Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Tuesday, April 15, 2008
Are You Chemically Unbalanced?
This will be quick; I'm actually headed off to work.
In his "In Practice" blog, Peter Kramer discusses the issue of whether the concept of a chemical imbalance is still a useful one and he looks at the evidence for and against such a theory, concluding that the concept met a premature death.
"Since 1993, other biochemical contributors to depression have claimed their roles, especially “stress hormones” and factors that influence nerve cell growth. The new overarching biological model of depression (I outline it in Against Depression) integrates all three factors—monoamines, stress, and cell growth—but serotonin dysregulation remains very much on the table as a contributor to depression."
Dr. Kramer talks about PET scans and genes and differential rates of monoamine metabolism, and the stupid little bouncing Zoloft mascot with the smiley face.
For the shrink in the field, so far it doesn't mean much. I can't order a test to find out if someone has too much of one enzyme breaking down any given neurotransmitter and thereby telling me what to prescribe. I'm waiting. In the meantime, what I do have is patients who come in wanting to know what they have. "Do I have a chemical imbalance?" Now what does that even mean? Do you have too much serotonin in some places in your brain and not enough in others? How would I know that? Too much (compared to what?) monamine oxidase breaking down your noradrenergic neurotransmitters? Should we inhibit them and this will make you better? Let me get my probe.
What I do know is that while I don't know what is meant by a "Chemical Imbalance," my patients do. For them it is a term that explains things, that writes the story, that has meaning. There's something socially acceptable about it. "I have poor coping skills" is pejorative and equally unprovable. "I have a chemical imbalance" is somehow explanatory, though still unprovable in a day-by-day psychiatric practice.
So, generally, if a patient with Major Depression asks, "Do I have a Chemical Imbalance?" I simply say "yes." It seems to work.
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I think the "chemical imbalance" thing is BS. Inherent in it is an assumption there that there is an "ideal" or "normal" balance of chemicals and one size fits all.
That little phrase also takes a person's self-determination out of the equation, as in, "I can't help it, I have a chemical imbalance."
I would consider it a cop-out if my shrink said that. "Chemical imbalance" is so vague and has lost its meaning, if it ever had one. I know that I have to take responsibility for my recovery. That means going to the doctor, and eventually returning to therapy. It means that I *can* help myself and that I can't just succumb to the hopelessness of the abyss, even thought I want to. "Chemical imbalance" is disempowering. I don't want to be a "poor pitiful me." OK, that's a lie, but I try to fight it. I have too. No one will fight for my life more than me. Not my shrink. Not anyone.
I for one would not want to be told I am "chemically imbalanced" given the state of knowledge on the topic. I wouldn't ask that question though.
In therapy I give the closest answer to "truth" that I am able to provide and I expect (and get) the same in return from my therapist.
My point wasn't that I'm dishonest-- I used to go into in-depth descriptions and try to explain the concept of "Chemical inbalance." My point was that this is something that somehow makes sense to people and resonates with them. I don't believe it explains away or excuses bad behavior anymore than "I have PMS" or "Bad Hair Day" does, or means that therapy isn't needed.
It's counterpart is "Nervous Breakdown"--- people seem to know what that means (even if I don't)
Since no one really understands why exactly these meds work, when they do work, or on whom, or if we're even searching in the right place, when a patient needs an explanation and asks "Do I have a chemical imbalance" and something somewhere is obviously out of whack, then, for whatever it means to them, it sometimes, in some places, with some patients, seems to be empowering or explanatory, or at least offers some form of comfort.
I like comfort.
I think the comfort/making sense part comes from the message (which they may be getting out of the "chemical imbalance" idea) that what they have is an illness and that it can be treated. So if it were me (not that I'm a shrink) I would think a good answer to "Do I have a chemical imbalance?" would be "You have an illness that can be treated." I too do not like the idea of reinforcing the misleading and meaningless "chemical imbalance" stuff.
What I wanted to know back in the days when I would ask myself that question wasn't so much are my brain chemicals measurably weird. It was more 'Is this happening because I am a bad person?'
