A number of readers have weighed in on “Debunking the Two Chemical Imbalance Myths (Again),” by Ronald W. Pies, MD. The article appeared in the April 2019 issue of Psychiatric Times.
LETTER TO THE EDITOR I, By Boris Vatel, MD
LETTER I, by Boris Vatel, MD
In his article, Dr Pies criticizes the position of anti-psychiatrists who question the rationale of telling patients that emotional problems are due to a chemical imbalance when it is known known all along that a chemical imbalance theory is bogus. Dr Pies says that these critics cite no credible evidence that psychiatrists describe emotional problems in this way. However, that there are no studies of how many psychiatrists actually use that explanation does not mean that this is not what often happens in reality. In fact, the “chemical imbalance” theory may be the best approximate explanation a psychiatrist can give a patient as a reason for using an antidepressant in the first place. If these medications were synthesized with restoration of serotonin activity in mind and if we find them useful in clinical practice, is it wrong to invoke the “chemical imbalance” theory when discussing them with patients? SSRIs and other medications may work or fail to work for reasons other than restoration of optimal neurotransmitter function but the alternative to using the “chemical balance” explanation in clinical work with patients is admitting that we don’t really know how they work. Whether such an explanation, for all its honesty, is a therapeutic communication to a patient in distress is a good question.
Dr Pies points out in his article that an explanatory theory which combines brain volume loss, dysregulation of glial-neuronal interaction, abnormal hypothalamic-pituitary-adrenal function, and inflammatory activation cannot be reduced to chemical imbalances. I would challenge any practicing clinical psychiatrist to explain this model satisfactorily to himself, much less to a patient with mental illness, as a way of avoiding the term “chemical imbalance” which gives Dr Pies so much trouble. The fact is that psychiatrists in general practice are and have been for decades in a precarious position of having at their disposal imperfect tools for addressing a problem which they cannot adequately describe either to themselves or to those who suffer from it. This inability to clearly explain what has caused the “disease” and what the rationale is for using such-and-such drug for it is precisely the weakness which the anti-psychiatry movement preys upon. Rather than admitting that we do not have a unified theory of mental illness, that research on the biology of mental illness is comprehensible mostly to those well-versed in neurogenetics, microbiology, and neuro-science, and that our medications work often enough to be used and fail or cause harm often enough to be avoided we hide behind terms such as “the bio-psycho-socio-cultural model” which sound important but can mean anything at all. Perhaps if as a field psychiatry did not pretend to a knowledge it does not possess the anti-psychiatry movement would have fewer arguments at its disposal. In the meanwhile, as a face-saving measure, there is little reason to denigrate the “chemical imbalance” hypothesis – it sounds as good as anything else we have by way of explanation to our patients.