"Chemical imbalance" could be interpreted so broadly as to be tautological. But it can also plausibly be interpreted as meaning "caused by an excessive or insufficient concentration of an identifiable chemical and ameliorable by addressing that excess or deficit."
The latter definition is still extremely broad but not so much so as to be meaningless. For example, it would not cover an hypothetical explanation of depression as being caused by widespread cell death in a brain region due to traumatic injury.
Now if you want to mock psychiatrists for tautological claims then look at forensic psychiatrists who try to support an insanity defense by claims "the defendant only did <bad thing> because of <brain condition>!"
Well, of course, he did! Everything everybody does they do because of a brain condition! "But I have this paper that claims to identify the brain condition!" So why does that matter? The brain condition must exist a priori. Why does the validity of an insanity defense depend on whether science has identified it yet?
That is not to say that there cannot be valid insanity defenses. But the whole "it wasn't me, it was me brain that made me do it!" is not one of them.
If the brain were *purely* a chemical soup, you'd be completely right, but we're not "merely made of chemicals." The brain uses electrochemical signaling and has a plastic physical structure. (Of course, that structure is made of chemicals, but structure is not purely defined by its chemical ratios/balance.) Assuming a materialist model of the brain (as anyone in their right mind should), you could assess a psychiatric condition by focusing on the brain's (electro)chemical state at a given time, such as in the serotonin hypothesis, but you could also focus on its neuronal structure.
Obviously the structural and the electrochemical are intimately bound up, but saying "an ongoing chemical imbalance causes structural abnormalities that lead to depression" is different from "an ongoing chemical imbalance in itself leads to depression," which is different from "a temporary chemical imbalance causes a structural abnormality, but the chemical imbalance itself does not persist," or "the modern world filled with tons of electronic devices messes with the electrical signaling in our brain." (I wouldn't believe the last point, but it's still a testable hypothesis.)
That said, I think your point is important! Much of psychiatry feels very circular and truly is in the dark about ultimate causes, and we have to hold it (any many other disciplines) to higher standards.
I love "Chemical Imbalance", it's such a delightfully stupid explanation .
You know those deaths by gun violence that have caused so much concern recently ? It's not a criminal justice issue at all, in fact recent studies indicate that it's caused by a chemical imbalance due to the toxic heavy metal lead (Pb). Once this metal is absorbed by the body in high enough doses and velocities it can cause negative health outcomes.
One could describe it in the reverse way, by saying, "Whatever its causes in any particular individual, depression is a condition of uncomfortable symptoms which can often be treated (i.e., relieved in the direction of the patient's desires) by means of pharmaceutical interventions that work via *chemical rebalancing* of the patient's neurological environment." There is no question whatsoever that many substances are mild mood-lifters for most people, depressed or not.
This isn't the same interpretive framework as 'blaming' the depression as *caused* by the baseline condition of the patient's neurological chemical environment. That would be like attributing pain resulting from an injury to the brain's failure to make and release enough Beta-endorphin to block the pain.
The main danger with the chemical imbalance interpretation is that one's one diagnosis will be off and one will be manipulating conditions that are upstream of 'mood', but that themselves are downstream of the true root causes which will not be felt so likely not addressed, thus leading to a chronic and permanent need for medications.
That being said, my impression is that addressing the root causes of a lot of depression is simply not a tractable problem for medical professionals in our society given their limited authority over patients and the general regime of legal liabilities which incentivizes strict conformity with the field's conventional practices and narratives about such conditions.
If a psychiatrist can't actually do anything about the root causes of a patient's depression, and the patient himself is unlikely to do those things on his own, and that stating the actual causes out loud will only make the patient even more depressed in terms of feeling bad about himself, then it's not implausible that the best one can do it perpetuate a kind of noble lie about it not being the patient's fault, baby you were born that way, it's not your life situation or bad past decisions but just an unlucky defect in your brain chemicals, and here's a drug that will 'fix' that 'balance', and by so fixing, you mood will return to 'normal'.
Well, the "lead theory of violence" is a "chemical" theory, as opposed to a sociological theory like "poverty causes violence". And (before you've studied the issue), both are plausible.
Check out Edward Hagen (an admirer of Szasz) and his <a href="https://anthro.vancouver.wsu.edu/documents/309/Hagen_2003_The_bargaining_model_of_depression_EUeAUAw.pdf">bargaining model of depression</a>. The bargaining model of depression is one of those theories that -- when I first read it -- struck me immediately as being obviously right (another example is Robert H Frank's theory of romantic love as a commitment mechanism). In fact, the two are related in that they work only because they are powerful emotions that are not under voluntary control by the individual experiencing them.
Of course there must be some kind of physiological mechanism behind both "falling madly in love" and also "falling into depression", and it's possible that we could find drugs to combat one or both of these emotions. But neither are fundamentally diseases or disorders -- they are adaptations. Of course, saying that they are adaptive doesn't mean that they work well or are beneficial in every individual case -- only that they are beneficial on average so that natural selection created and sustains them.
Out of curiosity would you feel differently about psychiatrists if you just thought of them as knowledgeable advisors about what kind of drugs you might enjoy taking in the long term?
