I had this letter published today with my co-author Ron Pies, MD. It is basically a rebuttal to a more elaborate article (linked at the top of the letter) on chemical imbalance theory. I encourage any interested reader to look at that argument and then read our brief essay on why none of it supports a chemical imbalance theory. Both Dr. Pies and I have written about this in the past – me on this blog and Dr. Pies in other literature (5-8). Several other authors have also discussed related issues (1-4, 9). I think the refutation is fairly straightforward so this blog will be about the process. Why does this along with many other inaccurate portrayals of psychiatry continue to come up in the literature? What follows is a few very clear answers but I fully realize that theses and explanations are rarely adequate to counter rhetoric.
1: Repeating
inaccurate claims is a standard strategy these days – it actually has been for
decades. The clearest modern example if
the Big Lie of the last Presidential election.
Even a comprehensive presentation of the real evidence by the January 6th
Congressional Panel is not enough to shake the belief of election
deniers. In fact – election denial has
become the latest cottage industry delivering hundreds of local lectures across
the country. Chemical imbalance theory
has a similar life of its own and a group of proselytizers. If the political comparison is too harsh – consider
the advertising approaches. Any number of products that make health claims are
sold every day based on repeating the same messages. For years alcohol carried the message that it
was a heart healthy product that increased HDL cholesterol and reduced the risk
of heart attacks. Now we know that those studies were biased because they
included alcohol users in recovery in the control group. Dietary supplements are a $62
billion dollar industry despite questionable value and some concerns about
toxicity in healthy populations with no clear nutritional deficiencies. All of
these examples illustrate the power of repetitive messaging.
2: It appeals to
anecdotal experience – a common response is “well I heard somebody say it”, “I
saw it posted on a web site”, or “my psychiatrist said it to me.” Anecdotal experiences exist and obviously we
cannot examine the intent of every statement. The reality for psychiatrists is
that in psychopharmacology and biological psychiatry lectures, in textbooks,
and in the published literature there is no reference to “chemical imbalance
theory”. In fact after reviewing the literature I
concluded that comprehensive theories really don’t exist in psychiatry. On the
other hand, over the past 40 years there have been over a hundred hypotheses
about the causes of depression.
3: There are clear
biases against psychiatry as a field – when reading authors whether in
professional journals, periodical, or books it is always useful to consider
what else they have written. Is the book or paper a one-sided harsh
criticism? Does their previous work seem
to make similar statements about the field?
It is already known that psychiatry gets much more than the expected levels
of criticism in the press. Is that
criticism warranted? In many areas of this blog, I have pointed out that it is
not warranted and, in many cases - it is grossly inaccurate.
4: There have been
no accurate histories of the intellectual development of the field. To be sure there are specialized biographies
of prominent historical figures and some of their influences but no clear
timeline of how developments build on previous thought. I recently read that
now that one of these historical figures has “scholars” rather than clinicians
describing his work – we could expect much more, but I am not seeing it. To me –
people who train and teach in the field are still the primary keepers of the working
intellectual development of the field and everything that is relevant.
Given all of these factors what can readers of our published letter do with that information? If you are a psychiatrist or a physician – think carefully about your use of terms. If you have used the term “chemical imbalance theory” or just “chemical imbalance” as a metaphor or something else – please reconsider. I think it is more useful to patients to let them know that depression or other clinical entities cannot be reduced to a single chemical event and I would invite you to use a statement from Nicholas Giarman – a noted neuropharmacologist:
“…nosologically it might be fair to compare the
depressive syndrome with the anemias. Certainly, no self-respecting
hematologist would subscribe to a unitary biochemical explanation for all of
the anemias.”
Nicholas J Giarman (1920-1968) – The Biochemical
Basis of Neuropharmacology – Fourth Edition 1982. p. 212
An explanation of heterogeneity and brain function would be
ideal, but given time constraints and variable expectations of patients – an
illustration of biological complexity is superior to a hopelessly inadequate
metaphor. The same is true for literature that is handed out to patients. In
that case, quoting the typical disclaimers in FDA approved package inserts as
well as a brief summary of the research evidence for specific patients is a
more optimal approach.
That is the real take home message.
