Tuesday, February 15, 2011

There's no such thing as a "chemical imbalance"

I've known at least a hundred clients who think that the cause of their symptoms might be a "chemical imbalance." Some have said, "maybe I don't have enough Serotonin." It bothers me, every time, because there is no such thing.

About 30 to 40 years ago, some scientists hypothesized that anti-depressants corrected a chemical imbalance in the brain, primarily Serotonin. 
But as early as 1994, it became clear that the hypothesis of a chemical imbalance in the brain was over-simplistic, and, there was not a significant amount of research to support the hypothesis. 

Dozens of ideas about the brain have come and gone.
Even though it's false, the chemical imbalance ideas
sticks around because of pharmaceutical marketing.

For years, scientists had studied Serotonin in the human brain and there was no indication that increasing Serotonin or decreasing Serotonin would cure or cause depression. Interestingly, one anti-depressant used in Europe decreases Serotonin availability in the brain.

Some ideas die hard. Pharmaceutical Corporations still make the claim that antidepressants "may correct a chemical imbalance in the brain." Pharmaceutical sales reps continue to tell physicians the same thing, and doctors tell their patients.

Why do Pharmaceutical commercials and sales reps still mention the chemical imbalance hypothesis if its not true? There's no law against it. I suspect they continue to use it because it sounds so simple: chemical imbalance + pill = cure. Like adding salt to french fries.

The "Alternative Medicine" industry has also climbed on the bandwagon with all sorts of pills that allegedly cure this chemical imbalance - 5HT, SAMe, and St. John's Wort. None of these supplements seem to work very well in clinical trials, and they also can complicate existing treatments, for example, by lessening the effects of other medications. These supplements can have undesirable side effects like antidepressants (weight gain, insomnia, irritability, nausea, etc...) - so much for au natural.

Even if there was a chemical imbalance in your brain, it doesn't mean that it was the cause of your depression. It is extremely difficult to understand cause and effect. Life events that we find depressing may increase the presence of one neuro-modulator while decreasing another. Would it be fair to say that the change in neuromodulators caused your depression? or, did the upsetting life stress cause your brain to change it's chemistry in order to make you feel a certain way and for a certain reason? Is it possible that we need to have certain feelings? Is it possible that certain feeling states can become habitual or maintained? Is this in our control?

There are two primary neurotransmitters: GABA and Glutamate. Other chemicals, like Serotonin, Dopamine, Epinephrine and Nor-epinephrine are called neuromodultors and they modulate GABA and Glutamate. There are many neuromodulators: Opiates (Endorphins and Enkephalins), peptides and hormones (estrogen, testosterone, etc...) which also modulate GABA and Glutamate. At this point, information about neurochemistry becomes much more complex, and this may be why doctors appeal to the "chemical imbalance" hypothesis - it's less time consuming and so simple to understand. Pass the salt.

The "chemical imbalance" phrase has been around a long time. We tend to believe things the more that we hear it. That's why commercials are played repeatedly, ad nauseum. Pretty soon, you're doing the work of the sales rep: you go to the doctor and ask them for the medication that the pharmaceutical company has been telling you that you need! "Hey doc, I've been feelin' down way too long, maybe I have one of them chemical imbalances; maybe I need that medication in the commercial with the smiling bubble?"

The reality is that nobody knows if antidepressants really work and, when scientists think that they do work, they are unable to explain why - with any degree of certainty. It sounds terrible, but it's terribly true. One factor that has confused and confounded scientists for decades is the Placebo Affect. 

It can be hard to believe that the placebo effect can be powerful enough to cure depression, anxiety, and alleviate other health problems. There are many studies on the placebo effect. A couple years ago, one study found that people given Ibuprofen, for pain management, did just as well as people given Oxycontin - if they believed that they were taking Oxycontin. About 33% of Americans are susceptible to the placebo affect. Perhaps this is why not everyone is helped by antidepressants. Some people feel "cured" while others feel nothing; some people feel "numb" while others feel "a little better."

Antidepressants are pills with side effects. Sometimes people feel better when they take them, sometimes nothing changes, and sometimes they feel worse; in rare cases, they are associated with suicide ideation, suicide behavior, and self mutilation behaviors. 

There are alternatives to medication, such as Cognitive Behavioral Therapy (CBT) and other types of therapy. Medication is often given as the first line of treatment by physicians, however, it is probably best used as a last line of treatment.

A significant advantage of therapy is that you learn to overcome your problems or symptoms independently of medication. Also, there tend to be no negative side effects to therapy, such as weight gain, loss of sex drive, or others.

Since writing this post, I was finally able to read The Emperor's New Drugs by Dr. Irving Kirsch. No one has conducted a more thorough scientific investigation into the effectiveness of Anti-Depressants as he. It turns out that, with regards to depression and anxiety, Anti-Depressants are only placebos. One of the most striking findings was that the effectiveness of Anti-Depressants was almost perfectly correlated with the amount of reported side effects. I strongly recommend this book to anyone who is prescribed Anti-Depressants.

Mental Health Advice Disclaimer

The information included in this post and blog are for educational purposes only. It is not intended nor implied to be a substitute for professional mental health treatment or medical advice. The reader should always consult his or her mental health provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a mental health or medical condition or treatment plan. Reading the information on this website does not create a therapist-patient relationship.

1 comment:

  1. Absolutely amazingly put. I couldn't agree more with you. The placebo effect does wonders. If the mind believes something to be true than it can and will be. I once had a friend in high school tell me that if I thought I was skinny, I would be skinny. Oddly enough, I began working on my outward thinking and feeling about myself, in turn, I lost weight. Which, what had really happened was when I felt better about myself, I was more active, I ate less (I eat when depressed or laying around watching tv) and I lost weight. I didnt lose a huge amount but I could tell a difference in myself. Of course that did not last and I began to believe it was not working anymore and so...it didnt. We can train our minds to think what we would like to. I love that. I do however, believe in medications used as a stepping stone for those "too far gone" as they would put it. Or in other words, unable to cope right away. Maybe that perfect "sugar" pill *wink wink* would be nice to help them start somewhere and as they began to grow stronger, down the dosage *wink*, and off they go. Training them that they are strong enough to do it on their own. Little trickery if you may have it. Excellent post!!!