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Dan Carlat MD has just come out with a book on American psychiatry that has got a lot of people talking. In Unhinged: The Trouble With Psychiatry – A Doctor’s Revelations About a Profession in Crisis Dr. Carlat describes the practices of the typical psychiatrist. In order to generate the most income, most of the appointments are 15 minute “med checks,” and the treatments are based on psychopharmacology and the biological psychiatry model. Patients are fed the pharma marketing explanations of how psychotropic medications work, providing solace for all involved, although there really isn’t good evidence for the explanations. Meanwhile, psychiatrists have farmed out therapy to the other professions, and have adopted a herd em through mentality toward their patients.
A July 13, 2010 interview about the book with Dr. Carlat on NPR’s “Fresh Air” show (which you can listen to here) has evoked some controversy. Giovanna Pompele wrote a critique on the Beyond Meds blog that takes him to task for his comments. She feels that by describing these practices and not apologizing for them, or implying that they still go on, that he is committing an offense. He also had some people throw some rocks about the implication that psychiatric training did not place a high value on therapy training.
I’m not sure I really see it that way. I think it is good that he is bringing this stuff out into a public discussion. I too used to give “drug talks” (see “Confessions of a Psychnetter“) but at the time I deluded myself into thinking that I was providing a useful “education”. However when they wouldn’t let me pick my own slides I realized I was doing nothing more than paid ads for the drug companies, and they dropped me for being difficult. I didn’t like it anyway, because the conversations with the psychiatrist attendees were like “I gave her Zoloft, and she got sleepy, so I gave amphetamines, and she developed… what should I do now?” Years later, the situation has degenerated to the point where my academic physican colleagues openly bemoan the fact that they can’t give “promotional talks” (yes, they actively call them that now). As for clinical work, I refuse to do the 15 minute med check thing, and restrict my clinical work to doing one hour evaluations. The part about telling patients that antidepressants increase serotonin in the brain is kind of a joke, because that is just marketing PR, and researchers like myself who have spent a lot of time reading the primary literature know it is a joke. However I’n not sure how much psychiatrists in the community have read that literature.
The idea of prescription medications like psychotropics being used to treat chemical imbalances has been burned into the public consciousness. Just take the example of Lindsay Lohan, who is on trazodone, Zoloft, Adderall and dilaudid, mixed with alcohol and cocaine, just one in a string of celebrity disasters to bite the dust on these lethal combinations. And when I pointed that out on TV last night, a caller practically took my head off, and there was a general discussion about her “depression” and how she needs to keep her meds in jail. How do we know she has real depression until all those drugs get out of her system? You don’t throw prescription meds at people who are actively abusing drugs (oopes, unless they are a Hollywood celebrity, of course).
I also see a little bit of the reaction to the acadmic psychiatist speaking the truth syndrome which is like “get him!” The whole psychiatry field has been perpetuated by myths and disttortions for so long that when someone talks frankly everyone freaks out.
By way of disclosure Danny wrote thispost in my support last year. I mention this as as a disclosure of my potential bias.
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Good commentary Doug.
I took great offense at Carlat’s interview because I feel totally duped. In reading excerpts from his book, made available on the internet, I got the distinct impression that he had recognized the errors of his ways in sticking to the strictly bio treatment model and doing nothing more than pill pushing to patients who sought his help.
In reading his interview, I realized I was totally wrong and worse yet, he admitted he is still telling patients the lies most complained about in the field of psychiatry.
Putting myself in the role of patient, I feel his attitude toward patients is totally demeaning and he views us as idiots.
Like we’re cattle – move em in and move em out. Never mind if we have an extreme or immediate problem we desperately need to talk about – the money meter is running.
Admitting that he was prescribing sleeping pills to an elderly woman for year and never even realized she was drinking heavy with them was revealing – and disgusting.
I’ll tell you what I think. Carlat has been running a great scam with his blog and saying everything he knew people wanted to hear to make it seem like he was a reformed highly paid quack when the whole act was staged because he knew he had a book coming out to sell.
The guy’s good – he had me totally fooled.
The problem was that he acted like what he was doing was completely fine and dandy… Why did that interview make me think of the banality of evil?
Because he is evil. Evidenced by the fact that he says the things he does without even recognizing how he comes across.
Obviously he doesn’t feel the least bit guilty about lying to patients or being nothing more than a drug pusher in a white coat writing scripts for useless pills that cost a fortune and have tons of side effects.
I agree, Evelyn… Well, I always had a bad feeling about him, like he was somehow capitalizing on his rogue status… Whereas even though Doug is more mainstream than I would like (from a medical perspective) and is still a fucking psychiatrist (sorry for the profanity, but those two words seem to belong together)… I never doubt his ethics
Very true Kimbriel. Doug talks in layman’s terms with few, if any, caveats.
