The "chemical imbalance" theory has been in existence for at least 5 decades, and over the last 2 decades has been the primary rationale for use of antidepressants, mood stabilizers, antipsychotics, and other powerful psychiatric drugs. The prevailing message is, "You need this drug to manage a chemical imbalance in your brain." Media shows, advertisements to the public, articles in professional medical journals, continuing education programs for doctors, and drug information pamphlets all refer to these ideas as if they were established scientific fact. How reliable are these messages, and how much should they affect our choices about how to manage depression?
After several months of careful research and study, here are some answers I found to several commonly asked questions:
First, How well supported is the chemical imbalance theory in the current scientific research?
Second, Is it helpful or unhelpful to clients to believe the chemical imbalance theory?
Third, What are the pros and cons of antidepressant use, as they're understood in current scientific literature?
Finally, What alternatives for depression treatment exist?
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First, How well supported is the chemical imbalance theory in the current scientific research?
The answer to this question was shocking - but consistent - "Not at all!" In book after book, article after article, over the past five or so years that I've been studying this topic, I have not encountered one shred of solid evidence for this theory. In fact, the only places I could find support for the theory were on commercial websites and advertisements promoting antidepressants and other psychiatric drugs.
Given the prevalence of this theory, I was stunned to find how many researchers, doctors, psychiatrists, investigative journalists, scientists, counselors, and other professionals have come out publicly declaring their opposition to it. If you browse the Bookstore, in the "Chemical Imbalance?" section, you will see what I mean. Or check out the Article List I posted in 2011, with clickable links drawn from professional medical journals and websites. Over and over , you find expressions of outrage over the lack of scientific proof for this broadly-marketed, widely-promoted idea.
Interestingly, over the past decade, the loudest critics of the theory have been those from the medical, psychiatric, and scientific communities. The antidepressant ads often claim that "Scientists believe that depression is caused by an imbalance in the brain." This is simply inaccurate, and it's important to learn what the actual scientists are saying. It is a very different message than the multi-billion dollar advertising industry might have led you to believe. Study these resources for yourselves, and consider: Just because an idea appears six times a day on television doesn't mean it's true. It just means it's been paid for.
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Second, Is it helpful or unhelpful to clients to believe the chemical imbalance theory?
This is a significantly important question. For some clients, the theory gives them a sense of hope - that there is a reason they feel so bad, and that it isn't their fault, and that somebody out there knows how to help. On the other hand, the theory can distract these individuals away from addressing the core causes of their distress. Expecting the drug to "fix the problem," they often fail to address lifestyle habits, relationship issues, problem beliefs or behaviors, or other factors contributing to their distress. They may sit passively by and "wait for the drug to work," rather than taking action themselves to fix what's wrong. This can lead to a psychological, if not physical, dependence on the drug - "The only way I know how to manage my life is by taking this drug." Ultimately, that can become a frightening, anxiety-producing condition.
My experience as a counselor of nearly 25 years is - If clients choose to take medication for symptom relief, that may be an appropriate, time-limited option to help them get back on their feet. But it is never the answer to the whole problem. Unless clients identify and resolve the underlying issues that are feeding their distress, the problem will continue. And more often than not, side effects of the medications will kick in, producing new challenges in addition to the challenges they started with. Often this begins a whole new battle of finding new medications to counter or amplify the effects of the original one. Medication itself can become part of the distress - and meanwhile, the original causes for the distress remain unexplored and unresolved.
Whether or not clients choose to include medication in their treatment regimen, I urge them not to buy into the "chemical imbalance theory." The idea that the only cause of their depression is "chemical imbalance" (an idea disproved, not proved, by actual scientific research), and that the only way to correct this "imbalance" is continuous reliance on a commercial product, is ultimately disheartening, disempowering, and discouraging. It cannot help but get in the way of actual recovery - largely, because a "chemical imbalance" is seen as a permanent, pervasive condition - you don't even expect to recover from such an "imbalance." That negative expectation often becomes a self-fulfilling prophecy - people "manage" their symptoms, but don't expect to get better - and they don't. This works for the drug companies, keeping their sales consistently high (which is why they push this disempowering model.) But it doesn't work for the people that buy into it.
There are better, more hopeful models, and they work better to correct depression, short-term and especially longterm. So, even if you choose to use medication for symptom relief today, don't buy into an idea that can keep you psychologically dependent for a lifetime.
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Third, What are the pros and cons of antidepressant use, as they're understood in current scientific literature?
There is no question that antidepressant has brought relief of depressive symptoms to thousands of users - hence their popularity. There is no question that they produce their initial effects more quickly than many forms of therapy. So, when symptoms become unmanageable, or when short-term, immediate results are of prime importance, antidepressants can be a choice to consider - not because they "correct imbalance" - because there is no evidence that this is the case - but because they do seem to take the edge off of symptoms for many users.
However, this potential benefit has many strings attached. First and foremost, any chemical product brings side effects. Some are noticeable early on; some aren't observed till later. Some side effects end up being more distressing than the original condition itself. Second, financial costs. In an environment of diminishing insurance benefits, many people are finding health care costs to be an increasing burden - both on themselves, and on the general culture. Antidepressant costs have become the number one medication cost in the U.S. - in our nation we consume 70% of all antidepressants sold in the world. This is contributing heavily to the health care costs that weigh on our increasingly stressed economy - in addition to the financial burden it places on individual and family budgets - especially since the ongoing cost of doctor visits accompany medication costs themselves.
