Monday, May 10, 2010

Unhinged-- The Trouble With Psychiatry by Daniel Carlat, my Review

Unhinged. The Trouble with Psychiatry--A Doctor's Revelations about a Profession in Crisis by Daniel Carlat.

Disclaimer: I wrote this book review while I was working on the final draft of our own book, so it's hard not to compare our book and style to those of Dr. Carlat. Ours is better (just so you know). This is not the result of a controlled study and there was no pharmaceutical agency support. It's simply my biased opinion.

So, I started out poised to hate this book. Dr. Carlat is a shrink/writer who has both a blog and an e-newsletter. He has a good reputation in the medical blogosphere, at least I think that's the case. So why was I poised to hate the book? I was offered a review copy by the publisher -- an inquiry email came with hype: "Carlat exposes deeply disturbing problems plaguing his profession." “The shocking truth is that psychiatry has yet to develop a convincing explanation for the pathophysiology of any illness at all.” "This has to stop—and it can. Throughout the book, Dr. Carlat provides empowering advice for prospective patients, describing the kinds of treatments that work, and those that should be avoided. In the final chapter, he provides a powerful prescription for how to get psychiatry back on track."

Yup, it's true, we don't know the actual pathophysiology of most of the psychiatric disorders. Is this shocking? Deeply disturbing? We've got a long way to go and we've got issues in our field. . Does it help to use language that sensationalizes these problems? It's kind of shocking that we haven't cured cancer, dementia, or obesity . I started reading. Carlat presents the fact that we don't know the actual causes of psychiatric disorders as though it's some big secret, something we purposefully withhold from our patients. He doesn't say that exactly, but he implies it with statements about how doctors don't like to admit what they don't know.

Okay, so the book is full of Carlat's epiphanies and revelations: he starts with the realization that it is limiting to see patients for a 50 minute evaluation, write a prescription, and then have the patient come back in a month for a 15-minute visit and refer them to a social worker or psychologist for therapy. Maybe this isn't the type of practice Dr. Carlat was meant to have! It's the way some psychiatrists practice, but it is not the way all psychiatrists practice. He writes as though this is the standard in the field and what we're "taught" to do. It's what some docs do and are comfortable with, but we aren't told that this is how you must practice, and no one packages this version of care as the best, highest standard of treatment. I personally don't like that he peddles the notion that a large volume/brief contact practice is the only thing psychiatrists do.

Later in the book, he talks about the use of therapy by psychiatrists, and discusses one psychiatrist who sees patients for psychotherapy -- she lives in a rural area and she makes half the income of the average US psychiatrist. She is the only psychiatrist he talks about who sees patients for psychotherapy--the others are a now-retired, lost generation of older docs who had it right. I know psychiatrists with psychotherapy practices who make reasonable livings. He doesn't even touch on this possibility, and in a single sentence he dismisses the idea of a fee-for-service, non-insurance based practice. It's not reasonable to present the field in the light that all psychiatrists do is write prescriptions....quickly and badly at that...and that there's no time for thoughtfulness. It got me thinking that -- at least among Shrink Rap readers -- and our informal, non-scientific polling reveals that 44% of readers who responded see their shrink for 45-60 minutes per session (the most frequent answer by far) and that less than 20% of readers see their psychiatrists for 15 minutes or less. Granted, we may have a skewed readership of those who are thinking a lot about their care and perhaps more apt to seek out something more fulfilling. A quarter of our readers see their psychiatrist weekly (also the most common answer but not by much), about the same number who see their psychiatrists every three months. At least among Shrink Rap readers, we can conclude that psychiatrists practice in a variety of ways and it's not uncommon for people to see psychiatrists for 50 minute sessions, or to see them weekly. I'm sure this varies depending on the region of the country, the availability of psychiatrists, the financial needs of those psychiatrists, the setting in which treatment takes place, and the role insurance has in determining care, and the age of the practice-- with the idea that patients may start out with weekly treatment and move to every one-to-three months after they get better. But Carlat glances over those issues. Dr. Carlat notes that fewer docs offer all their patients psychotherapy. One of the figures he quotes is that only 11% of psychiatrists offer psychotherapy to all patients at every visit. Hmm... All patients. Every visit. Some of this might depend on how we each define psychotherapy -- and there is no standard to that -- but if I was asked this same question, I'd say No. I work a half day a week in a clinic and there I see patients who also see a social worker/therapist. I see two patients an hour there, and sometimes they talk and I listen and sometimes it feels a lot like psychotherapy, and sometimes it doesn't feel anything like psychotherapy, but I would say that No, the therapy is done by the social workers and I don't "offer" psychotherapy to "every patient" I see in every capacity of my practice of psychiatry. And I would ask, "how exactly are you defining psychotherapy?" Read the Shrink Rap book (Spring, 2011) and we'll talk more about this. Interestingly, by the end of the book, Carlat talks about doing psychotherapy in 20 minute sessions.

