Two years ago, psychiatrist Daniel Carlat wrote a piece in the New York Times Magazine called Dr. Drug Rep, in which he told his story of being paid to push the anti-depressant Effexor to his colleagues.
Carlat joins Fresh Air contributor Dave Davies today to talk about his new book, called Unhinged: The Trouble With Psychiatry. But the book isn't just concerned with the influence of drug companies in the profession.
Carlat believes in prescribing medication, but he says too many psychiatrists have all but abandoned talk therapy — leaving in-depth interaction with patients to others — while they pursue medical fixes for mood problems and mental disorders.
"Based on a survey of psychiatrists throughout the United States [conducted by Columbia University], it turns out only 11 percent of all psychiatrists now offer therapy to all of their patients," he explains. "So essentially, 1 out of 10 psychiatrists are really doing psychotherapy on a regular basis."
He says time and billing constraints have also made it difficult for psychiatrists to integrate in-depth sessions back into their practices.
"I have hundreds of patients. And if I start to do one-hour therapy sessions with most of my patients, I am going to have to kick patients out of my practice because I won't have time to see them," he says. "So it's been difficult and I've had to do creative things where I don't do one-hour therapy sessions, I might do 45-minute therapy sessions or half-hour therapy sessions so I can still fit a fair number of people into my practice while performing what I would consider a better quality of psychiatry."
Daniel Carlat was trained at Harvard and is on the faculty of the Tufts Medical School. He edits a monthly newsletter called the Carlat Psychiatry Report.
Dan Carlat is an assistant clinical professor of psychiatry at Tufts University School of Medicine.
Dan Carlat is an assistant clinical professor of psychiatry at Tufts University School of Medicine.
On what Dan Carlat does
"We are in the business of making diagnoses using the DSM — the official diagnostic manual for the psychiatric disorders of the American Psychiatric Association. We make our diagnoses. And then we usually prescribe medications. And psychiatrists used to, in the past, also do a lot of talk therapy and used to combine drugs with talk therapy — although frankly, in the more distant past, maybe 30 years ago — before there were effective medications, we just did psychotherapy which, often times, was not terribly effective."
How a diagnosis is made
"It's very hard to make a psychiatric diagnosis and we're not talking about a diagnosis where we can get a blood scan or a brain scan or an X-ray. At this point, all of those types of things are research tools although we certainly hear a lot about them in the media. We do our diagnoses based on the kind of interaction that you and I are having right now. We have a conversation and I ask my patients questions about how they're feeling, what they're thinking, how they're sleeping, what their concentration level is, what their energy level is, and I put all of those pieces of information together and then I come up with a diagnosis based on the DSM guidebook that we have. And then once we have a diagnosis, I match those symptoms up with a medication. So modern psychiatry is really a conversation, a series of symptoms and then a matching process of medication to these symptoms."
On communication between a patient's psychiatrist and therapist
"Often we don't really get that much information. Presumably the psychiatrist and the therapist would be communicating frequently on an ongoing basis but ... these situations come up with alarming frequency when you split the treatment up between a psychopharmacologist and a psychotherapist.
On the length of visits
"There's kind of an unofficial policy among psychiatrists, at least among some, which is the 'don't ask, don't tell' policy, which is that when we have our patients coming in, we know we have 15 or 20 minutes to see them. We want to learn a certain amount about how they're doing, obviously because we want to make sure our medications are working and if we need to increase the dose. But on the other hand, we don't want to ask too many questions because if we start to hear too much information, we're going to run into a time issue where we're going to have to push them out of the office perhaps at a time that they're going to reveal something that could really be crucial to understanding their treatment."
On conclusive evidence in psychiatry vs. other fields
"We don't have any direct evidence that depression or anxiety or any psychiatric disorder is due to a deficiency in serotonin because it's very hard to actually measure serotonin from a living brain. Any efforts that have been made to measure serotonin indirectly — such as measuring it in the spinal fluid or doing post-mortem studies — have been inconclusive. They have not shown conclusively that there is either too little or too much serotonin in the fluids. So that's where we are with psychiatry. ... In cardiology, we have a good understanding of how the heart pumps, what electrical signals generate electricity in the heart. And due to that understanding, we can then target specific cardiac medications to treat problems like heart failure or heart attacks. Again, based on a pretty well worked out knowledge of the pathophysiology — again not perfect, but pretty well worked out."
