In media interviews and public appearances, there almost always comes a point when I tell people that the chemical imbalance theory of depression is a myth. I generally add that I mean “myth” in the best way possible:  a powerful explanation of a complicated and disturbing phenomenon, but one that is not necessarily true in the sense that we expect scientific explanations to be true.  I explain that the credibility of the myth hinges on a faulty logic: People take antidepressants and feel better. Antidepressants increase the availability of serotonin. Therefore a lack of serotonin was the cause of feeling bad. That’s a post hoc fallacy at best, but it is not too simplistic to say that this is the main source of the myth.

My comments are often met with incredulity, which makes sense, given how widespread this myth is, and given its role as a linchpin in the depression industry. After all, how many people are taking antidepressants because they have been told that they are suffering from a chemical imbalance that the drugs will rectify in the same way that insulin does for diabetes? And the corollary: that if you don’t take the drug, it will be like leaving diabetes untreated. So my comment is discomfiting and hard to believe. I generally acknowledge this and then suggest that people buy Manufacturing Depression if they want to get the whole story. Never pass up an opportunity for a plug.

The question that hangs in the air in this discussion is how it is possible that there can be such a  disconnect between what doctors know and what they tell the public. That is a hard one to explain without resorting to conspiracy theories or attributing bad faith to doctors. I don’t like either of those explanations, and I am sure that neither does justice to the phenomenon. But so long as doctors say one thing to their colleagues and another to the public, the question looms. So I was pleased to see in today’s New York Times an article by Richard Friedman, a professor at Weill Cornell Medical College in New York City, and a frequent contributor to the Times. Friedman is anything but a psychiatric renegade, and here is what he says about the chemical imbalance theory:

Knowing how a drug works in the brain doesn’t necessarily reveal the cause of the illness. For example, just because an S.S.R.I. antidepressant increases serotonin in the brain and improves mood, that does not mean that serotonin deficiency is the cause of the disease; many depressed patients get better with medications that have no effect on serotonin.

So there you have it. Right from the horse’s mouth.

(One thing Friedman doesn’t mention: that many depressed patients get better with no medication at all.)

Well, I don’t know about the drop out part. But if you turn on your radio and tune in to Science Friday, an NPR show, today at 215, you will hear Tom Insel, head of NIMH, Jeff Lieberman, president of the APA, and me talk about whatever Ira Flatow wants us to talk about.

Predictions:

Insel and Lieberman reprise their rendition of Kumbaya, attributing their differences to a division of labor–the NIMH does research, which needs to detach itself from DSM, while the DSM is for clinicians, who need it.

Insel and Lieberman will team up to defend psychiatry against antipsychiatrists like me. But they will be very nice about it.

I will try to explain  why I am not an antipsychiatrist, which is sort of like explaining that you don’t beat your wife. I will also be very nice about it.

Insel and Lieberman will say that I indict the DSM because its diagnoses don’t have any biology to them, but that this is a straw man argument. They will point out that many medical diagnoses are like DSM diagnoses, and that it is unreasonable to hold psychiatry to a standard that the rest of medicine does not meet.

I will try to explain that I never said I think biology is a necessary condition for determining that a particular suffering is a disease. I will then try to explain that nonetheless the biology thing is the myth that gives us confidence in what doctors tell us, and that the DSM is an attempt to command confidence by suggesting that psychiatry knows more than it does. I will try to invoke history, the way that the DSM-III was a response to a crisis of confidence. I may even  invoke David Brooks, who accused psychiatry of having Physics Envy. But I probably won’t get far, since this is a hard one to get into NPR-=sound-bite shape.

They will say that we can’t do without the DSM, for the sake of the patients.

I will say that this is what people in bad marriages say all the time–that it’s bad but must be preserved for th sake of the children. I will allow that sometimes the parents are right, and sometimes they are wrong.

We will agree that psychiatry has a long way to go.

And, most important, I will talk about “my book” as often as possible.

And so much to catch up on. First has to be the David Brooks column from earlier this week, in which he called psychiatrists “heroes of uncertainty,” praising them as “daring adapters, perpetually adjusting in ways more imaginative than scientific rigor.” Take away the sermonizing and the sentimentality, take away Brooks’s compulsion to turn every event he writes about into an object lesson in the virtues Burkean social theory leavened by his half-baked notion of negative capability, and what you’re left with is only the damning praise. Psychiatry is not a science, Brooks says, but a “semi-science” (I’ve never heard that one before either), one that suffers from Physics Envy (and note the capitalization here; the Times style book says you don’t capitalize the names of mental disorders, but I guess they make an exception for op-ed columnists) and needs to stop claiming more knowledge than it has.

