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Psychiatrist Ronald Pies says doctors tell patients the "chemical imbalance" lie as a favor

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Attempting to explain why patients hear the discredited "chemical imbalance" theory so often from doctors, Psychiatric Times editor-in-chief Ron Pies says doctors tell patients this misinformation in order to comfort them.

 

Dr. Pies was trying to dig himself out of a hole he'd dug in an earlier article, where he embarrassed himself with the the non-credible claim that psychiatrists never espoused the "chemical imbalance" theory.

 

Doctor, Is My Mood Disorder Due to a Chemical Imbalance?

By Ronald Pies, MD August 4, 2011 PsychCentral

 

Dear Mrs. ——–

 

You have asked me about the cause of your mood disorder, and whether it is due to a “chemical imbalance”. The only honest answer I can give you is, “I don’t know”—but I’ll try to explain what psychiatrists do and don’t know about the causes of so-called mental illness, and why the term “chemical imbalance” is simplistic and a bit misleading.

 

....

Now, this notion of the “chemical imbalance” has been much in the news lately, and a lot of misinformation has been written about it—including by some doctors who ought to know better 2. In the article I referenced, I argued that “…the “chemical imbalance” notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.”1 Some readers felt I was trying to “re-write history”, and I can understand their reaction—but I stand by my statement.

 

Of course, there certainly are psychiatrists, and other physicians, who have used the term “chemical imbalance” when explaining psychiatric illness to a patient, or when prescribing a medication for depression or anxiety. Why? Many patients who suffer from severe depression or anxiety or psychosis tend to blame themselves for the problem. They have often been told by family members that they are “weak-willed” or “just making excuses” when they get sick, and that they would be fine if they just picked themselves up by those proverbial bootstraps. They are often made to feel guilty for using a medication to help with their mood swings or depressive bouts.

 

So, some doctors believe that they will help the patient feel less blameworthy by telling them, “You have a chemical imbalance causing your problem.” It’s easy to think you are doing the patient a favor by providing this kind of “explanation”, but often, this isn’t the case. Most of the time, the doctor knows that the “chemical balance” business is a vast oversimplification.

 

My impression is that most psychiatrists who use this expression feel uncomfortable and a little embarrassed when they do so. It’s a kind of bumper-sticker phrase that saves time, and allows the physician to write out that prescription while feeling that the patient has been “educated.” If you are thinking that this is a little lazy on the doctor’s part, you are right. But to be fair, remember that the doctor is often scrambling to see those other twenty depressed patients in her waiting room. I’m not offering this as an excuse–just an observation.

 

Ironically, the attempt to reduce the patient’s self-blame by blaming his brain chemistry can sometimes backfire. Some patients hear “chemical imbalance” and think, “That means I have no control over this disease!” Other patients may panic and think, “Oh, no—that means I have passed my illness on to my kids!” Both of these reactions are based on misunderstanding, but it’s often hard to undo these fears. On the other hand, there are certainly some patients who take comfort in this “chemical imbalance” slogan, and feel more hopeful that their condition can be controlled with the right kind of medication.

 

They are not wrong in thinking that, either, since we can get most psychiatric illnesses under better control, using medication—but this should never be the whole story. Every patient who receives medication for a psychiatric illness should be offered some form of “talk therapy”, counseling, or other kinds of support. Often, though not always, these non-medication approaches should be tried first, before medication is prescribed. But that’s another story—and I want to get back to this “chemical imbalance” albatross, and how it got hung around the neck of psychiatry. Then I’d like to explain some of our more modern ideas of what causes serious psychiatric illnesses.

 

Back in the mid-60s, some brilliant psychiatric researchers—notably, Joseph Schildkraut, Seymour Kety, and Arvid Carlsson– developed what became known as the “biogenic amine hypothesis” of mood disorders. Biogenic amines are brain chemicals like norepinephrine and serotonin. In simplest terms, Schildkraut, Kety, and other researchers posited that too much, or too little, of these brain chemicals was associated with abnormal mood states—for example, with mania or depression, respectively. But note two important terms here: “hypothesis” and “associated”. A hypothesis is just a stepping-stone along the path to a fully-developed theory—it’s not a full-blown conception of how something works. And an “association” is not a “cause”. In fact, the initial formulation of Schildkraut and Kety 3 allowed for the possibility that the arrow of causality might travel the other way; that is, that depression itself might lead to changes in biogenic amines, and not the other way around. ....

 

Now remember, Mrs. ——, these are the pioneers whose work helped lead to our modern-day medications, such as the “SSRIs” (Prozac, Paxil, Zoloft and others). And they certainly did not claim that all psychiatric illnesses—or even all mood disorders—are caused by a chemical imbalance! Even after four decades, the “holistic” understanding that Schildkraut and Kety described remains the most accurate model of psychiatric illness. In my experience over the past 30 years, the best-trained and most scientifically-informed psychiatrists have always believed this, despite claims to the contrary by some anti-psychiatry groups.4

 

Unfortunately, the biogenic amine hypothesis got twisted into the “chemical imbalance theory” by some pharmaceutical marketers,5 and even by some misinformed doctors. And, yes, this marketing was sometimes aided by doctors who—even if with good intentions–didn’t take the time to give their patients a more holistic understanding of psychiatric illness. To be sure, those of us in academia should have done more to correct these beliefs and practices. For example, the vast majority of antidepressants are prescribed not by psychiatrists, but by primary care physicians, and we psychiatrists have not always been the best communicators with our colleagues in primary care.

