Saturday, September 24, 2011

A Psychiatrist Criticizes His Own Profession: A Review of “Unhinged” by Daniel Carlat

It’s not news that the profession of psychiatry is in a crisis state. I’ve talked about problems with psychiatry on this blog, and there have been many books, articles, and blogs written criticizing psychiatry. There’s no shortage of things to criticize. The fact that there is little understanding of the neurobiology of psychopathology, that there are no diagnostic tests for psychiatric disorders, that drugs have become widely prescribed with little evidence supporting their long-term efficacy, that most psychiatrists have become exclusively pill pushers, eschewing the need to understand and connect to their patients beyond a 15 minute med check, and that many psychiatrists have allowed themselves to be corrupted by drug money, are some of the problems with contemporary psychiatry.

Daniel Carlat, in his book Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations about a Profession in Crisis, provides an insider’s look at the problems with psychiatry. Carlat was motivated to pursue a career in psychiatry because of his depressed mother’s suicide. He begins his book by giving an account of his medical training. Much of what he learned from the medical school curriculum and clinical rotations was useless in his later practice. Psychiatrists don’t perform surgeries, don’t order lab tests (except to rule out rare physical problems), and (usually) don’t order brain scans. They diagnose based on symptoms, which is what all doctors used to do before the twentieth century, but which is only a minor part of medical diagnosis today. Psychiatrists, like other doctors, prescribe drugs, so they need to understand psychopharmacology, but as Carlat describes in his book their decisions about medications are usually subjective.

Carlat did his residency at Massachusetts General Hospital (MGH), beginning in 1992, after the introduction of second generation antidepressants like Prozac. Although his supervisors were divided between therapy and drug advocates, Carlat admits that “the main thing you learn in a psychiatric residency, then or now, is how to write prescriptions” (p. 34). After completing his residency, Carlat, like most psychiatrists of his generation, specialized in psychopharmacology, i.e. prescribing drugs. He saw patients for 15 to 20 minute medication visits. The reason why he and other psychiatrists did this was that it was more profitable. Seeing three patients an hour for med checks allowed him to make about $180 an hour minus expenses. Seeing one patient an hour for therapy allowed him to make between $80 to $100 an hour, which is about 50% less. Carlat blames managed care companies for forcing psychiatrists into becoming pill pushers. But managed care companies can’t force psychiatrists to do something that they don’t believe in. The “key opinion leaders” in psychiatry, those leading academic psychiatrists who set the direction of their profession via their research and publications, are fanatical advocates of the biochemical/drug paradigm. This advocacy is quite profitable for them, as Carlat describes in his book.

Carlat talks about his experiences as a “hired gun,” someone who is paid (i.e. bought out) by drug companies. Carlat worked for Wyeth Pharmaceuticals to promote the antidepressant drug Effexor to primary care doctors. He made $750 per talk. He describes that although he was officially an “expert consultant,” in reality he was basically a highly-credentialed salesman. Sales reps attended his talks, and they communicated to him via body language and other feedback whether he was doing what they expected of him, i.e. to promote their product. When he tried to be more balanced and neutral, they criticized him. He eventually gave up his hired gun position.

Although Carlat was a minor figure among the drug company hired guns, he assumes that the same thought processes and corruption happened among the more famous and successful psychiatrists. He discusses the Senator Grassley investigations of several key opinion leaders in psychiatry, including:
  • Melissa DelBello, a researcher who was paid $180,000 by AstraZeneca to promote the antipsychotic drug Seroquel.
  • Joseph Biederman, Timothy Wilens, and Thomas Spencer of MGH, who were paid a combined $4.2 million by drug companies over a 7 year period. These men also received taxpayer money in the form of NIH research grants, which explicitly disallows such large drug company income. Biederman and colleagues pioneered the diagnosis of bipolar disorder in toddlers, which has led to thousands of preschool children receiving drug cocktails including powerful antipsychotics.
  • Alan Schatzberg of Stanford, president of the American Psychiatric Association, controlled more than $4.8 million of stock in Corcept Therapeutics, a company he cofounded to test a drug to treat psychotic depression. He was also the principal investigator of a huge NIH study to test the same drug. This combination represented a major conflict of interest.
  • Charles Nemeroff, chairman of the department of psychiatry at Emory University, earned $2.8 million from consulting arrangements, but failed to disclose at least $1.2 million. Some of this money was from the drug company GlaxoSmithKline, whose drugs Nemeroff was studying with $3.9 million of taxpayer money.
Carlat describes the insidious methods that drug companies use to market their products to psychiatrists. He used the epilepsy drug Neurontin as an example. The evidence in favor of Neurontin’s effectiveness for treating psychiatric disorders was poor, and did not meet the FDA’s criteria for effectiveness. Warner-Lambert, the drug company that introduced this drug, decided to illegally market it off-label for various disorders, including bipolar disorder, pain, and anxiety. The company bribed doctors to prescribe Neurontin, and hired marketing firms to ghost-write articles pushing this drug. It also paid doctors to allow drug reps to shadow them during their patient visits. These drug reps persuaded some doctors to prescribe Neurontin off-label. The sleazy techniques paid off, earning Warner-Lambert $2.7 billion in 2003 Neurontin sales, almost all of them from off-label uses.

