Dr Leaf, Mental Health, and the Chemical Imbalance Theory

Dr Leaf claims to be an expert on mental health, but her statements on mental health would suggest otherwise.

Under the title of “Chemical imbalance and mental health”, on her misleadingly named “Scientific FAQ” page on her website, Dr Leaf continues her logically flawed and factually inaccurate criticism of modern psychiatry and psychopharmacology.  This is Dr Leaf’s anti-psychiatry manifesto, a regurgitation of the rancid opinion of various disgruntled fringe psychiatrists rather than a fresh review of the original evidence.

The first iteration of this information was on a blog post which she published in late October 2015.  It’s not clear exactly when or why, but at a subsequent point in time, Dr Leaf took the post down and rebirthed it on her “Scientific FAQ” page.

A good example of all that's wrong with this smokescreen of distrust is contained in the opening paragraph.

“Today, it has become commonplace to say that people have chemical imbalances in their brain, most notably a disruption in the proper production of dopamine (for “diseases” like ADHD) and serotonin (for “diseases” like depression). These people, it is supposed, need drugs to “cure” these chemical imbalances, hence the terms “antipsychotics” or “antidepressants”.

The first thing to note is how Dr Leaf uses the term "cure” as a pejorative term implying that modern medicine is only interested in permanently fixing things. But it's a straw man fallacy, a false premise that Dr Leaf then uses to cast the medical model as impotent and futile.  In reality, good doctors don’t rely on drugs as the only cure, but objectively review the evidence for drug and non-drug management and recommend what is best for the individual patient.  That doesn't mean that drugs aren't useful, nor that the medical model is broken.  Medications are extremely helpful for certain conditions, when used carefully, as are non-drug treatments like CBT.

Dr Leaf also puts inverted commas around the word "diseases" as if to suggest that ADHD and depression aren't diseases, something which seems silly and petulant, and is insulting to those who have or who have ever suffered from ADHD and depression.   In comments on her Facebook posts in October 2015, Dr Leaf was happy to share that her eldest daughter suffered from bulimia and depression, but now she's suggesting that depression isn't really a disease. So Dr Leaf’s daughter was weak or malingering or something?  It’s sad to see Dr Leaf denigrate her daughter in such a public fashion.

The weight of scientific evidence certainly crushes Dr Leaf’s intellectual defiance.  For example, ADHD is associated with dopamine dysfunction as well as the dysfunction a number of other neurotransmitters [1-3]. And depression is associated with a decrease in the growth factor BDNF, (known as the neurotrophic hypothesis of depression) [4-6]. Schizophrenia, which Dr Leaf conveniently failed to mention, is clearly related to dopamine dysfunction in nerve cells of the pre-frontal cortex and the striatum, two parts of the brain that are incredibly important for how your brain processes incoming and outgoing signals [7-9].  There's nothing to suppose here … there's overwhelming evidence that psychiatric diseases are related to dysfunction within the brain.  The general public might incorrectly ascribe psychiatric disease to a “chemical imbalance”, but the opinion of the general public does not invalidate the volumes of scientific evidence that psychiatric disease is primarily caused by  dysfunction of the brain.

Dr Leaf goes on to claim that psychiatric drugs don't fix chemical imbalances but create them, citing the 1950's observations of French researchers Deniker and Delay who noted that chlorpromazine, the first anti-psychotic drug, caused symptoms of Parkinson's Disease.

In one of the most delicious ironies, by making this claim, Dr Leaf invalidates her most fundamental premise, because chlorpromazine was indeed a cause of parkinsonian symptoms.  Though it wasn't a new disease, just evidence that it worked.

Psychosis, a pathological state involving hallucinations and delusions, is because of an excess of the neurotransmitter called dopamine. Dopamine is the neurotransmitter that's used by the nerve cells deep in the brain in a part called the basal ganglia.  The basal ganglia, in turn, acts like a central mail delivery centre for incoming and outgoing signals from other parts of the brain. The function of the nerves in one part of the basal ganglia are responsible for sending sensory signals to the frontal lobes of the brain. In another part, the signals are important for smooth movements of our muscles. Proper function depends on just the right amount of dopamine - too much and you get psychosis. Not enough and you get Parkinson's disease symptoms.

The French researchers Dr Leaf referred to were simply noting the side-effects of too much medication blocking the action of dopamine in the basal ganglia - the psychosis had improved, but the blockade of dopamine was just too much in some patients, who had the opposite symptoms.

Again, Dr Leaf's position is diametrically opposed to the published science [10, 11].  And she invalidates her own arguments because if chemical imbalances are myths, then how can chlorpromazine create a "new neurological syndrome" because of a chemical imbalance?

