The Politics of Deprescribing: Deconstructing the HHS Mental Health Agenda

Since May 2026, Department of Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. has promoted an initiative to restructure U.S. mental health delivery. The plan heavily emphasizes "prevention and holistic treatments" while actively discouraging the use of psychiatric medications, under the premise that they are widely overprescribed—especially in children.

A May 4, 2026 memo outlines the core strategy: addressing the "mental health crisis" by making deprescribing (tapering and discontinuing medications) and annual pharmacological reviews reimbursable services, alongside launching federal webinars to teach clinicians how to taper patients off medications.

While these proposals may sound progressive to the public, they collapse under scientific scrutiny for three primary reasons.

1. The Myth of Overprescribing

The administration's central premise—that the mental health crisis is driven by overmedication—is medically inaccurate.

• The Reality of Undertreatment: Up to 23% of the U.S. population has a treatable psychiatric condition warranting antidepressants, yet only a fraction of those individuals receive a prescription.

• Non-Psychiatric Indications: Antidepressants are heavily prescribed for non-psychiatric, FDA-approved or clinically indicated conditions, including migraines, tension headaches, chronic pain, fibromyalgia, and smoking cessation. Studies show that 50% to 64% of all antidepressant prescriptions are written for these non-psychiatric diagnoses [4-8].

• The Gap: When accounting for these physical health prescriptions, only about a quarter of Americans who actually need antidepressants for psychiatric conditions are receiving them. The real crisis is undertreatment, not overmedication [11-13]. Primary care settings miss or misdiagnose depression 40% to 50% of the time, and there is a 90% gap between individuals diagnosed with depression and those receiving clinically effective treatment [14].

2. Redundant "Solutions" to Standard Medical Training

The proposal to have HHS educate doctors on tapering is highly redundant and ignores existing clinical infrastructure.

• Tapering is Foundational Medicine: Psychiatrists and primary care physicians are already trained in tapering and discontinuing medications. Clinicians have been acutely aware of antidepressant discontinuation syndrome since the first case report in 1959, and it has been standard textbook material since at least 1993.

• Complex Cross-Tapering: In practice, stopping a medication rarely happens in a vacuum. Clinicians routinely manage highly complex transitions—such as cross-tapering (stopping one drug while initiating another) or managing patients who arrive with shopping bags full of conflicting medical and psychiatric prescriptions.

• Existing Resources: Detailed clinical guidance on switching and stopping antidepressants has been readily available in industry-standard databases like UpToDate for over 18 years [9,10]. Rather than funding political webinars, a far more effective HHS initiative would be providing free UpToDate access to all practicing U.S. clinicians.

• Routine Care vs. Political Incentives: Assessing medication efficacy, side effects, and whether to continue, adjust, or stop a drug is already a mandatory component of every standard psychiatric visit. Rebranding this routine care as a newly incentivized "deprescribing service" is purely rhetorical.

3. The Clinical Danger of Forced Deprescribing

Both the American Psychiatric Association (APA) and the American Foundation for Suicide Prevention (AFSP) have issued sharp responses to the HHS initiative:

• The APA strongly objects to defining the mental health crisis as an issue of "overprescribing."

• The AFSP warns that aggressive, medically unsupported "deprescribing" carries severe risks, including increased all-cause mortality, cardiovascular mortality, suicidal behavior, completed suicides, decreased quality of life, and long-term disability.

The Double Standard: Fast-Tracking Psychedelics

While the administration seeks to restrict standard, rigorously studied psychiatric medications, it simultaneously pushes to expedite the review and approval of innovative psychedelics (e.g., psilocybin, noribogaine, and methylone/MDMC) under "Right to Try" laws [19-23].

This presents a glaring policy contradiction:

• High Risks: These compounds carry documented risks of severe psychiatric, cardiac, and systemic side effects (such as QT interval prolongation and arrhythmias linked to ibogaine) [22,23].

• No Infrastructure: Administering psychedelic therapy safely requires intensive, highly staffed clinical infrastructure that the current healthcare system does not possess.

• Hypocrisy: It is ideologically inconsistent to demand less medication use while fast-tracking high-risk, under-studied substances with relaxed regulatory oversight.

The Broader Landscape of Public Health Misinformation

The antidepressant initiative is part of a broader, systemic pattern of health policy distortion outlined below (and in the lead table):

Scientific Debunking vs. Public Policy (from lead table)

Misinformation Claim	Scientific & Empirical Reality	Citation(s)
Vaccines cause autism	Long-debunked conspiracy theory; actively promoted by RFK Jr. to undermine public trust in vaccines.	[1]
SSRIs cause mass shootings	Debunked. Mass shootings correlate heavily with firearm density, not antidepressant use. Meanwhile, the administration is actively rolling back firearm restrictions for the mentally ill.	[1]
Diet/Keto replaces schizophrenia meds	No clinical evidence supports this. While RFK Jr. claims a ketogenic diet can "cure" schizophrenia, medical consensus remains that clozapine and standard antipsychotics are the gold standard.	[2, 16]
SSRIs are "more addictive than heroin"	Scientifically false statement made by RFK Jr. during his confirmation hearings. Retraction was formally demanded by 25 members of Congress in March 2025.	[2]
Acetaminophen causes autism	Not supported by rigorous sibling-controlled genetic analyses.	[3, 4]
Alcohol is a healthy social beverage	Promoted by CMS Administrator Mehmet Oz. Directly debunked by modern dietary analyses showing no safe level of alcohol consumption.	[14, 15]

The Policy Fallout: Cutting Resources While Mandating Treatment

The administration's legislative agenda, highlighted by H.R. 1 / One Big Beautiful Bill Act (OBBBA) and Executive Orders 14321, 14379, and 14401, represents a systematic defunding of the mental health safety net under the guise of reform.

1. The Homelessness Mandate (EO 14321)

This order effectively ends "Housing First" policies by making federal housing assistance contingent upon unhoused individuals entering mandatory psychiatric and substance use treatment [17].

• The Error: It ignores the reality that homelessness increases are driven primarily by a lack of affordable housing, not sudden spikes in mental illness.

• No Support: It broadens civil commitment powers without building the clinical infrastructure or beds needed to house or treat these individuals.