Now that I’ve been paying attention, I noticed that Carlat is always quick to give psych drugs a plug. But then he’d have to being that’s all he still does – push pills. I think he even recognizes that he could continue to rack in $1,000 an hour writing scripts if he admitted that the benefits of the pills did not outweigh their risks accept in the most severe cases of mental illness.
Also, how could he continue to dole out psych drug cocktails, which have never been tested on animals, much less humans, if he did not continue to claim the drugs worked.
I’ve come to the conclusion that he only quit his shill job for Effexor because he could make more money per hour sitting in his office writing scripts.
I’m not sure many community psychiatrists have read the primary literature either. I’m an ER doc, and I’ve read it, and I am equally unconvinced, honestly. Serotonin is an insufficient explanation for the frankly very minor effect most meds have on mild to moderate depression.
As for Carlat…haven’t heard the interview, and so don’t have a basis to say much about it. OTOH, I’ve read his blog, which is cogent and on target. A lot of what he says, by the way, could apply just as well to other fields of medicine-in particular, cardiology is a heavily marketed practice.
Speaking personally, I have declared myself a drug-rep free zone since about 1995, when I graduated from residency. My residency used to allow one drug rep sponsored event per week (the weekly academic conference had a drug rep lunch with a brief (5 minute) talk from the rep to “pay for the lunch”. It always made me uncomfortable, and I have learned that shortly after I completed my training they moved to a department sponsored lunch and banned drug reps from the department; they were later banned from Boston University entirely.
As an FYI, Dr. Carlat did attempt to clarify his comments on his blog. He said the chemical imbalance is a theory but it may be something else. He goes on to say the drugs work, wink, wink.
I am not the best summarizer so if you want to read the whole post, please go to the link Doug posted.
I am not buying his explanation. It sounds like he still believes the Serotonin issue. Otherwise, why would you mention it?
And to keep insisting they work. That says it all.
Doug, you do make some good points. Part of me was glad that Carlat mentioned things I had long believed. But another part of me was angry as heck that he could be arrogant. Actually, no offense but actually alot of your colleagues are.
Thanks for bringing up the topic, I think:)
I noticed Carlat’s attempt to explain. I’m not sure whether it was on his site or in comments on the interview site.
Don’t buy it – he is not stupid or naive. He spoke the truth during the interview.
I have to say I was really amazed to see how many people let him know what they thought of him. Before I read all the comments by other people I had started to wonder if maybe I had overreacted. Was relieved to find I had not.
All that said, it occurred to me yesterday that shrinks who make a living strictly by pushing pills don’t dare say the drugs don’t work because there would be no reason for people to go to them.
They’d be an unskilled worker in the unemployment lines.
Evelyn, I wish it was just greed or needing to pay the bills but the fact is, I think shrinks are just delusional….
Hi Evelyn,
The comments are on his blog as I posted there. I was angry as heck.
Kimbriel, they are definitely delusional.
Hi AA. I saw your comments. I just posted a link to Carlat’s site on my fb.
There are definitely a fair share of arrogant shrinks out there. I always saw those stupid serotonin diagrams from pharma marketing and just rolled my eyes. When people ask me about neurobiology I point them to one of my books or websites. There is nothing wrong in there although heavy at times. What I didnt realize is that pharma had trained the psychiatrists do give this goofy over simplified story.
I think the propaganda involved in the chemical imbalance lie might be a chicken or the egg case.
there was definitely a whole generation of “academic psychiatrists” who were willing to go along with the lie.
Oh I know and to some of their credit, I think they believed it for some time. A shrink told me that in probably 1975 and he was definitely a good guy – I’m sure he believed it.
Evelyn, Not to make light of your concern over Carlat’s practice, but I wouldn’t worry too much. The people in Newburyport have sailboats and bookstores and can find stuff out.
Evil? Not that I’m defending him, but if you think he’s evil, I’d say you haven’t seen the face of evil.
The bottom line about Carlat is, that he is still a practicing psychiatrist who bases his treatment on medications, and is a member of the APA which touts the same paradigm. As an ex-sales pitch guy for Effexor, he appears to have grand ideas in his book…namely to help mentally ill patients ‘find out’ they need help, via giving psychologists ability to rx medications, you see he believes ppl do not have enough treatment, due to a shortage of psychiatrists in America. So he wants to explode onto the scene MORE drugs more drugs more drugs more drugs more drugs.
Until Carlat says I QUIT he is what he is, and represents psychiatry in America perfectly.Everything that is wrong with the psychiatric paradigm is what Carlat represents.
Slick salesman.
