This past Saturday, I was on my way back from Europe to Boston, and while on a stop in Iceland, I checked my email and was directed to a new blog by Ronald Pies in Psychiatric Times, in which he once again revisited the question of whether American psychiatry, and the American Psychiatric Association (APA), ever promoted the idea that chemical imbalances caused mental disorders. And just like when I read his 2011 writings on this subject, I found myself wondering what to make of his post.
Why was he so intent on maintaining psychiatry’s “innocence?” And why did it matter?
First, a recap. In a 2011 blog, Pies wrote that “in truth, the chemical imbalance notion was always a kind of urban legend, never a theory seriously propounded by well-informed psychiatrists.” In addition, Pies partly blamed the promotion of the chemical imbalance story on “opponents of psychiatry” who tossed around the “chemical imbalance” story and then “mendaciously” attributed “the phrase to psychiatrists themselves,” with the goal of making psychiatry look bad.
Now, as Philip Hickey documented in several blogs posted on MIA, it is quite easy to find numerous instances when prominent psychiatrists, including leaders of the APA, informed the public, as they did in a 2002 magazine article, 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.”1 And given that fact, one might think that Dr. Pies, who is editor-in-chief emeritus of Psychiatric Times, would do well to think like a poker player: he had a losing hand, and it was time to fold.
Instead, a few days ago, on September 15, Pies reiterated his earlier claims, and this time in even stronger terms: “To my knowledge, no professional psychiatric organization has ever publicly promoted a ‘chemical imbalance theory’ of mental illness in general.” Note that strong line: no professional organization has ever promoted such an idea.
And once again, Pies found reason to take a shot at “antipsychiatry bloggers,” who were using this story to try to make psychiatry look bad. “That antipsychiatry bloggers assiduously comb the Internet and find a handful of ‘celebrity psychiatrists’ quotes to the contrary neither surprises nor impresses me.”
In support of his latest claim, Pies points readers to a 2005 brochure published by the APA titled: “Let’s talk facts: what is mental illness?” In that publication, Pies correctly notes, the APA wrote: “The exact causes of mental disorders are unknown.”
And thus did Dr. Pies put forth his evidence, and play his poker hand. With that brochure, one might say he had shown—oh, I don’t know—a pair of deuces.
However, let’s now continue with the laying down of cards. The “Let’s Talk About Facts” brochures that the APA published in 2005 were part of an ongoing pr campaign titled “Healthy Minds, Healthy Lives,” and that same year the APA also published a brochure for the public titled, Let’s Talk Facts About Depression. This brochure, in a section titled “How is Depression Treated,” informed the public that: “Antidepressants may be prescribed to correct imbalances in the levels of chemicals in the brain.”
There is more. That same year, 2005, the APA put out a press release celebrating the fact that, based on a survey it had conducted, “75 percent of consumers believe that mental illnesses are usually caused by a chemical imbalance in the brain.” The survey results, said APA President Steven Sharfstein, was evidence of “good news for [public] understanding of mental health.” Indeed, the APA stated in its press release that a psychiatrist was “a specialist specifically trained to diagnose and treat chemical imbalances.”2
I would call that, in poker terms, the laying down of a royal flush. I do presume that Dr. Pies considers the APA a “professional organization.”
One could go on and on. When I looked at this question in the summer of 2014, while co-writing Psychiatry Under the Influence with Lisa Cosgrove, it was easy to find websites run by prominent advocacy organizations, which boasted of scientific advisory boards composed of top academic psychiatrists, that were still telling the public this chemical imbalance story. That was true, for instance, of the website of the Child & Adolescent Bipolar Foundation (which had recently been renamed the Balanced Mind Parent Network.) That organization had a scientific advisory board composed of more than 20 academic psychiatrists, and it informed readers that “antidepressant medications work to restore proper chemical balance in the brain.”
But why should we care about this? Why is this important now?
Ever since 1980, when the APA published the third edition of its Diagnostic and Statistical Manual, it has been committed to informing the public that mental disorders are “diseases” of the brain, which are regularly under-recognized and undertreated, and that its drugs for those diseases are both very safe and very effective. The chemical imbalance story comprised the heart of this disease-model narrative: Psychiatric researchers were discovering the pathology of mental disorders, and its drugs fixed that pathology, like insulin for diabetes.
This was a narrative that served psychiatry’s interests as a guild. Specifically:
- It told of how its disorders in DSM III had been “validated” as real diseases.
- It told of a medical specialty that was making great scientific progress, which elevated its power and authority in our society.
- It told of a medical specialty that had a product—e.g. drugs—that was of great worth in treating those diseases.
- Most important of all, this narrative provided a reason for psychiatry, as a medical specialty, to have authority over this part of our lives.
And how did our society respond to this narrative? We organized ourselves around it, thinking it was a story of science. We medicated our children, and when parents objected, there were leading psychiatrists who said, in public forums: If your child had diabetes, wouldn’t you give your child insulin? We medicated ourselves as adults. Insurance companies organized their reimbursements around that “disease” model story. We financed mental health care around that story. And, in a very profound way, even our understanding of ourselves changed: we were not so responsible for ourselves, but rather the puppets of our neurotransmitters, and when we tumbled into depression or anxiety, or our children fidgeted too much in school, we were trained to think that we really couldn’t do much to fix such difficulties.
In short, the narrative told to us by psychiatry following its publication of DSM III, which had the chemical imbalance tale at its core, has done extraordinary damage to our society. We have organized ourselves around a false narrative.
And here is why Ronald Pies’ continued posts on this are important: If there is going to be any chance that psychiatry is going to reform itself, in a way that will enable it to serve the public (rather than its own guild interests), it must first confront its past: Why did it tell this false narrative—of drugs that fixed chemical imbalances in the brain—to the public? Perhaps then it could understand that its duty, as a medical specialty, is to tell a narrative to the public that is consonant with the relevant science. If that were so, then the public would be hearing that the biological causes of psychiatric disorders remain unknown, and that its drug treatments are of marginal efficacy over the short term, and that over the long-term, outcomes for medicated patients are very poor.
However, Pies’ posts reveal that psychiatry, in an institutional sense, has no interest in such self-examination. Instead, by blaming the promotion of the chemical imbalance story on “antipsychiatry” activists and the pharmaceutical industry, it is choosing to serve its own interests. Most important, it retains its positive self image in the mirror: as a medical specialty that never promoted a false story to the public, and one that has always understood the complexity of the human brain, and thus, as a medical specialty that deserves to retain its dominion over this area of our lives.
Or, in the language of cognitive dissonance, Pies has now embraced this self-serving conclusion: errors were made, but not by us.
So what should society do? As Lisa Cosgrove and I wrote in Psychiatry Under the Influence, we see only one possible solution. We cannot expect psychiatry to reform itself, and that leaves only one option: We need to strip psychiatry of its authority over this domain of our lives. The challenge for society is to figure out how to do that.
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1. R. Harding, “Unlocking the Brain’s Secrets.” Family Circle, Nov. 20, 2001, p. 61.
2. American Psychiatric Association. “Mental Illness Stigmas are Receding,” press release, May 4, 2005.