The Spurious Chemical Imbalance Theory is Still Alive and Well

On April 5, 2015, Scott Alexander, MD, a trainee psychiatrist, posted an article titled Chemical Imbalance on his website Slate Star Codex.  (The writer tells us that Scott Alexander is a blog handle and not his real name, but for convenience, I will refer to him as Dr. Alexander.)

Dr. Alexander begins by noting that there have been a number of articles recently that have criticized psychiatry for “botching the ‘chemical imbalance’ theory.”

“According to all these sources psychiatry sold the public on antidepressants by claiming depression was just a chemical imbalance (usually fleshed out as ‘a simple deficiency of serotonin’) and so it was perfectly natural to take extra chemicals to correct it.”

“This narrative is getting pushed especially hard by the antipsychiatry movement, who frame it as ‘proof’ that psychiatrists are drug company shills who were deceiving the public.”

[Actually, it’s proof that psychiatrists are either very misinformed or very deceptive.  Proving that many of them are drug company shills is a separate matter.]

. . . . .

As an example of this trend, he cites an article of mine that was published on Mad in America on June 6, 2014.  The article was titled Psychiatry DID Promote the Chemical Imbalance Theory, and was written specifically as a response to three statements made by the eminent psychiatrist Ronald Pies, MD.  Here are the three statements:

“…the ‘chemical imbalance theory’ was never a real theory, nor was it widely propounded by responsible practitioners in the field of psychiatry.” (April 15, 2012)

“In truth, the ‘chemical imbalance’ notion was always a kind of urban legend – never a theory seriously propounded by well-informed psychiatrists.’ (July 11, 2011)

“But I stand by my claim that no respected representatives of the profession seriously asserted a simple, ‘chemical imbalance’ theory of mental illness in general.” (September 2, 2011; response to comment on July 11, 2011 article)

My article was lengthy (6079 words), and I quoted seven prestigious psychiatrists in which a simplistic chemical imbalance theory was promoted unambiguously.

“In the last decade, neuroscience and psychiatric research has begun to unlock the brain’s secrets.  We now know that mental illnesses – such as depression or schizophrenia – are not “moral weaknesses” or “imagined” but real diseases caused by abnormalities of brain structure and imbalances of chemicals in the brain.”  Unlocking the Brain’s Secrets, by Richard Harding, MD, then President of the APA, in Family Circle magazine, November 20, 2001, p 62.

“ADHD often runs in families.  Parents of ADHD youth often have ADHD themselves.  The disorder is related to an inadequate supply of chemical messengers of the nerve cells in specific regions of the brain related to attention, activity, inhibitions, and mental operations.”  Paying Attention to ADHD, by Timothy Wilens, MD, Associate Professor of Psychiatry at Harvard Medical School, and Psychiatrist at Massachusetts General Hospital.  Op. Cit., p 65

“…the way nerves talk to each other, and communicate, is through the secretion of a chemical called a neurotransmitter, which stimulates the circuit to be activated.  And when this regulation of chemical neurotransmission is disturbed, you have the alterations in the functions that those brain areas are supposed to, to mediate.  So in a condition like depression, or mania, which occurs in bipolar disorder, you have a disturbance in the neurochemistry in the part of the brain that regulates emotion.”  Causes of Depression, a video by Jeffrey Lieberman, MD, Psychiatrist-in-Chief at NewYork Presbyterian/Columbia University Medical Center, and then President-elect of the APA.  Video made by The University Hospital of Columbia and Cornell. (June 19, 2012)

“The various forms of mental illness are due to many different types of brain abnormalities, including the loss of nerve cells and excesses and deficits in chemical transmission between neurons; sometimes the fault may be in the pattern of the wiring or circuitry, sometimes in the command centers, and sometimes in the way messages move along the wires.” (p 221) [Emphasis added] Nancy Andreasen’s book The Broken Brain: The Biological Revolution in Psychiatry (1984).  Nancy Andreasen, MD, PhD, is Chair of Psychiatry at the University of Iowa.  She served on the DSM-III and DSM-IV Task Forces, and is past president of the American Psychopathological Association and the Psychiatric Research Society.

“Since the pharmacological agents that ameliorate depression and mania appear to act upon and alter the concentration and metabolism of the biogenic amines in what are presumably corrective directions, it may be inferred that in the affective disorders there exists a chemical pathology related to these compounds…positive evidence is slowly accumulating and negative evidence is thus far lacking.” [Emphasis added] opinion piece for the American Journal of Psychiatry (September, 1970, p 133), titled Affective Disorders:  Progress, But Some Unresolved Questions Remain, by Morris Lipton, PhD, MD.  The late Dr. Lipton was Chair of Psychiatry at Chapel Hill at the time of writing.

