On March 17, 2022, the very eminent and illustrious psychiatrist Ronald Pies, MD, published a piece on return.life. The article is titled The Myth of the Chemical Imbalance. Subtitle: What psychiatrists really believe about mood disorders.
The gist of the article is that psychiatry, as a profession, never endorsed the chemical imbalance theory of depression. This has become an almost constant obsession of Dr. Pies which has attracted a good deal of compelling criticism from members of the anti-psychiatry movement, to which Dr. Pies addresses no meaningful or cogent response. Indeed, his responses have consisted of little more than a re-writing of the same old invalid material, laced generously with his customary and pretentious diversions into Greek history, the difference between a theory and a hypothesis, and other interesting but irrelevant material. I have personally discussed and refuted Dr. Pies’ various contentions on these matters, but like the Energizer Bunny, he keeps going on. Readers can find my various posts on these topics on Mad in America or on my own site. Search for Dr. Pies.
DR. PIES’ CONTENTIONS
About halfway through the current piece, Dr. Pies writes:
“… I have little doubt that many psychiatrists, in the ‘80s, ‘90s, and early 2000s, used some version of the phrase, ‘chemical imbalance’ in their meetings with patients. Some may have placed that phrase in a valid ‘biopsychosocial’ context; others may not have done so. And, yes, during that period, a dozen or so prominent psychiatrists promoted some version of the CIT in their public pronouncements.”
So we have a very clear and specific admission from Dr. Pies: during the period 1980-2000, a dozen or so prominent psychiatrists “promoted some version of the CIT [Chemical Imbalance Theory of Depression] in their public pronouncements”. Note that he doesn’t name these individuals, though the wording of his admission suggests that he knows who they are.
Then he continues:
“On the one hand, even if done with good intentions, such comments by psychiatrists inadvertently contributed to an inaccurate understanding of depression and other psychiatric illnesses.”
Here again, we see indications that the learned doctor may have specific individuals in mind. He has introduced the possibility that their intentions might have been good (of course), and that their promotion of this “inaccurate understanding of depression” might have been “inadvertent”. Honest errors. Nobody’s perfect!
But he’s still not giving us names, and this is a critical issue. He has stated in the earlier quote that a dozen or so prominent psychiatrists promoted the CIT in their public pronouncements, but by failing to identify them, he is sharing in their guilt. And this is a big part of the reason that psychiatrists have such a poor reputation. The CIT was not a harmless falsehood. It induced millions of people worldwide, who would otherwise not have taken the drugs, to do so. The resultant damage, disempowerment, and stigmatization is probably incalculable.
Dr. Pies continues:
“On the other hand, the vast majority of antidepressant prescriptions in the US are written by primary care physicians, not psychiatrists. It’s almost impossible to know how, in the 1980s and ‘90s, primary care providers explained the nature and etiology of depression to their patients. I suspect – but can’t prove – that for the average, harried primary care provider, explaining depression as a ‘chemical imbalance’ was a tempting time saver, during those fifteen minute appointments. Nonetheless, we psychiatrists (myself included) should have done more to inform our colleagues in primary care that the CIT was a simplistic and misleading canard.”
Let’s open this up.
- Most antidepressant prescriptions are written by GPs – NOT BY PSYCHIATRISTS.
- And who knows how these turf-poaching wretches explained the nature and etiology of depression to their patients.
- They allowed only 15 minutes for an appointment so they were probably harried and stressed and overworked.
- Anybody in those circumstances would be tempted to give a simplistic and false explanation. I can’t prove this, mind. I’m just saying…
- But with the benefit of hindsight, we psychiatrists (myself included) [self-effacing grimace] should have done more to enlighten these poor devils. They were doing the best they could, but as we psychiatrists know only too well, you can’t make a silk purse from a sow’s ear. You can’t expect a harried GP to understand the nuances and complexities of these matters.
And yes, psychiatrists (the eminent Dr. Pies included) should have done a great deal more to correct this false narrative that quickly became the dominant theory of depression nationwide and in many areas overseas. And it should never have needed the benefit of hindsight to recognize these realities. They were as plain as pikestaffs to anyone with even a modicum of science and an ounce of ethics.
FIFTEEN MINUTE MED CHECKS
And wouldn’t psychiatrists, whose “treatments” had also deteriorated to 15-minutes med checks, be just as tempted to cut corners on tedious explanations when a bumper sticker slogan would do the job nicely? Or is Dr. Pies insinuating here that psychiatrists are somehow more ethical in these regards than the harried GP’s? And if he is so confident that a dozen or so prominent psychiatrists publicly promoted the chemical imbalance theory of depression, how can he possibly know that they weren’t emulated in this regard by thousands of less prominent psychiatrists? After all, the only operational distinction between prominent psychiatrists and ordinary run-of-the-mill psychiatrists is the size of their audiences. The fact is that psychiatrists en masse embraced the chemical imbalance theory of depression and used every opportunity to foist it on the public, on various government departments, on insurance companies, and on any other groups that could impact their business. The chemical imbalance theory was never about brain chemicals. It was a BUSINESS MODEL, pure and simple, using junk science to create a bigger customer base. It was no more valid than “Things go better with Coca Cola”, but a great deal more destructive.