 

All that said, what have we learned about the causes of serious psychiatric illness in the past 40 years? My answer is, “More than many in the general public, and even in the medical profession, realize.” First, though: what we don’t know, and shouldn’t claim to know, is what the proper “balance” is for any given individual’s brain chemistry. Since the late 1960s, we have discovered more than a dozen different brain chemicals that may affect thinking, mood, and behavior. While a few seem particularly important—such as norepineprhine, serotonin, dopamine, GABA, and glutamate—we have no quantitative idea of what the optimal “balance” is for any particular patient. The most we can say is that, in general, certain psychiatric illnesses probably involve abnormalities in specific brain chemicals; and that by using medications that affect these chemicals, we often find that patients are significantly improved. (It is also true that a minority of patients have adverse reactions to psychiatric medications, and we need further study of their long-term effects).6

 

But neuroscience research has moved beyond any simple notion of a “chemical imbalance” as the cause of psychiatric illnesses. The most sophisticated, modern theories posit that psychiatric illness is caused by a complex, often cyclical interaction of genetics, biology, psychology, environment, and social factors. 7 Neuroscience has also moved beyond the notion that psychiatric medications work simply by “revving up” or toning down a couple of brain chemicals. For example, we have evidence that several antidepressants foster the growth of connections between brain cells, and we believe this is related to the beneficial effects of these medications.8 Lithium—a naturally occurring element, not really a “drug”—may help in bipolar disorder by protecting damaged brain cells and promoting their ability to communicate with each other. 9

 

Let’s take bipolar disorder as an example of how psychiatry views “causation” these days (and we could have a similar discussion of schizophrenia or major depressive disorder). We know that a person’s genetic make-up plays a major role in bipolar disorder (BPD). So, if one of two identical twins has BPD, there is better than a 40% chance that the other twin will develop the illness, even if the twins are reared in different homes. 10 But note that the figure is not 100%–so there must be other factors involved in the development of BPD, besides your genes.

 

Modern theories of BPD hold that abnormal genes lead to abnormal communication between various inter-linked regions of the brain—so-called “neurocircuits”—which in turn increases the likelihood of profound mood swings. There’s growing evidence that BPD may involve a sort of top-down, “failure to communicate” within the brain. Specifically, the frontal regions of the brain may not adequately dampen over-activity in the “emotional” (limbic) parts of the brain, perhaps contributing to mood swings. 11

 

So, you ask—is it still all a matter of “biology”? Not at all—the person’s environment certainly matters. A major stressor may sometimes trigger a depressive or manic episode. And, if a child with early-onset BPD is raised in an abusive or unloving home, or is exposed to many traumas, this is likely to increase the risk of mood swings in later life12—though there is no evidence that “bad parenting” causes BPD. (At the same time, abuse or trauma in childhood may change the “wiring” of the brain permanently, and this in turn may lead to more mood swings—truly, a vicious circle).13 On the other hand, in my experience, a supportive social and family environment can improve the outcome of a family member’s BPD.

 

Finally—while the individual’s approach to “problem-solving” is not a likely cause of BPD—there is evidence that how the person thinks and reasons makes a difference. For example, cognitive-behavioral therapy and family-focused therapy may reduce the risk of relapse, in BPD.14 And so, with appropriate support, the person with bipolar disorder can take some control of her illness–and maybe even improve its course– by learning more adaptive ways of thinking.

 

So, boiling it all down, Mrs.——–, I certainly can’t tell you the exact cause of your or anybody’s psychiatric illness, but it’s a lot more complicated than a “chemical imbalance”. You are a whole person–with hopes, fears, wishes, and dreams—not a brain filled with chemicals! The originators of the “biogenic amine” hypothesis understood this over forty years ago—and the best-informed psychiatrists understand it today.

 

Sincerely,

 

Ronald Pies MD

 

Note: The above “letter” was addressed to a hypothetical patient. A full disclosure statement for Dr. Pies may be found at: http://www.psychiatrictimes.com/editorial-board

 

References

 

Pies R: Psychiatry’s new brain-mind and the legend of the chemical imbalance. Psychiatric Times, July 11, 2011. http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1902106

See, for example, M. Angell MD, in the New York Review of Books: “The shift from “talk therapy” to drugs as the dominant mode of treatment coincides with the emergence over the past four decades of the theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs…” http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/

Schildkraut JJ, Kety SS. Biogenic amines and emotion. Science. 1967; 156:21-37.

See, eg, “The cornerstone of psychiatry’s disease model today is the theory that a brain-based, chemical imbalance causes mental illness.” http://www.cchr.org/sites/default/files/Blaming_The_Brain_The_Chemical Imbalance_Fraud.pdf (PDF)

Lacasse JR, Leo J. Serotonin and Depression: A Disconnect between the Advertisements and the Scientific Literature. PLoS Med. 2005; 2(12): e392. doi:10.1371/journal.pmed.0020392

El-Mallakh RS, Gao Y, Jeannie Roberts R. Tardive dysphoria: the role of long term antidepressant use in-inducing chronic depression. Med Hypotheses. 2011; 76:769-73.

Moran M: Brain, Gene Discoveries Drive New Concept of Mental Illness. Psychiatric News, June 17, 2011.

Castrén E, Rantamäki T. The role of BDNF and its receptors in depression and antidepressant drug action: Reactivation of developmental plasticity. Dev Neurobiol. 2010;70:289-97.

Machado-Vieira R, Manji HK, Zarate CA Jr. The role of lithium in the treatment of bipolar disorder: convergent evidence for neurotrophic effects as a unifying hypothesis. Bipolar Disord. 2009;11 (Suppl 2):92-109.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800957/?tool=pubmed

Kieseppä T, Partonen T, Haukka J et al. High concordance of bipolar I disorder in a nationwide sample of twins. Am J Psychiatry. 2004 161; 1814-21.

