395. Is depression just a chemical imbalance?

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Speaker 1: Hello everybody. I'm Jemma Spake and welcome back to the Psychology of Your Twenties, the podcast where we talk through the biggest changes, moments, and transitions of our twenties and what they mean for our psychology. Hello everybody, Welcome back to the show. Welcome back to the podcast. It is so great to have you here back for another episode. Today, I have a bonus episode for you guys, and if you are new around here, let me tell you about our bonus episode. So our bonus episodes are our little shorter, sharper, more focused episodes that we do on a singular term, a singular theory, a singular idea that you may have heard thrown around to do with psychology, to do with mental health, something that gets a lot of traction online, but perhaps you never see properly discussed. This is like my chance to just dive into the research for you guys and for myself. And today we have a significant one. We are talking about the theory that depression is just a chemical imbalance. Is that really true or is it a little bit too simple? A lot of how we approach depression, think about depression is based on this biological model, but there are definitely parts of it that are no longer accurate and that we know are no longer accurate as we kind of gain more medical understanding. So that is what we are going to talk about today. A quick disclaimer, please do not take this as medical advice. A lot of our discussion today does have implications for things like antidepressants. I'm on antidepressants. I literally just took my like five minutes go. They help me. I will continue to stay on them, and I do believe they work. You know, some articles that we're going to cite today are skeptical of that, but as always, you know, what works for you might not work for everyone. If you are on antidepressants, if you are considering it, always talk to your doctor before starting or stopping this kind of medication. Just want to put that in here, because yeah, you know, this discussion does have some big implications for that, and I don't want anybody to be making rash decisions around thirty minutes of audio. So with that being said, let's get into it, starting with what do we actually mean by depression is a chemical imbalance? This is widely believed to be to be quite an outdated description actually these days and yet it is still used all the time. But when people say this, what they actually mean is the idea that depression and happens because your brain doesn't have enough of certain neurotransmitters, especially serotonin, and therefore increasing the balance or the level of that neurotransmitter will correct the deficiency and will eliminate depression. Neurotransmitters just for a very quick biological refresh. Other brains chemical messengers, your brain cells, your neurons. They don't actually touch each other directly. They communicate across these tiny gaps to stop electrical signals from interrupting each other. And the things that pass through those gaps and pass on messages are your neurotransmitters. So they influence everything from mood to motivation, sleep, appetite, attention, stress response, everything that is going on in your body at any given moment. As I've mentioned, one transmitter you will hear constantly in these conversations is serotonin. Serotonin is a chemical messenger involved in so many processes. I think a lot of people just think of it as the happiness drug or the happiness chemical, but it affects everything from mood to sleep, to appetite to emotional regulation. Those things have a correlation with happiness, which is why yeah it or gets yeah, it's why it gets that simplistic definition of like this is the happy chemical or dopamine often gets cided as that as well for the same reasons. So this is how the biological story of depression came to be. Serotonin controls mood. Mood controls happiness. Depressed people aren't happy, Therefore, working in reverse, someone who is unhappy and with the low mood must have disturbances in serotonin. Therefore, artificially changing or influencing serotonin availability will improve depression. Because this is, at the end of the day, just a bio logical shortage problem. When did this theory actually first come to be? Because I feel like now it's just taken for granted. I was literally like my dad says this all the time, like it's just a chemical imbalance. We just take it for granted, whether it is correct or not. To understand this, you have to look back to the fifties and sixties when there was this huge medical push to basically create a drug for every condition, and doctors started noticing during this process kind of by accident, that certain drugs developed for completely different reasons were affecting mood. Drugs for like what treatment, drugs for epilepsy, drugs for hair growth, just like anything you can think of. They started noticing that it was also changing how people felt. There was a really notable review paper from this man called Shinderkraut in nineteen sixty five, who was kind of the first one to be like, hey, maybe this is saying something, Maybe some depressions could be linked to a deficiency in certain chemicals. And he concluded this based on his study of animals alone, because back then this theory was quite an experimental one that he was doing. And also that's normally the first stage of any theory that wants to have like pharmaceutical implications, like you test on animals. But at that time, like I said, it was not controversial, it was just different. It was just a different idea, And so it led researchers