Dr Leaf then launches into a discussion on the history of the DSM and psychiatric medications. This is just the first in her ad hominem attacks on the medical profession … discrediting the medications by discrediting the doctors that prescribe them.  She writes, ”It was just assumed that since these drugs affected brain chemistry in a certain way, the opposite reaction must be the result of the disease, notwithstanding the fact that this has never been adequately proven."

First of all, understanding why or how something works is not a prerequisite for observing that it does work.  For example, I know my car engine turns on when I turn the key in the ignition, but I have no idea how it works.  Further, the history of medicine is littered with cures being found without the disease being fully understood.  Take Edward Jenner, for example, who is the founder of the modern technique of vaccination. He didn't know why his smallpox vaccine worked, only that it did. Electron microscopes and a modern understanding of the immune system were centuries away, but Jenner saved billions of lives through his observation that prior vaccination with a small sample of cowpox virus would protect against smallpox [12].  Scientists observed that amphetamines caused psychotic symptoms and reserpine improved psychotic symptoms.  Since amphetamines increased dopamine concentrations in the brain and reserpine blocked dopamine, it logically followed that dopamine was a good candidate as a cause of psychosis and schizophrenia.  Decades of research have gone on to further confirm and delineate the link [7]. Again, this is not "an overly simplistic explanation of chemical imbalances". It is well proven, and rather complex.

Dr Leaf goes on to vilify psychiatrists.  She claims that the invention of the DSM induced public suffering and caused "a public health disaster".  She went on to say that, "... institutions like the American Psychiatric Association and the DSM would define what is normal, in turn telling us what it means to suffer and, essentially, what it means to be human. They medicalized misery, and today millions are suffering because of their actions, creating a public health disaster."

That's like saying that classifying the different types of cancer causes cancer and that millions of people are suffering from cancer because doctors know to call it 'cancer', because the DSM, the 'Diagnostic and Statistical Manual' is a standardised classification system for psychiatric diagnoses.  It allows psychiatrists and researchers to speak a common language and attempt some coherence among their diagnoses.  That’s all.  People were suffering long before the DSM came into existence, and they don’t need to consult the DSM to know they’re miserable.  The DSM certainly doesn't define what it is to be human.  Such statements are disingenuous and melodramatic.

For good measure, Dr Leaf continues, "Today a psychiatrist can be praised for drugging a depressed person with mind-altering substances and, if these do not work, institutionalizing them and shocking their brain with ECT (electroconvulsive therapy). It is even an acceptable and commonplace practice to imprison mentally ill persons, drug them and lock them in solitary confinement, compelling them to live their days marinating in their own excrement."

This is deceptive fear-mongering, pandering to the Hollywood portrayal of psychiatric institutions, like from ’One Flew Over the Cuckoo's Nest', 'Shutter Island' or '12 Monkeys'. There are more oversight boards and lawyers than there are psychiatric patients, and the only people who are institutionalised are those who are clearly a danger to themselves or others.  While institutionalised, they are not subjected to random bouts of electric shock as if some doctor is wandering around with a medical grade cattle prod, zapping people and laughing maniacally, and nor is anyone locked in solitary confinement and forced "to live their days marinating in their own excrement".

The vilification of psychiatrists continues as Dr Leaf accuses all psychiatrists of ignorance, and then vilifies and insults  primary care physicians by accusing them of negligence, claiming that family physicians prescribe medications they don’t understand because of the bribes and a pretty smile from a pharmaceutical rep.

She claims that, “Despite the recognition amongst many psychiatrists and medical health professionals that the chemical imbalance theory is not valid, drug companies like Eli Lilly still claim that 'antipsychotic medicines are believed to work by balancing the chemical found naturally in the brain’.”

Except that as discussed earlier, antipsychotic medications DO balance the naturally occurring chemical in the brain (dopamine).  Dr Leaf attempts to prove that drug companies mislead doctors by giving an example of the exact opposite.

Ignorant of another own goal, Dr Leaf continues her charge to discredit the medications by claiming that they’re simultaneously ineffective and dangerous.  In citing the placebo effect, she makes the argument that the effect of the medications is just because someone tells you it will work. Of course, the placebo effect is part of the therapeutic effect, but that's the same for all treatments, even Dr Leaf's programs ... "So, if the pastor or cell-group leader says that these programs are safe and will fix your toxic thinking, even though they get most of their information from the author, we believe wholeheartedly in what he or she may say and are more inclined to believe the program will work for us. These beliefs, which ignore actual scientific results, are buttressed by a flood of distorted and biased news reports, press releases and scientific journal articles on supposed toxic thoughts, and have transformed the theory into church dogma. So, obviously, if we experience negative side effects and do not feel the program is working, it must be something wrong with us, not the program." Is that a fair statement?  Although it should be noted that, as opposed to Dr Leaf’s various programs, psychiatric medications have been shown to work over and above the placebo effect in well-constructed double blinded placebo controlled trials [10].