Lagopoulos J, Malhi G. Impairments in “top-down” processing in bipolar disorder: a simultaneous fMRI-GSR study. Psychiatry Res. 2011; 192:100-8.

MacKinnon D, Pies R. Affective instability as rapid cycling: Theoretical and clinical implications for borderline personality and bipolar spectrum disorders. Bipolar Disord. 2006;8:1–14.

Heim C, Newport DJ, Bonsall R, et al: Altered pituitary-adrenal axis responses to provocative challenge tests in adult survivors of childhood abuse. Am J Psychiatry. 2001;158:575-81.

Zaretsky AE, Rizvi S, Parikh SV. How well do psychosocial interventions work in bipolar disorder? Can J Psychiatry. 2007;52:14-21.

 

Recommended reading:

 

Kramer P: In defense of antidepressants. New York Times Sunday Review, July 9, 2011. http://www.nytimes.com/2011/07/10/opinion/sunday/10antidepressants.html?pagewanted=all

 

Ronald Pies MD

 

is Professor of Psychiatry and Lecturer on Bioethics & Humanities at SUNY Upstate Medical University, Syracuse, NY; and Clinical Professor of Psychiatry, Tufts University School of Medicine, Boston. He is the author of several psychiatric textbooks....

 

 

http://psychcentral.com/blog/archives/2011/08/04/doctor-is-my-mood-disorder-due-to-a-chemical-imbalance/

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cinephile

Call me crazy (you're crazy!) but I don't think Pies is one of the worst psychiatric offenders. I think he made some good points in his article about the chemical imbalance BS.

 

I think this is the key passage about the chemical imbalance theory (from here on abbreviated CIT):

 

My impression is that most psychiatrists who use this expression feel uncomfortable and a little embarrassed when they do so. It's a kind of bumper-sticker phrase that saves time, and allows the physician to write out that prescription while feeling that the patient has been "educated." If you are thinking that this is a little lazy on the doctor's part, you are right. But to be fair, remember that the doctor is often scrambling to see those other twenty depressed patients in her waiting room. I'm not offering this as an excuse–just an observation.

The bolded point is key here. Pies also admits it's lazy for doctors to use the CIT. Now, of course, I believe (as do most on this board) that it's more than lazy -- it's toxic and unethical. But AT LEAST Pies admits it's not right.

 

In fact, the most revealing (and infuriating) part about this article wasn't about CIT at all -- it was basically a parenthetical admission (a subconscious attempt to push it to the sidelines?) about iatrogenic harm. Here it is:

 

(It is also true that a minority of patients have adverse reactions to psychiatric medications, and we need further study of their long-term effects)

UM, HELLO? THIS NEEDS TO BE SHOUTED FROM THE ROOFTOPS!

 

This marginalizing of one of the most explosive issues of psych meds, which entails everything from protracted withdrawal to PSSD, actually angers me more than his back-peddling of the CIT. If anything, I think the discovery that SSRIs can cause permanent sexual dysfunction and emotional blunting (in men and women not even into their 20s!) and horrific protracted withdrawal in more than just a minority of patients is a fact that psychiatry is far more afraid to admit to than the fallacy of the CIT. I am furious that Pies just shoves this off to the side.

 

So all in all, this article is a real mixed bag -- it's not all bad, but it ain't exactly what we want to hear, either.

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Fid

As you will note, Dr Pies has, on many of his responses, replied to me in person. His latest reply was brought to my attention via the Surviving Antidepressants Facebook post.

 

I have just left a response to Dr Pies, I don't know if it will be added as comments are moderated before being allowed through.

 

Here's my reply:

 

Dear Dr Pies,

 

With respect, some of your comments here are very misleading and go against what both the pharmaceutical industry and medicine regulators state.

 

You wrote:

 

"I would like to make a few comments

about antidepressants. The notion that “SSRIs” or other antidepressants can cause some-

one to commit suicide is far-fetched and simplistic; it is also not supported by

many carefully-done studies."

 

What studies have you been reading? Have you ever heard of the Paxil 329 studies?

 

Are black box warnings added to boxes because it makes the packaging look pretty?

 

I guess you are from the school that blames the "illness" rather than the medication, right?

 

Could you explain the suicides and attempted suicides in healthy clinical trials on SSRi's?

 

Do you oppose what the FDA, MHRA, indeed the global regulatory system claim that SSRi's can cause suicidal thoughts and suicide? It appears that you do.

 

The chemical imbalance theory was a promotional tool. Consumers were fed the line, "You are depressed because you have a chemical imbalance, X,Y,Z can correct that imbalance."

 

We now know that was an outright lie, it was a genius marketing strategy to sell drugs and to dupe the public.

 

Your headache analogy is wafer thin, I've never known anybody to take a headache tablet twice a day for 10, 12, 15, 20 years to 'cure' their headache, have you?

 

If you were to be totally honest Dr Pies, you would tell your readers that there is much evidence to suggest that SSRi type medication can cause suicidal thoughts and suicide in a number of patients that take them...or do you totally dismiss the abundance of anecdotal evidence that exists today?

 

I am astounded that you deny there is an SSRi/suicide link and, to be quite frank, fear for any of your patients that you prescribe this type of medication to.

 

If one of your patients came to you and said, "Hey Doc, I have just read the warning on the patient information leaflet and the drug you prescribed me can cause suicidal thoughts and suicide." Would you tell him/her that the information provided is "far-fetched"?

 

When taking an SSRi, one alters the chemicals in their brain with the medication, therefore giving the patient a chemical imbalance, an imbalance that wasn't there before they started taking the meds, or at the very least could not be proven existed before the start of medication.