George Dawson, MD, DFAPA
Supplementary 1: What about advice to patients? If you are considering taking an antidepressant
or any other medication as a patient that usually means you are having a
significant problem that you expect help with. The literature critical of
psychiatry often suggests that this decision is casually made but that is not
my experience either as a patient or a prescribing physician. Consider what is
written about the mechanism of action of antidepressants. Chemical Imbalance
Theory often implies that there has been dishonesty in presenting how a
medication works and by extrapolation that psychiatrists don’t know much about
anything. In fact, there are probably very few medications that you take where
the mechanism of action is known with any high degree of certainty. Aspirin was used for 70 years before its mechanism
of action was determined (10). Acetaminophen was first used clinically in
1887 and a preliminary report suggesting several potential mechanisms of action
became available in 2009 (11). Most decisions to take medications are not
made based on knowing a mechanism of action. The overemphasis on mechanism of
action of antidepressants is most likely based on pharmaceutical company
advertising in the 1980s and 1990s. At
that time, the manufacturers of newer antidepressants emphasized that they were
novel agents that probably worked through different mechanisms than the older
medications and had a more favorable side effect profile.
As a patient you are entitled to as much detail on
mechanism of action as you want and I hope that you will be able to get it
directly from your physician or from other sources. I have treated basic scientists
for depression and bipolar disorder and was able to give them adequate
information – so it is definitely out there. But at a practical level – every person
with a significant problem wants relief from that problem and no additional
problems. The clinical discussion needs to be focused on whether the medication
is working and the side effects are either non-existent or tolerable. Further – informed consent means that you
should have adequate information to make a decision about taking a medication. That includes the likelihood of severe
adverse drug events as well as more common side effects. Another common discussion
in the media these days is withdrawal from antidepressant medications. A prescribing
physician should be able to discuss that side effects in detail as well as rare
events and a plan to address them.
Credits:
1: My co-author Ron Pies, MD read this post and made valuable suggestions for modifications. It is difficult to indicate but he is a co-author of this post.
2: Eduardo A. Colon, MD took the photograph used at the top of this post.
References:
1: Morehead D. It’s
Time for Us To Stop Waffling About Psychiatry. Psychiatric Times. Dec 2, 2021
https://www.psychiatrictimes.com/view/its-time-for-us-to-stop-waffling-about-psychiatry
2: Morehead D. It’s Time for Us to Realize We Are All on the
Same Side. Psychiatric Times. Jan 18,
2022 https://www.psychiatrictimes.com/view/its-time-for-us-to-realize-we-are-all-on-the-same-side
3: Morehead D. The History of Psychiatry—A History of
Failure? Psychiatric Times. April 19, 2022
https://www.psychiatrictimes.com/view/the-history-of-psychiatry-a-history-of-failure
4: Morehead D. Is There a Cure for Ignorance? The Shocking
Truth About Psychiatric Treatment.
Psychiatric Times. June 27, 2022 https://www.psychiatrictimes.com/view/is-there-a-cure-for-ignorance-the-shocking-truth-about-psychiatric-treatment
5: Pies RW. Debunking the Two Chemical Imbalance Myths, Again. Psychiatric Times. August 1, 2019 https://www.psychiatrictimes.com/view/debunking-two-chemical-imbalance-myths-again
6: Pies RW. Nuances, narratives, and the “chemical imbalance” debate. Psychiatric Times. April 1, 2014. https://www.psychiatrictimes.com/view/nuances-narratives-and-chemical-imbalance-debate
7: Pies RW. Psychiatry’s New Brain-Mind and the Legend of the “Chemical Imbalance”. Psychiatric Times. July 11, 2011 https://www.psychiatrictimes.com/view/psychiatrys-new-brain-mind-and-legend-chemical-imbalance
8: Pies RW. Doctor, Is My Mood Disorder Due to a Chemical Imbalance? Psychiatric Times. August 12, 2011 https://www.psychiatrictimes.com/view/doctor-my-mood-disorder-due-chemical-imbalance
9: Ruffalo, M. L., & Pies, R. W. (2018, August 19). The reality of mental illness: Responding to the criticisms of antipsychiatry. Psychology Today. https://psychologytoday.com/us/blog/freud-fluoxetine/201808/the-reality-mental-illness…
11: Smith HS.
Potential analgesic mechanisms of acetaminophen. Pain Physician. 2009
Jan-Feb;12(1):269-80. PMID: 19165309.
This makes me think of Dr. Jose Maldonado’s mechanism of delirium diagram. There’s no doubt the mechanism is complicated, but the diagram’s bewildering pathways are almost comical. I usually chuckle over it. As far as I know there’s still no model that everyone agrees on.
ReplyDeleteThe same goes for catatonia, which can complicate delirium. You’d think there would be a clearer pathoetiological model for catatonia, which in many cases miraculously resolves (though usually only temporarily) within minutes of administration of a single 2 mg dose of injectable lorazepam. There is not.
Both conditions can mimic what would be called primary mental disorders including depression, anxiety, and psychosis. Are GABA and glutamate the only relevant receptors? I don’t know.