Chemical imbalances or problems in living? You don’t decide! by H. Spandler

A new study might signal the final nail in the coffin of the ‘chemical imbalance’ theory of depression. This new review of existing studies has concluded the idea that low levels of serotonin cause depression does not stand up to scrutiny.

Serotonin is a chemical transmitter that appears to play a role in governing mood and emotions. Most antidepressants are selective serotonin reuptake inhibitors (SSRIs). Therefore, SSRIs were originally said to work by correcting abnormally low serotonin levels. There have been significant doubts about this theory for some time, but this is the first study to pull together all of the available evidence.

The lead author of the recent review, Joanna Moncrieff, Professor of critical and social psychiatry at UCL, said:

“It is always difficult to prove a negative, but I think we can safely say that after a vast amount of research conducted over several decades, there is no convincing evidence that depression is caused by serotonin abnormalities, particularly by lower levels or reduced activity of serotonin…The popularity of the ‘chemical imbalance’ theory of depression has coincided with a huge increase in the use of antidepressants…

Thousands of people suffer from side-effects of antidepressants, including the severe withdrawal effects that can occur when people try to stop them, yet prescription rates continue to rise…We believe this situation has been driven partly by the false belief that depression is due to a chemical imbalance. It is high time to inform the public that this belief is not grounded in science.”

The reaction of the psychiatric profession has been somewhat contradictory, with some psychiatrists arguing that “no one takes this hypothesis seriously anymore anyway”, whilst others claiming that “it’s premature to dismiss it”. It seems clear that this latest in a long line of biological explanations for our mental distress needs to be de-bunked once and for all. So, I’m pleased to see this report getting the wide media coverage it deserves. However, whilst the authors of the report have been very careful about communicating its findings, I’m a bit concerned about the media’s enthusiasm for reporting, especially in the current political context, and the desperate clamour for similarly simplistic alternative explanations.

Depression is hugely complex and can involve a complex interplay of social, economic, political, cultural, spiritual, and biological factors (for example, there is growing evidence about the links between underlying, often undiagnosed, inflammatory and auto-immune conditions and depression). Notwithstanding this, it seems abundantly clear that life events and circumstances are the main factors involved in most people’s experience of depression. This is reflected in recent calls for a shift from asking ‘what’s wrong with you?’, to ‘what’s happened to you?’ and is often reduced to catch-all terms like ‘problems in living’.

Unfortunately, whilst these phrases encompass more than ‘chemical imbalances’, they can have other negative effects – appearing to minimise suffering and inadvertently blaming the individual for bad lifestyle choices. Why, neoliberals might ask, should the NHS support people’s ‘problems in living’? Thomas Szasz, who originated this phrase, didn’t think it should: he said people should take responsibility for their own mental health and pay privately for individual psychotherapy. Whilst most modern proponents of ‘problems in living’, at least in the UK, strongly disagree with this, it’s not difficult to see how neoliberal Governments could mis-use its message. It’s perhaps not surprising that some survivors have experienced this discourse, when coupled with wider welfare attacks on disabled people, and shrinking service provision, as ableist.

Many global right-wing news outlets have greeted the new report with great enthusiasm. For example, The Times ran with the headline ‘Low serotonin causing your depression? This man says it could be your life instead’. This could be read as: ‘Thought you had a mental illness? Maybe it’s just you!’. Or, in other words, ‘Poor employment or an abusive relationship? Get another job or find another relationship!’ Whilst this may not have been the authors intended message, it’s difficult to ignore the fact that these are the same newspapers that attack benefits claimants and refugees, mobilise transphobia, and deny climate change – all of which negatively impacts our mental health. Moreover, in the US, these news outlets frequently platform right wing Republicans who blame psychiatric medications, especially SSRIs (and mental illness), for mass shootings, shifting the focus away from gun control.

Of course, the idea of ‘problems in living’ tends to be a shorthand for much more complex and nuanced understandings. But psychiatrists said the same about ‘chemical imbalances’ – that it was a shorthand for a set of complex biopsychosocial mechanisms which had been oversimplified and misunderstood. Perhaps it is inevitable that complex messages get boiled down to simplifications in practice. But surely we need to be vigilant about the way these messages can be used as another stick to beat us with. Remember the enthusiasm that greeted the modern ‘recovery’ movement? Early proponents wanted to challenge the damaging idea that people with ‘serious mental illness’ would be unlikely to lead meaningful and productive lives. However, under neoliberal austerity, what had its roots in therapeutic optimism became a justification for therapeutic neglect – or what activists in Recovery in the Bin have termed ‘neo-recovery’.

