On June 23, 2020, Awais Aftab, MD, a clinical professor of psychiatry at Case Western, interviewed Ronald Pies, MD, also a psychiatrist, and a professor at Tufts and SUNY.
During the interview, Dr. Aftab stated:
“I have followed the controversy surrounding ‘chemical imbalance’ with some interest over the years, including the multiple articles you have written on this issue. Generally, I agree with you that the chemical imbalance was never accepted as the ‘truth’ by academic psychiatry or by our professional organizations. It was likely an advertisement strategy by pharmaceutical companies that took on a life of its own. However, I am not sure I am ready to exonerate our profession. At best, it seems like we were silent spectators, watching as this misleading idea spread like wildfire in the society (including among our patients and patient advocacy groups), doing little to nothing to correct these public misperceptions. At worst, it seems like at least some of us were participants. Ken Kendler writes in a 2019 JAMA Psychiatry commentary, ‘I would commonly see patients who would say some version of “my psychiatrist said I have a chemical imbalance in my brain.”‘10 I have had a very similar experience myself. Either way, surely as a profession, we could have done a better job of educating our patients and the public?”
To which Dr. Pies responded:
“Yes, I agree that we – all of us – could have done a better job of counteracting the so-called ‘chemical imbalance’ trope, which, as your comments imply, was more a creature of ‘Mad Men’ than of men and women who study madness! I wish I had tackled the issue earlier than my 2011 article.11“
“Mad Men”, incidentally, for those not familiar with the term, means people who work in the advertising industry in Madison Avenue, New York.
“And, yes – we often hear anecdotes concerning patients who tell their current clinician some version of, ‘My psychiatrist said I have a chemical imbalance . . .’ `But where is the evidence that this is what patients were actually told? Who has contacted the patient’s psychiatrist, or reviewed his/her case notes, to see if that was really what the patient was told? To my knowledge, there has never been a study examining the ‘other side of the story’ – and, to be clear: patients are not infallible recorders of what their doctors tell them. So, we are really left to speculate, and with the knowledge that about 80% of antidepressant prescriptions are written not by psychiatrists, but by primary care physicians and family practitioners. Who knows what these doctors told their patients? So, I consider this really a fruitless debate, unless and until I see contemporaneous documentation of what patients were actually told by their psychiatrists; or, failing that, a large ‘N’ of psychiatrists confirm that they regularly used the ‘chemical imbalance’ trope to explain the nature of their patients’ problem. I will add that, in my own practice over 25 years or more, I did include a discussion of neurotransmitters in my explanations to patients, but always in the context of ‘bio-psycho-social’ causes and risk factors.“
This struck me as an egregious display of disrespect towards the people on whom the great and learned doctor depends for a living, and on November 5, 2020, I wrote a post critiquing many of the positions Dr. Pies promoted in the interview, especially the expressions of disrespect that he had directed towards psychiatric customers.
The Aftab-Pies interview was about seven months ago, and to the best of my knowledge, Dr. Pies made no public comment on the interview until January 12, 2021. On that date, he published on Psychiatric Times a piece titled What We Tell Patients about Depression, and What They Say They Have Been Told (subtitle: Is there a way to find balance in discussing the chemical imbalance theory of depression?). On first glance, I thought that this was going to be an apology. But I was mistaken. Here are the two opening paragraphs:
“Since my interview with Awais Aftab, MD, I have received a good deal of feedback on my positions, both pro and con. Upon further reflection, I would like to clarify my position regarding the following comments I made in the interview:”
“And, yes – we often hear anecdotes concerning patients who tell their current clinician some version of, ‘My psychiatrist said I have a chemical imbalance . . .’ But where is the evidence that this is what patients were actually told? Who has contacted the patient’s psychiatrist, or reviewed his/her case notes, to see if that was really what the patient was told? To my knowledge, there has never been a study examining the other side of the story – and, to be clear: patients are not infallible recorders of what their doctors tell them.“
Notice the word “clarify” in the first paragraph. So the piece is not an apology; it’s a “clarification”. But more importantly, notice that he has omitted more than half of the second paragraph. Compare the second quote above to the full paragraph quoted by me earlier. He has omitted everything from:
“So, we are really left to speculate…” to “causes and risk factors.“
It could be argued that this was merely an oversight on Dr. Pies’ part, but the vituperative tone of the omitted material casts doubt on such an interpretation. Difficult as it may be for us to countenance, it seems credible that the omission stems more from an effort to whitewash his earlier remarks than from an oversight.
