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.

The past week has been an interesting one in the psychiatry field. After I described my experiences getting “un-invited” for my post on the DSM-5 Anxiety Disorders Committee, there was this followup in the Carlat Psychiatry blog. He described his own experiences getting blocked from a practice guidelines committee of the American Psychiatric Association (when I couldn’t think of anyone more scholarly and unbiased to do it).

The cause? A comment posted anonymously on his blog stating that Alan Schatzberg, MD, had pressured the DSM committee to loosen the guidelines for psychotic depression so that there would be an expanded market for the medication for depression he developed, mifepristone. Dr. Schatzberg was in the news last year because he had an NIH grant to study the drug but also was revealed to be the owner of four million dollars worth of stock in Corcept, a company that he co-founded and that makes the drug. Dr Schatzberg has since stepped down as Chair of the Department of Psychiatry at Stanford, source of the complaint against me that, yes, I had brought up two of the member of the DSM Anxiety Committee in the context that they were from Brown and Dartmouth, departments that were also sites of financial disclosure issues, so add to that my own university (which cannot be named), we pretty much have brought the circle to completion for the universities involved in last year’s financial disclosure broo ha ha. Also last week the CL Psych blog noted that Dr. Schatzberg in his speech accepting the Presidency of the APA stated that:

…some of the detractors in the press have voiced concern that some folks have earned too good a living, often by doing presentations…I have heard from colleagues and directly from one reporter asking me about one of my colleagues having too high an annual income…our members and residents have never taken vows of poverty…We need to ask ourselves how we have contributed to our own devaluation with which others seem to resonate, and we need to reverse the course. The rewards for our dedication should not be limited to a sense of pride, but we are also entitled to be paid commensurate to the challenge…

It doesn’t seem to me that Dr. Schatzberg has gotten the point that the American public is fed up with academic physicians been paid large sums of money from private industry and using their academic positions to promote their own and their industry partners financial advantages, especially if it impacts on patients. But there hasn’t been a lot of soul searching in psychiatry these days. I guess they’d rather spend their time getting people like me to shut up.

An interesting Anonymous followup comment to Dr. Carlat’s posting I was talking about earlier said that he shouldn’t wonder that people didn’t want him on their committees as he might use things he learns about in secret as “fodder” for his blog which he described as highly read. He also said you “can’t have your cake and eat it to.” Wa-aa? You mean if you want to be honest and transparent that you can’t serve on one of the APA committees? I guess because by implication they are corrupt and operate like the mafia? Hmmm, gonna go have some cake and think about that one…

Lolcat CAN have his cake and eat it too!

In this recent piece from Howard Brody MD of the Hooked blog about how the American Psychiatric Association (APA) recently voted to eliminate pharmaceutical industry funding of educational symposia as well as free meals etc. from their annual meeting, he asks what they will do to pay for their education. I am not involved in the politics of the APA (or any other organization, for that matter, not that I shouldn’t be based on my research accomplishments, but maby they just think I am a curmudgeon or something. And neither me nor Mrs. Bremner have ever gotten one of those lifetime achievement awards).

The last time I went to an APA meeting it was in New York several years ago and I took my daughter so we could have a bonding experience and see the sights. I typically have gone to the American College of Neuropsychopharmacology (ACNPee pee) which doesn’t have overt drug sales displays but which is perhaps a more covert form of drug company coercion after all, so I am going to have to look into doing something at APA given these new rules (and forgoing ACNP). Good job guys. And hat tip to Danny Carlat who has gotten involved in the internal politics of education within the APA and surely must have played a role in this decision.

The fact is that the APA is the first medical organization to make such a move and hats off to them. Let’s celebrate.

Yeah! The wicked drug company is dead!

Howard quoted someone from the APA saying that without drug companies they would have to hold their lectures at the YMCA. Well I think I have a pretty good analogy for you. For one of our NIH funded grants we added as a consultant Lori Davis MD of the Tuscaloosa VA and the University of Alabama Birmingham Department of Psychiatry. Lori came over to Atlanta and gave a lecture on “Diagnosis and Treatment of PTSD” and then met with our staff and fellows to review diagnostic assessments of PTSD. She will return in May. The lecture was delivered in the auditorium of the old Georgia Mental Hospital which is now owned by Emory and called Emory Briarcliff. Not the Ritz, but no overhead, free, easy, and free of commercial influence. Isn’t that the way it should be?