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UnhingedReview - Unhinged
The Trouble with Psychiatry - A Doctor's Revelations about a Profession in Crisis
by Daniel Carlat
Free Press, 2010
Review by S. Nassir Ghaemi, M.D., M.A., M.P.H.
Jan 25th 2011 (Volume 15, Issue 4)

I have learned, through experience in writing and reviewing books, that years of labor in writing can be undone by an hour spent in thoughtless review.  I can understand it from the reviewer's perspective though too: so many books to review, so many other things to do. 

Indeed most readers, who are not themselves authors of books, do not appreciate how important the reader is to the book publishing process.  A writer can spend years agonizing on his material, but if a reader is not willing to put out an iota of effort to understand it, all those years will pass by the readers eyes as if they are but shadows.

I once gave one of my books to a senior colleague, a friend and advisor in the world of academia.  A few months later, in one of our meetings, he said he had read the book and proceeded to make some vague and general criticisms.  He admitted that he had read it in 2-3 days, because he "speed reads."  I could not say it, but I thought: You must also "speed think" and thereby you missed the point of my book.

Some books are to be tasted, Bacon once said, others swallowed whole, others chewed and digested slowly.  I would go further:  No book can be "speed read", with proper respect to the efforts of the author.

I say all this because I could not read, understand, and certainly comment on this book without having waited quite a while to digest what it means.  In so doing, I still fear I won't do it complete justice; I'm sure I've misunderstood some things.  But I will try.

A disclosure: I have known the author for two decades since he was a medical student, and we serve on the same academic faculty, and we trained in similar residencies with similar teachers, and he helped me publish one of my first books.  So we have a long, positive personal history, which readers should take into account.  If anything, I think my personal regard has made me even more hesitant to express disagreement with the content of Dr. Carlat's ideas.  But the academic life has, as William James said, its heroic responsibilities, and so I will try to present my views here in relations to the author's ideas although I may be biased in his favor given my personal experiences with him.

A younger colleague told me he was much impressed by Dr. Carlat's book because it at least does not take psychiatry for granted; it sees something as wrong, and seeks to address it. I agree. This is the main benefit of the book, in my view, and a not inconsiderable one.  On the one hand, it is not particularly original, because there are a host of books that criticize psychiatry these days. On the other hand, there still seems to be a bedrock of resistance with psychiatry to recognizing that our ship is not sailing straight.  Or if we think it is off course, that the course correction is to go further off course, thinking that we are setting it straight.

My view is that Dr. Carlat takes the latter approach.  I agree with his diagnosis that something is wrong.  I don't agree with his prescription for a solution. I'm not even entirely clear what that prescription is.

One reads about "integrative" psychiatry; the specific examples he gives here and in earlier newspaper articles have to do with listening to patients more, not just giving them pills for symptoms in rapid "med checks."  Agreed. But in the example he gives in a New York Times magazine article, he listens to someone more closely, then determines the patient has marked inattention, and prescribes an amphetamine, which of course makes the patient feel better, hence confirming his approach. 

This seems to me to be analogous to seeing a patient with pain symptoms, listening closely to all the descriptions of pain symptoms, then prescribing opiates for the pain symptoms, which of course make the patient feel better.  But, in the process, one might ignore that the pain symptoms might be caused by a disease, like bone marrow cancer, and that person's disease would be left untreated, and ultimately harm the patient.

In this book, the author discusses the overdiagnosis of ADHD and the risks of overuse of amphetamines, but he doesn't seem to appreciate the inherent risks of this symptom-based approach to psychopharmacology:  "…while I prescribe plenty of stimulants, I also know how important it is to scrutinize [the pharmaceutical industry's] claims at every turn."  

The fatal flaw I see in Dr. Carlat's approach is that he simply replaces "med-check" symptom-based psychopharmacology with "integrative" symptom-based psychopharmacology. One listens to patients more, but then does the same thing.  Since symptom-based psychopharmacology is simple (anxiolytics for anxiety symptoms, antidepressants for depressive symptoms, amphetamines for cognitive symptoms), he then recommends expanding prescribing privileges to psychologists.  This is not just an answer to a practical problem (not enough psychiatrists) but importantly it is an answer to a theoretical problem (psychiatry is too biological). I think it just exaggerates the problem (psychopharmacology is symptom-based).

He ends this book with another example of eclectic psychopharmacology:  a young woman who was abused by her father as a child has PTSD symptoms.  The authors listens carefully and attentively and takes many notes, and prescribes the SRI Celexa.  She notices some benefit but also feels she needs therapy for her anxieties especially in relation to her own children.  I agree with the need for psychotherapy; I don't see the need for the Celexa, especially when this is just the kind of scenario when the benefits of antidepressants are minimally, if at all, better than placebo.

"Medications became the new [psycho]therapy" as one chapter title has it. It seems the solution is psychotherapy plus medications, the standard eclectic solution of more is better.  We still don't see, in this approach, an answer to the question: What is the best solution in circumstance X versus Y?  Are there conditions or setting where just medications, or just therapy, might be the right answer? 

