say it is doing some of these things.
[01:16:41.960 --> 01:16:47.480] It's sort of altering serotonin and the serotonin pathway in some way.
[01:16:49.640 --> 01:16:52.120] What is that doing then to our brains?
[01:16:52.120 --> 01:16:55.800] Like, why is it that people can feel when they're on these things?
[01:16:56.120 --> 01:17:09.480] Yeah, so we don't know exactly how that translates into what people feel, but we know that it is disrupting the serotonin system and probably many other neurochemical systems in the brain.
[01:17:09.480 --> 01:17:15.920] Well, it must be, because if we're saying that you're going to get, let's say, emotional numbness, that must be an effect of it.
[01:17:15.920 --> 01:17:20.320] If you're going to have sexual dysfunction, or what did you say around the genitalia?
[01:17:20.960 --> 01:17:22.080] Genital anesthesia.
[01:17:22.080 --> 01:17:22.880] Genital anesthesia.
[01:17:23.600 --> 01:17:32.240] Well, even if you assume that they are working on that narrow pathway that we're told they're working on, it's pretty clear they're doing other things as well.
[01:17:32.240 --> 01:17:33.040] Yes, yes, absolutely.
[01:17:33.280 --> 01:17:34.240] They're not just doing one thing.
[01:17:34.240 --> 01:17:35.280] Yeah, yeah, yeah.
[01:17:35.280 --> 01:17:38.240] I mean, we don't know very much about serotonin overall.
[01:17:38.240 --> 01:17:46.800] Probably the one thing we do know that it's involved with in terms of sort of mental or behavioral things is sexual function.
[01:17:46.800 --> 01:17:59.600] And we know that higher serotonin activity impairs your sexual functioning, reduces your libido, reduces sexual activity in animals, for example.
[01:18:00.240 --> 01:18:05.200] And apart from that, we really don't know very much about what serotonin does.
[01:18:05.200 --> 01:18:08.720] But as you say, what we do know is what these drugs do to people.
[01:18:09.280 --> 01:18:12.320] So they do something to the brain, and we know what the end result is.
[01:18:12.320 --> 01:18:25.840] And we know that this is sexual dysfunction, emotional numbing, degree of lethargy, agitation in some people, particularly young people, after they start taking the drugs, that can happen.
[01:18:25.840 --> 01:18:38.880] And that's probably related to the cases where they can lead to an increase in suicidal thoughts, which I think is probably rare, but has been shown to happen in clinical trials.
[01:18:39.600 --> 01:18:44.000] I know I've already mentioned this point, but I really think it's worth highlighting.
[01:18:45.280 --> 01:18:52.640] If you came in fresh to this conversation, or I don't know, I was going to say the world, right?
[01:18:52.640 --> 01:18:54.160] You come in fresh, right?
[01:18:54.400 --> 01:18:57.680] You haven't ever heard of this chemical imbalance theory before.
[01:18:57.680 --> 01:19:00.000] Let's say there's someone out there who's never heard of this.
[01:19:00.680 --> 01:19:04.840] And they were just hearing that part of our conversation.
[01:19:05.160 --> 01:19:13.240] Someone might think, okay, Joanna, so you're talking to Rongan about people with low moods who are really struggling with their life.
[01:19:13.880 --> 01:19:22.520] And you're also talking about giving them a drug that may increase their risk of suicidal thoughts, even though that's rare.
[01:19:22.520 --> 01:19:24.440] Isn't that madness on one level?
[01:19:24.840 --> 01:19:26.520] It's kind of, I know, we're so used to it.
[01:19:26.520 --> 01:19:33.960] It's hard for us to say as medical doctors, but I think it's a bit ridiculous to even think about, or even these other things, right?
[01:19:33.960 --> 01:19:34.920] Lethargy.
[01:19:34.920 --> 01:19:35.240] Yes.
[01:19:35.400 --> 01:19:39.000] If you're struggling with your mood, right, you don't want to be more lethargic.
[01:19:39.400 --> 01:19:45.240] You want a bit of energy, a bit of get up and go so you can start doing things that change the way you feel.
[01:19:45.720 --> 01:19:48.600] It's kind of remarkable thinking about these side effects.
[01:19:48.600 --> 01:19:52.440] And I don't know, people can argue that they're rare, right?
[01:19:52.760 --> 01:19:54.040] But I don't know.
[01:19:54.040 --> 01:19:55.400] They seem pretty significant.
[01:19:55.400 --> 01:19:56.200] No, absolutely.
[01:19:56.200 --> 01:20:13.800] I think if you think about the effects that what we call antidepressants, SSRIs, and other drugs have, how they change people's states of mind and physical functions, it doesn't seem to me that anything they do is actually likely to be very helpful in people with depression.
[01:20:13.800 --> 01:20:23.960] And indeed, for many people, it's likely to be harmful or not beneficial, as you say.
[01:20:24.600 --> 01:20:29.160] It raises the question for me of informed consent.
[01:20:29.480 --> 01:20:35.480] So there's a few principles that we hold dear as doctors, right?
[01:20:35.480 --> 01:20:37.080] Do no harm.
[01:20:37.720 --> 01:20:43.160] You could question some of that in the context of what we've just said about antidepressants, right?
[01:20:43.240 --> 01:20:44.600] In terms of do no harm.
[01:20:44.600 --> 01:20:46.880] First, do no harm, right?
[01:20:48.880 --> 01:20:57.680] Another principle that we'd like to think we adopt, although I don't think we adopt it as much as we think we do, is informed consent.
[01:20:57.680 --> 01:21:07.600] Before we put someone on something, give them a proper list of the potential benefits and the potential downsides.
[01:21:07.920 --> 01:21:18.240] How many patients who have been prescribed SSRIs for depression do you think are being told about all these potential side effects?
[01:21:18.560 --> 01:21:20.960] So I should think very few.
[01:21:20.960 --> 01:21:46.320] And even before you get to the side effects or the sort of more uncommon side effects like suicide, I think it's very few people who are presented with the idea, or not it's an odd idea, but the fact that antidepressants are drugs that change our normal brain chemistry, our normal physiological functioning, and therefore change our normal states of mind.
[01:21:46.320 --> 01:21:49.360] And it's a mind-altering drug.
[01:21:50.320 --> 01:21:52.560] Exactly, that it's a mind-altering drug.
[01:21:52.880 --> 01:22:04.720] Because people are just presented with, you know, there's this idea that antidepressants work and it doesn't matter how, people are just presented with this drug and, you know, suggested that it's going to be beneficial.
[01:22:04.720 --> 01:22:12.800] It's not explained to them that this is a mind-altering drug and that, you know, it will change the way that you think and you feel to some extent.
[01:22:12.800 --> 01:22:18.080] And on top of that, some people may also be told that, you know, they need to take it because they have a chemical imbalance.
[01:22:18.240 --> 01:22:20.640] Maybe that's less common now.
[01:22:20.880 --> 01:22:32.120] But I still think that unless people are positively, specifically told that actually this idea is not supported, most people will assume that that's the case.
[01:22:32.280 --> 01:22:40.200] Because if you're not given another explanation for what these drugs are doing, then why else would you be being prescribed them?
[01:22:40.200 --> 01:22:49.720] So it sort of starts with failing to inform people about the very nature of antidepressants, what they are as drugs, and what it means to take them.
[01:22:49.720 --> 01:22:51.800] We want these simplistic explanations, don't we?
[01:22:51.800 --> 01:22:53.240] Unfortunately.
[01:22:53.880 --> 01:23:02.280] Oh, because then it's like, oh, yeah, there's this one chemical out for all the biological processes in our body and all the neurochemicals.
[01:23:02.280 --> 01:23:07.320] Oh, there's this one thing that's low or imbalanced, whatever that means.
[01:23:07.320 --> 01:23:09.880] Let's correct it and you're fine.
[01:23:10.200 --> 01:23:12.360] Biology doesn't work like that, does it?
[01:23:12.440 --> 01:23:18.360] And, you know, two weeks ago, I was interviewed by a journalist for an article on happiness.
[01:23:18.360 --> 01:23:28.040] And the first question he asked me was: when you're happy, what is the main neurochemical that is involved?
[01:23:28.680 --> 01:23:31.640] And I thought that really highlights this problem, isn't it?
[01:23:31.640 --> 01:23:38.600] That when you're feeling good, there's not just one, you know, we can't put that on dopamine or serotonin or noradrenaline.
[01:23:38.600 --> 01:23:48.600] Like, there's a combination of all kinds of things that we know about that we don't know about, but we're trying to go, oh, this is dopamine, this is serotonin, this is noradrenaline.
[01:23:48.600 --> 01:23:54.200] And I just don't think the human system, the human animal, works like that.
[01:23:54.200 --> 01:23:55.080] No, absolutely.
[01:23:55.080 --> 01:23:56.280] So it's exactly the same.
[01:23:56.680 --> 01:24:02.040] When we published the paper, people would say to me, so if it's not serotonin, what is it exactly?
[01:24:02.040 --> 01:24:03.560] Is it inflammation?
[01:24:04.040 --> 01:24:05.400] Is it another chemical?
[01:24:05.400 --> 01:24:08.120] You know, and the mistake is even to ask that question.
[01:24:08.120 --> 01:24:08.680] Yeah.
[01:24:09.000 --> 01:24:15.200] So, this informed consent, this is tricky because, because, you know, you can apply this to surgery, right?
[01:24:14.840 --> 01:24:19.600] You know, how many patients are being told all of the potential side effects?
[01:24:19.760 --> 01:24:21.600] Because here's the harsh reality.
[01:24:21.600 --> 01:24:30.560] If you were to go through all the potential side effects of any procedure or any pharmaceutical, it would take quite a bit of time, right?
[01:24:30.560 --> 01:24:34.800] I mean, if you if you I wish I had a BNF here, do I have one?
[01:24:34.800 --> 01:24:37.280] No, I used to have one up on that shelf, right?
[01:24:37.280 --> 01:24:39.280] So, but there'll be a lot, yes.
[01:24:39.680 --> 01:24:48.800] Just on one drug, let's say citalipram, we've mentioned that, one of the SSRIs, there will be a good two or three pages of potential side effects, right?
[01:24:48.800 --> 01:25:02.800] So, if you actually, as a doctor, read all of them out to the patient, nausea, vomiting, diarrhea, sexual dysfunction, gut changes, personality, if you actually went through them, I think most patients would go, oh, no, thank you.
[01:25:03.760 --> 01:25:14.240] You know, but what we would do, and I, and I've, I've been this person for, you would say, look, some of the common side effects that we often see are A, B, C, D, and E.
[01:25:14.240 --> 01:25:15.120] Yes.
[01:25:15.520 --> 01:25:19.440] You don't mention, you can't mention all of them, right?
[01:25:19.440 --> 01:25:31.040] But I think it's important for doctors to really appreciate that and also the general public to understand there are potential side effects that are documented that you may not being told about.
[01:25:31.040 --> 01:25:39.200] So, when that patient is deciding, shall I go on this drug or not, you're actually not making an informed decision unless you've been told everything.
[01:25:39.200 --> 01:25:39.680] Yeah.
[01:25:40.000 --> 01:25:58.480] But I also think that people are not being warned enough, probably, about fairly common side effects, like persistent sexual dysfunction and like dependence, physical dependence, and the fact that many people experience withdrawal problems.
[01:25:58.480 --> 01:26:10.760] Yeah, well, okay, I want to talk about withdrawal because there will no doubt be some people listening to this or watching it on YouTube who are going, okay, well, I've been on this drug, I've been on an SSRI for several years now.
[01:26:10.760 --> 01:26:17.800] You're saying me that there's no basis for this, and so I want to make sure that they feel they understand what they should be doing.
[01:26:17.800 --> 01:26:25.320] Just before we get to that, though, you said something really interesting, which is antidepressants are mind-altering.
[01:26:25.320 --> 01:26:33.480] Okay, so they may not correct a serotonin imbalance, but they fundamentally are changing something in how we experience life.
[01:26:33.800 --> 01:26:46.760] Could we draw an analogy to common drugs that people use that often they don't think about as drugs, alcohol and caffeine, right?
[01:26:47.080 --> 01:26:56.920] So if you're feeling a bit anxious, right, you could drink alcohol and that may reduce your anxiety, right?
[01:26:57.240 --> 01:27:00.120] So it's a mind-altering substance.
[01:27:00.120 --> 01:27:02.200] Caffeine is a psychoactive stimulant.
[01:27:02.200 --> 01:27:07.000] Although many of us drink our tea or coffee and we enjoy it, I very much do.
[01:27:07.320 --> 01:27:08.600] We often don't appreciate this.
[01:27:08.600 --> 01:27:09.720] It's a psychoactive stimulant.
[01:27:10.200 --> 01:27:13.720] You can feel a bit low and are not quite with it in the morning.
[01:27:13.720 --> 01:27:15.480] Have a strong cup of coffee.
[01:27:15.560 --> 01:27:17.080] You feel like you can take on the world, right?
[01:27:17.080 --> 01:27:18.680] So it's mind-altering.
[01:27:19.080 --> 01:27:24.280] But with those things, let's say caffeine, for example, we know, don't we?
[01:27:24.280 --> 01:27:35.640] Like if you are a habitual caffeine drinker, anyone who's tried to give up coffee before as a regular drinker, we will know the withdrawal can be pretty severe.
[01:27:35.640 --> 01:27:38.680] Mood swings, headache, like real fatigue.
[01:27:38.680 --> 01:27:42.600] Like, you know, because caffeine's legal and we all, you know, we enjoy it.
[01:27:42.600 --> 01:27:43.960] So we don't see it like that.
[01:27:43.960 --> 01:27:54.080] But what we don't believe, I don't think, is if you're stopping caffeine and you have withdrawals, you don't think, yeah, oh, God, I needed the caffeine, don't I?
[01:27:54.080 --> 01:27:56.880] You know, I've got this problem that caffeine solves.
[01:27:56.880 --> 01:28:01.120] Now, you understand that it's withdrawal, but we don't think about that with antidepressants.
[01:28:01.120 --> 01:28:01.280] Yes.
[01:28:01.600 --> 01:28:04.960] We think, oh, this is a, oh, you know, I need it for my condition.
[01:28:04.960 --> 01:28:06.080] So, can you help me?
[01:28:06.080 --> 01:28:07.600] Do you think that's a reasonable analogy?
[01:28:08.000 --> 01:28:09.520] I think that's a very useful analogy.
[01:28:09.520 --> 01:28:13.120] I think it's a useful analogy to think about the effects of antidepressants.
[01:28:13.120 --> 01:28:23.920] And in a lot of my work, I draw the analogy with alcohol that you drew because alcohol, you know, we recognize that it can be helpful if you're anxious.
[01:28:24.240 --> 01:28:30.960] You know, if you go out and have a load to drink and you're feeling depressed, you may not feel depressed for a few hours while you're under the influence.
[01:28:30.960 --> 01:28:32.080] We have a phrase for that.
[01:28:32.080 --> 01:28:34.320] We call it drowning our sorrows.
[01:28:35.040 --> 01:28:41.760] So, you know, we recognize that mind-altering drugs change the way that we feel temporarily while we're under the influence.
[01:28:41.760 --> 01:28:48.000] But we also recognize that dealing with depression by getting drunk every day is probably not a good idea.
[01:28:48.000 --> 01:28:55.520] Now, I'm not saying that the effects of antidepressants are exactly the same as the effects of alcohol, that they're not.
[01:28:55.520 --> 01:29:04.880] Every chemical substance changes the brain in a different way and produces different changes in our mental state and our feelings and things.
[01:29:05.600 --> 01:29:11.280] But the principle is the same, that it's changing the way that it's changing our normal feelings.
[01:29:11.280 --> 01:29:13.680] And also, we know that alcohol is a depressant.
[01:29:13.680 --> 01:29:14.000] Yeah.
[01:29:15.280 --> 01:29:17.680] But again, it's funny how we use language.
[01:29:17.680 --> 01:29:22.720] We don't go round talking about alcohol as oh, you're gonna oh, you're going to consume more depressants tonight.
[01:29:22.720 --> 01:29:23.760] Are you coming around to my party?
[01:29:23.760 --> 01:29:24.880] Do you want some depressants?
[01:29:24.880 --> 01:29:25.280] Yes.
[01:29:25.280 --> 01:29:26.080] We don't, do we?
[01:29:26.080 --> 01:29:26.400] Right?
[01:29:26.400 --> 01:29:33.640] But we're like, yes, but we know that that actually, a lot of people will know when they've had a few drinks the following day, they feel pretty low, right?
[01:29:33.640 --> 01:29:37.880] It is a depressant, but we don't, it's interesting even the language we use.
[01:29:37.880 --> 01:29:39.560] So, okay, all right.
[01:29:39.560 --> 01:29:45.160] So, if you're on it, yes, and so the other analogy is very good as well.
[01:29:45.160 --> 01:30:02.520] That we know that, you know, if we think of mind-altering drugs, as you say, like caffeine or like heroin, 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.
[01:30:02.520 --> 01:30:14.600] And those withdrawal symptoms, because the drugs have, you know, there have been adaptations in the brain as well as parts of the body, those withdrawal symptoms will include, you know, emotional symptoms.
[01:30:14.600 --> 01:30:30.520] So people may become, when they're coming off antidepressants, very anxious, for example, 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.
[01:30:30.520 --> 01:30:37.480] So people can become very anxious and also emotionally labile, very changeable and tearful.
[01:30:38.520 --> 01:30:58.120] 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, you know, oh goodness, my depression's coming back.
[01:30:58.120 --> 01:30:59.880] I feel anxious again.
[01:31:00.760 --> 01:31:08.280] Then, if you ask people in more detail, it's often apparent that actually it's not quite the same as their original symptoms.
[01:31:08.280 --> 01:31:10.120] It's actually a bit different.
[01:31:10.400 --> 01:31:14.600] But, you know, but of course, the differences are quite subtle, so that might be missed.
[01:31:14.720 --> 01:31:28.160] And I think practitioners as well, although there's been a lot more publicity over the last few years about antidepressant withdrawal, I think a lot of clinicians aren't necessarily as aware of it as they might be.
[01:31:28.160 --> 01:31:36.400] And therefore, again, if someone's trying to come off their antidepressants, having difficulties, the knee-jerk reaction will often be, oh dear, you know, it's not worked.
[01:31:36.720 --> 01:31:38.000] That's your depression again.
[01:31:38.000 --> 01:31:40.880] You need to go back on it or you need to increase the dose again.
[01:31:40.880 --> 01:31:50.000] Because with caffeine, of course, you know, you kind of need to white-knuckle it for a few days, get through it to not experience those symptoms.
[01:31:50.000 --> 01:31:57.440] But again, it's not the similar to PPIs, as I mentioned before, like the proton-pump inhibitors that loads of the population are on.
[01:31:57.760 --> 01:32:08.160] There's a belief when you come off them, when you especially been on them for a while, that, oh, you know, by the fact that I'm getting indigestion and these acidite symptoms, oh, I have to still be on it.
[01:32:08.160 --> 01:32:10.640] But it's like, no, no, this could be withdrawal, actually.
[01:32:10.960 --> 01:32:14.080] That's so interesting and really interesting in that.
[01:32:14.080 --> 01:32:22.400] Also, I think we've come to assume that more conditions are chronic and ongoing than they actually are.
[01:32:22.400 --> 01:32:26.880] Whereas actually, lots of conditions fluctuate, you know, physical and mental conditions, don't they?
[01:32:26.880 --> 01:32:33.040] So, you know, you may need your proton pump inhibitor for a bit, but then actually, you might be fine.
[01:32:33.040 --> 01:32:33.760] Yeah, exactly.
[01:32:33.760 --> 01:32:37.200] And as we've said before, the trials are generally for a short period of time.
[01:32:37.200 --> 01:32:40.880] The trials aren't there to support using it for five years, unfortunately.
[01:32:40.880 --> 01:32:41.280] Absolutely.
[01:32:42.000 --> 01:32:46.560] So, okay, so let's think about a patient and then also a professional.
[01:32:46.520 --> 01:32:47.200] Okay, okay?
[01:32:47.240 --> 01:33:01.960] So for the patient who's currently on antidepressants, or let's say SSRIs, and has been on them for a period of time, and they've heard this conversation, maybe they'll get your book and read it and go, oh, wow, there really isn't that much data to support me being on them.
[01:33:02.840 --> 01:33:07.800] And they want to start thinking about getting off them.
[01:33:08.120 --> 01:33:09.560] What should they do?
[01:33:09.560 --> 01:33:14.360] So the first thing they shouldn't do is throw them down the toilet and stop them straight away.
[01:33:14.840 --> 01:33:32.040] That's really important thing to say, particularly if people have been on them for a number of years, because it seems that if you come off them very suddenly, you have worse withdrawal symptoms that potentially can go on for a lot, you know, be quite protracted and go on for a long period of time.
[01:33:32.040 --> 01:33:43.160] If you come off your medication slowly and carefully, you're more likely to be able to minimize those symptoms and for them not to sort of turn into a protracted state.
[01:33:43.160 --> 01:33:44.200] Are there guidelines somewhere?
[01:33:44.200 --> 01:33:48.040] Because I think one of the problems people may face is their doctor may know nothing about this.
[01:33:48.040 --> 01:33:48.200] Yeah.
[01:33:48.600 --> 01:33:48.760] Right.
[01:33:48.760 --> 01:33:58.760] So their doctor who's prescribed them 20 milligrams of citalopram for the last three years, they can go in and go, hey, I just heard a podcast saying there's no evidence to support this.
[01:33:59.000 --> 01:34:01.640] I'd like your help in trying to come off this.
[01:34:02.520 --> 01:34:07.560] Now, of course, there's a whole variety of different podcasts of different qualities and all that kind of stuff.
[01:34:07.560 --> 01:34:12.120] But nonetheless, I just want to predict because I want to be helpful.
[01:34:12.120 --> 01:34:18.680] So I want to make sure that that person understands what to do if they're facing a bit of a block when they go and see their doctor.
[01:34:19.240 --> 01:34:27.240] So the Royal College of Psychiatrists has actually published some quite helpful information on their website on stopping antidepressants.
[01:34:27.240 --> 01:34:27.800] Okay, great.
[01:34:27.800 --> 01:34:32.520] It was published in about 2019 and it's pretty succinct.
[01:34:33.960 --> 01:34:37.000] May not be enough, but there are other resources I'll mention in a minute.
[01:34:37.000 --> 01:34:43.400] But it's really good that the Royal College have done that.
[01:34:43.400 --> 01:34:55.200] They were spurred to do that under pressure from people who'd had really difficult withdrawal experiences, and their previous advice had been come off the medication in two to four weeks, that should be fine.
[01:34:55.200 --> 01:35:03.040] And lots of people got together and wrote to the college saying, actually, that's not fine for many people if they've been on them for a long time.
[01:35:03.200 --> 01:35:04.800] So you need to have better advice.
[01:35:04.800 --> 01:35:12.400] So there is some good advice on the Royal College website under the stopping antidepressants section.
[01:35:13.040 --> 01:35:14.400] A colleague of mine called Dr.
[01:35:14.400 --> 01:35:25.680] Mark Horowitz, who's a psychiatrist who himself has experienced difficulties coming off antidepressants, has recently published the Maudsley Deprescribing Guidelines.
[01:35:25.680 --> 01:35:38.320] So the Maudsley Prescribing Guidelines are the sort of main textbook about how to prescribe psychiatric drugs in the first place and all their effects and side effects.
[01:35:38.320 --> 01:35:47.040] The Maudsley Deprescribing Guidelines is a very detailed volume on how to get off psychiatric drugs for clinicians.
[01:35:47.040 --> 01:35:48.640] For clinicians, yes, yes.
[01:35:48.640 --> 01:35:55.040] And I just want to Maudsley, for people who are not familiar, spell M-A-U-D-S-L-E-Y, Maudsley.
[01:35:55.040 --> 01:35:55.360] That's right.
[01:35:55.360 --> 01:35:58.400] The Maudsley is named after the Maudsley Hospital in London.
[01:35:58.400 --> 01:36:13.680] So potentially the patients could say to their doctor, if they've got a helpful doctor, says, look, I don't know much about this, they could say, hey, listen, there are actually some published guidelines now and point the doctor in that direction to go and learn a little bit about this.
[01:36:13.680 --> 01:36:14.880] Exactly, exactly, yes.
[01:36:14.880 --> 01:36:23.200] And as I say, those are very detailed and go into how some people might need to transfer onto liquids or break up tablets in order to reduce the doses, you know, carefully.
[01:36:23.680 --> 01:36:39.320] One thing I heard you say in a previous interview, Joanna, is that I think at least this is what you said, that it's easier to cut at the start, but when you're getting to very low doses, you've got to be really, really careful then.
[01:36:39.320 --> 01:36:44.520] So, for example, if you're on 20 milligrams of citalopram, and again, please correct me if I haven't quite got this right.
[01:36:44.520 --> 01:36:52.280] Maybe it's you can go from 20 to 10, but then when you go from 10 to 10 to 5, it's a much bigger jump in terms of your symptoms.
[01:36:52.280 --> 01:36:52.840] Yes, it is.
[01:36:52.840 --> 01:36:57.080] And five to zero is a massive jump.
[01:36:57.080 --> 01:36:57.320] Exactly.
[01:36:57.800 --> 01:36:58.040] Exactly.