I mean surely you grant that some drugs, taken long term, even if only caffeine or moderate alcohol can be life and productivity improving. OTOH, other drugs which might initially feel beneficial such as opiates, fenphen or MDMA turn out to have downsides when taken regularly which can't be inferred just from how they feel at first. Moreover, different people will often react differently to the same drug (don't get stoned at a party if you have social anxiety).
Given those two facts surely it makes sense for there to be people who specialize in advising others about which drugs are likely to improve their life and which are likely to be harmful. And how does that differ from psychiatry?
I was recently in a state in which it was legal under local law to recreationally purchase and use cannabis-derived substances obtained at licensed dispensaries. While I'm generally against the drug war, cannabis isn't my thing so I don't partake. But a relative invested in a growing operation and encouraged me to visit the dispensary which retails his products, and I wanted to satisfy my curiosity.
The fellows behind the counter were perhaps a bit too on-the-nose as regards the stereotypical attributes of the pothead stoner, however, they were *incredibly knowledgeable* in just the way you describe above and in terms of describing with precision the fine distinctions in psychological effects that each of their numerous offerings would produce in the typical customer, and helping people find the kick (within the limited range of what's possible with cannabis, anyway) that they were most likely to enjoy or which was just the kind of thing they were looking for. Better than any sommelier I've encountered, and probably more accurate. I'd trust them much more to assess relative quality from blind taste tests, er, smoke tests.
I agree in part but I think some of that 'expertise' is placebo (both from the sommeliers and dispensary folks). That might be a plus when you are just talking about weed or your wine pairing but when it comes to taking drugs long term (things like Adderall etc) I'd like some controlled studies as well.
I mean the potheads are great for advice on how it will feel but it was the controlled studies showing that even chronic mj use by adults (once you had a month w/o use for very heavy users) didn't have negative effects on cognition that convinced me initially it wasn't a problem to use and similar studies that convinced me to keep my MDMA use to a minimum back in college. So I think there is something to be said for both.
That's fair, however, the problem (quite a common and tricky one, as it happens) with many of those studies is that the methodology and analysis is often based on an implicit model of low dispersion of human reaction, which is quite often not at all the case with regards to drugs due to high levels of human genetic and metabolic diversity. By way of illustration, consider a study on the effect of lactose. Well the issue is that humans range from highly lactose tolerant to highly intolerant, and if the study doesn't pick up on this diversity it will give a kind of nonsense result of an average actually describes nobody because the distribution of symptoms tends to be bifurcated. The trouble is that unless one has very large N, it is hard to distinguish between high dispersion in the studied population on the one hand and data that looks 'noisy' and results of simple regression will lack statistical significance. And, unfortunately, claims of low ps are what get published.
Kind of tragically - because the problem is institutional and hasn't been due to technical or economic constraints for a long time now - the era of 'genetic medicine' never really arrived except for a few exceptions that don't reflect anything near the potential that could be feasibly exploited right now. We could be splitting up different kinds of advice for different kinds of people, but we are still stuck in the objectively false one size fits most mindset.
For instance, your example of MDMA and what frequency of use is prudent to avoid neurotoxic consequences provides a good example of my point about genetic diversity and metabolic dispersion. The various amphetamines are principally metabolized by an oxidative enzyme in the liver called cytochrome p450 2d6. The amphetamines also tend to bind and stick to 2d6 during that reaction, which prevents it from working on anything else for a long time, which can cause all sorts of drug-drug interactions, some potentially nasty in effect.
But in many populations, people are *all over the place* with regards to 2d6, in terms of producing different levels, whether they have multiple duplicate copies of the alleles in their chromosomes, and the wide spread of relative effectiveness of a number of variant forms. In most populations it's not rare at all to encounter normal metabolizers, non-metabolizers, and ultra-rapid metabolizers. There is no good advice to give to the general population, as any claim is only suitable for a narrow slice of people near the mean while being plausibly inaccurate and perhaps even hazardous for an actual majority of the population.
The same phenomenon applies to the effects of codeine which one can model as a prodrug for morphine which conversion is also accomplished by 2d6. Non-metabolizers don't get any pain relief, normal metabolizers get a slow drip of low levels of morphine as analgesic, while ultra-rapid metabolizers convert the whole ingested dose right away and feel like they've had a hit of heroin.
Well, we can hope that eventually actual normal medical practice catches up to the genetic revolution and this knowledge base which has been around for a long time. But the interesting thing about the cannabis sommeliers is that by sheer volume of experience and observations of people indulging in those substances, my impression is that they've been able to recognize some real patterns of 'metabolic types' and have some crude but reasonably effective heuristics in terms of being able to determine one's type with one's answers to just a few questions about one's past experiences. In this regard they are probably better than both sommeliers and actually credentialed psychiatrists.
Yes, learning things is hard and I agree about the limitations of pure observational studies. That's one reason that in vitro (and animal bases) studies are useful. While I wouldn't doubt that MDMA toxicity is affected by variation in CYP 2D6 (tho I have a vague memory that it may have been 3A4 that was relevant ...but I'm probably just confusing it with benzodiazepenes since it's been decades since I dug into the studies) the various animal studies were suggestive that there were more direct effects meaning everyone was going to face some level of toxicity (tho somewhat undermined by one study that didn't find any harm when administered directly to the brain stem).
