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

Has Psychiatry Lost Its Mind? A Review of Daniel Carlat’s ‘Unhinged’ Coming Soon

In late 2007 the psychiatrist Dan Carlat wrote a provocative article about why he quit giving paid talks for drug companies, many about Effexor, an anti-depressant that causes high blood pressure. Now he’s back with Unhinged: The Trouble With Psychiatry (Free Press, 256 pp., $256), a book that indicts his profession for shunning therapy for the more lucrative practice of prescribing medications. A review of the book will appear soon on One-Minute Book Reviews.

The ‘Tyranny of Positive Thinking’ and Cancer Patients — A Physician-Author Says That It’s Not Always Best to Tell People to ‘Be Optimistic’

Can you give too much encouragement to people who are ill?

By Janice Harayda

Not long ago, I reviewed Betty Rollin’s Here’s the Bright Side and objected to its theme that all human suffering holds “a hidden prize waiting to be found.” I argued that some losses are so sad — the death of a child, say — that urging people to find their “bright side” is cruel.

Later I read some interesting, related comments by Jimmie Holland, chair of Department of Psychiatry and Behavioral Sciences at the Memorial Sloan-Kettering Cancer Center. They appeared in an article Leslie Brody wrote about caring for her husband, who has pancreatic cancer, for the New Jersey daily, The Record, on May 20, 2007.

“Think twice before telling the patient to ‘be positive,’” Brody wrote. She added:

“Dr. Jimmie C. Holland, author of The Human Side of Cancer and a pioneer in the psychological aspects of the illness, has written about the ‘tyranny of positive thinking.’ When people insist patients should ‘be optimistic,’ they imply that those who get sicker may be to blame for not trying hard enough to stay upbeat and conquer the disease.

“Holland says a patient’s mind-set might help him stick to a grueling chemo regimen, but it’s less clear whether attitudes and emotions in themselves can affect tumor growth or the body’s response. Patients — and their families — should feel free to vent depressing and anxious thoughts without being judged.

“Instead of saying ‘Chin up,’ or, ‘You’ll be fine,’ it’s better to say, ‘Hang in there,’ or ‘We’re thinking of you,’ or ‘We’re hoping for the best.’”

Links: To read the original review of Here’s the Bright Side, click here www.oneminutebookreviews.wordpress.com/2007/08/21/. To read about The Human Side of Cancer, click here www.humansideofcancer.com.

© 2007 Janice Harayda. All rights reserved.

www.janiceharayda.com