"Medical school is the wrong place to train psychiatrists," writes Daniel Carlat in his new book, Unhinged: The Trouble with Psychiatry - A Doctor's Revelations About a Profession in Crisis. In place of the sort of education that makes psychiatrists fifteen-minutes-per-patient pill dispensers, and gives them little in the way of slower, psychotherapeutic skills, he proposes something like a "doctor of mental health" program: Perhaps "two years of combined medical and psychological courses, followed by three years of psychiatric residency."
An ego- and money-driven need to be the equal of other MD's will, as Carlat knows, probably keep this from happening any time soon; indeed, a need to feel that one's clinical activity has the same empirical warrant as a heart surgeon's will also keep the pills flowing.
Yet I lost track of the number of times Carlat, in the course of this book, cautions the reader that
new diagnoses are based on votes of committees of psychiatrists, rather than neurobiological testing. Because diagnosis in psychiatry is more art than science, the field is vulnerable to 'disease-mongering,' the expansion of disease definitions in order to pump up the market for medication treatment.
(There are any number of competing phrases for disease-mongering. My current favorite is psychosprawl.)
Elsewhere, Carlat writes, "Our diagnoses are subjective and expandable, and we have few rational reasons for choosing one treatment over another." "Our diagnostic process is shallow." "We know so little about the underlying neurobiology of ... causes that our treatments are often a series of trials and errors." "Psychiatry has yet to develop a convincing explanation for the pathophysiology of any illness at all." "I have no idea how Lexapro works to relieve depression, nor does any other psychiatrist." "To a remarkable degree, our choice of medications is subjective, even random. Perhaps your psychiatrist is in a Lexapro mood this morning, because he was just visited by an attractive Lexapro drug rep." "When psychiatrists start using what I call neurobabble, beware, because we rarely know what we are talking about. ... Using these words makes [the] illness seem more biological... But few laypeople realize how little we actually know about the underpinnings of these disorders."
Onto this unknowing shallow ground marches a tenth of the American population:
In 1996, 13 million Americans were taking an antidepressant; nine years later, in 2005, that number had more than doubled, to 27 million. One in ten Americans over the age of six is now taking an antidepressant.
Not surprisingly, "direct-to-consumer drug advertising has tripled in the last ten years, from $1.3 billion in 1999 to $4.8 billion in 2008." Drug firms prop up the empirical claims behind what are, in many cases, expensive placebos with side effects, by skewing research and publishing its always-positive results with the use of paid ghostwriters among medical school professors:
When they haven't been able to find academics to write up the results, they have hired ghostwriters, and then paid academics to simply put their names on the articles.
In the case of Zoloft, for instance, "the bulk of the medical literature was literally written by the drug company that manufactured the drug."
If, as the old joke Carlat quotes goes, "internists know everything and do nothing, surgeons know nothing and do everything, pathologists know everything and do everything (but a day too late), and psychiatrists know nothing and do nothing," the drug companies more than make up for psychiatric inactivity. Their brazenly illegal marketing practices mean that the companies pay out billions of dollars in legal judgments every year, but this is simply the cost of their hyperactivity. Tireless salespeople follow doctors around from their offices to their hospitals, plying them with gifts so that they will prescribe the company's new pill. The same salespeople are all over medical school campuses, cultivating prescribers-to-be. They chase down ghostwriters among greedy and corrupt university researchers.
Inchoate diagnoses, omnipresent advertising, and the generalized anxiety everyone's capable of feeling about whether they're a mite weird, makes for tens of millions of pill takers. Carlat quotes Paul McHugh, a Johns Hopkins psychiatry professor:
The problem is that the diagnostic manual we are using in psychiatry is like a field guide and it just keeps expanding and expanding. Pretty soon we'll have a syndrome for short, fat Irish guys with a Boston accent, and I'll be mentally ill.
Yet "the new drugs introduced over the past fifty years [for depression, schizophrenia, bipolar disorder and hundreds of subsidiary disorders] are no more effective than the original prototypes." They're more expensive, with more side effects.
So it's not a pretty picture. "Many of my patients seem tentatively held together by a patchwork of new medications whose mechanisms of action are mysterious and whose side effects are still being discovered. ... In treating emotional problems with medications, I worry that we are discouraging patients from learning life skills that they could use to truly solve their problems."
Carlat reviews the now-notorious cases of Joseph Biederman, Charles Nemeroff, Alan Schatzberg, and other targets of Senator Charles Grassley's crusade against corruption in the drug industry and in university departments of psychiatry. For years, their universities didn't care about the grotesque conflict of interest by which these men championed drugs that would make them rich. Biederman, a particularly nasty piece of work, insisted that millions of American children as young as two years old should be on powerful anti-psychotics. He was -- and remains -- at the center of what one influential journal calls an "ethical crisis" in child psychiatry.
[Biederman] did not adequately declare over a million dollars of income that he received from pharmaceutical compaines as consulting fees, calling into question the credibility and impartiality that he brought to several of the trials he guided.
Psychotherapy might be more effective and less physically destructive than powerful drugs, as Carlat suggests, but it's got one big problem:
For years [as a pill dispenser] I typically saw three patients per hour, and was reimbursed about $60 per visit... This worked out to about $180 an hour ... If I did therapy, I could see one patient in that hour, and insurance companies reimbursed anywhere from $80 to $100 for that visit. After expenses, this came down to around $70/hour. The bottom line is if I did therapy exclusively, I would have to take a 40-50 percent pay cut.
Carlat wants psychiatrists to become once again "psychological healers, returning to the basics of understanding our patients... Over the past two decades, psychiatry has gone astray. We have allowed our treatment decisions to be influenced by the promise of riches from drug companies... [and] we have unquestioningly sought to become just as 'medical' as other doctors, when we should embrace the fact that psychiatry is remarkably different form the rest of medicine."
Unfortunately, for all the eloquence and persuasiveness of Carlat's book, psychiatry takes place in the same culture as the rest of medicine. And that culture, as a wise colleague tells Carlat, "is obsessed with performance.... We love our stimulants in this country" because whether we're a Goldman Sachs trader or a college student, we always have to be on -- we can't be sad or a bit slow some days or musing or drifting even for a moment. We're pumped. We're wired...
Biederman, Nemeroff, Schatzberg -- these are psychiatry's highest-profile figures! They're sharpies, heavy-hitters, broad-shouldered men out there performing at the very top of their game every single day. Compassionate psychotherapy is for losers.