2. Dismantling Harm Reduction (EO 14379 & 14401)

The "Great American Recovery Initiative" restructures national addiction policy by stripping away proven harm reduction tools [18].

• The Damage: It bans the distribution of fentanyl test strips, defunds medication-assisted treatment (MOUD) programs that do not force annual drug tapering, and bans the very term "harm reduction" from federal programs.

• Data Blackout: It effectively suspended the National Survey on Drug Use and Health (NSDUH), blinding researchers to national addiction and mental health trends, while imposing sweeping budget cuts on SAMHSA.

3. Stripping Medicaid (OBBBA / H.R. 1)

Medicaid is the nation's largest payer of mental health and substance use disorder care, and the primary funding vehicle for addressing Social Determinants of Health (SDOH) (housing, food security, and transportation) [24-29].

• The Cuts: The bill slashes $911 billion from Medicaid over the next decade to offset $4.5 trillion in tax cuts.

• The Toll: Economists estimate these cuts will strip health coverage from 7.6 million to 16 million Americans, resulting in 16,642 to over 140,000 medically preventable deaths annually [24,26].

• The Demographics: These cuts disproportionately harm rural communities, Black and Hispanic populations, perinatal care, and those seeking addiction treatment—all while 92% of Medicaid recipients already meet work and eligibility requirements.

Conclusion: Rhetoric Over Reality

When health policy is systematically distorted, we must look at the underlying political strategy. The current administration relies heavily on creating rigid in-groups and out-groups, framing public health officials, scientists, academics, and social advocates as "enemies" who are oppressing their core demographic.

The HHS antidepressant and "deprescribing" initiative is not a sincere effort to improve clinical care. It is a rhetorical distraction. By framing the mental health crisis as a personal failure of "overprescribing" doctors and "drugged" citizens, the administration conveniently avoids addressing the structural, economic, and social determinants of health—all while actively dismantling the financial and clinical infrastructure that keeps vulnerable Americans alive.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  Not loving the table.  I tried everything possible to convert my 4 page Word table that is the basis for this post to a single continuous image.  I also tried pasting it directly into this post without any success.  The table alone was too large for the Blogger format and I could not find any way in the HTML to modify the size.  The expected continuous images were too narrow and I could not resize them.  Until I find a way - just click on each table page and it is readable.  The references in the table are in the table and not at the bottom of the post.

References:

1:  WTAS: HHS Launches MAHA Action Plan to Curb Psychiatric Overprescribing.  https://www.hhs.gov/press-room/wtas-hhs-launches-maha-action-plan-curb-psychiatric-overprescribing.html

An embarrassing collection of attention seekers and compromisers.  Note how the APA position reads compared with the link above.

2: Centers for Medicare & Medicaid Services.  The Mental Health Parity and Addiction Equity Act (MHPAEA): https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity  (accessed 07/13/2026)

3: Kessler, Glenn (January 23, 2021). "Trump made 30,573 false or misleading claims as president. Nearly half came in his final year". The Washington Post. Archived from the original on January 24, 2021.

4:  Mojtabai R, Olfson M. Proportion of antidepressants prescribed without a psychiatric diagnosis is growing. Health Aff (Millwood). 2011 Aug;30(8):1434-42. doi: 10.1377/hlthaff.2010.1024. PMID: 21821561.

5: Rhee TG, Rosenheck RA. Initiation of new psychotropic prescriptions without a psychiatric diagnosis among US adults: Rates, correlates, and national trends from 2006 to 2015. Health Serv Res. 2019; 54: 139–148. https://doi.org/10.1111/1475-6773.13072

6:  Wong J, Motulsky A, Abrahamowicz M, Eguale T, Buckeridge DL, Tamblyn R. Off-label indications for antidepressants in primary care: descriptive study of prescriptions from an indication based electronic prescribing system. BMJ. 2017 Feb 21;356:j603. doi: 10.1136/bmj.j603. PMID: 28228380; PMCID: PMC5320934.

7:  Zhang X, Nie X, Shi L. Treatment indications for antidepressants prescribed in primary health care facilities in Beijing, China. Int Psychogeriatr. 2025 Aug;37(4):100057. doi: 10.1016/j.inpsyc.2025.100057. Epub 2025 Mar 12. PMID: 40074596.

8:  Camacho-Arteaga LF, Gardarsdottir H, Ibañez L, Souverein PC, van Dijk L, Hek K, Vidal X, Ballarín E, Sabaté M. Indications related to antidepressant prescribing in the Nivel-PCD database and the SIDIAP database. J Affect Disord. 2022 Apr 15;303:131-137. doi: 10.1016/j.jad.2022.02.001. Epub 2022 Feb 5. PMID: 35134393.

9: Hirsch M, Birnbaum RJ.  Antidepressant discontinuation syndrome and discontinuing antidepressants in adults.  UpToDate.  Accessed 7/15/2026:  https://www.uptodate.com/contents/antidepressant-discontinuation-syndrome-and-discontinuing-antidepressants-in-adults

10:  Hirsch M, Birnbaum RJ.  Switching antidepressant medications in adults.  UpToDate.  Accessed 7/15/2026:  https://www.uptodate.com/contents/switching-antidepressant-medications-in-adults

11:  US Preventive Services Task Force. Screening for Depression and Suicide Risk in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2023;329(23):2057–2067. doi:10.1001/jama.2023.9297

12:  Jackson-Triche  ME, Unützer  J, Wells  KB.  Achieving mental health equity: collaborative care.   Psychiatr Clin North Am. 2020;43(3):501-510. doi:10.1016/j.psc.2020.05.008

13:  Wang  PS, Angermeyer  M, Borges  G,  et al.  Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization’s World Mental Health Survey Initiative.   World Psychiatry. 2007;6(3):177-185.

14:  Vigo D, Haro JM, Hwang I, et al. Toward measuring effective treatment coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder. Psychol Med. 2022 Jul;52(10):1948-1958. doi: 10.1017/S0033291720003797. Epub 2020 Oct 20. PMID: 33077023; PMCID: PMC9341444.