[01:36:58.280 --> 01:36:58.760] Do we know?
[01:36:58.760 --> 01:37:09.800] So that's because of what's called the hyperbolic relationship between drug dose and the activity of the drug in the body.
[01:37:11.240 --> 01:37:16.200] It's effects on the serotonin transporter and binding to receptors and things like that.
[01:37:16.200 --> 01:37:21.400] And apparently, this is a property that most drugs have.
[01:37:21.400 --> 01:37:35.160] And it's actually been recognized for quite a long time because the advice on coming off benzodiazepines was the same, that you had to go most slowly and carefully when you got down to the lowest doses.
[01:37:35.160 --> 01:37:35.560] Yeah.
[01:37:35.800 --> 01:37:39.320] If you were reducing valium diazepam, for example.
[01:37:39.560 --> 01:37:47.720] So, yeah, so that's so it can be really quite a tricky thing because some of these drugs don't come in very low-dose preparations.
[01:37:47.720 --> 01:37:49.320] In fact, lots of them don't.
[01:37:49.320 --> 01:37:52.520] Some of them you can get liquids for, some of them you can't.
[01:37:52.920 --> 01:38:01.240] Some people I know who've been coming off venlafaxine, that's one of these SNRI antidepressants.
[01:38:01.240 --> 01:38:05.000] That's a serotonin and noradrenaline reuptake inhibitor.
[01:38:05.400 --> 01:38:07.080] Oh, a second neurotransmitter.
[01:38:07.080 --> 01:38:08.600] Yes, exactly.
[01:38:09.240 --> 01:38:14.040] So, Venlafaxine, the lowest dose is 37.5 milligrams.
[01:38:14.040 --> 01:38:21.840] And it seems that that actually is a relatively high dose and has quite strong effects.
[01:38:21.920 --> 01:38:23.200] It's a 30 or a 25.
[01:38:23.280 --> 01:38:25.840] And exactly, and you can't reduce more slowly.
[01:38:25.840 --> 01:38:37.840] So, some people have been reduced to breaking open the capsules, which contain lots of little beads of the drug, and literally weighing out beads, the beads, the tiny beads inside the drug, in order to reduce slowly enough.
[01:38:38.080 --> 01:38:39.920] Easy to get on, very hard to get on.
[01:38:40.160 --> 01:38:41.280] Exactly, exactly.
[01:38:41.280 --> 01:38:49.920] And another thing I wanted to say about this is: you know, you were saying that lots of doctors, you know, struggle with how to help people come off.
[01:38:49.920 --> 01:39:06.720] And it should be another thing that really shocks us that there's all this literature about, you know, starting people on the drugs, as you say, and these short-term studies, very little research on what happens to people over the long term and how to get people off safely.
[01:39:06.720 --> 01:39:18.880] And therefore, what patients have been doing for a long time is banding together and giving people advice, peer sort of peer support and advice on how to come off antidepressants on the internet.
[01:39:18.880 --> 01:39:25.920] And so, the you know, the best information on this for a long time has been online groups on Facebook and other internet.
[01:39:26.240 --> 01:39:27.200] Sharing their experiences.
[01:39:27.360 --> 01:39:28.240] Exactly, exactly.
[01:39:28.240 --> 01:39:36.480] And the profession has taken a while to catch up with all the expertise that has actually existed in these groups.
[01:39:36.800 --> 01:39:47.040] Okay, so for a patient, there are these guidelines that they can either look at themselves, discuss with their doctor, and at least start that process off.
[01:39:47.040 --> 01:40:03.400] And I do believe this is going to change a lot anyway because you are raising such phenomenal awareness of this that it seems highly likely that it's going to become very clear very soon that actually we need to start doing this differently.
[01:40:03.720 --> 01:40:13.000] For a doctor or a professional, a healthcare professional who's been listening so far and is like, first of all, they might feel a bit of guilt, right?
[01:40:13.000 --> 01:40:18.440] An acknowledgement that, oh, wow, you know, I didn't realize that I was potentially causing all this harm.
[01:40:18.440 --> 01:40:26.600] Because a lot of doctors didn't know and might go, but you know, what would you say to that doctor who's feeling really guilty at the moment?
[01:40:26.600 --> 01:40:28.360] It's like, oh my God, what have I been doing?
[01:40:28.360 --> 01:40:30.120] What would you say to that person?
[01:40:30.440 --> 01:40:36.440] So your jobbing GP or psychiatrist that's sitting in their office, I don't think needs to feel guilty.
[01:40:36.440 --> 01:40:40.760] But I do think some of the leaders of the profession need to take some responsibility for this.
[01:40:40.760 --> 01:40:41.160] Yeah.
[01:40:41.480 --> 01:40:47.880] Actually, because, you know, it's been known really for a long time that antidepressants weren't correcting a serotonin.
[01:40:48.200 --> 01:40:49.400] You've been talking about this for a long time.
[01:40:49.400 --> 01:40:49.720] A long time.
[01:40:49.880 --> 01:40:51.400] Not just this paper 2022.
[01:40:51.560 --> 01:40:52.840] You've been talking about this for a long time.
[01:40:52.840 --> 01:40:53.800] But okay, then.
[01:40:53.800 --> 01:41:05.560] 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.
[01:41:05.560 --> 01:41:17.000] 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 have prescribed an SSRI.
[01:41:17.320 --> 01:41:19.320] What would you ask that doctor to do?
[01:41:19.640 --> 01:41:32.360] So the recent NICE guidelines are quite helpful in this respect in that they list a whole number, it's about eight or nine, alternative treatments for people with depression that you can give instead of giving an antidepressant.
[01:41:32.360 --> 01:41:43.640] And they include treatments inverted commas because they include things like recommending exercise, mindfulness, problem-solving therapy, CBT, of course.
[01:41:44.280 --> 01:41:45.920] So they do include some.
[01:41:45.920 --> 01:41:52.080] Obviously, I know there's usually a waiting list for therapy, and that's, you know, that can be an issue if someone's feeling really desperate.
[01:41:52.080 --> 01:41:55.680] But they do include some things that people could go off and do straight away.
[01:41:55.680 --> 01:42:04.480] So I think that doctors should be trying to guide patients towards these alternative ways of managing their depression.
[01:42:04.800 --> 01:42:16.400] 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.
[01:42:16.400 --> 01:42:37.760] So to have this discussion that we've been talking about of 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 and the common and important adverse effects.
[01:42:37.760 --> 01:42:44.640] Yeah, it's really interesting hearing you say what the NICE guidelines are now saying.
[01:42:48.160 --> 01:42:53.600] My very first book was called The Four Pillar Plan and it came out right at the end of 2017.
[01:42:53.600 --> 01:43:02.640] 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.
[01:43:02.640 --> 01:43:18.880] And I, at that time, and I still subscribe to what was in that book, the four pillars of health that I say have the most impact on our well-being and that we have a degree of control over, although it's different for different people, are food, movement, sleep, and relaxation.
[01:43:18.880 --> 01:43:26.720] And I break down those pillars and I give people actionable advice that doesn't cost much for all of them.
[01:43:27.360 --> 01:43:39.160] I can't tell you, Joanna, over the years, and that book's what's 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.
[01:43:39.160 --> 01:43:42.120] Now, I don't mention depression, a diagnosis in it.
[01:43:42.120 --> 01:43:52.440] I don't mention, but I think there comes a fundamental, there's a fundamental conundrum which we have to wrestle with, right?
[01:43:52.760 --> 01:43:57.160] Which is, do we believe that there are fundamental problems with the human body, right?
[01:43:57.160 --> 01:44:15.880] There are deficiencies we want, 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 have a consequence, right?
[01:44:15.880 --> 01:44:17.080] Maybe with our mood.
[01:44:17.080 --> 01:44:35.080] And if we can correct or improve within our capabilities, some of those things like more exercise, better nutrition, prioritizing your sleep a little bit more than perhaps you were, learning a few helpful stress management techniques.
[01:44:35.080 --> 01:44:37.160] Well, that's kind of what I shared in that book.
[01:44:37.160 --> 01:44:45.960] And actually, it means that for some people, of course, not everyone, actually, some of their emotions and symptoms start to get better.
[01:44:45.960 --> 01:44:52.680] Yes, probably because of the direct impacts of those behaviors, but also because the sense of agency that they feel over their life.
[01:44:52.680 --> 01:44:54.120] I can do something that makes a difference.
[01:44:54.440 --> 01:44:55.560] Do you have any comments on that?
[01:44:55.560 --> 01:44:58.120] Well, I think it's a really sensible approach for that reason.
[01:44:58.120 --> 01:45:08.120] And I think what's nice about it is because you've broken it down into four different areas, it's not quite so overwhelming as you know, someone feeling, oh my god, I've got to change everything.
[01:45:08.160 --> 01:45:18.160] You know, they can focus 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.
[01:45:18.480 --> 01:45:21.680] You tweeted recently, or what do you call it now?
[01:45:21.680 --> 01:45:22.400] You X'd.
[01:45:23.200 --> 01:45:27.200] You made a post on the platform formerly known as Twitter.
[01:45:27.680 --> 01:45:29.920] And I think it was to do with Chris Palmer.
[01:45:30.400 --> 01:45:32.480] Chris Palmer's a Harvard psychiatrist.
[01:45:32.480 --> 01:45:36.640] Chris has been on my show before, and he's doing some quite incredible work.
[01:45:36.640 --> 01:45:50.640] And he's published research showing that for some people with severe mental health problems, a ketogenic diet, so improving their metabolic health, can have a huge effect.
[01:45:50.960 --> 01:45:54.640] And I seem to recall from your post that you were questioning some of that.
[01:45:54.640 --> 01:46:00.160] So not questioning, but just saying you don't want us to fall into the same trap going it was all serotonin.
[01:46:00.480 --> 01:46:04.560] I think what you were trying to say is we can't now say it's all metabolic.
[01:46:04.800 --> 01:46:06.240] Could you just expand on that a little bit?
[01:46:06.240 --> 01:46:08.000] Because I found that really interesting.
[01:46:08.000 --> 01:46:16.240] 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 having a healthy body and mind.
[01:46:17.120 --> 01:46:37.760] But I am slightly wary that there are a group of people who want to replace the chemical imbalance with a metabolic imbalance model and suggest that some metabolic abnormality is a sort of specific direct cause of depression, as people were suggesting that a serotonin abnormality was a specific and direct cause of depression.
[01:46:38.000 --> 01:46:56.160] And I think certainly the way I look at all chronic health conditions, and again, I don't really like the label of depression, but for the purpose of this conversation, let's use it, whether it would be depression or something else, is these things are all multifactorial, or I think largely multifactorial.
[01:46:56.160 --> 01:47:02.920] So, there are multiple things going on that in combination result in certain symptoms.
[01:47:03.240 --> 01:47:14.600] So, could it be that for certain individuals with really bad metabolic health, that if they improve it, they can see an improvement in certain symptoms or their mood?
[01:47:14.600 --> 01:47:15.480] Yeah, absolutely.
[01:47:15.880 --> 01:47:19.160] I've seen that, and I, you know, and I think Chris is showing that.
[01:47:19.160 --> 01:47:27.720] At the same time, I think what you're trying to caution is us saying that all depression now is metabolic, whereas all depression was previously serotonin.
[01:47:27.720 --> 01:47:33.480] Do you believe that for some patients, a metabolic component could be at play, or do you not subscribe to that?
[01:47:33.800 --> 01:47:35.080] Not really.
[01:47:35.560 --> 01:47:35.960] Okay.
[01:47:35.960 --> 01:47:42.520] I mean, so we know that depression is more common in people who are overweight, for example.
[01:47:42.520 --> 01:47:44.520] And there might be a number of reasons for that.
[01:47:44.520 --> 01:47:47.320] And probably a lot of it is socioeconomic.
[01:47:47.640 --> 01:47:56.840] But one of it might be because if you're overweight, it's more difficult to exercise, to be active, to do things that might actually make you, you know, lift your mood and make you feel better.
[01:47:56.840 --> 01:47:58.360] So stigma in society.
[01:47:58.440 --> 01:47:59.560] And stigma, exactly.
[01:47:59.560 --> 01:48:00.600] So lots of reasons.
[01:48:00.600 --> 01:48:02.920] Yeah, absolutely, huge thing, of course.
[01:48:02.920 --> 01:48:08.120] And, you know, self-stigma, people, you know, are very aware of how they look, aren't they?
[01:48:08.120 --> 01:48:17.400] And so, so losing weight so that you're not overweight anymore is probably a very helpful thing for mood.
[01:48:18.440 --> 01:48:21.080] And being overweight is an unhelpful thing for mood.
[01:48:21.080 --> 01:48:28.520] But I think that's a bit different from saying that, you know, that there's a metabolic cause of depression, even if you're only saying that's in a few people.
[01:48:28.520 --> 01:48:30.360] Yeah, I think there's a lot there.
[01:48:30.360 --> 01:48:32.440] I really appreciate you sharing your perspective.
[01:48:32.440 --> 01:48:39.480] I'd love to dive deeper on that with you, maybe in a part two conversation, because I think there's a lot for us to talk about.
[01:48:39.880 --> 01:48:41.160] I do like Chris's work.
[01:48:41.480 --> 01:48:43.080] I'm really interested.
[01:48:43.080 --> 01:48:48.240] I've certainly seen patients when they really are able to improve their diet.
[01:48:44.760 --> 01:48:50.800] I have seen some quite big improvements in mood.
[01:48:50.880 --> 01:48:55.600] So I do think that for some people at least, that can be really helpful.
[01:48:55.600 --> 01:48:59.040] I guess for others, if that's not playing a role, it probably won't do anything at all.
[01:48:59.040 --> 01:49:06.000] You know, if it's due to early life experiences or really bad trauma, you're probably going to need to address that.
[01:49:06.800 --> 01:49:22.400] So I think, again, I would also argue that maybe that term, again, depression is quite misleading because it's such a broad umbrella term that encompasses maybe all kinds of different etiologies and physiologies.
[01:49:22.400 --> 01:49:25.440] And, you know, do we need different terms for these things?
[01:49:25.440 --> 01:49:26.080] Do you know what I mean?
[01:49:26.480 --> 01:49:30.640] Metabolic dysfunction-induced mood problems, for example.
[01:49:31.040 --> 01:49:32.640] Oh, yeah, that's my issue.
[01:49:33.120 --> 01:49:37.600] Yeah, I mean, as you mentioned earlier, sleep can affect people's mood really profoundly.
[01:49:37.600 --> 01:49:38.160] Massively.
[01:49:38.480 --> 01:49:43.040] And so, obviously, you know, our physiology can impact our mood.
[01:49:43.040 --> 01:49:47.200] And I wouldn't want to suggest that it's never about that.
[01:49:48.160 --> 01:50:01.280] But I suppose that I think in general, when we talk about depression, we are talking about a meaningful reaction to things that are going on rather than just a consequence of poor sleep or metabolic problems or whatever it is.
[01:50:01.600 --> 01:50:05.120] Well, listen, I've thoroughly enjoyed this conversation, Joanna.
[01:50:05.200 --> 01:50:10.800] I think what we've spoken about so far is really summed up with a phrase that you wrote.
[01:50:10.880 --> 01:50:14.480] It's not in this book, actually, I think it was in the one just before that.
[01:50:14.480 --> 01:50:20.160] My concern is that we have fundamentally misunderstood what psychiatric drugs do.
[01:50:20.160 --> 01:50:28.800] And because of this, we overestimated their potential benefits and underestimated the harm they can cause.
[01:50:28.800 --> 01:50:30.000] Do you still stand by that statement?
[01:50:30.600 --> 01:50:31.400] Yes, absolutely.
[01:50:31.400 --> 01:50:48.840] And I think it relates very much to your points about the limitations of medicine and recognizing the limitations and not rushing in to try and correct things when actually we don't really understand what's going on and the tools we have are very crude.
[01:50:49.160 --> 01:50:52.760] You, I know, lecture to medical students quite a lot.
[01:50:54.200 --> 01:50:58.360] What's their reaction to what they're learning from you, would you say?
[01:50:58.360 --> 01:51:00.200] Give me some hope for the future, Joanna.
[01:51:00.360 --> 01:51:06.040] Well, medical students are very sweet and polite generally, so I probably only hear from the ones that agree with me.
[01:51:06.040 --> 01:51:07.880] So I have to caveat it with that.
[01:51:07.880 --> 01:51:20.600] But I've given a couple of talks to medical students recently and they've been very positive, very receptive, really, you know, enthusiastically wanting to take these ideas forward and improve mental health care by doing so.
[01:51:20.600 --> 01:51:21.800] I think things are changing.
[01:51:21.800 --> 01:51:22.280] I really do.
[01:51:22.280 --> 01:51:32.600] I think there's a new generation coming in who actually, you know, a lot of people don't like the new media landscape that exists with podcasts and social media and stuff.
[01:51:32.760 --> 01:51:41.160] But for all the potential harms of that, there are huge benefits, which is information like this is getting disseminated to more and more people.
[01:51:41.160 --> 01:51:45.400] And I know there's a ton of medical students who listen to this show, so we're very interested in these ideas.
[01:51:45.400 --> 01:51:48.360] These are going to be the clinicians of tomorrow, right?
[01:51:48.680 --> 01:51:49.400] Absolutely.
[01:51:49.400 --> 01:51:57.640] I think it's actually a really important point because as I experienced, there is a section of the psychiatric establishment who want to shut this debate down.
[01:51:58.440 --> 01:52:04.760] And if social media didn't exist and all these new media platforms didn't exist, they would have done so.
[01:52:04.760 --> 01:52:05.960] They would have been able to do so.
[01:52:05.960 --> 01:52:07.880] But they've not been able to.
[01:52:07.880 --> 01:52:09.160] You can't shut it down anymore.
[01:52:09.160 --> 01:52:10.680] People are going to talk about this stuff.
[01:52:10.680 --> 01:52:11.880] These ideas are going to spread.
[01:52:11.880 --> 01:52:14.040] People are going to look at the research.
[01:52:14.280 --> 01:52:20.720] I certainly would highly recommend that people read your new book, Chemically Imbalanced, The Making and Unmaking of the Serotonin Myth.
[01:52:20.800 --> 01:52:22.560] I think it's great for the public.
[01:52:22.560 --> 01:52:31.920] But if you are a clinician and if you currently prescribe SSRIs, please, please take a look at Joanna's 2022 paper.
[01:52:31.920 --> 01:52:42.160] Please take a look at this book because I think when a clinician reads this and understands it, they'll at the very least ask themselves some questions about what they're doing.
[01:52:42.160 --> 01:52:45.360] To finish off, Joanna, you have got a lot of experience.
[01:52:45.360 --> 01:52:47.840] You're still in clinical practice.
[01:52:48.480 --> 01:53:00.960] For a member of the public who's heard this conversation, who is struggling with their mood and doesn't know what to do, what would you say to them?
[01:53:02.880 --> 01:53:07.600] So I'd say to them to try and try and work out why.
[01:53:08.640 --> 01:53:11.120] What is this mood signaling to you?
[01:53:12.320 --> 01:53:15.120] Maybe there's something at work that's not right.
[01:53:15.120 --> 01:53:20.960] Maybe there are some relationship problems or been some issues in some friendships.
[01:53:20.960 --> 01:53:22.800] Try and identify that.
[01:53:23.680 --> 01:53:26.960] And it may just be a case of making those sorts of changes.
[01:53:27.600 --> 01:53:34.800] If you can't identify it and are already struggling, then it might be helpful to have some psychotherapy.
[01:53:35.600 --> 01:53:42.480] And there is psychotherapy now available on the NHS, the talking therapist service.
[01:53:42.480 --> 01:53:48.080] You can access that by going to see your GP or you can phone them up directly and refer yourself.
[01:53:48.480 --> 01:54:06.200] And then there are other things that you can do that will generally be helpful for your mood, such as taking exercise, doing some mindfulness or relaxation, probably having a good diet and making sure that your physical health is in good shape.
[01:54:06.840 --> 01:54:08.520] So I would do all those things.
[01:54:08.520 --> 01:54:20.120] I would talk to the people that you're close to and share your feelings with them, and they may be able to help you identify what the problem is.
[01:54:20.120 --> 01:54:30.040] If you feel that you need to go and see a doctor and want to talk about antidepressants, just please bear in mind what we've said about all their adverse effects.
[01:54:30.040 --> 01:54:37.480] And if you do end up feeling that you have to take them, then please try and take them for as short a time as possible.
[01:54:37.480 --> 01:54:53.720] I think that's really important because actually a lot of the adverse effects we've been talking about, the really serious ones like dependence and persistent sexual dysfunction, are more likely to happen and going to be more severe if you end up on antidepressants for long periods of time.
[01:54:53.720 --> 01:54:54.920] Yeah, brilliant advice.
[01:54:54.920 --> 01:55:01.800] Joanna, honestly, I think you're doing some really, really important work.
[01:55:01.800 --> 01:55:10.600] And as I said to Susanna Sullivan when she was in the studio last week, even if people push back at any of these concepts, we have to be having these conversations.
[01:55:10.600 --> 01:55:14.280] We have to be questioning what it is we're doing.
[01:55:14.280 --> 01:55:21.400] Why is it that one in five UK adults almost are taking some form of antidepressants?
[01:55:21.400 --> 01:55:27.400] You know, and if we shut down these conversations, we can't see what's working, what's not working.
[01:55:27.400 --> 01:55:29.320] So I really want to appreciate you.
[01:55:29.320 --> 01:55:30.920] I think it's not easy doing what you're doing.
[01:55:31.000 --> 01:55:35.240] You are literally going up against established practice.
[01:55:35.240 --> 01:55:36.680] Thank you for writing the book.
[01:55:36.680 --> 01:55:38.600] Thank you for publishing your research.
[01:55:38.600 --> 01:55:40.040] And thank you for coming on the show.
[01:55:40.040 --> 01:55:41.560] Thank you very much for inviting me.
[01:55:41.560 --> 01:55:54.160] And really, thank you for highlighting how important this is and really how radical it is and helping people to unpick that, I think, in a way that hopefully isn't too overwhelming.
[01:55:57.760 --> 01:56:00.320] Really hope you enjoyed that conversation.
[01:56:00.320 --> 01:56:06.080] Do think about one thing that you can take away and apply into your own life.
[01:56:06.080 --> 01:56:11.120] And also have a think about one thing from this conversation that you can teach to somebody else.
[01:56:11.120 --> 01:56:18.800] Remember, when you teach someone, it not only helps them, it also helps you learn and retain the information.
[01:56:18.800 --> 01:56:22.240] Now, before you go, just wanted to let you know about Friday 5.
[01:56:22.240 --> 01:56:29.360] It's my free weekly email containing five simple ideas to improve your health and happiness.
[01:56:29.360 --> 01:56:43.440] In that email, I share exclusive insights that I do not share anywhere else, including health advice, how to manage your time better, interesting articles or videos that I've been consuming, and quotes that have caused me to stop and reflect.
[01:56:43.440 --> 01:56:54.080] And I have to say, in a world of endless emails, it really is delightful that many of you tell me it is one of the only weekly emails that you actively look forward to receiving.
[01:56:54.080 --> 01:57:04.800] So if that sounds like something you would like to receive each and every Friday, you can sign up for free at drchattergy.com forward slash Friday5.
[01:57:04.800 --> 01:57:21.120] Now, if you are new to my podcast, you may be interested to know that I have written five books that have been bestsellers all over the world, covering all kinds of different topics: happiness, food, stress, sleep, behavior change, and movement, weight loss, and so much more.
[01:57:21.120 --> 01:57:23.040] So, please do take a moment to check them out.
[01:57:23.040 --> 01:57:30.000] They are all available as paperbacks, e-books, and as audio books, which I am narrating.
[01:57:30.280 --> 01:57:39.320] If you enjoyed today's episode, it is always appreciated if you can take a moment to share the podcast with your friends and family or leave a review on Apple Podcasts.
[01:57:39.320 --> 01:57:41.320] Thank you so much for listening.
[01:57:41.320 --> 01:57:42.840] Have a wonderful week.
[01:57:42.840 --> 01:57:53.800] And please note that if you want to listen to this show without any adverts at all, that option is now available for a small monthly fee on Apple and on Android.
[01:57:53.800 --> 01:57:59.080] All you have to do is click the link in the episode notes in your podcast app.
[01:57:59.080 --> 01:58:03.880] And always remember, you are the architect of your own health.
[01:58:03.880 --> 01:58:11.000] Making lifestyle change is always worth it because when you feel better, you live more.

