One-Minute Book Reviews

May 29, 2010

Psychiatrist Daniel Carlat Diagnoses His Profession’s Ills in ‘Unhinged: The Trouble With Psychiatry’


“Psychiatry has become a proving ground for outrageous manipulations of science in the service of profit.” Unhinged

Unhinged: The Trouble With Psychiatry. By Daniel Carlat. Free Press, 256 pp., $25.

By Janice Harayda

Has the profession of psychiatry lost its mind? You might think so after reading this relentless and mostly successful assault on current practices in the field.

Daniel Carlat focuses in Unhinged on the harm that he believes has resulted from the march of psychiatry away from psychotherapy and toward the better-paying practice of prescribing drugs. And he forges links between that shift and many ills in his field, including scandals at top-flight hospitals, one-sided articles in medical journals, and pharmaceutical-company payments to doctors who hawk questionable drugs to their peers.

Some of the statistics in Unhinged are chilling. In 2006, an estimated 10 percent of all 10-year-old boys in the U.S. were taking the stimulant Ritalin or an equivalent each day, and shabby medicine often accounts for its use or that of other psychotropic drugs. Psychiatrists routinely write prescriptions after 15- or 20-minute consultations. They know so little about the biology of most mental illnesses that they prescribe based on little or no science. And they mislead patients by presenting as fact theories formed by working backward from the discovery that a drug seemed to ease the symptoms of a disease. One of the most popular of those theories holds that depression results from a “chemical imbalance” in the brain:

“… the fact that many antidepressants increase levels of serotonin has led to a serotonin deficiency theory of depression, even though direct evidence of such a deficiency is lacking. By this same logic one could argue that the cause of all pain conditions is a deficiency of opiates, since narcotic pain medications activate opiate receptors in the brain.”

Carlat delivers his indictment in a crisp, journalistic style that serves him well, though he writes with less depth and elegance than his fellow physician Atul Gawande. But he doesn’t take his critique of the profession as far as it warrants. He clearly wants psychiatrists to do more psychotherapy but doesn’t make a strong case that patients would benefit from this – only that they would benefit from fewer bad drugs. He seems to take for granted that psychotherapy “works.”

This view clashes with that of respected critics of the profession such as the social scientist Robyn Dawes, who drew on decades of research for his brilliant House of Cards, which argues that psychotherapy itself is a con game: There is no evidence that psychiatrists or psychologists are better at counseling than minimally trained civilians, and both types of professionals have strayed so far from their roots in the study of human behavior that they offer little more than glorified intuition.

Unhinged may have the worthy effect of prompting patients to demand better explanations for why certain drugs are recommended for them — and it would be welcome for that reason alone — but it has little to say to people who remain unconvinced that psychotherapy would be better than the cavalier prescribing of Prozac or Wellbutrin. If psychiatrists are as willing as Carlat suggests to pimp for drug companies, why should Americans trust them with their deepest secrets?

Best line: “ … psychiatry has become a proving ground for outrageous manipulations of science in the service of profit.”

Worst line: Carlat says that an Ambien drug rep named Valerie once gave him a gift worth about $25, and later that day, he saw a patient and thought, “Why not prescribe Valerie’s drug for this patient?” That phrasing is too neat. Carlat also appears to be rationalizing in some of his comments on why he served briefly as a paid drug-company rep for the maker of Effexor.

Caveat lector: This review of Unhinged was based on an advance reading copy. Some material in the finished book may differ, and some people in it are composites.

Furthermore: Carlat is a psychiatrist in Newburyport, MA, specializing in psychopharmacology, and an associate clinical professor of psychiatry at Tufts University School of Medicine.You can follow him on Twitter at a @dcarlat (www.twitter.com/dcarlat). Carlat tells why he quit giving paid talks for drug companies in the New York Times article “Dr. Drug Rep.” Some of the material in Unhinged about brain scans appeared in different form in an article he wrote for Wired, “Brain Scans as Mind Readers?”

Contrary to the date you see under the headline, this review was posted on May 31, 2010. WordPress appears to be having technical problems that have led to scrambled dates. For this reason, I’ve removed a May 30 post about my forthcoming review of the young-adult novel The Things a Brother Knows.

You can follow Jan Harayda (@janharayda) on Twitter at www.twitter.com/janiceharayda.

© 2010 Janice Harayda. All rights reserved.
www.janiceharayda.com

September 18, 2008

Maybe You Don’t Need That Colonoscopy or Those Statins — A Noted Doctor Challenges the Medical Establishment – ‘Let My Polyps Go’

Angioplasties and stents are "good ideas that proved bad."

“Dr. Hadler sees no evidence that mild high blood pressure or mildly elevated blood sugar pose much of a risk to longevity — certainly not enough to warrant the aggressive drug treatment often offered for them. The same goes for … the modest elevations in serum cholesterol that, these days, spell a statin drug for life for many healthy people.”

Self-help books that urge you to micromanage every health risk have become disease unto themselves. So it was cheering to see the New York Times giving serious attention to a new book by a noted physician who still believes that less medicine can be more.

Abigail Zuger, an internist and frequent contributor to Times, recently reviewed Worried Sick: A Prescription for Health in an Overtreated America (Univesity of North Carolina Press, 376 pp., $28), by Nortin M. Hadler, “a rheumatologist and professor of medicine at the University of North Carolina who is a longtime debunker of much the establishment holds dear.” Zuger wrote:

“Dr. Hadler may not actually keep a skull on his desk, but he might as well. We are all going to die, he reminds us. Holding every dire illness at bay forever is simply not an option. The real goal is to reach a venerable age — say 85 — more or less intact.”

Zuger adds that Hadler believes the way to achieve that goal is to ignore much of the conventional advice:

“Reviewing the data behind many of the widely endorsed medical truths of our day, he concludes that most come up too short on benefit and too high on risk to justify widespread credence.

“Dr. Hadler sees no evidence that mild high blood pressure or mildly elevated blood sugar pose much of a risk to longevity — certainly not enough to warrant the aggressive drug treatment often offered for them. The same goes for the extra 20 pounds that make you overweight but not obese, and the modest elevations in serum cholesterol that, these days, spell a statin drug for life for many healthy people.

“He deplores the careful attention we pay to the state of our coronary arteries. Angioplasties, stents, coronary artery bypass grafts — all these procedures, he writes, ‘should be consigned to the annals of good ideas that proved bad.’

“As for the screening that purportedly keeps us safe from cancer, mammography and the blood test for prostate cancer are, in his view, blunt cudgels that can harm as much as help. Nor does he want any part of routine colonoscopies: ‘Let my polyps go.’”

Zuger compared Worried Sick with a new guide by Nancy Snyderman, a surgeon and the chief medical editor of NBC News, who — as anyone who has watched her televised reports may know — is ever-ready to parrot the medical establishment’s prescriptive-flavor-of-the-week. And though Zuger doesn’t come down on the side of either approach, her review is lively, open-minded, and worth reading www.nytimes.com/2008/06/24/health/24book.html?ref=science.

To read more about Hadler and Worried Sick, click here uncpress.unc.edu/browse/book_detail?title_id=1545. Hadler’s book and individual chapters from it are available in e-book or downloadable formats through the Caravan Project www.caravanbooks.org/.

© 2008 Janice Harayda. All rights reserved.
www.janiceharayda.com

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