By Evgeny Legedin
Last week a bright final-year student asked me to look over the University of Glasgow “Psychiatry Revision Guide” that everyone still uses for finals and OSCE preparation. In almost every respect it is a solid, helpful document.
One station, however, stopped me in my tracks.
The model script for “Explain antidepressant therapy” is more or less unchanged from the one doctors learned as a medical students fifteen years ago:
“Neurotransmitters are the chemicals which transmit signals between the cells in our brains – chemical messengers. In depression some of these neurotransmitter systems don’t seem to be working properly. Antidepressants work by increasing the activity/levels of these chemicals in our brains.”
Students are still expected to deliver that paragraph almost word-for-word to the simulated patient, then reassure them that antidepressants are not addictive and quote the familiar 50–65 % improvement figure at three months (against 25–30 % on placebo).
Everything else in the guide is up to date: side-effects are listed honestly, discontinuation problems are properly described, risks are not minimised. Only the explanatory model itself feels like it belongs in a different era.
Thirty years after many of us first began quietly questioning the simple chemical-imbalance story, a major British medical school continues to examine students on their ability to repeat it.
We now have:
• Joanna Moncrieff et al.’s 2022 umbrella review which found no consistent evidence linking depression to lower serotonin concentration or activity;1
• A growing literature (including Michael Hengartner’s 2021 book Evidence-biased Antidepressant Prescription) documenting how publication bias, outcome-reporting bias, and inflated baseline severity have led to over-estimation of clinical benefit, particularly in milder cases;2
• Repeated demonstrations that published trial efficacy has been considerably overstated, and long-term cohort studies that point again and again to social reconnection, agency and meaningful occupation as the strongest predictors of sustained recovery.
None of this is secret knowledge. Most consultants I speak to accept these points without hesitation in private conversation. Yet the teaching slides and the mark schemes change very slowly.
I am not criticising the authors of the revision guide; they inherited the script just as today’s students do. I simply wonder whether the moment has come to bring the examined explanation into line with what most of us now quietly acknowledge.
Patients are not helped by being told their suffering is caused by a proven neurochemical deficit that tablets correct. They are helped by an honest, calm conversation about what we do and do not yet understand, and by decisions taken together on the basis of the evidence we actually possess.
Could we agree on a short, clear, evidence-congruent paragraph that students can safely learn and examiners can accept? One that keeps all the practical information and the reassurance, but gently drops the part that no longer stands up.
I think our students would be grateful, and our patients certainly deserve it.
- Moncrieff J, et al. The serotonin theory of depression: a systematic umbrella review of the evidence. Molecular Psychiatry, 2022.
- Hengartner MP. Evidence-biased Antidepressant Prescription: Overmedicalisation, Flawed Research, and Conflicts of Interest. Palgrave Macmillan, 2021.
About the author
Evgeny Legedin is a trainee psychiatrist working in Glasgow, Scotland. He has a long-standing interest in critical psychiatry, evidence-based practice and the honest communication of uncertainty to patients.