“Depression is known to be caused by a deficit of certain neurochemicals or neurotransmitters, especially norepinephrine and serotonin.” (p 47) Daniel Amen, MD, from his bestselling book Change Your Brain, Change Your Life (1998)

I also provided the following quote from the psychiatry textbook Psychiatry (2003),  Tasman, Kay, and Lieberman (eds.)

“A final reason for studying the mechanisms of psychopathology is to inform our patients, their families, and society of the causes of mental illness.  At some time in the course of their illness, most patients and families need some explanation of what has happened and why.  Sometimes the explanation is as simplistic as ‘a chemical imbalance,’ while other patients and families may request brain imaging so that they can see the possible psychopathology or genetic analyses to calculate genetic risk.” (p 290, Vol 1)

I made the point that although this passage is not entirely clear, it does suggest that it is OK to tell clients and their families the chemical imbalance lie if they ask for an explanation.

Dr. Alexander reproduces two of my quotes – those from Drs. Harding and Lieberman – and continues:

“I have no personal skin in this game. I’ve only been a psychiatrist for two years, which means I started well after the term ‘chemical imbalance’ fell out of fashion. I get to use the excuse favored by young children everywhere: ‘It was like this when I got here’. But I still feel like the accusations in this case are unfair, and I would like to defend my profession.”

And here’s his defense: [incidentally, he confuses Mad In America with me personally, but his meaning is clear.]

“I propose that the term ‘chemical imbalance’ hides a sort of bait-and-switch going on between the following two statements:

(A): Depression is complicated, but it seems to involve disruptions to the levels of brain chemicals in some important way

(B): We understand depression perfectly now, it’s just a deficiency of serotonin.

If you equivocate between them, you can prove that psychiatrists were saying (A), and you can prove that (B) is false and stupid, and then it’s sort of like psychiatrists were saying something false and stupid!

But it isn’t too hard to prove that psychiatrists, when they talked about ‘chemical imbalance’, meant something more like (A). I mean, look at the quotes above by which Mad In America tries to prove psychiatrists guilty of pushing chemical imbalance. Both sound more like (A) than (B). Neither mentions serotonin by name. Both talk about the chemical aspect as part of a larger picture: Harding in the context of abnormalities in brain structure, Lieberman in the context of some external force disrupting neurotransmission. Neither uses the word ‘serotonin’ or ‘deficiency’. If the antipsychiatry community had quotes of APA officials saying it’s all serotonin deficiency, don’t you think they would have used them?”

In other words, he’s saying that the quotes from Drs. Harding and Lieberman were not simplistic chemical imbalance assertions, but were in fact more nuanced, and that they recognized the complicated, contextual aspects of depression.

So let’s take a look at the quotes in detail.  First, Dr. Harding:

1. Neuroscience and psychiatric research has begun to unlock the brain’s secrets.
2. We now know [note the unambiguous expression of certainty]
3. that mental illnesses such as depression or schizophrenia
4. are not ‘moral weaknesses’ or ‘imagined’,
5. but real diseases
6. caused by abnormalities of brain structure and imbalances of chemicals in the brain.

And Dr. Lieberman:

1. Brain circuits are activated by neurotransmitters.
2. Disturbances in this chemical neurotransmission lead to disturbances in function.
3. So [implying causality],
4. in depression or mania, there is a disturbance in brain neurochemistry.

Dr. Alexander contends that these quotes do not promote a simplistic chemical imbalance theory because:

1.  Neither mentions serotonin by name! I had never said that they mentioned serotonin by name.  Nor had there been any mention of serotonin in Dr. Pies’ original statements.  The issue was (and still is) that they promoted the chemical imbalance theory.  Dr. Alexander’s introduction of serotonin is irrelevant, and is, I suggest, an example of precisely the kind of intellectual dishonesty which he attributes to me.

2.  Both talk about the chemical aspect as part of a larger picture. This is simply false.  Dr. Harding clearly cites “imbalances of chemicals’ as a cause of mental “diseases.”  The fact that he also promotes abnormalities of brain structure does not modify or contextualize the primary contention.  And the fact that his article was embedded in a five-page “Special Advertizing Feature” for Paxil leaves little room for doubt as to his meaning. 

3.  Dr. Alexander contends that Dr. Lieberman’s statements about chemical imbalance was made in the context of  “…some external force disrupting neurotransmission.”  This, I suggest, is a very creative reading of Dr. Lieberman’s statement:

“And when this regulation of chemical neurotransmission is disturbed, you have the alterations in the functions that those brain areas are supposed to, to mediate.  So in a condition like depression, or mania, which occurs in bipolar disorder, you have a disturbance in the neurochemistry in the part of the brain that regulates emotion.”