There is increasing evidence that trauma, rather than a chemical imbalance, underlies much of our mental distress. So I wholeheartedly welcome the move to more trauma-informed care, especially as the history of the mental health system is one of coercive, and often (re)traumatising, ‘care’. However, whilst there are plenty of good examples of trauma informed care, it can also be mis-used and over-simplified in practice. For example, in a recent post on the excellent Psychiatry is Driving me Crazy blog, the author eloquently recounts being refused the diagnosis, medication and support she felt she desperately needed during a crisis – in the name of ‘trauma informed care’. This is, unfortunately, not an isolated example.

Replacing the question “what’s wrong with you?” with “what’s happened to you?” might have been intended to shift focus onto the central importance of life events in causing distress. However, in practice, it often merely shifts the search for the ‘underlying causes’ away from internal factors (chemical imbalances) and onto external events (traumatic events). Whilst there is actually a hugely complex relationship between trauma and its effects on the mind, and the body, we are left with a simple binary – either something is ‘wrong’ with you, or something ‘happened’ to you. What if nothing is wrong with you, but nothing (specific) happened to you either? What if your struggles are caught up, in complex ways, with who you are and who you’ve become? This question could point to a neurodiverse/Mad Pride perspective which has been advanced by mad, neurodiverse and trans activists for whom psycho-social explanations, as well as psychiatric ones, have historically been used to pathologise and ‘treat’ us.

Let’s be clear. I’m not suggesting that we simply replace our current understanding with this either. Any singular causal explanation is problematic, particularly if the narrative itself is outside of the individual’s control, and especially if it is imposed on us under social conditions over which we have little control. If we must reduce complex issues to simple practical guidelines – and I’d much prefer we didn’t – maybe ‘what matters to you?’ would be preferable. At least that potentially leaves the person more in control of their narrative.

In the meantime, it appears we are left with two prevailing ideological tropes – the bio-psychiatric (‘chemical imbalances’) and the alternative (‘problems in living’). Both betray the complexities of our lives, the relationships we have with our bodies, the worlds we inhabit and the substances we use. Plenty of people report both benefits and harms from SSRIs, and whilst Moncrieff’s study concludes that there is insufficient evidence that SSRIs correct ‘serotonin imbalances’, it cannot be used to conclude that any improvements are simply due to ‘placebo’ or ‘numbing’ effects either. Although those factors probably play a crucial part in any effects, that explanation would effectively undermine our agency and suggest that we are passive dupes of Big Pharma. We rarely understand the mechanisms involved in the drugs that we routinely take for many physical ailments, and they don’t always tackle underlying causes either. The problem isn’t necessarily that antidepressants are prescribed or used, but the ideological weight that has gone into pretending otherwise (and, of course, the massive over-reliance on these medications in society).

So, while Moncrieff et al.’s study is hugely welcome, it inevitably begs more questions than it answers. Moreover, it offers little comfort to people who have been misinformed about the causes of their distress, who feel they need antidepressants, or have little access to alternatives. Sadly, ideologically driven debates in the media often take place at the expense of people trying to survive as best they can in the here and now. Yes, we need wholesale change in the way we understand and provide mental health support. And we need to radically change society. But, in our attempts to achieve that, let’s not replace one simplistic trope with another. Neat soundbites might sell books and newspapers, but they are not good guides for mental health practice.

I suggest we need to:

• Consign the ‘chemical imbalance’ theory of depression to the dustbin of history whilst avoiding overly reductive alternative explanations.
• Understand how the ‘chemical imbalance’ narrative came to dominate public discourse, despite the lack of evidence to support it.
• Investigate the impact of the ‘chemical imbalance’ narrative – especially on patients and on public understanding.
• Highlight societal causes of rising rates of depression (and other mental health conditions).
• Have a more honest discussion about society’s over-reliance on SSRIs (and other psychiatric medications).
• Investigate the long-term effects of SSRIs and take seriously feedback from people who feel they been helped and harmed by them.
• Campaign for adequate and meaningful support for people who wish to reduce or come off SSRIs.
• Create suitably complex, meaningful and sustainable alternatives – prioritising service user’s choice and control – both of medication use and the narratives around them.

H. Spandler is the managing editor of Asylum.

This is a sample article from the Autumn 2022 issue of Asylum (29.3).  Subscribe to Asylum magazine.