to focus on one group of neurotransmitters in particular called monoamines. Monoamine monoamines, I should say plural is just a class of neurotransmitters that include things like serotonin, like neuropinephrine, and like dopamine, And they concentrated on all those as kind of one. In a way, this became the monamine hypothesis. You probably you may have heard about this, but it was basically the earliest biological theory of depression. Depression is because of a disruption in chemical messenger systems. Fast forward over a decade. I guess a decade, yea a decade. In nineteen seventy five, the first big, big paper came out about a drug called fluoxetine, which is still on the market today and worked by it works still by increasing serotonin in the brain of rats, of people by preventing the reuptake of serotonin. So basically how our brain cleans up and gets rid of serotonin that's sitting in the signapps. That's like the simple way of putting it. This drug became so popular, so popular almost instantly, probably because like the other treatments for depression at that time were not amazing. They weren't that great. Yeah, they just weren't. They weren't great. So prozac floxatine just like hit the market running and also started being kind of like recommended for heaps of other things. So like, yes, major depressive disorder, but then also OCD, panic disorder, eating disorders as well, anything that people believed came down to mood and our attempts to or inability to regulate our mood or regulate things that, you know, any behaviors that we use to try and regulate our mood that were becoming problematic or whatever. Like, they basically just were like, this is the one you just you grab you, you get on this, and you're gonna be feeling so much better. So this is when the public narrative became that simplified version of depression is just a chemical imbalance, because now there was this drug, like this cure that could just in their words, like eliminate all those dark bad thoughts, like those dark bad feelings that people felt a lot of shame towards that I guess also yeah, really impairing people. It all came down to this really simple equation, there isn't enough of this one thing in your brain. We increase it, you will feel better. And that's really reassuring to a lot of people, and it's easy to deliver. Like in a healthcare perspective, you know, if you're a GP, if you're a doctor, if you're a psychologist, psychiatrist, whatever, and you've got a short amount of time with a patient. You've got a waiting room full of people who are really struggling this this idea that you can give somebody this tablet and that's going to make them feel better. It is a great one and it's one that people really want to hang on to. Obviously, a two thousand and five paper from researchers in the US actually later analyzed as well how antidepressants were marketed to the American public when they first came out, and they argued that a lot of these campaigns really pushed the use of antidepressants by basically again using this chemical imbalance message, and that marketing was really significant in how a whole generation in the generation after that of people including you and me, started thinking of this of this condition, started thinking of depression. So it wasn't plucked out of thin air, as I said, like it all came down to the first really promising treatment pathway and why that treatment pathway seemed to work. And the thing is, there are literally thousands of randomized trials that show antidepressants do work. They do work, they beat a placebo on average. But the problem is it is not the miracle drug that people think it is at least not for everyone, and the effects aren't as dramatic as maybe we've been led to believe if we kind of average out everybody's response. And this is where the skepticism around depression is just a chemical imbalance comes in. Basically, a drug is a great safety net, it is life changing, but depression is a three four five headed monster and taking medication only cuts off one of those heads. So our healthcare system does need to be providing more than what a biological approach would suggest. You've probably heard of this. There has been a major push recently around this prominent theory that the reason SSRIs work is basically because they are a place ebo. The biological model is not correct. It's just the idea that people are doing something for their mental health that improves their mental health. I don't personally believe that my thoughts about this are complicated. Let's just get into the evidence. So this theory really took the world by storm with the publication of this big paper in twenty eleven that seemed to conclude that in most cases, I think their estimate was like, in eighty percent of cases, what people are experiencing when their symptoms get better by taking an SSRI is purely the belief that, again, this medication is doing something that belief influences our perception of reality, and that perception and belief is what makes us feel better. This study, again was massive, it did look at so many people, but a follow up or I guess one a prior review showed that it's probably a little bit different. It is not that this many people are reacting to a placebo effect. It's that the real benefit comes and the real benefit can be seen based on severity first. So basically, this FDA review found that an SSRI offers more noticeable benefits for people with more severe depression, who are more likely to have a larger biological component, compared to people with milder presentations who may still have a biological component, but perhaps their depression is coming down to