In citing the side effects of the medications, Dr Leaf fails to point out that side effects only occur in a sub-group of patients, not in all patients.  For instance, thrombocytopenia, anaphylaxis, cutaneous hypersensitivity reactions including skin rashes, angioedema and Stevens Johnson syndrome, bronchospasm and hepatic dysfunction are all known side effects for paracetamol (acetaminophen in the US). People take paracetamol all the time without even thinking about it.  I don’t see Dr Leaf up in arms over paracetamol.

Licencing and prescribing a medication depends on the overall balance of the good and the harm that a medication does. And no one has ever hidden these side effects from the public as if there is a giant conspiracy from the doctors and the pharmaceutical companies. They're listed in the product information on the internet and in every box of pills.

Finally, it should also be noted that medications are not just doled out like sweets at a candy store. You require a minimum of ten years of university level education to be able to prescribe them.  And patients ALWAYS have a right to ask questions about possible benefits and side effects (in my practice, I tell my patients the pros and the cons before prescribing, and I give them the choice of whether they want them or not). No one is ever forced into taking them.

In her final page of ranting, Dr Leaf throws together a potpourri of anti-intellectual and inaccurate rants. Let me quickly go through some of the honourable mentions:

* "Most people recover from depression without antidepressants" - true, because most cases of depression are mild. That doesn't mean to say that antidepressants shouldn't be used for severe depression, just like most people recover from upper respiratory infections without antibiotics, but that doesn't mean that we shouldn't use antibiotics for severe tonsillitis or pneumonia.
* "Antidepressants are no better than placebos" - It's a controversial topic right now. There are many pushing the barrow that SSRI medications are no better than a sugar pill. But Dr Leaf has conveniently ignored several Cochrane reviews (the best of medical evidence) that shows anti-depressants work for a variety of disorders [13-15], but that psychological therapy might not [16].
* Equating antidepressants and antipsychotics with illicit drugs, and claiming that "more people die from overdoses of psychiatric drugs than illicit drugs" - This is Reductio ad absurdum - the logical conclusion from this argument is that illicit drugs are safer than psychiatric drugs. And therefore we should not give people psychiatric drugs since we don't give people the 'safer' illicit drugs. But that conclusion is absurd, and when you think about it, the whole thing is based on hidden false premises - people rarely die of illicit drug overdoses because they're illegal and are hard to come by. And also, people who use illicit drugs are not usually suicidal, whereas those given psychiatric medications sometimes are suicidal, and sometimes use them to try and commit suicide. But modern psychiatric drugs are much less dangerous in overdose than their old counterparts.  It should also be noted here that more overdose suicide attempts are with paracetamol or ibuprofen than with psychiatric medications [19], but again, I don't see Dr Leaf demonising paracetamol or ibuprofen.
* Psychiatric medications are part of a neo-liberal capitalist plot to keep the rich, richer and the poor, poorer - This is a desperate argument.  Dr Leaf says that, "By emphasizing that the problem lies within an individual’s biology, we are less inclined to look at their experiences and the social context of why they are feeling the way they feel. We look at the mythical chemical imbalance instead of economic exploitation, violence and inept political structures”.  That is false.   Schizophrenia is often seriously discussed in terms of neurodevelopment and not just 'chemical imbalances' [17, 18].  So it's just plain wrong to suggest that researchers don't look at the "economic exploitation, violence and inept political structures".  People are not forced to take psychiatric medications so that they can be controlled.  And children with not being abused by being force-fed Ritalin because they "move a lot in class".  This is the promotion of fear not fact.  Dr Leafs emotional rhetoric is hollow.

Dr Leaf is welcome to hold whatever personal views she likes.  Unfortunately, her expert opinion is like a desiccating sandcastle, crumbling in the heat of the midday sun.  She's ignored solid published medical and scientific evidence in coming to an opinion based on the discontented rumblings of a few vocal but outspoken critics.  In order to make her arguments, she has had to resort to borderline-slanderous ad hominem attacks on scientists and the medical profession, and purely emotional arguments based on fear and mistrust.  In trying to make her case, she has disproven her own argument, and more than once.

After all, if psychiatric drugs cause changes in your brain, then it must be the brain that changes your thought life, or alternatively, if thought was the dominant force over the brain and the mind controlled the brain, then the medications would have no effect since they're physical and aren't connected to our mind, both of which directly contradict Dr Leaf’s most fundamental of premises.

