Daniel Carlat

A good, easy-to-read analysis of the psychiatric profession today, along with recommendations for improvement.

Dr. Carlat was disturbed that he spent his days prescribing drugs. Although financially rewarding, this activity was not what brought him into psychiatry in the first place. His practice consisted of interviewing patients, and, when warranted, prescribing medications and referring them to therapists. The therapists were psychologists, family therapists, and other professionals trained in "talk therapy". From there, he would see his patients for short appointments to adjust drugs every few months or so.

One reason psychiatrists lean toward prescribing is that they like to consider themselves biologically oriented, more science than woo. But in fact there has yet to be established a medical basis for the syndromes they treat most. We are told that there may be a "chemical imbalance", that the patient was born with it, but in fact this has never been proven and there is good reason to believe it never will be. Carlat acknowledges this fact, but he doesn't part ways with drugs altogether.

Dr. Carlat believes that psychiatric drugs work, on the whole. But they aren't magic bullets and they often cover over underlying issues the patient fails to address. He further found that drug companies deliberately misguide the doctors who prescribe, by attributing qualities to their drugs that they don't have, or that are actually no different from other similar drugs.

Carlat became a "hired gun" himself for a time. He was drawn into this lucrative field when offered good pay for little work. Mostly, he would speak to other doctors at educational meetings, describing his experience with various drugs. It wasn't long before he discovered that, while he was never told to lie or to promote a manufacturer's drug over others, he was given signals when he took a more evenhanded approach by telling the truth. He realized that he was subject to influence, because when he continued to speak honestly about his experiences his speaking engagements started to fall off. By tailoring his talks to promote his employer's (drug company's) drugs, he received better and more frequent requests to speak. He and others also received many gifts. Interestingly, he points out that even a small gift like a memo pad or a book can make a person feel a sense of obligation.

Carlat felt his patients weren't getting all that he could give them. They needed prescriptions that were the best for them and they needed a more acute listener. He found at times that when he spent a little more time listening he sometimes found other issues that required different treatment. He also found that he was rusty and not expert in actual talk therapy. He felt like a fraud (although he doesn't use that word here).

The profession of psychiatry has become eroded over time. Now certain other professions can prescribe psychiatric medications. He can't find fault in how well these others are doing their jobs. Where does the psychiatrist actually fit today?

There are newer types of talk therapy that yield remarkable results. Even exercise can relieve many symptoms, as well as or better than drugs. Carlat believes psychiatrists should become proficient in these techniques so that they can choose the proper course of action for each patient.

Carlat explores various different paths psychiatrist and psychiatric schools might take to energize the profession and make it more useful. He falls on the side of finding a way to combine talk therapy and prescribing that doesn't eat away greatly at the doctor's income.

I appreciated the simplicity of the book, the clear descriptions and examples of his positions. I had to question his belief about the efficacy of psychiatric drugs. He says they work, yet in many patients there is no improvement. Further, many conditions, like depression, resolve on their own. How do you determine that the effects are better than placebo? Some studies have been made in this area and they find that drugs usually do not do better than talk therapy, and certainly not better than talk therapy and exercise combined. It also concerns me that many patients are on these drugs for a lifetime when their underlying issues could be resolved and the drugs eliminated. Carlat himself experienced a panic attack and, not having drugs available, he turned to cognitive behavioral therapy techniques. They worked. This is partly why he recommends that doctors learn the different therapies available so they can choose what works best for their patients. I felt more emphasis could have been placed on these alternatives that do not involve drugs. And that have no side effects.
… (altro)

The book’s subtitle basically says it all.

Carlat writes in clear, accessible prose about a number of problems within the field of psychiatry. First of all, there is the matter of diagnosing mental illness. Based on an interview with a patient, a psychiatrist (fairly subjectively, using observational skills and drawing on experience) matches up what he sees in the patient with the description—essentially, a list of symptoms—of a condition included in the Diagnostic and Statistical Manual of the American Psychiatric Association. No laboratory or diagnostic imaging tests exist to diagnose mental illnesses. For many disorders, symptoms overlap. This means a patient could potentially visit three different psychiatrists and end up with three different diagnoses..

