A decade ago (2005) Lacasse and Leo published an article about the serotonin deficiency theory of depression.
This is a 2015 reflection and update on the discourse.
Florida State Universities Libraries, Faculty Publications, College of Social Work.
Lacasse J. R. and Leo J. 2015, Antidepressants and the Chemical Imbalance Theory of Depression: A Reflection and Update on the Discourse.
Refer full text here- http://diginole.lib....ject/fsu:267045
In 2005 Lacasse and Leo found that,
"Advertisements did not accurately reflect the scientific status of the serotonin theory in the psychiatric research community. Some advertisements were more tentative or clever in their wording than others, but it seemed obvious that the drug companies were at least pushing the boundaries. We thought several of them were going over the line in plain sight of the FDA, which ostensibly regulates direct to consumer advertising. Our goal was to illustrate the clear disconnect between the existing psychiatric science and what the public was being told in these advertisements and we argued that the FDA should issue warning letters to pharmaceutical companies. Of course there were ramifications for clinicians – if it was illegal to claim this in advertisements, wasn't it also an unacceptable thing to be telling vulnerable clients? "
The Problematic Advertisements Disappear
"Newer medications were promoted as "adjusting" or "affecting" neurotransmitter levels, in contrast to "correcting a chemical imbalance"...(...) .. And drugs are now advertised as "affecting" neurotransmitters.
There is no public explanation for why this happened. To our knowledge, the FDA has never sent a warning letter to a pharmaceutical company over claims that antidepressants corrects a chemical imbalance. In our assessment, the promotion of chemical imbalances theory in advertise mince for SSRI drugs was wildly successful for the drug companies in the psychiatric profession alike. Wallace difficult to imagine that they pulled them arbitrarily, we don't know why they largely disappeared."
The authors suggest it may be due to the widespread public criticism of it and emerging transparency of information on the Internet obviously creating problems, or at least a dilemma.
The authors highlight a few examples of the recent discourse on these issues under the following headings:
I Don't Really Believe It, But I Say It to Patients Anyway
Psychiatrist Daniel Carlat is a practising psychiatrist, a clinical instructor at Tufts University ..(..)...
"I think I say that because patients want to know something. And they want to know that we as physicians have some basic understanding of what we're doing when we are prescribing medications. They certainly don't want to know that a psychiatrist essentially has no idea how these medications work."
...(..)...The consistent lack of difference between SSRI and placebo in the clinical literature is one of the most compelling arguments against the serotonin deficiency theory...(...)... one thing that has happened is that because there's been such a vacuum in our knowledge about mechanism, the drug companies have been happy to sort of fill that vacuum with their own version of knowledge...(..)... in fact scientists have known for a long time that the serotonin theory presented by the drug companies and Carlat is not true.....(...)... the simple alternative would be to tell patients the truth – that the pathophysiology of depression is unknown and that we have no idea how SSRIs work.
The Positive Aspects of Misinformed Thinking
There were many angry comments... Apparently many psychiatric patients never realised they were hearing a metaphor and not science....(...)... some such patients now understandably feel lied to by the clinicians. The claim that presenting the chemical imbalance metaphor is in the best interests of patients needs to be considered in light of the existing empirical research. This in fact is not what the literature shows.
The Role of Journalism
It Wasn't Us, It Was the Drug Companies
Ronald Pies is a psychiatrist at Tufts University....(...)... Pies doesn't believe that the chemical imbalance metaphor should be attributed to psychiatry...
" In truth the chemical imbalance notion was always a kind of urban legend – never a theory seriously propounded by well-informed psychiatrists".
...(...)..[Yet]... Among 237 psychology students Francis, Lysaker and Robinson found that 46% had heard the chemical imbalance explanation from a physician ..... Many people reported hearing it's a 'chemical imbalance' from psychiatrists.... If Pies is correct, that is an awful lot of uninformed clinicians.
A Bumper Sticker Slogan to Educate Patients
In subsequent articles Pies moderates his tone...... he claims that it is the result of overbooked clinicians looking for quick explanations to accompany medication, perhaps to reduce self blame on the part of patients(he acknowledges this may backfire). ....(...)... academic psychiatry in general has done a highly effective job of convincing PCPs to diagnose and treat depression with antidepressants.
Academic Psychiatry As Silent Partner in the Promotion of Chemical Imbalance
...Prominent academic psychiatrists could have set the record straight on serotonin imbalance decades ago. Yet to our knowledge no one did so....(...)... is it possible that the flow of money from the pharmaceutical companies to influential academic psychiatrists… has brought with it a certain willingness to remain silent?
[Pies] sounds vaguely critical of the drug industry in his recent articles and never discloses any history of financial conflicts of interest. However Pies has received funding from....[lists many pharma companies]. Pies blames the drug companies for running misleading advertisements about chemical imbalance, belatedly admits he should have said something sooner, but fails to mention that he was paid to help them promote their products at the time the advertisements were running.
But We Never Promoted the Theory
In Table 1 and Table 2 it is apparent that there are often two different conversations occurring. One is the actual scientific discourse. The other conversation is between influential psychiatrists and the public, or between psychiatrists and primary care physicians. In this second conversation the company advertising line about SSRIs correcting chemical imbalances is repeated as fact by psychiatric authorities including the APA.
[I recommend having a read of:
Table 1- Evidence the chemical imbalanced theory of depression is not valid: selected quotations and,
Table 2-Promotion of the chemical imbalance theory of depression as valid: selected quotations].
The Chemical Imbalance Theory Is a Little White Lie
.. By 2014 Pies refers to the use of the chemical imbalance metaphor as "a little white lie"....(...)... how many patients with reservations about SSRIs have agreed to take medication after being told this "little white lie"?
... The propagation of misleading advertising is only possible in the absence of vigorous government regulation… Or outcry from professional associations. That outcry never came....(...)...
...while we are hesitant to overemphasise conflicts of interest as an explanation for what has occurred, we can't help but notice that the silence of psychiatry regarding chemical imbalance only ended when the profits had been extracted from the SSRI marketplace.
The new narrative will apparently be that psychiatrists recently discovered that the chemical imbalance theory was incorrect. Psychometric researchers are changing their mind based on the data, so the story goes and adjusts took a while to let the public know. We believe this is empirically incorrect. The idea that the withdrawal of the chemical imbalance theory was caused by recent data should be rejected.
As the theory has been withdrawn and a dialogue has taken place, many mental health clients have reacted negatively to the news that there was never any reason to believe that depression was caused by a serotonin imbalance.
Many mental health clients find it unacceptable, and perhaps a violation of ethical informed consent, for clinicians to give patients metaphorical explanations for their mental health problems and promote them as scientific truth.
Patients who start an SSRI because they have been told it will correct the chemical imbalance, that it is like thyroid medication for hyperthyroidism are likely to eventually conclude that they have simply not been told the truth.
Previously we argued that misleading consumer advertisements for SSRIs should end (2005).
A decade later the serotonin theory of depression is acknowledged to be dead and most SSRI advertising campaigns are now part of history....(...) we encourage our colleagues in organised psychiatry to work towards this end by improving medical education and ongoing training, by endorsing shared decision-making, and by ensuring that informed consent is based on the scientific literature.