"Chemical Imbalance": Oversimplification or Metaphor?

Apr 04, 2006

Until recently, direct-to-consumer advertisements for selective serotonin reuptake inhibitors (SSRIs) touted their ability to correct a chemical imbalance, most memorably through the cartoon "ovoid creature" that thanked a drug for improving its mood. Over the past few years, consumer groups and patients have implored the FDA to require more accurate wording in ads. This has resulted in the appearance in ads of such qualifiers as "helps to restore," "appears to work," "may be related to," and "presumed to be linked."

Until recently, direct-to-consumer advertisements for selective serotonin reuptake inhibitors (SSRIs) touted their ability to correct a chemical imbalance, most memorably through the cartoon "ovoid creature" that thanked a drug for improving its mood. Over the past few years, consumer groups and patients have implored the FDA to require more accurate wording in ads. This has resulted in the appearance in ads of such qualifiers as "helps to restore," "appears to work," "may be related to," and "presumed to be linked."To Jeffrey Lacasse, MSW, a PhD candidate at Florida State University in Tallahassee, and Jonathan Leo, PhD, associate professor of anatomy at Lake Erie College of Osteopathic Medicine, the oversimplified depiction of SSRIs was more than fodder for comedians. They investigated the circa-1967 origin of the serotonin hypothesis and chronicled its evolution.1,2Lacasse contacted several pharmaceutical companies to ask how the "chemical imbalance" idea arose from findings that SSRIs inhibit reuptake of serotonin and that low serotonin levels are associated with depression. "They responded that since the drug works on serotonin, if someone responds, they must have had a serotonin imbalance in the first place," he said. FDA officials claimed the imbalance-model verbiage was designed for consumers with a reading level below the sixth grade.Leo offers another take-the "chemical imbalance" mantra is more metaphor than dummying down. He compared the situation with the conversations that doctors have with patients about cholesterol and statins, where the drug's effect is quantitatively clear. "How are patients supposed to know when the conversation has switched from science to metaphor?"Lacasse and Leo also would like future ads to be more truthful about risks. "In a world of fully informed consent, patients also would be told that there is a strong placebo effect, that some [drugs] have side effects, that there are non-medical treatments, and that many people will get better without the medications," said Leo.REFERENCES1. Lacasse JR, Leo J. Serotonin and depression: a disconnect between the advertisements and the scientific literature. PLoS Med. 2005;2:101-106.2. Coppen A. The biochemistry of affective disorders. Br J Psychiatry. 1967;113:1237-1264.

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