In vilifying psychiatric drugs and the doctors who prescribe them, Dr Leaf only succeeds in undermining her own arguments and her own teaching.

References

[1]        Prince J. Catecholamine dysfunction in attention-deficit/hyperactivity disorder: an update. J Clin Psychopharmacol 2008 Jun;28(3 Suppl 2):S39-45.
[2]        Del Campo N, Chamberlain SR, Sahakian BJ, Robbins TW. The roles of dopamine and noradrenaline in the pathophysiology and treatment of attention-deficit/hyperactivity disorder. Biological psychiatry 2011 Jun 15;69(12):e145-57.
[3]        Cortese S. The neurobiology and genetics of Attention-Deficit/Hyperactivity Disorder (ADHD): what every clinician should know. European journal of paediatric neurology : EJPN : official journal of the European Paediatric Neurology Society 2012 Sep;16(5):422-33.
[4]        Haase J, Brown E. Integrating the monoamine, neurotrophin and cytokine hypotheses of depression--a central role for the serotonin transporter? Pharmacol Ther 2015 Mar;147:1-11.
[5]        Bus BA, Molendijk ML, Tendolkar I, et al. Chronic depression is associated with a pronounced decrease in serum brain-derived neurotrophic factor over time. Molecular psychiatry 2015 May;20(5):602-8.
[6]        Sousa CN, Meneses LN, Vasconcelos GS, et al. Reversal of corticosterone-induced BDNF alterations by the natural antioxidant alpha-lipoic acid alone and combined with desvenlafaxine: Emphasis on the neurotrophic hypothesis of depression. Psychiatry research 2015 Sep 1.
[7]        Howes OD, Fusar-Poli P, Bloomfield M, Selvaraj S, McGuire P. From the prodrome to chronic schizophrenia: the neurobiology underlying psychotic symptoms and cognitive impairments. Curr Pharm Des 2012;18(4):459-65.
[8]        Williams GV, Castner SA. Under the curve: critical issues for elucidating D1 receptor function in working memory. Neuroscience 2006 Apr 28;139(1):263-76.
[9]        Der-Avakian A, Markou A. The neurobiology of anhedonia and other reward-related deficits. Trends Neurosci 2012 Jan;35(1):68-77.
[10]      Leucht S, Tardy M, Komossa K, et al. Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis. Lancet 2012 Jun 2;379(9831):2063-71.
[11]      Torniainen M, Mittendorfer-Rutz E, Tanskanen A, et al. Antipsychotic treatment and mortality in schizophrenia. Schizophrenia bulletin 2015 May;41(3):656-63.
[12]      Riedel S. Edward Jenner and the history of smallpox and vaccination. Proc (Bayl Univ Med Cent) 2005 Jan;18(1):21-5.
[13]      Arroll B, Elley CR, Fishman T, et al. Antidepressants versus placebo for depression in primary care. The Cochrane database of systematic reviews 2009(3):CD007954.
[14]      Soomro GM, Altman D, Rajagopal S, Oakley-Browne M. Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). The Cochrane database of systematic reviews 2008(1):CD001765.
[15]      Kapczinski F, Lima MS, Souza JS, Schmitt R. Antidepressants for generalized anxiety disorder. The Cochrane database of systematic reviews 2003(2):CD003592.
[16]      Jakobsen JC, Lindschou Hansen J, Storebo OJ, Simonsen E, Gluud C. The effects of cognitive therapy versus 'treatment as usual' in patients with major depressive disorder. PloS one 2011;6(8):e22890.
[17]      van Os J, Linscott RJ, Myin-Germeys I, Delespaul P, Krabbendam L. A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychological medicine 2009 Feb;39(2):179-95.
[18]      Howes OD, Murray RM. Schizophrenia: an integrated sociodevelopmental-cognitive model. Lancet 2014 May 10;383(9929):1677-87.
[19]     Prescott K, Stratton R, Freyer A, Hall I, Le Jeune I. Detailed analyses of self-poisoning episodes presenting to a large regional teaching hospital in the UK. Br J Clin Pharmacol 2009 Aug;68(2):260-8.

Disclaimer

1. Do not abruptly stop any medications that you are taking. Talk to your licenced physician first. They're not all money-hungry, imbecilic drug-company bitches. Most of them actually know what they're talking about.
2. For the record, the author of this page declares no conflict of interest, including no connection with any pharmaceutical company.  The author does not accept gratuities of any form from any sales representative, eat their food, take their pens, or listen to their sales pitches.