Do You Still Believe in the “Chemical Imbalance Theory of Mental Illness”?

Bruce Levine

counterpunch.org

Originally published 29 APR 22

Here are two excerpts:

If you knew that psychiatric drugs—similar to other psychotropic substances such as marijuana and alcohol—merely “take the edge off” rather than correct a chemical imbalances, would you be more hesitant about using them, and more reluctant to give them to your children? Drug companies certainly believe you would be less inclined if you knew the truth, and that is why we were early on flooded with commercials about how antidepressants “work to correct this imbalance.”

So, when exactly did psychiatry discard its chemical imbalance theory? While researchers began jettisoning it by the 1990s, one of psychiatry’s first loud rejections was in 2011, when psychiatrist Ronald Pies, Editor-in-Chief Emeritus of the Psychiatric Times, stated: “In truth, the ‘chemical imbalance’ notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.” Pies is not the highest-ranking psychiatrist to acknowledge the invalidity of the chemical imbalance theory.

Thomas Insel was the NIMH director from 2002 to 2015, and in his recently published book, Healing (2022), he notes, “The idea of mental illness as a ‘chemical imbalance’ has now given way to mental illnesses as ‘connectional’ or brain circuit disorders.” While this latest “brain circuit disorder” theory remains controversial, it is now consensus at the highest levels of psychiatry that the chemical imbalance theory is invalid.

The jettisoning of the chemical imbalance theory should have been uncontroversial twenty-five years ago, when it became clear to research scientists that it was a disproved hypothesis. In Blaming the Brain (1998), Elliot Valenstein, professor emeritus of psychology and neuroscience at the University of Michigan, detailed research showing that it is just as likely for people with normal serotonin levels to feel depressed as it is for people with abnormal serotonin levels, and that it is just as likely for people with abnormally high serotonin levels to feel depressed as it is for people with abnormally low serotonin levels. Valenstein concluded, “Furthermore, there is no convincing evidence that depressed people have a serotonin or norepinephrine deficiency.” But how many Americans heard about this?

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Apparently, authorities at the highest levels have long known that the chemical imbalance theory was a disproven hypothesis, but they have viewed it as a useful “noble lie” to encourage medication use.

If you took SSRI antidepressants believing that these drugs helped correct a chemical imbalance, how does it feel to learn that this theory has long been disproven? Will this affect your trust of current and future claims by psychiatry? Were you prescribed an antidepressant not from a psychiatrist but from your primary care physician, and will this make you anxious about trusting all healthcare authorities?

The info is here.

Well-Being, Burnout, and Depression Among North American Psychiatrists: The State of Our Profession

R. F. Summers

American Journal of Psychiatry
Published 14 July 2020

Objective:

The authors examined the prevalence of burnout and depressive symptoms among North American psychiatrists, determined demographic and practice characteristics that increase the risk for these symptoms, and assessed the correlation between burnout and depression.

Methods:

A total of 2,084 North American psychiatrists participated in an online survey, completed the Oldenburg Burnout Inventory (OLBI) and the Patient Health Questionnaire–9 (PHQ-9), and provided demographic data and practice information. Linear regression analysis was used to determine factors associated with higher burnout and depression scores.

Results:

Participants’ mean OLBI score was 40.4 (SD=7.9) and mean PHQ-9 score was 5.1 (SD=4.9). A total of 78% (N=1,625) of participants had an OLBI score ≥35, suggestive of high levels of burnout, and 16.1% (N=336) of participants had PHQ-9 scores ≥10, suggesting a diagnosis of major depression. Presence of depressive symptoms, female gender, inability to control one’s schedule, and work setting were significantly associated with higher OLBI scores. Burnout, female gender, resident or early-career stage, and nonacademic setting practice were significantly associated with higher PHQ-9 scores. A total of 98% of psychiatrists who had PHQ-9 scores ≥10 also had OLBI scores >35. Suicidal ideation was not significantly associated with burnout in a partially adjusted linear regression model.

Conclusions:

Psychiatrists experience burnout and depression at a substantial rate. This study advances the understanding of factors that increase the risk for burnout and depression among psychiatrists and has implications for the development of targeted interventions to reduce the high rates of burnout and depression among psychiatrists. These findings have significance for future work aimed at workforce retention and improving quality of care for psychiatric patients.

