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Sunday, June 24, 2012

Chemical Imbalances and Other Black Unicorns


Like a black unicorn we have created a dangerous mythology in promoting the idea mental illnesses are caused by chemical imbalances.

“What do you think caused your problems?”, I asked.

“I have a chemical imbalance, a chemical imbalance, an imbalance in the brain that makes me ill.”

Sarah* had a diagnosis of bipolar disorder. Since her adolescence she had become acquainted with dark, shifting moods that meant she was sometimes uncontrollable and frenzied, and other times found it so effortful to live that she would retire to her bed for weeks, not eating, not bathing, not sleeping. Her every waking moment was spent contriving her own end, but to do that was too effortful itself.

Sarah joins an ever-growing troupe of patients who tell me that they have a chemical imbalance in their brain. Some have been told this by psychiatrists, others by their relatives, others still from mental health charities. None have heard this term from me. The notion that mental illnesses are caused by chemical imbalances is neither true, nor helpful. Worse still, the idea of mental illnesses as chemical imbalances is making us ill.


Medical or a Marketing Term

The term ‘chemical imbalance’ is not a medical or scientific term. Indeed a quick scientific literature search will show that the term is conspicuous by its absence. Despite this, patients and their families are often told by their physicians that their problems are caused by a chemical imbalance in the brain. Most pharmaceutical advertising for psychiatric drugs also tells consumers that mental illnesses are caused by chemical imbalances. The wide array of information for patients and their families on mental illness also frequently couches mental disorders as due to chemical imbalance. At once so simple and yet technical, it is easy to see why so many people find the idea their problems are due to chemical imbalances so compelling. It provides a simple explanation during a time when individuals crave certainty, and is packaged in the respectable veneer of pseudo-medical jargon. Make no mistake, however. There is only one reason why we have ‘learned’ that mental disorders are caused by chemical imbalances. To sell more drugs. There is one main reason too, why doctors tell their patients their problems are due to chemical imbalances. To convince people to take these drugs.

It was supposed to be a beautiful narrative. A previously well person becomes depressed, feels too listless and tired to live. A chemical imbalance is identified as the perpetrator. The ‘chemical imbalance’ is corrected with an antidepressant, and the patient is restored to her previous self. It is a story of restitution. It is a story where medicine is the hero and bad biochemistry the villain. It is a story with no basis in reality. Instead, we have convinced individuals that they are in some way defective and in need of lifelong treatment.


Making Us Sick

When a physician prescribes an antidepressant, he cannot but help but also prescribe an idea. He may not wish to prescribe the idea, indeed, he often is not aware he is prescribing the idea, but the physician nevertheless is prescribing the idea. The idea is that the problem is a chemical one, with a chemical solution. If it is a chemical problem, then it is largely outside of one’s control. The source of distress is no longer rooted in the fabric of society, interpersonal discord, a life story punctuated by loss, trauma and abuse, but it is located within the individual. It is located within the brain. Suddenly, the problem is no longer unemployment, widening inequality, social disadvantage, or alienation: the problem is you.

Once individuals become inculcated in dealing with their problems with psychiatric medication, they often increasingly see their emotions and life problems as outside their control. Further, they have little problem with medicating away emotions within the usual scope of mental life. It is not unusual for such patients who are a little upset, a little anxious, or angry, and mostly understandably so, to dull away these feelings with a dose of antipsychotic or benzodiazepine. In doing so, they undermine their coping skills and ability to tolerate the rich array of emotions threaded into the tapestry of life.