Dr. Lieberman makes no reference to an external force disrupting neurotransmission, but even if such an external force were implied, the fundamental message is clear:  conditions like depression and mania are caused by disturbances in chemical neurotransmission, i.e. chemical imbalances!

. . . . .

It’s noteworthy that Dr. Alexander made no mention of the other quotes in my article, e.g:

Nancy Andreasen, MD, an eminent psychiatrist:

“The messages passed along these circuits are transmitted and modulated primarily through chemical processes.  Mental illnesses are due to disruptions in the normal flow of messages through this circuitry” (p 219)

Daniel Amen, MD, successful CEO and Medical Director of six psychiatric clinics, and a Distinguished Fellow of the APA:

“Depression is known to be caused by a deficit of certain neurochemicals or neurotransmitters, especially norepinephrine and serotonin.”

There’s not much ambiguity there.

And, incidentally, Dr. Alexander’s statement:  “If the antipsychiatry movement had quotes of APA officials saying it’s all serotonin deficiency, don’t you think they would have used them?” is a red herring.  In Dr. Pies’ original statements, to which I was responding, there’s no mention of APA officials.  Rather, Dr. Pies’ contentions embraced “responsible practitioners in the field of psychiatry”; “well-informed psychiatrists”; and “respected representatives of the profession.”

. . . . .

In addition, I also provided numerous unambiguous quotes promoting the chemical imbalance theory from :

• Child and Adolescent Bipolar Foundation;
• Depression and Bipolar Support Alliance;
• Mental Health America; and
• National Alliance for the Mentally Ill

and I pointed out that all of these organizations had eminent psychiatrists on their advisory boards, and that it was reasonable to infer that these advisers approved, or at least had made no objection to, the chemical imbalance messages.

. . . . . 

Nevertheless, Dr. Alexander concluded:

“So if you want to prove that psychiatrists were deluded or deceitful, you’re going to have to disprove not just statement (B) – which never represented a good scientific or clinical consensus – but statement (A). And that’s going to be hard, because as far as I can tell statement (A) still looks pretty plausible.”

Dr. Alexander himself concedes that statement (B) is false, but he refuses to accept the evidence I presented in the quotes – clear evidence that leading psychiatrists did promote the simplistic and false chemical imbalance theory.  And I should stress that I limited my search to psychiatrists who had achieved a measure of eminence and stature in their field (because that was the challenge presented by Dr. Pies).  If I had widened my search to include less prestigious psychiatrists, I’m sure I could have found a great many more.  The fact is that the promotion of the chemical imbalance theory is no secret.  I have personally heard dozens of psychiatrists proclaim it with total confidence, and I truly could not begin to estimate the number of clients I’ve talked to over the years who told me that their psychiatrists had told them they had a chemical imbalance in their brains, and that they needed to take the pills for life to correct this imbalance.  Even today, I regularly receive emails from readers contesting the assertions in my posts and telling me in no uncertain terms that they have chemical imbalances in their brains that cause their problems.

In addition, the simplistic chemical imbalance theory is still being promoted by some prestigious psychiatrists.  Cognitive Psychiatry at Chapel Hill (CPCH) has published 10 Common Myths About Psychiatry on their webpage.  Here are two quotes:

“Actually, the majority of patients we see have an actual illness or imbalance (much like diabetes), that with the proper treatment, the imbalance is corrected and they are no longer ill.”

“… many patients that see a Psychiatrist actually have an illness or imbalance that is causing a mental discrepancy. Once this imbalance is corrected, they are, in fact, cured of their mental illness.”

. . . . .

Dr. Alexander’s article was critiqued on Mad in America by Rob Wipond on April 15, 2015.  Rob’s article cites numerous other examples of psychiatrists promoting the chemical imbalance theory of depression.

The promotion of the chemical imbalance theory did occur, and continues to occur, and is a most shameful chapter in psychiatry’s history.  It is arguably one of the most destructive, far-reaching, and profitable hoaxes in history.

. . . . .

But, although the chemical imbalance theory has been soundly refuted, and the more astute psychiatrists, such as Dr. Pies, are actively distancing themselves from it, Dr. Alexander is clearly still a believer.  Here’s his final paragraph:

“So this is my answer to the accusation that psychiatry erred in promoting the idea of a ‘chemical imbalance’. The idea that depression is a drop-dead simple serotonin deficiency was never taken seriously by mainstream psychiatry. The idea that depression was a complicated pattern of derangement in several different brain chemicals that may well be interacting with or downstream from other causes has always been taken seriously, and continues to be pretty plausible. Whatever depression is, it’s very likely it will involve chemicals in some way, and it’s useful to emphasize that fact in order to convince people to take depression seriously as something that is beyond the intuitively-modeled ‘free will’ of the people suffering it. ‘Chemical imbalance’ is probably no longer the best phrase for that because of the baggage it’s taken on, but the best phrase will probably be one that captures a lot of the same idea.”