The info is here.

Why parents are struggling to find mental health care for their children

Bernard Wolfson
Kaiser Health News/PBS.org
Originally posted May 7, 2019

Here is an excerpt:

Think about how perverse this is. Mental health professionals say that with children, early intervention is crucial to avoid more severe and costly problems later on. Yet even parents with good insurance struggle to find care for their children.

The U.S. faces a growing shortage of mental health professionals trained to work with young people — at a time when depression and anxiety are on the rise. Suicide was the No. 2 cause of death for children and young adults from age 10 to 24 in 2017, after accidents.

There is only one practicing child and adolescent psychiatrist in the U.S. for about every 1,800 children who need one, according to data from the American Academy of Child & Adolescent Psychiatry.

Not only is it hard to get appointments with psychiatrists and therapists, but the ones who are available often don’t accept insurance.

“This country currently lacks the capacity to provide the mental health support that young people need,” says Dr. Steven Adelsheim, director of the Stanford University psychiatry department’s Center for Youth Mental Health and Wellbeing.

The info is here.

The Troubled History of Psychiatry

Jerome Groopman
The New Yorker
Originally posted May 20, 2019

Here is an excerpt:

Yet, despite the phenomenal success of Prozac, and of other SSRIs, no one has been able to produce definitive experimental proof establishing neurochemical imbalances as the pathogenesis of mental illness. Indeed, quite a lot of evidence calls the assumption into question. Clinical trials have stirred up intense controversy about whether antidepressants greatly outperform the placebo effect. And, while SSRIs do boost serotonin, it doesn’t appear that people with depression have unusually low serotonin levels. What’s more, advances in psychopharmacology have been incremental at best; Harrington quotes the eminent psychiatrist Steven Hyman’s assessment that “no new drug targets or therapeutic mechanisms of real significance have been developed for more than four decades.” This doesn’t mean that the available psychiatric medication isn’t beneficial. But some drugs seem to work well for some people and not others, and a patient who gets no benefit from one may do well on another. For a psychiatrist, writing a prescription remains as much an art as a science.

Harrington’s book closes on a sombre note. In America, the final decade of the twentieth century was declared the Decade of the Brain. But, in 2010, the director of the National Institute of Mental Health reflected that the initiative hadn’t produced any marked increase in rates of recovery from mental illness. Harrington calls for an end to triumphalist claims and urges a willingness to acknowledge what we don’t know.

Although psychiatry has yet to find the pathogenesis of most mental illness, it’s important to remember that medical treatment is often beneficial even when pathogenesis remains unknown. After all, what I was taught about peptic ulcers and stress wasn’t entirely useless; though we now know that stress doesn’t cause ulcers, it can exacerbate their symptoms. Even in instances where the discovery of pathogenesis has produced medical successes, it has often worked in tandem with other factors. Without the discovery of H.I.V. we would not have antiretroviral drugs, and yet the halt in the spread of the disease owes much to simple innovations, such as safe-sex education and the distribution of free needles and condoms.

The info is here.

Psychiatrist suspended for ‘inappropriate relationship.’ He got a $196K state job.

Steve Contorno & Lawrence Mower
www.miamiherald.com
Originally posted February 28, 2019

Less than a year ago, Domingo Cerra Fernandez was suspended from practicing medicine in the state of Florida.

The Ocala psychiatrist allegedly committed one of the cardinal sins of his discipline: He propositioned a patient to have a sexual and romantic relationship with him. He then continued to treat her.

But just months after his Florida suspension ended, Cerra Fernandez has a new job. He’s a senior physician at the North Florida Evaluation and Treatment Center, a maximum-security state-run treatment facility for mentally disabled adult male patients.

How did a recently suspended psychiatrist find himself working with some of Florida’s most vulnerable and dangerous residents, with a $196,000 annual salary?

The Department of Children and Families, which runs the facility, knew about his case before hiring him to a job that had been vacant for more than a year. DaMonica Smith, a department spokeswoman, told the Herald/Times that Cerra Fernandez was up front about his discipline.

The info is here.

President Trump’s Mental Health — Is It Morally Permissible for Psychiatrists to Comment?

