Channel 4 News / Ways to Change the World Interview
Date: 16 April 2025
Presenter: Krishnan Guru-Murthy (K.G-M.)
Guest: Professor Joanna Moncrieff, Professor of Psychiatry at UCL (J.M.)
Introduction and Vision for Change
K.G-M.: My guest this week is Joanna Moncrieff. Now Joanna is a psychiatrist and is perhaps the leading sceptical voice in the use of anti-depressants to treat depression. She has written widely, she’s appeared in a lot of media, and she’s a controversial figure. Her latest book is called Chemically Imbalanced: The Making and Unmaking of the Serotonin Myth. Joanna, how would you change the world?
J.M.: I would radically de-medicalise our understanding and treatment of mental health problems. I think that understanding things like depression, anxiety, ADHD, etc. as if they are medical problems that arise from the brain is harmful to the individuals themselves. I don’t think it leads to good outcomes, and I think it’s harmful to society because it distracts our attention from what is actually making people unhappy and stressed in the first place.1 And so I would relocate help for people with mental health problems out of medical facilities, out of GP surgeries, probably to somewhere like social services where they wouldn’t be treated for a diagnosis, for their label, but actually helped to deal with the problems that had made them unhappy or anxious or stressed in the first place.
K.G-M.: So you’re not talking about just replacing drugs with therapy. You’re talking about tackling the underlying causes of depression.
J.M.: Yes, absolutely. I mean, I do think therapy is helpful for some people in some situations, but I don’t think it’s a panacea.2 And I think the main problem is that we think of people who are depressed as having this thing called “depression”. And we treat the depression rather than helping the individual with their individual difficulties.
No Biological Basis for Depression
K.G-M.: I mean, there are between eight and nine million people, we think, being treated for depression with anti-depressants in Britain at the moment. And it’s thought to be a growing diagnosis post-pandemic – big increase in mental health treatment. And what you’re saying is there’s nothing biologically wrong.
J.M.: Yes, I am saying that we haven’t found evidence that there is a biological process that causes this condition, if we want to call it a condition.3
The Serotonin Myth
K.G-M.: What is the serotonin myth that you think you’re correcting?
J.M.: One of the biological theories of depression that was proposed several decades back now was the idea that depression is due to a deficiency of certain brain chemicals, and serotonin was one of the brain chemicals that was suggested to be relevant in depression in particular. So this was referred to as the serotonin theory of depression. It was articulated by medical researchers back in the 1960s. There was a big project to try and detect abnormalities in serotonin and other brain chemicals that were proposed in the 1970s and 80s. They didn’t find anything. The theory sort of fell out of favour in the 1980s, but then it was recruited by the pharmaceutical industry when they released the SSRIs in the late 1980s and early 1990s to help to market that range of drugs. And that’s when this idea that depression is caused by a chemical imbalance became really widely known by the general public and featured in advertisements and on pharmaceutical industry websites and that sort of thing.3
K.G-M.: That is not an explanation that is used now for depression or for prescribing SSRIs, but you’re saying that’s still a common misunderstanding.
J.M.: Well, I think the question has to be: if anti-depressants are not correcting a serotonin deficiency or some other chemical imbalance, as they were initially said to be doing, then what are they doing? That’s a slightly different question.
K.G-M.: I mean, what I’m trying to tackle – to get answers – what you think is wrong with the way things are prescribed at the moment is: do you think people who go on to anti-depressants still think that this is the reason, and what’s your evidence for that?
J.M.: I think there’s an assumption by the medical profession as well as by patients that anti-depressants work by targeting some underlying biological abnormality, and yet that has not been demonstrated.3 And there is another way that anti-depressants work which is not presented to patients and not widely acknowledged.
Antidepressants as Mind-Altering Drugs
K.G-M.: So are you saying that SSRIs are a bit like alcohol?
