Earlier this month, nine members of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) wrote to their College President, Associate Professor Vinay Lakra, requesting that the RANZCP immediately remove a misleading webpage that claimed that antidepressants and other psychiatric 'medications work by rebalancing the chemicals in the brain'.
The nine psychiatrists were concerned that this misinformation 'reflects poorly on the College and seriously misleads consumers'. Along with their criticism, they offered their substantial collective research and clinical expertise to help the College review its online resources.
Their letter (3 September 2022) was written in response to President Lakra's reply (23 August) to an earlier letter sent to him by us, the PsychWatch Australia Editorial Team (12 August). All three letters are copied below.
The letter from the nine RANZCP members appears to have had the desired effect. On Friday 16 September President Lakra advised PsychWatch Australia that the misleading webpage 'will be unpublished while a thorough review is conducted.'
As detailed in the last PsychWatch Australia blog, our original letter was critical of the RANZCP for continuing to promote the discredited myth that medications balance brain chemistry, and for putting 'a positive spin on the safety and efficacy of medications that does not reflect reality'.
In his initial reply, RANZCP President Lakra did not address our concerns about the safety and efficacy of medications. He did acknowledge that the claim that medications rebalance brain chemicals is 'technically not accurate'; however, he claimed that 'the mechanism is very complex and it can be very difficult to find a word that matches the science in lay language'.
As the nine RANZCP members pointed out, the problem is not that the 'mechanism is complex', but rather that there is great uncertainty about the mechanism. Current scientific understandings are rudimentary at best. Compared with other aspects of medicine, very little is known about how biochemistry, brain, body and behaviour interact.
It was therefore misleading for President Lakra, in his initial reply to us, to imply that the problem is that the public would not understand the science. The truth is that settled science explaining the mechanisms of mental health medications simply does not exist.
Despite these initial shortcomings, to his credit President Lakra has taken onboard the advice of the nine RANZCP fellows and decided to remove the webpage and conduct a review of the College's online resources. This decision will help to prevent ongoing damage to the College's credibility. More importantly, it has helped to ensure that consumers visiting the RANZCP website are no longer misled.
Although it would have been better if the RANZCP had never misled consumers, PsychWatch Australia applauds President Lakra's action. We are also very grateful for the involvement of the nine RANZCP members – Professor Jon Jureidini, Dr Paul Denborough, Dr Mark Horowitz, Dr Sam Lieblich, Dr Niall McLaren, Professor Peter Parry, Dr Robert Purssey, Associate Professor Carolyn Quadrio, and Dr David Ward.
Moving forward, we urge President Lakra and the College to accept the offer from these nine College members to assist the RANZCP with the review of its online material. These ethical and experienced psychiatrists have much to offer.
by Dr Martin Whitely and Dr Melissa Raven, Editorial Team, PsychWatch Australia.
19 September 2022
Note: At the time of publication of this blog the misleading RANZCP webpage was still accessible, however as promised it was removed shortly afterwards.
Dear Associate Professor Lakra
President, RANZCP
9 August 2022
Re: Misleading information on the RANZCP website claiming psychotropic 'medications work by rebalancing the chemicals in the brain'
We are writing to request that the Royal Australian and New Zealand College of Psychiatrists (RANZCP) correct its webpage titled Medications for Mental Illness[1] and the linked fact sheet pdf [copy below]. Both foster the false belief that medications address chemical imbalances.
You are probably aware of research recently published that demonstrated that there is ‘no [evidentiary] support for the hypothesis that depression is caused by lowered serotonin activity or concentrations’.[2] This research has been widely accepted as finally debunking the myth that depression is caused by a chemical imbalance.
However, some experts, including Melbourne psychiatrist Professor Christopher Davey, have claimed that the chemical imbalance theory of depression was already known to be invalid well before the research was published. Professor Davey claims ‘few psychiatrists with an understanding of the nuance of brain function believed the chemical imbalance theory’.[3]
It is difficult to reconcile Davey’s claim with the RANZCP’s assertion that medications rebalance brain chemistry. If Davey is correct, and competent psychiatrists have long known that this is false, why does Australia and New Zealand’s peak professional organisation for psychiatrists continue to promote this falsehood?
Although the recent research relates only to antidepressants, the RANZCP webpage and the fact sheet pdf refer to all medications* for mental illness, including amphetamine-like stimulants used to treat attention deficit hyperactivity disorder (ADHD).
For many years, the increasingly discredited dopamine theory was promoted as the likely cause of ADHD.[4] However, research indicates that the extended use of amphetamine-type stimulants may permanently impair dopaminergic pathways.[5] So, rather than normalising or ‘rebalancing’ brain function, the long-term administration of amphetamine-type stimulants appears to cause permanent brain damage.