. . . . . . . . . . . . . . . .
Then he continues:
“I regret that I did not state my point more clearly.”
Actually, I thought he stated his point with total clarity:
Clients can’t be trusted to tell the truth, unless their statements are confirmed by their psychiatrists.
Back to the non-apology article:
“In particular, I inadvertently implied that the psychiatrist’s recollections or case notes are, in some sense, always dispositive regarding what patients were actually or really told, as if psychiatrists were infallible recorders of what was said in a session.”
Note the “inadvertently implied”. And glance back at what he said in the interview. It is difficult to believe that the latter represented a series of inadvertent slips of the tongue rather than his heartfelt, petulant, and prejudicial beliefs.
- We often hear anecdotes;
- Where is the evidence…?
- Who has contacted the psychiatrist?
- Who has reviewed the case notes?
- to see if that was really what the patient was told?
- There has never been a study;
- patients are not infallible recorders of what their doctors tell them;
- I consider this really a fruitless debate;
- unless and until I see contemporaneous documentation of what patients were actually told by their psychiatrists;
- a large ‘N’ of psychiatrists confirm; etc.
None of this sounds remotely inadvertent. Rather, it sounds pretty much like a very specific, well-rehearsed, and disrespectful client-bashing narrative.
In addition, Dr. Pies’ meaning was not lost on Dr. Aftab, whose response to Dr. Pies’ outburst included the following:
“You have already stated that you would need a high level of evidence to change your mind,”
. . . . . . . . . . . . . . . .
From there, the present non-apology piece goes steadily downhill.
“This was not my intention, nor is it my belief.”
It seems clear from all this that Dr. Pies’ priority in this matter is to remove from his reputation the stain left by his earlier attack on the credibility of his clients.
“My point in the interview was that any valid claim or report regarding what patients have been told about so-called ‘chemical imbalances’ must take into account not only the patient’s recollection, but also: what psychiatrists themselves recall saying; what they intended to convey; and in what context the term chemical imbalance was used.”
This was most emphatically NOT the point that the eminent doctor made in the interview.
The point that he made in the interview was simple and clear: psychiatric clients are not credible unless their statements are confirmed by the psychiatrist.
It should also be noted that it is not at all unusual – at least in my experience – for psychiatrists to dismiss, and even ridicule, the statements and assertions of clients as not credible, especially if these reports are critical, or even questioning, of psychiatrists, or their methods. Critical self-scrutiny is a rare quality in the psychiatric community.
Back to the non-apology paper:
“For example, did the psychiatrist say something like, ‘Your illness is definitely caused by a chemical imbalance’? Or was it more like, ‘We don’t know the precise causes of depression, but chemical changes in the brain may play some role, along with psychological, social, and environmental factors’?”
Which to my reading smacks a little of: come now, my dear (or sir), are you sure that the psychiatrist didn’t say something along the lines of….
This is pure gaslighting. Are you sure that you’re not misremembering? Are you sure that the psychiatrist said those exact words? Perhaps he (or she) explained the matter in more detail? Didn’t he (or she) mention psychological or social factors such as …? Didn’t he (or she) stress the importance of environmental matters? …
So, not only is Dr. Pies failing to apologize for his earlier expressions of disrespect, he’s actually piling on more!
Back to the non-apology:
“In addition, the therapeutic alliance is built on trust. Accordingly, our patients’ reports should always be considered prima facie credible, absent extraordinarily compelling evidence to the contrary (eg, obvious delusions, documented malingering, and so on). But credible – ie, worthy of belief or confidence – does not necessarily mean factually correct in all aspects and details. The same may be said, of course, of claims made by clinicians.”
Note the phrase “documented malingering”, which raises the question: documented by whom? We’re back presumably to the psychiatrists’ case notes, which in Dr. Pies’ world are clearly the preferential source of truth.