The reactions from friends and family to the symptoms of depression, especially when it gets really bad, tend to lean towards depression being my fault and completely within control at any given point. I have actually been told to "Pray, eat right, exercise and think positive thoughts and you'll be just fine." As if I woke up one morning and said to myself, "Self, I want to be miserable and suicidal today. I'm going to ignore God, stop eating, stay in bed and be pessimistic solely for the purpose of making myself feel bad."
I don't want to be told a lie. I want to know if they are right. Is this within my conscious control and I am just not doing it right? Or is there more to it than deciding to be happy? And maybe it is all within my control and all I really need to do is want to be healthy enough that I become healthy. Or maybe my brain isn't processing the right chemicals in the right places at the right times and needs some help.
Does a diabetic have a chemical imbalance? By telling them that their body doesn't process the right things in the right quanitites at the right times are you absolving them from all responsibility in managing their condition? Or are you explaining to them why they need to take X medication at X time and change their behaviors in specific ways to keep their body healthy?
Is it not the same with depression in a lot of cases? Knowing that something is diagnostically wrong doesn't take control of it out of my hands. But it does take some of the issue of guilt out of the picture.
Maybe it shouldn't... maybe the friends and family that get so frustrated with me are right. Maybe it isn't my brain not processing the right things in the right places at the right times. After all, it can't be proven...
I love it.
From the perspective of someone who is "mentally ill" - for me, the idea of a "chemical imbalance" - termed thus while I was in college from a close friend then in med school - gave me a sense of relief, in that for years I had been fighting myself tooth and nail to just GET OVER IT, as if I could cease feeling suicidally depressed through sheer willpower alone. I was opposed to medication, though I'd tried it, and had not (at the time) experienced any real success from therapy.
Over the years, what my med-school friend once termed "chemical imbalance" has come to mean a vague sense of something-somewhat-off-somewhere-in-my-neurochemical-makeup feeling. It hasn't left me feeling pitiful or disempowered. I've never for a second stopped believing that I was responsible for my own recovery. But the concept of having a "chemical imbalance" (or my more (?) educated conception of something not-quite-normal, whatever that is, in my neurochemical makeup) allowed me to consider the idea of treating what I had always strongly considered to be nothing more then a lack of personal strength/determination/what have you. In other words, the concept of a "chemical imbalance" allowed me to begin considering major depression as perhaps having some sort of physical, or biological component as well. A component that definitely needed to be treated in order to successfully treat the rest of it.
I feel much the same as "Sara" and "The Silent Voices in My Mind" about the term chemical imbalance. For years my husband and some in my family, and even psychiatrists other than my pdoc, have berated my Treatment Resisant Depression as a result of me not trying hard enough, or me not doing the right things, or me having a weak will to change etc.
(and yes...I fit the criteria for TRD, given I have tried antidepressants from MAOI's to all the SSRI's, SNRI's, 3 Trycyclics, Lithium, Epival etc., etc,...the list of meds and combos tried is huge)
The idea that I have a "chemical imbalance", which to me means there is some biological, or genetic component to my depression that is out of my control, helps alleviate how much guilt I feel for continuing to remain depressed despite trying everything I can think of in terms of chnaging my behaviours, working hard in therapy, reducing my stress and all those things I can do to help myself.
I also wanted to make a comment about your last podcast (#45), most of which I really loved. I found Dr. DePaulo's information very helpful. I also found the information the three of you provided to be interesting as always.
I was however, disappointed when one of you made the comment, and this is a paraphrase, that if you saw a patient who remained depressed for over a year you would tell them to go see someone else. Otherwise your whole practice would be full of hard to treat patients.
When I heard that it really reinforced my belief that my illness must be a huge burden on my pdoc. I felt like what if he feels that way too, or what if all pdoc's feel that way? Where does that leave the souls, like myself, who struggle so hard to get well, but never seem to manage to get well.