15:  White A, Thornton RLJ, Greene JA. Remembering Past Lessons about Structural Racism - Recentering Black Theorists of Health and Society. N Engl J Med. 2021 Aug 26;385(9):850-855. doi: 10.1056/NEJMms2035550. PMID: 34469642

16:  McCoy J, Rahman T, Somer M. Polarization and the global crisis of democracy: Common patterns, dynamics, and pernicious consequences for democratic politics. American behavioral scientist. 2018 Jan;62(1):16-42.

17:  Mason L. Uncivil agreement: How politics became our identity. University of Chicago Press; 2022 Dec 22.

When politics is your identity merged with other identities like race, religion, local culture – the intensity toward out-group hostility intensifies because it seems like an existential threat - but - it is not.  

More Lessons From Dermatology......

 

I have several dermatological ailments and fortunately a very good clinic of dermatologists.  The main problems have been atopic dermatitis (eczema) that did not start until I was 65 and rosacea starting slightly later.  I have posts on the pathophysiology of these conditions at the links.  I have the predisposing factors including genetics, ethnicity (fair-skinned individuals of Celtic and northern European heritage (Fitzpatrick skin types I–II), and associated conditions (childhood and adult allergic asthma) but did not get the associated atopic dermatitis at the time.  One of my siblings had both in childhood.  My father probably had rosacea but he lived during a time when dermatology treatment was generally not done by dermatologists and quite primitive. By primitive I mean, physicians tried to excise inflammatory areas from his face instead of treating them medically like they do now.

The global prevalence of rosacea is estimated at 5.46% (4).  Women are affected more than men and peak prevalence occurs in middle age (45-60 years old).  In a study that looked at how many people were untreated – the prevalence was 12.3% in Germany and 5% in Russia.  Nearly half of those affected had not received any care in the previous year despite 1/3 endorsing a significant effect on quality of life (5).  In addition to cosmetic effects rosacea is a cause of dry eyes and other significant ocular complications and sensitive skin lowering the threshold for pain and irritation.

I was doing quite well until I needed a change in sleep apnea treatment.  Three months ago I changed from APAP to BiPAP because of an increasing AHI.  Because it was running at much higher pressure, they suggested using a mask rather than nasal CPAP.  That mask led to a flareup of rosacea that required a month of treatment with doxycycline.  But even after that treatment I was left with a 4-5 mm inflammatory nodule beneath my right eye that did not resolve. 

I saw a new dermatologist today and the conversation went something like this:

Me:  “This started about 3 months ago when I tried a CPAP mask and it caused a flare-up of rosacea.  This nodular area did not clear with doxycycline.  At about 2 weeks the area of inflammation extended up into the orbital area but stopped there ever since.

Derm:  “Are you still using the triple cream?”

Me:  “Yes twice a day.  It generally works great.”

Derm:  Inspects the area with a dermatoscope in detail and then: ’Yes, it looks like inflammation.  There may be some microabscesses in the area.  It does not look like cancer or infection.  What we need to do is try a different antibiotic for a month and then if it doesn’t clear up – do a biopsy.  I am going to prescribe cefuroxime after we make sure there are no drug interactions.  I notice you are on flecainide.  We were told never to prescribe it so I want to make sure it does not interact.”

His scribe ran a drug interaction check. I set up an appointment to see him in a month and picked up the prescription for cefuroxime.  On the way to the pharmacy, I recalled enrolling patients in a cefuroxime trial for urinary tract infections.  And then I tried to recall all of the serious side effects of cephalosporins – the class of antibiotics that cefuroxime is in.  That is just the way my mind works. 

What are the lessons about psychiatry here?  I don’t think the lessons are for psychiatrists because we know better.  The lessons are basically to counter all of the misinformation about psychiatric treatment and medications from antipsychiatrists, health and wellness influencers, and other critics who don’t seem to know very much about the field.  Here goes:

1:  Diagnoses are not easy – and experts are more likely to make them and even then most are provisional.  In all my teaching about diagnostic thinking in medicine pattern matching is a significant component.  Dermatologists and ophthalmologists are the examples I typically used comparing their diagnoses to other physicians. In this case, the question is what any other physician would have diagnosed the mark on my face as and how it would have been treated.  I have actually been there and done that and it would vary from no diagnosis or treatment to acne and metronidazole. 

2:  Transdiagnostic – yes probably – you would think the term had been invented for psychiatry in the last 10 years.  It is typically used as a criticism of categorical diagnosis as in “there are just so many transdiagnostic symptoms nothing is specific?”  And "all of this comorbidity is a strike against categorical diagnoses."  The reality is there are many so-called transdiagnostic symptoms across all of medicine and many of them are more robust than psychiatric symptoms.  Rash is one of the more robust.  Rashes are transdiagnostic across the 2,000 to 3,000 conditions that produce similar rashes across disorders as well as within the same category.  There are many different rashes (intermediate phenotypes) presenting as rosacea for example, in this case a solitary inflammatory papule.

3:  No labs?  There is no lab test for rosacea or most dermatology conditions. They are clinical diagnoses made on that basis considering all of the findings at the time of the exam.

4:  Is there a biopsy result specific for rosacea?  This is a familiar criticism of psychiatric diagnoses – there is no specific test that rules in the diagnosis. From reference 1 below: “A skin-biopsy specimen is obtained only to rule out other diagnoses, since the histopathological features of rosacea are typically not specific to rosacea.”  Rosacea is a clinical diagnosis based on history and phenotypic criteria and no specific diagnostic test is needed to confirm it (3).

4:  Prevalence and Quality of Life Considerations – prevalence and quality of life considerations for rosacea and common psychiatric disorders are similar. 

 

Rosacea studies looked at pooled prevalence (5.46%) and geographic prevalence (Germany 2.1–12.3%, Russia 5.0%, U.K. incidence rate 1.65 per 1,000 person-years (the only study to quantify incidence) rather than interval prevalence (4-6).  Rosacea is not reported in the same intervals as psychiatric disorders because it is considered a chronic relapsing condition even though a segment of these specific psychiatric disorders has that same property.  There is no cure - another frequent criticism of psychiatric diagnoses.  