 

Remember Dr Pies, healthy volunteers in clinical trials who went on to either have suicidal thoughts or to complete suicide only did so because of the drug they were taking. For you to dismiss this is dangerous, unethical and downright ignorant.

 

It would appear that you are not going to alter your opinion on this matter, that could have dire consequences on any of your future patients who come to you with their concerns about the medication you have prescribed them.

 

Next you will be telling me that there is no addiction problem with SSRi's.

 

Bob Fiddaman

Author of 'The evidence, however, is clear...the Seroxat scandal'

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compsports

Bravo Bob. This is why I don't have as favorable an impression as Cine does of Pies although I understand his point of view.

 

Your post really struck a chord with me as I became suicidal on Prozac and guess what, the illness was blamed. None of the 7 psychiatrists I saw realized it was the drug and not the Prozac. This led to being on meds for 15 years.

 

To address the few points you made, yup, if a patient pointed out the suicidal warnings, they would be told by most psychiatrists it is far fetched. Sorry for my cynicism but after reading so many blogs and comments by psychiatrists, I honestly feel that would happen.

 

I love your comment about taking a headache remedy for twenty years. I will have to remember that point.

 

CS

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Fid

"None of the 7 psychiatrists I saw realized it was the drug and not the Prozac."

 

I bet you my left nut that they knew.

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compsports

"None of the 7 psychiatrists I saw realized it was the drug and not the Prozac."

 

I bet you my left nut that they knew.

 

Fid, you are totally correct as painful as it is for me to admit that.

 

Damm them all.

 

CS

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Fid

Just went on over to the site to see if they had published my last comment.

 

Got the following:

 

Briefly unavailable for scheduled maintenance. Check back in a minute.

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Altostrata

I hope you saw Iatrogenia's post!

 

Ron Pies excels as an apologist for psychiatry. He always manages to formulate rationalizations explaining away any criticisms of psychiatry.

 

My impression of him is negative -- really, the "chemical imbalance" theory was manufactured as a slur by anti-psychiatry? -- but I think he may be a nice man who's kind to children and animals and wants respect and appreciation for psychiatry.

 

I very strongly doubt that doctors have told patients the "chemical imbalance" lie out of compassion, as Pies would have it. Besides, telling patients any lie to get them to accept treatment is a breach of ethics.

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Rhiannon

Bravo Bob. This is why I don't have as favorable an impression as Cine does of Pies although I understand his point of view.

 

Your post really struck a chord with me as I became suicidal on Prozac and guess what, the illness was blamed. None of the 7 psychiatrists I saw realized it was the drug and not the Prozac. This led to being on meds for 15 years.

 

To address the few points you made, yup, if a patient pointed out the suicidal warnings, they would be told by most psychiatrists it is far fetched. Sorry for my cynicism but after reading so many blogs and comments by psychiatrists, I honestly feel that would happen.

 

I love your comment about taking a headache remedy for twenty years. I will have to remember that point.

 

CS

 

You too, huh? I became suicidal on Prozac and, eventually, on every other AD I was given to treat the "mental illness" that was causing me to be suicidal. Basically I've been intermittently/episodically suicidal for most of the past 20 years, with two attempts.

 

I haven't been actively suicidal since after the first six months of my taper. And now, eighteen months into my taper, even feeling passively suicidal has become such a rare experience that most of the time I can't even imagine wanting to die. Which is so weird, because that was my continuous state of mind almost all the time for so many long years.

 

Gianna (Beyond Meds) says this is pretty much universal, the suicidality going away once off the drugs.

 

I think suicidality due to psych drugs is a huge problem, especially with ADs, because the presenting "depression" is usually blamed. Now whenever I hear of a sudden suicide in someone who had no previous history of being suicidal but may have been feeling a little down or stressed recently, I just presume some idiot doctor gave them an AD.

 

What really pisses me off about this is, other side effects are reversible, and so is the suicidality IF you survive it. If you don't--it's such a huge tragedy for everyone. Yet the drug companies have actively, intentionally suppressed this finding, repeatedly. It's one thing (bad enough) to suppress findings of ineffectiveness relative to placebo. But what kind of mind would say, profits are more important than letting people know these drugs cause people to DIE? Who ARE these guys?

 

Okay, a bit of a digression from the topic of the thread. Sorry. I get worked up about this.

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Rhiannon

I hope you saw Iatrogenia's post!

 

Ron Pies excels as an apologist for psychiatry. He always manages to formulate rationalizations explaining away any criticisms of psychiatry.

 

My impression of him is negative -- really, the "chemical imbalance" theory was manufactured as a slur by anti-psychiatry? -- but I think he may be a nice man who's kind to children and animals and wants respect and appreciation for psychiatry.

 

I very strongly doubt that doctors have told patients the "chemical imbalance" lie out of compassion, as Pies would have it. Besides, telling patients any lie to get them to accept treatment is a breach of ethics.

 

Snort! "re kind to children and animals..."

 

My thoughts also when I read the piece. Trying to worm out of 25 years of lies and excuses by making up more BS. The fact that he now includes some stuff that's actually true and accurate just reminds me of a kid who gets in trouble and gets busted lying about something they did, who then comes up with new excuses for why they were lying. If they're good liars they know how to work some humility and flattery and truth into it. (One of my daughters was pretty good at it.) I ain't buyin it.

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compsports

Rhi, I am so sorry to hear about your experiences and am glad that the suicidal ideation stopped once you started tapering your meds.

 

Fid, I noticed your message didn't show up. Have you emailed John Grohol to complain? He has always been responsive to me when I have encountered similar situations.

 

CS

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btdt

I hope you saw Iatrogenia's post!

 

Ron Pies excels as an apologist for psychiatry. He always manages to formulate rationalizations explaining away any criticisms of psychiatry.