Unhinged: The Trouble with Psychiatry — A Doctor's Revelations about a Profession in Crisis By Daniel Carlat Hardcover, 256 pages Free Press List price: $25
The Trouble with Psychiatry
For the last fifteen years, I've practiced psychiatry in a small town north of Boston. It is a solo private practice. I see mostly middle-class patients who come to me with depression, anxiety, substance abuse, and occasionally more severe problems, such as bipolar disorder or schizophrenia.
Like most other psychiatrists of my generation, I have specialized in prescribing medications and have referred patients in need of talk treatment to a psychotherapist. During my training at Massachusetts General Hospital, I was taught that we are on the threshold of understanding the biochemistry of mental illness. After I graduated from residency, I worked hard to keep up with the explosion of neuroscience knowledge, and I absorbed the intricacies of how to use the new psychopharmaceuticals as they poured forth from the drug companies at a dizzying clip. By harnessing these powerful medications, I thought I was providing my patients the best psychiatric treatment possible.
But a couple of years ago, I saw a patient who made me question both my profession and my career.
Carol, in her midthirties, had short brown hair and strikingly green eyes that were filled with despair. Once we were seated in my office, I asked her, "How can I be of help?"
"My father was killed in a car accident," she said, choking back tears.
"How awful — when did this happen?"
Carol told me that she had been in the car with her father, who was driving. They came over a rise in the road, and another car was just pulling out of a driveway in front of them. Her father tried to swerve, but it was too late. They collided with the other car, and her father, who was not wearing a seat belt, was killed instantly. Miraculously, Carol was not seriously injured.
Since then, she said, she had recurrent dreams about the accident, and couldn't prevent herself from replaying the scene during the day. The events would unreel themselves like a movie in front of her, and often she would start sobbing uncontrollably. I recognized these experiences — nightmares and flashbacks — as typical symptoms of post-traumatic stress disorder, or PTSD. I asked her a series of questions about other symptoms, such as poor concentration, insomnia, being easily startled, and the need to avoid situations reminding her of the crash, all of which are commonly associated with PTSD.
She said she was experiencing all of them. Her life was constricting inward. She drove rarely, avoiding especially the road where the accident had occurred.
"Are you avoiding anything else?" I asked.
"I won't watch TV. I can't read the newspaper. I never realized how many stories there are about car accidents in the news."
I asked her about symptoms of depression. She reported insomnia and poor motivation, but no suicidal ideation.
"The worst thing," she said, "is how guilty I feel."
"Why guilty?" I asked.
"It was my fault that we crashed. I got him upset."
Her eyes began to well up. "I was telling him that he shouldn't be drinking."
"He was drinking and driving?"
She nodded. "I told him I could smell it on his breath and that he shouldn't be driving. He got mad, started yelling at me. And then he floored the gas pedal, said something like 'Am I driving good enough now?' That's when it happened."
I could see that this was more than a simple case of PTSD. She would have complicated feelings about her father to wrestle with — grief, regret, and eventually a good deal of anger.
As the end of the hour approached, I told her a bit about PTSD, about the prognosis for recovery, and about the usual treatments.
"So what do you think I should do?" she asked me.
"I'd like to give you some medication to help you through this," I said. I wrote out prescriptions for the antidepressant Zoloft and for the tranquilizer Klonopin. Then I reached into my file cabinet, and handed her a business card. "And this is a good therapist who I often work with. I recommend that you give her a call and set up an appointment. The medication works better when you are also seeing a counselor."
She looked confused. "Aren't you my therapist?"
I shook my head. "Unfortunately, I don't have time in my practice to do therapy. I usually refer patients to psychotherapists whom I trust."
"So . . . am I going to see you again?"
"Yes, we'll schedule another appointment in about a month, to see how the medications are working. But in the meantime, I hope you'll have had a couple of sessions with this other doctor."
Carol still didn't look at all happy with this.
"But aren't there any psychiatrists that do therapy?"
"There are a few," I said, "but not many. They're hard to find these days."