other things, and for them a placebo and an SSRI, the fake version and the real version might impact behavior and impact how they feel in similar ways. They also found that the reason why this is the case is because an SSRI isn't always acting directly on our mood. It's affecting things that are going to impact mood down the line. So another trial from twenty nineteen shows this really well. It looked at cetraleine cetraline for depressive symptoms and it found that in the first six weeks, like in under six weeks, if somebody was like, I feel amazing, it probably wasn't because of a biological of an immediate biological impact on serotonin levels. It was more so because it affected how they were able to sleep, It affected a sense of control over the depressive symptoms, It affected energy levels, It affected, yeah, their mindset, especially in that in that first part. What this is really coming down to, like the placebo effect, let's be real, is probably real for some people, like it probably is real, but not for everyone. And it's not just the placebo effect that's having an impact. That is one part of perhaps some people's experience with SSRIs, but it's also the fact that even if this drug doesn't act directly on happiness or directly on mood, it does act on all these other things that do make people feel better. And that if you have and I hate to say, like I hate to say mild depression, but that's kind of the clinical term. If you have mild depression, right, those things may be contributing more to your hopelessness and your sadness and your depressed state, then we think, and so taking those out and influencing them is what's making us feel better. Let's discuss this a little bit more, because I do have a problem with this theory. I have a big problem whether a drug is a plus ebo or not. Obviously, it is important because you don't want to put people on medications that are going to do that could impact them in other ways if they literally aren't impacting the primary symptom. But what I will say is that if it works for people who otherwise feel hopeless, is that really a bad thing? You know, thoughts are powerful. Taking a medication that impacts your ability to deal with your thoughts by providing you with a control mechanism is powerful. It's just another version of all these thought therapies, of all the ways that we try and change people's thoughts to change their coping b My other issue with the placebo theory is that you cannot take a theory as big and large as the biological theory of depression, a theory that supports one of the first and only lines of treatment for millions of millions of people who are suffering. You cannot take that theory, tear it apart and not offer another one. I think that is deeply callous and unethical. And this is my opinion. I think people are so quick to want to make a headline, to want to disprove a theory under the guise of helping people, and it actually leaves them feeling worse. Right, there has been this whole push recently, and it's a valid push right to be like, is the biological theory correct? Like is medication even really doing anything for people? Like what are we wasting our time on? And people are really quick to be like, it's not. This is my final conclusion. It's just a plus ebo, rip it to shreds, and it's like, so what else are you offering people? And don't say exercise, don't say diet, Like what else are you offering people with treatment resistant depression? Or what else are you offering? People who who have our own SSRIs find them to be life saving? And now are like, so do I not take this and go back to the way I was before? Like I think that's I think that's a really hard call to make. The same goes with people online like Now that this placebo theory has really gained legs, it's become a lot more prominent, a lot more accepted. People are now using it as a way to kind of shame people for health decisions. I made this post the other day, no, not the other day, a couple months ago, about how going on lexipo in my twenties was life changing, and it is. And there was this woman all up in arms in my comment section, being like, science has completely disproved this. Science says that, like, these drugs aren't doing anything for you, that's why I would never take them. And when I asked her, what would you suggest instead, she gave me some really pathetic answers, and it annoyed me so freaking much, and actually it made me really mad. Why come here, coming here to my page into my life in a way, interrogate my health choices, rip them apart, introduce a sense of hopelessness about the thing that has helped me, and then walk out like you've helped me without providing me with an alternative, without understanding my situation, Like that is cruel. That is cruel. And I think when we go to tear apout the chemical imbalance, biological model. We do have to think about that impact, So let's talk about that a little bit more after this shotbreak. Once the chemical imbalanced rhetoric became the dominant story, it not only changed like scientific research headlines, it also changed how people understood themselves, how families responded to diagnosis, how the healthcare system treated depression. And that has been really, really positive for a lot of people. The chemical imbalance framing made depression finally feel legitimate. If you grew up with a societal narrative that mental health was superfluous, it was an indulgent thing to pay attention to. Then hearing that depression has links to our literal brain chemistry can be immensely validating, and it brings a sense of relief by knowing you are actually unwell in a physical s sense. It also reduces