Do I have a better solution?  I've written two books on the topic and can't do justice to the matter in a paragraph, and this review is about the author and not about me, but I'll try to give the essence of my alternative.  Psychiatry has always gone back and for the between dogmatisms, initially biological reductionism and then psychoanalytic orthodoxy.  About three decades ago, an eclectic cease-fire occurred, called the biopsychosocial model, in which any or all approaches were deemed acceptable.  Consequently, the new medications were increasingly used, and the old psychotherapies maintained.  This approach is at its core, conceptually, eclecticism: the view that any method or theory can be right.  The eclectic philosophy assumes that more is better, hence the common combination of drugs and psychotherapies.  But the problem is that this approach produces professional anarchy: there is no rhyme or reason to what many clinicians do.  (This agrees with the diagnosis made in this book, though I provide a cause not discussed in this book).  Because no one can really defend what they are doing well, the pharmaceutical and insurance industries push the profession economically in the direction of drugs and brief visits or hospitalizations.  The solution:  one has to be neither eclectic nor dogmatic.  There is not one single method or theory that applies everywhere (dogmatism), nor are any or all methods fine (eclecticism).  Some methods are better for some conditions, and not others.  One can call this method-based psychiatry. So the biological disease method is appropriate for likely diseases, like schizophrenia or manic-depression, but not for likely social problems, like divorce-related insomnia.  The psychoanalytic method is appropriate for trauma, the existential method for problems of living, social methods for public health problems (poverty-related child abuse, neglect-related childhood inattention).  Dimensional approaches are appropriate for understanding extremes of personality traits (like neuroticism, rather than the disease-like categories of "personality disorders").   In each of these settings, one method is the best, and the other ones should not be used. Occasionally, if the scientific evidence shows it to be the case, some conditions (like perhaps "neurotic depression", an appellation missing in DSM-IV, but which has reasonable scientific merit) might be best understood by use of more than one method (e.g., biological and existential approaches), although even there methods might be used sequentially rather than simultaneously, or ad hoc, as is currently the case.   This kind of thinking has been fleshed out in the works of Karl Jaspers, originally, and Leston Havens and Paul McHugh, more recently, and I've tried to extend and expand it.  It is much more complicated than eclectic treatment of symptoms with drugs and/or psychotherapy, but it is both more conceptually clear and scientifically-based.

So, on the question of when and how to use drugs, my solution would be to reject symptom-based psychiatry and move to a disease-based psychiatry, just as in medicine. That patient's inattention may be due to depression or mania or anxiety, all of which can happen in bipolar disorder, for instance. If she has that disease, then the treatment is lithium, not amphetamines, which in fact can worsen bipolar disorder in the long run.  If the patient does not have bipolar disorder, I'm not certain I would recommend any medication prescription, much less an addictive drug which, in animal studies, causes hippocampal atrophy, and thus may worsen cognition in the long run.  In this sense, I think my approach is more conservative pharmacologically, even though it is more biological, than what is recommended here.

This is only one aspect of the discussion in the book.  I will not get into the deserved critique of the excessive marketing of the pharmaceutical industry, although that is the main aspect of the book that seems discussed in some settings, such as the author's National Public Radio interview. Such public influences are not minor.  This is a "trade" book, in the publishing lingo, put out by a major New York publisher for the general public.  It is not an academic book published by a university press. As such, it has wider impact in society. The author knows how to write for the larger public, a skill which is to be admired, and which we psychiatrists should all seek to practice.  What he says, though, will be interpreted through the assumptions of our larger society.   In the general public, whatever the author's intentions, this book will be seen as another attack on psychiatry, feeding into the stigma against the field and against mental illness that is already a major social prejudice.  One gets the sense of this from the press release provided by the publisher:  "….the overdiagnosis of mental illness has gotten so out of control that the diagnosis of bipolar disorder in children has increased by 8000 percent [italics in original] in just nine years."  What the press release doesn't say is that the starting point was a diagnosis rate of practically zero (literally 0.01%) which increased 40-fold (yes 8000%) to the whopping figure of 0.4%, which, by the way, is the actual frequency of bipolar disorder in children according to the most accepted scientifically valid NIMH epidemiological study.   Put another way, 99.6% of children are not diagnosed with bipolar disorder: a major epidemic. 

This kind of exaggeration is expectable and appears to have happened since the book's publication; unfortunately such books lend themselves to such misinterpretations.  In that sense, I think the book may be both more and less than people might understand.  It is not just another critique of the pharmaceutical industry, and as such, it may just add to the cacophony of critiques that does not inherently clarify many of our current problems. It is a larger critique of psychiatry, with a proposal for more psychotherapy and more symptom-based medication treatment extended to non-physicians.  In that larger critique, I think the view expressed here is an extension of, not the solution to, the current fatal problem of psychiatry: an "anything goes" eclecticism whereby any and all symptoms are treated with any and all drugs (plus or minus psychotherapies).  The authors seems only to want to remove the minus sign in front of the psychotherapies, and to remove pharmaceutical marketing as the reason to use drugs: drugs are still to be used plenty, based on deeper psychotherapeutic understanding of a patient's symptoms.   For those seeking a broadside against the pharmaceutical industry, there is plenty of legitimate material here.  For those more profoundly critical of the overuse of drugs in psychiatry, or seeking a new approach to psychiatry beyond our current eclecticism, this is a sheep in wolf's clothing. 

 

© 2011 Nassir Ghaemi

 

S. Nassir Ghaemi, M.D., M.A., M.P.H., Director, Mood Disorders Program, Tufts Medical Center, Dept of Psychiatry. Dr. Ghaemi is author of The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness, Johns Hopkins University Press, 2003.  His book A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness will be published later in the year.


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