Prompt 6: Key Takeaways

Now please extract the key takeaways from the transcript content I provided.

Extract the most important key takeaways from this part of the conversation. Use a single sentence statement (the key takeaway) rather than milquetoast descriptions like "the hosts discuss...". 

Limit the key takeaways to a maximum of 3. The key takeaways should be insightful and knowledge-additive. 

IMPORTANT: Return ONLY valid JSON, no explanations or markdown. Ensure:
- All strings are properly quoted and escaped
- No trailing commas
- All braces and brackets are balanced
Format: {"key_takeaways": ["takeaway 1", "takeaway 2"]}

Prompt 7: Segments

Now identify 2-4 distinct topical segments from this part of the conversation.

For each segment, identify:
- Descriptive title (3-6 words)  
- START timestamp when this topic begins (HH:MM:SS format)
- Double check that the timestamp is accurate - a timestamp will NEVER be greater than the total length of the audio
- Most important Key takeaway from that segment. Key takeaway must be specific and knowledge-additive.
- Brief summary of the discussion

IMPORTANT: The timestamp should mark when the topic/segment STARTS, not a range. Look for topic transitions and conversation shifts.

Return ONLY valid JSON. Ensure all strings are properly quoted, no trailing commas:
{
  "segments": [
    {
      "segment_title": "Topic Discussion", 
      "timestamp": "01:15:30",
      "key_takeaway": "main point from this segment",
      "segment_summary": "brief description of what was discussed"
    }
  ]
}

Timestamp format: HH:MM:SS (e.g., 00:05:30, 01:22:45) marking the START of each segment.

Prompt 8: Media Mentions

Now scan the transcript content I provided for ACTUAL mentions of specific media titles:

Find explicit mentions of:
- Books (with specific titles)
- Movies (with specific titles)  
- TV Shows (with specific titles)
- Music/Songs (with specific titles)

DO NOT include:
- Websites, URLs, or web services
- Other podcasts or podcast names

IMPORTANT: 
- Only include items explicitly mentioned by name. Do not invent titles.
- Valid categories are: "Book", "Movie", "TV Show", "Music"
- Include the exact phrase where each item was mentioned
- Find the nearest proximate timestamp where it appears in the conversation
- THE TIMESTAMP OF THE MEDIA MENTION IS IMPORTANT - DO NOT INVENT TIMESTAMPS AND DO NOT MISATTRIBUTE TIMESTAMPS
- Double check that the timestamp is accurate - a timestamp will NEVER be greater than the total length of the audio
- Timestamps are given as ranges, e.g. 01:13:42.520 --> 01:13:46.720. Use the EARLIER of the 2 timestamps in the range.

Return ONLY valid JSON. Ensure all strings are properly quoted and escaped, no trailing commas:
{
  "media_mentions": [
    {
      "title": "Exact Title as Mentioned",
      "category": "Book",
      "author_artist": "N/A",
      "context": "Brief context of why it was mentioned",
      "context_phrase": "The exact sentence or phrase where it was mentioned",
      "timestamp": "estimated time like 01:15:30"
    }
  ]
}