It is frequently claimed that stimulants affect the brains of people with ADHD differently. However, the truth is that, with a low dose of stimulants, most people (irrespective of their ADHD status) become more compliant.[6] Furthermore, when the drugs wear off, there are often ‘rebound’ or withdrawal effects that can worsen ADHD-type behaviours.[7] Witnessing the rebound effect often reinforces parents’ and teachers’ belief that the child is chemically imbalanced without the drug and that he or she needs to keep taking medication.
It is absurd to assert that amphetamine-type stimulants ‘rebalance’ or in any sense ‘balance’ brain chemistry. Their effects are extremely short-acting. They create inconsistent (i.e. unbalanced) brain chemistry and temporarily interfere with brain and body biochemistry, and behaviour. It is, therefore, grossly irresponsible for the RANZCP to reinforce false beliefs that chemically unbalanced ADHD brains are rebalanced by taking medications.
Similar criticisms could be made for other drugs that the RANZCP suggests rebalance brain chemistry. We therefore contend that, in addition to correcting the misleading webpage and fact sheet pdf, the RANZCP should publicly acknowledge that it has published misleading information.
These criticisms are not the only ones we could make about the webpage and the fact sheet pdf. They put a positive spin on the safety and efficacy of medications that does not reflect reality. Adverse effects are referred to as 'side effects', downplaying their severity. It is claimed that 'Side effects will often feel worst in the first week, then get better over time'. There is no mention of adverse effects that can emerge after months or years, such as tardive akathisia and tardive dyskinesia. Patients deserve more accurate and balanced information.
We intend to publish this letter on the PsychWatch Australia website and we would like to simultaneously publish your response. To give you the opportunity to adequately consider the issues raised, we will delay publication until at least Monday 22 August 2022. In the meantime, we would welcome the opportunity to discuss the issues we raise with you.
Yours sincerely
Dr Martin Whitely and Dr Melissa Raven PsychWatch Australia Editorial Team psychwatchaustralia@gmail.com
*The medications listed on the RANZCP fact sheet pdf that claims 'medications work by rebalancing the chemicals in the brain' include antidepressants, antipsychotics, benzodiazepines, mood stabilisers and [amphetamine type] stimulants.
References
[1] RANZCP Medication for mental illness. https://www.yourhealthinmind.org/treatments-medication/medication
[2] Moncrieff, J, et al.The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatr 2022 https://doi.org/10.1038/s41380-022-01661-0 https://www.nature.com/articles/s41380-022-01661-0
[3] Davey C. The chemical imbalance theory of depression is dead – but that doesn’t mean antidepressants don’t work. The Conversation. 3 August 2022. https://theconversation.com/the-chemical-imbalance-theory-of-depression-is-dead-but-that-doesnt-mean-antidepressants-dont-work-187769
[4] Gonon F. The dopaminergic hypothesis of attention-deficit/hyperactivity disorder needs re-examining. Trends Neurosci. 2009 Jan;32(1):2-8. doi: 10.1016/j.tins.2008.09.010. https://pubmed.ncbi.nlm.nih.gov/18986716/ https://www.cell.com/trends/neurosciences/fulltext/S0166-2236(08)00247-6
[5] Wang G-J et al. Long-Term Stimulant Treatment Affects Brain Dopamine Transporter Level in Patients with Attention Deficit Hyperactive Disorder. PLOS ONE 8(5), e63023. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0063023
[6] Furman L, ‘What is Attention-Deficit Hyperactivity Disorder (ADHD)?’, Journal of Child Neurology, Vol. 20 No. 12, 2005, p. 998. https://journals.sagepub.com/doi/10.1177/08830738050200121301 https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.985.3161&rep=rep1&type=pdf https://www.researchgate.net/profile/Lydia_Furman/publication/7354308_What_Is_Attention-Deficit_Hyperactivity_Disorder_ADHD/links/5555e9b508ae6fd2d8232e29.pdf
[7] Rapoport JL, et al., ‘Dextroamphetamine: cognitive and behavioural effects in normal prepubertal boys’, Science, Vol. 199, No. 4323, (3 February 1978), p. 561. [The dose was 0.5mg/kg.] https://www.researchgate.net/profile/Christy_Ludlow/publication/22798084_DextroamphetamineCognitive_and_behavioral_effects_in_normal_prepubertal_boys/links/5597e85708ae5d8f3933c33a/DextroamphetamineCognitive-and-behavioral-effects-in-normal-prepubertal-boys.pdf
Excellent work. The next question to ask is for how long have they known the information was “technically not accurate” and why did they persist to mislead the public