Nuances, Narratives, and 'Chemical Imbalance' in Psychiatry

A Biopsychosocial Balance

Psychiatry's critics also conveniently omit reference to what was arguably the most prevalent paradigm in academic psychiatry, during the 1980s and beyond: the biopsychosocial model (BPSM) of Dr. George Engel.^[6] The BPSM has been subjected to much criticism, and some would argue that few psychiatrists nowadays use the BPSM in a systematic, evidence-based manner.^[7,8] And in recent years, several prominent psychiatrists have warned that "...pharmacotherapy and psychotherapy, the major treatment modalities in psychiatry, have become fragmented from one another, creating an artificial separation of the psychosocial and biological domains in psychiatry."^[9]

These are worrisome observations. But one thing is beyond dispute: The BPSM can hardly be reduced to a chemical imbalance theory of mental illness. As far back as 1991, in my book on psychotherapy for the general public, I wrote, "In recent years, the "biopsychosocial" model of mental illness has gained prominence. This holds that mental problems have biological, psychological, and social roots. Therapy may therefore involve treatment in all three spheres."^[10]

I was far from the only psychiatrist promoting the biopsychosocial model -- and none of my academic colleagues, to my knowledge, publicly endorsed a simplistic chemical imbalance model as a blanket explanation for all mental illness. Indeed, over 20 years ago, the late Dr. Theodore Nadelson -- one of my teachers and a highly respected psychiatrist -- wrote the following in his foreword to my 1994 biopsychosocial textbook on psychiatric diagnosis and treatment^[11]:

Neuronal tissue grows in response to its environment at least as much as it is obedient to any lockstep process choreographed immutably by the "gene machine." We are creatures in nature, but we create our own nature.... If we are to understand patients and, as doctors, to help them, we require the broadest base.... [In addition to biological research] we should also pursue greater understanding of the psychological and social environment. That task is further informed by literature -- poetry, philosophy, theater. That is our "biology" also.

Ted Nadelson understood that the brain is the crucible in which all the elements of human life intermingle, including our genetic makeup; our brain chemistry; and the influences of parents, culture, ethnicity, and even diet. Derangements, deficiencies or abnormalities in any of these biopsychosocial elements can lead to what we call, for lack of a better term, mental illness, which often represents the end result of innumerable interacting "pathogens."

Thus, in the introduction to my 1994 textbook, I wrote that "...the central assumption throughout the text is that the clinician must be able to integrate the complex biological, psychological and sociocultural data of the case at hand."^[11] Most well-trained psychiatrists, in my experience, have always understood this need and done their best to fulfill it in practice.

The Nobel Prize-winning psychiatrist and neuroscientist Dr. Eric Kandel observed that "...all mental processes, even the most complex psychological processes, derive from operations of the brain...as a corollary, behavioral disorders that characterize psychiatric illness are disturbances of brain function, even in those cases where the causes of the disturbances are clearly environmental in origin."^[12] But in practice, Kandel is no biological reductionist. He is certainly no fan of a chemical imbalance hypothesis! Rather, Kandel paints a picture of the new psychiatry, in which psychoanalytic and biological constructs complement and reinforce one another.

It is time for psychiatry's critics to drop the conspiratorial narrative of the "chemical imbalance" and acknowledge psychiatry's efforts at integrating biological and psychosocial insights.

Editor’s Note: A slightly shorter, modified version of this piece originally appeared on the Psychiatric Times Website.

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