© Bruce Rolff | 123rf.com

There is a curious phenomena within the debate over the evidence base of psychiatric drug treatment, namely whether psychiatry itself ever promoted or supported the chemical imbalance theory. Ronald Pies, an emeritus editor for Psychiatric Times, has repeatedly claimed that the chemical imbalance theory “was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.” Further, Pies said that to his knowledge, “No professional psychiatric organization has ever publically promoted a ‘chemical imbalance theory’ of mental illness in general.” But it seems his statements are incorrect.

The two above quotes by Ronald Pies were from blog articles he posted on the Psychiatric Times website in “Psychiatry’s New Brain-Mind and the Legend of the Chemical Imbalance,” and “Serotonin: How Psychiatry Got Over Its ‘High School Crush’”.  He claimed “the ‘chemical imbalance’ trope” has been used by the opponents of psychiatry and erroneously attributed to psychiatrists themselves. Yet Robert Whitaker commented in his response to “Serotonin: How Psychiatry Got Over Its ‘High School Crush’” that it is quite easy to find numerous instances where prominent psychiatrists, including leaders of the APA [American Psychiatric Association], informed the public that “mental illnesses—such as depression or schizophrenia—are not ‘moral weaknesses’ or ‘imagined’ but real diseases caused by abnormalities of brain structure and imbalances of chemical in the brain.” This quote was in a 2001 Family Circle article, “Unlocking the Brain’s Secrets,” by the president of the APA, Richard Harding.

Another example given by Whitaker was in a 2005 brochure published by the APA, “Let’s Talk Facts About Depression.” In the section “How Is Depression Treated?” it says: “Antidepressants may be prescribed to correct imbalances in the levels of chemicals in the brain.” In 2005 APA press release, “Mental Illness Stigmas Are Receding, But Misconceptions Remain,” the results of an APA survey indicated that although 75% of consumers believe mental illnesses are usually caused by a chemical imbalance in the brain, they are more likely to consult a primary care physician rather than a psychiatrist—“a specialist specifically trained to diagnose and treat chemical imbalances and other determinants of mental illness.”

Whitaker’s thesis is that since the publication of the third edition of the DSM in 1980, the APA has been committed to the position that mental disorders are diseases of the brain; and that drugs for those diseases are safe and effective. “The chemical imbalance story comprised the heart of this disease-model narrative: Psychiatric researchers were discovering the pathology of mental disorders, and its drugs fixed that pathology, like insulin for diabetes.”  He sees this narrative as serving psychiatry’s interests as a guild.

• It told of how its disorders in DSM III had been “validated” as real diseases.
• It told of a medical specialty that was making great scientific progress, which elevated its power and authority in our society.
• It told of a medical specialty that had a product—e.g. drugs—that was of great worth in treating those diseases.
• Most important of all, this narrative provided a reason for psychiatry, as a medical specialty, to have authority over this part of our lives.

Whitaker said our society has responded to this narrative by organizing itself around it, and assuming it is the legitimate “story of science.” In “The Scientism of Psychiatry,” Sami Timimi said this tendency has led mainstream psychiatric literature to prefer rhetoric to scientific accuracy. Psychiatric research and discourse, according to Timimi, “are now dominated and infected by scientism — the promotion of a belief … that because what you do and talk about sounds and looks like ‘science,’ it is ‘scientific’”.

In “What Is Scientism?” Thomas Burnett said philosopher Tom Sorell defined scientism as putting too high a value on natural science in comparison with other branches of learning. A more precise and extreme definition by physicist Ian Hutchinson was also quoted from his book: Scientism: Philosophy and the Infatuation with Science: “Scientism is a matter of putting too high a value on natural science in comparison with other branches of learning or culture.”  Hutchinson also said the health of science was jeopardized by scientism.

Burnett gave a brief history of scientism up through the logical positivism embodied in The Vienna Circle. “In this system, there are only two kinds of meaningful statements: analytic statements (including logic and mathematics), and empirical statements, subject to experimental verification. Anything outside of this framework is an empty concept.” However Karl Popper pointed out there were very few statements that could be completely verified in science. “A single observation has the potential to invalidate a hypothesis, and even an entire theory.” So he proposed that instead of experimental verification, “the principle of falsifiability should demarcate what qualified as science, and by extension, what can qualify as knowledge.” Timimi noted how this has been incorporated into scientific methodology as a process of rejecting or disproving the null hypothesis.