Okay, so he says psychiatrists are taught to write prescriptions and aren't taught how to do therapy. Only he talks in some detail about his therapy supervisors, their thoughtful insights, how he was supervised in a psychodynamic style, and later he talks about how his training program educated residents in Cognitive Behavioral Therapy. Are we taught therapy or not? This all sounds quite reasonable-- what's he complaining about? For the record, I think I finished training at the same time Carlat started (so, 3 years earlier than he) at an institution with a strong biological focus, so I don't think our differences in opinion on how docs practice is about orientation or timing .At the end of the book, Carlat proposes some solutions: Psychiatrists should NOT go to medical school, it's a waste, and they should have more stream-lined training. All psychologists should be taught to prescribe medications. He had no problems with the DOD program in Louisiana, where 7 years of the program taught a total of 10 psychologists to prescribe. He says this type of program is safe and works well. He fails to note that it cost the military over $600,000 per psychologist (why? no idea?) and that's why they stopped it. Or that it did not decrease the mental health treatment shortage in Louisiana. I'll spare you my rants, you can read about
psychologist prescribing here, in a piece by Ron Pies and the article does reference Dr. Carlat. He talks about his own revelations that Cognitive Behavioral Therapy works well, that it's good to ask a patient with a recurrence of depression if anything is going on in their lives (funny how that works), and how he he now does a brand of therapy that he calls "therapy lite." I found the examples to be a bit condescending -- his description of therapy sounds a bit like common sense.

Carlat's book may make him enemies. I'm wondering who his audience is:

-- it might appeal to the anti-psychiatry audience, at least from the cover hype, only much of the book is a fairly reasonable discussion of our work, and so it's not really anti-psychiatry.

-- I don't think many psychiatrists will agree that medical school should be done away with for us, or that other professionals can do what we do as well and as safely.

-- The alarmist tone just didn't go over well with me.

-- Sometimes it felt like he quoted studies when they fit his agenda. There were several mentions of how psychiatrists feel inferior to other doctors, and I'm not sure what to make of that one. Is this a universal phenomena?

-- His bash on how pharmaceutical companies interface with psychiatry include some of our major psychiatrist players here. But if you want to hate the drug companies, this is the book to read.

So what was good about it, why did I read it to the end, and why would I ever put this review on Shrink Rap? After the beginning, Carlat presents a reasonable view of how the DSM is crafted, including the controversies about disclosure in the process of writing the new DSM-V. The most interesting part of the book, however, is his discussion of how the drug companies have influenced research, publications, and practice. Some of this I had read in the New York Times. Some was news to me. I've never seen this side of the pharmaceutical hard-sell -- it was interesting, a bit shocking, and definitely eye-opening. His insider's view of this world is revealing.

So is Daniel Carlat the emissary of truth and ethics while the rest of us remain busy trying to get the big bucks by seeing too many patients too quickly or by getting money unjustly from the pharmaceutical industry? Read the book and see what you think.


tracy said...

Another good review and discussion on "Reidbord's Reflections".

lockupdoc said...

I appreciate your review. In recent months I've read some of Carlat's writing about some of the topics you refer to--his rationale for psychologist prescribing, that he believes psychiatrists don't need to go to medical school, and various other slams against psychiatry. Our field is quite imperfect and in many ways still in its infancy. And I'm all for thinking critically and trying to figure out how we can do things better. But, I think much of what he says will do nothing but further discredit and further stigmatize our field and not help it to advance. As you say, it will appeal to the anti-psychiatry crowd.

Hopefully your book will help to balance the negative impact his may have.

Anonymous said...

wow. that was a defensive post. if i would have responded like that to any shrink i've ever seen, s/he would have been all over it.

i certainly don't buy all or even most of what Carlat says. But your post was something else! You might want to take some time to think about why you responded so vehemently in such a public setting.

Daniel Carlat said...