this age old sense of blame that depression is something that you can choose, you can snap out of it. This model helped people realize that that is not the case. You cannot go into your brain and change chemical messaging, like that's not something that you're able to do. You were born this way. This is just who you are. So on a human level, like this story this chemical and balanced story gave people a bridge, gave people a language for suffering and for their condition that others could understand. And it also made medication and it made treatment feel less scary. It brought a lot of people out of the dark, a lot of people out of the you know, the hiding spaces of shame, and said we can help you, We can help you, this isn't your fault. And that has reduced stigma greatly. It's been an incredibly positive thing. There are some trade offs, though. As much as I don't like the placebo idea, I also think the prerely biological I don't know, I don't want to say, mindset approach belief hypothesis is also incorrect. And the reason I think it's problematic is because it's reduced a very huge, complex condition into a single, simplistic explanation which actually shrink and continues to shrink down the magnitude of people's experience with it. In a way. It confuses what the treatment changes with what caused the problem in the first place. SSRIs change serotonin signaling, that's true, but saying SSRIs affect serotonin, because serotonin is the reason that you are depressed is not entirely accurate. Just in the same way as paracetamol helps a headache, but it's not a lack of paracetamol that causes the headache is also true. It might be you know you need paracetamol, you have a headache because you're ill, because you didn't drink enough water, because you're hung over. The paracetamol still helps. The origin of the symptom isn't the lack of paracetamol. The same way the origin of symptoms may not be just a lack of serotonin. A lot of treatments work by compensating for symptoms rather than getting down to the underlying issue. And there are a lot of people who are depressed not because of brain chemistry or because brain chemistry, and then a bunch of other stuff on top of that. But it's not just this biological thing. It's an interplay of grief, trauma, loneliness, burnout, chronic stress, poverty, discrimination, life events. You know, a relationship that flawed them, a life without rest, a job hunting process that's been really terrible. The chemical imbalanced story can sometimes make those factors feel irrelevant and say like, oh, if we get you on this antidepressant, you will feel better. And sometimes that's why they don't work, because they cannot fix what lives outside the bloodstream. Medication can definitely reduce symptoms mood, anxiety, agitation, sleep, appetite, concentration, those sort of things, but it doesn't actually repair financial pressures, caregiving pressures, academic stress, workplace drama, loneliness, disconnection, an unhappy, unsafe relationship, a life that feels meaningless, people treating you badly in society. How can we claim that a tablet can fix all of that and call it a day. We can't. Literally, it just can't. It can help you with coping, it doesn't change what physically surrounds you. You know, sometimes depression is a signal that something isn't working in your life, and it cannot reduce those physical circumstances if those are the cause. And I say if, because yes, the biological model is valid on some front. But when we talk about another theory that probably makes more sense, right that theory that I was waiting for people to offer, I would say a social and development theory mixed with the biological theory is probably more accurate. You know this, like the interpersonal model cognitive models which say that our you know, the conditions that we have are shaped by our risk over time and by our internal and external environment over time. So yes, we have a biological vulnerability, but then include the fact that you were hurt as a child, then you had inconsistent parenting, then you had you experienced violence, or you had cheated on Then you couldn't find a job, then you you really struggled at uni at work, then you felt purposeless on top of all of that, plus you're broke again. Like, that's not just biology. You cannot medicate your way out of structural stress. We need to be focusing on that as well, and we also need to be focusing on even further research that talks about how a lot of people in modern day society lack a sense of purpose the way that they used to really have in what they were doing, in how they were living in their free time. There was a twenty twenty three meta analysis that found greater purpose in life is significantly associated with lower depression and anxiety levels. Having a sense that, like you mean something is incredibly influential on how we feel, and I think in today's age, like it's harder to feel like you actually do mean something. You know, it's harder to feel like you're going to find a job that you really can give back in. It's hard to feel like you're going to make an impact when the world feels really terrible. So we do need to look more broadly. There's this really interesting book I read from Johann Hari called Lost Connections, and he looks at this idea. His central argument is because the story of a chemical imbalance is so simple and easy to understand, it's meant that we've underpaid attention to the ways that modern life disconnects us from what we as humans need, and he frames many of the drivers of depression and anxiety as basically different forms of disconnection, not just biological vulnerabilities. You