But yes, I agree the studies arent easy to interpret. In the case of recreational drugs this is made much worse by the biasing effect of the DEA controlling who can run those studies and pretty clearly favors researchers who were going to demonstrate harm. There was even one case of a paper showing absurd mortality rates in primates that turned out to be bc they administered meth rather than MDMA but refused to acknowledge the mistake until ppl pressured them on the poin that their results should have some really high fraction of ravers should have died on their first dose...and the way it unrolled convinced me that if they'd found no harmful effect they wouldn't have shrugged and published.
So yah, these studies aren't magic and one certainly has to be on the lookout both for variation in the population, bias etc etc but I still do think they add some value. Even if I don't know exactly how bad MDMA is for me it gave me enough information to know that I didn't want to be using it every weekend or stacking a bunch of doses while there have been times in my life I've been happy to do the same with marijuana.
I think that the chemical imbalance meme is an over simplification, one that has unfortunately become widely disseminated. However, outside of the more naive branch of pop sci and Buzzfeed articles, it is my impression that the contemporary field no longer takes this view very seriously. From what I've read, it seems that taking the various antidepressants is analogous to putting your brain in a bucket and shaking it (albeit without the obvious physical trauma). I think the reasoning is something along the lines of "well, if your equilibrium is THAT bad, might as well do some semi-random shit and see if you land in a better one". At least these drugs sometimes seem to work for some people, and have been tested to rule out neurotoxicity and the like.
I'd also say that this explanation of how antidepressants (sometimes seem to) work might also partially explain the recent successes of psychedelics in treating depression: shaking the brain into a new equilibrium, except in this case, on a level that is also clearly conscious and cognitive.
No, this isn't a tautology. Even in a Szazian framework the 'chemical imbalance' claim is meaningful. You just have to take the stickers off and put new ones on.
Depression is a 'chemical imbalance' in that we can 'treat' it with drugs. That fact about reality persists in a Szazian description of reality. We can say instead that those the mainstream typically diagnoses with depression can (if they choose) adjust their preferences closer to the norm with drugs by adjusting their chemical 'balance' closer to the norm with drugs. This reality is 100% different from a reality where it is NOT possible to adjust one's preferences closer to the norm with drugs/treat the disease with drugs.
The distinction between Szazian and mainstream psychiatry is in the map they use. Whether depression/ADHD/schizophrenia can in theory be 'treated'/'adjusted to a more typical value' through psychiatric medication that adjusts chemical levels is a question about the territory. And the answer is obviously yes, this is possible at least in theory for many 'mental illnesses.' We know that because we have drugs that do nothing but adjust 'chemical levels' which 'treat'/'make more typical' many patients for these mental illnesses.
Consider the quote you gave:
> Theories abound, but the explanation for lithium’s effectiveness remains unknown. Patients are often told it corrects a biochemical imbalance, and, for many, this explanation suffices. There is no evidence that bipolar mood disorder is a lithium deficiency state or that lithium works by correcting such a deficiency.
Not knowing how the drugs work is irrelevant to the fundamental question of whether they do, and whether they do so by altering the chemistry of the brain *somehow*. We don't really know how any number of drugs work. That doesn't interfere with us knowing that they DO. Empirical knowledge sometimes runs ahead of theoretical knowledge, especially in fields like neuroscience that we barely understand theoretically at all. It's still knowledge. And of course, given that Lithium WORKS (at either treating a disease or at bringing certain types of unusual brain patterns closer to average, depending on which framing of reality one prefers), we know that it has to be by adjusting a chemical balance somehow. It's not altering the structure of the brain significantly. It's not altering someone's metaphysical soul or conscience or virtues. It's adjusting chemical levels. That's the category of effects we're dealing with.
I have no objection to a Szazian saying 'your child has an unusual brain chemical set up which makes them want to lay in bed more than typical children, makes them want to walk up stairs and exercise less and more slowly than typical children, and makes them dislike themselves and be more prone to a particular set of irrational thinking than the typical child, and they have a good chance of becoming more typical if you give them an SSRI.' That's all true, and maybe Szazians are right that a disease-framing is unhelpful and doesn't cut reality at the joints. But the 'chemical imbalance' structure of reality remains; the operational bits are 'your child is different from usual' and 'your child can likely become more usual via adjusting brain chemicals.' All the rest is ethics and norms.