J.M.: Absolutely. They change the way you feel. Anti-depressants are mind-altering, brain- and mind-altering drugs, like alcohol, like cannabis, etc. That doesn’t mean that the effects that they produce are exactly the same as the effects that alcohol produces, but in principle they do the same thing. They change our mental states – quite subtly in the case of many anti-depressants, but nevertheless they do produce these changes, particularly this characteristic emotional numbing.4
K.G-M.: Isn’t there something bigger here though about our whole approach to medicine – that too many people think that scientists really understand how medicines work? We’ve got very used to just taking pills to make things better, and the truth is that a lot of it is just trial and error. We don’t really know.
J.M.: Yeah, I do think we put far too much faith in medical pronouncements or the pronouncements of medical research or neuroscience findings, and those can be over-interpreted. But I think that taking something, for example for pain – people often cite the fact that we don’t know exactly how paracetamol works – is different from taking something that is changing your mental state, like alcohol as you say, and therefore changing your thoughts and feelings by changing your brain chemistry. We do that with alcohol. We recognise that if you take a lot of alcohol you’ll probably temporarily feel better, feel less depressed or less anxious, but we don’t regard that as a sensible long-term solution to feeling low or fearful. And so I think that way that anti-depressants are working, those effects that they have, need to be clearly explained to people so that they can make properly informed decisions about whether they want to take brain- and mind-altering substances to address their emotional problems.
Evidence Base for Antidepressants
K.G-M.: So you think there is no use for anti-depressants, is that right?
J.M.: So I think that the evidence base for anti-depressants shows that they are probably not very beneficial. They are minimally different from a placebo, and that difference is probably explained by the fact that people in these randomised control trials who are meant not to know whether they get the placebo or the anti-depressant probably do know in a lot of cases, and that gives the people who are taking the anti-depressant an amplified placebo effect.5 So I think that’s probably what explains the small difference between anti-depressants and placebo – but it’s very small anyway.
K.G-M.: Just to be clear on that, the evidence is that there is an improved outcome for people on anti-depressants, isn’t there? It’s slightly better than if you’re just on a placebo.
J.M.: It’s slightly better, yes. And your hypothesis is that people somehow know…
K.G-M.: What’s that based on?
J.M.: So there are trials where people have asked the participants to guess whether they’re taking the anti-depressant or the placebo. In most of those – not all, but in most of those – people can guess more accurately than would be predicted by chance what they’re taking. And then we also know from some studies that what you guess you’re taking has really quite a strong impact on outcome. It can improve your depression scores by quite a bit more than the difference between the drug and the placebo.5
K.G-M.: Isn’t there a bit of a problem with summarising that because people are correctly guessing that they’re on the drug rather than the placebo – they’re probably guessing that because they’re feeling better?
J.M.: Yeah, absolutely, so that’s been proposed by people. The trouble is it’s also been shown in negative trials where there’s no difference between the drug and placebo that people who guess they’re on the active drug do better than people who guess they’re on the placebo, regardless of what they’re actually taking.5
K.G-M.: I suppose the summary position for you is that you don’t think the medical trial outcome which shows that people are better off taking anti-depressants than not is sufficiently good for it to be scientifically sound.
J.M.: I don’t think that it justifies the mass prescribing of anti-depressants. But another really important point is that we’ve assumed that what anti-depressants are doing is correcting some underlying biological process that leads to the symptoms of depression. We don’t have evidence of that. That was the paper that I did on the serotonin hypothesis – that’s what sparked me writing the book.3 And there’s another way that anti-depressants might be working or might be having their effects when people take them for depression, and that is that they’re not inert. They are drugs that change our normal brain chemistry and by doing so change our normal mental states, our normal feelings, thought processes, etc. They’re not massively strong drugs in this respect – most of the anti-depressants that we use nowadays – but they do induce feelings of emotional numbing. They numb people’s positive and negative emotions, and they have been shown to do this in volunteers as well as people with depression. And of course if you give people with depression a drug that numbs them a bit, that may be what’s reducing their depression scores compared to placebo, as well as this amplified placebo effect.4
Criticisms and Straw Man Argument
K.G-M.: One of the criticisms around your work is that you’ve created a straw man – an imaginary myth – which is that this explanation around brain chemistry… when if you go on the NHS website or if you look up any of the charity websites, they’re pretty clear they don’t say there’s a problem with your serotonin, therefore go on one of the many common anti-depressants.