Carlat describes his own experiences with the pharmaceutical marketing machine. One experience was a lavish party put on by Janssen, the manufacturer of the antipsychotic drug Risperdal, during the 1999 American Psychiatric Association annual meeting. Janssen rented the entire Smithsonian Air and Space Museum, with live jazz band, buffet food, and free drinks, all for the benefit of psychiatrists whom they wanted to prescribe Risperdal.

Another experience was with Valerie, his Ambien rep. Ambien, marketed by Sanofi-Aventis, was the first in a new category of non-benzodiazepine sleeping pill. Since Ambien was going off patent soon, Valerie tried to sell him Ambien CR (“Controlled Release”), a longer-acting drug than the original. Carlat was skeptical of the science behind the new pill. Valerie knew that he wasn’t prescribing much Ambien CR. She had access to this information since pharmacies have been selling their prescribing data to drug companies since the 1990’s. Valerie was persistent, offering a free medical textbook as a gift. Carlat prescribed Ambien CR to a patient, subconsciously or consciously reciprocating Valerie’s gift. The patient didn’t like the drug due to a hangover side effect. Carlat didn’t tell his patient that he prescribed Ambien CR as a favor to a drug rep.

Carlat criticizes the chemical imbalance theory. This theory, i.e. that depression is caused by a deficiency of the neurotransmitters serotonin and norepinephrine, and that schizophrenia is caused by too much dopamine, came about from discoveries of the pharmacology of antidepressant and antipsychotic drugs. It’s now known that antidepressant drugs block the reuptake of serotonin and/or norepinephrine (thus increasing the amount of these neurotransmitters in the synapse). Antipsychotic drugs block dopamine receptors. The chemical imbalance theory took as a given that the drugs were effective, and that they were not just treating symptoms, but treating the biochemical cause of mental disorders.

There has been no direct evidence in favor of the chemical imbalance theory. Part of the problem with verifying the theory is that scientists can only indirectly measure neurotransmitters via breakdown products in the blood, urine, or cerebrospinal fluid, or post-mortem exams. The studies utilizing these techniques have been inconclusive for both depression and schizophrenia. The result is that since virtually all biological psychiatric research in the past several decades has been based on the chemical imbalance theory, “the shadow of our ignorance [of psychiatric disorders] overwhelms the few dim lights of our knowledge” (p. 80). Carlat admits that with the lack of a scientific basis for drug choice, prescribing is more of an art than a science. “To a remarkable degree, our choice of medications is subjective, even random. Perhaps your psychiatrist is in a Lexapro mood this morning, because he was just visited by an attractive Lexapro drug rep” (p. 83).

Carlat talks about the overdiagnosis of psychiatric disorders, which is caused by a combination of lack of scientific understanding of mental disorders, and greed. The DSM-IV, the “bible” of psychiatry, classifies mental disorders based on a list of symptoms. If you have five of the symptoms it mentions, you have depression. If you only have four, you don’t have depression. Since this symptom-based diagnosis is ultimately based on subjective or arbitrary factors, there is no way to prevent multiplication or redefinition of disorders. One of the criticisms of the upcoming revision (entitled “DSM-V”), is that new definitions of disorders would make it too easy to diagnose patients. An example is the proposed “prepsychotic” category, attempting to identify individuals who might in the future develop schizophrenia. In the words of Allen Frances, who was the chair of the DSM-IV committee, these broadened categories “would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatment” (p. 65).

The problems with the DSM also affect clinical practice. For example, bipolar disorder is a diagnosis in the DSM based on symptoms such as alternating manic and depressive episodes. This diagnosis was intended for adults, although sometimes older teenagers have these symptoms. Joseph Biederman and his colleagues at MGH decided to expand the diagnosis of bipolar disorder to toddlers. In 1996, Biederman published a paper reporting that nearly a quarter of children he was treating for ADHD also met his criteria for bipolar disorder. Since preschool children don’t have mania or depression, how could they have bipolar disorder? Biederman decided that irritability was a defining attribute for mania in young children, even in the absence of euphoria or grandiosity. How could he make this diagnostic change? It wasn’t based on science, since the neurobiology of bipolar disorder in adults or children is unknown. Biederman was able to do this, and get a lot of other psychiatrists to follow his lead, because he was a full professor at Harvard, next to God, in his own words, on the psychiatric prestige scale. His diagnostic change led to a forty-fold increase in the number of children and adolescents treated for bipolar disorder. These children have been prescribed powerful drug cocktails, including antipsychotic drugs. The antipsychotic drugs have side effects such as sedation and weight gain that are much more harmful to children than adults. As I mentioned above, Biederman and colleagues received over $4 million dollars from drug companies, which was certainly a powerful incentive to expand diagnosis (and drug treatment) of bipolar disorder to children.