It's nice that you have it all cut and dry, but have you ever been inside MY brain? I have Bi-Polar Disorder II, and told I have a chemical imbalance, blahblahblah. Where did it all come from? Well, it's hereditary, I got a BAD gene, as my late father put it, you got dealt a bad hand of cards at birth kid, sorry about that, Gee, thanks Pop, but it's not like you and Mommie Dearest did anything to help me because you did not want the stigma of having a screwball kid. Heaven forbid, so suffer I did. My biological mother was the carrier, and her mother had Bi-polar disorder II, and her father was a carrier, and his mother had it, and his brother had it also. Keep it in the family....however, Mommie Dearest was six bricks shy of a full load and my father had chemical inbalances as well and so did my older biological brother. But nothing put the fear of God into them worse than anything else than the thought of a mental healthcare worker-the thought of having someone like that tell them they were mentally ill, as well as not a nice person, God forbid! Nope, that was my burden alone to shoulder, and I was turned into a guinea pig for all kinds of God-awful medications, some which had nearly deadly side-effects on me, including lithium. Trying to find the right drug cocktail that is going to work for you is like, well, alchemy, and it can take a lot of tries and fails before you find one, and there is no magic bullet. I have been overmedicated, undermedicated, nearly killed by some of this stuff, and sometimes the meds just stopped being effective. I also came to rely on medical cannabis to help with the anxiety as well as the PTSD that came with the abuse I endured throughout my life at the hands of my family(no one likes a mentally-deficient psycho loser with no redeeming qualities I guess). Yes, part of mental illness is that there is a chemical imbalance, but there is so much more, and you cannot compartimentalize it all. It is not that cut and dry, and you cannot debunk it and say it is a myth-until you have walked in a person's shoes such as myself, you really have no idea what it is like. Part of my daily meds are the anti-depressants-I take 125 mg of Effexor XR, and without it I am a wreck and the depression is horrific and I feel like I wanna die. Then there is 20 mg of buSPirol which is an anti-anxiety med, and then 300 mg of topiramate, which is the mood stabilizer, it is actually an anti-epileptic drug and also used for migraines(although it doesn't do jack for mine). Plus I have my medical cannabis as well. This is a life sentence I life that I was cursed with at conception that I never asked for, one that some ignorant people still give me a lot of hell for, and I walk around with a target on my back. God forbid the cops find out I am mentally ill, they shoot first and ask questions later, or beat my brains in till they are oozing out on the ground. Yeah, sounds bad, but that is how they treat mentally ill people and it is truly frightening. It is like you have a demon inside you that you are constantly doing battle with, and somedays the demon wins and somedays you win, and that is with taking your meds. It is a very crippling disease, and I got shunned and rejected by my family because of it, and believe me, men don't always want someone like me. My soulmate and love of my life, my late boyfriend Phil, had BPDII like me, so we were a good fit. We understood each other and our quirks, but it could be a real rollercoaster. Somedays the depression could be really tough, whether it was me with the depression or him, and somedays if he was amped up it could be tough for me. We just took the good with the bad because that is how the disease was, because what mattered most was that we loved each other, not our illness. We didn't have to front with each other because we both understood what it was to battle mental illness and all the bullsh%t that went with it, the judgement, the ignorance, and all the myths. There is no cure and there is no magic bullet and it never goes away....it's a lifelong sentence until the day you die. Only thing that can help sort of keep it in check is meds and counseling, but even then there are days where it will still kick your butt, and no, you just don't get over it. That is why also there is a lot of self-medication with alcohol and drugs, it happened to me when I was a teenager and it also happened to my late boyfriend. You are trying to fill that deep, black void and all the pain, and the drugs and/or alcohol dull it. I also had to learn much later in life that you also have to remove yourself from bad situations as well as remove harmful people from your life who are inflicting pain upon you and are making your life a living hell which can also exacerbate depression too. Not an easy thing to do but it must be done-having to cut off my former family and disown them, never speaking to them, hearing from them and seeing them again helped greatly. I realized they were the ones doing the greatest harm to me and causing a lot of pain, exacerbating the depression I was already naturally experiencing due to my illness. Learning to take yourself out of harmful situations is a big part of the equation to help improve things, it is still a learning process for me, but again, there is no magic bullet or instant cure for depression or chemical imbalance. They do exist, I am living proof of it.
"One scientific-sounding synonym for 'bad' is 'imbalanced,' right? So when psychiatrists say, 'Depression is caused by a chemical imbalance,' it’s basically true by definition."
It really depends what the people writing and reading the papers understand by the term chemical imbalance. My sense is that it's something a fair bit more specific than just 'bad'.
I fit the profile of agreeing with you on most everything but having dealt with the mentally ill I think that they are not in their right mind and they can get very destructive of others and themselves and they need the help of others. I do understand that even the mentally ill have rights but we should push them to take their meds. BTW The most realistic movie I've ever seen was "A Beautiful Mind".
”’Depression is caused by a chemical imbalance’, it’s basically true by definition.” I disagree (even though we are “made of chemicals”), since a *physical* defect or malformation is a different possible cause of poor functioning. Example: a broken bone is not a chemical imbalance.
"Chemical imbalance" is not a tautology if you're speaking to any of the vast number of laypeople who are Cartesian dualists, and I think Cartesian dualists are clearly the target of the "chemical imbalance" framing.
Bryan, you may or may not remember me. I am an FSU professor and was a good friend of Tom Szasz. He always argued for the ridiculousness of biological psychiatry as you suggest but his was a philosophical, intellectual, and ethical argument. He has simply been proven to be right. I and two colleagues published the book, Mad Science: Psychiatric Coercion, Diagnosis, and Drugs in 2013 which provided the empirical arguments for Tom's position including his strong objection to psychiatric coercion. It only takes a few decades to get the science aligned with the obvious falsehoods of the psychiatric medical model and its often unprincipled approach to dealing with human travail.
This is the line from the study, about belief in the chemical imbalance theory, that is potentially tragic: "this belief shapes how people understand their moods, leading to a pessimistic outlook on the outcome of depression and negative expectancies about the possibility of self-regulation of mood."
I kind of but not entirely agree.
"Chemical imbalance" could be interpreted so broadly as to be tautological. But it can also plausibly be interpreted as meaning "caused by an excessive or insufficient concentration of an identifiable chemical and ameliorable by addressing that excess or deficit."