I wasn't sure if your comment was meant to express that the patient may need a second opinion, or that the patient needs to try someone else because therapy obviously is not helping.
I have had second opinions, but in my experience having a pdoc who has consistently supported and stuck by me, despite all the treatment failures, has been the one thing that has kept me trying. For the record when I met my pdoc he did work in a clinic that sounds similar to Dr. DePaulo's (a mood disorder clinic where Patient's with TRD, or other TR mood disorders were referred by GP's), so maybe his circumstances are different from someone who is in private practice. He does not work there anymore, but continues to see me despite my difficulties getting well.
The problem with the chemical imbalance theory is that it is a theory, not a fact. Nobody really knows, but the public doesn't know that nobody really knows. It is a theory that is treated as a fact, to the detriment of some trauma survivors whose real issues are rarely addressed. The chemical imbalance explains away the effects of trauma. It invalidates the experience and/or allows for further blocking and denial that the trauma was even significant. NAMI even proclaims that PTSD is a chemical imbalance because the trauma rearranges brain chemicals!
Aqua-- I think the point of the One Year thing was really just a theoretical food-for-thought idea, not a literal "Kick the Patient out the Door." I believe the thought was that one shouldn't treat a patient who isn't getting better on auto-pilot, that it gets easy for both parties to get complacent, and that perhaps if the patient isn't getting better, that we should be thinking, "What else might help?" Would someone else have something to add? Would someone else do better? If therapy is helping, if new strategies are being employed, or if both parties agree that while the illness isn't getting better but the therapy still provides comfort or support, then it's reasonable to continue. But if at the end of a reasonable period of time (? one year?) a patient feels frustrated and no better, then maybe changing docs is reasonable. More about thinking about it then an actual rigid rule. I've never heard of a psychiatrist who would actually only treat people for a year.
Chemical Imbalance: pretty clear that their is a biological component of some type to major mental illnesses-- the genes do something. If the concept helps, go with it. If it helps someone else, but not you, well..... life is like that sometime. Somehow it resonates for some folks, obviously not for others.
aqua, In the comments to podcast 45 I commented on the 1-year thing that was mentioned...
I have no 1-yr rule or anything like that. In an old podcast (which one?) I recalled meeting a psychiatrist who did have such a practice of re-evaluating whether he wanted to continue with a pt after one year, taking into consideration whether he felt he was helping the pt and whether the pt was "clinically interesting". I found that to be a selfish way of looking at it, but expressed my own thoughts of how that would keep one's practice "fresh" and avoid accumulating many chronically ill pts (the ones who improve move on, the ones who do not stay). I did not propose this to be a desirable state of affairs.
But the bottom line for a pt might be to take the time periodically to assess what you are getting out of treatment, what are your goals, are you closer to achieving them, etc. Then discuss this assessment with your treating clinician.
I really appreciated your note. I wasn't clear about what you meant. What you say makes sense. I feel confident my therapy is helping me, it's just that I have had depression so long it's sticking like glue.
Jayme: I've had lots of trauma in my life too, so I definately recognize that some of my depression is because of that and other experiences in my life. I really feel like that has been addressed and I have worked through that in therapy, but still the depression remains.
I am a materialist when it comes to brain/mind theories so it makes perfect sense to me that experiences change brain chemicals/and or neural pathways. From a materialist's perspective thoughts, senses, anything that enters the brain is physical and becomes a physical entity.
So, for example, thought X caused by the Trauma A, impacts the neurons and dendrites, how they grow and where they grow differently than would thought Y and Trauma B. The physical structure of the brain becomes changed by experiences.
You and I must have been posting at the same time. I understand what you are saying and it makes sense for the patient to question whether a different approach would be better for them. (still not so keen on the psychiatrist you mention who dumps his patients if they don't get better in a year:>)...guess with him I'd be the patient asking myself if I could do better with someone else!
Oh, and the whole CHEMICAL IMBALANCE thing...
I agree with Dinah, that some people find it comforting to have a concept that says "this is not because you are a bad person."