BELIEF ABOUT THE CAUSES OF DEPRESSION
Dr. Pies then cites a recent study which “…evaluated the prevalence of etiological beliefs about depression in a sample of acutely distressed psychiatric patients in an intensive hospital treatment program.” The study cited is Schroder et al Stressors and chemical imbalances: Beliefs about the causes of depression in an acute psychiatric treatment sample, Journal of Affective Disorders 276 (2020) 537–545. The study was conducted at McLean Hospital and Harvard Medical School. Here’s what Dr. Pies wrote about the study:
“The study found that the most commonly endorsed explanation for depression was not one invoking the chemical imbalance notion; rather, psychosocial explanations of depression were the most commonly endorsed etiology, with the chemical imbalance belief coming in second. The authors noted that popular beliefs about what causes depression ‘may be adopted from a variety of external sources, including television advertisements, anti-stigma campaigns promoting biogenetic explanations, and discussions with treatment providers.1‘”
This summary of Dr. Pies’, however, is extremely misleading. Here are some quotes from elsewhere in Schroder et al:
“In current times, as the medical model of psychiatry has risen in popularity in the United States, conceptions of mental distress as stemming primarily from biological, chemical, or genetic abnormalities – what we refer to here as biogenetic explanations – have become increasingly widespread.” (p 537)
“The most well-known biogenetic explanation is the ‘chemical imbalance theory’, according to which depression is caused by an imbalance in neurotransmitters.” (p 537)
“The chemical imbalance belief is the most widely endorsed biogenetic explanation of depression. In one study of 262 undergraduate students taking a psychology course (France et al., 2007), nearly all (91.6%) participants were familiar with the chemical imbalance explanation, which was endorsed as a potential cause of depression by 84.7% of participants vs. 61.8% who endorsed the genetics/inherited belief. Additionally, in a study of 1829 people who were using or had recently used prescription antidepressants, 84.8% agreed that a chemical imbalance was a likely cause of depression, whereas 77.4% agreed that heredity played a role, and 70.7% agreed that depression was caused by a disorder of the brain (Read et al., 2014). To summarize, although psychosocial explanations of depression are the most commonly endorsed, biogenetic explanations – especially the chemical imbalance explanation – have risen in recent years, especially in the United States.” (p 538)
. . . . . . . . . . . . . . . .
And here are some quotes from Schroder et al concerning their recent study:
“Patients rated the likelihood that depression was caused by psychogenic causes (ongoing stressors and childhood adversity) and biogenetic causes (chemical imbalances and genetic problems)” (p 538)
So Schroder et al used two factors to assess the prevalence of psychogenic causal beliefs (ongoing stressors and childhood adversity) and two factors (chemical imbalances and genetic problems) to assess the prevalence of biogenetic causes, and found:
“Consistent with past findings, the most strongly endorsed belief was the ongoing stressor belief, followed by the chemical imbalance belief, genetic belief, and finally the childhood belief.” (p 540)
“Endorsement of the chemical imbalance belief was not significantly different from the ongoing stressor belief…p = .15…” (p 540) [Emphasis added]
“…compared with psychogenic beliefs, chemical imbalance beliefs were endorsed nearly as strongly (ongoing stressor explanation) or more strongly (childhood events explanation).” (p 540)
“…when examining individual predictors in Step 2, the chemical imbalance belief predicted significantly more depressive symptoms at discharge. None of the other belief items were significant predictors of discharge PHQ-9 scores…” (p 542) [Emphasis added] (The PHQ-9 is the nine-item Patient Health Questionnaire and is widely used as a measure of depressive “symptoms”.)
. . . . . . . . . . . . . . . .
DR. PIES’ FURTHER DISTORTION OF SCHRODER ET AL’S FINDINGS
Here’s the actual quote that Dr. Pies took from the study:
[These viewpoints, as to what causes depression] “may be adopted from a variety of external sources, including television advertisements, antistigma campaigns promoting biogenetic explanations, and discussions with treatment providers.” (p 543) [Emphasis in original]
After which, Dr. Pies continues with a discussion of potential internal sources of belief.