Third, withdrawal effects. When people start feeling better, it is appropriate for them to withdraw from the medication. The official recommendation for the duration of a antidepressant treatment is six to eighteen months. However, when people go off these drugs, some find ugly surprises. They may be confronted with withdrawal effects that may be even more severe than their original symptoms before going on the medication. This is especially true if they withdraw too quickly - a tapered withdrawal over time, under physician supervision, is always the wisest course. Some patients and doctors conclude that it's "safer" to just stay on the medication indefinitely. But over time, this adds to the cumulative side effects and financial costs mentioned previously.
In light of all this, in my own practice, if clients arrive at my office medication-free, I most often encourage them to remain so, as we focus on other strategies for managing their distress. If they're already on medication, I encourage them to remain on it, without changing their dosage, while they're learning other strategies and skills - then to withdraw gradually, under the supervision of a qualified physician, and with plenty of support from family, friends, and books that teach them what to expect.
Most often, I find the whole treatment process to be shorter and more effective without involving medication. When people are in touch with their own distress, they are more motivated to work hard to address core issues to overcome it. And there is no "medication withdrawal" to navigate through at the end of the process. However, there are instances when symptoms are so severe that some medication intervention is the best option for a time. But this must never become a "solo intervention," nor should they buy into the "chemical imbalance" mentality - otherwise, the condition is much more likely to become chronic.
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Finally, What alternatives for depression treatment exist?
There are many of these - though none of them have the visibility that advertising dollars buy for the pharmaceutical approach. Some of my favorites are:
1) Lifestyle approaches - These can be done with or without professional supervision. Improving nutrition, engaging in regular exercise, going to bed and getting up early, building strong relationships with others, engaging in service to others, and strengthening spirituality are just a few of the research-supported approaches to overcoming emotional distress. There are no prescription costs - no visits to the doctor or pharmacist required. If needed, professionals can offer short-term support and guidance, helping you fine-tune your program to get the most effective results. Many books, articles, and websites contain crucial guidance in these areas (many of them are referenced in this site.) But by and large, lifestyle management is something you can begin and carry out for yourself - free of charge, with great effectiveness.
2) Cognitive therapy - In or out of therapy, this approach has been shown to be tremendously effective in battling depression - as effective as medication short-term, and far more effective longterm. This is approach teaches you to recognize the negative thoughts or "cognitive distortions" that contribute to depression - and learn to replace them with more effective, positive thoughts. You can learn this from a professional counselor, or even out of a book. David D. Burns cognitive therapy classic, "Feeling Good: The New Mood Therapy" has been shown in research to be remarkably effective, even if people just read the book and do the exercises outlined there. Other books can also be helpful in teaching you this crucial, helpful method. Even if you're already in therapy and/or on medication, you can get better, faster, more enduring results by incorporating this wise and helpful strategy. Check out the Bookstore, under the category "Healing Depression," to find "Feeling Good" and other helpful books on this topic.
3) Relationship therapy and/or trauma resolution therapies - Frequently, depression is triggered by distressing realistic events - whether current (such as a conflicted marriage, or a power struggle with a child) or past (such as a history of abuse or parental divorce.) Managing symptoms by medication approaches 1 and 2 above tends to be insufficient when dealing with such issues. Unless you resolve the triggering situation (past or present) your distress will continue - no matter how much "symptom management" (chemical or non-chemical) you pile on. These kinds of issues are challenging enough, in many cases, to require professional help. Whether mild or severe, relationship or trauma issues can be greatly helped by self-education. Visit the Bookstore for many helpful titles on a range of relevant topics.
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Conclusion: There are better theories, and better helping strategies
After five decades of attempts, research scientists have been unable to find any direct physical evidence for the chemical imbalance theory - yet it continues to be marketed as established scientific truth. Depression is often likened to diabetis, and antidepressants to insulin. The difference is - insulin is a known and measurable substance. You can very quickly know what your insulin levels are, and take action to remedy them. There is no similar process with brain chemicals. There is no way to objectively check levels of serotonin or any other substance in a living human brain. Even if you could, research has not been able to determine any kind of "optimal level" for serotonin or any other neurotransmitter. Studies in which serotonin levels are directly manipulated have not shown any direct correlation to mood change. So chasing "the magic bullet" - a chemical solution to a complex emotional problem - has not proved to be successful for most people.
In contrast, many helpful, effective, and research-supported strategies have been developed over the last several decades - strategies that empower people, from the inside, to discover the causes of emotional distress, and to resolve them. This website exists largely to make you aware of these alternative strategies that you can use to find relief for yourself, a loved one, or (if you are a professional) a distressed patient or client. More information will be added soon to this site. In the meantime, it is hoped that the resources available here and elsewhere can help bring relief, hope, and direction to the many who struggle with emotional distress.
-- Carrie M. Wrigley, LCSW - 3/17/2011