Although dermatology and psychiatry use different quality of life (QoL) impairment scales, in the respective disorders about 11% of rosacea patients report severe impairment and anxiety and depressive disorders report ranges of 26-85% using a cut-off of 2 standard deviations over average community ratings (7).  There are also comorbidity considerations with high percentages of rosacea patients reporting significant levels of depression and anxiety. 

5:  Under and missed diagnoses – deference to expert diagnosis is a time-honored tradition in medicine with a more recently established empirical basis. Overall diagnostic accuracy for dermatology conditions is 37-57%.  Roughly ½ of these conditions are incorrectly diagnosed in primary care compared with dermatologists (8). That rate of misdiagnoses is similar to the rate for anxiety and depressive disorders in primary care of 40-50% (9-11).

6:  Under treatment – undertreatment follows underdiagnosis in most cases, but undertreatment can also occur when the diagnosis has been established.  In the case of rosacea delayed diagnosis can lead to progressive (granulomatous) disease and ocular complications. Seborrheic dermatitis is also a frequently co-occurring condition and patients are often unaware that they have this condition as well.

Not treating depression and anxiety on a timely basis leads to similar chronicity and conditions more resistant to treatment.  It increases both the risk of suicide and self harm with chronicity. Untreated depression and anxiety are risk factors for cardiovascular disease and substance use. Chronic pain can be increased.  Both conditions are well documented causes of significant disability.

7:  Uncertain pathophysiology – The pathophysiology of most psychiatric disorders where the possible cause has been ruled out is not known.  The same is true for rosacea.  In any similar group of medical disorders there are commonly suggested hypotheses that can be grouped by general mechanism as indicated in the table below:

8:  Uncertain medication mechanism of action/placebo response -  Since the underlying pathophysiological is unknown the mechanisms of action of the recommended treatments is unknown for rosacea and psychiatric disorders.   This means that clinical trials are needed to test the efficacy and safety of treatments and clinical care follows.

Comparisons of response rates in a selection of antidepressant and rosacea medication trials show significant placebo response in both with a slightly higher response rate in the rosacea trials (66% v. 50%).  At the same time the metrics used for effect size in both tables are not comparable.  If we change to a comparable metric like Number Needed to Treat (NNT) we see ranges of 3-8 for rosacea and 4-6 for antidepressants.  On that basis it is fair to say that response rates to rosacea medication and antidepressants are generally comparable.

The strict comparison is limited by the fact that studies have different outcome measures.  Rosacea studies use a clinician rated global improvement score.  Antidepressant trials may also have a global improvement score but more likely use clinical scales like the HAM-D or MADRS.  Both types of ratings have a consensus marker for improvement but they are not calibrated against one another.    The placebo response rates may have different mechanisms.  Both may have a regression to the mean and clinical care/therapeutic alliance component but the rosacea trials can also be affected by atmospheric conditions and additional topicals that can affect skin moisture.  Rosacea trials tend to be longer than antidepressant trials (12-16 weeks versus 8-12 weeks).

There is a question of real-world effectiveness with both conditions.  It has been studied in depression (12). It was found that for MDD, there is a 90% gap between those with the diagnosis and this receiving effective treatment (41.8% receive treatment and of those only 23.2% of those diagnosed received effective treatment.)  The RISE study (5) suggests that in a screened population for rosacea,  80% were never previously diagnosed.  Of the 20% who were 47.5% had received no rosacea care whatsoever, and only 23.7% had received topical and/or systemic drugs suggesting similar underdiagnosis and treatment as depression.   

Whenever clinical trials of antidepressant are discussed, some critics say that the lack of hard outcomes (all-cause mortality, cause-specific mortality (MI, stroke, suicide), hospitalization) as opposed to symptom-based outcomes is a major problem.  In the comparison with rosacea – all of the outcome measures are symptom-based and no evidence that treatment prevents associated or long-term complications like rhinophyma, telangiectasia, or ocular complications.  There are register based/naturalistic studies (outside of clinical trial design) that show long term use of antidepressants reduces all cause mortality, suicidal ideation, and cardiovascular mortality (13-17).  Not all analyses agree and in some cases the argument was made that it was an antidepressant class effect (18,19).  Rosacea on the other hand has not been studied against an all cause mortality endpoint because it is not associated with increased mortality.    

9:  On label - off-label -  There are currently 40 FDA approved medication for depression and 10 FDA approved medications for rosacea.  Antidepressant development dates back to the 1950s  when it was discovered that medications used to treat tuberculosis also had positive effects on mood.  Rosacea medication development began as an early topical antibiotic treatment (Sodium sulfacetamide 10%/sulfur 5% for papules/pustules).  That early treatment was before 1962.  The next development did not occur until topical metronidazole in 1988.  The only oral antibiotic approved is doxycycline 40 mg MR (Oracea) that is a combination of doxycycline 30 mg IR and doxycycline 10 mg delayed release (DR).  There are no combination medications approved despite the fact that there are compounded formulations.  As an example the Rosacea triple cream contains metronidazole, ivermectin, and azelaic acid.  Each component is FDA approved for monotherapy.    

10: Politicalization – the only real criticism I have seen of dermatologists was comedic. In an episode of Seinfeld, Jerry was trivializing what dermatologists do until he was reminded that they diagnose and treat skin cancer.  Despite the parallels to psychiatry, they have no anti-factions or health and wellness influencers suggesting they are creating more problems than they solve or negative media coverage or high visibility criticism by experts in their own field.  The head of HHS is not suggesting their treatments are overprescribed.

There is no great agitation over dermatology – their methods or treatments despite similar levels of uncertainty and clinical methods with psychiatry.  I am not suggesting there should be.  I am suggesting that psychiatry should be approached by outsiders with the same levels of acceptance that they have for dermatology.  I am also suggesting that if you have a skin condition and nobody seems to be able to diagnose or treat it – see a dermatologist. The advice applies to a mental disorder.  See an expert in that field. 

I know this does happen but there is always a delay.  And there is always plenty of misinformation about the field.  As I have posted here before – practically all of the people I saw over my 40-year career had seen somebody else first – often many different people over a number of years before they decided to see a psychiatrist. It was often the result of a referral decision.  But most importantly – don’t believe what you read in the papers whether it is health and wellness advice or recommendations by the current Secretary of HHS. 

If there is a serious problem with your mental state – see the right person.