If no media is mentioned, return: {"media_mentions": []}

Full Transcript

[00:00:00.720 --> 00:00:08.800] We've set up this expectation in society that there is this thing called depression and it's a medical condition and you should go and see your doctor about it.
[00:00:08.800 --> 00:00:17.120] But I would say that depression is a natural human emotion and emotions are reactions to the events in our lives.
[00:00:17.120 --> 00:00:19.840] Emotion is a meaningful response.
[00:00:19.840 --> 00:00:27.200] It's a reflection of our values and it's a way of expressing, you know, we don't like this situation.
[00:00:27.200 --> 00:00:28.960] Hey guys, how are you doing?
[00:00:28.960 --> 00:00:31.040] Hope you're having a good week so far.
[00:00:31.040 --> 00:00:32.000] My name is Dr.
[00:00:32.000 --> 00:00:38.240] Rongan Chatterjee and this is my podcast, Feel Better, Live More.
[00:00:39.840 --> 00:00:48.560] I want to start by saying that this may be one of the most important conversations I have ever had on this podcast.
[00:00:48.560 --> 00:00:50.960] And I don't say that lightly.
[00:00:51.280 --> 00:00:59.840] Did you know that nearly one in five UK adults and almost one in four women are currently taking antidepressants?
[00:00:59.840 --> 00:01:01.520] Does that strike you as normal?
[00:01:01.520 --> 00:01:04.800] Is that something we should regard as okay?
[00:01:05.120 --> 00:01:13.760] And if so, what does this tell us about our culture and what does it say about the way we treat mental health disorders?
[00:01:13.760 --> 00:01:21.680] Do one in five of us really have chemical imbalances that can only be fixed by pharmaceutical medication?
[00:01:21.680 --> 00:01:24.240] Well, this week, my guest is Dr.
[00:01:24.240 --> 00:01:26.400] Joanna Moncrief.
[00:01:26.400 --> 00:01:45.200] Joanna is professor of critical and social psychiatry at University College London, a consultant psychiatrist for the NHS, and the author of the groundbreaking book, Chemically Imbalanced, the Making and Unmaking of the Serotonin Myth.
[00:01:45.200 --> 00:02:11.960] In our truly thought-provoking and wide-ranging conversation, Joanna explains how the diagnosis of depression itself is subjective and based on criteria that she describes as completely made up, and how the widely accepted belief that depression is caused by a chemical imbalance or serotonin deficiency has very little scientific evidence to support it.
[00:02:11.960 --> 00:02:52.840] You'll also hear about the research showing that there is very little difference between antidepressants and placebo, how pharmaceutical marketing campaigns fundamentally changed our cultural understanding of depression, why withdrawal from antidepressants can be extremely challenging and is not actually something that doctors are trained to do, and the concerning side effects of SSRIs, a type of so-called antidepressant like Prozac and Citalopram, including emotional numbness, sexual dysfunction, and an increase in suicidal thoughts.
[00:02:52.840 --> 00:03:15.640] We also discuss the actual causes of what we term depression, how alternatives like exercise, mindfulness, and addressing underlying life issues might be more effective than drugs, and whether visiting a healthcare professional should really be our first option when experiencing low mood symptoms.
[00:03:15.640 --> 00:03:27.480] Joanna and I both believe that we've been disempowering people by teaching them that negative emotions represent a deficiency rather than a natural human experience.
[00:03:27.480 --> 00:03:38.760] And this conversation encourages all to view our emotional responses as meaningful signals rather than medical disorders that need chemical correction.
[00:03:38.760 --> 00:03:52.400] If you or someone you know has ever taken antidepressants or been diagnosed with depression, this conversation offers a perspective that could fundamentally change the way you see things.
[00:03:56.880 --> 00:04:02.480] You have been a practicing psychiatrist for over three decades.
[00:04:02.480 --> 00:04:04.640] Let's start off with the elephant in the room.
[00:04:04.640 --> 00:04:20.640] Okay, 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?
[00:04:20.960 --> 00:04:23.920] So that's a very good question.
[00:04:23.920 --> 00:04:31.280] And the answer primarily is because of the efforts of the pharmaceutical industry from the 1990s onwards.
[00:04:31.280 --> 00:04:50.640] So the chemical imbalance theory of depression was first constructed in the 1960s by psychiatrists and researchers who were experimenting with various drug treatments for depression and trying to come up with a justification for using drug treatment in this situation.
[00:04:50.960 --> 00:04:55.520] But it wasn't an enormously well-known or popular theory at that time.
[00:04:55.520 --> 00:05:04.160] 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.
[00:05:04.160 --> 00:05:06.480] That didn't come up with anything.
[00:05:07.120 --> 00:05:09.840] So, you know, the theory wasn't really getting anywhere.
[00:05:09.840 --> 00:05:23.520] 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.
[00:05:23.520 --> 00:05:34.600] And so there were massive advertising campaigns that told people that depression was caused by a chemical imbalance, or sometimes they'd say it might be caused by a chemical imbalance.
[00:05:34.840 --> 00:05:40.360] But this was repeated so many times that basically people became convinced it was true.
[00:05:40.360 --> 00:05:41.080] Yeah.
[00:05:41.400 --> 00:05:54.680] 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.
[00:05:54.680 --> 00:05:55.560] Absolutely, absolutely.
[00:05:55.800 --> 00:05:57.720] It's not just, oh, that's a theory.
[00:05:57.720 --> 00:06:03.000] I think the general public, or much of the general public, believe this to be true.
[00:06:03.000 --> 00:06:24.920] And so your work for many years, including your brand new book, Chemically Imbalance, 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.
[00:06:24.920 --> 00:06:28.440] But I think what you've done is give people the evidence for that.
[00:06:28.440 --> 00:06:30.520] Yeah, or I should say the lack of evidence for that.
[00:06:30.680 --> 00:06:31.400] Yeah, yeah.
[00:06:31.400 --> 00:06:43.240] 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.
[00:06:43.240 --> 00:06:45.240] They think it's proven.
[00:06:45.240 --> 00:06:52.360] 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.
[00:06:52.360 --> 00:06:59.560] So that's why I thought, right, we need to look at the evidence properly, set it out, get it published and see what it says.
[00:06:59.560 --> 00:07:15.680] 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.
[00:07:14.760 --> 00:07:16.400] Yeah, it's interesting.
[00:07:16.560 --> 00:07:24.720] 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.
[00:07:24.720 --> 00:07:30.160] And the resident GP said on that segment, Well, why does it matter?
[00:07:30.160 --> 00:07:30.480] Right?
[00:07:30.480 --> 00:07:31.360] Why does it matter?
[00:07:31.360 --> 00:07:32.480] We know that they work.
[00:07:32.480 --> 00:07:35.120] It doesn't really matter why they work.
[00:07:35.120 --> 00:07:39.680] Now, it was quite shocking for me to read that, to go, it doesn't really matter why they work.
[00:07:39.680 --> 00:07:40.720] Hold on a minute.
[00:07:40.720 --> 00:07:46.640] There are a ton of side effects to these drugs, right?
[00:07:46.960 --> 00:07:55.440] So if the whole principle upon which they're prescribed is built on sand, we kind of need to know about it, right?
[00:07:55.440 --> 00:07:55.760] Absolutely.
[00:07:55.840 --> 00:07:56.880] So what is your take on that?
[00:07:56.880 --> 00:08:11.440] And what are, 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?
[00:08:11.760 --> 00:08:28.880] Yeah, so just to say first, 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 other leading doctors to say it doesn't matter, it doesn't matter how they work.
[00:08:28.880 --> 00:08:31.840] And I think that is absolutely shocking.
[00:08:31.840 --> 00:08:34.240] I think it matters a lot how they work.
[00:08:34.240 --> 00:08:47.440] And it is absolutely essential that we discuss this with the public 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.
[00:08:47.440 --> 00:08:57.360] So, SSRIs, the idea was that they would work by correcting an underlying serotonin deficiency.
[00:08:57.360 --> 00:09:06.520] And it turns out that actually the evidence for that is weak, inconsistent, and not compelling, and certainly not proven.
[00:09:07.400 --> 00:09:09.800] But they are, you know, they are drugs.
[00:09:09.800 --> 00:09:14.120] They do change the normal state of your brain chemistry.
[00:09:14.120 --> 00:09:17.400] They do modify our biology in some way.
[00:09:17.880 --> 00:09:25.560] And we know that they cause, you know, that they change people's thinking and feeling processes.
[00:09:25.560 --> 00:09:31.000] And one of the common effects they have, for example, is that they cause a state of emotional numbing.
[00:09:31.000 --> 00:09:39.400] So people often say that they can't, you know, they may not feel quite so sad anymore, but also they can't feel happy anymore and they can't cry.
[00:09:39.400 --> 00:09:51.480] And some people might welcome that effect, but some people, a lot of people report that it's actually quite unpleasant and, you know, they don't feel like themselves anymore when they're in that sort of state.
[00:09:51.480 --> 00:09:52.280] Yeah, it's interesting.
[00:09:52.280 --> 00:10:02.840] As I was reading your book and diving into your work, Joanna, I reflected a lot on my own practice over the years as a medical doctor.
[00:10:03.160 --> 00:10:11.080] 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.
[00:10:11.080 --> 00:10:27.640] 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.
[00:10:27.640 --> 00:10:33.240] And I remember early in my days as a GP, there was one patient.
[00:10:33.240 --> 00:10:36.040] I don't think I started an SSRI on her.
[00:10:36.360 --> 00:10:42.600] I think she'd been started it by a colleague of mine, but she came in for her four-weekly review, right?
[00:10:43.240 --> 00:10:46.880] And she was a young lady, I think she's about 23 years old.
[00:10:46.880 --> 00:11:00.480] 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.
[00:11:00.480 --> 00:11:01.520] I don't feel high.
[00:11:01.520 --> 00:11:02.640] I don't feel joy.
[00:11:02.640 --> 00:11:04.160] I feel nothing.
[00:11:04.160 --> 00:11:06.240] So I always remember that so well.
[00:11:06.240 --> 00:11:08.560] I thought, that's really interesting.
[00:11:08.560 --> 00:11:12.640] She's potentially having what you're calling this emotional numbness or emotional blunting.
[00:11:12.640 --> 00:11:14.880] And I thought, well, how is that helpful?
[00:11:14.880 --> 00:11:25.440] 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?
[00:11:25.600 --> 00:11:29.920] So that's one case I really remember super, super well.
[00:11:30.880 --> 00:11:48.160] And the other case I remember really, really well is without going 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 hear in order to make the diagnosis of depression.
[00:11:48.160 --> 00:11:50.160] And I remember looking in the BNF.
[00:11:50.160 --> 00:11:54.240] So for people listening to the show all around the world, so the British National Formulary.
[00:11:54.240 --> 00:12:01.200] So our kind of byball of drugs and the consequences, what the indications are, what the side effects are.
[00:12:01.200 --> 00:12:05.200] And I remember looking through it, and I knew this anyway, but I was just looking through it.
[00:12:05.200 --> 00:12:15.200] 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.
[00:12:15.520 --> 00:12:18.240] And I thought, this doesn't make any sense to me.
[00:12:18.240 --> 00:12:21.280] I've got someone in front of me with low moods.
[00:12:21.280 --> 00:12:28.880] And I'm potentially going to be putting her on a drug that, yes, it might be a small risk that may increase her risk of suicidal thoughts.
[00:12:28.880 --> 00:12:32.200] And I thought, this doesn't kind of make any sense.
[00:12:32.200 --> 00:12:34.200] So, any comments on what I've just said, Joanna?
[00:12:34.200 --> 00:12:35.640] Yeah, yeah, no, absolutely.
[00:12:29.440 --> 00:12:43.240] I mean, so it comes back to there being, you know, two very different ways of understanding what these drugs might be doing.
[00:12:43.240 --> 00:12:52.120] And if you understand that they are correcting an underlying abnormality, an underlying deficiency, then it sounds like a good idea to take them.
[00:12:52.120 --> 00:13:01.320] And you might take a small, you know, a small increased risk of something if you're correcting, you know, an underlying biological disease that you have.
[00:13:01.640 --> 00:13:21.320] Yeah, so just on that, so if you have an infection, for example, which is, you know, a pneumonia, right, which is 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, right?
[00:13:21.320 --> 00:13:23.480] So I'm just trying to draw the analogy, that sort of thing.
[00:13:23.480 --> 00:13:23.720] Exactly.
[00:13:23.880 --> 00:13:26.760] But you think that the benefits outweigh the risks.
[00:13:27.000 --> 00:13:28.280] Yes, exactly.
[00:13:28.280 --> 00:14:02.360] But if it's not the case that there's an underlying abnormality, and that's what we've shown, and you are taking something that changes your normal, the normal state of your brain and your normal feelings and thoughts and behaviors because of that, 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, including positive emotions, blunted, you might feel lethargic a lot of the time.
[00:14:03.400 --> 00:14:08.960] You are very likely to have sexual dysfunction, at least while you're taking the drug, possibly afterwards.
[00:14:09.360 --> 00:14:11.880] Then all these things actually become much more important.
[00:14:11.880 --> 00:14:13.920] They're not just incidental.
[00:14:13.560 --> 00:14:18.560] They're part of weighing up whether actually this is a good idea.
[00:14:18.960 --> 00:14:25.040] Yeah, going back to your TV segment where the other doctor said, well, it doesn't matter.
[00:14:25.040 --> 00:14:25.760] It doesn't matter.
[00:14:25.760 --> 00:14:26.720] If they work, they work.
[00:14:26.720 --> 00:14:28.160] We don't need to know the reasons.
[00:14:28.160 --> 00:14:30.800] Well, these are pretty significant side effects.
[00:14:30.800 --> 00:14:33.920] Of course, we need to know the reasons before we put people on them.
[00:14:34.080 --> 00:14:35.280] Absolutely, absolutely.
[00:14:35.280 --> 00:14:57.360] And I think, 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 having a, you know, like having a drink of alcohol or something like that will numb you temporarily.
[00:14:58.240 --> 00:15:01.600] Many people, I think, will decide actually, no, I don't want that.
[00:15:01.760 --> 00:15:03.680] You know, I can get through this myself.
[00:15:03.680 --> 00:15:04.880] I don't want to be numbed.
[00:15:04.880 --> 00:15:06.480] I don't want to be drugged.
[00:15:06.480 --> 00:15:10.240] Do you know how common it is in the UK?
[00:15:10.240 --> 00:15:14.400] You know, how prevalent is the prescriptions of antidepressants?
[00:15:14.400 --> 00:15:16.960] Or do you know how many people are on them currently in the UK?
[00:15:17.280 --> 00:15:24.480] So the estimate is about 17% or a little bit more of the population.
[00:15:24.480 --> 00:15:27.600] So almost one in five are taking them at the moment.
[00:15:27.920 --> 00:15:30.080] Those are figures from about 2017.
[00:15:30.560 --> 00:15:37.680] That's including, I think that's, yeah, I think that's the population of over 18s.
[00:15:37.680 --> 00:15:43.120] So over 18, so maybe one in five adults in the UK are on some form of antidepressants.
[00:15:43.280 --> 00:15:44.720] And it's more for women.
[00:15:44.720 --> 00:15:47.200] So 23% of women take them.
[00:15:47.200 --> 00:15:49.840] So almost one in four women are taking an antidepressant.
[00:15:50.080 --> 00:15:52.880] Do we know under the age of 18 how common it is?
[00:15:52.880 --> 00:15:58.480] Because I understand that more and more adolescents are being prescribed these things.
[00:15:58.480 --> 00:16:02.680] Yeah, yeah, I don't have precise figures for younger people, but you're absolutely right.
[00:15:59.840 --> 00:16:04.840] The rates of prescribing are rising.
[00:16:05.160 --> 00:16:16.840] I feel like when I'm talking to my children and their friends, that a lot of their group are on antidepressants, sometimes other sorts of medication, but a lot of them are taking antidepressants.
[00:16:16.840 --> 00:16:17.800] It's really interesting to me.
[00:16:17.800 --> 00:16:35.960] Last week, Susanna O'Sullivan was here in the studio and she's written another very important book, The Age of Diagnosis, where she questions many things to do with how many people are being diagnosed with a variety of different conditions, including depression.
[00:16:36.600 --> 00:16:40.680] It's kind of interesting how these books are coming out in, you know, at similar times.
[00:16:40.680 --> 00:16:41.320] Yeah, yeah.
[00:16:41.320 --> 00:16:41.640] Right.
[00:16:41.640 --> 00:16:51.080] 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.
[00:16:51.080 --> 00:17:04.440] 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.
[00:17:04.440 --> 00:17:08.840] Good feelings, bad feelings, struggles, positive emotions, negative emotions.
[00:17:08.840 --> 00:17:12.360] These things are part of the human condition.
[00:17:12.360 --> 00:17:14.840] Yeah, yeah, no, I absolutely agree.
[00:17:14.840 --> 00:17:20.520] And the ways it's negative is there are a number of ways.
[00:17:21.000 --> 00:17:33.480] When you give someone a label, a diagnostic label, you often cease to see the individual and their individual problems, and you're then treating the label.
[00:17:34.040 --> 00:17:40.440] And actually, what we need to do is see people as individuals, and people, you know, people do struggle with their emotions.
[00:17:40.440 --> 00:17:56.160] I think sometimes we're, you know, maybe unnecessarily medicating people who are having 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.
[00:17:56.160 --> 00:18:11.280] But nevertheless, I don't think it helps to say, you know, to treat this as a diagnosis, to label everyone, because then you don't actually uncover what the real problems are that need to be addressed.
[00:18:11.280 --> 00:18:14.160] We've mentioned this term SSRI quite a bit.
[00:18:14.160 --> 00:18:27.440] Okay, so first of all, I'd love you to expand upon, 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.
[00:18:27.440 --> 00:18:33.360] And then, if possible, John, it would be really good to understand what did the trials actually show?
[00:18:33.360 --> 00:18:54.080] Okay, because you're saying that this serotonin chemical imbalance theory is got minimal evidence to support it, but nonetheless, one in five of the UK population, at least probably, and because that was 2017, mental health has got a lot worse in the last few years.
[00:18:54.080 --> 00:18:55.920] There was COVID, there was lockdowns, right?
[00:18:55.920 --> 00:18:57.920] So it could well be more than that now.
[00:18:59.520 --> 00:19:06.400] On what evidence was the prescription of these drugs even based upon in the first place?
[00:19:07.680 --> 00:19:12.960] So, yes, so this comes down to the clinical trials that have been done.
[00:19:14.160 --> 00:19:40.120] So, the justification for the use of antidepressants, apart from this idea of the chemical imbalance, is these trials that show that antidepressants perform a little bit better than a placebo tablet if you randomize people and allocate them either to take the placebo or the antidepressant, and then you measure their mood using these mood scales.
[00:19:40.120 --> 00:19:49.320] Now, there are lots of problems with these studies, including that measuring mood is a very artificial thing to do and questionable at best.
[00:19:49.640 --> 00:19:59.160] But even if you just put that aside for a minute, the difference between the antidepressant and the placebo in these trials is very small.
[00:19:59.480 --> 00:20:18.680] And it's not large enough to actually register as a clinically significant difference if you use other ways of measuring people's function, like something called the clinical global rating scale, which is a sort of general impression of how someone is doing, for example.
[00:20:19.880 --> 00:20:25.640] And there are various other ways of sort of judging the clinical relevance of a difference.
[00:20:25.640 --> 00:20:27.640] So it's very small.
[00:20:27.640 --> 00:20:36.360] And it may well not be a pharmacological effect anyway, because we know that a lot of these trials are not fully double-blind.
[00:20:36.360 --> 00:20:47.880] People can guess whether they've got the actual antidepressant or the placebo because of some of the side effects they get, particularly if people have been on antidepressants before, which many of them have.
[00:20:48.200 --> 00:20:55.480] And we know that what you think you're taking has a significant impact on your outcome in the short term.
[00:20:55.480 --> 00:21:03.320] 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.
[00:21:03.320 --> 00:21:03.960] Yeah.
[00:21:04.280 --> 00:21:05.640] There's quite a few things there, Joanna.
[00:21:05.600 --> 00:21:06.760] If we can we just unpack a few questions?
[00:21:06.840 --> 00:21:07.560] Yeah, of course, yeah, yeah.
[00:21:08.120 --> 00:21:14.760] So, um, first of all, you mentioned how one is diagnosed with depression in the first place.
[00:21:15.360 --> 00:21:18.560] Now, we're both medical doctors, okay?
[00:21:18.560 --> 00:21:27.520] But for the general public who are listening, they may not be aware of the subtleties and the subjective nature of diagnosis like this.
[00:21:27.520 --> 00:21:28.640] So, can you break it down?
[00:21:28.880 --> 00:21:29.920] What are these scales?
[00:21:29.920 --> 00:21:31.920] What sort of questions do they ask?
[00:21:31.920 --> 00:21:36.560] Because I think that would help people understand that this is kind of, I wouldn't say it's flimsy.
[00:21:36.560 --> 00:21:40.320] Well, I would actually, it's a little bit flimsy how we diagnose these conditions in the first place.
[00:21:41.200 --> 00:21:46.720] Well, so, I mean, I mean, we diagnose depression in practice, don't we?
[00:21:46.720 --> 00:21:53.920] Because someone comes and says they, you know, they don't feel well, they're feeling low, they've lost interest in things.
[00:21:54.240 --> 00:22:08.320] But then there are official criteria for making a diagnosis, which include that you have to have had a low mood for two weeks at least and some other symptoms, which might include difficulties sleeping or loss of appetite.
[00:22:08.320 --> 00:22:14.000] But of course, you know, whether or not you've had a low mood for two weeks or not is completely subjective.
[00:22:16.160 --> 00:22:26.240] 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.
[00:22:26.720 --> 00:22:28.640] That's just completely made up.
[00:22:28.640 --> 00:22:35.520] It's just what psychiatrists drawing up these manuals have decided is a reasonable criteria.
[00:22:35.520 --> 00:22:48.560] 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.
[00:22:48.880 --> 00:22:55.040] And I really noticed this when I worked in a practice in Alden where there was a huge ethnic variety in the practice.
[00:22:55.040 --> 00:23:08.680] 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.
[00:23:08.680 --> 00:23:18.200] Like, so pain, for example, and, you know, without going down a rabbit hole, you know, even the way we ask that question, have you had a low mood?
[00:23:18.200 --> 00:23:20.760] Well, to 10 different people, that means 10 different things.
[00:23:20.760 --> 00:23:21.480] Yes, doesn't it?
[00:23:21.480 --> 00:23:27.720] So there's an inherent bias, even within the question, as to whether someone even answers yes or no to that.
[00:23:27.720 --> 00:23:28.600] Yeah, yeah, absolutely.
[00:23:28.600 --> 00:23:29.160] Yeah.
[00:23:29.160 --> 00:23:50.920] And the way that low mood is judged with one of these commonly used 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 just have some of the symptoms.
[00:23:50.920 --> 00:23:53.960] So the language you use will actually influence your score.
[00:23:54.280 --> 00:23:55.240] Exactly, exactly.
[00:23:55.640 --> 00:23:56.760] Which is ridiculous.
[00:23:56.760 --> 00:23:58.200] And also the way that you present.
[00:23:58.200 --> 00:24:12.040] So if you're someone that 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 subdued, stoical, more restrained.
[00:24:12.040 --> 00:24:16.120] Okay, so the diagnosis in and of itself is very subjective.
[00:24:16.600 --> 00:24:18.440] And I think this is a point to really hammer home.
[00:24:18.440 --> 00:24:23.640] We're not doing a blood test for depression and going, oh, yeah, you know, your blood test is in this range.
[00:24:23.640 --> 00:24:24.520] We can say you're depressed.
[00:24:24.520 --> 00:24:25.320] We're not doing that.
[00:24:25.320 --> 00:24:25.720] Okay.
[00:24:25.880 --> 00:24:29.160] We're doing it on a questionnaire, which is open to interpretation.
[00:24:29.160 --> 00:24:37.720] Let's assume the questionnaire accurately diagnoses depression, okay, which, of course, we're questioning in the first place.
[00:24:39.320 --> 00:24:52.800] My understanding from the paper you published in 2022, that sort of game-changing paper, I think, which I think is, if you could tell us about the impact that paper has had, how many times it's been cited and shared, which is really profound.