Speaking as the author, I understand the post. This is the kind of reaction I expected when I wrote the book, and I'm sure this is tame compared to other reviews that will be unleashed once the book actually hits the stands. I certainly am not trying to discredit the field, in fact I aim to vastly improve psychiatry, and I believe we need to "take back" our training from medical school and recreate ourselves as much more competent mental health practitioners who are experts at both psychopharm and psychotherapy. While I know there are those who see me as playing into the scientologists and other anti-psychiatry factions, I believe that I am submitting an honest critique and a call for reform.

By the way Dinah, I continue to love your blogs and podcasts no matter how many bad things you have to say about me!

Danny Carlat

Dinah said...
This comment has been removed by the author.
Dinah said...

So I started to respond to Anon and Dr. Carlat by engaging in this whole debate about psychologist prescribing and psychiatrists not going to medical school. I deleted it because I decided that I will leave that argument to those who will be inflamed by the topics.

When an author writes a provocative book, it's good to be prepared for those who will be provoked.

Danny--thank you for your gracious comment, and I think you're right that the Shrink Rap version will be tame.

Tracy: thanks for introducing me to Dr. Reidbord's blog.

Lockupdoc--I don't think the Shrink Rap book is particularly provocative. It explains what we do and talks about the different faces our field wears--so lots on split treatment and how that works, but I don't think we mentioned psychologist prescribing. I wasn't aware this was a source of psychiatrist controversy.

Ronald Pies MD said...

Hi, Dinah--

First, many thanks for the "shout out" to my article on psychologists "prescribing". For a less polemical and more philosophical piece, you and your readers may want to see my editorial on "Psychiatrists, Physicians and the Prescriptive Bond", in which I talk about the need for integrating psychiatry into the larger framework of general medicine, and why "prescribing" is a very misleading term for what physicians do.

Re: my friend and Tufts colleague, Danny Carlat, and his new book: I have just read sections of it so far, and I'll say that it is much more "temperate" and balanced than the lurid press releases from the publisher! I would counsel readers not to be put off by those ads, as Danny does have some important things to say about the field, even though we disagree about many
issues. For example, while, in principle, I support a reduction in the length of medical school to 3 years, I believe psychiatry must remain firmly in the fold of general medicine, while at the same time returning to its humanistic roots.

'Nuff said...thanks for the notice and for the book review. --Best regards, Ron Pies MD

Novalis said...

I think psychiatrists have suffered from years of overhyped expectations purveyed to some degree by others: the "Decade of the Brain" (which so far has added not one iota to our actual tools for treatment), glowing pharma ads all over the airwaves.

I don't know if the field is in its infancy; perhaps adolescence, searching for identity. It may be a protracted phase, best measured in decades.

Most psychiatrists obviously are neither sinister nor charlatans--they're doing their best with the limited means at their disposal.

It's interesting that in twenty years Prozac went from being too strong--a powerfully mind-altering drug threatening to distort society's mindset--to being too weak, no better than placebo. Psychiatrists are forever either mad scientists or quacks according to stereotype. In reality, they have 2.3 kids, listen to NPR, and tend to be liberal.

Anonymous said...

"So is Daniel Carlat the emissary of truth and ethics while the rest of us remain busy trying to get the big bucks by seeing too many patients too quickly or by getting money unjustly from the pharmaceutical industry? Read the book and see what you think."

I don't know about the first part, but the latter is definitely true of the majority, the MAJORITY of psychiatrists. I have worked with and seen several.

Anonymous said...

I find it interesting that the term anti-psychiatry is always used when there is criticism of the field. When there is criticism of other medical fields, you never hear anyone say, "that will appeal the to the anti cardiology crowd for example.

You're totally missing the point about psychiatry not knowing the actual pathphysiology of most disorders. Many psychiatrists (not all) have falsely claimed a chemical imbalance and have used it as false justification to keep a patient on meds for life.

Dr. Carlat has been very contradictory on this. He says that in this book he debunks the serotonin myth but when he meets his patient, JJ, as detailed in the article, Mind over Meds, he says that antidpressants will top up serotonin to a normal level. Dr. Carlat needs to explain that contradiction.

Finally, I agree with first anonymous that your critique comes across as very defensive. I too would like to know why what seem to be legitimate criticisms lead to that type of post.

Anyway, slinging mud like term anti psychiatry does nothing to help your field advance. Just saying.