 

My impression of him is negative -- really, the "chemical imbalance" theory was manufactured as a slur by anti-psychiatry? -- but I think he may be a nice man who's kind to children and animals and wants respect and appreciation for psychiatry.

 

I very strongly doubt that doctors have told patients the "chemical imbalance" lie out of compassion, as Pies would have it. Besides, telling patients any lie to get them to accept treatment is a breach of ethics.

I agree.

"My impression is that most psychiatrists who use this expression feel uncomfortable and a little embarrassed when they do so. It’s a kind of bumper-sticker phrase that saves time, and allows the physician to write out that prescription while feeling that the patient has been “educated.”

 

This is just an out and out lie the term chemical imbalance was coined by a marketing company and shrinks lapped it up by choice or stupidity neither are tolerable. 

 

It started as a LIE and continues the same... 

more lies about the withdrawal the long term maybe forever damage....

 

lie lie lie 

all they know how to do...

 

and they keep getting away with it for over 30 years now...

proving they can... 

expecting to get away with even more makes me wonder what other bull they have tried since this have been able to pull of this great scam so well and nobody is the wiser... not really they still sell them 

I will say the system has changed when the take these drugs off the market. 

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Altostrata

Dr. Pies had a choice between admitting psychiatrists are fools or portraying them as informed but well-meaning liars of little white lies. He chose the latter.

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Narcissus

...what we don’t know, and shouldn’t claim to know, is what the proper “balance” is for any given individual’s brain chemistry. Since the late 1960s, we have discovered more than a dozen different brain chemicals that may affect thinking, mood, and behavior. While a few seem particularly important—such as norepineprhine, serotonin, dopamine, GABA, and glutamate—we have no quantitative idea of what the optimal “balance” is for any particular patient. 

 

I think it's very important for people to understand this and I'm grateful to Dr. Pies for stating it in such a succint and quotable way. By and large, however, I think we're getting a lot of mystification from Dr. Pies. I won't try to get into all of it, but I had a few responses to Pies' comments here.

 

Dr. Pies' complaints about the “chemical balance” theory seems two-pronged: first, he regrets that it's mostly espoused by pharmaceutical companies and physicians (non-psychiatrists), and second he sees it as a “vast simplification”. That he sees it as a simplification suggests that the theory isn't fundamentally wrong-headed, it's just too crude and too narrow, having been translated too many times (by non-psychiatrists) from the original psychiatric research. To Pies the problem isn't neuroscience or psychiatric research, its the process by which this research is disseminated into the public. The psychiatrists are only to blame to the extent that they introduce the idea to their patients, and Dr. Pies insists this happens largely because of the patients' need for absolution from guilt and self-blaming. This raises all sorts of questions, like where do we draw the line between psychiatric research and its application? Are psychiatrists simply bearers of information drawn from the front lines of medical research? Why do people feel a persistent responsibility (or guilt) for the way that they feel? Is it the psychiatrist's duty to dispel this sense of responsibility, or at least to reduce it to the appropriate levels? What are the appropriate levels?

 

Dr. Pies wants to lay the “chemical imbalance” theory over the heads of Big Pharma marketers and an ignorant public. But the “chemical imbalance” theory is not an “albatross” that's been somehow “hung around the neck of psychiatry” (and this is really a ridiculous thing to say), it is the popular conception of an enduring trend in psychiatry (as well as in modern science in general). As early as 1972 the epidemiologist Alvan Feinstein said that, “The concept of pharmalogic action is a fashion of this era. It represents whatever particular patterns of physiologic, biochemical and mechanistic thought exist at any given point in time.” From what I can see the “brilliant researchers” Pies refers to were principally interested in “pharmalogic action” and its role in depression. I don't know the details of their research, but I think Pies' use of the word of “holistic” to describe their research of neurotransmitters and their respective mechanisms is probably too generous. Neuroscience is notoriously mechanistic, and holistic theories generally resist hard mechanistic approaches. When Pies tells us that the “chemical imbalance” theory is too narrow and overlooks social and environmental information I don't think he's being particularly holistic. Rather he's referring to a more up to date reductionism which aims to include social and environmental factors. The aim of this more up to date approach to mental illness is the same as it's always been, to locate the respective “causes” of mental illness and to isolate and control them. We're still dealing with mechanisms here, with the idea that people's feelings and behaviors can be reduced to webs of isolatable cause and effects that recur in more or less equivalent ways among millions of different people. Dr. Pies' statement that in the apparent link between neurotransmitters and “mood disorders” “the arrow of causality might travel the other way; that is, that depression itself might lead to changes in biogenic amines, and not the other way around...” is interesting to me. It seems to get at the ambiguity inherent in causality, the immensely difficult and always somewhat arbitrary task of distinguishing between causes and effects. Yet somehow I'm not sure that Pies takes this ambiguity very seriously. Perhaps I'm wrong. Does the biogenic amine hypothesis really restrict itself to acknowledging a correlation between neurotransmitters and mood disorders? Perhaps it does, but you wouldn't know that by looking at it's legacy.

 

And this is precisely the problem that I think Dr. Pies actively avoids. We need to remember that psychiatry is both a science and an institution, which is to say its not just a body of knowledge but also a body of action. Given that psychiatry serves the public and the state there will always be an immense pressure for it to apply its knowledge, no matter how crude that knowledge ultimately is. NO part of psychiatry, including the research Pies wants to present as somehow pristine, exists independent of the massive social pressures placed on it. Pies would have us think that the chemical imbalance theory is the result of some sort of failure to communicate, when it is in fact the necessary rationalization for the widespread application of incomplete ideas.  And this application isn't an unfortunate accident, it's the imperative of psychiatry!