[00:24:53.120 --> 00:25:07.040] But also my understanding is that actually all the trials have shown on average is that taking an antidepressant improves your score by just a two-point difference?
[00:25:07.040 --> 00:25:08.400] Could you just elaborate on that?
[00:25:08.480 --> 00:25:08.720] Yes.
[00:25:08.720 --> 00:25:23.360] So the difference between taking an antidepressant and taking a placebo in these placebo-control trials is two points on this common depression rating scale, which has a maximum score of 54 points.
[00:25:23.360 --> 00:25:25.680] So it's a very small difference.
[00:25:25.680 --> 00:25:36.880] So as you've concluded and other people have as well, that actually most of the benefit, if any, is from placebo.
[00:25:37.520 --> 00:25:40.960] But also, as you said before, it's not only placebo, is it?
[00:25:40.960 --> 00:25:53.840] Because these drugs, these so-called antidepressants, and I want to question even why we call them antidepressants in the first place, if there's no evidence for it actually helping this imbalance theory, shouldn't we even be calling them antidepressants?
[00:25:54.080 --> 00:25:54.560] Good question.
[00:25:54.800 --> 00:25:57.440] We should probably say we're talking about SSRIs here, right?
[00:25:59.040 --> 00:26:06.800] But these drugs, because they have side effects, you may already know when you're on it.
[00:26:06.800 --> 00:26:10.800] And therefore, it's, is it almost like a heightened placebo effect?
[00:26:10.800 --> 00:26:11.200] Exactly.
[00:26:11.200 --> 00:26:20.400] So people get an amplified placebo effect, the people who are taking the real drug, because they get some signs that indicate they're on the real drug rather than the placebo.
[00:26:20.400 --> 00:26:30.000] And equally, people who are on the placebo may be able to guess that they haven't got the real drug and therefore may get a negative placebo effect.
[00:26:30.520 --> 00:26:50.200] And it's been shown in one study that the effect of guessing, of thinking you were taking the antidepressant, the difference between thinking you were taking the antidepressant and people who thought they were taking the placebo in terms of the depression rating scale was five or six points.
[00:26:52.440 --> 00:27:04.600] So the effect of thinking that you were taking the real drug versus the placebo was much bigger than the effect of actually getting the drug in, if you look across all the different trials.
[00:27:04.600 --> 00:27:21.240] John, it's pretty remarkable to think that if the evidence supports, or if the evidence says that there is a two-point difference on this 54-point scale, and a two-point difference can be accounted for in a multitude of different ways.
[00:27:21.560 --> 00:27:23.640] Again, I come back to my initial question.
[00:27:23.960 --> 00:27:33.560] How did this industry, how did it become so common where one in five of the adult population of the UK are on these drugs?
[00:27:33.560 --> 00:27:37.320] I mean, it seems utterly remarkable, does it not?
[00:27:37.320 --> 00:27:38.680] Absolutely, absolutely.
[00:27:39.000 --> 00:27:40.600] Is this the power of marketing?
[00:27:41.400 --> 00:27:42.680] I think it's partly that.
[00:27:42.680 --> 00:27:45.640] I mean, I think it's a confluence of interests.
[00:27:45.640 --> 00:28:02.600] And the main driver has undoubtedly been the pharmaceutical industry and the big marketing campaigns that they did that persuaded people that taking an antidepressant was correcting a chemical imbalance, that antidepressants weren't addictive and were safe and basically, persuaded people to take them.
[00:28:02.600 --> 00:28:11.880] But the medical profession, particularly psychiatrists, have also had an interest in medicalizing depression for many decades.
[00:28:12.680 --> 00:28:24.480] And then, of course, you know, people in general like the idea of, you know, of there being a simple solution to complicated life problems.
[00:28:24.960 --> 00:28:28.400] I mean, in a way, if there was, of course, we'd all like that.
[00:28:28.640 --> 00:28:34.960] It's just unlikely, in my view, that there is going to be a chemical solution for life problems.
[00:28:34.960 --> 00:28:35.600] Yeah.
[00:28:36.480 --> 00:28:38.880] A few weeks ago, I spoke to Camilla Nord.
[00:28:39.120 --> 00:28:41.600] She's a neuroscientist at Cambridge University.
[00:28:41.600 --> 00:28:45.440] And, you know, she studies the neuroscience of mental health.
[00:28:45.440 --> 00:28:57.120] And one of the things she told me in my conversation with her on the show, she even said in psychedelic trials, there is some evidence of the power of the placebo effect.
[00:28:57.200 --> 00:29:08.960] So if you think you're taking a psychedelic, right, and this is mind-blowing for people, you can still have some of the hallucinations of some of these things that you, you know, even if you're taking the placebo.
[00:29:09.280 --> 00:29:22.960] And I think there's a wider point here, isn't there, that we've really undervalued the importance of placebo and the power of placebo, I would say beyond just depression and mental health, I think across the whole of medicine.
[00:29:22.960 --> 00:29:24.560] Yes, I agree.
[00:29:25.280 --> 00:29:30.560] But I would just caveat that with I think there are some negative effects of giving people a placebo.
[00:29:30.560 --> 00:29:30.880] Oh, yes.
[00:29:31.120 --> 00:29:35.440] So I think it's sort of how we harness those effects, isn't it, that's important.
[00:29:35.440 --> 00:29:45.920] So there's good evidence that giving someone a placebo tablet temporarily elevates them, you know, elevates their mood.
[00:29:47.120 --> 00:30:12.200] But in the long run, I think people's beliefs that they need a tablet in order to get better, to feel better, might actually undermine their improvement in the long run and undermine all the sort of all the strategies that actually might help people to improve their mood and stay well and stay happy.
[00:30:12.360 --> 00:30:20.040] The trials that did show a two-point improvement on placebo, how long were they conducted for?
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[00:33:30.920 --> 00:33:34.360] So, most of them are conducted for eight weeks or less.
[00:33:34.360 --> 00:33:42.440] There are very few studies that have been conducted more than three months, very small handful that have lasted about six to nine months.
[00:33:42.440 --> 00:33:53.560] Which again is truly remarkable because the amount of people who start off on these things, and before you know it, 18 months has passed and they've been giving repeat prescriptions, right?
[00:33:53.560 --> 00:34:06.680] And you know, we'll talk about the system and how doctors currently work and how the reality is, if you've got a busy clinic, the easiest thing in the world to do is to continue a repeat prescription.
[00:34:06.920 --> 00:34:10.040] It is, and that's not having to go at any individual doctor.
[00:34:10.040 --> 00:34:14.200] The system is almost, as you said, there's a confluence of factors, right?
[00:34:14.200 --> 00:34:24.440] The way, you know, having a 10-minute appointment with your GP to try and deal with these complex life problems, it's quite easy to prescribe something because that sort of closes the consultation down.
[00:34:24.440 --> 00:34:28.680] Yeah, and the patient feels as though they got something, the doctor feels like they've done something, right?
[00:34:28.680 --> 00:34:40.920] So, I get all that, but there's a wider point here because I know in the book sometimes you make the case that mental health is fundamentally different from physical health in a variety of ways, okay?
[00:34:41.240 --> 00:34:47.720] But actually, I have a slightly different perspective in the sense that, and we'll maybe talk about that throughout this conversation.
[00:34:48.040 --> 00:34:52.840] But let's take those trials, very few of them have been done over eight weeks.
[00:34:52.840 --> 00:34:58.040] Whereas many people, dare I say, the majority of people on SSRIs are taking them for more than eight weeks.
[00:34:58.040 --> 00:35:01.320] So, there's no trials showing you that you should be doing that.
[00:35:01.320 --> 00:35:04.040] It's the same with PPIs, like proton pump inhibitors.
[00:35:04.040 --> 00:35:08.000] Most of those trials were done for four to six weeks, yeah, yeah.
[00:35:08.000 --> 00:35:08.360] Right?
[00:35:08.360 --> 00:35:19.760] Yeah, you've got patients who are literally on a five-year repeat prescription, and then the similarity is when they try and come off it, they've had their acid production suppressed for five years.
[00:35:20.080 --> 00:35:23.360] Of course, when they try and come off it, they have a rebound side effect.
[00:35:23.360 --> 00:35:27.920] But the belief is, oh, I need to stay on the medication.
[00:35:27.920 --> 00:35:28.400] Yeah, yeah.
[00:35:28.480 --> 00:35:29.280] That's quite similar.
[00:35:29.280 --> 00:35:31.520] That's a physical issue, right?
[00:35:31.520 --> 00:35:35.200] But that's not dissimilar to what happens when people try and stop the antidepressants, is it?
[00:35:35.200 --> 00:35:36.880] Oh, yeah, no, I agree with you.
[00:35:36.880 --> 00:35:45.600] And, you know, I mean, I think all sorts of drugs can lead to physical adaptations and withdrawal effects when you stop them.
[00:35:45.600 --> 00:36:02.880] And stopping antidepressants is, you know, is helping people come off antidepressants, enabling them not to remain on them for long periods of time is difficult for both for, you know, because of those, because of physical dependence, but also for all sorts of psychological reasons.
[00:36:03.200 --> 00:36:09.760] You know, people might get some withdrawal symptoms and then assume that they're relapsing or the doctor thinks they're relapsing.
[00:36:09.760 --> 00:36:12.000] I want to go into withdrawal in a minute.
[00:36:12.560 --> 00:36:15.120] Let's just finish off this placebo piece.
[00:36:15.120 --> 00:36:15.600] Right.
[00:36:15.840 --> 00:36:25.520] 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 clinical psychiatrist.
[00:36:25.520 --> 00:36:28.080] You work in a very prestigious hospital.
[00:36:28.080 --> 00:36:31.200] You've been working for over three decades in psychiatry.
[00:36:31.200 --> 00:36:40.560] You're telling me that there's no evidence or not very convincing evidence that there is a chemical imbalance in depression.
[00:36:40.560 --> 00:36:44.400] Yet they might be thinking, well, yeah, I'm hearing you.
[00:36:44.400 --> 00:36:51.840] But when I started taking Prozac, let's say, or citalopram, I started to feel better.
[00:36:52.160 --> 00:36:52.920] What would you say to that person?
[00:36:53.200 --> 00:36:55.920] Yeah, yeah, that's that's a really important point to make.
[00:36:55.920 --> 00:36:57.760] So, two things.
[00:36:57.760 --> 00:37:06.680] One is that most people with depression will start to feel better naturally at some point, anyway.
[00:37:07.000 --> 00:37:14.360] And often, people come and see the doctor at a low point and therefore will gradually improve after that.
[00:37:14.680 --> 00:37:21.560] And there's also, I think, something about coming to the doctor itself, which sometimes is a sort of wake-up call for people.
[00:37:21.560 --> 00:37:24.760] You know, oh my goodness, it's really got this bad.
[00:37:24.760 --> 00:37:27.960] You know, I've got to do something now.
[00:37:27.960 --> 00:37:34.600] And, you know, and often it will galvanize friends and family to come and be supportive.
[00:37:34.600 --> 00:37:35.000] Of course.
[00:37:35.160 --> 00:37:40.760] Make people, you know, really reflect on, you know, do I really want to carry on in this job that's got me into this state?
[00:37:40.760 --> 00:37:43.320] And people make other changes in their lives.
[00:37:43.320 --> 00:37:48.040] So people often do improve after they start taking an antidepressant.
[00:37:48.440 --> 00:37:54.920] But we know from the clinical trials that people also improve after they've started taking a placebo.
[00:37:55.240 --> 00:38:00.920] So some of the effect is some of the effect is what would naturally occur anyway.
[00:38:00.920 --> 00:38:02.920] It's making changes in your life.
[00:38:02.920 --> 00:38:07.400] And some of it is due to believing that you're taking a tablet that's going to help you.
[00:38:07.640 --> 00:38:08.920] And the sense of hope.
[00:38:08.920 --> 00:38:09.560] Yeah, exactly.
[00:38:09.880 --> 00:38:12.520] Oh, I just, I knew there was something wrong with me.
[00:38:12.520 --> 00:38:18.600] And now the doctor's told me I've got a chemical imbalance and that, you know, I'm going to take this pill and it's going to correct it.
[00:38:18.600 --> 00:38:23.400] So you're going out with that belief that, oh man, my life's going to change now.
[00:38:23.400 --> 00:38:23.960] Absolutely.
[00:38:23.960 --> 00:38:25.560] Hope is the, I think, is the key thing.
[00:38:25.560 --> 00:38:27.560] That's that's what you're giving people.
[00:38:27.560 --> 00:38:30.840] Yeah, but you can also give hope as a doctor without giving a pill.
[00:38:30.840 --> 00:38:31.720] No, I agree.
[00:38:31.720 --> 00:38:35.880] And for a variety of different conditions, and it goes back to that sense of agency, autonomy.
[00:38:35.880 --> 00:38:37.640] What can we give that person?
[00:38:37.960 --> 00:38:44.760] How can we give them hope without necessarily giving them a pill that may have all these potential side effects?
[00:38:45.120 --> 00:38:48.960] I think giving people a pill in this situation is giving them false hope.
[00:38:48.960 --> 00:38:49.280] Yeah.
[00:38:49.680 --> 00:38:50.720] There's a real cost to it.
[00:38:51.040 --> 00:38:51.920] Yes, absolutely.
[00:38:51.920 --> 00:38:59.520] 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.
[00:38:59.840 --> 00:39:01.360] I didn't feel great again.
[00:39:01.360 --> 00:39:06.080] You know, the sort of initial stimulus I got, you know, wore off.
[00:39:06.080 --> 00:39:13.040] And then I felt really awful, even worse than before, because I thought, oh my goodness, this thing that was supposed to make me better isn't working.
[00:39:13.040 --> 00:39:13.600] Yeah.
[00:39:13.920 --> 00:39:18.720] It's really profound.
[00:39:18.720 --> 00:39:28.800] 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, because there will be people pushing back.
[00:39:28.800 --> 00:39:29.280] Yeah.
[00:39:29.840 --> 00:39:30.640] What are you talking about?
[00:39:30.640 --> 00:39:32.560] You know, of course, there's a chemical imbalance.
[00:39:32.560 --> 00:39:34.320] I've been hearing about this for two decades.
[00:39:34.320 --> 00:39:41.360] You know, I learned it at medical school, but this whole thing that, you know, someone might be thinking, well, I got better when I started taking it.
[00:39:41.360 --> 00:39:43.360] Look at it through another lens, right?
[00:39:44.000 --> 00:39:51.120] Again, I think this pattern is common and prevalent in medicine, both with doctors and with patients' beliefs.
[00:39:51.120 --> 00:39:56.320] So, for example, let's say you've had a really bad cold for weeks, right?
[00:39:56.320 --> 00:39:57.280] And this is very common.
[00:39:57.280 --> 00:40:01.920] All general practitioners will have been in this position before where you know something is viral.
[00:40:01.920 --> 00:40:03.680] You know that the patient is coming in.
[00:40:03.680 --> 00:40:11.200] There's no symptoms to just a bacterial infection, which, again, for anyone who doesn't know, antibiotics treat bacterial infections.
[00:40:11.200 --> 00:40:13.760] They don't treat viral infections.
[00:40:13.760 --> 00:40:18.880] But, you know, if someone's coming and they're getting annoyed, saying, Look, I've been off work for three weeks.
[00:40:18.880 --> 00:40:20.640] And you're like, yeah, there's no fever here.
[00:40:20.640 --> 00:40:22.000] There's no product disputum.
[00:40:22.000 --> 00:40:23.200] This is just one of those things.
[00:40:23.200 --> 00:40:27.920] You prescribe an antibiotic because it's easier to do so.
[00:40:27.920 --> 00:40:32.920] They may well get better that week, but they probably would have got better anyway.
[00:40:33.240 --> 00:40:34.760] They'd already had it for four weeks, right?
[00:40:29.840 --> 00:40:37.320] And the natural course of the infection is, oh, I'm going to get better.
[00:40:37.640 --> 00:40:48.520] Now, I can't say that in every case, but then and the real problem with that is then the patient goes out with the belief, oh, the antibiotic is what made me better.
[00:40:48.520 --> 00:40:49.240] What does that mean?
[00:40:49.240 --> 00:40:56.600] It means in 12 months' time, when you get another infection, you've got this ingrained belief that you need that pill.
[00:40:56.600 --> 00:40:58.680] We can draw that same analogy in depression.
[00:40:58.680 --> 00:40:59.960] Yeah, that's a really good analogy.
[00:41:00.280 --> 00:41:00.520] Are we?
[00:41:01.240 --> 00:41:01.480] Absolutely.
[00:41:02.280 --> 00:41:05.800] If it comes back to you in three years' time, oh, I know what it is.
[00:41:05.800 --> 00:41:08.520] It's that old chemical that I need to make sure I get an antidepressant again.
[00:41:08.680 --> 00:41:10.280] Yes, absolutely, absolutely.
[00:41:10.280 --> 00:41:22.520] And people haven't learned a very important lesson that depression will get better on its own and that there are things that you can do about it to help yourself because they've invested their beliefs in the pill.
[00:41:22.520 --> 00:41:24.760] Even that term depression, okay.
[00:41:25.080 --> 00:41:30.040] I always struggled even with the concepts of clinical depression as a thing.
[00:41:30.040 --> 00:41:32.040] I'm like, what does that mean?
[00:41:33.080 --> 00:41:39.000] What does it mean where these emotions now are, oh, it's now clinical depression, whereas that isn't?
[00:41:39.320 --> 00:41:43.320] So, help me understand your perspective on that, because I think that's another thing that people think about.
[00:41:43.320 --> 00:41:45.160] Oh, you've got some symptoms of low mood.
[00:41:45.160 --> 00:41:47.000] Yeah, but is it clinical depression or not?
[00:41:47.000 --> 00:41:48.280] Well, what is clinical depression?
[00:41:48.280 --> 00:41:49.720] Yeah, yeah, it's a good question.
[00:41:49.720 --> 00:42:04.920] And it also, I think, um, touches on what you were saying earlier about the you know, the difficulty of sitting there with someone in your consulting room and wanting to feel that you're able to give them something.
[00:42:04.920 --> 00:42:14.600] Um, so we've, you know, we've set up this expectation in society that there is this thing called depression and it's a medical condition, and you should go and see your doctor about it.
[00:42:15.760 --> 00:42:20.560] And this is actually not how people used to think about depression.
[00:42:20.880 --> 00:42:29.760] But now we've got so used to thinking about depression as clinical depression, as a clinical condition, that it's even got difficult to use that word, I think.
[00:42:29.760 --> 00:42:39.520] But, you know, I would say that depression is a natural human emotion, and emotions are reactions to the events in our lives.
[00:42:39.520 --> 00:42:47.600] They're coloured by everything that's happened to us, by our personal history, and probably a bit by our genes and our biology, too.
[00:42:47.920 --> 00:42:59.520] And those things will mean that some people are more vulnerable to, you know, reacting extremely to things than others, might get more anxious or more depressed when things go wrong than other people.
[00:42:59.520 --> 00:43:01.760] Of course, there's individual variation.
[00:43:01.760 --> 00:43:06.400] But nevertheless, emotion is a meaningful response.
[00:43:06.400 --> 00:43:13.520] It's a reflection of our values, and it's a way of expressing, you know, we don't like this situation.
[00:43:13.520 --> 00:43:16.800] There's something about this that, you know, is getting me down.
[00:43:17.120 --> 00:43:21.200] Should it even be a clinical or medical diagnosis?
[00:43:21.520 --> 00:43:33.600] So that's what I was driving at: by suggesting that when we've got to the stage with someone sitting in front of a doctor, expecting a diagnosis and expecting a treatment, there's a problem.
[00:43:33.600 --> 00:43:37.840] And I think we need to roll back from that situation.
[00:43:37.840 --> 00:43:41.520] I think we need to demedicalize depression radically.
[00:43:42.480 --> 00:43:53.360] And instead of treating depression, we need to help people who are depressed in whatever ways they need help with.
[00:43:53.360 --> 00:43:59.600] And that will be a great variety of ways because people are depressed for a myriad of different reasons.
[00:43:59.800 --> 00:44:10.040] Which leads to the natural question for me at least: is going to see your doctor the best place to go when you have symptoms consistent with depression?
[00:44:10.040 --> 00:44:22.680] I've often thought if you do have symptoms consistent with low mood and your particular medical doctor or your GP is very much in that what's the diagnosis, how do I treat model?
[00:44:23.320 --> 00:44:33.640] It may be that, I don't know, a life coach or a psychologist or someone else might be better for you than a medical professional for that particular condition.
[00:44:33.640 --> 00:44:38.760] Not in every case, but I think in some cases we have to acknowledge that that may well be a possibility.
[00:44:38.760 --> 00:44:39.480] Absolutely.
[00:44:39.480 --> 00:44:56.600] So when we first published the serotonin paper, one of the criticisms of us was that we would stop, you know, if we were publicizing this and raising questions in people's minds about the necessity or benefits of antidepressants, that would stop people seeking medical help.
[00:44:56.600 --> 00:45:09.080] Now, one of the important responses to that is that this whole idea of people seeking medical help for depression, there's very little evidence that this is doing people any good in the long term.
[00:45:09.080 --> 00:45:19.080] Actually, if you look at the long-term outcomes of people with depression who've had medical treatment and people who haven't had medical treatment, the people who haven't had medical treatment are doing much better.
[00:45:19.080 --> 00:45:25.800] Now, that's probably partly because they may well have less severe problems than the people who get medical treatment.
[00:45:25.800 --> 00:45:34.360] But even the studies that control for the severity to some extent are still showing that the people who don't have treatment are doing better.
[00:45:34.360 --> 00:45:41.000] And certainly, there's no good evidence that in the long run, the people who have medical treatment do better.
[00:45:41.000 --> 00:46:05.040] And if we just look at some of the sort of objective indicators of how well this strategy is working, the mass treatment of depression with antidepressants, such as the numbers of people on disability benefits with depression and anxiety, these have been going up and up dramatically since the 1990s, at the same time that the use of antidepressants has been going up.
[00:46:05.600 --> 00:46:13.440] So the widespread treatment, medical treatment of depression, is not helping people to get back to work.
[00:46:13.440 --> 00:46:15.600] Yeah, it's got unintended consequences.
[00:46:15.600 --> 00:46:18.000] You know, it's disempowering for many people.
[00:46:18.000 --> 00:46:19.280] Oh, I've got this thing.
[00:46:19.280 --> 00:46:21.600] There's nothing I can do about it.
[00:46:21.920 --> 00:46:27.520] That criticism that, well, some people may not seek medical advice then for there.
[00:46:27.520 --> 00:46:29.840] I have a real issue with that as a critique, right?
[00:46:29.840 --> 00:46:40.720] Because that's predicated on the belief that, you know, that humans are incapable and we're really fragile.
[00:46:40.720 --> 00:46:45.440] And when we have difficult scenarios in our life, oh, we must go and see a doctor.
[00:46:45.440 --> 00:46:47.360] And I don't believe that, right?
[00:46:47.360 --> 00:46:49.920] Yes, we're living more isolated lives now.
[00:46:49.920 --> 00:46:54.560] There's been a fragmentation of communities and people often don't have the support that they need.
[00:46:54.560 --> 00:46:56.160] I accept all of that.
[00:46:56.160 --> 00:47:05.840] We're living in a capitalist culture where lots of people have been driven to work long hours and jobs that they can't stand and they don't have access to, you know, cheap, good quality food.
[00:47:05.840 --> 00:47:07.040] They're sleep deprived.
[00:47:07.040 --> 00:47:08.880] I get all of those things.
[00:47:08.880 --> 00:47:13.040] It doesn't mean, though, that medicine is the solution to this.
[00:47:13.360 --> 00:47:19.920] 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.
[00:47:19.920 --> 00:47:21.840] And it wasn't always this way.
[00:47:21.840 --> 00:47:27.680] There's many cultures around the world who still don't believe that depression is a medical thing, right?
[00:47:27.680 --> 00:47:28.640] There's some cultures around the world.
[00:47:28.640 --> 00:47:31.960] I think the Hadza tribe don't even have a word for depression, right?
[00:47:31.960 --> 00:47:39.720] They naturally see these things as, oh, this is a signal that there is something that we need to address.
[00:47:39.720 --> 00:47:51.560] And 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, we need to give you a treatment.
[00:47:51.560 --> 00:47:53.640] It's like the question is, why?
[00:47:53.640 --> 00:47:57.000] What's going on in this person's life that means that they're feeling like that?
[00:47:57.480 --> 00:48:05.240] But these viewpoints are quite antithetical to the way modern Western medicine looks at condition like depression.
[00:48:05.240 --> 00:48:05.880] Yeah, yeah.