After Carol left my office, I finished writing her intake note. I closed her chart, put my pen down, and looked out my office window at the white-steepled Unitarian church across the street. There was nothing unusual about my encounter with Carol. I did what most psychiatrists do when they encounter a new patient. I sat comfortably in my red leather chair, wearing my suit and tie, and I asked her a series of diagnostic questions. Her answers fit neatly into a recipe book of psychiatric diagnoses called the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition), and I pieced together a diagnosis that made sense to me. I then reached over to my desk, wrote out a prescription, and handed it to her.
Pondering this typical appointment, what struck me most was what I did not do. I am an MD, having gone through four years of medical school, one year of grueling medical internship in a general hospital, and three years of psychiatric residency at Massachusetts General Hospital. But, like most psychiatrists, I did little to take advantage of those years of training. I did not do a physical exam, nor did I take Carol's pulse or blood pressure. Indeed, the only times I stirred from my chair were to meet her in the waiting room at the beginning and to show her into my secretary's office to make a follow-up appointment at the end.
Just as striking to me as the lack of typical doctorly activities in psychiatry is the dearth of psychotherapy. Most people are under the misconception that an appointment with a psychiatrist will involve counseling, probing questions, and digging into the psychological meanings of one's distress. But the psychiatrist as psychotherapist is an endangered species. In fact, according to the latest data from a group of researchers at Columbia University, only one out of every ten psychiatrists offers therapy to all their patients. Doing psychotherapy doesn't pay well enough. I can see three or four patients per hour if I focus on medications (such psychiatrists are called "psychopharmacologists"), but only one patient in that time period if I do therapy. The income differential is a powerful incentive to drop therapy from our repertoire of skills, and psychiatrists have generally followed the money.
So, like most of my patients, Carol saw me for medications, and saw a social worker colleague for therapy. Her symptoms gradually improved, but whether this was due to the medications or the therapy, or simply the passage of time, I cannot say.
Carol's treatment was not particularly dramatic, but her story illustrates both the triumphs and the failures of modern psychiatry. Over the last thirty years, we have constructed a reliable system for diagnosing mental disorders, and we have created medications that work well to treat a range of psychological symptoms. But these very successes have had unpredictable consequences. As psychiatrists have become enthralled with diagnosis and medication, we have given up the essence of our profession — understanding the mind. We have become obsessed with psychopharmacology and its endless process of tinkering with medications, adjusting dosages, and piling on more medications to treat the side effects of the drugs we started with. We have convinced ourselves that we have developed cures for mental illnesses like Carol's, when in fact we know so little about the underlying neurobiology of their causes that our treatments are often a series of trials and errors.
Theories of the neurobiology of PTSD, depression, and the range of other mental illnesses have come and gone over the years, but we are still far away from a true understanding of the biological causes of these diseases. Clearly, thoughts and emotions arise from the activity of neurons, and it makes sense that when emotions are distorted severely, the neurons must in some way be "broken."
Theories about depression over the years have included different versions of the "chemical imbalance" idea. The 2009 version of the American Psychiatric Association's Textbook of Psychopharmacology reviews these candidate chemicals in depth.2 Researchers have found evidence of abnormalities in serotonin, norepinephrine, dopamine, cortisol, thyroid, growth hormone, glutamate, and brain-derived neurotrophic factor — yet no specific defect has been identified. Straying outside the world of chemistry, other researchers have tried to find the causes of depression through neuroimaging scans. But this research has been just as inconclusive. Some of the major findings include decreased activity in the left frontal lobe, a shrunken hippocampus, an oversized amygdala, disrupted circuits around the basal ganglia, and miscellaneous abnormalities in the thalamus and the pituitary gland.
The APA textbook authors, utterly unable to tie together these disparate findings, concluded that the "central question of what variables drive the pathophysiology of mood disorders remains unanswered." You can say that again. The problem is not in the enthusiasm or intelligence of the researchers — but rather in the inherent complexity of the brain itself. A typical brain contains one hundred billion neurons, each of which makes electrical connections, or synapses, with up to ten thousand other neurons. That means a quadrillion synapses are active at any given time — the number of people on 150,000 Earths. It is therefore no surprise that we know almost nothing definitive about the pathophysiology of mental illness — the surprise is that we know anything at all.
Excerpted from Unhinged: The Trouble with Psychiatry — a Doctor's Revelations about a Profession Crisis by Daniel J. Carlat. Copyright 2010 Daniel Carlat. Excerpted with permission by Free Press, a Division of Simon & Schuster Inc.