A third-year medical student recently informed me that after nearly a year of deliberation, he had finally decided to specialize in psychiatry. What impressed him, he said, was that psychiatrists continue to debate among themselves some fundamental issues concerning their discipline and that they do not shy away from questioning their identity as a profession. The student’s choice may well put him in the minority. For some, such controversies suggest that the profession is becoming what Dr Daniel Carlat describes in his new book, Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a Profession in Crisis.
Controversies are certainly not new to medicine. In antiquity, there was controversy between the doctrines and practices of the medical schools of Cos and Cnidus. The Cnidians were preoccupied with classification of diseases into which patients had to fit on the basis of signs and symptoms, whereas the school of Cos maintained that this categorization of diseases led to the neglect of patients as individuals. Interestingly, there are echoes of this debate in modern psychiatry. Some psychiatrists even question the very existence of mental illness.
In 1989, Professor Samuel Guze famously asked, “Biological psychiatry: is there any other kind?” Daniel Carlat, Unhinged author and well-known editor of the Carlat Psychiatry Report, asks whether psychiatrists have forsaken talk therapy—arguably the raison d’être of psychiatry—for pharmacotherapy.
Dr Carlat dedicates his book to his mother, who committed suicide when he was in his early twenties. He acknowledges his father, a psychiatrist, for being his mentor, but not much is said about the impact his mother’s suicide might have had on young Daniel. Dr Carlat found much of what he learned in medical school irrelevant to his subsequent work as a psychiatrist: “Why do we go to medical school?” he writes. “How do months of training in surgery, internal medicine, and radiology, etc, help psychiatrists treat mental illness?” Dr Carlat does not, however, say that training in neurology in medical school is not of help to psychiatrists. Indeed, he even questions whether medical training is at all necessary to prescribe psychotropic medications.
For those who work in the public sector, especially in inpatient services, patients with exclusively psychiatric problems are a rarity. Multiple diagnoses are more common. Physical illnesses brought about by substance abuse, sheer neglect, or old age are common in patients who present with psychiatric symptoms. Psychiatrists often treat patients with minor medical ailments and request consultations from specialists in more complicated cases. The situation is clearly different for those treating suburban Sybarites.
Unhinged is, strictly speaking, neither a memoir nor a polemic. Rather, it is something in between—more like investigative journalism. In fact, The New York Times published excerpts of the book this year. The book recapitulates Sen Charles Grassley’s investigations of the execrable behaviors of drug companies and, above all, those of our colleagues. Dr Carlat’s list of villains is extensive. There are few “good guys” in this sorry episode; drug companies, universities, researchers, and finally the practitioners themselves share the blame. Dr Carlat offers his own mea culpa for being a paid speaker—a “hired gun”—for a drug company.
Dr Carlat also subjects the sales representatives who visit doctors’ offices and buy the staff lunches and offer trinkets to particular derision. What is lost in this obloquy is that everyone—all of us [psychiatrists]—are unsuspecting, often unwilling participants absorbed in this maelstrom.
What is the general public—the intended audience—to make of Unhinged? Anyone who reads the problems the author alludes to regarding the marketing of psychotropic drugs is likely to conclude that most medications are useless and the proof submitted to the FDA is suspect. The problem is not unique to psychiatry; recent scandals concerning drugs such as Avandia and Vioxx have raised similar concerns in general medicine. Corporations present data to the FDA to get approval for the drugs. However, there are often problems in selecting patients for the studies, in establishing the criteria to define a drug benefit, and in choosing which studies should be submitted to the FDA.
Recent studies, not surprisingly, have questioned the efficacy of antidepressants. Lest readers, especially the general public, get the impression that psychotropic medications are useless, Dr Carlat admits that without drug companies, we would not be able to research new drugs. He also tells us about patients who have benefited from the medications he has prescribed.
Until recently, psychiatry residency programs did not offer adequate training in psychotherapy, and much emphasis was placed on psychopharmacology. This is no longer the case. For those who trained a few decades ago, the reverse was true: for even the most psychiatrically disturbed patients, intense psychotherapy was the only treatment offered. Most psychiatrists will agree that a more eclectic approach using both psychotherapy and medications is the proper way to treat patients.
Dr Carlat cites a study showing that it is less expensive when 1 psychiatrist offers both medication management and psychotherapy than when 2 practitioners separately offer pharmacotherapy and talk therapy. We should all be aware of cost issues, but this could not be what one means by evidence-based practice. Or is it?
There are studies that compare medication-psychotherapy combination with psychotherapy or medication management alone in treating depression. After all the railing against the influence of drug companies on our practices, should we exempt the insurance industry? We might be more convincing if we informed our patients that studies have shown the combined approach to be effective. Dr Carlat admits that he, too, was depressed and treated himself successfully with medications, but there is no mention of his receiving psychotherapy. Medications alone do indeed work for some.
Accompanied by an investigative reporter from The New York Times, Dr Carlat visits booths at an annual convention of the American Psychiatric Association advertising various drugs and vagus nerve stimulation (VNS). VNS was subsequently shown not to be better than placebo in treating patients with depression. The pair then meets a person who claims to have benefited from VNS. The author makes gratuitous interpretation, a coup de grâce, of the CEO’s passion, which he believes is “motivated by the fact that both his [CEO’s] mother and his grandfather committed suicide.” Mutatis mutandis, might something similar be said about the author and his passion?
There is one final issue that is likely to raise eyebrows. The author advocates that psychologists be granted the right to prescribe medications. After all, he does not believe that conventional medical education helped him as a psychiatrist. Since psychologists were granted the privilege of prescribing in some states a few years ago, Dr Carlat reassuringly informs us that thus far, “there have been no adverse outcomes or patient complaints related to these practitioners.”
Psychologists are not unique in asking for prescribing privileges. Nurse practitioners, midwives, physician assistants, and optometrists are seeking to expand the scope of their practices. Can psychologists rule out or treat underlying medical problems or medication adverse effects? A predictable response might be that the primary care physician could deal with such issues if and when they arise. But wait. Did we not hear that fractured care is more expensive?
Unhinged is one of many books published in the past few years critical of psychiatry. One would have expected more from a talented and erudite psychiatrist such as Daniel Carlat. Instead, we have a book of scandals and debates, and a polemic of sorts—a “trahison des clercs”—rather than an intellectual discussion about psychiatry. Therein lies the trouble with psychiatry.
Click here for the response to Dr Haldipur's review by Dr Carlat