Anonymous said...

"Carlat presents the fact that we don't know the actual causes of psychiatric disorders as though it's some big secret, something we purposefully withhold from our patients."

In my more-extensive-than-I'd-like experience, this is _exactly_ what psychiatrists do.

Daniel Carlat said...

Just to respond to anonymous' comment that I have been contradictory on whether we understand the mechanisms of antidepressants--I believe we have only the most limited understanding. Yet I find myself parroting the serotonin story to patients to this day, as a way of having something to say when they ask me what the heck these drugs are doing. I now usually say, "we really don't know how the drugs work, but one theory is..." yada yada yada. Anyway in the book I go through my understanding of the pitfalls in the serotonin hypothesis.

Anonymous said...

Since shrinks do not understand the long term effects of the meds they prescribe (no one does until it is too lae) and since the older ones have forgotten most stuff they learned in any rotation other than psych, why do they need to go to medical school esp when social workers do therapy in the clinic and you do it in your office. I would be more inclined to trust a urologist to diagnose a skin condition than i would to trust a psych to diagnose the chicken pox.

Dinah said...

Why do you think prescribing psychologists won't resort to 15 minute med checks. Nurse practitioners here do.

nardilfan said...

So 11% of psychiatrists offer psychotherapy to all patients at every visit (in the USA, presumably), do they?

Talk about the hard sell! I think that unless that 11% are psychiatrists who only take referrals from other mental health practitioners on the expectation that they will provide psychotherapy, it's inappropriate to offer psychotherapy to every patient at every visit, just as it would be inapproprate for a cardiologist to offer heart surgery for every patient at every visit.

I'd stop seeing a psychiatrist like that. It would feel like they cared more about their income that about what is best for me and my condition.

Anonymous said...

I think patients are sent very mixed messages. On the hand we're told we have a chemical imbalance, so then it becomes about finding "the" med or meds to correct that chemical imbalance. Then, physicians grumble about patients wanting a quick fix with a pill. Maybe if we weren't being told we've got a chemical imbalance then we wouldn't be expecting that the pill was going to fix the chemical imbalance.

I found that the more I was told I was a victim of brain chemistry gone awry, the more I believed I was helpless in any way to change my situation. Not particularly empowering.

~Another Anon

Daniel Carlat said...


Who knows how psychologists will practice? Certainly those medical psychologists I've met have told me that they typically see patients for 30-60 minute visits and focus on psychotherapy. Many have specialized in seeing patients who have been over-medicated by well-meaning psychiatrists who have been focused on treating every last symptom with meds. Using the usual psychotherapeutic approaches, such as CBT, such patients can often be weaned off some of their meds with a reduction in side effect burden. And of course the research on CBT shows that the effects are more long-lasting than meds, at least for prevention of relapse to depression.

Nurse practitioners tend to be steeped in the medical model, often even more so than psychiatrists. In my area, they do a great job nonetheless, because they always spend at least 30 minutes with their patients. Some do therapy, but most have little formal therapy training and therefore do supportive therapy to augment meds--which can work fine, of course, and frankly this is what most of my therapy consists of.

Anyway, to come back to your specific question. Psychologists are trained in a culture that emphasizes psychological approaches to healing and so in general I would be surprised if we saw a lot of 15 minute med check psychologists practicing. This has not happened in either Louisiana or New Mexico. But some will end up following the money like anyone else.

thecrazymusiclady said...

I happen to have the pleasure of working with some amazing psychiatrists who meet none of the molds described here, so I can't really speak to the 'norm' in psychiatry.

The best phrase I've ever heard to describe med use is this:
"The medicine is the get your head above water, so that you'll be more receptive to therapy". It's kind of hard to engage in CBT, DBT, or any other type of therapy when you're racked by intrusive thoughts, thoughts of death or suicide or worthlessness, and just all around feeling like crap. SO I love this statement.

That being said, I personally do not see a psychiatrist. I have a therapist I meet with every two weeks (money issues currently), and my GP who has a very good knowledge of psychiatric meds is my 'prescriber'. Since lots of people do see a psychiatrist as a 'prescriber', I would personally be VERY concerned if they weren't equipped with the medical knowledge to recognize side effects, understand how the meds are supposed to work, and have enough working knowledge of the human body to know something is going wrong. Yes, an older psychiatrist won't have the knowledge of someone fresh out of med school, but that's where continuing education comes in. Maybe that is what needs to be stepped up. (We have one who can't function during a code blue. I can do better CPR).