Now where have I heard this argument before? I have no idea if Brooks read my book. He’s surely not saying, and I don’t blame him. AFter all, writing in the Nation I did call his last book “the love child of Malcolm Gladwell and Kilgore Trout,” which  wasn’t terribly kind, even if it was true. I also don’t blame him for going out of his way to mention Al Frances’s Saving Normal, as I’m sure he recognizes Frances’s underlying notion that psychiatrists can (and should) moderate their power as a version of his own noblesse oblige, his faith in the aristocracy to limit their own power. The irony here, by the way, is that Frances and I spent a fair amount of time parsing our mutual dislike of Brooks, and he might loathe Brooks (and by this I mean his work, not his person) more than I do. Not only that, but I suspect Frances would reject this idea that he and his colleagues are heroes of uncertainty as just so much bullshit, especially to the extent that it demotes psychiatry to a semi-science.

But whatever Frances thinks, it’s hard to imagine that the folks at the APA want to accept the David Brooks Medal of Uncertainty, even if they agree with him. It’s a tight spot. Acknowledging the uncertainty of psychiatric diagnosis, ratcheting back its claims, is at once honest and dangerous. To the extent that psychiatry is, scientifically speaking, in its infancy, the honesty is refreshing and even necessary. That’s why Tom Insel’s comments were so important–he was only saying out loud what he and other psychiatrists have been saying for years, and what is undeniable. But to the extent that psychiatry must command the confidence of it patients and patrons, acknowledging its immaturity is very risky. That’s why Insel’s comments were also inflammatory.

Brooks, of course, is completely tone-deaf when it comes to this last point. His instincts are anti-political, so he doesn’t understand, or even perceive, the complex dance that goes on between a public desperate to believe that psychological suffering can be understood and treated like pneumonia and a profession desperate to fulfill that hope.

I heard from my ex-wife today. She was very kind, but also pretty upset about a thoughtless comment I made about her at an event that was recorded and podcast. A man in the audience was recounting how he had once been married to a woman with borderline personality disorder. I cracked wise–that I had also met that fate. That was totally uncalled for, and I regret having said it.

She and I did have a pretty bad marriage. We picked ourselves up and dusted ourselves off, left each other alone, and got on with better lives. There was no reason for me to dredge any of that up.

Oddly enough, her note came on the same morning that Andrew Scull diagnosed me with Narcissistic Personality Disorder. So there may be justice in the universe after all.

I awoke here in Portland (where it is of course raining, and where I will be conversing with Will Hall at 730 at Powell’s) to a chunky, satisfying LA Review of Books review of Book of Woe by Andrew Scull. The book is paired with Hippocrates Cried, written by neuropsychiatrist Michael Taylor.

It is a relief for once for Book of Woe not to be reviewed along with Saving Normal, which for all its other virtues, doesn’t present critics (or readers) with what is strangest about the DSM-5 backlash: the way that even ardent defenders of psychiatry are despairing about descriptive psychiatry, and deeply worried about the professional empire erected upon it. An astute reading my BOW and SN together will yield the bromance, maybe even the rivalry between Allen Frances and me, and will have two easily detectable sides to pit against one another: his, which defends psychiatric diagnosis by viewing the DSM-5 as an outlier, and mine, which argues that the DSM-5’s weaknesses are only the latest instance of a problem that underlies the whole DSm project.

But by putting together my book with Taylor’s, a jeremiad by a mainstream psychiatrist who agrees with me nearly entirely about what’s wrong with DSM, Scull hits on the way that the DSM-5 debacle has made for strange, to say the least, bedfellows. Or to put it in a way that will no doubt reinforce Scull’s notion that I am narcissistic and preening, the way that writing this book has ended up putting me in bed with the most unexpected paramours, and I take that as a sort of compliment.

By the way, I think Scull is trying to be droll when he suggests that Taylor and I both suffer from Narcissistic Personality Disorder and thus points out one of the least appreciated uses of the DSM: as a dictionary of insult. (And as the guy who once called DAvid Brooks’s book the love child of Kilgore Trout and Malcolm Gladwell, I can hardly complain when someone takes a cheap shot. ) But what is interesting about his comment, and about the review that ensues once he gets the name-calling out of the way is the way it captures this strange bedfellows phenomenon. I don’t know Michael Taylor, although I am pretty sure that he’s the same guy who coauthored the proposal to put melancholia into the DSM-5, which I report about in BOW. But the fact is that Andrew Scull thinks that we are cut from the same cloth, and at least in one sense I have to agree.