What is Carlat’s prescription for change in his broken profession? Carlat wants psychiatrists to go back to providing therapy, which can be balanced with medications. 15 minute medication checks are not sufficient to get to know a patient, to know what makes him tick. Sometimes changes in symptoms are not due to medications but life changes or stresses. Since most psychiatrists don’t have time to inquire about anything other than symptoms and medications, they are blind to what is going on in their patients’ lives. Carlat changed his own practice from exclusively 15-20 minute med checks, to somewhat longer medication sessions (20- 25 minutes), alternating with 45 minute therapy visits. He doesn’t use traditional psychodynamic therapy, but instead “a version of supportive therapy that I now try to weave into the fabric of all my sessions with patients, whether they are seeing me primarily for medications or for therapy” (p. 199).

Carlat also wants to see an alternative to medical school for training psychiatrists. He feels that medical school, in addition to be largely useless to future psychiatrists, indoctrinates these students into an excessively biomedical viewpoint. It also makes them feel inferior to other doctors, since psychiatry is in such a primitive state compared to the rest of medicine, and makes them feel superior to other mental health professionals, since psychiatrists have a medical degree. Carlat would like to see a new training program modeled on the “Doctorate in Mental Health” experiment in San Francisco in the 1970’s and 1980’s. This program combined two years of medical and psychological classes with three years of on-the-job training similar to a psychiatric residency. This shaved three years from the standard medical training, but unfortunately fizzled when psychiatrists successfully lobbied to prevent its graduates from being licensed. This program can be revived, and serve as a way to train new practitioners who would be better able to integrate drugs and therapy.

Carlat assumes that drugs are effective. In his book, he gives a number of case examples of patients who he says were helped by medications he prescribed. But how does he know that? His conclusions about drug effectiveness are based on his own clinical observations, which derive from 15 to 25 minute appointments. How can he, or any other psychiatrist, make any conclusion about effectiveness based on such short patient visits, and in the absence of any objective lab tests? Many people with mental disorders are in a complete state of denial about their condition. They are unable to recognize when they’re behaving strangely or irrationally. Family members and friends can usually notice changes, but they don’t always accompany a patient to a psychiatrist doctor visit. Even if they do, they may not speak up.

I have a personal example to support this. I have a relative who for years has been in denial about his depression, anxiety, paranoia, and OCD. When he went for his 10 minute medication visits (which was every month or every other month), he would tell his psychiatrist that everything was fine. His psychiatrist didn’t have time to ask probing questions or to try to make some independent observations. My relative's wife, who would drive him to the appointment and usually not go into the doctor’s office, was afraid to speak up. She was afraid because if she did speak up, my relative would become extremely angry, paranoid, and hostile, and blame her for triggering his bad mood, which would persist sometimes for days. So in the absence of any contradicting information, the doctor would usually tell him that he was doing great, and refill his prescriptions. This is pill pushing, not medicine. But it is the current standard of care in psychiatry.

I can give an example of where a 15 minute appointment would represent quality medical care. Let’s take a hypothetical example of Mary, who has diabetes. She is in denial about her condition. When she goes to the doctor, she tells him that she feels fine. He looks at her lab tests, however, and sees that her blood sugar is elevated. He tells her that she’s not fine, and then discusses possible causes for the elevated blood sugar, and prescribes a treatment plan. The doctor has an independent, objective source of information to balance Mary’s account of how she feels.

A psychiatrist doesn’t have any objective lab tests to balance a patient’s testimony. He needs more time to make an accurate diagnosis of the patient’s current state of mind. I think that an hour a patient is a bare minimum, even if the psychiatrist is only prescribing drugs, and not doing any therapy. In an hour, the psychiatrist has more time to observe and hear the patient, and ask questions. While it’s easy for a disturbed patient to put on an act for 15 minutes, it’s a lot harder do maintain this for 50 minutes. If a family member is present, it would also give the psychiatrist time to interview the family member away from the patient.

