Psychiatry on the Couch
By Taylor McNeil
In his new book, Daniel Carlat writes a prescription for his profession
“The sad thing is that psychiatrists are missing the boat here,” says Daniel Carlat. Photo: Jodi Hilton
When Daniel Carlat began practicing psychiatry 15 years ago, his routine was simple. Patients would come in for an initial consultation, usually 45 minutes. At the end of it, he would prescribe medication and sometimes recommend a therapist. After that, the patients would come in for 15- to 20-minute check-ins every month or two for a medication adjustment.
Now Carlat, an associate clinical professor of psychiatry at the School of Medicine, sees that kind of practice as a symptom of what is wrong with his profession. “The essential problem with psychiatry is that it is hyper-focused on psychopharmacology at the expense of other effective techniques,” he writes in his new book, Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations about a Profession in Crisis (Free Press).
Carlat notes, first of all, that the biological basis for mental illness isn’t at all well understood. “When psychiatrists start using what I call neurobabble, beware, because we rarely know what we’re talking about,” he writes in the book. “When I find myself using phrases like ‘chemical imbalance’ and ‘serotonin deficiency,’ it is usually because I’m trying to convince a reluctant patient to take a medication.”
But medication isn’t the only way to treat mental illness, of course, and Carlat argues that physicians in this medical specialty need to have a better appreciation of the alternatives. While some mental illnesses—for example, schizophrenia—respond primarily to medication, he says, others are treated equally well or better by some form of talk therapy, such as cognitive behavioral therapy, which focuses on the role of thinking in how we feel and what we do, or psychodynamic therapy, in which a patient develops an understanding of how past events are influencing current behaviors.
“In depression, which has been the most studied illness, cognitive behavior therapy is just about as effective as medication, and in some cases more effective, particularly when you’re talking about preventing depression over a long term,” Carlat says. Cognitive behavioral therapy is also “at least as effective” as medication, if not more so, for anxiety disorders, including panic disorder, he adds.
“The sad thing is that psychiatrists are missing the boat here,” says Carlat. “They are spending so much time and energy on different sophisticated medication combinations, and then often you have to treat side effects with more medications.” Sometimes medications even “start to cause psychiatric problems themselves,” he says.
Unhinged has had a mixed reaction among psychiatrists, Carlat says. “On the one hand, there’s a large group of psychiatrists, psychologists, lay people and social workers who are very pleased with the overall argument of my book, which essentially is that patients deserve more integrative care: therapy as well as medication,” he says. Then there are detractors, “a whole other group of people who are more conservative, mainstream guild-based psychiatrists who are very threatened by my position, who believe I’m selling psychiatry as a profession too short.”
Expanding Diagnoses
One of the key issues for psychiatrists is how diagnoses are made, which is often not clear-cut. Meet five of nine criteria for depression, say, and you’ll qualify for medication. But why it is five and not four? The answer is that it’s the number in the Diagnostic and Statistical Manual for Mental Disorders, or DSM, the bible for mental health practitioners. The DSM is written by committees of psychiatrists who vote on what criteria should define specific diagnoses. Not surprisingly, the criteria are subject to change, depending on shifts of opinion within the profession.
In Unhinged, Carlat recounts how the DSM, which is undergoing revision for a fifth edition, dictates the treatment of mental illness in this country. He uncovers a trend toward expanding diagnostic categories—a trend in which the psychiatric profession seems to collude with the pharmaceutical industry. For instance, many children who previously would have been considered healthy now meet the criteria for mental disorders such as attention deficit hyperactivity disorder (ADHD) and are duly medicated for them.
And if there are symptoms that don’t quite match up with the main classifications of mental illnesses, the DSM has a solution—what Carlat calls “wastebasket categories,” referred to as NOS, or not otherwise specified. “So somebody could get ‘depressive disorder NOS,’ and ‘bipolar disorder NOS,’ ” he says. “The DSM gives psychiatrists a way to diagnose even more people by allowing them to use the NOS category.” Drug companies benefit hugely.
“I think there is a really genuine argument to be made that the pharma industry does influence the DSM, if indirectly,” Carlat says. “They are the ones that have a big financial incentive to get psychiatrists to diagnose more and more disorders, because the more disorders that are diagnosed, the more of their medications get prescribed.”
Carlat cites the example of diagnosing bipolar disorder in toddlers. In 1996, a prominent psychiatrist published a study arguing that nearly a quarter of the children he treated for attention deficit hyperactivity disorder (ADHD) met his criteria for bipolar disorder. “Up until then, bipolar disorder was almost unheard of in younger children, but this study, published by such an influential figure, prompted psychiatrists throughout the country to dig for bipolar disorder in children,” Carlat writes in Unhinged. A subsequent study found that from 1994 to 2003, the number of children and adolescents nationwide treated for bipolar disorder rose forty-fold—a boon for drug makers.
But there are also other ways that psychiatrists serve the interests of Big Pharma, Carlat argues. A New York Times story he cites noted, for instance, that between 1997 and 2005, more than a third of Minnesota’s psychiatrists took money to act as spokespeople for drug makers, one being paid more than $689,000 over a seven-year period.
In Unhinged, he describes his own experiences giving paid talks to other psychiatrists for the drug company Wyeth. He was, he says, naïve about the implications of what he was doing, and quit after a year. Carlat ended up writing a story for the New York Times Magazine detailing his journey from drug company hired gun to critic, which needless to say didn’t win him many friends in the pharmaceutical industry.
“The practice of hiring physicians to give sales talks has become an integral part of the marketing strategy of all drug companies,” he writes. “According to a survey by Eric Campbell and colleagues [from the University of Melbourne], from 2003 to 2004 at least 25 percent of all doctors in the United States received drug money for lecturing to physicians or for helping to market drugs in other ways.”
A Natural Correction
A recent proposal making the rounds for a more integrated approach to mental health care is to allow psychologists to prescribe medications, which is currently legal in only a handful of states. Carlat supports the idea. Granted, psychiatrists are medical doctors and psychologists are not—which might seem to disqualify psychologists from prescribing medications. Yet as Carlat points out, the diagnoses that psychiatrists make are purely psychological.
The diagnostic process “involves asking patients questions, determining if they have delusional thoughts or hallucinations, if they are disorganized in the way they talk to you, the way they dress, their behavior,” he says. “There’s no brain scan, no blood test, no physical exam, no vital signs that help us in any way.” So “it becomes very hard to argue that psychologists should not be able to prescribe medications and diagnose these conditions with substantial extra training in psychopharmacology,” he adds.
Carlat advocates the integrative approach, and he sees this as a natural correction for psychiatry. He remarks that “there was a period when there was perhaps too much long-term therapy, and now the pendulum has swung to the point where we are doing too much medication treatment and not enough therapy.” Psychiatrists need to “bring things back to a more moderate level,” he says.
It’s worth noting that he practices what he preaches. Over the years, he’s begun devoting more time to his medication check-ins. He sees some patients for 45 minutes of psychotherapy in addition to prescribing their medications.
And he readily acknowledges that this way of doing business “isn’t easy.” At the end of his book, he talks about the challenges posed by a particular patient. To help just that one person, Carlat has had to put in extra hours studying psychological treatments for post-traumatic stress disorder. He’s spent more time simply listening, too. “You try to maneuver your schedule in a way that works best for your patients’ needs,” he says, “and that’s what I’ve been trying to do.”
Taylor McNeil can be reached at taylor.mcneil@tufts.edu.