The latter definition is still extremely broad but not so much so as to be meaningless. For example, it would not cover an hypothetical explanation of depression as being caused by widespread cell death in a brain region due to traumatic injury.
Now if you want to mock psychiatrists for tautological claims then look at forensic psychiatrists who try to support an insanity defense by claims "the defendant only did <bad thing> because of <brain condition>!"
Well, of course, he did! Everything everybody does they do because of a brain condition! "But I have this paper that claims to identify the brain condition!" So why does that matter? The brain condition must exist a priori. Why does the validity of an insanity defense depend on whether science has identified it yet?
That is not to say that there cannot be valid insanity defenses. But the whole "it wasn't me, it was me brain that made me do it!" is not one of them.
If the brain were *purely* a chemical soup, you'd be completely right, but we're not "merely made of chemicals." The brain uses electrochemical signaling and has a plastic physical structure. (Of course, that structure is made of chemicals, but structure is not purely defined by its chemical ratios/balance.) Assuming a materialist model of the brain (as anyone in their right mind should), you could assess a psychiatric condition by focusing on the brain's (electro)chemical state at a given time, such as in the serotonin hypothesis, but you could also focus on its neuronal structure.
Obviously the structural and the electrochemical are intimately bound up, but saying "an ongoing chemical imbalance causes structural abnormalities that lead to depression" is different from "an ongoing chemical imbalance in itself leads to depression," which is different from "a temporary chemical imbalance causes a structural abnormality, but the chemical imbalance itself does not persist," or "the modern world filled with tons of electronic devices messes with the electrical signaling in our brain." (I wouldn't believe the last point, but it's still a testable hypothesis.)
That said, I think your point is important! Much of psychiatry feels very circular and truly is in the dark about ultimate causes, and we have to hold it (any many other disciplines) to higher standards.
I love "Chemical Imbalance", it's such a delightfully stupid explanation .
You know those deaths by gun violence that have caused so much concern recently ? It's not a criminal justice issue at all, in fact recent studies indicate that it's caused by a chemical imbalance due to the toxic heavy metal lead (Pb). Once this metal is absorbed by the body in high enough doses and velocities it can cause negative health outcomes.
You're forgetting the important part of the phrase "high velocity lead poisoning".
One could describe it in the reverse way, by saying, "Whatever its causes in any particular individual, depression is a condition of uncomfortable symptoms which can often be treated (i.e., relieved in the direction of the patient's desires) by means of pharmaceutical interventions that work via *chemical rebalancing* of the patient's neurological environment." There is no question whatsoever that many substances are mild mood-lifters for most people, depressed or not.
This isn't the same interpretive framework as 'blaming' the depression as *caused* by the baseline condition of the patient's neurological chemical environment. That would be like attributing pain resulting from an injury to the brain's failure to make and release enough Beta-endorphin to block the pain.
The main danger with the chemical imbalance interpretation is that one's one diagnosis will be off and one will be manipulating conditions that are upstream of 'mood', but that themselves are downstream of the true root causes which will not be felt so likely not addressed, thus leading to a chronic and permanent need for medications.
That being said, my impression is that addressing the root causes of a lot of depression is simply not a tractable problem for medical professionals in our society given their limited authority over patients and the general regime of legal liabilities which incentivizes strict conformity with the field's conventional practices and narratives about such conditions.
If a psychiatrist can't actually do anything about the root causes of a patient's depression, and the patient himself is unlikely to do those things on his own, and that stating the actual causes out loud will only make the patient even more depressed in terms of feeling bad about himself, then it's not implausible that the best one can do it perpetuate a kind of noble lie about it not being the patient's fault, baby you were born that way, it's not your life situation or bad past decisions but just an unlucky defect in your brain chemicals, and here's a drug that will 'fix' that 'balance', and by so fixing, you mood will return to 'normal'.
Well, the "lead theory of violence" is a "chemical" theory, as opposed to a sociological theory like "poverty causes violence". And (before you've studied the issue), both are plausible.
To test the economic knowledge of your comedy audience:
"I have a great joke about opportunity cost which unfortunately I have better things to do than share with you."
Check out Edward Hagen (an admirer of Szasz) and his <a href="https://anthro.vancouver.wsu.edu/documents/309/Hagen_2003_The_bargaining_model_of_depression_EUeAUAw.pdf">bargaining model of depression</a>. The bargaining model of depression is one of those theories that -- when I first read it -- struck me immediately as being obviously right (another example is Robert H Frank's theory of romantic love as a commitment mechanism). In fact, the two are related in that they work only because they are powerful emotions that are not under voluntary control by the individual experiencing them.
Of course there must be some kind of physiological mechanism behind both "falling madly in love" and also "falling into depression", and it's possible that we could find drugs to combat one or both of these emotions. But neither are fundamentally diseases or disorders -- they are adaptations. Of course, saying that they are adaptive doesn't mean that they work well or are beneficial in every individual case -- only that they are beneficial on average so that natural selection created and sustains them.
Out of curiosity would you feel differently about psychiatrists if you just thought of them as knowledgeable advisors about what kind of drugs you might enjoy taking in the long term?
