. . . A Doctor's Revelations about a Profession in Crisis
Review by Richard Evans, M.D.
Dr. Daniel Carlat is a serious practitioner of psychiatry as well as the founder and editor-in-chief of a monthly psychiatric newsletter. (Full disclosure: I have subscribed to his Carlat Psychiatric Report for many years and find it eminently readable, informative and trustworthy.) He is deeply troubled by the state of psychiatric practice and wants to do something to make it better. Written in sorrow and in anger, Unhinged: The Trouble with Psychiatry -- A Doctor's Revelations about a Profession in Crisis provides an account of the lessons learned in his career since the early 90's combined with a comprehensive overview of the past three decades in the field. It shines a strong light on both the inflated claims and misrepresentation of research data contained in drug promotion directed at (unfortunately) susceptible psychiatrists. Finally, it mourns the loss of what he refers to as "the missing skill", i.e. the use of psychotherapy as an integrated part of psychiatric treatment.
Psychiatry has become the practice of psycho-pharmacology (surely needed for "difficult" cases), while social workers, psychologists and other "mental health" professionals are called upon for psychotherapy while the "easy cases" are medicated by primary care physicians and physician assistants. Dr. Carlat sees this as fragmentation of care, or, as the title of his book states , "unhinged." It is not only psychiatry that is "unhinged" but the entire health care system. Thus the story he tells so well needs to be expanded in order to fully appreciate how this has happened.
Carlat entered psychiatry in the early 90's after having been trained in programs devoted to biological treatments (primarily medication), with little or no attention paid to the teaching of psychotherapy or its integration into treatment. This arrangement of training priorities began to develop in the 80's when neuro-scientists (primarily psycho-pharmacologists) became directors of psychiatric training, displacing the clinicians who had held sway during the decades when psychoanalysis was deemed the best and only worthwhile form of therapy. Psychoanalysis was, in terms of its claims, a disappointment and the new medications (antipsychotics antidepressants, and anti-anxiety drugs) seemed to relieve people of symptoms more quickly than "talk therapy" and at lower cost.
Health insurance companies were delighted with this and soon began to balk at significant reimbursement for "talk therapy". Concurrently there were substantive developments in psychotherapy (e.g. family and cognitive behavior therapy) that were becoming part of the training curriculum of psychologists and social workers. In the world of Big Pharma the new psychiatric medications became a central focus in terms of drug development (in which they were short on innovation but long on the promotion of what are called "me too drugs") and heavy marketing to physicians.
Connections between academic research and drug company funding (as Carlat fully details) strengthened. Drug companies were eventually found to be untrustworthy and research findings often questionable, news that has saturated the last decade. But these realizations came slowly. In the meanwhile, psychiatrists found the allure of psychopharmacology was strong both in terms of apparent drug effectiveness and insurance company reimbursement. To a great extent psychiatry became only psychopharmacology, and the former ideal of psychiatry as practice within an integrated "bio-psycho-social" model was lost.
Carlat mourns this loss, as I do, but I'm not sure there is any way of restoring that integrative model of treatment given the economics and politics of our health care system. Psychiatry has always had an awkward place in medicine. There is a widespread belief that psychiatrists are not "real doctors" and the fact is that much (though not all) medical training is of little relevance to the practice of psychiatry. Of course psychopharmacology rescues psychiatrists from this; the use of psychotropic medication is at least as complex and challenging as any other in terms of diagnosis, choices, side effects, follow-up and so on. And, like "real doctors", they have precious little time to "talk" with their patients though many squeeze this into a 15 minute medication session (as does Carlat). Outside of psychiatry non-medical mental health practitioners take up the psychotherapy and both sides attempt to stay in communication so that the mind-body separation does not lead to fragmentation of care. Insurance companies are happy because non-medical therapists charge significantly less than doctors, though some psychiatrists opted to lower their fees so that patients could use their insurance to pay for therapy.
The attractive solution for psychiatry advanced by Carlat is the development of a five year training program, similar to that attempted in the 70's by Dr. Robert Wallerstein, leading to a Doctorate in Mental Health. The program would be comprised of two years of medical training with emphasis upon neuroscience and three years of clinical training in psychology and therapy techniques. One weeps considering how eminently sensible this would be and the small chance it has of occurring. Here one must think "turf" and how this upheaval would be opposed by the powers-that-be in medicine,psychiatry and psychology.
For now we will most likely hobble along within a market-based model with fragmentation of care for both those in the public health system with major mental illness and those like Dr. Carlat's patients who are less ill, have decent health insurance and can afford drug treatment and psychotherapy. Those who see doctors like him will be fortunate, receiving trustworthy guidance in a system where trust has become a precious commodity.
A favorite quip in psychiatric journals is that the field has moved "from the brainless 50's to the mindless 90's." In other words the pendulum has swung from an almost worshipful belief in psychoanalysis to an over-emphasis upon biological factors and reliance upon drugs. Somehow we manage to lose the sane middle ground. This is harsh self-judgment of a profession that has an extremely challenging mandate, continually revises its theories and accepts new findings even if uncertainty and discomfort is the price to be paid. Since calls for help will continue, resisting claims about new drugs (or devices) that are either overly enthusiastic or downright dishonest will be a continual necessity and Dr. Carlat will be in the forefront of that effort. Some psychiatrists will seek post-residency training in psychotherapy and abjure the role of psychopharmacologist or create a workable synthesis in practice. Taking his book seriously will lead, if not to rebuilding of the house, at least an effort to keep the roof from caving in.
Dr. Richard Evans is the Director of Mental Health Services at Volunteers in Medicine (VIM), Great Barrington, Mass. He has been on the faculties of the departments of psychiatry at Einstein College of Medicine, and Columbia Presbyterian Hospital, and a former staff psychiatrist at Gould Farm. He is a recipient of the NAMI Exemplary Psychiatrist award.