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alexjuice

Pies argument is terrfying on the play-it-all-out... I am glad to forever be free of modern psychiatry.

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btdt

 

...what we don’t know, and shouldn’t claim to know, is what the proper “balance” is for any given individual’s brain chemistry. Since the late 1960s, we have discovered more than a dozen different brain chemicals that may affect thinking, mood, and behavior. While a few seem particularly important—such as norepineprhine, serotonin, dopamine, GABA, and glutamate—we have no quantitative idea of what the optimal “balance” is for any particular patient. 

 

I think it's very important for people to understand this and I'm grateful to Dr. Pies for stating it in such a succint and quotable way. By and large, however, I think we're getting a lot of mystification from Dr. Pies. I won't try to get into all of it, but I had a few responses to Pies' comments here.

 

Dr. Pies' complaints about the “chemical balance” theory seems two-pronged: first, he regrets that it's mostly espoused by pharmaceutical companies and physicians (non-psychiatrists), and second he sees it as a “vast simplification”. That he sees it as a simplification suggests that the theory isn't fundamentally wrong-headed, it's just too crude and too narrow, having been translated too many times (by non-psychiatrists) from the original psychiatric research. To Pies the problem isn't neuroscience or psychiatric research, its the process by which this research is disseminated into the public. The psychiatrists are only to blame to the extent that they introduce the idea to their patients, and Dr. Pies insists this happens largely because of the patients' need for absolution from guilt and self-blaming. This raises all sorts of questions, like where do we draw the line between psychiatric research and its application? Are psychiatrists simply bearers of information drawn from the front lines of medical research? Why do people feel a persistent responsibility (or guilt) for the way that they feel? Is it the psychiatrist's duty to dispel this sense of responsibility, or at least to reduce it to the appropriate levels? What are the appropriate levels?

 

Dr. Pies wants to lay the “chemical imbalance” theory over the heads of Big Pharma marketers and an ignorant public. But the “chemical imbalance” theory is not an “albatross” that's been somehow “hung around the neck of psychiatry” (and this is really a ridiculous thing to say), it is the popular conception of an enduring trend in psychiatry (as well as in modern science in general). As early as 1972 the epidemiologist Alvan Feinstein said that, “The concept of pharmalogic action is a fashion of this era. It represents whatever particular patterns of physiologic, biochemical and mechanistic thought exist at any given point in time.” From what I can see the “brilliant researchers” Pies refers to were principally interested in “pharmalogic action” and its role in depression. I don't know the details of their research, but I think Pies' use of the word of “holistic” to describe their research of neurotransmitters and their respective mechanisms is probably too generous. Neuroscience is notoriously mechanistic, and holistic theories generally resist hard mechanistic approaches. When Pies tells us that the “chemical imbalance” theory is too narrow and overlooks social and environmental information I don't think he's being particularly holistic. Rather he's referring to a more up to date reductionism which aims to include social and environmental factors. The aim of this more up to date approach to mental illness is the same as it's always been, to locate the respective “causes” of mental illness and to isolate and control them. We're still dealing with mechanisms here, with the idea that people's feelings and behaviors can be reduced to webs of isolatable cause and effects that recur in more or less equivalent ways among millions of different people. Dr. Pies' statement that in the apparent link between neurotransmitters and “mood disorders” “the arrow of causality might travel the other way; that is, that depression itself might lead to changes in biogenic amines, and not the other way around...” is interesting to me. It seems to get at the ambiguity inherent in causality, the immensely difficult and always somewhat arbitrary task of distinguishing between causes and effects. Yet somehow I'm not sure that Pies takes this ambiguity very seriously. Perhaps I'm wrong. Does the biogenic amine hypothesis really restrict itself to acknowledging a correlation between neurotransmitters and mood disorders? Perhaps it does, but you wouldn't know that by looking at it's legacy.

 

And this is precisely the problem that I think Dr. Pies actively avoids. We need to remember that psychiatry is both a science and an institution, which is to say its not just a body knowledge but a body of action. Given that psychiatry serves the public and the state there will always be an immense pressure for it to apply its knowledge, no matter how crude that knowledge ultimately is. NO part of psychiatry, including the research Pies wants to present as somehow pristine, exists independent of the massive social pressures placed on it. Pies would have us think that the chemical imbalance theory is the result of some sort of failure to communicate, when it is in fact the necessary rationalization for the widespread application of incomplete ideas.  And this application isn't an unfortunate accident, it's the imperative of psychiatry!

 

It is a lie!  No matter how fancy you say it and white washing it will not make it true.  

These drug do change how you feel so do pot and booze... that does not mean they are FIXING anything in your or anyone else's brain.  No defect has been found in depressive people that shows a change in serotonin NONE!  Booze and pot are drugs of choice they are not repairing anything in a broken brain but people choose to use them these psych drugs they offer to us are the same they will change how you feel... but just like we are told our entire lives of the dangers of pot and booze we should be told the ramifications of taking these psych drugs and we are NOT!!!

Substance P may be the neurotransmitter that relates to depression they still don't know.  Serotonin dopamine and norepinephrine all are the transmitter messed with by booze pot and illegal drugs... you have a choice to take these or not... to damage your brain with them or not.  The same should be true of legal drugs and the truth is not being told...period. I do know that taking these drugs can mess with your brain and body and maybe create an imbalance... we were never warned and we were lied to it is not ok to cover it up with fancy talk and it never will be. 

http://survivingantidepressants.org/index.php?/topic/4291-again-chemical-imbalance-is-a-myth-stop-the-lies-please/

http://www.madinamerica.com/2012/01/psychiatrys-grand-confession/

http://beyondmeds.com/2012/01/25/chemicalimbalancemythfalls/

http://www.topix.com/forum/drug/effexor/T07UM5C67CHT1KGU2

 

I can post you links all day and maybe I like to do it so much now because only a few short years ago there would have been nothing for me to link to.. it is slowly coming along too slow for me.