J.M.: Lots and lots of medical websites have told people that there’s a problem in their brain chemistry historically. They have started to correct that over the last few years – some have corrected it since we published the paper on serotonin and depression.3 But the thing is, if you don’t tell people this other explanation – that these drugs are altering your brain chemistry and thereby altering your normal mental states – then people will assume, particularly after all the promotion that’s come from the pharmaceutical industry persuading people that depression was a chemical imbalance, that the drugs are targeting some underlying abnormality. So they’re being fixed.
Mass Prescribing and Pharmaceutical Influence
K.G-M.: At the moment anti-depressants are doled out very, very easily by GPs who are not psychiatrists. How have we got into that situation?
J.M.: Well, that’s a really good question. I think there are a number of factors. The first is that the pharmaceutical industry has promoted anti-depressants very heavily since the release of SSRIs in the early 1990s. So GPs and psychiatrists have been deluged with advertising and promotional material. Another reason is that doctors want to be able to help people, and what does a doctor usually do? They give you a pill, they give you a prescription. And psychiatrists in particular want to feel that they have a medical solution for a common mental health complaint that is depression. And people themselves, of course – the idea that you could get rid of really troubling feelings with a pill is appealing.
K.G-M.: Patients ask for SSRIs now, don’t they? They don’t go to the doctor and say “What can I do?” They’ll say “I think I need to take anti-depressants.”
J.M.: I think there are some patients that come to doctors like that, but I think there are also many patients that come to doctors and are not sure really whether they should be taking a drug or not. And so I do think that the encounter with a doctor is an opportunity to de-medicalise the situation and try and suggest other approaches to people.
Therapy vs. Antidepressants
K.G-M.: We do have a national therapy service now in the UK… there are other options.
J.M.: Yeah, it will start within a few weeks – the basic level of the NHS talking therapy service.
K.G-M.: But therapy often doesn’t work, does it?
J.M.: No, not always. But I don’t think that anti-depressants help either.2
K.G-M.: Billions of people are taking them and presumably a lot of them feel that they are being helped… otherwise they wouldn’t carry on taking them.
J.M.: Which is why we need to look at the randomised control trials and recognise that actually most of the effect of the anti-depressant is a placebo effect. And a placebo effect, of course, is about having some hope that you will get better… The trouble is that I think anti-depressants are giving people false hope, and a lot of people may feel better initially, but actually there will come a point when they realise that the anti-depressant isn’t working any more or they’ve still got problems, and then they can often feel even worse because they feel, “Oh gosh, I’ve had the treatment that’s supposed to work. It’s not working for me. I must be a really specially severe case. What on earth am I going to do?” And that can put people in an even worse place.5
Placebo Effect and Agency
K.G-M.: Even if it was, let’s say, 75% placebo, why does that matter if it’s not harming them?
J.M.: Because it’s reaffirming this idea that the problem is in your brain and that you need a drug to fix it. And we know that people who have that idea actually have worse outcomes than people who don’t, who think that depression is a reaction to circumstances. People who view depression in that way have a stronger belief that they can do something to help themselves and affect their circumstances.1
K.G-M.: Why do you think it’s better to tell somebody that the problem isn’t your brain, the problem is your mind – which is an even more amorphous, difficult thing to try and understand?
J.M.: I suppose it gives people more agency. If you locate the problem in the brain then you need a medical biological intervention to deal with it. If it’s to do with you and your life and your circumstances, then there are ways to change those.1
K.G-M.: A lot of people don’t feel they can change their circumstances. That’s often the cause of depression, isn’t it?
J.M.: Yes it is. And some people are in circumstances that are very difficult to change. I still don’t think we have evidence that anti-depressants help in that situation.1
Long-Term Use and Withdrawal
K.G-M.: So you don’t think the evidence that so many people are taking it for so long is evidence that they are helpful?