 

George Dawson, MD, DFAPA

 

1:  van Zuuren EJ. Rosacea. N Engl J Med. 2017 Nov 2;377(18):1754-1764. doi: 10.1056/NEJMcp1506630. PMID: 29091565.

2:  Frazier W, Zemtsov RK, Ge Y. Rosacea: Common Questions and Answers. Am Fam Physician. 2024 Jun;109(6):533-542. PMID: 38905551.

3:  Dirr MA, Ahmed A, Schlessinger DI, et al. Rosacea Core Domain Set for Clinical Trials and Practice: A Consensus Statement. JAMA Dermatol. 2024 Jun 1;160(6):658-666. doi: 10.1001/jamadermatol.2024.0636. PMID: 38656294.

4:  van Zuuren EJ, Arents BWM, van der Linden MMD, Vermeulen S, Fedorowicz Z, Tan J. Rosacea: New Concepts in Classification and Treatment. Am J Clin Dermatol. 2021 Jul;22(4):457-465. doi: 10.1007/s40257-021-00595-7. Epub 2021 Mar 23. PMID: 33759078; PMCID: PMC8200341.

4:  Gether L, Overgaard LK, Egeberg A, Thyssen JP. Incidence and prevalence of rosacea: a systematic review and meta-analysis. Br J Dermatol. 2018 Aug;179(2):282-289. doi: 10.1111/bjd.16481. Epub 2018 May 31. PMID: 29478264.

5:  Tan J, Schöfer H, Araviiskaia E, Audibert F, Kerrouche N, Berg M; RISE study group. Prevalence of rosacea in the general population of Germany and Russia - The RISE study. J Eur Acad Dermatol Venereol. 2016 Mar;30(3):428-34. doi: 10.1111/jdv.13556. PMID: 26915718; PMCID: PMC5067643.

6:  Hilbring C, Augustin M, Kirsten N, Mohr N. Epidemiology of rosacea in a population-based study of 161,269 German employees. Int J Dermatol. 2022 May;61(5):570-576. doi: 10.1111/ijd.15989. Epub 2021 Dec 12. PMID: 34897653.

7:  Rapaport MH, Clary C, Fayyad R, Endicott J. Quality-of-life impairment in depressive and anxiety disorders. Am J Psychiatry. 2005 Jun;162(6):1171-8. doi: 10.1176/appi.ajp.162.6.1171. PMID: 15930066.

8:  Bridges C, Morris C, McElroy JA, Quinn K, Dyer J, Becevic M. Utility of Dermatology Extension for Community Healthcare Outcomes (ECHO) sessions in the adult and paediatric population. J Telemed Telecare. 2021 Jul;27(6):376-381. doi: 10.1177/1357633X19874200. Epub 2019 Sep 16. PMID: 31526083.

9:  US Preventive Services Task Force. Screening for Depression and Suicide Risk in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2023;329(23):2057–2067. doi:10.1001/jama.2023.9297

10:  Jackson-Triche  ME, Unützer  J, Wells  KB.  Achieving mental health equity: collaborative care.   Psychiatr Clin North Am. 2020;43(3):501-510. doi:10.1016/j.psc.2020.05.008

11:  Wang  PS, Angermeyer  M, Borges  G,  et al.  Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization’s World Mental Health Survey Initiative.   World Psychiatry. 2007;6(3):177-185.

12:  Vigo D, Haro JM, Hwang I, et al. Toward measuring effective treatment coverage: critical bottlenecks in quality- and user-adjusted coverage for major depressive disorder. Psychol Med. 2022 Jul;52(10):1948-1958. doi: 10.1017/S0033291720003797. Epub 2020 Oct 20. PMID: 33077023; PMCID: PMC9341444.

13:  Chan JKN, Solmi M, Lo HKY, Chan MWY, Choo LLT, Lai ETH, Wong CSM, Correll CU, Chang WC. All-cause and cause-specific mortality in people with depression: a large-scale systematic review and meta-analysis of relative risk and aggravating or attenuating factors, including antidepressant treatment. World Psychiatry. 2025 Oct;24(3):404-421. doi: 10.1002/wps.21354. PMID: 40948054; PMCID: PMC12434377.

14:  Lagerberg T, Fazel S, Sjölander A, Hellner C, Lichtenstein P, Chang Z. Selective serotonin reuptake inhibitors and suicidal behaviour: a population-based cohort study. Neuropsychopharmacology. 2022 Mar;47(4):817-823. doi: 10.1038/s41386-021-01179-z. Epub 2021 Sep 24. PMID: 34561608; PMCID: PMC8882171.

15:  Gusmão R, Quintão S, McDaid D, Arensman E, Van Audenhove C, Coffey C, Värnik A, Värnik P, Coyne J, Hegerl U. Antidepressant Utilization and Suicide in Europe: An Ecological Multi-National Study. PLoS One. 2013 Jun 19;8(6):e66455. doi: 10.1371/journal.pone.0066455. PMID: 23840475; PMCID: PMC3686718.

16:  Korkeila J, Salminen JK, Hiekkanen H, Salokangas RK. Use of antidepressants and suicide rate in Finland: an ecological study. J Clin Psychiatry. 2007 Apr;68(4):505-11. doi: 10.4088/jcp.v68n0403. PMID: 17474804.

17:  Pan YJ, Yeh LL. Associations between mortality and exposure to psychotropic medication: A population-based cohort study for depressive disorders. Aust N Z J Psychiatry. 2023 Sep;57(9):1253-1262. doi: 10.1177/00048674221145337. Epub 2023 Jan 11. PMID: 36629047.

18:  Zhou S, Wang C, Zhang Y. Antidepressant use and all-cause mortality in depressed individuals: A real-world cohort study. PLoS One. 2025 Jul 11;20(7):e0327844. doi: 10.1371/journal.pone.0327844. PMID: 40644427; PMCID: PMC12250549.

19:  Zhuang X, Chen W, Zhan Y, Feng X, Liu C. Antidepressant selection modifies survival in depression: A National Cohort Study Using NHANES 2005 - 2018 data. Gen Hosp Psychiatry. 2026 Jan-Feb;98:33-40. doi: 10.1016/j.genhosppsych.2025.12.001. Epub 2025 Dec 3. PMID: 41351935.