Multi-disciplinary approaches are awesome for a reason.

expended libido said...

Love the to and fro on the comments. I just finished residency and in the last year I have just been trying to figure out the vastness of difficulties that I am facing. Balance in spheres of life, personal and professional. Professional life is definitely run by the slogan "no dead time is good time". I am doing what all the senior people are doing in the group practice and that does resort to 15 minute med checks and obtaining money from the government coffers. There was a remark on the blog about the paperwork and all the "craziness" that comes from those 15 minute med checks and the lack of connection with patients. Over time I have read more than what I asked for, in terms of negative comments from physicians. Embittered souls trapped in what it seems like one of the circles of hell. I would not like to be one of them but then the question arises what to do differently. The "old timers" guide us in to the uncertain terrain of the future and the people who have figured out answers seem to be cloistered up somewhere, which is probably the thing one must learn.
Anyways great blog. Will definitely be following it.

moviedoc said...

Having just read that aspirin helps schizophrenia and bone marrow transplants help mentally ill mice I joked that we psychiatrists will have nothing left to treat but maybe cross dressing. Maybe that's another argument for non-medical training of those who treat non-medically associated (I was going to say caused, but we don't have a clue.) mental illness. But Dr. Carlat, did you forget that non-psychiatrist physicians write most psychiatric prescriptions? What do you propose to do about them? Will they all have to provide psychotherapy too?

Anonymous said...

Psychiatry is useless and dangerous and their drugs for depression are nothing but placebo's. But it gets worse, these drugs can serously destroy your life and turn it into a living hell.

Stamp in Post SSRI Sexual Dysfunction (PSSD) into your browser and see what comes up. I in 4 users of serotinic antidepressant drugs will develop peramnent loss of sex drive, and it is miserable I can tell you.

This is one useless and a totally crooked profession - because there are no biochemiacal imballances. But that wouldn't matter much, except these people can totally destroy your life with the toxins they prescribe.

Anonymous said...

I had a wife with biploar mainc depression; the pschiatrists solution was lots of pills and marriage counseling as if I had the problem. The courts lawyers and doctors have left me in financial ruination. My brother also has bipolar manic depression., he takes pills. Neither one of these people would have to take as many pills if they received cognitive therapy to help them to recognize boundaries and limitations; instead these people perpetuate their problems by allowing their condition to run rampant blaming people ooutside and away from them. Just like the literature says.

Paul said...

I had a wife with biploar mainc depression; the pschiatrists solution was lots of pills and marriage counseling as if I had the problem. The courts lawyers and doctors have left me in financial ruination. My brother also has bipolar manic depression., he takes pills. Neither one of these people would have to take as many pills if they received cognitive therapy to help them to recognize boundaries and limitations; instead these people perpetuate their problems by allowing their condition to run rampant blaming people ooutside and away from them. Just like the literature says.

Ed B. said...

Today, on a flight back from Los Angeles, I finished reading Unhinged. In my opinion, this book is filled with contradictions, misinformation, false assumptions, and errors in logic. It is irresponsible and destructive. I cannot see what would motivate a psychiatrist to publish something like this other than self-promotion and self-aggrandizement, two of the very sins the book points the finger at others for. I would love to write a rebuttal and a clarifying book to provide balance to what, in my opinion, amounts to intellectual/professional encopresis and smearing. I cannot see how this book is helpful to anyone other than promoting the author’s ambitions as a journalist. This is precisely the kind of material that damages our profession’s credibility and feeds into the anti-psychiatry forces out there. No other specialty in medicine, indeed no other profession at all, seems to have members who do things like this. Oh, and one more thing, I would add that I feel a little embarrassed to see that the author is now on faculty of the medical school from which I graduated and received a wonderful education in medicine, including psychiatry!

Surviving said...

Some day psychiatrists will realize many patients have learned to despise them and their field because of their own practices: trial and error, to heck with the side effects, it's all in your head, withdrawal -- what's that? Not to mention the condescension and disrespect for the patient's own subjective report of his or her own experiences.

Face it: The reason people hate psychiatrists is because millions have been hurt by psychiatric treatment. So-called anti-psychiatry is not a bunch of nuts -- so convenient for psychiatrists to dismiss them as such! That's outrage you're hearing.

Denial is a river in psychiatry.