The most troubling aspect of the message is, instead of one of resilience and recovery, it is one of vulnerability and reliance. Although part of the reason why antidepressants ‘work’ is the idea provides a lifeline to an individual as a message of hope, this is transient. Eventually, patients come to wonder, ‘If I have a chemical balance, won’t it come back if I stop taking this pill?’ or ‘If antidepressants are like insulin for diabetes, don’t I need to take this forever?’ Whilst antidepressant prescriptions have on the whole been rising, the number of new prescriptions for antidepressants has not been increasing year on year. This fits with epidemiological data that show that the number of new cases of depression has actually been decreasing, but the total number of people depressed has been increasing2. What this suggests is not that more people are becoming depressed, but that fewer people are getting better. It is not so much we are all becoming depressed, but when we do, we’re staying that way. In convincing people that they have a chemical imbalance, we have disempowered them to look at how they can change their life for better, and instead made them reliant on medication. As a result instead of making people better we have kept people sick.


The New Phrenology and the Eclipse of the Social World

Today, the majority of research into the causes of mental distress focuses on neuroimaging and genetics. There are other niche interest including immunology, endocrinology, and proteomics, but on the whole, most research is biologically-oriented and focuses on brain scanning and genes. This has come at the expense of research into the social world in which people become depressed, go manic, or have psychotic experiences.

Now we should not ignore avenues of research that have the potential to transform our understanding and help individuals. My contention is that, with the possible exception of dementia, not a single patient has actually benefited from any neuroimaging research. Despite billions of research dollars, many at the public expense, not a single treatment or innovation has come out of this funding. In contrast, the finding that the relapse rate for schizophrenia was higher in families with high expressed emotion led to the development of family therapies, the finding that depression followed particular life events led to the development of interpersonal therapy, and the finding that women lacking a close confiding relationship were more likely to develop depression led to the development of befriending programs for depressed women. Yet, it has become exceedingly hard to get research funding to explore further the social and environmental determinants of health. If I wanted to do a study neuroimaging manic hedgehogs, I would not find much difficulty getting funding. On the other hand, If I wanted to explore the role of social support in outcomes for those who have psychotic experiences, it would be an uphill battle.

It comes as no surprise that when there is a Republican administration, research exploring the social determinants of mental health dwindles, and there is more funding for biological research. The obfuscation of the wider social determinants of mental distress is deliberate. Unfortunately, we have become so obsessed with finding the elusive cause of mental illness using new technologies, we have become complicit in forgetting about the determinants of our mental health in the social world.

Like a black unicorn, we have cultivated a dangerous mythology in the promotion of the notion that mental illnesses are due to chemical imbalances. Whilst there is of course a biological basis to our emotions, thoughts and behaviors, this level of explanation is unhelpful because it ignores what our feelings and experiences of living mean, and ignores the context in which we experience joy, love, anger, sadness and fear. By convincing individuals that their problems are due to chemical imbalances, we have succeeded not only in creating a generation who has recoded their moods and feelings into neurochemicals, we have undermined their ability to manage these problems themselves. Most troubling of all, the notion of chemical imbalances has transformed mental illnesses from temporary aberrations of mental states understandable within a particular context, to permanent disorders of the self embedded in the brain.

*Sarah represents a composite of different patients and not one individual. 

4 comments:

  1. Nice post. I am still amazed how normally 'intelligent' people such as Steven Novella, of the Neurologica blog and JREF crowd can easily dismiss Szasz as a total unscientific 'crank' for expressing similar views. Such is the power of myth over science a la Popper. Oh well.

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  2. To get on a hobbyhorse of mine, with physical illness, people don't seem to expect a single explanation, but in the UK at least, so very often mental illness is all lumped together as if it were a single condition and then it seems to me that people often expect a single explanation for all mental illness. Personally, I think that different illnesses have different explanations.

    If two people break a leg, one person may have a bone disorder and have simply rolled over in their sleep and the other may have strong bones but be hit by a big lump of metal. We wouldn't look at just one cause or expect just one treatment. (Forgive me if this is a clumsy example.)

    Take the high expressed emotion and psychosis. I experience psychosis. Trying to get my family to express any emotion at all was, to say the least, difficult. It has taken my father until his eighties to visibly express anger and frustration. But that doesn't mean that the explanation doesn't hold true for others.

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  3. Fantastic post, very lucid. You've read Gary Greenberg?

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