Once a diagnosis is made, there’s the problem of what to prescribe. No one is quite clear on how psychoactive medications work. There are a whole slew of “me-too” drugs modelled on the initial big sellers like Prozac. Choosing one medication over another is tricky, as the drugs in a particular class can be chemically very similar. Ultimately, the decision might be based on a psychiatrist’s own preferences or on trial and error. A related problem is that the pharmaceutical industry currently doesn’t think it is financially worthwhile to develop new psychiatric drugs. Science is not clear on the causes of mental illness. If you don’t know enough about the actual biology at the root of the problem, how do you treat it? For now, it’s more about symptom reduction than real understanding—in spite of all the pseudo-scientific talk you’ve heard about “chemical imbalances” in the brain or insufficient serotonin.

Carlat also discusses psychiatrists’ lucrative and highly problematic relationship with the pharmaceutical industry. He presents a number of prominent cases in which big-name psychiatrist-researchers were less than forthcoming about their work with major drug companies. These psychiatrists withheld information about pharmaceutical affiliations from the university and hospital research facilities that employed them, conveniently receiving federal grant money to investigate the very drugs that companies wanted them to push. Studies were not uncommonly conducted (manipulated) in such a way as to prove the efficacy of those psychoactive drugs—or even expand their use to new patient populations. Powerful antipsychotics were, for example, increasingly being dispensed to young children who’d been given the controversial diagnosis of bipolar disorder.

Most psychiatrists nowadays are “psychopharmacologists” or pill-pushers, writes Carlat. They practice no psychotherapy; rather, they refer patients to psychologists and other mental-health counsellors. Psychotherapy is time-consuming, and it doesn’t pay well enough to make it worth a psychiatrist’s while. In referring patients to other professionals, however, psychiatrists can miss out on critical information about patients’ daily lives, relationships, and thought processes.

Carlat believes that psychiatric education needs to be reconfigured. Traditional medical education, with student rotations through a variety of specialties from surgery to obstetrics, he says, is simply not useful to a person who wants to pursue a career in psychiatry. Carlat also believes that the training and scope of practice of clinical psychologists should be expanded so that these mental-health professionals could prescribe psychoactive medications.

Carlat’s book is now a decade old, but, based on some of the recent mental-health memoirs I’ve read, not a great deal has changed within psychiatry. Some of the material is a bit dated, but the facts seem to basically stand.… (altro)

A look inside psychiatry by a psychiatrist. The author is troubled by the way psychiatrists have become simply medicine dispensers, and have outsourced therapy to various other professionals. He is also disturbed at the influence the drug companies have in determining what drugs doctors prescribe, and is willing to tell stories on himself of ways in which he was influenced by drug company gifts (including rather large checks) to prescribe certain meds. The book loses a half star because the doctor totally missed the real problem in dealing with his "solutions" chapter; it ran like a thread through the entire book, but he was unable to see it, because it was his own acceptance of the need to make a "good living". Which apparently means they must make at least four times the median income for the country, and cannot possibly take pay cuts down to only twice what most of the middle class live on. The push for money is all there, when the doctor proposes that he couldn't cut down his practice because then he would only make $70 an hour instead of $180 an hour, which is unacceptable. While I realize the price of medical school is astonishingly high, many other professionals come out with just as heavy a debt load, but don't automatically assume it is impossible to live on $80,000 a year. Until the profession addresses this assumption, he will not find the solutions he seeks. Otherwise, well written, thought provoking, and worth a look. A very easy read.… (altro)

As someone who has written a good bit of health journalism in my career I'm aware of how easy it is for a health story to be influenced by bias, whether it be a well written PR piece that comes across your desk when you have a deadline looming (you may or may not be surprised to learn how many stories in newspapers and magazines are printed with huge chunks of text lifted verbatim from a given company's press release), or a study that promises an exciting health breakthrough and will make for a great cover story people will want to read (never mind that the study is funded by a drug company, or authored by a doctor on that company's payroll).

So what delighted me about this book is that not only did it expose the many systemic weaknesses in how psychiatric medicine is being practiced today, but it also gives a very detailed analysis of how misinformation about psychiatric drugs becomes FACT, however false. Not only pharmaceutical companies but also doctors and journalists and even patients have strong incentive to believe in their treatments, however lacking the science might be, and however bad the side effects, and however little real improvement is seen. There aren't any bad guys here...well, not so many of them...Carlat describes instead how simple human nature--a combination of vulnerability, hope, and a little greed--has led to a runaway industry. Great journalism.… (altro)