But, and this is the critical distortion, Dr. Pies skipped about two column inches between “discussions with treatment providers” and the “internal sources” material. And those two column inches are the most critical part of Schroder et al from the present perspective. Here’s what was omitted:
“The latter [discussions with treatment providers] is likely to have had an effect in the present sample, as the patients here had significant inpatient hospitalization experience – where medical terms and assessments are abundant. Indeed, in the present data, the number of prior inpatient hospitalizations was associated with endorsement of both the chemical imbalance belief and the genetic belief but not the psychogenic belief items. Although these are correlational data, these findings may suggest that further or deeper experience with intensive psychiatric treatment fosters the adoption of more biogenetic beliefs. Further, nearly all patients were prescribed at least one psychiatric medication, and merely taking medication may reinforce the putative biochemical origins of the problem. If so, extensive psychiatric care may reinforce biogenetic beliefs in highly depressed patients – those most sensitive to the negative consequences of the beliefs.” (p 543) [Emphasis added]
It is, of course, entirely possible that Dr. Pies merely overlooked the critical two column inches, and also overlooked the fact that the finding he cited did not even come close to statistical significance, though it is difficult to reconcile such an interpretation with his reputation as a great thinker and scholar, and the critical importance of the omitted material.
One is compelled to wonder whether Dr. Pies actually read Schroder et al, or merely skimmed through, looking for a quote to support his preconceived position.
Dr. Pies continues his non-apology:
“All of this is simply to note that popularization of the chemical imbalance canard is almost certainly an over-determined effect, in which the role of psychiatrists (or other clinicians) is but 1 possible causal factor.”
In this paragraph, Dr. Pies appears to be attributing this conclusion to Schroder et al, but he is omitting any reference to the two column inches that he “conveniently” ignored, and to other material from Schroder et al that he also “conveniently” ignored. Schroder et al do not assert, or even imply, that the role of psychiatrists “is but 1 possible causal factor”. On the contrary, they suggest, based on the very research that Dr. Pies himself has introduced into the discussion, that psychiatric input of the chemical imbalance message may be the most important causal factor, and that this input in turn may have a deleterious effect on treatment efficacy.
Here are Schroder et al’s actual conclusions as given in their final paragraph under the heading Limitations and Conclusions:
“As we noted at the outset, public perceptions of mental distress have changed over the course of history. Sociologists have documented the various consequences of these etiological perceptions – including what we would now consider to be unethical treatments (Conrad and Schneider, 1980). As the public is increasingly exposed to and accepting of biogenetic explanations of mental distress, it is paramount to acknowledge some unintended consequences of this narrative. Our findings are in line with accumulating evidence that some biogenetic beliefs, like the chemical imbalance belief, are linked with poorer expectations for improvement, especially among those with the most troubling symptoms. Further research is warranted to understand the etiology and rising popularity of these beliefs, particularly in clinical settings, and to promote alternative messaging that may help foster more positive feelings toward treatment.” (p 544)
Note in particular the clear statement:
“Our findings are in line with accumulating evidence that some biogenetic beliefs, like the chemical imbalance belief, are linked with poorer expectations for improvement, especially among those with the most troubling symptoms”,
which when read in conjunction with the earlier Schroder et al excerpt [“The latter is likely to…”] means that psychiatrists for about the past fifty years have been effectively encouraging clients to expect poor outcomes in the psychiatric “treatment” of depression. And, unsurprisingly, poor outcomes is precisely what they all too frequently receive.
BACK TO THE ISSUE IN HAND
All this, of course, is wonderfully heartening, but actually has nothing to do with the issue in hand.
The issue in hand is the dismissive and frankly insulting way that Dr. Pies vilified psychiatric clients as lacking in credibility unless their statements could be verified by their psychiatrists.
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Not only has Dr. Pies failed to address the main issue, he opens up another self-exculpatory avenue.
“I believe that in the near decade since I described the chemical imbalance notion as a kind of urban legend,2 psychiatry has matured and deepened in its mode of explanation to patients – though research on that point is sorely needed.”