[00:48:05.880 --> 00:48:12.600] It just reminds me of a really interesting anthropological study of the introduction of depression into Japan.
[00:48:12.600 --> 00:48:20.680] So in the 1990s, up until the 1990s, depression wasn't something that was commonly diagnosed in Japan.
[00:48:20.680 --> 00:48:30.040] And like you're saying about Indian culture, it wasn't really, it certainly wasn't a sort of recognized medical condition.
[00:48:30.680 --> 00:48:34.680] And therefore, there weren't many antidepressants being prescribed in Japan.
[00:48:34.680 --> 00:48:39.880] And the pharmaceutical industry recognized this was potentially an untapped market.
[00:48:41.400 --> 00:48:42.440] Yes, yes.
[00:48:43.080 --> 00:48:49.640] So they set out to introduce depression into Japan and to increase the sales of antidepressants.
[00:48:49.640 --> 00:49:07.480] And we know about this because they employed a well-known anthropologist, Lawrence Kirkmayer, who's written up his experience of being involved in this strategy of the pharmaceutical industry to persuade the Japanese that they were depressed.
[00:49:07.800 --> 00:49:16.400] So they employed him as an anthropologist to tell them about the culture of Japan and why it was that people didn't consider themselves to be depressed.
[00:49:16.400 --> 00:49:26.160] And that was partly because depression was understood as a meaningful reaction to things, not seen as a clinical disease.
[00:49:26.160 --> 00:49:46.640] And so they came up, just as the pharmaceutical industry did in this country, actually, they came up with ways of overriding the cultural norms and people's sort of intuitions about what depression was in order to persuade them that it was a medical condition and it was very successful.
[00:49:46.640 --> 00:49:51.200] And the rate of prescribing of antidepressants, you know, escalated as a consequence.
[00:49:51.200 --> 00:49:52.800] So that's actually a case study.
[00:49:52.800 --> 00:49:54.160] And it goes very interesting.
[00:49:54.800 --> 00:50:05.120] We smile and we laugh, but actually, underlying that laughter is a real disturbing truth here.
[00:50:05.120 --> 00:50:17.760] 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?
[00:50:17.920 --> 00:50:18.800] So let's go into that.
[00:50:19.040 --> 00:50:19.600] So we're doing that.
[00:50:19.600 --> 00:50:22.960] And we are also changing people's sense of self, aren't we?
[00:50:22.960 --> 00:50:44.720] We're changing people's idea 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 at times, are a disease that can be eradicated somehow, not something that they would previously have understood as a part of themselves that they need to manage and integrate.
[00:50:44.800 --> 00:50:46.840] And address, this is this is okay.
[00:50:46.840 --> 00:50:53.120] Maybe this might come across as a glib example, but I'm going to share it anyway because I think it's relevant to what you just said.
[00:50:53.120 --> 00:50:53.680] Okay.
[00:50:54.240 --> 00:51:01.160] So I'm normally a pretty upbeat, calm, optimistic human, I would say.
[00:51:01.160 --> 00:51:03.960] I've just come to the end of an extremely busy period.
[00:50:59.840 --> 00:51:07.320] Okay, so my new book came out earlier in the year.
[00:51:07.640 --> 00:51:13.880] 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.
[00:51:13.880 --> 00:51:17.960] And I went straight from that into my first national theater tour.
[00:51:17.960 --> 00:51:22.280] So I created a two and a half hour show on what it means to thrive.
[00:51:22.280 --> 00:51:31.240] 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.
[00:51:31.240 --> 00:51:34.600] Okay, so I've not had a weekend off for six weeks.
[00:51:34.600 --> 00:51:36.600] And I'm not, I'm not bragging about this, to be clear.
[00:51:36.600 --> 00:51:38.600] I'm not saying this is a good thing, right?
[00:51:39.720 --> 00:51:44.040] And I tried to balance that by what I was doing in the week, right?
[00:51:44.040 --> 00:51:46.120] But it didn't work so well.
[00:51:46.120 --> 00:51:51.320] Okay, so I was getting progressively more and more tired because I normally go to bed at nine and I wake up at five.
[00:51:51.320 --> 00:51:52.360] That's my rhythm.
[00:51:52.360 --> 00:51:57.560] But normally after a show, I wasn't really getting to bed till about one or 1.30 by the time I'd switched off.
[00:51:57.560 --> 00:52:00.520] But I was still waking up at five or six, right?
[00:52:01.800 --> 00:52:03.080] So I've just come to the end of that.
[00:52:03.080 --> 00:52:04.600] And it was a phenomenal experience.
[00:52:04.600 --> 00:52:05.960] I don't regret any of it.
[00:52:05.960 --> 00:52:10.840] But early on this week, I had a few days where I felt really low.
[00:52:10.840 --> 00:52:12.280] This is very unusual for me.
[00:52:12.280 --> 00:52:14.200] My outlook on life was quite negative.
[00:52:14.200 --> 00:52:16.200] I was being quite reactive.
[00:52:16.200 --> 00:52:18.840] Things that I'm not usually anymore.
[00:52:19.160 --> 00:52:19.800] Okay.
[00:52:19.800 --> 00:52:26.040] Now, again, I'm not saying that I necessarily met the criteria for a diagnosis.
[00:52:26.200 --> 00:52:27.640] I probably didn't.
[00:52:28.280 --> 00:52:35.000] But the principle that I'm trying to sort of get across is I didn't see this as a deficiency in me.
[00:52:35.000 --> 00:52:36.840] I thought, oh, this is interesting, Rongan.
[00:52:37.320 --> 00:52:41.880] This is a signal that you are overly tired.
[00:52:41.880 --> 00:52:42.840] You're overly stressed.
[00:52:42.840 --> 00:52:44.040] You need some relaxation.
[00:52:44.040 --> 00:52:45.920] You need some resetting, right?
[00:52:45.920 --> 00:52:49.360] So instead of going, oh my God, why am I feeling so low?
[00:52:49.360 --> 00:52:54.640] I saw these things as signals that, hey, Rongan, you need to make some changes at the moment.
[00:52:54.640 --> 00:52:56.240] You need to be really careful.
[00:52:56.240 --> 00:52:59.840] Make sure you've got some time off, all this kind of stuff.
[00:53:00.320 --> 00:53:04.880] And I, you know, within a couple of days, I'm back to my usual self, right?
[00:53:04.880 --> 00:53:08.880] It's not quite the same thing, but there's a kind of principle there, isn't there?
[00:53:08.880 --> 00:53:09.440] Definitely.
[00:53:10.240 --> 00:53:17.040] I think seeing emotions as signals is a really good way of putting it because that's what they are.
[00:53:17.040 --> 00:53:23.280] Your body and your mind is reacting to what's going on around you and saying, we don't like this.
[00:53:23.280 --> 00:53:23.680] Yeah.
[00:53:24.320 --> 00:53:37.440] 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.
[00:53:37.440 --> 00:53:44.880] 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.
[00:53:44.880 --> 00:53:48.560] You often have to take other medications to counter the side effects.
[00:53:48.560 --> 00:53:50.960] You can sometimes feel worse in the long run.
[00:53:50.960 --> 00:53:53.200] Your personality can change.
[00:53:53.520 --> 00:53:56.640] These are pretty significant and severe.
[00:53:56.640 --> 00:53:58.240] So, can we go through them one by one?
[00:53:58.240 --> 00:54:01.520] You know, you mentioned emotional numbness before.
[00:54:01.520 --> 00:54:02.000] Yeah.
[00:54:02.640 --> 00:54:03.680] Can you just expand on that?
[00:54:03.680 --> 00:54:04.160] What is that?
[00:54:04.160 --> 00:54:05.760] And why is that a problem?
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[00:58:40.760 --> 00:58:47.400] Yes, so this seems to be a pretty consistently reported effect of most antidepressants.
[00:58:47.400 --> 00:58:56.040] Um, that uh, it's like the intensity of your emotions is sort of dialed down or they're sort of suppressed or restricted in some way.
[00:58:56.200 --> 00:59:00.360] People will often say they can't cry when they're taking antidepressants.
[00:59:00.360 --> 00:59:08.680] Um, and most people find that pretty unpleasant, especially after the sort of first initial crisis has passed.
[00:59:08.680 --> 00:59:16.440] 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.
[00:59:16.440 --> 00:59:31.640] And that is connected with probably the evidence seems to suggest with the ability of most antidepressants to interfere with our sexual function to cause sexual dysfunction in various ways.
[00:59:31.640 --> 00:59:39.960] Um, and both of these things can, uh, it's been shown recently, can persist after people stop taking the drug.
[00:59:39.960 --> 00:59:45.000] So, that's really worrying and something that I really wanted to highlight in the book.
[00:59:45.760 --> 00:59:57.360] Because if that happens to you, if you've taken antidepressants 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, that's a catastrophe.
[00:59:57.360 --> 00:59:59.600] Okay, let's just sort of dive in there.
[00:59:59.600 --> 01:00:01.280] So, I think that's a really important point.
[01:00:01.280 --> 01:00:13.760] Okay, so if you're struggling with your mood, whether we want to label it depression or not, on some level, you're not able to experience pleasure or joy, right?
[01:00:14.080 --> 01:00:16.560] And you mentioned sexual dysfunction there.
[01:00:16.560 --> 01:00:26.160] As a psychiatrist, Joanna, how important is it for an individual to not have sexual dysfunction?
[01:00:26.160 --> 01:00:37.680] 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 well-being?
[01:00:37.680 --> 01:00:39.760] Yeah, well, I think it's hugely important.
[01:00:39.760 --> 01:00:45.680] It's a part of being human, being alive, being a living organism, isn't it?
[01:00:45.680 --> 01:00:58.960] And certainly, people who lose it or have it damaged feel very upset about that and feel that they're not, you know, living being their full selves anymore.
[01:00:58.960 --> 01:01:09.440] 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.
[01:01:09.760 --> 01:01:16.160] You're saying that actually, for some people, the sexual dysfunction continues after they've stopped the antidepressants.
[01:01:16.160 --> 01:01:29.360] 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 percent or more, sexual dysfunction while they're taking them.
[01:01:29.880 --> 01:01:37.960] Um, but what hasn't been recognized but has been emerging recently is that for some people this problem persists.
[01:01:37.960 --> 01:01:45.240] And another point that I think is important to make here is that, of course, when people are depressed, their libido you know can go down.
[01:01:45.720 --> 01:01:49.960] They as part of constellation exactly.
[01:01:49.960 --> 01:02:03.400] 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.
[01:02:03.400 --> 01:02:07.640] So it's not just the depression, the drugs have an additional um effect.
[01:02:07.640 --> 01:02:20.840] And one of the particular things they do, which is not characteristic of sexual dysfunction in depression, is they cause um anesthesia of the genitals, so they sort of dial down the sensitivity of the genitals.
[01:02:20.840 --> 01:02:25.960] Um, and that that seems to be this sort of parallel effect to numbing emotions.
[01:02:25.960 --> 01:02:40.040] There's this sort of dialing down of sensitivity, um, and that uh and and and that and other effects like reduced libido are what can persist when people stop taking the antidepressants.
[01:02:40.040 --> 01:03:01.480] This is and sorry, and just one more point that's very important: is um persistent sexual dysfunction has it's been reported by a lot of patients now, and there are several online um patient groups uh who have described it and are campaigning for more research on it and for you know people to research possible treatments.
[01:03:01.480 --> 01:03:12.720] Um, but there's also animal research that's shown that if you give animals um SSRIs, uh, that they will show reduced sexual activity after coming off them.
[01:03:13.680 --> 01:03:17.520] If you just take a step back from what you're saying, Joanna, right?
[01:03:18.480 --> 01:03:20.320] It's how things work in medicine often, right?
[01:03:14.920 --> 01:03:22.160] We're now looking at, well, let's get some more research into that.
[01:03:22.320 --> 01:03:23.920] Of course, we need that.
[01:03:23.920 --> 01:03:29.280] But if you step outside this for a minute and go, well, wait a minute.
[01:03:29.600 --> 01:03:31.280] We're trying to research stuff.
[01:03:31.280 --> 01:03:40.000] We're trying to research side effects to something which may have hardly any evidence to support it in the first place.
[01:03:40.000 --> 01:03:40.320] Right?
[01:03:41.520 --> 01:03:42.080] Yep.
[01:03:42.480 --> 01:03:50.160] I know it sounds obvious, but we're saying that maybe one in five of the adult population are taking drugs like this.
[01:03:50.160 --> 01:03:59.600] There's a reasonably high percentage of people having sexual dysfunction that happens while they're taking it and when they stop it.
[01:03:59.600 --> 01:04:02.880] And so we're downstream trying to go, well, let's have some more research here.
[01:04:02.880 --> 01:04:11.120] But we could just go upstream and go, we kind of need to make the case why we should even be starting anyone on this in the first place.
[01:04:11.120 --> 01:04:14.400] But we don't do that because there's a belief.
[01:04:14.400 --> 01:04:18.480] It's almost a truth now that actually there's a chemical imbalance.
[01:04:18.480 --> 01:04:19.920] That's why your book's so important.
[01:04:19.920 --> 01:04:22.080] That's why your 2022 paper is so important.
[01:04:22.080 --> 01:04:30.560] Because once you start to challenge the existing belief at the root cause of these, we may not need to study these downstream things.
[01:04:30.560 --> 01:04:37.120] We may just go upstream and go, well, let's be a lot more cautious before we start it in the first place.
[01:04:37.120 --> 01:04:37.840] Absolutely.
[01:04:38.080 --> 01:04:39.280] I mean, absolutely.
[01:04:39.280 --> 01:04:46.480] The emergence of this fact that they can cause persistent sexual dysfunction, I think, is, you know, it is so serious.
[01:04:46.480 --> 01:04:50.400] We don't know exactly how many people that will affect.
[01:04:50.360 --> 01:04:56.080] Um, but you know, there are certainly tens of thousands of people online reporting it.
[01:04:56.080 --> 01:04:59.520] Let's say they recover from their initial bout of depression.
[01:04:59.520 --> 01:05:03.320] If you do want to label it and call it a medical condition, right?
[01:05:05.560 --> 01:05:22.200] If our sexuality and our libido and our ability to, let's say, enjoy sex is a part of who we are as humans, as animals, what is the long-term effect of having sexual dysfunction, right?
[01:05:22.200 --> 01:05:24.200] It's not exactly going to help your moods.
[01:05:24.200 --> 01:05:25.560] No, exactly, exactly.
[01:05:25.640 --> 01:05:30.600] I mean, it's going to obviously interfere in our ability to have relationships.
[01:05:30.600 --> 01:05:40.200] Yeah, and relationships are part of what keeps us, you know, stable and happy and part of what is so rewarding about being a human being.
[01:05:40.200 --> 01:05:49.000] Could you just name-check some commonly prescribed SSRIs so people can maybe attach that term with things that they may be taking?
[01:05:49.000 --> 01:05:55.640] Yes, so the first SSRI that was commonly used was Prozac.
[01:05:55.640 --> 01:05:56.680] That's still prescribed.
[01:05:56.680 --> 01:05:59.240] Its other name is fluoxetine.
[01:05:59.800 --> 01:06:06.680] Sertraline is the most commonly prescribed SSRI and antidepressant at the moment.
[01:06:06.680 --> 01:06:08.200] Then the citalopram, of course.
[01:06:08.200 --> 01:06:12.520] And then cetaloprams, citalopram is quite widely prescribed.
[01:06:12.520 --> 01:06:15.640] And es-citalopram has also been prescribed.
[01:06:15.640 --> 01:06:21.720] Venlifaxine is something that's used quite widely within psychiatry, I think, a bit less so in general practice.
[01:06:22.280 --> 01:06:28.360] What's the implications of pharmaceutical advertising?
[01:06:28.360 --> 01:06:39.080] And I guess the reason that popped into my mind is, again, your work is making me think back to various points in my career that I'd kind of semi-forgotten about.
[01:06:39.080 --> 01:06:54.320] But I seem to recall a drug company lunch, maybe at one of the general practice surgeries I worked on, and they were telling me about acetalopram and the benefits for people who aren't getting better on citalopram.
[01:06:54.320 --> 01:07:03.040] And I can't quite remember it all, but I vaguely remember picking up my sandwich and actually at lunchtime just hearing them talk about this.
[01:07:03.040 --> 01:07:05.840] What is, you know, maybe that's a broader question.
[01:07:06.000 --> 01:07:12.640] What is the implication of pharmaceutical companies coming in and teaching doctors about the benefits of their new drugs?
[01:07:12.640 --> 01:07:14.320] What are the implications of that?
[01:07:14.960 --> 01:07:27.840] So I think it's worth saying that the pharmaceutical industry were incredibly active from the 1990s onwards, well, and before, but particularly over antidepressants from the 1990s.
[01:07:28.080 --> 01:07:32.480] And that means that they were, you know, they were advertising everywhere.
[01:07:32.480 --> 01:07:39.600] They were supplying doctors with mugs and pens with, you know, with their drug embossed on.
[01:07:39.760 --> 01:07:41.520] They were taking doctors out for meals.
[01:07:41.520 --> 01:07:43.200] They were providing lunches.
[01:07:43.200 --> 01:07:46.480] They were subsidizing lavish conferences.
[01:07:47.040 --> 01:07:54.640] And we know, even though individual doctors may feel that they're not influenced by this, we know that they are.
[01:07:54.640 --> 01:08:05.200] You know, there's been research that shows that actually if you've had contact with representatives from drug companies, you'll be more likely to prescribe their product.
[01:08:05.680 --> 01:08:14.800] So what it means is that this message that the pharmaceutical industry had, you know, picked up and wanted to disseminate became embedded within medicine.
[01:08:14.800 --> 01:08:32.120] And although most leading researchers knew way before we published our paper in 2022 that there wasn't good evidence for the serotonin hypothesis of depression, I think there were many, many doctors who still believe that there was.
[01:08:29.760 --> 01:08:35.720] And certainly there were doctors who were still telling patients that there were.
[01:08:36.680 --> 01:08:46.120] There was, you know, there were doctors on national radio telling people that depression was a chemical imbalance only a few months before our paper was published.
[01:08:46.120 --> 01:08:49.400] So, and that is a consequence of this marketing.
[01:08:49.400 --> 01:09:10.760] And another thing I wanted to just say that something you said about how you felt about depression reminded me that in the early days of these marketing campaigns, some of the medical royal colleges and medical institutions helped out the pharmaceutical industry and ran depression awareness campaigns.
[01:09:10.760 --> 01:09:23.240] And one of them was the Royal College of Psychiatrists Defeat Depression campaign that ran in the early 1990s and was partly funded by Eli Lilly, the makers of Prozac or fluoxetine.
[01:09:23.560 --> 01:09:41.640] And in the initial stages of that campaign, they did some market research and they found that most people at that time thought that depression was a reaction to getting divorced or being unemployed or being lonely or having been abused as a child.
[01:09:41.640 --> 01:09:42.600] What year was this?
[01:09:42.600 --> 01:09:44.280] This is about 1992.
[01:09:44.600 --> 01:09:46.760] So even in the early 90s, we thought...
[01:09:46.840 --> 01:09:47.240] Yeah.
[01:09:47.240 --> 01:09:47.720] Okay.
[01:09:48.040 --> 01:09:57.080] And then when they asked people what they thought about antidepressants or taking drugs for taking medication for depression, they said, we don't think that's a good idea.
[01:09:57.080 --> 01:10:03.320] We think that that's just going to numb the feelings and people might get addicted or dependent.
[01:10:03.320 --> 01:10:08.360] And the majority of the population, that was their underlying ideas about depression.
[01:10:08.360 --> 01:10:20.720] And the pharmaceutical industry set out to change those, to change people's minds, to stop people seeing depression in that intuitive way and replace it with this idea that it's a medical condition and that you need a depression.
[01:10:21.040 --> 01:10:23.280] You know, it's remarkable when I hear that.
[01:10:23.920 --> 01:10:42.720] It was only 33, 34, 35 years ago where we thought that depression or these symptoms of low mood and lack of pleasure and not experiencing joy were a meaningful response to life circumstance.
[01:10:44.160 --> 01:10:51.680] And it just shows you how easy it is to manipulate us and change our view with clever marketing.
[01:10:52.000 --> 01:10:52.480] Absolutely.
[01:10:52.480 --> 01:10:54.480] I mean, that is what marketing is, isn't it?
[01:10:54.480 --> 01:10:55.040] Exactly.
[01:10:55.040 --> 01:10:58.320] And all of us know, you know, we're all human, we're all susceptible.
[01:10:58.320 --> 01:11:01.520] I think, well, Johan Hari's coming to mind for a couple of reasons.
[01:11:01.520 --> 01:11:18.080] When he first came on my show about his book, Lost Connections, which again is quite relevant in the context of what you're talking about, I think he shared some research, or maybe this was for his book on the problems with, you know, the digital age and the constantly consuming contents.
[01:11:18.080 --> 01:11:25.440] I think he shared some research saying that even watching one advert, for a child to watch one advert, it pops up on YouTube.
[01:11:25.440 --> 01:11:29.200] It fundamentally changes your desires and what you want in life.
[01:11:29.200 --> 01:11:29.600] Right.
[01:11:29.600 --> 01:11:32.560] So none of us are immune to marketing.
[01:11:32.560 --> 01:11:37.440] But also another thing in Johan's book, Lost Connections, he shared this story with me.
[01:11:37.520 --> 01:11:42.320] I think it was a Cambodian rice farmer who'd had an injury.
[01:11:42.320 --> 01:11:44.560] He had a prosthetic limb.
[01:11:44.560 --> 01:11:47.200] And, you know, he was struggling with his moods.
[01:11:47.200 --> 01:11:51.040] And the solution where he lived was to give him a cow, right?
[01:11:51.200 --> 01:11:55.120] So, the sense of meaning, the sense that I can now do what I'm meant to do.
[01:11:55.120 --> 01:11:56.640] I have something to help me do that.
[01:11:56.640 --> 01:12:00.520] It wasn't, let me go on a pill, right?
[01:12:00.840 --> 01:12:05.560] And it's interesting, isn't it, when we think about this, how quickly it's changed.
[01:11:59.440 --> 01:12:06.120] Yes, yes.
[01:12:06.360 --> 01:12:14.360] So, that reminds me: I had some medical students from the Caribbean when I was first a consultant who came over and did an attachment with me.
[01:12:15.000 --> 01:12:19.240] I was actually working in a ward with people with quite severe mental illness.
[01:12:19.240 --> 01:12:26.440] And she said, and I thought it was such a good idea, you know, what would be really helpful here is if they had some pets.
[01:12:26.760 --> 01:12:31.720] And then, lo and behold, a stray dog appeared, and the ward adopted this dog.
[01:12:31.720 --> 01:12:39.960] And the patients loved it and were, you know, and it gave them a sense of purpose and a sense of being able to nurture something themselves.
[01:12:39.960 --> 01:12:44.920] And these were, you know, these were people who were who had sort of quite severe chronic mental health problems.
[01:12:45.480 --> 01:12:58.200] This sense of who we are, what's our meaning, what are we here for, is such an important aspect of who we are.
[01:12:58.200 --> 01:12:59.560] Are you valued somewhere?
[01:12:59.560 --> 01:13:01.080] Does that pet need you?
[01:13:01.080 --> 01:13:02.760] Are you needed?
[01:13:02.760 --> 01:13:03.320] Right?
[01:13:03.320 --> 01:13:15.480] And I also wonder-I mean, you said this from the 1990s, how much has the increase in depression and antidepressant prescription mirrored the loss of religion in society?
[01:13:15.480 --> 01:13:22.600] Like, I don't know if there's any studies on that, but it wouldn't surprise me for all the positives or perceived negatives that people may have on religion.
[01:13:22.600 --> 01:13:33.720] One thing I think it's fair to say is that these religious institutions, no matter what religion you belong to or you identify with, they helped foster a sense of community.
[01:13:33.720 --> 01:13:42.040] And these are the principles of what it means to live: be kind, don't do harm to others, you know, give to people, have charitable pursuits.
[01:13:42.040 --> 01:13:42.680] Do you know what I mean?
[01:13:42.680 --> 01:13:43.320] How do you know?
[01:13:43.320 --> 01:13:51.600] Is there any research to there's no sort of empirical research that I know of, but I think you're absolutely right.
[01:13:51.600 --> 01:13:55.840] I mean, religion and it gives people a sense of purpose and meaning, doesn't it?
[01:13:55.840 --> 01:13:58.880] I think that's you know really important for people too.
[01:13:59.360 --> 01:14:06.400] Or you feel sad or you feel low, you will go and talk about it with your congregation, your community.
[01:14:06.400 --> 01:14:10.240] There'll be, I don't know, there was a mechanism in society to do that.
[01:14:10.240 --> 01:14:14.560] Yes, and also, I think religions help people with acceptance.
[01:14:14.720 --> 01:14:30.960] They help people to accept that suffering is part of life and to and to get through that and to see it as something that we can all come together and sort of support people through rather than something that has to be completely eradicated and something that we can learn from.