 

I read a book a couple of years ago called Our Daily Meds said the term was manufactured in a pharma marketing office.  It caught on. 

 

Even Wiki knows it is a lie... it can no longer be defended. 

http://en.wikipedia.org/wiki/Chemical_imbalance

 

If you choose to be a drug addict to use psych drugs to escape an emotional state that is your choice but it is a lie to say these drugs are fixing something broken in your brain.  LIE

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Narcissus

^btdt, you are aware that I'm agreeing with you, right? Sorry, it's just not entirely clear to me.

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Altostrata

The thing is, most psychiatrists enthusiastically bought in to the "chemical imbalance" theory. It's not a conspiracy by pharma and anti-psychiatry. Psychiatry is populated by many fools. Pies is completely full of it.

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btdt

I did not think that you did not agree but somehow other things slipped in... like this. 

" NO part of psychiatry, including the research Pies wants to present as somehow pristine, exists independent of the massive social pressures placed on it. " 

 

In my mind from the research I have done online and reading books it became clear to me that they knew after the clinical trials the problems with these drugs and they made a conscious choice to hide this information. I don't know understand how this could not be a conspiracy or some other evil doing by pharma as Alto suggests.  

Not only did the hide the suicides in the data by coding it incorrectly but they added benzos to the next drug trial to offset the anxiety caused by the drugs... how can this not be wrong... 

Tho the term chemical imbalance was made up by the marketing team who worked for pharma ... pharma did not have to take this and run with it.. they made a choice... Pharma approved the marketing to the doctors including psychiatrists that included the idea that they were correcting a chemical imbalance in the brain.....

 

 

 

I don't understand... how could pharma not be to blame for all this... HOW?  It started with them pharma were the first to know all the true information... I suggest before doctors before the FDA... they knew and made the choice to continue on selling and marketing.  Take a look at all the charges laid against pharma/fines paid...  for improper marketing of these drugs in doctor journals  not only false claims but the off label uses.  

 

 Who could stop it.. pharma doctors maybe... and the FDA.  From the entire group doctors would be last on my list.  The trip to market was full of lies and fraud it should never have made it to the doctors.  Information given to the doctors and the FDA was corrupted. Who else would you blame... shrinks... ?  Just shrinks?   How could that be?

 

I tried to do a multi quote it may not have worked....

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btdt

^btdt, you are aware that I'm agreeing with you, right? Sorry, it's just not entirely clear to me.

I answered you above where I also failed to do a multi quote going to need a lesson in that....

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btdt

The thing is, most psychiatrists enthusiastically bought in to the "chemical imbalance" theory. It's not a conspiracy by pharma and anti-psychiatry. Psychiatry is populated by many fools. Pies is completely full of it.

 It's not a conspiracy by pharma and anti-psychiatry.

 

There is a good chance I have gone completely stupid as I do not understand this... 

anti-psychiatry and pharma in the same sentence....both selling the chemical imbalance theory as fact....

If it is padded room time I would rather hear it from you...lol

I have answered this or what I think it says above....

rough read as I am starting to think I am losing it.. 

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Altostrata

You'd have to read Pies's article.

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btdt

You'd have to read Pies's article.

I did read the article they are at odds with each other with anti-psychiatry groups saying the imbalance theory has not been proven.  

 

" In my experience over the past 30 years, the best-trained and most scientifically-informed psychiatrists have always believed this, despite claims to the contrary by some anti-psychiatry groups.4"

 

He is referring to the imbalance theory. 

 

He admits this term was started by marketers ones hire and paid for by pharma and further made popular by doctors also well versed in medical journal articles and well paid visiting pharma reps... 

All the warning letters from the FDA to pharma about false marketing to doctors ... reg these meds... Pharma too the marketing ideas they paid for and used them to further push these drug not only on doctors but to the unsuspecting public.  

 

Pharma love this term used it to the fullest bet the guy who came up with it owns a yacht today.  That part is in my opinion It's not a conspiracy by pharma.

To put all the blame on doctors is ridiculous... and here is one doctor who tried to find out the truth about these drugs and this is what he found...worth looking at. 

http://www.ted.com/talks/ben_goldacre_what_doctors_don_t_know_about_the_drugs_they_prescribe.html

 

 It sounds to me like he is suggesting  a conspiracy by pharma.

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btdt

I hope you saw Iatrogenia's post!Ron Pies excels as an apologist for psychiatry. He always manages to formulate rationalizations explaining away any criticisms of psychiatry.My impression of him is negative -- really, the "chemical imbalance" theory was manufactured as a slur by anti-psychiatry? -- but I think he may be a nice man who's kind to children and animals and wants respect and appreciation for psychiatry.I very strongly doubt that doctors have told patients the "chemical imbalance" lie out of compassion, as Pies would have it. Besides, telling patients any lie to get them to accept treatment is a breach of ethics.

He may do a bit of a dance with words but I have seen much worse. 

 

If you watch the doctor above you will see it was not so easy in the old days to know it was a lie... this is seemingly an honest doctor trying to find some honest facts ... 

Pharma paid for the marketers to put the ads in medical journal that doctors read. 

 

http://www.anxietycentre.com/downloads/Chemical-Imbalance-Theory-is-False.pdf

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Altostrata

Ben Goldacre wrote a book detailing exactly what he thinks is going on to corrode medicine.

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Narcissus

Thanks for the article btdt.

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btdt

Ben Goldacre wrote a book detailing exactly what he thinks is going on to corrode medicine.