20:  Andrade C. A Primer on How to Critically Read an Observational Study on Adverse Medical Outcomes Associated With Long-Term Antidepressant Drug Use. J Clin Psychiatry. 2022 Dec 7;83(6):22f14733. doi: 10.4088/JCP.22f14733. PMID: 36479952.

21:  Egeberg A, Fowler JF Jr, Gislason GH, Thyssen JP. Nationwide Assessment of Cause-Specific Mortality in Patients with Rosacea: A Cohort Study in Denmark. Am J Clin Dermatol. 2016 Dec;17(6):673-679. doi: 10.1007/s40257-016-0217-1. PMID: 27480418.

22:  Egeberg A, Hansen PR, Gislason GH, Thyssen JP. Assessment of the risk of cardiovascular disease in patients with rosacea. J Am Acad Dermatol. 2016 Aug;75(2):336-9. doi: 10.1016/j.jaad.2016.02.1158. PMID: 27444070.

Chemical Imbalance Theory - Meme, Trope or Metaphor?

 

A while back I posted about how the “chemical imbalance theory” was a meme that originated in pharmaceutical advertising and all of the evidence to support that observation. This post is about whether that was really a trope and also why psychiatrists should not do too deep of a dive into the neurobiology of medications as a reaction. My concern about the deep dive came from something I saw on LinkedIn, that made the mistake of taking chemical imbalance quite literally rather than the rhetoric commonly used by the detractors of psychiatry.  The suggested strategy was outlining the known neurobiology of antidepressants – a strategy I do not favor.

First things first.  The difference between a meme and a trope has always seemed poorly delineated.  Richard Dawkins is credited with defining a meme as a unit of cultural transmission for evolutionary purposes.  Common modern usage is that it is an image, piece of text, or video that spreads rapidly on the internet and is adapted by various users.  A famous example is the Bernie Sanders mitten meme. A trope is a recurring theme or literary device used in storytelling that audiences immediately recognize.  It is a figure of speech.  In advertising the tropes may be less explicit.  Some examples include a white coat expert speaking authoritatively about a product, the suggestion that a product either directly or indirectly makes you more attractive or successful, or the suggestion that a product makes you more savvy or competent.

Here is a direct comparison between memes and tropes across key cultural and linguistic dimensions (1).

Considering all of the dimensions and definitions the chemical imbalance theory is possibly one of the most effective advertising tropes ever used.  At the time that the first SSRIs and SNRIs were approved by the FDA, all of the companies involved were focused on this trope.  From my original post - the chemical imbalance theory was also referred to when bupropion was marketed in the negative sense that it was “non-serotonergic” and had “minimal risk of sexual dysfunction”.  Some of the ads included a rough scorecard of receptor activity.  These medications were being marketed like potential customers were neurochemists and the mechanism of action of the medications were known.  As noted in the core definition in the above table, the figurative language of chemical imbalance is a shortcut to bypass a very complex process.

An additional consideration of an advertising trope is that it can also be turned into a meme and I think this occurred. In those pre-Internet days, early SSRI advertising overlapped with National Depression Screening Day.  Exposure of attendees and physicians at that screening was thorough and people in the community were being exposed to the same trope in TV and magazine ads.  It was not long before I started to encounter patients in the late 1990s that wanted to know if they had a chemical imbalance.

The academic literature at the time did not reflect the term and has not ever since.  The originators of the monoamine hypothesis of depression were much more circumspect – considering depression to be a complex multifactorial disorder that could not be explained by a simple change in monoamines. Since that era there have been over 100 hypotheses about depression with many carried forward to current times.  The serotonin based theories of depression have faded rapidly over the past 2 decades even though serotonergic systems are important for brain function and sophisticated in vivo monitoring has shown that antidepressants of several classes all increase extraneuronal serotonin levels.  As noted in the above link, Charney and Nestler’s text currently aggregates depression hypotheses under neurotrophic, immune, and neuroendocrine headings.  The specifics at this point are lacking and since depression is a heterogenous condition with multiple known medical and substance induced etiologies it will take subtypes that are clearly defined by more than written criteria.  At some point I hope to provide a more detailed map, but for now I will get back to the trope rather than the science.

The detractors of psychiatry can always be counted upon to throw a trope at the wall and see what sticks.  What better trope to use than a wildly successful one from Pharma marketing?  Just add that psychiatrists are intellectually dishonest and are just selling pharmaceuticals like drug companies and pretending to know the cause of depression and the mechanism of action of antidepressants. You might even extend that rhetoric to suggest that psychiatrists need to cling to that certainty in order to legitimize themselves in medicine.

Is any of that rhetoric legitimate? First, all FDA approved package inserts have a Mechanism of Action section.  For many medications that section has a complete or provisional statement about the mechanism of action being unknown (14-18).  In the case of antidepressants, the mechanism of action is generally listed as involving monoaminergic transporters or receptors at some level.  Second, in reviews of drug targets in general antidepressant and antipsychotic medications are listed with respective targets like most other medications in clinical use (19).  Third, and most importantly – there is a tendency to think of rhetoric, memes, tropes, and metaphor as being limited to arts and literature.  Cognitive scientists and linguists view these dimensions as the foundational mechanics of human communication and there is ample evidence that they are used in every discipline – including medicine and science.

At least part of the issue is that tropes, memes, and metaphors are not really part of the mainstream of medical or scientific literature. Nothing will be found in neurology, psychiatry, or even neuroscience texts.  It is generally covered by linguists or researchers who identify as both linguists and cognitive psychologists. That literature is useful to read because of the overlap with cognitive psychology and also how these foundational mechanics of language are used on a daily basis.  It provides an additional dimension for analysis of the literature in your primary field. It goes beyond language disorders and aphasias noted in medical practice.

The following table is a compilation of the current theories of metaphor – since that is the basis for many (but not all) tropes.  It shows how metaphors are theoretically more or less efficient and the main mechanism of action.  Interestingly the suggested mechanisms are basically processing metaphors.  In reading about modern theories of metaphors, it is clear that the landscape has changed to one that sees much human communication as being dependent on metaphors and the line between literal and figurative language as being much less clear.  Beyond that metaphors are seen as foundational cognitive mechanisms rather than just linguistic or literary devices.