In case anyone missed the ‘live’ Twitter interview of Carlat w Ivan Oransky (Reuters Health) here’s a link that has an article and the Twitter feed you can scroll to re-read.
http://blogs.reuters.com/great-debate/2010/05/17/what%E2%80%99s-wrong-with-psychiatry-a-conversation-with-dr-daniel-carlat-2/
I’m sorry to say this criticism of Carlat is nothing new. I realized a long time ago that though he was able with some success show an ability to play both sides of the fence while facing little condemnation from either side.
His answers in the past along with towing the modern day psychiatric pharmacological for mental health issues modality line, have been to promote over the counter sale of anti-depressant drugs without prescription as just a jumping off point. I wrote a post a while back when he was defending Harvard’s J. Biederman “of let’s drug those kids early and often fame”.
http://bipolar-stanscroniclesandnarritive.blogspot.com/2009/03/drcarlat-apologist-for-biederman.html
or more recently here:
http://bipolarsoupkitchen-stephany.blogspot.com/2010/05/drdaniel-carlat-unhinged-is-right.html
In the Carlat case, the leopard has not changed his spots, just brought the prey in a little closer.
I read through the twitter talk and you’re right Stephany. Carlat says the pills work well for some people and there needs to be more of them. A thought just occurred. Maybe he quit Wyeth but now gets an under the table slush fund from all the psych drug makers. LOL.
I mistakenly said Carlat says pills work well for “some” people. He actually said they work for a lot of people. I’ve seen him make this comment before in blogs and instantly wondered then too how he could say this. If he’s referring to SSRIs we all know what the final analysis shows. Yep he’s just a general pill pusher now – does not specify any drug by name. So much for reformed shrinks.
I have asked repeatedly on his blog for studies showing that the meds work to no avail.
When I made the same request of Dr. David Allen on the blog, he couldn’t provide me any other than to say in physician’s experiences which is different from anecdotal (yeah right), they do work.
Do you think Carlat and Allen would be satisfied if they went to see a surgeon to discuss potential surgery and was given the same type of response? I don’t think so.
Essentially, this is the arrogance that Doug speaks about with psychiatry. We don’t have to present evidenced based medicine that they work because you patients are nobody but a bunch of crazy extremists.
By the way, this arrogance extends to the medical profession in general. I dealt with a medical professional yesterday who denied that a certain psych med caused a very common side effect listed on drugs.com.
I was alarmed years ago, when Carlat had said he thought certain SSRI’s were OK to go OTC, I emailed him and asked him to clarify, and asked if I could use his comment (that he left in his own comment section)in a post and he said yes, so I wrote the post. The SSRI’s he thought were safe for OTC use, in my opinion, are dangerous for withdrawal reasons, for pregnancy safety reasons, etc. Imagine, ppl going to buy Advil and an SSRI and not have informed consent about what the drug is….
I also took offense to Carlat stating his “epiphany” about seeing a so-called “drug resistant” patient and asking her FINALLY what was happening in her life. Imagine that! drugs didn’t work, because of life situational upset of the patient, and he just decided to finally ask what was wrong? oh brother!
I got this from Stan’s blog and it was supposedly said by Carlat on his blog:
“Bipolar disorder does, in fact, occur in children, whether you call in bipolar or conduct disorder or juvenile delinquency. And it is clear that antipsychotics moderate the behavior, though at the cost of significant side effects.”
“Welcome to medicine, a world where there are no perfect solutions to many challenging problems.”
Oh well let’s just label every kid bipolar for life, the second most serious mental illness on earth. Who cares if it’s really only misbehavior – druggem!
When these kids grow up and want to be pilots or surgeons they can just explain that they used to be bipolar when they were 2 but they grew out of it, so give them a license for any occupation they want.
Carlat is a lot more dangerous than I ever imagined. Parents will no doubt believe this guy when he says their kids need drugged. This is scary.
Stephany – I think one of his most alarming comments in the interview was when he said he had prescribed sleeping pills to an elderly woman for a year before he discovered she was a heavy drinker. That’s a pitiful example of a doctor of any kind!
Evelyn,
I totally agree about the woman on sleeping pills.
But what is even more scarier is the interviewer didn’t seem to challenge Dr. Carlat on anything. I know I shouldn’t be surprised but I still find it shocking.
Dearest Doug Bremner:
I erroneously concluded my prior comment was deleted in this threat. Instead it was awaiting moderation do to included links.
My BAD, I was obviously having a momentary Psychiatric MD moment….lol Pardon my mistake with humble apology.
Of course I stand by my comment and the content of newest post on my blog without such apology.
No problemo
An apologist for Biederman, that is bad! So, Carlat seems to be a wolf in reformer-sheep’s clothing.