know, we are disconnected from nature. We are disconnected from meaningful work. We are disconnected from people, from our communities, from a meaningful future that is having a real life impact. With this perspective, I think depression gets the complexity it deserves, whilst also acknowledging how medication is a valuable part of that if we do not also look outside of our own brains at the world we are living in and acknowledge how that is probably making us feel terrible. The blame does start to come back, right, It does start to feel like as well, our depression becomes treatment resistant, Like we are taking the medication, we are subscribing to the biological model, and you know it's not working. And so maybe I am to blame. Maybe this is a permanent state of being. Maybe I'm a much harder case than anybody has ever seen before, when actually it's just that people are looking at your case, or you are looking at your circumstances through a narrow lens, and other things, other levers in your life could be pulled, could be readjusted so that you are happier, Like I've definitely found this since moving to London, Like my dosage of my antidepressant has stayed the same, but it looks like it's not working because I've become a lot sad and meaner and shorter and agitated, just because now I'm living in an environment that makes me feel less and less seen and more and more like stressed out again. I don't want this to come through as though medication is the wrong thing to do. That's actually not what I think. But I do think it is a medical disservice to give someone a prescription to a drug that is really hard to come off of that does change things like your sex drive, like your weight, like your sleep, like your dreams, your energy, and not maybe just maybe look at some other factors and search for something else first. So what do we do with all this information? One of the main takeaways I want to leave you with is that depression is as unique as we are. It is a label for a cluster of symptoms, and people can end up in a depressed state through totally different pathways, through grief, loneliness, illness, rumination, loss of meaning, chronic stress, often a mix of several and then maybe also a biological component. That's why a one size fits all explanation never really works. There is an infinite number of combinations of biological and environmental and psychological factors that all come together to create this experience. That's why two people can go through the same thing, beyond the same medications, even have totally different outcomes, and why they're like a neat explanation. Any narrative that wants a simple phrase to explain this probably won't work. I think instead of hunting for these single cause that makes people depressed these single cause that is easy to digest. We recognize how complex this is. We focus on reducing stress where possible, rebuilding protective connections to people, to purpose, to safety, to community, finding emotional outlets that work for us, increasing coping skills in children, finding play and joy, strengthening the parts of you that are vulnerable through therapy, through skills, through routine, and then allowing medication to remain as the sidekick, not the star of the show. And I think that that would allow people to just feel more seen think would also allow people to just get better in a way that is more sustainable and holistic and meaningful. So there we go. That's how I'm going to wrap up the episode. I know I said at the start, like this is going to be a short, bonus episode. Obviously that is not the case. I have a lot to say about this topic, and honestly, even as I'm wrapping up, I'm like, oh, I didn't even mention this. I didn't mention that. But yeah, I want to keep it short and sweet for you guys. I hope that this episode, even if you didn't agree with everything I said, I'm sure there's going to be some of you like it just spurred conversation. Honestly, people in either camp stick to their guns very strongly. This interesting thing where like the answer you go looking for is the one that you will probably find because there is actually a lot of evidence for both. But you are still free to form your own opinion based on what works for you. Honestly, at the end of the day, whatever works for you, if a biological model really works for you, and that's like just just something to tell yourself. Honestly, who cares what the evidence is, keep it up, keep that explanation going in your mind. You know, really, if that is the thing that's making you feel better, I really don't see a problem with that. So yeah, I hope you enjoyed the episode. Thank you, as always to our researcher Lebby Colbert for her assistance with this episode. If you do not know, you can actually go on watch full episodes of the podcast, not this episode though, because this was a special bonus episode, but other episodes of the podcast in video format on Netflix. That's right, you can watch this show on Netflix. You can go there right now and check it out. You can prove me right, prove me wrong. Also, you can follow us on substack. You can follow us on Instagram if you want to connect in other ways. Instagram is a really great place to contribute to future episodes like this one, if that's something that you would like to do, and also to give feedback to keep the conversation going, and yeah, to share your own lived experience if this is something that you've been through. I always love hearing from you, guys, I love hearing from the listeners. So I will hopefully see you over there, But until next time, be safe, be kind, be gentle to yourself, and we will talk very very soon.