In Conceptual Metaphor Theory (CMT) the mapping is a simplified or mechanistic view of the brain is mapped onto a complex (multifactorial/multidimensional) emotional state.  Once that is established the result is reasoning from that state suggests that correcting the imbalance with correct the associated stated. The cognitive load is decreased because thinking about all of the real neuroanatomy and neurophysiology is not necessary.  The reasoning is more like keeping your car full of gas or oil to keep it running.

Categorization Theory (CT) states that two unlike categories are not mapped but instead a new superordinate category is created.  The example in this case would be the category of things with mechanical or material deficiencies. This category includes things that are depleted and in need of repair like broken automobiles or vitamin deficiencies.  The brain and the car both do not work because of a material deficiency and once that is identified they can be repaired.

Career of Metaphor Theory (COMT) says that metaphors shift over time as they become more familiar.  They start out as active comparisons as suggested in the first two theories but eventually become their own categorizations as dead metaphors.  A dead metaphor no longer requires the active comparison. For example, early in the course chemical imbalance could be compared with another deficiency diseases like diabetes, but as time goes on and it is more accepted chemical imbalance is accepted as equivalent to depression without any imagination of the chemistry involved.

Deliberate Metaphor Theory (DMT) draws a distinction between metaphors that are used unconsciously and those that are introduced deliberately. The intentional metaphors are more often used rhetorically.  In this case, chemical imbalance was used intentionally as a marketing device to explain or legitimize the use of antidepressants.  It also shifts explanatory power away from environmental or psychological causes to biological ones.

As I read about these theories, I recalled the first time I was confronted with the chemical imbalance theory back in the 1980s.  It was presented to me by two pharmaceutical representatives.  As a guy with considerable biochemistry and chemistry experience my reaction was: “It sounds like you are saying the brain is just a bag of chemicals.”  They were not very happy with me.  But this approach and the theory did not have any traction with me.  There is concern within the science community about the use of metaphor and the possible inadequacies.  With chemical imbalance theory there are several including: it does not adequately describe the level of complexity involved, it does not accurately reflect the scientific literature, it creates a level of certainty that does not exist, and it has led to a trope where it is accepted at a political rather than a scientific level.

For all of these reasons, no psychiatrist should be using this trope clinically.  In the general population it is pervasive to the point that I have talked with patients who tell me how they are trying to correct their chemical imbalance.  The people I am referring to have never seen a psychiatrist and are trying to correct that imbalance by using street drugs.  They often have an elaborate scheme about how they can selectively increase various neurotransmitters to get certain effects. They were shocked when I advised them that things don’t work that way.

Returning to the reason for this post, what is necessary to say to most people for adequate and ethical informed consent?  I have reviewed this in several posts on this blog (20-26). Informed consent about both the diagnosis and treatment intervention is critical and it needs to be adapted for the abilities and preferences of every patient.  When I saw the reaction to the problems of the chemical imbalance trope being countered by the suggestion that psychiatrist present more detailed neurobiological information – I thought it reflected a lack of understanding of clinical reality and here is why:

1:  It does not reflect what most people want.  People come in to see psychiatrists at the last possible moment. The people I saw over the course of my career had already seen primary care physicians and therapists.  They were seeing me because nothing has worked.  In some cases, they had specific concerns about treatments or medications and wanted those concerns addressed initially.  That is often the easiest unasked question.

2:  Discussing alternate treatments and a no treatment option.  In the process I clarify my role as providing the best possible advice based on current science.

3:  In the case of medications – discussing my experience with the recommended medication including time course of response, typical side effects, rare but serious side effects, and indications to call me.  I also included a statement that most people wait too long to call or decide that they might “get used to” a side effect but that I prefer they call me about it.  

4:  A discussion of the therapeutic alliance, how that works, and the informed consent aspects.  This is often referred to as “shared decision-making” these days.  I will always prefer the models of therapeutic alliance and informed consent as a better fit for psychiatric practice.

5:  A discussion of other metaphors and tropes.  There are many more out there today due to the internet and popular science sites promoting them.  Just a few examples – “rewiring your brain”, “neuroplasticity”, “cleaning/cleansing your brain”, “reprogramming your brain”, brain as a "switchboard", brain regions as an "orchestra", need for brain "reset", brain as "hardware" and mind as "software", etc.  They are often used as a reason for diet, exercise, branded psychotherapies, self help, even a walk in the outdoors.  As far as I know none are used rhetorically and repeatedly by antipsychiatry despite the fact that many of the claims overblown.

Effective treatment should be what the informed consent decision is based on and that does not require that everyone become a neuroscientist any more than receiving dental care requires everyone to become an expert in teeth.       

This post has been an interesting excursion into linguistics, cognitive psychology, and rhetoric.  I discovered an entire field of metaphorical linguistics that I was unaware of.  Metaphor and simile are concepts right out of freshman English composition – but the idea that metaphor is a cognitive process is much more current.  The progression of metaphors over time is consistent with the conversion of episodic memory into semantic memory.  I have not been able to confirm whether any of the metaphor theorists believe that at this point or whether it has been written down anywhere.  I do encourage caution in using metaphors in psychiatry and agree with Kendler’s thesis that we do not need to avoid biological reality in discussions with patients. At the same time Kendler saw the need for metaphorical brain talk as arising out of the need for a brain focus combined with an explanatory gap, status anxiety over a clear underlying pathology, and a wish that we may eventually get to the deeper understanding of the brain that we all seek.  This missing piece is from linguistic theory that metaphor is a basic cognitive mechanism that we all use and the evidence is all of the depression tropes well beyond chemical imbalance at this point.     

In conclusion, meme, trope or metaphor - chemical imbalance has utility from a linguistic perspective and that may be why it persists at a rhetorical level today.  There is also overlap with the goals of that rhetoric as pejorative and I would argue it has attained dead metaphor status in that regard and therefore is not a term any psychiatrist should use.  

George Dawson, MD, DFAPA

 

Supplementary 1:

If you are a cognitive psychologist or linguist - I am interested in references that you would consider state of the art about the role of metaphor in cognition.