So, over the past ten years or so, Dr. Pies tells us:
“…psychiatry has matured and deepened in its mode of explanation to patients…”
The only interpretation I can put on this last assertion is that Dr. Pies is conceding that psychiatry’s “mode of explanation to patients” is improving (maturing and deepening). And given the context of the discussion, the only kind of improvement that makes any sense would be a shift from chemical imbalance explanations, to something more accurate. So Dr. Pies is apparently conceding that back in those bad old days (ten years ago), the explanations of their “disorders” that psychiatrists were giving to their customers were based on the chemical imbalance deception or possibly other biogenetic theories.
And, although in the Urban Legend piece (2011) Dr. Pies stated categorically that:
“In the past 30 years, I don’t believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim [the chemical imbalance theory], except perhaps to mock it.”
he now seems to be acknowledging that psychiatrists were at that same time explaining depression to their clients in chemical imbalance terms.
He then goes on to make things even worse:
“For now, the best explanation we have is that clinically significant depression is the outcome of biological, psychosocial, environmental, and even spiritual causes.3 The relative contribution of any single component almost certainly varies from patient to patient, and case to case. I believe that well-informed psychiatrists have known and embraced that holistic view for decades. The remaining challenge lies in communicating it clearly and consistently to our patients—and on that score, we can all do better.”
So, if we stay with the narrative here, well-informed psychiatrists have known for decades that the chemical imbalance explanation is nonsense, but nevertheless went on dishing it out to their “patients”. Or I suppose there could be another interpretation: there were remarkably few well-informed psychiatrists in those bad old days. So which is better, to be a deceiver or to be ill-informed?
The bottom line in all of this is very simple: psychiatrists, including Dr. Pies himself, promoted the chemical imbalance deception of depression, even though they knew it to be false, and had every reason to recognize that it is associated with poorer expectations for improvement. Indeed, it’s not a huge leap to attribute psychiatry’s frequently-endorsed injunction, that anti-depressants had to be taken for life, to this deception, that was, and still is, being avidly and self-servingly promoted by psychiatrists. After all, if one’s neurotransmitters are “unbalanced”, and this affliction is corrected by drugs, isn’t it reasonable to infer that, as the drugs are metabolized, they will need to be topped up indefinitely?
I printed a copy of Dr. Pies’ non-apology shortly after it was published on January 12, 2021. At that time, the final words in the text were: “…and on that score, we can all do better.” However, when I opened the article again on February 2, an additional two paragraphs had been added:
“I am aware that the American Psychiatric Association once had a statement posted on their public education website that referred to ‘imbalances in brain chemistry.’ I am happy to report that, in response to my conferring with the APA, the old statement has been deleted and replaced with the following:”
“‘While the precise mechanism of action of psychiatric medications is not fully understood, they may beneficially modulate chemical signaling and communication within the brain, which may reduce some symptoms of psychiatric disorders.'”
Here’s a screenshot of what was formerly the final paragraph, with the two-paragraph addition:
It is clear that Dr. Pies is pleased with this change, though it still seems very like chemical imbalance to me. But much more importantly, Dr. Pies doesn’t seem to realize that it gives the lie to his frequent assertion that no official psychiatric body had ever endorsed the chemical imbalance theory of depression. For instance;
“Moreover…psychiatry as a profession and medical specialty never endorsed such a bogus ‘theory,’ when judged by its professional organizations, its peer-reviewed publications, its standard textbooks, or its official pronouncements.” (here) [Emphasis added]
“Yes, our critics tirelessly quote this or that notable psychiatrist who used the phrase, ‘chemical imbalance,’ but this doesn’t mean the psychiatric profession as a whole ever embraced the chemical imbalance theory. Nor was it ever a model espoused by academic psychiatrists, or the official position of our professional organizations.” (here) [Emphasis added]
Yet here he admits that he himself had approached the APA and persuaded them to delete from their public education website a reference to “imbalances in brain chemistry”.
He is probably just confused.
In his non-apology piece, Dr. Pies thanks Joe Pierre, MD, for referring the Schroder et al piece to him. Given what Schroder et al found, I feel that I should also extend my thanks to Dr. Pierre, and indeed to our eminent scholar Dr. Pies himself, for providing this important support to the anti-psychiatry movement. May their pens never cease to flow.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.