And at this point, Dr. Pies’ paper gets even more evasive.
“In any event, it seems clear that many people in the US and elsewhere came to believe that mental illness was due, entirely or largely, to some sort of ‘chemical imbalance in the brain.’ But in my view, the most powerful force fueling this belief was not what psychiatrists said or did; but rather, the huge wave of ‘direct-to-consumer’ advertising that pharmaceutical companies heavily financed, during the 1980s and 90s.”
Let’s open this up:
- So according to Dr. Pies’ entirely impartial view, the great momentum behind the chemical imbalance drivel was NOT what psychiatrists said or did (Heavens, No!), but rather the huge wave of pharma advertising during the 80’s and 90’s.
- And against this veritable tsunami of mendacity and corruption, the poor ethical psychiatrists were helpless. Foundering as they were in the storm, there simply was nothing they could do. They couldn’t battle a tsunami – well maybe they could, but they definitely would have gotten their shoes wet! And although they were appalled at the tactics used by pharma (such cads), and never took any of pharma’s largesse (the very thought!), they – simple souls that they were – could see no way to correct the stream of falsehoods emanating from the mean ol’ pharma giants, even when these falsehoods were included in pharma ads in psychiatric journals. Even the APA couldn’t manage to publish a brief disclaimer.
- All of which is odd, in that – at least here in the US – the Federal Trade Commission regulates advertising with truth-in-advertising laws. Indeed, the entire truth-in-advertising apparatus began in 1905 when Samuel Hopkins Adams published a series of papers concerning the false claims of the patent medicine industry. One outcome of this initiative was the creation of the FDA in 1906. But apparently the APA never thought to contact the FDA or FTC.
- But psychiatrists – poor lamps – had no knowledge of any of this and could think of no better course of action than to let the tsunami roll over them, and do the best they could to keep their humble businesses afloat. The tragedy of it all. And they just didn’t notice that an increasing number of their customers were mentioning the chemical imbalance theory of depression and were actually phrasing their requests for help in terms of something to balance their brain chemicals. Well how could they notice such trivia while battling a tsunami?
NANCY ANDREASEN AND THE BROKEN BRAIN
Dr. Pies devoted about a page of his article to Nancy Andreasen’s book The Broken Brain, 1984. He cites a few passages to “prove” that Dr. Andreasen did not promote a simplistic chemical imbalance theory of depression. But as I’ve stressed in previous posts (here and here) , Dr. Andreasen did promote a simplistic chemical imbalance theory of depression in the text in question.
The most obvious indication of this is the material on the front and rear covers. On the front cover we have an endorsement from the New York Times Book Review:
“Her book will be especially valuable to anyone who knows someone afflicted with a mental illness.”
This is followed by the title:
“THE BROKEN BRAIN”
Clearly suggesting that “mental illnesses” are caused by malfunctioning brains.
“The Biological Revolution in Psychiatry”
Which clearly identifies biopathology as the major – or perhaps even the only – causative factor in “mental illnesses”.
The front flyleaf contains the following:
“This is the best survey and explanation of the new biological psychiatry.”
“The Broken Brain is a superior achievement of scientific writing and explanation for nonscientists….Dr. Andreasen has made the case compellingly for the biological basis of most serious mental illnesses….Dr. Andreasen’s comprehensive and superbly written book should be of interest to nearly everyone”
The rear cover contains the following:
“Dr. Andreasen’s lucid and comprehensive book should be enthusiastically welcomed by patients and families with severe psychiatric disorders. It puts up-to-date knowledge into the hands of consumers; such knowledge becomes power. The Broken Brain is another clarion call signaling the biological revolution in psychiatry.”
Dr. E. Fuller Torrey, psychiatrist and founder of the Treatment Advocacy Center
“Dr. Andreasen has produced the best book on psychiatry in many years. With immaculate prose and immense erudition, she chronicles a revolution in psychiatry that has returned this battered specialty to its birthplace in medicine. The revolution is real and the book is a gem.” [Emphasis added]
Dr. Donald Goodwin. Dr. Goodwin was Psychiatry Chair at University of Kansas from 1976 to 1995. He is now deceased.