Supplementary 2:

This post reminded me that as a senior psychiatry resident, I was fortunate enough to have an office down the hall from two excellent speech and language pathologists. We had many great discussions about language, speech, and cognition.  That happened at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin.

References:

1:  Animétudes.  Postmodern Media : Memes and Database Consumption.  May 3, 2020:  https://animetudes.com/2020/05/03/postmodern-media-memes-and-database-consumption/

2:  Kole M. Science fiction tropes: a guide for writers.  Good Story Company.  October 2019:  https://www.goodstorycompany.com/science-fiction-tropes

3:  Everywriter R.  100 science fiction tropes. Everywriter May4, 2024:  https://www.everywritersresource.com/100-science-fiction-tropes/

4:  TV Tropes.  Science fiction:  https://tvtropes.org/pmwiki/pmwiki.php/Main/ScienceFiction

5:  Taylor C, Dewsbury BM. On the problem and promise of metaphor use in science and science communication. Journal of microbiology & biology education. 2018 Mar;19(1):10-128.

6:  Bradie M. Science and metaphor. Biology and Philosophy. 1999 Apr;14(2):159-66.

7:  Reynolds AS. Understanding metaphors in the life sciences. Cambridge University Press; 2022 Apr 28.

8:  Mahootian F. Metaphor in chemistry: An examination of chemical metaphor. In: Philosophy of Chemistry: Growth of a New Discipline 2014 Oct 19 (pp. 121-139). Dordrecht: Springer Netherlands.

9:  Muller CH, Rau MA. Instructional analogies dominate, domain-inherent metaphors are overlooked: A systematic review of metaphorical mappings in chemistry education. Journal of Chemical Education. 2025 Jun 6;102(7):2576-91.

10:  Rodriguez X, Arroyo-Santos A. The function of scientific metaphors: An example of the creative power of metaphors in biological theories. InThe paths of creation. Creativity in science and art 2011 Jan (Vol. 9, pp. 81-96). Peter Lang Publishing Group Bern.

11:  Swiatczak B. Understanding life through metaphors: Andrew S. Reynolds: Understanding metaphors in the life sciences. Cambridge: Cambridge University Press, 2022, xx+ 200 pp,£ 11.99 PB.

12:  Veit W, Ney M. Metaphors in arts and science. European Journal for Philosophy of Science. 2021 Jun;11(2):44.

CT doesn’t mean all metaphors in science are legitimate. Just like some metaphors in artistic works are bad in various ways – bland, tasteless, confusing,etc. – some in science might be bad. Neither does it imply that the same criteria need to be used in evaluating metaphors in science as in the arts.

13:  Fernyhough C.  Metaphors of the mind.  British Psychological Society.  The Psychologist.  June 18, 2006:  https://www.bps.org.uk/psychologist/metaphors-mind

14:  FDA Package Insert: nortriptyline.

The mechanism of mood elevation by tricyclic antidepressants is at present unknown. Pamelor is not a monoamine oxidase inhibitor. It inhibits the activity of such diverse agents as histamine, 5-hydroxytryptamine, and acetylcholine. It increases the pressor effect of norepinephrine but blocks the pressor response of phenethylamine. Studies suggest that Pamelor interferes with the transport, release, and storage of catecholamines.

15:  FDA Package Insert: fluoxetine.

Although the exact mechanism of PROZAC is unknown, it is presumed to be linked to its inhibition of CNS neuronal uptake of serotonin.

16:  FDA Package Insert: venlafaxine.

The exact mechanism of the antidepressant action of venlafaxine in humans is unknown, but is thought to be related to the potentiation of serotonin and norepinephrine in the central nervous system, through inhibition of their reuptake. Non- clinical studies have demonstrated that venlafaxine and its active metabolite, ODV, are potent and selective inhibitors of neuronal serotonin and norepinephrine reuptake and weak inhibitors of dopamine reuptake.

17:  FDA Package Insert: bupropion.

The exact mechanism of the antidepressant action of bupropion is not known, but is presumed to be related to noradrenergic and/or dopaminergic mechanisms. Bupropion is a relatively weak inhibitor of the neuronal reuptake of norepinephrine and dopamine, and does not inhibit the reuptake of serotonin. Bupropion does not inhibit monoamine oxidase.

18:  FDA Package Insert: vortioxetine.

The mechanism of the antidepressant effect of vortioxetine is not fully understood, but is thought to be related to its enhancement of serotonergic activity in the CNS through inhibition of the reuptake of serotonin (5-HT). It also has several other activities including 5-HT3 receptor antagonism and 5-HT1A receptor agonism. The contribution of these activities to vortioxetine’s antidepressant effect has not been established.

19:  Santos R, Ursu O, Gaulton A, Bento AP, Donadi RS, Bologa CG, Karlsson A, Al-Lazikani B, Hersey A, Oprea TI, Overington JP. A comprehensive map of molecular drug targets. Nat Rev Drug Discov. 2017 Jan;16(1):19-34. doi: 10.1038/nrd.2016.230. Epub 2016 Dec 2. PMID: 27910877; PMCID: PMC6314433.

20:  The Spectrum of Caring About Medication Information:  https://real-psychiatry.blogspot.com/2014/05/the-spectrum-of-caring-about-medication.html

21:  Vigilance Is Required for Adequate Informed Consent:  https://real-psychiatry.blogspot.com/2019/04/vigilance-is-required-for-adequate.html

22:  The New Black Box Warning on Benzodiazepines:  https://real-psychiatry.blogspot.com/2021/03/the-new-black-box-warnings-on.html

23:  The Problem of Antidepressant Discontinuation:  https://real-psychiatry.blogspot.com/2018/06/the-problem-of-antidepressant.html

24:  2000 Words About the Last Ten Minutes of a Psychiatric Evaluation:  https://real-psychiatry.blogspot.com/2019/07/2000-words-about-last-ten-minutes-of.html

25:  Therapeutic Alliance - A Better Diagram:  https://real-psychiatry.blogspot.com/2017/09/therapeutic-alliance-better-diagram.html

26:  Components of Patient Outcome:  https://real-psychiatry.blogspot.com/2018/10/components-of-patient-outcome.html