I’m wondering, what do the people in this thread think of doctors who recommend ECT without qualms?
Louise – I am not of the line of thinking that there is no such thing as mental illness. I believe there is but it is rare and drugs should only be used when all else fails and they are absolutely necessary and for the least amount of time possible.
In the same vein, I’m not educated enough to say ECT might never help someone. But I would hope it would be a measure of absolute last resort and only be done on people who are fully informed of all the risks and knowingly give their consent. I do not believe it should ever be administered by force or to children.
From John Breeding’s site:
http://www.wildestcolts.com/links.html
I think ECT should be allowed, but with consent only. Forced ECT should never be permitted, nor should it be performed on children.
Carlat’s a phony.
Thanks, Evelyn. I agree that going after children’s brains is one of the most truly evil things about this whole drugging phenomenon. It’s difficult to believe it’s happened. On the PsychRights site, one reads that children can be taken from their parents and placed in foster care if the parents refuse to give their children drugs. Even so, I don’t think labeling people evil — or crazy — has much explanatory power.
In a Szaszian sort of way, I do think that mental “illness” is a misnomer. Dementia results from diseases like Alzheimer’s or syphilis, but since people really don’t know the etiology of depression or delusions or hallucinations, etc., why go after the brain? Now neuroimaging studies are supposedly going to unfold the secrets of such, for lack of a better word, maladaptive forms of cognition, but I suspect it will simply be more Shrinkspeak justifying damaging intervention as therapeutic.
One of the things Whitaker has said he hopes his book will accomplish is having a conversation about the drugs, engaging in debate about the facts he has uncovered, and alternative forms of therapy. If this is going to happen, I think there will have to be some kind of breaking down of the Us-and-Them oppositions that now exist between patient rights advocates-activists and Official Shrinkdom.
This does not mean, however, that I didn’t LOL over Doug’s photo art of David Kupfer in uniform!
I think all of it is evil. If we can recognize this shit is bad for kids, why is it supposedly “good” for adults?
Supposedly adults are able to make their own decisions, but considering that true informed consent does not exist in psycbiatry
I think all of it is evil. If we can recognize this shit is bad for kids, why is it supposedly “good” for adults?
Supposedly adults are able to make their own decisions, but considering that true informed consent does not exist in psychiatry and alternatives do not exist… That just isn’t the case
Hmmm. A couple of comments, based on my understanding of my research, and whatnot…
1) The “chemical imbalance” theory is completely unproveable, and therefore should not be regarded as fact, on any level.
2) I’m not sure about other classes of drugs, but when it comes to SSRIs, placebo appears to be as efficacious. Leastways, when a drug does out-perform placebo during trials, it tends to be by a clinically negligible degree (a couple of points on Hamilton).
3) NICE, in the UK, acknowledges the lack of efficacy of SSRIs in mild to moderate depression, and recommends the use of alternative remedies in such cases (although such “alternative remedies” (eg, psychotherapy), are in short supply with government reneging on promises of funds to train counsellors).
There’s not much in the way of valuable information floating around, is there? I’ve been “reading around the subject” for 3-4 years, now, and above is the sum total of my knowledge, based on what is made available by official sources. Unsubstantiated claims such as “these drugs have helped millions of people around the world,” do not count as valid information, needless to say – although this sort of thing seems to be the stock-in-trade of the UK regulator!
Should I speculate? Yeah, sure I should! The similarity of performance between placebo and drug is strikingly consistent. One could draw the conclusion that the efficacy of SSRIs is founded entirely on Placebo Effect. In other words, when people improve, they’re repairing themselves, and the drug has fuck all to do with it, other than as an anchor to fix the suggestion that a person should get well.
As prot said “for your information, Dr Powell, every being in the Universe has the ability to heal themselves”! [shrug] That’s a bit abstract, but still…
Matt
Matt,
I would have to agree with you.
We all have the power to heal ourselves.
It’s an ALL NATURAL thingy.
Too bad Psychiatrists are so fuckin lame!
oops FUCKIN PROFANITY DISORDER, SYNHDROME,DISEASE!!! (caps lock and spellcheck dependency too)I was all happy for a moment today because my friend Sarah lent me $100.00 to go see what I missed when some ASSHOLE bashed my head in ages ago and gave me a “Psychiatric Disorder”…by the time I got Gas, my nails done and bought hair dye I was broke again. This sent me swirling into a mad RAGE/DEPRESSION where the only way I could cope without having the PLATTEVILLE POLICE BASH my fuckin head in some more was to bust out my shiney new RAZOR BLADE and “Scarify” my arms some more….more “World Painted Blood” was created and now I will be homeless,insane,broke and MUTILATED Some more!!
Times like this I could really just use some MARIJUANA!!!