Science uses a methodological approach involving hypothesis generation and then testing the hypothesis through empirical methods. The best scientists can live with and accept uncertainty as a prerequisite to being objective in the pursuit of knowledge. Knowledge develops and builds through generating a hypothesis (often using results from previous research) and then carrying out an investigation aimed at proving that something called a ‘null hypothesis’ can’t be true. The null hypothesis is a general statement or default position that there is no relationship between certain measured phenomena. Rejecting or disproving the null hypothesis — and thus concluding that there are grounds for believing that there is a relationship and the actual hypothesis may be true — is a central task in the modern practice of science.

He then said one of the major problems with the current concepts used in psychiatry traces back to the basic assumptions on which much of psychiatric research rests. In order to scientifically evaluate a proposition that there is a natural category of dysfunction/disorder, we must start with the null hypothesis. Until proven otherwise, there is no characteristic relationship between what we are investigating (put the disorder of your choice here) and some measurable biological/neurological feature. “This is a foundational assumption behind the development of knowledge through the scientific method.” ADHD, Depression and essentially all other psychiatric disorders fail to meet this standard. “Until we have demonstrated that this basic null hypothesis can’t be true, then scientifically, we cannot proceed with research that assumes that ADHD [or any other diagnostic category] as a concept has explanatory power for the behaviours it describes.”

Mainstream psychiatry has been afflicted by at least two types of scientism. Firstly, it parodies science as ideology, liking to talk in scientific language, using the language of EBM [evidence based medicine], and carrying out research that ‘looks’ scientific (such as brain scanning). Psychiatry wants to be seen as residing in the same scientific cosmology as the rest of medicine. Yet the cupboard of actual clinically relevant findings remains pretty empty. Secondly, it ignores much of the genuine science there is and goes on supporting and perpetuating concepts and treatments that have little scientific support. This is a more harmful and deceptive form of scientism; it means that psychiatry likes to talk in the language of science and treats this as more important than the actual science.

Contrasting medical and psychiatric diagnosis, Timimi then said:

In medicine, diagnosis is the process of determining which disease or condition explains a person’s symptoms and signs. Diagnosis therefore points to causal processes. Making an accurate diagnosis is a technical skill that enables effective matching of treatment to address a specific pathological process. Pseudodiagnoses, like for example ADHD, cannot explain behaviours as there are only ‘symptoms’ that are descriptions (not explanations) of behaviours. Even using the word ‘symptom’ may be problematic, as in medicine ‘symptoms’ usually refers to patients’ suffering/experience as a result of an underlying disease process and is therefore associated in our minds with a medical procedure leading to an explanation for the ‘symptom.’ But psychiatric diagnoses do not explain symptoms.

Using ADHD as am example, Timimi said once we start interrogating basic assumptions like the validity of psychiatric diagnoses, it should be easy to see that much of the psychiatric literature is built on assumptions lacking validity. Since ADHD is a descriptive classification and not a medical diagnosis, we have no reliable empirical method for defining what qualifies as a case of ADHD. Determining what qualifies as a case of ADHD is then arbitrary and depends on the standards used by the person doing the diagnosis, “influenced by whatever prevailing ideology concerning diagnosis they have been exposed to.” So as a consequence, we cannot eliminate wide variation in ‘diagnostic’ practice.

Timimi said in Western culture, science has become a cosmology—“an ideology/faith that believes that science has an undeniable primacy over all other ways of seeing and understanding life and the world.” This makes us vulnerable to scientism. He suggested psychiatry keeps faith in scientism despite its flaws because of the value we place in our culture on technology and technological achievement; and because, “this connects with that broader ‘cosmology’ that wants to use ‘science’ to explain everything.” In order to have credibility and leverage in our society, “we are inclined to use technological/scientific-sounding language.” Michael Foucault and others have pointed out, “this is how institutional power builds up and get authority to create ‘regimes of truth’.” Robert Whitaker said if psychiatry is ever going to reform itself in a way that will serve the public, “rather than its own guild interests,” it has to confront its past.

Why did it tell this false narrative—of drugs that fixed chemical imbalances in the brain—to the public? Perhaps then it could understand that its duty, as a medical specialty, is to tell a narrative to the public that is consonant with the relevant science. If that were so, then the public would be hearing that the biological causes of psychiatric disorders remain unknown, and that its drug treatments are of marginal efficacy over the short term, and that over the long-term, outcomes for medicated patients are very poor.