This paragraph is not entirely clear, but here’s my best shot at a paraphrase:

1. Psychiatry never promoted a simple chemical imbalance theory.
2. But psychiatry did promote a complicated chemical imbalance theory.
3. The complicated chemical imbalance theory is plausible.
4. There are chemicals involved in depression. [This is non-contentious.  Brain chemicals are involved in literally everything humans do, think, and feel, from the simplest eyeblink, to writing great works of art, and everything in between.]
5. It’s useful to emphasize that brain chemicals are involved in depression, in order to convince people that depression is a serious problem that can’t be conceptualized in ordinary human terms.
6. But we can’t use the term “chemical imbalance” any more because it’s been outed as a hoax.
7. We need a new phrase that will mean essentially the same thing.

How about Chemical Imbalance, Version II?

And lest I be accused of putting words in Dr. Alexander’s mouth, here are some quotes from earlier in his paper:

“In other words, everything we do is caused by brain chemicals, but usually we think about them on the human terms, like ‘He went to the diner because he was hungry’ and not ‘He went to the diner because the level of dopamine in the appetite center of his hypothalamus reached a critical level which caused it to fire messages at the complex planning center which told his motor cortex to move his legs to…’ – even though both are correct. Very occasionally, some things happen that we can’t think about on the human terms, like a seizure – we can’t explain in terms of desires or emotions or goals an epileptic person is flailing their limbs, so we have to go down to the lower-level brain chemical explanation.

What ‘chemical imbalance’ does for depression is try to force it down to this lower level, tell people to stop trying to use rational and emotional explanations for why their friend or family member is acting this way. It’s not a claim that nothing caused the chemical imbalance – maybe a recent breakup did – but if you try to use your normal social intuitions to determine why your friend or family member is behaving the way they are after the breakup, you’re going to get screwy results.”

So if a person is despondent because of a marital break-up, one can’t conceptualize his despondency in ordinary human terms.  Doing so will produce “screwy results.”

“There’s still one more question, which is: are you sure that depression patients’ experience is so incommensurable with healthy people’s experiences that it’s better to model their behavior as based on mysterious brain chemicals rather than on rational choice?”  [Note the spurious implication that there are only two options.]

“And part of what I’m going on is the stated experience of depressed people themselves. As for the rest, I can only plead consistency. I think people’s political opinions are highly genetically loaded and appear to be related to the structure of the insula and amygdala. I think large-scale variations in crime rate are mostly attributable to environmental levels of lead and probably other chemicals. It would be really weird if depression were the one area where we could always count on the inside view not to lead us astray.”

And there it is – the very core of bio-psychiatry!  Political opinions (and, presumably political activity), criminal behavior, and, by implication pretty much anything else that we do think, or feel, are all best conceptualized in terms of brain structure and chemicals.

. . . . .

Twenty-five years ago an elderly friend of mine lost his wife in a car accident.  They had been married for sixty years.  I visited him, and found him understandably despondent.  His demeanor, normally active and curious, was downcast and withdrawn.  His face was haggard; his shoulders slumped; he was at times tearful; and his gait was slow and heavy.  We talked, and he told me that he felt utterly lost.  I asked him what was the worst thing about his situation.  He thought for a long while, then said:  “I have nobody to talk to.”

His words, which I’ve never forgotten, seemed to me to embody some of the essential elements of grief and despondency:  loneliness, helplessness, and isolation.  But according to Dr. Alexander, this kind of thinking is “screwy.”  Despondency is really a matter of chemicals, and we need to “convince” people to abandon their intuitive assessments of their feelings of despondency, and to recognize the psychiatric “truth” that, whatever its trigger, depression is essentially  “…a complicated pattern of derangement in several different brain chemicals…” And we should embrace this “truth,” despite the fact that several decades of highly motivated research has failed to identify any such “derangement” or “imbalance” or whatever similar term Dr. Alexander would choose.

So, just when we imagined that we had begun to lay this particular piece of inanity to rest, here it is surging back from a brand new psychiatrist, prescription pen poised, ready to put the world to rights, one aberrant molecule at a time.

This isn’t just faulty logic and poor science.  It is a fundamentally dehumanizing and intrinsically disrespectful way of conceptualizing human loss and suffering.