Claire Pouncey
The New England Journal of Medicine
December 27, 2107

Ralph Northam, a pediatric neurologist who was recently elected governor of Virginia, distinguished himself during the gubernatorial race by calling President Donald Trump a “narcissistic maniac.” Northam drew criticism for using medical diagnostic terminology to denounce a political figure, though he defended the terminology as “medically correct.” The term isn’t medically correct — “maniac” has not been a medical term for well over a century — but Northam’s use of it in either medical or political contexts would not be considered unethical by his professional peers.

For psychiatrists, however, the situation is different, which is why many psychiatrists and other mental health professionals have refrained from speculating about Trump’s mental health. But in October, psychiatrist Bandy Lee published a collection of essays written largely by mental health professionals who believe that their training and expertise compel them to warn the public of the dangers they see in Trump’s psychology. The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President rejects the position of the American Psychiatric Association (APA) that psychiatrists should never offer diagnostic opinions about persons they have not personally examined. Past APA president Jeffrey Lieberman has written in Psychiatric News that the book is “not a serious, scholarly, civic-minded work, but simply tawdry, indulgent, fatuous tabloid psychiatry.” I believe it shouldn’t be dismissed so quickly.

The article is here.

Will Trump Be the Death of the Goldwater Rule?

Jeannie Suk Gersen
The New Yorker
Originally posted August 23, 2017

Here is an excerpt:

The class of professionals best equipped to answer these questions has largely abstained from speaking publicly about the President’s mental health. The principle known as the “Goldwater rule” prohibits psychiatrists from giving professional opinions about public figures without personally conducting an examination, as Jane Mayer wrote in this magazine in May. After losing the 1964 Presidential election, Senator Barry Goldwater successfully sued Fact magazine for defamation after it published a special issue in which psychiatrists declared him “severely paranoid” and “unfit” for the Presidency. For a public figure to prevail in a defamation suit, he must demonstrate that the defendant acted with “actual malice”; a key piece of evidence in the Goldwater case was Fact’s disregard of a letter from the American Psychiatric Association warning that any survey of psychiatrists who hadn’t clinically examined Goldwater was invalid.

The Supreme Court denied Fact’s cert petition, which hoped to vindicate First Amendment rights to free speech and a free press. But Justice Hugo Black, joined by William O. Douglas, dissented, writing, “The public has an unqualified right to have the character and fitness of anyone who aspires to the Presidency held up for the closest scrutiny. Extravagant, reckless statements and even claims which may not be true seem to me an inevitable and perhaps essential part of the process by which the voting public informs itself of the qualities of a man who would be President.”

These statements, of course, resonate today. President Trump has unsuccessfully pursued many defamation lawsuits over the years, leading him to vow during the 2016 campaign to “open up our libel laws so when they write purposely negative and horrible and false articles, we can sue them and win lots of money.” (One of his most recent suits, dismissed in 2016, concerned a Univision executive’s social-media posting of side-by-side photos of Trump and Dylann Roof, the white supremacist who murdered nine black churchgoers in Charleston, South Carolina, in 2015; Trump alleged that the posting falsely accused him of inciting similar acts.)

The article is here.

Psychiatry Group Tells Members They Can Ignore ‘Goldwater Rule’ and Comment on Trump’s Mental Health

Sharon Begley
Global Research
Originally published July 25, 2017

A leading psychiatry group has told its members they should not feel bound by a longstanding rule against commenting publicly on the mental state of public figures — even the president.

The statement, an email this month from the executive committee of the American Psychoanalytic Association to its 3,500 members, represents the first significant crack in the profession’s decades-old united front aimed at preventing experts from discussing the psychiatric aspects of politicians’ behavior. It will likely make many of its members feel more comfortable speaking openly about President Trump’s mental health.

The impetus for the email was “belief in the value of psychoanalytic knowledge in explaining human behavior,” said psychoanalytic association past president Dr. Prudence Gourguechon, a psychiatrist in Chicago.

“We don’t want to prohibit our members from using their knowledge responsibly.”

That responsibility is especially great today, she told STAT, “since Trump’s behavior is so different from anything we’ve seen before” in a commander in chief.

