Wednesday, May 01, 2019

Who's going to take responsibility for promoting the chemical imbalance theory of mental Illness?

I reviewed Ronald Pies' book Psychiatry on the Edge a few years ago (see review and previous post). A recent Psychiatric Times article picks up his theme of debunking the chemical imbalance myths of depression and schizophrenia. I think I do understand his view that these notions were never really taken seriously by most well-informed psychiatrists (see previous post). He does admit, though, that it's not surprising the theory has "taken hold in the minds of so many in the general public". It worries me, though, that he may be seen to be blaming Laura Delano (whose New Yorker article led to his response) for her view, as a patient, "that [her] depression was caused by a precisely defined chemical imbalance, which her medications were designed to recalibrate". I hope he's not.

I'm not quite sure what's achieved by arguing that "there was never a unified, concerted effort within American psychiatry to promote a 'chemical imbalance theory' of mental illness in general", if that's the impression that's been created in Laura Delano and the public in general. Whose fault was it then? Certainly patients are given this professional opinion by psychiatrists (whether they really believe it or not) (see previous post). As I said in my review, Pies thinks that:-
Doctors know it’s an oversimplification ... but use it so patients don’t feel so blameworthy. He does agree this is “a little lazy” ... on the doctors’ part and doesn’t excuse their behavior, but says they are very pressed for time with so many patients to see.

I also agree with Pies that most psychiatrists are more eclectic than just biological (eg. see previous post). In fact, Pies is quite biological in his approach to psychiatry and admits for example that he's enamoured of the idea that depression is a form of inflammation, even though I think this hypothesis is nonsense (eg. see last post). I think Pies is just trying to say that psychiatrists are not simplistic in their biological (which doesn't omit psychosocial aspects) theories of mental illness. That's as may be and it's good he admits the chemical imbalance theory is bogus. But, if he doesn't attribute the chemical imbalance theory to psychiatrists, who take a much more complex view about the nature of mental illness, then who's been responsible for its promotion? Surely he doesn't think it's the silly patients who’ve believed it.


Richard Gipps said...

I find this an interesting (and not merely rhetorical) question. Might the answer not be: 'silly' drug companies, 'silly' psychiatrists, and 'silly' patients? To different degrees in different cases?

The chemical imbalance theory is compelling because it's so simple and so externalising of unwelcome blame (my difficulties are not a result of moral failure, not a result of my not rising to the challenges of moral and emotional development, tolerating and responding appropriately to my guilt, etc.).

We have a fundamental attribution bias. We tend both to i) unhelpfully try to take responsibility for what in life instead needs to be tolerated rather than controlled (so that a form of externalising would now be healthy), and ii) unhelpfully try to disown responsibility for what in life instead needs to be encompassed within the sphere of our agency (as a result of which we fail to learn to own our shit, fail to stay in the game of moral and emotional development, etc).

So whose responsibility is it if a false theory is believed in which helpfully demotes i) but unhelpfully promotes ii)? I suggest the answer depends in part on the motivations in play, and not just on the power structures or the sources of the misinformation.

Is a drug company exploiting a base human need for overly quick and relief-providing explanations to sell their product? For this they must take some but not all of the blame (same too for sugar manufacturers etc). Does the drug theory just take a place which the patient would otherwise be sure to fill with another daft theory (for example, and whether or not it was daft would depend on the case rather than on any generality: it was my parents, or the water supply, or my religious instruction, that messed me up)? In that case we'd often want to lay blame mainly at the patient's door. (Their blameworthiness here being just the same as every-human-being-that-ever-has-existed's blameworthiness for in some ways being an inveterate nobhead.)

Actually there's another problem. Those on the right tend to blame individuals, those on the left tend to blame authorities. To some degree it will be a matter of fact as to who, in some or other case, is right. In such cases political allegiances may blind, as well as sensitise us to a, recognition of the facts. But it's also plausible that these different political reactions sometimes exploit a constitutive indeterminacy in our concepts of motivation, responsibility and blame. What I mean is: there may sometimes simply be less of a fact of the matter, about who ought to take responsibility for something or other, than we tend to assume.

DBDouble said...

Richard, thanks! I think the real problem is that it is absurd and futile to expect to be able to explain mental processes in physical terms. This is what Kant said years ago. People are reticent about accepting this but actually it should be quite liberating. Why after all should we be able to solve the mind-body problem? Doesn't mean that we can't still have a pragmatic psychiatry, so let's just get on with it!

F68.10 said...

Much of medicine is still make-it-up-as-you-go-along-based medicine. Happily, evidence-based medicine is progressively taking hold. Science-based medicine seems to be fantasy of some pro-science doctors (no, not all MDs are pro-science...). Rationality-based medicine would be my own fantasy, where we'll start reflecting rationally of ethical issues in medicine. But more importantly, the goal to achieve would be Bullshit-free medicine.

"Doctors know it’s an oversimplification ... but use it so patients don’t feel so blameworthy."

In other words, doctors willingly promote bullshit to patients to make them comply. That's the real-world effect of the chemical imbalance theory.

Clearly, it doesn't fit my standards for Bullshit-free medicine.

Anonymous said...

The more 'fully' confident people are - the less open minded they tend to become. susanne