[01:14:30.960 --> 01:14:48.400] And of course, the religious message might be, you know, it helps you get closer to God, which you might not subscribe to if you're not religious, but makes a more general point that you may be able to learn something through suffering and it may ultimately bring you some benefits and help development.
[01:14:48.720 --> 01:14:52.880] What do SSRIs actually do then?
[01:14:52.880 --> 01:14:59.200] If they don't correct an underlying chemical imbalance, what do they do?
[01:14:59.200 --> 01:15:12.720] 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.
[01:15:13.040 --> 01:15:31.400] So, 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 or increase the activity of nerves that fire impulses where serotonin is the transmitter.
[01:15:35.000 --> 01:16:05.800] So, that's the theory, and they certainly do 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 the effects that they have in the long run, whether if people keep taking them, whether they keep increasing the activity of serotonin in the synapse or whether they might even reduce it.
[01:16:05.800 --> 01:16:24.280] There's some evidence that serotonin levels in the blood, for example, which may not reflect the levels in the brain, but probably going to be reasonably consistent with them, are actually lower in people who are taking SSRIs on a long-term basis.
[01:16:24.280 --> 01:16:28.520] So, it may be the case that they even lower serotonin in the long run.
[01:16:29.400 --> 01:16:37.560] 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.
[01:16:38.040 --> 01:16:39.880] And what's the effect on our symptoms, though?
[01:16:39.880 --> 01:16:41.960] So, let's say it is doing some of these things.
[01:16:41.960 --> 01:16:47.480] It's sort of altering serotonin and the serotonin pathway in some way.
[01:16:49.640 --> 01:16:52.120] What is that doing then to our brains?
[01:16:52.120 --> 01:16:55.800] Like, why is it that people can feel when they're on these things?
[01:16:56.120 --> 01:17:09.480] Yeah, so we don't know exactly how that translates into what people feel, but we know that it is disrupting the serotonin system and probably many other neurochemical systems in the brain.
[01:17:09.480 --> 01:17:15.920] Well, it must be, because if we're saying that you're going to get, let's say, emotional numbness, that must be an effect of it.
[01:17:15.920 --> 01:17:20.320] If you're going to have sexual dysfunction, or what did you say around the genitalia?
[01:17:20.960 --> 01:17:22.080] Genital anesthesia.
[01:17:22.080 --> 01:17:22.880] Genital anesthesia.
[01:17:23.600 --> 01:17:32.240] Well, even if you assume that they are working on that narrow pathway that we're told they're working on, it's pretty clear they're doing other things as well.
[01:17:32.240 --> 01:17:33.040] Yes, yes, absolutely.
[01:17:33.280 --> 01:17:34.240] They're not just doing one thing.
[01:17:34.240 --> 01:17:35.280] Yeah, yeah, yeah.
[01:17:35.280 --> 01:17:38.240] I mean, we don't know very much about serotonin overall.
[01:17:38.240 --> 01:17:46.800] Probably the one thing we do know that it's involved with in terms of sort of mental or behavioral things is sexual function.
[01:17:46.800 --> 01:17:59.600] And we know that higher serotonin activity impairs your sexual functioning, reduces your libido, reduces sexual activity in animals, for example.
[01:18:00.240 --> 01:18:05.200] And apart from that, we really don't know very much about what serotonin does.
[01:18:05.200 --> 01:18:08.720] But as you say, what we do know is what these drugs do to people.
[01:18:09.280 --> 01:18:12.320] So they do something to the brain, and we know what the end result is.
[01:18:12.320 --> 01:18:25.840] And we know that this is sexual dysfunction, emotional numbing, degree of lethargy, agitation in some people, particularly young people, after they start taking the drugs, that can happen.
[01:18:25.840 --> 01:18:38.880] And that's probably related to the cases where they can lead to an increase in suicidal thoughts, which I think is probably rare, but has been shown to happen in clinical trials.
[01:18:39.600 --> 01:18:44.000] I know I've already mentioned this point, but I really think it's worth highlighting.
[01:18:45.280 --> 01:18:52.640] If you came in fresh to this conversation, or I don't know, I was going to say the world, right?
[01:18:52.640 --> 01:18:54.160] You come in fresh, right?
[01:18:54.400 --> 01:18:57.680] You haven't ever heard of this chemical imbalance theory before.
[01:18:57.680 --> 01:19:00.000] Let's say there's someone out there who's never heard of this.
[01:19:00.680 --> 01:19:04.840] And they were just hearing that part of our conversation.
[01:19:05.160 --> 01:19:13.240] Someone might think, okay, Joanna, so you're talking to Rongan about people with low moods who are really struggling with their life.
[01:19:13.880 --> 01:19:22.520] And you're also talking about giving them a drug that may increase their risk of suicidal thoughts, even though that's rare.
[01:19:22.520 --> 01:19:24.440] Isn't that madness on one level?
[01:19:24.840 --> 01:19:26.520] It's kind of, I know, we're so used to it.
[01:19:26.520 --> 01:19:33.960] It's hard for us to say as medical doctors, but I think it's a bit ridiculous to even think about, or even these other things, right?
[01:19:33.960 --> 01:19:34.920] Lethargy.
[01:19:34.920 --> 01:19:35.240] Yes.
[01:19:35.400 --> 01:19:39.000] If you're struggling with your mood, right, you don't want to be more lethargic.
[01:19:39.400 --> 01:19:45.240] You want a bit of energy, a bit of get up and go so you can start doing things that change the way you feel.
[01:19:45.720 --> 01:19:48.600] It's kind of remarkable thinking about these side effects.
[01:19:48.600 --> 01:19:52.440] And I don't know, people can argue that they're rare, right?
[01:19:52.760 --> 01:19:54.040] But I don't know.
[01:19:54.040 --> 01:19:55.400] They seem pretty significant.
[01:19:55.400 --> 01:19:56.200] No, absolutely.
[01:19:56.200 --> 01:20:13.800] I think if you think about the effects that what we call antidepressants, SSRIs, and other drugs have, how they change people's states of mind and physical functions, it doesn't seem to me that anything they do is actually likely to be very helpful in people with depression.
[01:20:13.800 --> 01:20:23.960] And indeed, for many people, it's likely to be harmful or not beneficial, as you say.
[01:20:24.600 --> 01:20:29.160] It raises the question for me of informed consent.
[01:20:29.480 --> 01:20:35.480] So there's a few principles that we hold dear as doctors, right?
[01:20:35.480 --> 01:20:37.080] Do no harm.
[01:20:37.720 --> 01:20:43.160] You could question some of that in the context of what we've just said about antidepressants, right?
[01:20:43.240 --> 01:20:44.600] In terms of do no harm.
[01:20:44.600 --> 01:20:46.880] First, do no harm, right?
[01:20:48.880 --> 01:20:57.680] Another principle that we'd like to think we adopt, although I don't think we adopt it as much as we think we do, is informed consent.
[01:20:57.680 --> 01:21:07.600] Before we put someone on something, give them a proper list of the potential benefits and the potential downsides.
[01:21:07.920 --> 01:21:18.240] How many patients who have been prescribed SSRIs for depression do you think are being told about all these potential side effects?
[01:21:18.560 --> 01:21:20.960] So I should think very few.
[01:21:20.960 --> 01:21:46.320] And even before you get to the side effects or the sort of more uncommon side effects like suicide, I think it's very few people who are presented with the idea, or not it's an odd idea, but the fact that antidepressants are drugs that change our normal brain chemistry, our normal physiological functioning, and therefore change our normal states of mind.
[01:21:46.320 --> 01:21:49.360] And it's a mind-altering drug.
[01:21:50.320 --> 01:21:52.560] Exactly, that it's a mind-altering drug.
[01:21:52.880 --> 01:22:04.720] Because people are just presented with, you know, there's this idea that antidepressants work and it doesn't matter how, people are just presented with this drug and, you know, suggested that it's going to be beneficial.
[01:22:04.720 --> 01:22:12.800] It's not explained to them that this is a mind-altering drug and that, you know, it will change the way that you think and you feel to some extent.
[01:22:12.800 --> 01:22:18.080] And on top of that, some people may also be told that, you know, they need to take it because they have a chemical imbalance.
[01:22:18.240 --> 01:22:20.640] Maybe that's less common now.
[01:22:20.880 --> 01:22:32.120] But I still think that unless people are positively, specifically told that actually this idea is not supported, most people will assume that that's the case.
[01:22:32.280 --> 01:22:40.200] Because if you're not given another explanation for what these drugs are doing, then why else would you be being prescribed them?
[01:22:40.200 --> 01:22:49.720] So it sort of starts with failing to inform people about the very nature of antidepressants, what they are as drugs, and what it means to take them.
[01:22:49.720 --> 01:22:51.800] We want these simplistic explanations, don't we?
[01:22:51.800 --> 01:22:53.240] Unfortunately.
[01:22:53.880 --> 01:23:02.280] Oh, because then it's like, oh, yeah, there's this one chemical out for all the biological processes in our body and all the neurochemicals.
[01:23:02.280 --> 01:23:07.320] Oh, there's this one thing that's low or imbalanced, whatever that means.
[01:23:07.320 --> 01:23:09.880] Let's correct it and you're fine.
[01:23:10.200 --> 01:23:12.360] Biology doesn't work like that, does it?
[01:23:12.440 --> 01:23:18.360] And, you know, two weeks ago, I was interviewed by a journalist for an article on happiness.
[01:23:18.360 --> 01:23:28.040] And the first question he asked me was: when you're happy, what is the main neurochemical that is involved?
[01:23:28.680 --> 01:23:31.640] And I thought that really highlights this problem, isn't it?
[01:23:31.640 --> 01:23:38.600] That when you're feeling good, there's not just one, you know, we can't put that on dopamine or serotonin or noradrenaline.
[01:23:38.600 --> 01:23:48.600] Like, there's a combination of all kinds of things that we know about that we don't know about, but we're trying to go, oh, this is dopamine, this is serotonin, this is noradrenaline.
[01:23:48.600 --> 01:23:54.200] And I just don't think the human system, the human animal, works like that.
[01:23:54.200 --> 01:23:55.080] No, absolutely.
[01:23:55.080 --> 01:23:56.280] So it's exactly the same.
[01:23:56.680 --> 01:24:02.040] When we published the paper, people would say to me, so if it's not serotonin, what is it exactly?
[01:24:02.040 --> 01:24:03.560] Is it inflammation?
[01:24:04.040 --> 01:24:05.400] Is it another chemical?
[01:24:05.400 --> 01:24:08.120] You know, and the mistake is even to ask that question.
[01:24:08.120 --> 01:24:08.680] Yeah.
[01:24:09.000 --> 01:24:15.200] So, this informed consent, this is tricky because, because, you know, you can apply this to surgery, right?
[01:24:14.840 --> 01:24:19.600] You know, how many patients are being told all of the potential side effects?
[01:24:19.760 --> 01:24:21.600] Because here's the harsh reality.
[01:24:21.600 --> 01:24:30.560] If you were to go through all the potential side effects of any procedure or any pharmaceutical, it would take quite a bit of time, right?
[01:24:30.560 --> 01:24:34.800] I mean, if you if you I wish I had a BNF here, do I have one?
[01:24:34.800 --> 01:24:37.280] No, I used to have one up on that shelf, right?
[01:24:37.280 --> 01:24:39.280] So, but there'll be a lot, yes.
[01:24:39.680 --> 01:24:48.800] Just on one drug, let's say citalipram, we've mentioned that, one of the SSRIs, there will be a good two or three pages of potential side effects, right?
[01:24:48.800 --> 01:25:02.800] So, if you actually, as a doctor, read all of them out to the patient, nausea, vomiting, diarrhea, sexual dysfunction, gut changes, personality, if you actually went through them, I think most patients would go, oh, no, thank you.
[01:25:03.760 --> 01:25:14.240] You know, but what we would do, and I, and I've, I've been this person for, you would say, look, some of the common side effects that we often see are A, B, C, D, and E.
[01:25:14.240 --> 01:25:15.120] Yes.
[01:25:15.520 --> 01:25:19.440] You don't mention, you can't mention all of them, right?
[01:25:19.440 --> 01:25:31.040] But I think it's important for doctors to really appreciate that and also the general public to understand there are potential side effects that are documented that you may not being told about.
[01:25:31.040 --> 01:25:39.200] So, when that patient is deciding, shall I go on this drug or not, you're actually not making an informed decision unless you've been told everything.
[01:25:39.200 --> 01:25:39.680] Yeah.
[01:25:40.000 --> 01:25:58.480] But I also think that people are not being warned enough, probably, about fairly common side effects, like persistent sexual dysfunction and like dependence, physical dependence, and the fact that many people experience withdrawal problems.
[01:25:58.480 --> 01:26:10.760] Yeah, well, okay, I want to talk about withdrawal because there will no doubt be some people listening to this or watching it on YouTube who are going, okay, well, I've been on this drug, I've been on an SSRI for several years now.
[01:26:10.760 --> 01:26:17.800] You're saying me that there's no basis for this, and so I want to make sure that they feel they understand what they should be doing.
[01:26:17.800 --> 01:26:25.320] Just before we get to that, though, you said something really interesting, which is antidepressants are mind-altering.
[01:26:25.320 --> 01:26:33.480] Okay, so they may not correct a serotonin imbalance, but they fundamentally are changing something in how we experience life.
[01:26:33.800 --> 01:26:46.760] Could we draw an analogy to common drugs that people use that often they don't think about as drugs, alcohol and caffeine, right?
[01:26:47.080 --> 01:26:56.920] So if you're feeling a bit anxious, right, you could drink alcohol and that may reduce your anxiety, right?
[01:26:57.240 --> 01:27:00.120] So it's a mind-altering substance.
[01:27:00.120 --> 01:27:02.200] Caffeine is a psychoactive stimulant.
[01:27:02.200 --> 01:27:07.000] Although many of us drink our tea or coffee and we enjoy it, I very much do.
[01:27:07.320 --> 01:27:08.600] We often don't appreciate this.
[01:27:08.600 --> 01:27:09.720] It's a psychoactive stimulant.
[01:27:10.200 --> 01:27:13.720] You can feel a bit low and are not quite with it in the morning.
[01:27:13.720 --> 01:27:15.480] Have a strong cup of coffee.
[01:27:15.560 --> 01:27:17.080] You feel like you can take on the world, right?
[01:27:17.080 --> 01:27:18.680] So it's mind-altering.
[01:27:19.080 --> 01:27:24.280] But with those things, let's say caffeine, for example, we know, don't we?
[01:27:24.280 --> 01:27:35.640] Like if you are a habitual caffeine drinker, anyone who's tried to give up coffee before as a regular drinker, we will know the withdrawal can be pretty severe.
[01:27:35.640 --> 01:27:38.680] Mood swings, headache, like real fatigue.
[01:27:38.680 --> 01:27:42.600] Like, you know, because caffeine's legal and we all, you know, we enjoy it.
[01:27:42.600 --> 01:27:43.960] So we don't see it like that.
[01:27:43.960 --> 01:27:54.080] But what we don't believe, I don't think, is if you're stopping caffeine and you have withdrawals, you don't think, yeah, oh, God, I needed the caffeine, don't I?
[01:27:54.080 --> 01:27:56.880] You know, I've got this problem that caffeine solves.
[01:27:56.880 --> 01:28:01.120] Now, you understand that it's withdrawal, but we don't think about that with antidepressants.
[01:28:01.120 --> 01:28:01.280] Yes.
[01:28:01.600 --> 01:28:04.960] We think, oh, this is a, oh, you know, I need it for my condition.
[01:28:04.960 --> 01:28:06.080] So, can you help me?
[01:28:06.080 --> 01:28:07.600] Do you think that's a reasonable analogy?
[01:28:08.000 --> 01:28:09.520] I think that's a very useful analogy.
[01:28:09.520 --> 01:28:13.120] I think it's a useful analogy to think about the effects of antidepressants.
[01:28:13.120 --> 01:28:23.920] And in a lot of my work, I draw the analogy with alcohol that you drew because alcohol, you know, we recognize that it can be helpful if you're anxious.
[01:28:24.240 --> 01:28:30.960] You know, if you go out and have a load to drink and you're feeling depressed, you may not feel depressed for a few hours while you're under the influence.
[01:28:30.960 --> 01:28:32.080] We have a phrase for that.
[01:28:32.080 --> 01:28:34.320] We call it drowning our sorrows.
[01:28:35.040 --> 01:28:41.760] So, you know, we recognize that mind-altering drugs change the way that we feel temporarily while we're under the influence.
[01:28:41.760 --> 01:28:48.000] But we also recognize that dealing with depression by getting drunk every day is probably not a good idea.
[01:28:48.000 --> 01:28:55.520] Now, I'm not saying that the effects of antidepressants are exactly the same as the effects of alcohol, that they're not.
[01:28:55.520 --> 01:29:04.880] Every chemical substance changes the brain in a different way and produces different changes in our mental state and our feelings and things.
[01:29:05.600 --> 01:29:11.280] But the principle is the same, that it's changing the way that it's changing our normal feelings.
[01:29:11.280 --> 01:29:13.680] And also, we know that alcohol is a depressant.
[01:29:13.680 --> 01:29:14.000] Yeah.
[01:29:15.280 --> 01:29:17.680] But again, it's funny how we use language.
[01:29:17.680 --> 01:29:22.720] We don't go round talking about alcohol as oh, you're gonna oh, you're going to consume more depressants tonight.
[01:29:22.720 --> 01:29:23.760] Are you coming around to my party?
[01:29:23.760 --> 01:29:24.880] Do you want some depressants?
[01:29:24.880 --> 01:29:25.280] Yes.
[01:29:25.280 --> 01:29:26.080] We don't, do we?
[01:29:26.080 --> 01:29:26.400] Right?
[01:29:26.400 --> 01:29:33.640] But we're like, yes, but we know that that actually, a lot of people will know when they've had a few drinks the following day, they feel pretty low, right?
[01:29:33.640 --> 01:29:37.880] It is a depressant, but we don't, it's interesting even the language we use.
[01:29:37.880 --> 01:29:39.560] So, okay, all right.
[01:29:39.560 --> 01:29:45.160] So, if you're on it, yes, and so the other analogy is very good as well.
[01:29:45.160 --> 01:30:02.520] That we know that, you know, if we think of mind-altering drugs, as you say, like caffeine or like heroin, 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.
[01:30:02.520 --> 01:30:14.600] And those withdrawal symptoms, because the drugs have, you know, there have been adaptations in the brain as well as parts of the body, those withdrawal symptoms will include, you know, emotional symptoms.
[01:30:14.600 --> 01:30:30.520] So people may become, when they're coming off antidepressants, very anxious, for example, 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.
[01:30:30.520 --> 01:30:37.480] So people can become very anxious and also emotionally labile, very changeable and tearful.
[01:30:38.520 --> 01:30:58.120] 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, you know, oh goodness, my depression's coming back.
[01:30:58.120 --> 01:30:59.880] I feel anxious again.
[01:31:00.760 --> 01:31:08.280] Then, if you ask people in more detail, it's often apparent that actually it's not quite the same as their original symptoms.
[01:31:08.280 --> 01:31:10.120] It's actually a bit different.
[01:31:10.400 --> 01:31:14.600] But, you know, but of course, the differences are quite subtle, so that might be missed.
[01:31:14.720 --> 01:31:28.160] And I think practitioners as well, although there's been a lot more publicity over the last few years about antidepressant withdrawal, I think a lot of clinicians aren't necessarily as aware of it as they might be.
[01:31:28.160 --> 01:31:36.400] And therefore, again, if someone's trying to come off their antidepressants, having difficulties, the knee-jerk reaction will often be, oh dear, you know, it's not worked.
[01:31:36.720 --> 01:31:38.000] That's your depression again.
[01:31:38.000 --> 01:31:40.880] You need to go back on it or you need to increase the dose again.
[01:31:40.880 --> 01:31:50.000] Because with caffeine, of course, you know, you kind of need to white-knuckle it for a few days, get through it to not experience those symptoms.
[01:31:50.000 --> 01:31:57.440] But again, it's not the similar to PPIs, as I mentioned before, like the proton-pump inhibitors that loads of the population are on.
[01:31:57.760 --> 01:32:08.160] There's a belief when you come off them, when you especially been on them for a while, that, oh, you know, by the fact that I'm getting indigestion and these acidite symptoms, oh, I have to still be on it.
[01:32:08.160 --> 01:32:10.640] But it's like, no, no, this could be withdrawal, actually.
[01:32:10.960 --> 01:32:14.080] That's so interesting and really interesting in that.
[01:32:14.080 --> 01:32:22.400] Also, I think we've come to assume that more conditions are chronic and ongoing than they actually are.
[01:32:22.400 --> 01:32:26.880] Whereas actually, lots of conditions fluctuate, you know, physical and mental conditions, don't they?
[01:32:26.880 --> 01:32:33.040] So, you know, you may need your proton pump inhibitor for a bit, but then actually, you might be fine.
[01:32:33.040 --> 01:32:33.760] Yeah, exactly.
[01:32:33.760 --> 01:32:37.200] And as we've said before, the trials are generally for a short period of time.
[01:32:37.200 --> 01:32:40.880] The trials aren't there to support using it for five years, unfortunately.
[01:32:40.880 --> 01:32:41.280] Absolutely.
[01:32:42.000 --> 01:32:46.560] So, okay, so let's think about a patient and then also a professional.
[01:32:46.520 --> 01:32:47.200] Okay, okay?
[01:32:47.240 --> 01:33:01.960] So for the patient who's currently on antidepressants, or let's say SSRIs, and has been on them for a period of time, and they've heard this conversation, maybe they'll get your book and read it and go, oh, wow, there really isn't that much data to support me being on them.
[01:33:02.840 --> 01:33:07.800] And they want to start thinking about getting off them.
[01:33:08.120 --> 01:33:09.560] What should they do?
[01:33:09.560 --> 01:33:14.360] So the first thing they shouldn't do is throw them down the toilet and stop them straight away.
[01:33:14.840 --> 01:33:32.040] That's really important thing to say, particularly if people have been on them for a number of years, because it seems that if you come off them very suddenly, you have worse withdrawal symptoms that potentially can go on for a lot, you know, be quite protracted and go on for a long period of time.
[01:33:32.040 --> 01:33:43.160] If you come off your medication slowly and carefully, you're more likely to be able to minimize those symptoms and for them not to sort of turn into a protracted state.
[01:33:43.160 --> 01:33:44.200] Are there guidelines somewhere?
[01:33:44.200 --> 01:33:48.040] Because I think one of the problems people may face is their doctor may know nothing about this.
[01:33:48.040 --> 01:33:48.200] Yeah.
[01:33:48.600 --> 01:33:48.760] Right.
[01:33:48.760 --> 01:33:58.760] So their doctor who's prescribed them 20 milligrams of citalopram for the last three years, they can go in and go, hey, I just heard a podcast saying there's no evidence to support this.
[01:33:59.000 --> 01:34:01.640] I'd like your help in trying to come off this.
[01:34:02.520 --> 01:34:07.560] Now, of course, there's a whole variety of different podcasts of different qualities and all that kind of stuff.
[01:34:07.560 --> 01:34:12.120] But nonetheless, I just want to predict because I want to be helpful.
[01:34:12.120 --> 01:34:18.680] So I want to make sure that that person understands what to do if they're facing a bit of a block when they go and see their doctor.
[01:34:19.240 --> 01:34:27.240] So the Royal College of Psychiatrists has actually published some quite helpful information on their website on stopping antidepressants.
[01:34:27.240 --> 01:34:27.800] Okay, great.
[01:34:27.800 --> 01:34:32.520] It was published in about 2019 and it's pretty succinct.
[01:34:33.960 --> 01:34:37.000] May not be enough, but there are other resources I'll mention in a minute.
[01:34:37.000 --> 01:34:43.400] But it's really good that the Royal College have done that.
[01:34:43.400 --> 01:34:55.200] They were spurred to do that under pressure from people who'd had really difficult withdrawal experiences, and their previous advice had been come off the medication in two to four weeks, that should be fine.
[01:34:55.200 --> 01:35:03.040] And lots of people got together and wrote to the college saying, actually, that's not fine for many people if they've been on them for a long time.
[01:35:03.200 --> 01:35:04.800] So you need to have better advice.
[01:35:04.800 --> 01:35:12.400] So there is some good advice on the Royal College website under the stopping antidepressants section.
[01:35:13.040 --> 01:35:14.400] A colleague of mine called Dr.
[01:35:14.400 --> 01:35:25.680] Mark Horowitz, who's a psychiatrist who himself has experienced difficulties coming off antidepressants, has recently published the Maudsley Deprescribing Guidelines.
[01:35:25.680 --> 01:35:38.320] So the Maudsley Prescribing Guidelines are the sort of main textbook about how to prescribe psychiatric drugs in the first place and all their effects and side effects.
[01:35:38.320 --> 01:35:47.040] The Maudsley Deprescribing Guidelines is a very detailed volume on how to get off psychiatric drugs for clinicians.