An increasing number of psychologists and psychiatrists have denounced the restriction as a “gag rule” and flouted it, with some arguing they have a “duty to warn” the public about what they see as Trump’s narcissism, impulsivity, poor attention span, paranoia, and other traits that, they believe, impair his ability to lead.

The article is here.

Ethics of Coercive Treatment and Misuse of Psychiatry

Tilman Steinert
Psychiatric Services
http://dx.doi.org/10.1176/appi.ps.201600066

Abstract

The author discusses a pragmatic approach to decisions about coercive treatment that is based on four principles from principle-based ethics: respect for autonomy, nonmaleficence, beneficence, and justice. This approach can reconcile psychiatry’s perspective with the U.N. Convention on the Rights of Persons With Disabilities. Coercive treatment can be justified only when a patient’s capacity to consent is substantially impaired and severe danger to health or life cannot be prevented by less intrusive means. In this case, withholding treatment can violate the principle of justice. In the case of danger to others, social exclusion and loss of freedom can be seen as harming psychosocial health, which can justify coercive treatment. Considerable efforts are required to support patients’ informed decisions and avoid allowing others to make substitute decisions. Mental disorder alone without impaired capacity does not justify involuntary treatment, which can be considered a misuse of psychiatry. Involuntary detention without treatment can be justified for short periods for assessment and to offer treatment options.

The article is here.

Notes From Psychiatry’s Battle Lines

By George Makari
The New York Times - Opinionator
February 23, 2016

Here is an excerpt:

Consider this: Like most clinicians, I am eager for scientific progress, something new that will yield more clarity and provide my patients with faster or deeper relief. However, as I take stock of a new “neuroenhancer,” or the latest genetic correlation that may point to the cause of an illness, or a suddenly popular diagnosis, the historian in me senses ghosts beginning to stir.

Historians have shown that psychiatry has long suffered from the adoption of scientific-sounding theories and cures that turned out to be dogma. Perhaps the clearest example of such “scientism” was psychiatry’s embrace, in the early 19th century, of Franz Joseph Gall’s phrenology, in which all mental attributes and deficiencies were assigned to specific brain locales, evidence be damned. During much of the 20th century, psychoanalysis proposed far more conclusive answers than it could support, and today, the same could be said for some incautious neurobiological researchers.

The article is here.

Psychologists and psychiatrists serving as expert witnesses in court: what do they know about eyewitness memory?

Annika Melindera & Svein Magnussena
Psychology, Crime & Law
Volume 21, Issue 1, 2015, pp 53-61

Abstract

Expert witnesses have various tasks that frequently include issues of memory. We tested if expert witnesses outperform other practitioners on memory issues of high relevance to clinical practice. We surveyed psychiatrists and psychologists who reported serving as expert witnesses in court (n = 117) about their knowledge and beliefs about human memory. The results were compared to a sample of psychiatrists and psychologists who had never served as expert witnesses (n = 819). Contrary to our expectations, the professionals serving as expert witnesses did not outperform the practitioners who never served. A substantial minority of the respondents harbored scientifically unproven ideas of human memory on issues such as the memory of small children, repression of adult traumatic memories, and recovered traumatic childhood memories. We conclude that the expert witnesses are at risk of offering bad recommendations to the court in trials where reliability of eyewitness memory is at stake.

The entire article is here.

When Philosophy Meets Psychiatry

By D. D. Guttenplan
The New York Times
Originally published August 11, 2013

Here is an excerpt:

“We started out as a reading group for trainee psychiatrists,” said Gareth S. Owen, a researcher at the Institute of Psychiatry who co-founded the group in 2002. “Then, gradually, we developed and started inviting philosophers — at first it was quite low key. We would talk about our clinical experiences and then they would relate those experiences to their way of thinking.”

Robert Harland, another co-founder of the group, said he had known Dr. Owen since they “cut up a corpse together at medical school.”

“The analytic philosophers brought a real clarity to our discussions,” Dr. Harland said. “We were looking at various models to help us understand what we were doing as psychiatrists.

“There is lots of applied science now in psychiatry: neuroimaging, genetics, epidemiology. But they don’t have much to say about sitting with a patient and trying to understand that person’s experiences.”

The entire story is here.