In addition, there are multiple quotes in the text of the book that make similar assertions. For instance:
“As this book will explain in subsequent chapters, modern psychiatry is progressing rapidly toward discovering the anatomic and biochemical abnormalities that underlie mental illnesses and toward developing pharmacological methods for treating them. Although none of the mental illnesses is as yet as fully understood as Parkinson’s disease, biologically oriented psychiatrists hope that during the next ten to twenty years a similar logical progression from understanding structure to understanding cause to developing treatment will unfold for major mental illnesses such as depression or schizophrenia. ” (p 29) [Emphasis added]
“The major psychiatric illnesses are diseases. They should be considered medical illnesses just as diabetes, heart disease, and cancer are.” (p 29) [Emphasis in original]
“These diseases [the major psychiatric illnesses] are caused principally by biological factors, and most of these factors reside in the brain.” (p 30) [Emphasis in original]
“As a scientific discipline, psychiatry seeks to identify the biological factors that cause mental illness.” (p 30) [Emphasis in original]
“Because these diseases are considered to be biological in origin, the therapy is seen as correcting an underlying biological imbalance.” (p 30)
“The return of many psychiatrists to the biological model is likely to dramatically change the nature of health care in the 1980s.” (p 31)
“The remainder of this book explains in more detail the recent discoveries and contribution of biological psychiatry, which will revolutionize the treatment of mental illness during the 1980s and 1990s.” (p 32)
“When we talk, think, feel, or dream, each of these mental functions is due to electrical impulses passing through the complicated and highly specialized electrical circuits that make up the human brain. 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, and these ‘breaks’ in the brain can occur in many different ways.” (p 219) [Emphasis added]
“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]
DR PIES: CLOSING ON AN UPBEAT
Dr. Pies ends his article with a call to put this whole chemical imbalance myth behind us.
“At long last, it’s time to move beyond the myth of the chemical imbalance, and to see psychiatry for what it is today: a medical discipline whose core paradigm addresses psyche and soma, motives and molecules, in a holistic manner.”
And, of course, that’s a great idea. Let bygones be bygones! But first there is a pressing need for psychiatry to come clean on this issue. This is particularly important in that the chemical imbalance theory is still believed by millions of people here and overseas. Psychiatrists and psychiatric institutions need to admit that they actively promoted the chemical imbalance falsehood, knowing that it was false, and they did this, and continue to do this, for purely business reasons. The fact that Dr. Pies won’t rise above his guild concerns and address these matters in a straightforward fashion raises profound questions about his objectivity and his status as a medical ethicist.
Here’s Dr. Pies’ closing argument:
“Perhaps there are cultural and societal forces that keep this bogus notion alive, despite evidence to the contrary. Here I am reminded of Gresham’s Law, which posits that money of lower intrinsic value will circulate more freely than money of higher intrinsic value – i.e., ‘bad money drives out good money.’ Perhaps simplistic notions are better at surviving in the marketplace of ideas than more complex ones – like bumper stickers beating out thoughtful essays. Then, of course, there is the benighted state of science education in the US, which leaves the public ill-equipped to sort out scientific truths from urban legends like the CIT.”
Classic Dr. Pies. First the gratuitous and pedantic diversion on Gresham’s Law. Then bumper-sticker slogans (e.g., the chemical imbalance theory) beating out thoughtful essays (e.g. as written by the Great Doctor himself), and finally the benighted state of science education in the US. So it’s the teachers’ fault. The irony of the second item is profound in that, I suggest, one would be hard put to find a health-care specialty that is less invested in genuine science and more interested in bumper-sticker slogans than psychiatry.
Examples of bumper-sticker slogans used by psychiatry include:
“Treatment Works” (Richard Harding, MD, then President of the APA; Family Circle Advertising Feature November 20, 2001
“Mental illness…is a medical problem just like heart disease or diabetes” (American Psychiatric Association, ‘What is Mental Illness” page)
“End the Stigma” (APA on Twitter, 5:50AM, October 20, 2019)
And let us not forget Dr. Pies’ delightful little essay The Music of the Brain, the Chemistry of the Lute (Creative Non-Fiction, #13, 1999, pp 75-83). In his opening statement, Dr. Pies makes the obvious point that “…the brain is not a lute and the six brain chemicals” that he wants to explore “are not precisely like the six strings of the lute.”
Nevertheless, in the next paragraph he states clearly:
“Just as the lute’s strings may be out of tune, the brain’s chemistry may be out of balance.”
And on the following page:
“Just as the strings of a lute may be plucked too loudly or too softly, a particular neurotransmitter pathway may be overactive or underactive – spilling out too much or too little of its chemical messenger. This can have disastrous consequences for mental health and stability, as we will see.”
Despite the general caveat in the opening statement, it is clear that the great Dr. Pies himself is promoting here the notion that “a particular neurotransmitter pathway may be overactive or underactive.” (i.e. out of balance). And that this imbalance “can have disastrous consequences for mental health and stability.” Not much ambiguity there.