Monday, May 10, 2010

Unhinged-- The Trouble With Psychiatry by Daniel Carlat, my Review

Unhinged. The Trouble with Psychiatry--A Doctor's Revelations about a Profession in Crisis by Daniel Carlat.

Disclaimer: I wrote this book review while I was working on the final draft of our own book, so it's hard not to compare our book and style to those of Dr. Carlat. Ours is better (just so you know). This is not the result of a controlled study and there was no pharmaceutical agency support. It's simply my biased opinion.

So, I started out poised to hate this book. Dr. Carlat is a shrink/writer who has both a blog and an e-newsletter. He has a good reputation in the medical blogosphere, at least I think that's the case. So why was I poised to hate the book? I was offered a review copy by the publisher -- an inquiry email came with hype: "Carlat exposes deeply disturbing problems plaguing his profession." “The shocking truth is that psychiatry has yet to develop a convincing explanation for the pathophysiology of any illness at all.” "This has to stop—and it can. Throughout the book, Dr. Carlat provides empowering advice for prospective patients, describing the kinds of treatments that work, and those that should be avoided. In the final chapter, he provides a powerful prescription for how to get psychiatry back on track."

Yup, it's true, we don't know the actual pathophysiology of most of the psychiatric disorders. Is this shocking? Deeply disturbing? We've got a long way to go and we've got issues in our field. . Does it help to use language that sensationalizes these problems? It's kind of shocking that we haven't cured cancer, dementia, or obesity . I started reading. Carlat presents the fact that we don't know the actual causes of psychiatric disorders as though it's some big secret, something we purposefully withhold from our patients. He doesn't say that exactly, but he implies it with statements about how doctors don't like to admit what they don't know.

Okay, so the book is full of Carlat's epiphanies and revelations: he starts with the realization that it is limiting to see patients for a 50 minute evaluation, write a prescription, and then have the patient come back in a month for a 15-minute visit and refer them to a social worker or psychologist for therapy. Maybe this isn't the type of practice Dr. Carlat was meant to have! It's the way some psychiatrists practice, but it is not the way all psychiatrists practice. He writes as though this is the standard in the field and what we're "taught" to do. It's what some docs do and are comfortable with, but we aren't told that this is how you must practice, and no one packages this version of care as the best, highest standard of treatment. I personally don't like that he peddles the notion that a large volume/brief contact practice is the only thing psychiatrists do.

Later in the book, he talks about the use of therapy by psychiatrists, and discusses one psychiatrist who sees patients for psychotherapy -- she lives in a rural area and she makes half the income of the average US psychiatrist. She is the only psychiatrist he talks about who sees patients for psychotherapy--the others are a now-retired, lost generation of older docs who had it right. I know psychiatrists with psychotherapy practices who make reasonable livings. He doesn't even touch on this possibility, and in a single sentence he dismisses the idea of a fee-for-service, non-insurance based practice. It's not reasonable to present the field in the light that all psychiatrists do is write prescriptions....quickly and badly at that...and that there's no time for thoughtfulness. It got me thinking that -- at least among Shrink Rap readers -- and our informal, non-scientific polling reveals that 44% of readers who responded see their shrink for 45-60 minutes per session (the most frequent answer by far) and that less than 20% of readers see their psychiatrists for 15 minutes or less. Granted, we may have a skewed readership of those who are thinking a lot about their care and perhaps more apt to seek out something more fulfilling. A quarter of our readers see their psychiatrist weekly (also the most common answer but not by much), about the same number who see their psychiatrists every three months. At least among Shrink Rap readers, we can conclude that psychiatrists practice in a variety of ways and it's not uncommon for people to see psychiatrists for 50 minute sessions, or to see them weekly. I'm sure this varies depending on the region of the country, the availability of psychiatrists, the financial needs of those psychiatrists, the setting in which treatment takes place, and the role insurance has in determining care, and the age of the practice-- with the idea that patients may start out with weekly treatment and move to every one-to-three months after they get better. But Carlat glances over those issues. Dr. Carlat notes that fewer docs offer all their patients psychotherapy. One of the figures he quotes is that only 11% of psychiatrists offer psychotherapy to all patients at every visit. Hmm... All patients. Every visit. Some of this might depend on how we each define psychotherapy -- and there is no standard to that -- but if I was asked this same question, I'd say No. I work a half day a week in a clinic and there I see patients who also see a social worker/therapist. I see two patients an hour there, and sometimes they talk and I listen and sometimes it feels a lot like psychotherapy, and sometimes it doesn't feel anything like psychotherapy, but I would say that No, the therapy is done by the social workers and I don't "offer" psychotherapy to "every patient" I see in every capacity of my practice of psychiatry. And I would ask, "how exactly are you defining psychotherapy?" Read the Shrink Rap book (Spring, 2011) and we'll talk more about this. Interestingly, by the end of the book, Carlat talks about doing psychotherapy in 20 minute sessions.