Of course, that’s not the psychopathological sense. I don’t know about Taylor (or Scull for that matter) but it would be ridiculous to deny I’m self-regarding. I am a writer, for crying out loud. On the other hand, it’s not just self-regard. Like a therapist’s, a writer’s self-regard is (or should be) countered by unremitting doubt, which is in turn nurtured by a continuous infusion of self-directed misanthropy. I suppose a good writer is someone whose self-regard edges out his self-loathing  often enough to allow whatever talent he has, and whatever message, to emerge in words. And even Scull has to admit that my “constant need to inject [myself] into the story” doesn’t stop the book from being a “serious indictment.” (He is probably correct that my “self-consciously populist” approach “distracts the reader from the seriousness of the underlying issues,” but that’s probably a question of who the reader is. To an intellectual like Scull who is very familiar with this history and has taken it seriously enough to devote much of his career to, I’m sure it’s really annoying. To a lay reader who has only the vague idea that there’s something wrong with this whole business, the fact that I set out to entertain might actually be helpful in informing his or her antipathy.)

But the sense in which I think Scull’s observation about the likeness between Taylor and me (and, as he points out late in the essay, between Thomas Insel of the National Institute of Mental Health and me) is valuable is the way it highlights the direness of psychiatry’s predicament. In Scull’s words:

We’re stuck. Descriptive psychiatry is a shambles, as both Taylor and Greenberg’s books help to show, and as the events of this month (May 2013) have made even more dramatically obvious. But, at present, it has no plausible rival.

When a man who believes, as Taylor does, that psychiatry is poised to provide the answers we need, if only it would abandon the remnant of the Freudian shibboleths, agrees with a man like me, who believes that the total eradication of at least one of those shibboleths–thgat mental suffering is not the same as physical–then you know you’re down the rabbit hole.

Of course, this is where Taylor and I (at least according to Scull) part ways. Indeed, it the cracker-eating that leads all my odd bedfellows to give me the heave-ho–or, in the case of Allen Frances, to come to regret they ever took a tumble with me in the first place. I want to take the fact that psychiatry is in a shambles seriously enough to wonder whether we can do more than just plod along with a system that no one likes, all the while waiting for it to be replaced by a system–brain-based diagnosis–that I’m guessing only the drug companies will like. (Not that this matters right now, because brain-based diagnosis, its ontological problems aside, is a long long way off.)

So the question for everyone is what to do, now that the curtain is being drawn back. Taylor (and Tom Insel) thinks we should put pedal to metal on the brain research. Frances thinks we should let psychiatry limp along on its admittedly flawed foundation and in the meantime to keep quiet about those flaws, so that people can continue to benefit from it.  I think we should just get honest. As Scull points out, I do propose a solution, what he, quoting from Book of Woe, calls a thought experiment.

What would happen if [psychiatrists] told you that they don’t know what illness (if any) is causing your anxiety or depression, or agitation, and then, if they thought it was warranted, told you that there are drugs that might help (although they don’t really know why or at what cost to your brain, or whether you will be able to stop taking them if you want to; nor can they guarantee that you (or your child) won’t become obese or diabetic, or die early), and offer you a prescription [for these substances

Seems simple and straightforward enough, right? But there is a problem with this proposal, at least Scull thinks so:

Psychiatry’s status is precarious enough as it is. One can only guess to what depths it might sink in such a transparent world.

Perhaps on reflection both doctors and patients would prefer to cling to their illusions. But it seems they may not be able to do so for much longer. And then what?

Scull earlier talks about psychiatry as a con game (a point I make in the book, although he doesn’t cite it, by quoting from Melville’s The Confidence-Man). Confidence underlies the effectiveness of all healing, mental and otherwise. But it generally doesn’t survive the unmasking of its specious basis, any more than the Wizard’s authority in Oz could survive Toto’s indiscretion. Does that mean that psychiatry can’t survive? The Wizard masterfully turned his unmasking into a triumphal exit, leaving while he was still loved. But that means he left when the people were still duped. And this is what I can’t figure out about people who worry as Scull does about the future of psychiatry once the con game is up: do they have this little confidence in people, in our ability to use our trust judiciously? What exactly are they worried about?