I mean surely you grant that some drugs, taken long term, even if only caffeine or moderate alcohol can be life and productivity improving. OTOH, other drugs which might initially feel beneficial such as opiates, fenphen or MDMA turn out to have downsides when taken regularly which can't be inferred just from how they feel at first. Moreover, different people will often react differently to the same drug (don't get stoned at a party if you have social anxiety).
Given those two facts surely it makes sense for there to be people who specialize in advising others about which drugs are likely to improve their life and which are likely to be harmful. And how does that differ from psychiatry?
I was recently in a state in which it was legal under local law to recreationally purchase and use cannabis-derived substances obtained at licensed dispensaries. While I'm generally against the drug war, cannabis isn't my thing so I don't partake. But a relative invested in a growing operation and encouraged me to visit the dispensary which retails his products, and I wanted to satisfy my curiosity.
The fellows behind the counter were perhaps a bit too on-the-nose as regards the stereotypical attributes of the pothead stoner, however, they were *incredibly knowledgeable* in just the way you describe above and in terms of describing with precision the fine distinctions in psychological effects that each of their numerous offerings would produce in the typical customer, and helping people find the kick (within the limited range of what's possible with cannabis, anyway) that they were most likely to enjoy or which was just the kind of thing they were looking for. Better than any sommelier I've encountered, and probably more accurate. I'd trust them much more to assess relative quality from blind taste tests, er, smoke tests.
I agree in part but I think some of that 'expertise' is placebo (both from the sommeliers and dispensary folks). That might be a plus when you are just talking about weed or your wine pairing but when it comes to taking drugs long term (things like Adderall etc) I'd like some controlled studies as well.
I mean the potheads are great for advice on how it will feel but it was the controlled studies showing that even chronic mj use by adults (once you had a month w/o use for very heavy users) didn't have negative effects on cognition that convinced me initially it wasn't a problem to use and similar studies that convinced me to keep my MDMA use to a minimum back in college. So I think there is something to be said for both.
That's fair, however, the problem (quite a common and tricky one, as it happens) with many of those studies is that the methodology and analysis is often based on an implicit model of low dispersion of human reaction, which is quite often not at all the case with regards to drugs due to high levels of human genetic and metabolic diversity. By way of illustration, consider a study on the effect of lactose. Well the issue is that humans range from highly lactose tolerant to highly intolerant, and if the study doesn't pick up on this diversity it will give a kind of nonsense result of an average actually describes nobody because the distribution of symptoms tends to be bifurcated. The trouble is that unless one has very large N, it is hard to distinguish between high dispersion in the studied population on the one hand and data that looks 'noisy' and results of simple regression will lack statistical significance. And, unfortunately, claims of low ps are what get published.
Kind of tragically - because the problem is institutional and hasn't been due to technical or economic constraints for a long time now - the era of 'genetic medicine' never really arrived except for a few exceptions that don't reflect anything near the potential that could be feasibly exploited right now. We could be splitting up different kinds of advice for different kinds of people, but we are still stuck in the objectively false one size fits most mindset.
For instance, your example of MDMA and what frequency of use is prudent to avoid neurotoxic consequences provides a good example of my point about genetic diversity and metabolic dispersion. The various amphetamines are principally metabolized by an oxidative enzyme in the liver called cytochrome p450 2d6. The amphetamines also tend to bind and stick to 2d6 during that reaction, which prevents it from working on anything else for a long time, which can cause all sorts of drug-drug interactions, some potentially nasty in effect.
But in many populations, people are *all over the place* with regards to 2d6, in terms of producing different levels, whether they have multiple duplicate copies of the alleles in their chromosomes, and the wide spread of relative effectiveness of a number of variant forms. In most populations it's not rare at all to encounter normal metabolizers, non-metabolizers, and ultra-rapid metabolizers. There is no good advice to give to the general population, as any claim is only suitable for a narrow slice of people near the mean while being plausibly inaccurate and perhaps even hazardous for an actual majority of the population.
The same phenomenon applies to the effects of codeine which one can model as a prodrug for morphine which conversion is also accomplished by 2d6. Non-metabolizers don't get any pain relief, normal metabolizers get a slow drip of low levels of morphine as analgesic, while ultra-rapid metabolizers convert the whole ingested dose right away and feel like they've had a hit of heroin.
Well, we can hope that eventually actual normal medical practice catches up to the genetic revolution and this knowledge base which has been around for a long time. But the interesting thing about the cannabis sommeliers is that by sheer volume of experience and observations of people indulging in those substances, my impression is that they've been able to recognize some real patterns of 'metabolic types' and have some crude but reasonably effective heuristics in terms of being able to determine one's type with one's answers to just a few questions about one's past experiences. In this regard they are probably better than both sommeliers and actually credentialed psychiatrists.
Yes, learning things is hard and I agree about the limitations of pure observational studies. That's one reason that in vitro (and animal bases) studies are useful. While I wouldn't doubt that MDMA toxicity is affected by variation in CYP 2D6 (tho I have a vague memory that it may have been 3A4 that was relevant ...but I'm probably just confusing it with benzodiazepenes since it's been decades since I dug into the studies) the various animal studies were suggestive that there were more direct effects meaning everyone was going to face some level of toxicity (tho somewhat undermined by one study that didn't find any harm when administered directly to the brain stem).