Okay, so he says psychiatrists are taught to write prescriptions and aren't taught how to do therapy. Only he talks in some detail about his therapy supervisors, their thoughtful insights, how he was supervised in a psychodynamic style, and later he talks about how his training program educated residents in Cognitive Behavioral Therapy. Are we taught therapy or not? This all sounds quite reasonable-- what's he complaining about? For the record, I think I finished training at the same time Carlat started (so, 3 years earlier than he) at an institution with a strong biological focus, so I don't think our differences in opinion on how docs practice is about orientation or timing .At the end of the book, Carlat proposes some solutions: Psychiatrists should NOT go to medical school, it's a waste, and they should have more stream-lined training. All psychologists should be taught to prescribe medications. He had no problems with the DOD program in Louisiana, where 7 years of the program taught a total of 10 psychologists to prescribe. He says this type of program is safe and works well. He fails to note that it cost the military over $600,000 per psychologist (why? no idea?) and that's why they stopped it. Or that it did not decrease the mental health treatment shortage in Louisiana. I'll spare you my rants, you can read about
psychologist prescribing here, in a piece by Ron Pies and the article does reference Dr. Carlat. He talks about his own revelations that Cognitive Behavioral Therapy works well, that it's good to ask a patient with a recurrence of depression if anything is going on in their lives (funny how that works), and how he he now does a brand of therapy that he calls "therapy lite." I found the examples to be a bit condescending -- his description of therapy sounds a bit like common sense.

Carlat's book may make him enemies. I'm wondering who his audience is:

-- it might appeal to the anti-psychiatry audience, at least from the cover hype, only much of the book is a fairly reasonable discussion of our work, and so it's not really anti-psychiatry.

-- I don't think many psychiatrists will agree that medical school should be done away with for us, or that other professionals can do what we do as well and as safely.

-- The alarmist tone just didn't go over well with me.

-- Sometimes it felt like he quoted studies when they fit his agenda. There were several mentions of how psychiatrists feel inferior to other doctors, and I'm not sure what to make of that one. Is this a universal phenomena?

-- His bash on how pharmaceutical companies interface with psychiatry include some of our major psychiatrist players here. But if you want to hate the drug companies, this is the book to read.

So what was good about it, why did I read it to the end, and why would I ever put this review on Shrink Rap? After the beginning, Carlat presents a reasonable view of how the DSM is crafted, including the controversies about disclosure in the process of writing the new DSM-V. The most interesting part of the book, however, is his discussion of how the drug companies have influenced research, publications, and practice. Some of this I had read in the New York Times. Some was news to me. I've never seen this side of the pharmaceutical hard-sell -- it was interesting, a bit shocking, and definitely eye-opening. His insider's view of this world is revealing.

So is Daniel Carlat the emissary of truth and ethics while the rest of us remain busy trying to get the big bucks by seeing too many patients too quickly or by getting money unjustly from the pharmaceutical industry? Read the book and see what you think.