Doctors Protest Psychiatric Manual Revision in Global Petition

By Natasha Khan
Bloomberg News
May 15, 2013

Doctors are protesting new guidance for the diagnosis of some mental disorders, including autism, contained in the revised edition of a professional manual to be released in coming days.

The so-called “psychiatric bible,” whose first update in 19 years will be released at a medical meeting that opens in San Francisco on May 18, also influences the way patients are treated and reimbursed for mental disorders. A petition that raised concerns about the manual’s diagnostic categories and patient safety received more than 3,000 signatures from Paris to Montreal in recent months.

The Diagnostic and Statistical Manual of Mental Disorders is the standard used by mental-health professionals for diagnosing illness and for research. The newest edition is meant to incorporate the latest research findings and has collapsed several conditions, including Asperger’s syndrome and child disintegrative disorder, into a single autism diagnosis.

The entire article is here.

Psychiatry’s Guide Is Out of Touch With Science, Experts Say

By PAM BELLUCK and BENEDICT CAREY
The New York Times
Published: May 6, 2013

Just weeks before the long-awaited publication of a new edition of the so-called bible of mental disorders, the federal government’s most prominent psychiatric expert has said the book suffers from a scientific “lack of validity.”

The expert, Dr. Thomas R. Insel, director of the National Institute of Mental Health, said in an interview Monday that his goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.

While the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., is the best tool now available for clinicians treating patients and should not be tossed out, he said, it does not reflect the complexity of many disorders, and its way of categorizing mental illnesses should not guide research.

“As long as the research community takes the D.S.M. to be a bible, we’ll never make progress,” Dr. Insel said, adding, “People think that everything has to match D.S.M. criteria, but you know what? Biology never read that book.”

The entire story is here.

Why the Fuss Over the D.S.M.-5?

By Sally Satel
The New York Times - Opinion
Originally published on May 11, 2013

LATER this month, the American Psychiatric Association will unveil the fifth edition of its handbook of diagnoses, the Diagnostic and Statistical Manual of Mental Disorders. Fourteen years in the making, the D.S.M.-5 has been the subject of seemingly endless discussion.
      

The charges are familiar: the manual medicalizes garden-variety distress, leads doctors to prescribe unnecessary medications, serves as a cash cow for the association, and so forth.

      

But many critics overlook a surprising fact about the new D.S.M.: how little attention practicing psychiatrists will give to it.

      

There are dozens of revisions in the D.S.M. — among them, the elimination of a “bereavement exclusion” from major depressive disorder and the creation of binge eating disorder — but they won’t alter clinical practice much, if at all.

      

This is because psychiatrists tend to treat according to symptoms.

      

So why the fuss over D.S.M.-5? Because of the unwarranted clout that its diagnoses carry with the rest of society: They are the passports to insurance coverage, the keys to special educational and behavioral services in school and the tickets to disability benefits.

      

This is a problem because the D.S.M. is an imperfect guide to predicting what treatments will benefit patients most — a reality tied to the fact that psychiatric diagnoses are based on clinical appearances that tend to cluster, not on the mechanism behind the illness, as is the case with, say, bacterial pneumonia.

The entire article is here.

Psychiatrists Top List of Big Pharma Payments Again

By Deborah Brauser
Medscape Medical News
Originally published March 14, 2013

Once again, psychiatrists top the updated Dollars for Docs list of large payments from pharmaceutical companies to individual US clinicians.

On March 12, the investigative journalism group ProPublica released the names of the 22 physicians who, since 2009, received more than $500,000 from these companies in speaking and consulting fees. Mirroring the organization's first report released in 2010, psychiatrists dominate the list.

This time, the top recipient was Jon Draud, MD, medical director of the psychiatric and addiction medicine program at Baptist Hospital in Nashville, Tennessee, and from the Middle Tennessee Medical Center in Murfreesboro.

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APA Reaction

"My immediate, honest response was that this boggles the mind," James Scully, MD, CEO of the American Psychiatric Association (APA), told Medscape Medical News.

The entire story is here.

Thanks to Ed Zuckerman for this story.

