This is an informative book on the psychiatric professions written by three psychiatrists with different specialties: a forensic psychiatrist working within the correctional system, a consultation-liaison psychiatrist who informs doctors on how their hospitalized patients are doing, and a regular psychotherapist.
They provide a precise taxonomy of psychotherapists. A psychiatrist is a full fledge M.D. who is authorized to prescribe drugs. A psychologist does not have medical training and has either a masters or a Ph.D. in psychology. And, they can't prescribe drugs. A psychopharmacologist is a psychiatrist who purposefully does not conduct any therapy, and specializes solely in mental diagnosing and prescribing related drugs. Forensic psychiatrists have training in civil and criminal mental health issues. They testify as expert witnesses in many legal cases: insanity defenses, child custody, and juvenile hearings.
They explain the different types of therapy, including: psychoanalysis an insight-oriented therapy, cognitive-behavioral therapy (CBT) a supportive treatment exploring the patient's patterns of thinking. CBT is used to treat anxiety and depression. Therapy is often about helping patient accepting themselves and focus on their strengths rather than focusing on their weaknesses.
The chapter on forensic psychiatry operating within a penal and legal domains is fascinating. For one thing, the insanity defense is a lot more challenging to advance than you think. The criminal has to pass rigorous tests to be certified unable to attend court. In turn, the acquittee will be placed in a forensic hospital that caters to the violent mentally ill with maximum security. And, such hospitals are often notoriously difficult to get out off. This could turn into a painful and longer incarceration than a regular prison sentence. Nowadays, you don't consider the insanity defense lightly. Additionally, sex offenders often receive pretty severe treatment as seventeen states have laws that allow the indefinite commitment of sex offenders.
They describe the common protocol of "split treatment" driven by economic incentives. That's when someone is referred to a psychologist for therapy while being separately consulted by a psychiatrist for drug prescription. It is weird that it is the lesser qualified psychologist who does the more interesting work of understanding patients. The authors explain that economic incentives imparted by healthcare insurers discourage psychiatrists to spend much time with patients. This translates into doubling one's earnings for simply prescribing drugs and moving on to the next patient within 15 minutes instead of spending 50 minutes on a therapy session with a patient.
Much of psychiatric care is driven by legal considerations (malpractice suit and related insurance, laws and regulations) and insurance coverage (reimbursement to psychiatrist, cost to patient). Those considerations often take precedent over what is truly best for the patient from a medical standpoint.
The authors readily disclose the limitation of their field. They state on page 3: "psychiatry remains full of shortcomings. We don't know what causes some people to become mentally ill... We don't know why certain treatments work..." Later, they acknowledge that the theory of chemical imbalance has no scientific support as they state "there is no ... disorder for which we know ...which chemicals are "imbalanced" if any." Later, they cover the controversial practice of prescribing drugs for off label use meaning for purpose other than what the drug has been clinically tested for. As long as the FDA has approved a drug safety, it does not regulate how doctors prescribe it.
The authors mention therapies that were mentally harmful to patients and their families such as "recovered memory" therapy. In the 1980s and 1990s psychiatrists persuaded their patients they had been sexually abused during childhood. False accusations of sexual molestations lead to many malpractice lawsuits leading to multimillion-dollar settlements. And, this promptly eliminated "recovered memory" therapy.
They inform you what are the red flag of a bad therapist. And, the main one is a dogmatic adherence to an explanation of the patient behavior that actually does not fit the factual circumstances of the patient's life. The recovered memory therapists smacked of that. Another red flag is any therapist who encourages a patient's social isolation from family and friends.
They reveal how the FDA sometimes bows out to public pressure instead of Big Pharma's. The FDA stated that SSRIs antidepressants can cause younger people to have suicidal thoughts. Yet, the related clinical trial demonstrated that the rate of suicidal thoughts was less than half for antidepressants (12 out of 3,227 youngsters) vs placebo (24 out of 2,397). Ironically, the authors mention two pages later that after the FDA issued their warning, the use of anti-depressants declined and suicide rate among youngsters increased.
Drug companies marketing has always been a source of controversy. However, the influence of drug reps has strongly been curbed through recent legislations. Also, drug companies marketing to doctors through invitation to cruises, travels, and seminars at resorts is now also restricted. This is why drug companies now market directly to consumers through advertising (print, TV, Internet, telemarketing).
In the closing chapter "The Future of Psychiatry" they indicate how this field is moving further away from psychotherapy and towards technology. Functional magnetic resonance imaging or fMRI prospectively should allow us to have a better visual representation of the inner workings of the brain and eventually allow us to make far more precise psychiatric diagnosis. Also, three new technologies offer hope for patients whose mental disease (mainly depression) have resisted all other treatments. Those include repetitive transcranial magnetic stimulation (rTMS), vagal nerve stimulation (VNS), and deep brain stimulation (DBS). Others are not so enthusiastic about the advent of technology in psychiatry including Daniel Carlat in his interesting book "
Unhinged: The Trouble with Psychiatry - A Doctor's Revelations about a Profession in Crisis as he indicated that several of those new technologies have been approved by the FDA. But, they turned out into complete failures when subjected to more rigorous clinical studies.
Even though the psychiatric profession is moving away from psychotherapy, if you want to better understand the effectiveness of psychotic drugs and the relative merit of psychotherapy (vs drugs), I strongly recommend the excellent
The Emperor's New Drugs: Exploding the Antidepressant Myth.