Psychiatrists, including Carlat, blame managed care companies for forcing them to have such short patient visits. But it is psychiatrists who set the standard of care for their profession. If leading psychiatrists said that they needed to see patients for a longer time, that 15 minute visits represented poor patient care and shouldn’t be reimbursed at all, and they lobbied the government, Medicare, and managed care companies to reimburse them at a higher rate for longer visits, then these changes would get made. Psychiatrists are not helpless pawns in the face of powerful entities, they have significant power themselves and can use that power to improve patient care.

Carlat doesn’t question the basic effectiveness of psychiatric drugs. His prescribing habits seem conventional, including prescribing drug cocktails. He gives an example of James, whom he calls a “typical success story of modern psychopharmacology” (p. 70). Carlat prescribed James five different medications, including Celexa for depression, Ativan for anxiety, Ambien for insomnia, Provigil for fatigue (a side effect of Celexa), and Viagra for erectile dysfunction (another side effect of Celexa). Is this a success story, even if James reported feeling happier? Carlat compares James to an old pickup truck, held together with baling wire and duck tape. Is turning patients into fragile jalopies a good thing?

Drug cocktails make it impossible to identify what drug is responsible for what side effect or reaction. How does one know if the patient’s fatigue or agitation is due to Drug A, Drug B, Drug C, the interaction between Drug A and Drug B, the interaction between Drug B and Drug C, or the interaction between Drug A and Drug C? This is for only 3 drugs. If a patient is on 5 drugs, as is James in the case mentioned above, then there are 10 possible interactions to consider. (The number of drug interactions can be expressed as [{n*(n-1)}/2], where n is the number of different drugs).

Drug interactions aren’t the only thing to worry about. There is also the question of dose sizes. Maybe Drug A is causing problems because it’s at too high a dose. But with the drug interactions and the effects of Drugs B and C, it’s not easy to identify Drug A’s dose as the problem. Also, drugs have different long-term effects from short-term effects. If a patient is on three different drugs, and suddenly develops severe anxiety, how does one know if this anxiety is due to the long-term effect of a drug? More likely, the doctor will add another drug to the regimen, or increase the dose of the anti-anxiety pill. But the better solution would have been to reduce or eliminate the drug that is causing the reaction, a drug that is impossible to ascertain because the patient is on too many drugs.

I emphasize these problems with drug cocktails because of my own personal experience with psychiatric drugs. I avoided drug cocktails, usually talking no more than two drugs at a time. With two drugs, there is only one interaction to worry about. For a period of time, the two drugs I took were the antidepressants Anafranil and Zoloft. After two years on this combination, I had an attack of severe anxiety. Rather than allowing my psychiatrist to prescribe an anti-anxiety drug, which would have been the typical response to this problem, I discontinued taking Zoloft. I had been on Anafranil for 3 years before I started Zoloft, and I didn’t think that Anafranil was the problem. The anxiety abated, and never returned to the level it was. If I were taking three or more medications, it would have been harder to identify the drug that was the problem.

Psychiatrists, including Carlat, have a knee-jerk reaction to add more drugs when there is a problem, rather than take drugs away. This is how drug cocktails come into being. Drug cocktails represent a type of off-label prescribing, because the individual drugs in the cocktail were never clinically tested or approved as part of a cocktail, only when taken individually. They are part of what’s wrong with psychiatry today, something that Carlat doesn’t acknowledge.

It’s unlikely that Carlat would accept Irving Kirsch’s thesis in his book The Emperor’s New Drugs (which I review here) that antidepressants are no better than placebos, or Robert Whitaker’s more radical thesis in his book Anatomy of an Epidemic (which I review here) that psychiatric drugs do more long-term harm than good. The reason for this is that Carlat has spent his entire career prescribing drugs. For him to acknowledge that they are placebos with dangerous side effects, or that they harm patients long-term, would be for him to admit that his life’s work was a failure. It’s similar to getting a district attorney who, after years of prosecuting and convicting an innocent man, to admit that he made a terrible error. There are not many district attorneys who can make this admission. In the case of psychiatrists like Carlat, most will not admit that they have made a terrible error and harmed patients by prescribing drugs. Thus Unhinged, while a call for change in psychiatry, doesn’t go far enough in questioning the efficacy of drugs. Such questioning usually comes from people outside the profession, such as a clinical psychologist (Irving Kirsh) who treats patients via psychotherapy, and a journalist (Robert Whitaker) who isn’t a mental health practitioner.

In conclusion, Unhinged is a well-written, honest account of systemic problems in psychiatry written by someone with an insider’s perspective on the profession. Carlat does an excellent job describing the drug money corruption in psychiatry, in the overmedicalized view of a complicated phenomenon such as mental illness, and in the need for psychiatrists to better know their patients and provide some of them with therapy. He fails, however, to go far enough in questioning drug (and drug cocktail) efficacy.