Harold Koplewicz, Director, Child Study Center at New York University Medical Center
I am ready to launch into a discussion of one of my favorite subjects: mental illness. Now, please recall that the entire mass of the past 4 posts from me here were about mental health. And, please recall that we made the clear distinction early on that mental health is far different from a simple “absence of mental illness.”
To review, in my way of thinking mental health is a present-grounded, God-reliant, humble and open way of approaching life, in which we live joyfully, seeking grace moment by moment from a power source outside ourselves, trusting that wisdom will be given us sufficient to discern which things that come our way are in need of changing and thus require courage, and which things simply need to be accepted with serenity. It is centered around an attitude that desires to lay aside all selfishness, but also readily surrenders any need to control others, any wish to always have things the way we would want them, and any expectation that we should be catered to in life. Rather, this attitude begins with the assumption that life will be hard, that hardships and troubles WILL come our way on a regular basis, and that by living in concert with our loving Creator we will be able to address problems and hardships, as well as the joyful moments, and in this way will true happiness be found.
But, if the above serves as a description of mental health, what then is mental illness? Well, it is most certainly NOT a “chemical imbalance“! The whole notion of a “chemical imbalance” is quite simply absurd. This term, which has become a cultural byword (simple Google searches re. “chemical imbalance”, “chemical imbalance in the brain”, etc. all returned several million hits), was fabricated by physicians, I am fairly certain, who were too lazy to take the time to explain to their patients how the brain actually functions. Certainly the marketing departments of pharmaceutical companies have also encouraged the dissemination of the term. And since it first began sprinkling itself into varied conversations, in particular among physicians and their patients with either mood disorders or psychotic disorders, doctors began to realize that if one could convince a patient that what they had was simply a biological “imbalance”, correctable by simply taking a pill repeatedly, day after day, the likelihood of said patient actually following through and taking the medicine was much greater. So, if it “works” to oversimplify an illness to mere biological terms and thus improve “compliance”, then go with it! This seems to have become the dominant philosophy of many modern psychiatrists and other physicians.
The problem is that there is no such thing as a chemical imbalance!
That’s right … you read that last sentence correctly … here is a psychiatrist who does not believe such an entity exists! In terms of human beings and mental illness, one simply cannot distill down all the facets, causes, and manifestations of mental illness to nothing more than molecules of various chemicals being present in the brain in either insufficient or excess amounts. The brain is not just a big soup of chemicals sloshing around inside one’s skull. A swimming pool CAN have a chemical imbalance. The human brain is not a swimming pool. It is a marvelous collection of huge numbers of neurons, 100 billion or more in most adults. These neurons all have parts that extend out in various directions, called axons and dendrites, that then “attach” to other neurons’ axons and dendrites, often as many as a thousand different connections per neuron. These connections, or synapses, are where the communication and actual activity of the brain occurs. So, you have as many as 50-100 trillion(!) or more connections between brain cells in an adult brain. This is literally an unfathomable number to me.
Now, it is true that all neurons rely on certain chemicals to be present in order for them to do what they need to do. Obviously, water, oxygen, and energy in the form of glucose are all needed on a continuous basis by all functioning brain cells. However, if these are out of balance you don’t have mental illness; you have neuron death; If the deficiency of these chemicals is large enough (caused by arterial clots, hemorrhages, the heart failing, severe respiratory collapse, etc.), then many neurons die, and this is referred to as a stroke!
However, this is not the chemical imbalance referred to by various physicians trying to convince their patients that they might as well just give up and agree to take their medicines. No, the chemicals they are referring to are what are known as “neurotransmitters”. These chemical molecules, such as serotonin, dopamine, norepinephrine, glutamate, and others, are chemicals that neurons produce and then, when the neuron is stimulated to “fire”, are “spit out” toward other neurons in those tiny spaces between them at the “synapses” referred to above, which then causes the next neuron to be stimulated and “fire” as well. Thousands and even millions of these networks of neurons firing in certain sequences is what leads to everything that we humans think, feel, say, and do, and also comprise the system of “storing” of memories of all sorts, not to mention all the things the brain does without our conscious awareness, such as regulating our breathing and heart rate, our muscle tone, our bowel and bladder functioning, hormone production, and even our moods.
Yes, it is true that all of these billions of neurons are simply highly organized collections of chemicals, and they function by producing many chemicals: the neurotransmitters noted above, the “receptor” proteins that “receive” the transmitter chemical molecules, as well as the myriad of other supportive chemicals such as DNA, RNA, proteins, peptides, phosphglycolipids that form cell membranes, etc., etc. However, brain dysfunctions that lead to “mental illness” don’t just happen because there are not enough of these chemicals, or too much, or a mixed bag of altered “levels” of these or other chemicals. The truth is that we humans are amazing beings. We are an incredible tapestry of body, brain, mind, and soul. We are social, physical, emotional, mental, and spiritual beings. Every single thing that happens in any one of these spheres ripples out and can affect each or all of the other spheres. The biological portion is no different.
Thus, mental illness can be a result of both genetic expressions of the “hard-wiring” we inherited from our parents and other ancestors, as well as all the things that have happened to us, from our time in our mothers’ wombs, to all that happens during birth, to the bonding we had or didn’t have with our parents in infancy, to the nutrition we had as children, to all the many, many events of childhood and adolescence, to various stresses, traumas, losses, health problems, and any number of other factors that occur throughout adulthood. The body and brain constantly grow and adapt, changing as these things alternatively support or hinder our growth, as we learn to either trust that the world is relatively “safe”, or that it is a place one must be careful of, to “fear”. Emotions, thoughts, beliefs, biological events, social experiences, spiritual growth … all these and more contribute to our relative immunity to, or our development of, mental illness in its many faces.
The bottom line is that at a biological level, mental illness is never just a chemical imbalance. Rather, it is more an expression of neurophysiological dysfunction, but even then the biology is also a part of the social, the cognitive, the emotional, the physical, and the spiritual facets of one’s life. Mental illness comes because of all of these arenas, to greater or lesser degrees, and as it develops it in turn impacts every one of those arenas. Far be it from me or any of us to reduce such amazingly complex and sacred experiences as major depression or bipolar disorder or schizophrenia or panic attacks down to simple biology or chemistry. This is to deny our humanness. This is to sell our souls for the sake of pharmaceutical profits, and fewer headaches from patients who actually want to ask questions, who want to look deeper into the workings of their own minds and souls as they struggle to overcome emotional and cognitive disorders. So, let us all please, please forget the term, “chemical imbalance”. Unless you need to lower the pH of your swimming pool, or add more chlorine, just throw chemical imbalances onto the rubbish heap of history!
Up next: we throw ourselves into the very difficult task of understanding the highly debilitating condition known as depression. Depression is strong, but there is good reason for hope for all of us, and we’ll see why soon enough!
Craig Meek, M.D.