But yes, I agree the studies arent easy to interpret. In the case of recreational drugs this is made much worse by the biasing effect of the DEA controlling who can run those studies and pretty clearly favors researchers who were going to demonstrate harm. There was even one case of a paper showing absurd mortality rates in primates that turned out to be bc they administered meth rather than MDMA but refused to acknowledge the mistake until ppl pressured them on the poin that their results should have some really high fraction of ravers should have died on their first dose...and the way it unrolled convinced me that if they'd found no harmful effect they wouldn't have shrugged and published.
So yah, these studies aren't magic and one certainly has to be on the lookout both for variation in the population, bias etc etc but I still do think they add some value. Even if I don't know exactly how bad MDMA is for me it gave me enough information to know that I didn't want to be using it every weekend or stacking a bunch of doses while there have been times in my life I've been happy to do the same with marijuana.
A bunch of the NYC rationalists are going to be at the comedy show. My wife and I already have reservations.
I think that the chemical imbalance meme is an over simplification, one that has unfortunately become widely disseminated. However, outside of the more naive branch of pop sci and Buzzfeed articles, it is my impression that the contemporary field no longer takes this view very seriously. From what I've read, it seems that taking the various antidepressants is analogous to putting your brain in a bucket and shaking it (albeit without the obvious physical trauma). I think the reasoning is something along the lines of "well, if your equilibrium is THAT bad, might as well do some semi-random shit and see if you land in a better one". At least these drugs sometimes seem to work for some people, and have been tested to rule out neurotoxicity and the like.
I'd also say that this explanation of how antidepressants (sometimes seem to) work might also partially explain the recent successes of psychedelics in treating depression: shaking the brain into a new equilibrium, except in this case, on a level that is also clearly conscious and cognitive.
No, this isn't a tautology. Even in a Szazian framework the 'chemical imbalance' claim is meaningful. You just have to take the stickers off and put new ones on.
Depression is a 'chemical imbalance' in that we can 'treat' it with drugs. That fact about reality persists in a Szazian description of reality. We can say instead that those the mainstream typically diagnoses with depression can (if they choose) adjust their preferences closer to the norm with drugs by adjusting their chemical 'balance' closer to the norm with drugs. This reality is 100% different from a reality where it is NOT possible to adjust one's preferences closer to the norm with drugs/treat the disease with drugs.
The distinction between Szazian and mainstream psychiatry is in the map they use. Whether depression/ADHD/schizophrenia can in theory be 'treated'/'adjusted to a more typical value' through psychiatric medication that adjusts chemical levels is a question about the territory. And the answer is obviously yes, this is possible at least in theory for many 'mental illnesses.' We know that because we have drugs that do nothing but adjust 'chemical levels' which 'treat'/'make more typical' many patients for these mental illnesses.
Consider the quote you gave:
> Theories abound, but the explanation for lithium’s effectiveness remains unknown. Patients are often told it corrects a biochemical imbalance, and, for many, this explanation suffices. There is no evidence that bipolar mood disorder is a lithium deficiency state or that lithium works by correcting such a deficiency.
Not knowing how the drugs work is irrelevant to the fundamental question of whether they do, and whether they do so by altering the chemistry of the brain *somehow*. We don't really know how any number of drugs work. That doesn't interfere with us knowing that they DO. Empirical knowledge sometimes runs ahead of theoretical knowledge, especially in fields like neuroscience that we barely understand theoretically at all. It's still knowledge. And of course, given that Lithium WORKS (at either treating a disease or at bringing certain types of unusual brain patterns closer to average, depending on which framing of reality one prefers), we know that it has to be by adjusting a chemical balance somehow. It's not altering the structure of the brain significantly. It's not altering someone's metaphysical soul or conscience or virtues. It's adjusting chemical levels. That's the category of effects we're dealing with.
I have no objection to a Szazian saying 'your child has an unusual brain chemical set up which makes them want to lay in bed more than typical children, makes them want to walk up stairs and exercise less and more slowly than typical children, and makes them dislike themselves and be more prone to a particular set of irrational thinking than the typical child, and they have a good chance of becoming more typical if you give them an SSRI.' That's all true, and maybe Szazians are right that a disease-framing is unhelpful and doesn't cut reality at the joints. But the 'chemical imbalance' structure of reality remains; the operational bits are 'your child is different from usual' and 'your child can likely become more usual via adjusting brain chemicals.' All the rest is ethics and norms.