[01:35:47.040 --> 01:35:48.640] For clinicians, yes, yes.
[01:35:48.640 --> 01:35:55.040] And I just want to Maudsley, for people who are not familiar, spell M-A-U-D-S-L-E-Y, Maudsley.
[01:35:55.040 --> 01:35:55.360] That's right.
[01:35:55.360 --> 01:35:58.400] The Maudsley is named after the Maudsley Hospital in London.
[01:35:58.400 --> 01:36:13.680] So potentially the patients could say to their doctor, if they've got a helpful doctor, says, look, I don't know much about this, they could say, hey, listen, there are actually some published guidelines now and point the doctor in that direction to go and learn a little bit about this.
[01:36:13.680 --> 01:36:14.880] Exactly, exactly, yes.
[01:36:14.880 --> 01:36:23.200] And as I say, those are very detailed and go into how some people might need to transfer onto liquids or break up tablets in order to reduce the doses, you know, carefully.
[01:36:23.680 --> 01:36:39.320] One thing I heard you say in a previous interview, Joanna, is that I think at least this is what you said, that it's easier to cut at the start, but when you're getting to very low doses, you've got to be really, really careful then.
[01:36:39.320 --> 01:36:44.520] So, for example, if you're on 20 milligrams of citalopram, and again, please correct me if I haven't quite got this right.
[01:36:44.520 --> 01:36:52.280] Maybe it's you can go from 20 to 10, but then when you go from 10 to 10 to 5, it's a much bigger jump in terms of your symptoms.
[01:36:52.280 --> 01:36:52.840] Yes, it is.
[01:36:52.840 --> 01:36:57.080] And five to zero is a massive jump.
[01:36:57.080 --> 01:36:57.320] Exactly.
[01:36:57.800 --> 01:36:58.040] Exactly.
[01:36:58.280 --> 01:36:58.760] Do we know?
[01:36:58.760 --> 01:37:09.800] So that's because of what's called the hyperbolic relationship between drug dose and the activity of the drug in the body.
[01:37:11.240 --> 01:37:16.200] It's effects on the serotonin transporter and binding to receptors and things like that.
[01:37:16.200 --> 01:37:21.400] And apparently, this is a property that most drugs have.
[01:37:21.400 --> 01:37:35.160] And it's actually been recognized for quite a long time because the advice on coming off benzodiazepines was the same, that you had to go most slowly and carefully when you got down to the lowest doses.
[01:37:35.160 --> 01:37:35.560] Yeah.
[01:37:35.800 --> 01:37:39.320] If you were reducing valium diazepam, for example.
[01:37:39.560 --> 01:37:47.720] So, yeah, so that's so it can be really quite a tricky thing because some of these drugs don't come in very low-dose preparations.
[01:37:47.720 --> 01:37:49.320] In fact, lots of them don't.
[01:37:49.320 --> 01:37:52.520] Some of them you can get liquids for, some of them you can't.
[01:37:52.920 --> 01:38:01.240] Some people I know who've been coming off venlafaxine, that's one of these SNRI antidepressants.
[01:38:01.240 --> 01:38:05.000] That's a serotonin and noradrenaline reuptake inhibitor.
[01:38:05.400 --> 01:38:07.080] Oh, a second neurotransmitter.
[01:38:07.080 --> 01:38:08.600] Yes, exactly.
[01:38:09.240 --> 01:38:14.040] So, Venlafaxine, the lowest dose is 37.5 milligrams.
[01:38:14.040 --> 01:38:21.840] And it seems that that actually is a relatively high dose and has quite strong effects.
[01:38:21.920 --> 01:38:23.200] It's a 30 or a 25.
[01:38:23.280 --> 01:38:25.840] And exactly, and you can't reduce more slowly.
[01:38:25.840 --> 01:38:37.840] So, some people have been reduced to breaking open the capsules, which contain lots of little beads of the drug, and literally weighing out beads, the beads, the tiny beads inside the drug, in order to reduce slowly enough.
[01:38:38.080 --> 01:38:39.920] Easy to get on, very hard to get on.
[01:38:40.160 --> 01:38:41.280] Exactly, exactly.
[01:38:41.280 --> 01:38:49.920] And another thing I wanted to say about this is: you know, you were saying that lots of doctors, you know, struggle with how to help people come off.
[01:38:49.920 --> 01:39:06.720] And it should be another thing that really shocks us that there's all this literature about, you know, starting people on the drugs, as you say, and these short-term studies, very little research on what happens to people over the long term and how to get people off safely.
[01:39:06.720 --> 01:39:18.880] And therefore, what patients have been doing for a long time is banding together and giving people advice, peer sort of peer support and advice on how to come off antidepressants on the internet.
[01:39:18.880 --> 01:39:25.920] And so, the you know, the best information on this for a long time has been online groups on Facebook and other internet.
[01:39:26.240 --> 01:39:27.200] Sharing their experiences.
[01:39:27.360 --> 01:39:28.240] Exactly, exactly.
[01:39:28.240 --> 01:39:36.480] And the profession has taken a while to catch up with all the expertise that has actually existed in these groups.
[01:39:36.800 --> 01:39:47.040] Okay, so for a patient, there are these guidelines that they can either look at themselves, discuss with their doctor, and at least start that process off.
[01:39:47.040 --> 01:40:03.400] And I do believe this is going to change a lot anyway because you are raising such phenomenal awareness of this that it seems highly likely that it's going to become very clear very soon that actually we need to start doing this differently.
[01:40:03.720 --> 01:40:13.000] For a doctor or a professional, a healthcare professional who's been listening so far and is like, first of all, they might feel a bit of guilt, right?
[01:40:13.000 --> 01:40:18.440] An acknowledgement that, oh, wow, you know, I didn't realize that I was potentially causing all this harm.
[01:40:18.440 --> 01:40:26.600] Because a lot of doctors didn't know and might go, but you know, what would you say to that doctor who's feeling really guilty at the moment?
[01:40:26.600 --> 01:40:28.360] It's like, oh my God, what have I been doing?
[01:40:28.360 --> 01:40:30.120] What would you say to that person?
[01:40:30.440 --> 01:40:36.440] So your jobbing GP or psychiatrist that's sitting in their office, I don't think needs to feel guilty.
[01:40:36.440 --> 01:40:40.760] But I do think some of the leaders of the profession need to take some responsibility for this.
[01:40:40.760 --> 01:40:41.160] Yeah.
[01:40:41.480 --> 01:40:47.880] Actually, because, you know, it's been known really for a long time that antidepressants weren't correcting a serotonin.
[01:40:48.200 --> 01:40:49.400] You've been talking about this for a long time.
[01:40:49.400 --> 01:40:49.720] A long time.
[01:40:49.880 --> 01:40:51.400] Not just this paper 2022.
[01:40:51.560 --> 01:40:52.840] You've been talking about this for a long time.
[01:40:52.840 --> 01:40:53.800] But okay, then.
[01:40:53.800 --> 01:41:05.560] 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.
[01:41:05.560 --> 01:41:17.000] 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 have prescribed an SSRI.
[01:41:17.320 --> 01:41:19.320] What would you ask that doctor to do?
[01:41:19.640 --> 01:41:32.360] So the recent NICE guidelines are quite helpful in this respect in that they list a whole number, it's about eight or nine, alternative treatments for people with depression that you can give instead of giving an antidepressant.
[01:41:32.360 --> 01:41:43.640] And they include treatments inverted commas because they include things like recommending exercise, mindfulness, problem-solving therapy, CBT, of course.
[01:41:44.280 --> 01:41:45.920] So they do include some.
[01:41:45.920 --> 01:41:52.080] Obviously, I know there's usually a waiting list for therapy, and that's, you know, that can be an issue if someone's feeling really desperate.
[01:41:52.080 --> 01:41:55.680] But they do include some things that people could go off and do straight away.
[01:41:55.680 --> 01:42:04.480] So I think that doctors should be trying to guide patients towards these alternative ways of managing their depression.
[01:42:04.800 --> 01:42:16.400] 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.
[01:42:16.400 --> 01:42:37.760] So to have this discussion that we've been talking about of 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 and the common and important adverse effects.
[01:42:37.760 --> 01:42:44.640] Yeah, it's really interesting hearing you say what the NICE guidelines are now saying.
[01:42:48.160 --> 01:42:53.600] My very first book was called The Four Pillar Plan and it came out right at the end of 2017.
[01:42:53.600 --> 01:43:02.640] 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.
[01:43:02.640 --> 01:43:18.880] And I, at that time, and I still subscribe to what was in that book, the four pillars of health that I say have the most impact on our well-being and that we have a degree of control over, although it's different for different people, are food, movement, sleep, and relaxation.
[01:43:18.880 --> 01:43:26.720] And I break down those pillars and I give people actionable advice that doesn't cost much for all of them.
[01:43:27.360 --> 01:43:39.160] I can't tell you, Joanna, over the years, and that book's what's 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.
[01:43:39.160 --> 01:43:42.120] Now, I don't mention depression, a diagnosis in it.
[01:43:42.120 --> 01:43:52.440] I don't mention, but I think there comes a fundamental, there's a fundamental conundrum which we have to wrestle with, right?
[01:43:52.760 --> 01:43:57.160] Which is, do we believe that there are fundamental problems with the human body, right?
[01:43:57.160 --> 01:44:15.880] There are deficiencies we want, 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 have a consequence, right?
[01:44:15.880 --> 01:44:17.080] Maybe with our mood.
[01:44:17.080 --> 01:44:35.080] And if we can correct or improve within our capabilities, some of those things like more exercise, better nutrition, prioritizing your sleep a little bit more than perhaps you were, learning a few helpful stress management techniques.
[01:44:35.080 --> 01:44:37.160] Well, that's kind of what I shared in that book.
[01:44:37.160 --> 01:44:45.960] And actually, it means that for some people, of course, not everyone, actually, some of their emotions and symptoms start to get better.
[01:44:45.960 --> 01:44:52.680] Yes, probably because of the direct impacts of those behaviors, but also because the sense of agency that they feel over their life.
[01:44:52.680 --> 01:44:54.120] I can do something that makes a difference.
[01:44:54.440 --> 01:44:55.560] Do you have any comments on that?
[01:44:55.560 --> 01:44:58.120] Well, I think it's a really sensible approach for that reason.
[01:44:58.120 --> 01:45:08.120] And I think what's nice about it is because you've broken it down into four different areas, it's not quite so overwhelming as you know, someone feeling, oh my god, I've got to change everything.
[01:45:08.160 --> 01:45:18.160] You know, they can focus 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.
[01:45:18.480 --> 01:45:21.680] You tweeted recently, or what do you call it now?
[01:45:21.680 --> 01:45:22.400] You X'd.
[01:45:23.200 --> 01:45:27.200] You made a post on the platform formerly known as Twitter.
[01:45:27.680 --> 01:45:29.920] And I think it was to do with Chris Palmer.
[01:45:30.400 --> 01:45:32.480] Chris Palmer's a Harvard psychiatrist.
[01:45:32.480 --> 01:45:36.640] Chris has been on my show before, and he's doing some quite incredible work.
[01:45:36.640 --> 01:45:50.640] And he's published research showing that for some people with severe mental health problems, a ketogenic diet, so improving their metabolic health, can have a huge effect.
[01:45:50.960 --> 01:45:54.640] And I seem to recall from your post that you were questioning some of that.
[01:45:54.640 --> 01:46:00.160] So not questioning, but just saying you don't want us to fall into the same trap going it was all serotonin.
[01:46:00.480 --> 01:46:04.560] I think what you were trying to say is we can't now say it's all metabolic.
[01:46:04.800 --> 01:46:06.240] Could you just expand on that a little bit?
[01:46:06.240 --> 01:46:08.000] Because I found that really interesting.
[01:46:08.000 --> 01:46:16.240] 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 having a healthy body and mind.
[01:46:17.120 --> 01:46:37.760] But I am slightly wary that there are a group of people who want to replace the chemical imbalance with a metabolic imbalance model and suggest that some metabolic abnormality is a sort of specific direct cause of depression, as people were suggesting that a serotonin abnormality was a specific and direct cause of depression.
[01:46:38.000 --> 01:46:56.160] And I think certainly the way I look at all chronic health conditions, and again, I don't really like the label of depression, but for the purpose of this conversation, let's use it, whether it would be depression or something else, is these things are all multifactorial, or I think largely multifactorial.
[01:46:56.160 --> 01:47:02.920] So, there are multiple things going on that in combination result in certain symptoms.
[01:47:03.240 --> 01:47:14.600] So, could it be that for certain individuals with really bad metabolic health, that if they improve it, they can see an improvement in certain symptoms or their mood?
[01:47:14.600 --> 01:47:15.480] Yeah, absolutely.
[01:47:15.880 --> 01:47:19.160] I've seen that, and I, you know, and I think Chris is showing that.
[01:47:19.160 --> 01:47:27.720] At the same time, I think what you're trying to caution is us saying that all depression now is metabolic, whereas all depression was previously serotonin.
[01:47:27.720 --> 01:47:33.480] Do you believe that for some patients, a metabolic component could be at play, or do you not subscribe to that?
[01:47:33.800 --> 01:47:35.080] Not really.
[01:47:35.560 --> 01:47:35.960] Okay.
[01:47:35.960 --> 01:47:42.520] I mean, so we know that depression is more common in people who are overweight, for example.
[01:47:42.520 --> 01:47:44.520] And there might be a number of reasons for that.
[01:47:44.520 --> 01:47:47.320] And probably a lot of it is socioeconomic.
[01:47:47.640 --> 01:47:56.840] But one of it might be because if you're overweight, it's more difficult to exercise, to be active, to do things that might actually make you, you know, lift your mood and make you feel better.
[01:47:56.840 --> 01:47:58.360] So stigma in society.
[01:47:58.440 --> 01:47:59.560] And stigma, exactly.
[01:47:59.560 --> 01:48:00.600] So lots of reasons.
[01:48:00.600 --> 01:48:02.920] Yeah, absolutely, huge thing, of course.
[01:48:02.920 --> 01:48:08.120] And, you know, self-stigma, people, you know, are very aware of how they look, aren't they?
[01:48:08.120 --> 01:48:17.400] And so, so losing weight so that you're not overweight anymore is probably a very helpful thing for mood.
[01:48:18.440 --> 01:48:21.080] And being overweight is an unhelpful thing for mood.
[01:48:21.080 --> 01:48:28.520] But I think that's a bit different from saying that, you know, that there's a metabolic cause of depression, even if you're only saying that's in a few people.
[01:48:28.520 --> 01:48:30.360] Yeah, I think there's a lot there.
[01:48:30.360 --> 01:48:32.440] I really appreciate you sharing your perspective.
[01:48:32.440 --> 01:48:39.480] I'd love to dive deeper on that with you, maybe in a part two conversation, because I think there's a lot for us to talk about.
[01:48:39.880 --> 01:48:41.160] I do like Chris's work.
[01:48:41.480 --> 01:48:43.080] I'm really interested.
[01:48:43.080 --> 01:48:48.240] I've certainly seen patients when they really are able to improve their diet.
[01:48:44.760 --> 01:48:50.800] I have seen some quite big improvements in mood.
[01:48:50.880 --> 01:48:55.600] So I do think that for some people at least, that can be really helpful.
[01:48:55.600 --> 01:48:59.040] I guess for others, if that's not playing a role, it probably won't do anything at all.
[01:48:59.040 --> 01:49:06.000] You know, if it's due to early life experiences or really bad trauma, you're probably going to need to address that.
[01:49:06.800 --> 01:49:22.400] So I think, again, I would also argue that maybe that term, again, depression is quite misleading because it's such a broad umbrella term that encompasses maybe all kinds of different etiologies and physiologies.
[01:49:22.400 --> 01:49:25.440] And, you know, do we need different terms for these things?
[01:49:25.440 --> 01:49:26.080] Do you know what I mean?
[01:49:26.480 --> 01:49:30.640] Metabolic dysfunction-induced mood problems, for example.
[01:49:31.040 --> 01:49:32.640] Oh, yeah, that's my issue.
[01:49:33.120 --> 01:49:37.600] Yeah, I mean, as you mentioned earlier, sleep can affect people's mood really profoundly.
[01:49:37.600 --> 01:49:38.160] Massively.
[01:49:38.480 --> 01:49:43.040] And so, obviously, you know, our physiology can impact our mood.
[01:49:43.040 --> 01:49:47.200] And I wouldn't want to suggest that it's never about that.
[01:49:48.160 --> 01:50:01.280] But I suppose that I think in general, when we talk about depression, we are talking about a meaningful reaction to things that are going on rather than just a consequence of poor sleep or metabolic problems or whatever it is.
[01:50:01.600 --> 01:50:05.120] Well, listen, I've thoroughly enjoyed this conversation, Joanna.
[01:50:05.200 --> 01:50:10.800] I think what we've spoken about so far is really summed up with a phrase that you wrote.
[01:50:10.880 --> 01:50:14.480] It's not in this book, actually, I think it was in the one just before that.
[01:50:14.480 --> 01:50:20.160] My concern is that we have fundamentally misunderstood what psychiatric drugs do.
[01:50:20.160 --> 01:50:28.800] And because of this, we overestimated their potential benefits and underestimated the harm they can cause.
[01:50:28.800 --> 01:50:30.000] Do you still stand by that statement?
[01:50:30.600 --> 01:50:31.400] Yes, absolutely.
[01:50:31.400 --> 01:50:48.840] And I think it relates very much to your points about the limitations of medicine and recognizing the limitations and not rushing in to try and correct things when actually we don't really understand what's going on and the tools we have are very crude.
[01:50:49.160 --> 01:50:52.760] You, I know, lecture to medical students quite a lot.
[01:50:54.200 --> 01:50:58.360] What's their reaction to what they're learning from you, would you say?
[01:50:58.360 --> 01:51:00.200] Give me some hope for the future, Joanna.
[01:51:00.360 --> 01:51:06.040] Well, medical students are very sweet and polite generally, so I probably only hear from the ones that agree with me.
[01:51:06.040 --> 01:51:07.880] So I have to caveat it with that.
[01:51:07.880 --> 01:51:20.600] But I've given a couple of talks to medical students recently and they've been very positive, very receptive, really, you know, enthusiastically wanting to take these ideas forward and improve mental health care by doing so.
[01:51:20.600 --> 01:51:21.800] I think things are changing.
[01:51:21.800 --> 01:51:22.280] I really do.
[01:51:22.280 --> 01:51:32.600] I think there's a new generation coming in who actually, you know, a lot of people don't like the new media landscape that exists with podcasts and social media and stuff.
[01:51:32.760 --> 01:51:41.160] But for all the potential harms of that, there are huge benefits, which is information like this is getting disseminated to more and more people.
[01:51:41.160 --> 01:51:45.400] And I know there's a ton of medical students who listen to this show, so we're very interested in these ideas.
[01:51:45.400 --> 01:51:48.360] These are going to be the clinicians of tomorrow, right?
[01:51:48.680 --> 01:51:49.400] Absolutely.
[01:51:49.400 --> 01:51:57.640] I think it's actually a really important point because as I experienced, there is a section of the psychiatric establishment who want to shut this debate down.
[01:51:58.440 --> 01:52:04.760] And if social media didn't exist and all these new media platforms didn't exist, they would have done so.
[01:52:04.760 --> 01:52:05.960] They would have been able to do so.
[01:52:05.960 --> 01:52:07.880] But they've not been able to.
[01:52:07.880 --> 01:52:09.160] You can't shut it down anymore.
[01:52:09.160 --> 01:52:10.680] People are going to talk about this stuff.
[01:52:10.680 --> 01:52:11.880] These ideas are going to spread.
[01:52:11.880 --> 01:52:14.040] People are going to look at the research.
[01:52:14.280 --> 01:52:20.720] I certainly would highly recommend that people read your new book, Chemically Imbalanced, The Making and Unmaking of the Serotonin Myth.
[01:52:20.800 --> 01:52:22.560] I think it's great for the public.
[01:52:22.560 --> 01:52:31.920] But if you are a clinician and if you currently prescribe SSRIs, please, please take a look at Joanna's 2022 paper.
[01:52:31.920 --> 01:52:42.160] Please take a look at this book because I think when a clinician reads this and understands it, they'll at the very least ask themselves some questions about what they're doing.
[01:52:42.160 --> 01:52:45.360] To finish off, Joanna, you have got a lot of experience.
[01:52:45.360 --> 01:52:47.840] You're still in clinical practice.
[01:52:48.480 --> 01:53:00.960] For a member of the public who's heard this conversation, who is struggling with their mood and doesn't know what to do, what would you say to them?
[01:53:02.880 --> 01:53:07.600] So I'd say to them to try and try and work out why.
[01:53:08.640 --> 01:53:11.120] What is this mood signaling to you?
[01:53:12.320 --> 01:53:15.120] Maybe there's something at work that's not right.
[01:53:15.120 --> 01:53:20.960] Maybe there are some relationship problems or been some issues in some friendships.
[01:53:20.960 --> 01:53:22.800] Try and identify that.
[01:53:23.680 --> 01:53:26.960] And it may just be a case of making those sorts of changes.
[01:53:27.600 --> 01:53:34.800] If you can't identify it and are already struggling, then it might be helpful to have some psychotherapy.
[01:53:35.600 --> 01:53:42.480] And there is psychotherapy now available on the NHS, the talking therapist service.
[01:53:42.480 --> 01:53:48.080] You can access that by going to see your GP or you can phone them up directly and refer yourself.
[01:53:48.480 --> 01:54:06.200] And then there are other things that you can do that will generally be helpful for your mood, such as taking exercise, doing some mindfulness or relaxation, probably having a good diet and making sure that your physical health is in good shape.
[01:54:06.840 --> 01:54:08.520] So I would do all those things.
[01:54:08.520 --> 01:54:20.120] I would talk to the people that you're close to and share your feelings with them, and they may be able to help you identify what the problem is.
[01:54:20.120 --> 01:54:30.040] If you feel that you need to go and see a doctor and want to talk about antidepressants, just please bear in mind what we've said about all their adverse effects.
[01:54:30.040 --> 01:54:37.480] And if you do end up feeling that you have to take them, then please try and take them for as short a time as possible.
[01:54:37.480 --> 01:54:53.720] I think that's really important because actually a lot of the adverse effects we've been talking about, the really serious ones like dependence and persistent sexual dysfunction, are more likely to happen and going to be more severe if you end up on antidepressants for long periods of time.
[01:54:53.720 --> 01:54:54.920] Yeah, brilliant advice.
[01:54:54.920 --> 01:55:01.800] Joanna, honestly, I think you're doing some really, really important work.
[01:55:01.800 --> 01:55:10.600] And as I said to Susanna Sullivan when she was in the studio last week, even if people push back at any of these concepts, we have to be having these conversations.
[01:55:10.600 --> 01:55:14.280] We have to be questioning what it is we're doing.
[01:55:14.280 --> 01:55:21.400] Why is it that one in five UK adults almost are taking some form of antidepressants?
[01:55:21.400 --> 01:55:27.400] You know, and if we shut down these conversations, we can't see what's working, what's not working.
[01:55:27.400 --> 01:55:29.320] So I really want to appreciate you.
[01:55:29.320 --> 01:55:30.920] I think it's not easy doing what you're doing.
[01:55:31.000 --> 01:55:35.240] You are literally going up against established practice.
[01:55:35.240 --> 01:55:36.680] Thank you for writing the book.
[01:55:36.680 --> 01:55:38.600] Thank you for publishing your research.
[01:55:38.600 --> 01:55:40.040] And thank you for coming on the show.
[01:55:40.040 --> 01:55:41.560] Thank you very much for inviting me.
[01:55:41.560 --> 01:55:54.160] And really, thank you for highlighting how important this is and really how radical it is and helping people to unpick that, I think, in a way that hopefully isn't too overwhelming.
[01:55:57.760 --> 01:56:00.320] Really hope you enjoyed that conversation.
[01:56:00.320 --> 01:56:06.080] Do think about one thing that you can take away and apply into your own life.
[01:56:06.080 --> 01:56:11.120] And also have a think about one thing from this conversation that you can teach to somebody else.
[01:56:11.120 --> 01:56:18.800] Remember, when you teach someone, it not only helps them, it also helps you learn and retain the information.
[01:56:18.800 --> 01:56:22.240] Now, before you go, just wanted to let you know about Friday 5.
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[01:56:29.360 --> 01:56:43.440] In that email, I share exclusive insights that I do not share anywhere else, including health advice, how to manage your time better, interesting articles or videos that I've been consuming, and quotes that have caused me to stop and reflect.
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