I know he wrote two bad science and bad pharma have you read them?

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btdt

Thanks for the article btdt.

Your welcome.  

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Altostrata

Dr. Pies's latest article on "chemical imbalance"
 
http://www.psychiatrictimes.com/blogs/couch-crisis/serotonin-how-psychiatry-got-over-its-high-school-crush
 
 

Serotonin: How Psychiatry Got Over Its “High School Crush”
September 15, 2015 | Couch in Crisis
By Ronald W. Pies, MD

....
I invite you to consider 2 claims relating to mental illness:

• Psychiatrists think that most mental illnesses are caused by a “chemical imbalance.”

• Psychiatrists think that some mood disorders are associated with abnormal serotonergic neurotransmission, among other functional or structural brain abnormalities, which may or may not be the “cause” of the disorder.

Since there are light years of conceptual space between these 2 claims, you might imagine, or naively hope, that psychiatry’s most strident critics would be able to distinguish claim 1 from claim 2. Alas, antipsychiatry bloggers continue to bang away at the notion that “Psychiatry” (that sinister, monolithic corporate entity) deliberately duped the public by promoting a bogus “chemical imbalance theory,” in cahoots with “Big Pharma.” Suffice it to say that this line of argumentation is itself bogus, for reasons I have reiterated at length in several venues.
....
But there is a sense in which some of psychiatry’s critics have a point, and this brings us back to Dr McIntyre and our old friend (or “frenemy?”), serotonin. It was not hard for the general public—and, alas, some doctors—to pick up the skein of serotonin and weave an entire tapestry with it, ultimately producing the threadbare “chemical imbalance theory.” No doubt, this was abetted by drug company “illustrations” of serotonergic synapses, complete with little packets of neurotransmitters whose reuptake is inhibited by the company’s ace antidepressant.6 Even today, some non-pharma websites continue to post misleading diagrams that attribute depression to a “chemical imbalance,” as Dr John Grohol recently discovered.7
....

The neurobiology of depression is, of course, far more complicated than a simple deficiency of one or more neurotransmitters. In this regard, Dr McIntyre went on to elaborate an intriguing hypothesis that links some forms of depression to immune dysfunction, inflammation, and glucose dysregulation—what he calls the “immune inflammatory metabolic model.”1 But it turns out that this model may link up with the serotonin hypothesis. Dr McIntyre notes, for example, that inflammation reduces serotonin in the brain. In principle, pharmacologic agents (eg, cytokine antagonists) that alleviate certain inflammatory conditions might amplify serotonergic function and reduce some types of depression.10 All this is just to say that, while the serotonin story has been greatly overblown, there are still reasons to retain some role for serotonin in at least a subset of persons with mood disorders.
No, this does not necessarily mean that mood disorders are caused by an imbalance of serotonin—or any other brain chemical. Over 50 years ago, the fathers of the biogenic amine hypothesis, Drs Joseph Schildkraut and Seymour Kety, recognized the complexities of sorting out psychosocial causes from biological effects—which can in turn become new causes or predispositions.
.....
The causal chain in the genesis of major depression is almost certainly long and complex—probably beginning with a genetic predisposition to depression, exacerbated by psychosocial stressors and losses, and worsened by dysfunctional personality traits and poor social supports. And while the “self-defeating cognitions” posited by cognitive theorists may not be a proximal cause of depression, their presence may deepen or prolong the person’s depression.12 Recently, psychiatrists have also focused on socio-economic, educational, and cultural factors that contribute to the risk, and perhaps the onset, of clinical depression. In their recently released book, The Social Determinants of Mental Health,13 psychiatrists Michael T. Compton, MD, and Ruth S. Shim, MD, cite the following risk factors for depression: racial discrimination, poverty, unemployment, lack of social skills, reduced frustration tolerance and self-regulation, and food insecurity.14

All this is nothing radically new—it’s really an elaboration of the biopsychosocial model that has dominated academic psychiatry since the 1980s. Clearly, this multi-level model bears little resemblance to a simplistic chemical imbalance theory. And it gives the lie to those who claim that psychiatry has become reductionistic, hostile to the role of the “mind,” or void of psychodynamic understanding. On the contrary, this expanded biopsychosocial model opens the possibility for therapeutic interventions at several links in the causal chain. Thus, antidepressants—and perhaps, someday, anti-inflammatory agents—may ameliorate the biological components of depression, while psychotherapy reduces the experiential aspects of the illness, such as pathological guilt and self-loathing.

In short, if serotonin was once American psychiatry’s “high school crush,” the field now appears wedded to a more mature model of biological and psychosocial understanding.


Please allow me to say that of Dr. Pies's "2 claims relating to mental illness", the second is also nonsensical, begging the point that negative reactions to life experiences are unnatural.

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westcoast

Lip service. A nonsensical jumble.

 

The prescribers and the FDA don't object (or cannot?) to this ad for Brintellix. Big pharmaceutical companies are doing just fine without being in cahoots with their handmaidens. They call the shots, Dr. Pies. 

 

(click to enlarge)

post-3474-0-02493200-1443393692_thumb.jpg

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Altostrata

Well, it may be true that the drug elevates neurotransmitter levels. But "balancing" a "chemical imbalance" -- definitely not.

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manymoretodays

I find interesting his definitions of hypothesis, and then associations, and then he goes on to describe full blown theories.  Speaking of Dr. Pie in the face here.......no disrespect meant.......really........it's just something about his random, rambling manner........kind of made the hairs on my arms stand up.  Not so unlike me........sometimes.

 

Then he talks about "holistic" psychiatry........which is a big part and parcel of current day problems, I think..........it's not holistic at all.......psychiatry.

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