DSM-5 Wins APA Board Approval

By John Gever, Senior Editor
MedPage Today
Originally published December 1, 2012

The American Psychiatric Association's board of trustees has approved the fifth edition of its influential diagnostic manual, dubbed DSM-5, the group announced Saturday.

The board vote is the last step before the manual is formally released at the APA's annual meeting next May. The association's Diagnostic and Statistical Manual of Mental Disorders was last revised in 1994; that edition is known colloquially as DSM-IV.

According to an APA statement, changes include an end to the system of "axes" used to class diagnoses into broad groups, and an associated restructuring of diagnostic groups to bring disorders thought to be biologically related under the same headings.

Also, many of the diagnostic criteria will now include so-called dimensional assessments to indicate severity of symptoms.

Specific language in DSM-5 was not immediately released, and probably won't be until the formal unveiling in May. Detailed criteria that had been published on the APA's DSM5.org website for public review and comment have now been removed.

However, the statement released Saturday indicated that the manual will include many of the most controversial of the proposed changes from DSM-IV.

The entire article is here.

Psychiatry’s Legitimacy Crisis

All We Have to Fear: Psychiatry's Transformation of Natural Anxieties into Mental Disorders
by Allan V. Horwitz and Jerome C. Wakefield

Book Review by Andrew Scull
The Los Angeles Book Review
Originally published on August 8, 2012

ABOUT 40 YEARS AGO, American psychiatry faced an escalating crisis of legitimacy. All sorts of evidence suggested that, when confronted with a particular patient, psychiatrists could not reliably agree as to what, if anything, was wrong. To be sure, the diagnostic process in all areas of medicine is far more murky and prone to error than we like to think, but in psychiatry the situation was — and indeed still is — a great deal more fraught, and the murkiness more visible. It didn’t help that psychiatry’s most prominent members purported to treat illness with talk therapy and stressed the central importance of early childhood sexuality for adult psychopathology. In this already less-than-tidy context, the basic uncertainty regarding how to diagnose what was wrong with a patient was potentially explosively destabilizing.

The modern psychopharmacological revolution began in 1954 with the introduction of Thorazine, hailed as the first “anti-psychotic.” It was followed in short order by so-called “minor tranquilizers:” Miltown, and then drugs like Valium and Librium. The Rolling Stones famously sang of “mother’s little helper,” which enabled the bored housewife to get through to her “busy dying day.” Mother’s helper had a huge potential market. Drug companies, however, were faced with a problem. As each company sought its own magic potion, it encountered a roadblock of sorts: its psychiatric consultants were unable to deliver homogeneous populations of test subjects suffering from the same diagnosed illness in the same way. Without breaking the amorphous catchall of “mental disturbance” into defensible sub-sets, the drug companies could not develop the data they needed to acquire licenses to market the new drugs.

The entire story is here.

Psychiatry's identity crisis - A Response

The Lancet, Volume 379, Issue 9835, Page 2428, 30 June 2012
By Andres Barkil-Oteo

Psychiatry has attempted to cope with its identity problem (April 7, p 1274) mainly by assuming an evidence-based approach, favoured throughout medicine. Evidence-based, however, became largely synonymous with psychopharmacological approaches, with relative disregard for other evidence-based modalities.

This situation has created a dilemma since the evidence for many common medication-prescribing practices is being challenged, whereas many of the psychological approaches have very solid evidence but are underused (eg, family psychoeducation). A good example is the extensive use of second-generation antipsychotic drugs, despite evidence of their lack of superiority over first-generation medication, as well as additional economic cost and the added burden of medical complications.

The entire response is here.

Psychiatry's identity crisis - Original letter

The Lancet, Volume 379, Issue 9823, Page 1274, 7 April 2012

Last week, the American Psychiatric Association issued a press release highlighting an ongoing decline in the recruitment of medical students into the specialty—at a time when the numbers of practising psychiatric professionals in the USA is falling. Various reasons are proposed, including the short-term nature of placements (usually just 4 weeks); the sheer breadth of an evolving specialty, which is drawing students towards newer areas such as clinical neuroscience; and concerns that psychiatry is not as lucrative as other specialties.

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Psychiatrists, first and foremost, are clinicians. Evidence-based approaches should be at the core of the psychiatrist and non-clinical members of any mental health team.

The entire piece is here.