Depression – a chemical imbalance in the brain

This well-known theory first gained currency in an article which appeared in The American Journal of Psychiatry in 1965. Was the chemical concerned serotonin? No, it was norepinephrine. The author himself, Joseph Schildkraut, described the theory as ‘at best a reductionist simplification’. He was right, and this is still the case today.

But accepting the theory for argument’s sake, let’s make a comparison. Let us suppose that Madeleine is having trouble with her thyroid gland. She is producing too little thyroxine  and so has a chemical imbalance. The extent of the imbalance is measured by blood test and she is prescribed synthetically produced thyroxine to correct it. The amount of thyroxine required is worked out by reference to Madeleine’s test results.

And now a second case. Albert is a worried man. He goes to his doctor and, after a short chat, the doctor concludes that he is suffering from depression. She then prescribes an SSRI (selective serotonin re-uptake inhibitor) which will correct the chemical imbalance in Albert’s brain.

But wait a minute, where is the test in this case? Madeleine was tested, why wasn’t Albert? How can the doctor know there is a chemical imbalance to correct without testing the chemical levels in Albert’s brain?

So, in prescribing an SSRI, the doctor is assuming:
–  That the chemical imbalance theory has solid evidence to support it
–   That Albert is one of those affected by a chemical imbalance and his ‘depression’ does not have some other cause
–   That the SSRI she prescribes, and in the quantity she is prescribing it, will correct this supposed imbalance

When it comes to the prescribing of anti-depressants, bold assumptions like these are now being made on an industrial scale.

[To be fair to the doctor, she errs on the side of caution when it comes to quantity, starting with a small dose of Albert’s SSRI and gradually increasing it: something she would not do with thyroxine, where she would know – as a consequence of testing – how much was required.]

Homosexuality as a disease

According to DSM II (the Diagnostic and Statistical Manual of Mental Disorders), homosexuality was a mental disease. It was listed as a ‘sexual deviation’ and so found itself an unwilling bedfellow of paedophilia.

How did this change? Was it, for example,  as a result of painstaking research?

It was changed in 1974 at a meeting of the American Psychiatric Association (publishers of the DSM). When the issue was put to the vote 5854 psychiatrists voted to remove homosexuality from the list of mental diseases, 3810 voted to retain it. As a result, homosexuality was not listed as a mental disease in DSM III or subsequent editions.

So there we have it. What constitutes a mental disease or disorder can be decided by a show of hands. There’s nothing like democracy, right?

What’s wrong with psychiatry?

This is the first of four reports from the Edinburgh International Book Festival.

The event was a talk by James Davies about his recent book, ‘Cracked’, the subject of which is made clear in the publisher’s blurb.

‘Why is psychiatry such big business? Why are so many psychiatric drugs prescribed – 47 million antidepressant prescriptions in the UK alone last year – and why, without solid scientific justification, has the number of mental disorders risen from 106 in 1952 to 374 today?’

Davies couldn’t cover all this ground in one talk, especially since he left time to answer questions, so he concentrated on the DSM (Diagnostic and Statistical Manual of Mental Disorders). Since a large increase in the number of named conditions occurred with the publication of DSM 3 (we are now on DSM 5) he has attempted to find out how this has come about. There being very little in print on this subject, he travelled to the United States to interview those behind this project. Given how they had gone about their task, they were surprisingly cooperative.

Using slides, he showed his audience examples of replies to his questions, the burden of them being that certain self-selecting experts had got together in committee and agreed among themselves what qualified as mental disorders and what the symptoms of these disorders were. There was no scientific basis for their definitions.

Davies also maimtains that there is no scientific basis for the belief that some mental conditions result from chemical imbalances in the brain which may be corrected using medication. Davies is therefore critical of SSRIs (selective serotonin re-uptake inhibitors) which aim to ‘restore’ the balance.

James Davies was very articulate throughout, not only in his talk but also in responding to questions. The event was well attended and, as far as I could tell, the audience was persuaded by his arguments, though many were clearly sympathetic to his views before the event began. The reaction was positive. There were no hostile questions.

It seems to me that if we accept this analysis there are two ways to go here. The first is to change direction, to stop making it up as we go along and base as much as we can on biological research. We can attempt to place the study of mental function on a more scientific basis, to make it more objective. Moves in this direction are already taking place.
An alternative reaction would be to drop the pretence of being scientific altogether, to stop aspiring to it. This is the response of the narrator in my novel, Time to Talk. Max Frei has set himself up as a psychotherapist based entirely on his reading. He has no formal qualification but takes what he does very seriously. He inclines to the subjective, is aware of that fact, and considers it an advantage in psychotherapy.