J.M.: I think it’s evidence that they’re unhelpful… What happens is people take anti-depressants for a bit, maybe think they are doing a bit better… often when people start an anti-depressant they’re at their lowest point… But when they try and come off it they might experience some withdrawal symptoms – which can include anxiety, low mood, changeable mood, tearfulness – so often people will think they’re getting depressed again and put themselves back onto the drug and not realise that what they were going through is withdrawal. And so people end up taking these drugs for long periods of time. I think that’s evidence, first of all, that they’re not working, but also that people are becoming dependent on them and finding it difficult to get off them.6
Rising Mental Health Crises and Societal Factors
K.G-M.: Why do you think there are so many more cases of mental health crisis being reported now?
J.M.: First of all, the public have been educated for decades now that negative emotions are medical problems and they should go and see their doctors about them… And I think it’s also to do with factors in society. We’ve become a very competitive society… For many people life has got, of course, we’ve got a cost-of-living crisis… job employment has become less secure and precarious, housing of course is a huge problem. So there are lots and lots of social factors that I think give rise to stress among adults and younger people.1
K.G-M.: Do you think people want the diagnosis?
J.M.: I think some people have come to believe that they have a medical problem and that a medical label would be helpful for them… people are desperately looking for explanations.
K.G-M.: It does feel a little bit, listening to you, like you are basically saying “it’s all in your head” in a sort of academic kind of way.
J.M.: So I’m saying that there are real problems out there in society that make people feel stressed and anxious and unhappy, and we need to address those problems. And I think actually the people who are saying “it’s in your brain” are the people who are making it less likely that we’re going to resolve the problems that are making people unhappy and distressed and anxious in the first place.1
Alternative Approaches and Feasibility
K.G-M.: How realistic is it then to try and treat eight or nine million people a different way?
J.M.: Well, we have radically changed the way that we treat back pain, for example… I think that we can make large changes in medicine actually… In fact it’s already started. We have social prescribing now in general practices… What I’m saying is I think we need to take that further. I think we need to actually locate that sort of help outside of the NHS.
Advice for Those on Antidepressants
K.G-M.: There’s going to be a lot of people listening who are on anti-depressants. What should they do?
J.M.: So I think that people should – if they want to question, if they want to rethink being on anti-depressants, if they want to think about the possibility of coming off them – do some reading, discuss it with friends and family, and then go and see their doctors and make a plan to come off their anti-depressant slowly and carefully and at the right time.6
K.G-M.: Don’t read your book and just stop.
J.M.: No, don’t read my book and throw the drugs in the bin, because it’s very important to say that might make the withdrawal process a lot worse.6
Evidence for Talking Therapies and Spontaneous Recovery
K.G-M.: In terms of the evidence base for talking therapies and other therapies, how good is that?
J.M.: The evidence is that talking therapies are as good as anti-depressants… I think that this idea that we’re treating a disease is one of the problems… so it’s very unlikely that there’ll be something that just works in that sort of medical sense.2
K.G-M.: It’s quite a bleak outlook you’re offering, isn’t it?
J.M.: In some ways… I’m really not saying that… Most people will get better from depression because most people recover from depression spontaneously without anti-depressants… I think it’s really important to say most people recover from depression spontaneously… and giving anti-depressants to people is actually making that less likely, certainly less likely in the long run… I think it’s actually a much more hopeful message that you actually have the resources in yourself to deal with this problem.7
K.G-M.: Joanna Moncrieff, thank you very much indeed.
J.M.: Thank you.
- Nguyen TT, et al. Biological, Psychological, and Social Determinants of Depression: A Review of Recent Literature. Brain Sci. 2021;11(12):1633.
- Cox GR, et al. Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. Cochrane Database Syst Rev. 2014;2014(11):CD008324.
- Moncrieff J, et al. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry. 2022;27(8):3349-3356.
- Moncrieff J. Antidepressants: misnamed and misrepresented. World Psychiatry. 2015;14(3):347-348.
- Moncrieff J, et al. Active placebos versus antidepressants for depression. Cochrane Database Syst Rev. 2004;(1):CD003012.
- Moncrieff J, et al. Evidence on antidepressant withdrawal: an appraisal and reanalysis of a recent systematic review. Psychol Med. 2025.
- Whiteford HA, et al. Estimating remission from untreated major depression: a systematic review and meta-analysis. J Affect Disord. 2013;148(1):18-27.