But, I find it interesting that some people see the CI concept as a way to avoid responsibility for their illness ("it's genetic so I can't do anything about it") while others see it as empowering and HELPING one to take responsibility ("I am more prone to the damaging effects of stress so I need to be particularly vigilant about keeping my stress levels low").
It reminds me of the debate know about genetic testing for risk of certain forms of Alzheimers. Some would feel devastated and apathetic, while others would feel empowered and have renewed focus.
Is the "chemical imbalance" notion a projective test for the degree to which one is a glass half-empty or glass half-full sort of person?
I was told I had a chemical imbalance the first time I was ill and it was not true but I believed it. Believing that myth led to my taking lithium for 12 years without a break which led to my kidney failure. If I had been told the truth, that no one really knew what was causing me to be ill, which turned out to actually be complex PTSD, I would not be on the kidney transplant list today. So I would rather less comfort and more truth. Telling someone something you don't know to be true to comfort them seems patronizing/matronizing to me. http://hymes.wordpress.com
When you get down to it, while it's not yet provable, I believe there is something chemically/enzymatically/genetically wrong even if I can't point to a blood test.
We try to help patients understand. Our ability to do this is limited by the fact that our field is new, so much is unknown, we do our best.
If I didn't believe that there was a biological component, it would be lying to agree with whatever it is that rings clear for the patient who asks if they have a chemical imbalance. I do, however, believe that at least some part of it is biological, and so I can say "yes" with a clear conscience. If we learn otherwise (Ah, your depression is all because your mother yelled at you that time when you were eight) --then I would be untruthful/patronizing/ whatever. I don't see it that way and no one has taken it that way.
I see clear validity in Suzanne Ford's comment about being truthful about what we know and what we don't know, which is what Ray DePaulo was saying in Podcast 44 or 45.
But it is not that simple, as "truth" in science is a slippery notion. What is "true" in 1998 may not be "true" in 2008, as it may have been proven to be untrue. It is more appropriate to explain the evidence for and against a theory, and one's confidence in the quality of that evidence. Try doing that in a half-hour visit (or, worse, a 7-minute primary care visit).
While the evidence for some sort of "chemical imbalance" remains good, there are also competing evidence-based theories (eg, new nerve cell growth triggered by antidepressants and/or psychotherapy) that seem just as probable.
But saying that a psychiatric illness is caused by a chemical imbalance is about as specific as saying that Hurricane Katrina was caused by the sun (both are, ultimately, true, but provide little information about the actual underlying events leading to the end result).
For most, the mechanism doesn't matter if the end result is good. If lithium helps more than it hurts, people take it. If it doesn't help (or if it hurts more, like Suzanne's situation), they stop it. (The discussion about long-term side effects for lithium and other drugs is a whole 'nother discussion.)
Well put, Roy!
--your friend dinah
You might want to read this article by Jeffrey R. Lacasse, Jonathan Leo titled,
Serotonin and Depression: A Disconnect between the Advertisements and the Scientific Literature:
From what I head, Mr. Leo was begging psychiatrists to send him evidence of the chemical imbalance theory. No one took him up on the offer.
Roy, you said:
"new nerve cell growth triggered by antidepressants"
Do you have links to studies not financed by drug companies that show this?
I am having a hard time believing that because these drugs have caused me devastating neurological side effects. My experience is sadly shared by many people.
Unfortunately, no one is collecting the data so I can't point you to any doubled binded studies.
Sorry for getting off the topic. But since clink had made a similar comment previously in another thread, I felt the need to respond.
try doing a search on pubmed.gov for "neurogenesis antidepressants" (without the quotes).
Thanks T, that was very helpful.
Hmm, I don't see how you can project from studies on rats as to what will happen in humans. In my opinion, it would be more valid to get a baseline of neuropsychological test results on people before starting them on psychiatric meds. Then do testing during specific intervals to see how the scores compare.
Of course, you would have to factor in age but other than that, I can't see any problems.
Of course, this will never happen in a million years.
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