Millions of patients have been told, in all seriousness, by psychiatrists that their “depression” (so very flexibly diagnosed) is due to a “serotonin deficiency” or “chemical imbalance” and that psychiatric drugs correct this. (“Like insulin for diabetes.”) This dishonest compliance-engendering strategy is being used to this very day.

Either the doctors were disingenuous or they drank the Kool-Aid. Neither characterization is palatable for the profession of psychiatry, so to preserve self-regard, some representatives take the third way out: Blanket denial.

The truth is that some psychiatrists were always wary of the monoamine hypothesis, but most shrugged, went with the flow, and parroted that oh-so-easy party line. Rewriting of history does nothing to restore trust in the profession.

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So now analyze this issue from a PR perspective. Think of it like when a nuclear accident happens, and a nuclear expert goes on TV and says to everyone, “No one can ever know anything for 100% certainty, and we’re still gathering data every day and learning about the complexities of what’s happening out there. Nevertheless, the balance of evidence and expert opinion so far suggest that there’s no danger to the general public.” That statement is scientifically fairly open-ended with lots of wiggle room, but from a PR perspective it’s clearly designed to reassure and inspire confidence in the public, and that’s exactly what it does for most people most of the time. And all you have to do is go into a library media database and you’ll find thousands upon thousands of articles for decades where psychiatrists said both (A) and (B) at the same time in ways that reassured and inspired confidence in people that the science was saying that boosting serotonin had a very good chance of alleviating depression.

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* They almost always have an identifiable cause that is more or less in proportion, from the subjective view of the person whose mood it is, with the strength of the mood. Losing a parent = more severe sad than, say, losing a pen.
* They can usually be worked past with willpower. The difficulty of doing this is roughly in proportion to the strength of the mood, though it also seems clear that ‘work past mood’ is a skill people possess in varying amounts. You cannot necessarily change your mood this way but you can stop it from overly affecting your outward behaviour. Sometimes you can change your mood – you can cheer yourself up somehow, or a thing might happen that makes you sad even though you were previously happy.
* They last a reasonable amount of time, for a given definition of reasonable. Again, this depends on the cause. I might be sad or frustrated for five minutes if I lose my 50c bic, but the loss of a pen of great monetary or sentimental value will affect me for longer as well as more intensely.

Bipolar moods, for me, have the following traits:

* They have no identifiable cause. Sometimes this is literally ‘I feel x for no reason’, sometimes my mind will rationalize that y event must be the cause because it’s roughly the right sort of trigger, but on reflection I actually felt that way before y happened and that just caused me to notice it, or y is entirely too small to cause this length/intensity of mood.
* They are much harder to work past with willpower. It is not impossible to willpower it to the point where it does not overly affect outward behaviour, but this is difficult and consumes and energy source that feels limited. It is, as far as I can tell, not possible to ‘cheer up’ or ‘bring down’ these moods in the same way. New, real, moods just layer themselves over the larger canvas of the bipolar mood.
* They affect energy levels to a much greater extent than normal moods. Normally, people will have a bit more energy if they’re in a good mood or angry, and less if they are down. Bipolar moods greatly exaggerate this to the point where it has a powerful effect on how much sleep you get and how much productive work you can do.
* They last a completely random amount of time, but often much longer than normal moods that are not prompted by extreme and rare events. So Bipolar Moods might make me anxious for a week or so, whereas events that would cause someone to be anxious for that long with normal moods happen but are much rarer than moods that make you jumpy for a few minutes or hours.

This was a ramble, but the point is that they *feel* chemical. They feel like something that might plausibly be caused by, say, a make-x-emotion drug slipped into my drink, rather than an actual event in my life.

In fact the sensation when a mood comes on with no identifiable cause is very similar to when a drug provokes a certain mood (like weed making one feel calm, or paranoid) when nothing is provoking that mood other than having taken that drug.

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So I tell them, yes, that’s an oversimplification, but yes, this is a medical problem, not a personal failing, and there are medicines that probably will help. And about as often, people think there must be a pill that will substitute for solving a difficult problem, or can take away unhappiness. Getting the diagnosis right really matters, not just the over-broad DSM category, but a real understanding of constitutional, developmental, psychodynamic, and social contributions to a patient’s experience.

Who really buys into unscientific nonsense about chemicals? Try the hucksters in the supplements industry and the non-physician practitioners who claim to measure metabolites in urine and “prescribe” nutritional potions.

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