It's nice that you have it all cut and dry, but have you ever been inside MY brain? I have Bi-Polar Disorder II, and told I have a chemical imbalance, blahblahblah. Where did it all come from? Well, it's hereditary, I got a BAD gene, as my late father put it, you got dealt a bad hand of cards at birth kid, sorry about that, Gee, thanks Pop, but it's not like you and Mommie Dearest did anything to help me because you did not want the stigma of having a screwball kid. Heaven forbid, so suffer I did. My biological mother was the carrier, and her mother had Bi-polar disorder II, and her father was a carrier, and his mother had it, and his brother had it also. Keep it in the family....however, Mommie Dearest was six bricks shy of a full load and my father had chemical inbalances as well and so did my older biological brother. But nothing put the fear of God into them worse than anything else than the thought of a mental healthcare worker-the thought of having someone like that tell them they were mentally ill, as well as not a nice person, God forbid! Nope, that was my burden alone to shoulder, and I was turned into a guinea pig for all kinds of God-awful medications, some which had nearly deadly side-effects on me, including lithium. Trying to find the right drug cocktail that is going to work for you is like, well, alchemy, and it can take a lot of tries and fails before you find one, and there is no magic bullet. I have been overmedicated, undermedicated, nearly killed by some of this stuff, and sometimes the meds just stopped being effective. I also came to rely on medical cannabis to help with the anxiety as well as the PTSD that came with the abuse I endured throughout my life at the hands of my family(no one likes a mentally-deficient psycho loser with no redeeming qualities I guess). Yes, part of mental illness is that there is a chemical imbalance, but there is so much more, and you cannot compartimentalize it all. It is not that cut and dry, and you cannot debunk it and say it is a myth-until you have walked in a person's shoes such as myself, you really have no idea what it is like. Part of my daily meds are the anti-depressants-I take 125 mg of Effexor XR, and without it I am a wreck and the depression is horrific and I feel like I wanna die. Then there is 20 mg of buSPirol which is an anti-anxiety med, and then 300 mg of topiramate, which is the mood stabilizer, it is actually an anti-epileptic drug and also used for migraines(although it doesn't do jack for mine). Plus I have my medical cannabis as well. This is a life sentence I life that I was cursed with at conception that I never asked for, one that some ignorant people still give me a lot of hell for, and I walk around with a target on my back. God forbid the cops find out I am mentally ill, they shoot first and ask questions later, or beat my brains in till they are oozing out on the ground. Yeah, sounds bad, but that is how they treat mentally ill people and it is truly frightening. It is like you have a demon inside you that you are constantly doing battle with, and somedays the demon wins and somedays you win, and that is with taking your meds. It is a very crippling disease, and I got shunned and rejected by my family because of it, and believe me, men don't always want someone like me. My soulmate and love of my life, my late boyfriend Phil, had BPDII like me, so we were a good fit. We understood each other and our quirks, but it could be a real rollercoaster. Somedays the depression could be really tough, whether it was me with the depression or him, and somedays if he was amped up it could be tough for me. We just took the good with the bad because that is how the disease was, because what mattered most was that we loved each other, not our illness. We didn't have to front with each other because we both understood what it was to battle mental illness and all the bullsh%t that went with it, the judgement, the ignorance, and all the myths. There is no cure and there is no magic bullet and it never goes away....it's a lifelong sentence until the day you die. Only thing that can help sort of keep it in check is meds and counseling, but even then there are days where it will still kick your butt, and no, you just don't get over it. That is why also there is a lot of self-medication with alcohol and drugs, it happened to me when I was a teenager and it also happened to my late boyfriend. You are trying to fill that deep, black void and all the pain, and the drugs and/or alcohol dull it. I also had to learn much later in life that you also have to remove yourself from bad situations as well as remove harmful people from your life who are inflicting pain upon you and are making your life a living hell which can also exacerbate depression too. Not an easy thing to do but it must be done-having to cut off my former family and disown them, never speaking to them, hearing from them and seeing them again helped greatly. I realized they were the ones doing the greatest harm to me and causing a lot of pain, exacerbating the depression I was already naturally experiencing due to my illness. Learning to take yourself out of harmful situations is a big part of the equation to help improve things, it is still a learning process for me, but again, there is no magic bullet or instant cure for depression or chemical imbalance. They do exist, I am living proof of it.
"One scientific-sounding synonym for 'bad' is 'imbalanced,' right? So when psychiatrists say, 'Depression is caused by a chemical imbalance,' it’s basically true by definition."
It really depends what the people writing and reading the papers understand by the term chemical imbalance. My sense is that it's something a fair bit more specific than just 'bad'.
I fit the profile of agreeing with you on most everything but having dealt with the mentally ill I think that they are not in their right mind and they can get very destructive of others and themselves and they need the help of others. I do understand that even the mentally ill have rights but we should push them to take their meds. BTW The most realistic movie I've ever seen was "A Beautiful Mind".
”’Depression is caused by a chemical imbalance’, it’s basically true by definition.” I disagree (even though we are “made of chemicals”), since a *physical* defect or malformation is a different possible cause of poor functioning. Example: a broken bone is not a chemical imbalance.
"Chemical imbalance" is not a tautology if you're speaking to any of the vast number of laypeople who are Cartesian dualists, and I think Cartesian dualists are clearly the target of the "chemical imbalance" framing.
Bryan, you may or may not remember me. I am an FSU professor and was a good friend of Tom Szasz. He always argued for the ridiculousness of biological psychiatry as you suggest but his was a philosophical, intellectual, and ethical argument. He has simply been proven to be right. I and two colleagues published the book, Mad Science: Psychiatric Coercion, Diagnosis, and Drugs in 2013 which provided the empirical arguments for Tom's position including his strong objection to psychiatric coercion. It only takes a few decades to get the science aligned with the obvious falsehoods of the psychiatric medical model and its often unprincipled approach to dealing with human travail.
This is the line from the study, about belief in the chemical imbalance theory, that is potentially tragic: "this belief shapes how people understand their moods, leading to a pessimistic outlook on the outcome of depression and negative expectancies about the possibility of self-regulation of mood."