83 of 91 people found the following review helpful
on November 23, 2010
This is essentially a whistle blower reporting on the corruption of psychiatry by Big Pharma. Dr. Carlat went to UCSF med school in 1985 as psychiatry was rapidly transiting to psychopharmacology. He is practicing at Massachussetts General Hospital (MGH) where many of the key drug trials had taken place and where faculty members had received millions from Big Pharma to conduct such trials. He also used to accept Big Pharma's money ($30,000 in total, a very small amount relative to others) to lecture to pitch its drugs until his conscience regained the better of him. Thus, he had a front seat and was an active participant in psychiatry's' corruption. His confession is very insightful.
Carlat feels that psychiatry is in a state of crisis, as it has lost much credibility with the public. He mentions a recent Gallup poll that uncovered that only 38% of Americans trust psychiatrists, on par with chiropractors (36%) and even bankers (37%) and way below regular physicians (69%). There are several themes to Carlat's analysis of psychiatry devolution.
First, psychiatrists have given up on understanding their patients. They don't do psychotherapy anymore. They essentially just prescribe drugs (mainly anti-depressants). They now call themselves psychopharmacologists instead of psychotherapists. For psychotherapy, you have to go to a psychologist (who got a graduate degree in psychology, but did not go to med school, and is not allowed to prescribe drugs).
Second, psychiatrists overdiagnose their patients. Way too many children are overdiagnosed with ADHD and even bipolar disorder (the latter being often meaningless for young children). From 1994 to 2003, children and adolescent treated for bipolar disorder rose by 8,000%! The majority of cases are misdiagnosed. The psychological troubles are related to complex sociological problems the psychiatrists make no effort to understand. And, way too many adults are overdiagnosed with ADHD, social anxiety, and mild depression for what are often normal responses to the challenges of daily life.
Third, psychiatrists are overdrugging their patients. Psychiatrists too readily prescribe anti-depressants and stimulants to treat just about any small psychological discomfort that could better be resolved through just a few therapy sessions.
Fourth, the efficacy of most drugs are highly questionable because they are based on an unproven scientific hypothesis: the brain chemical imbalance theory (called "monoamine hypothesis"). Carlat states that chemical imbalance is a myth perpetrated by the profession. Depression is explained by a deficiency in the neurotransmitter called serotonin. The problem is that the causal link between serotonin level and depression has never been proven. Actually, several studies attempting to prove this link ultimately served to disprove it. Therefore, SSR anti-depressants aimed at boosting serotonin levels work no better than placebo. In 50% of drug trials, the drugs do not beat placebo. Another outstanding book on this subject is: The Emperor's New Drugs: Exploding the Antidepressant Myth.
Fifth, psychiatrists understand very little regarding the human brain. Its functioning at the neurobiological level remains a mystery. Additionally, "to a remarkable degree our choice of medication is subjective, even random" acknowledges Carlat.
Sixth, so far technological innovations within psychiatry have failed. Innovations such as the vagus nerve stimulator, transcranial magnetic stimulation have been complete failures. Yet, they have been approved by the FDA only to be rejected by more serious studies.
All those themes have a common root: economic conflict of interest. About three decades ago, psychiatrists noted that they could make a lot more money by prescribing drugs instead of conducting therapy. A therapy session takes an hour. During this same hour, a psychiatrist can see three patients, quickly diagnose them and give them a prescription. As a result, psychopharmacology is far more lucrative and efficient than psychotherapy. The increased efficiency translated into lower claim cost per patient. Therefore, insurance coverage became more generous for drugs than for therapy. This only accelerated the transition to psychopharmacology.
Carlat suggests there are two major problems with this transition to psychopharmacology. First, it does not work that well. Many studies have confirmed that psychotherapy works often better than drugs and with no side effects. The relapse rate is lower as patients learn lifelong solving skills. And, second psychopharmacology has turned psychiatry into the marketing arm of Big Pharma. Now, over 27 million Americans are on anti-depressants that work little better than placebo but with side effects. Big Pharma spends twice as much on marketing as research. Carlat states that all the "new" drugs work no better than the original ones of 50 years ago. They are just a lot more lucrative because they are under patent. Antidepressants often bring in between $1 billion to $5 billion in annual revenues.
The conflict of interest in psychiatry have reached a critical level whereby the credibility of the profession is being questioned. Dr. Carlat covers the practice of drug reps and leading psychiatrists receiving millions of dollars from Big Pharma to give speeches to other doctors pushing their drugs and even testing their drugs in clinical trials. Psychiatrists lead the pack of specialties receiving the most money from Big Pharma. How can a clinician objectively evaluate a drug when he is paid a fortune by the developer of that drug? This is an egregious conflict of interest resulting in poor science and perpetrating the ignorance of psychiatrists. How can they figure what really works since they can't trust the original studies.
In the last chapter, Carlat makes recommendations to reform the field of psychiatry. He feels psychiatrists should not be trained through traditional med schools. They waste several years learning everything they will never need (radiology, surgery, delivering babies, ER training, etc...). And, they learn very little of what they really need such as therapy. Instead, he refers to a prototype program in San Francisco that offered a special degree in mental health that combined extensive training in therapy and pharmacology. It prepared students far better than the long curriculum of med school. Yet, the program was killed by the psychiatry lobby. Carlat, similarly, feels we should license all psychologists to prescribe drugs after providing them additional training in pharmacology. He also feels that all psychiatrists should conduct therapy as they did in the past.
Carlat's recommendations make sense. But, the psychiatry lobby will resist all such proposals to protect their income. Nevertheless at the risk of becoming ostracized by colleagues, Carlat is really courageous for stating what is necessary to restore integrity to his profession.
63 of 71 people found the following review helpful
on May 24, 2010
Dan Carlat's Unhinged: The Trouble with Psychiatry is a brutally honest account of the gaps in understanding psychiatric illnesses, the relative lack of knowledge about the actions and effects of psychiatric medications, and the importance of psychotherapy. This book should be required reading for all psychiatry residents and psychiatry faculty and on the bookshelves of both early and late career psychiatrists. It is also a must read for clinical psychologists training to prescribe. Prescribing and Medical Psychologists do not want to make the same mistakes that lead psychiatry to where it is today.
Bret A. Moore, Psy.D., ABPP
28 of 30 people found the following review helpful
on August 16, 2010
Format: HardcoverVerified Purchase
The spotty record of the efficacy for psychotropics comes as no surprise, I have seen this on a daily basis for 20 years. But, the degree of deceit and fraudulent behavior by pharmaceuticals was astounding (why I should be so astounded is beyond me). This is a well written book, readable, sensible and helpful. His recommended solution to the problems with psychiatry are totally sensible, although its not likely at this time I would want to go back for the training needed.
85 of 114 people found the following review helpful
on July 16, 2010
Unhinged is the politically correct criticism of psychiatry that is safe enough to get Carlat interviews on mass media including NPR but which says nothing that will truly upset establishment psychiatry. Everything Carlat says here has been reported for a decade in the corporate media. Yes, psychiatrists are bribed by drug companies to push drugs - old news! Yes, most psychiatrists are nothing but drug pushers who farm out psychotherapy - old news! Yes, as Carlat quite timidly implies, psychiatry has little hard science to back up its biochemical claims - again old news.
Want to read the kind of critique of psychiatry that is BIG NEWS? Read investigative reporter Robert Whitaker's Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (Crown Publishers, April 2010). It is the most important book on psychiatric treatment in a generation. Whitaker, as a reporter for the Boston Globe, won a George Polk Award for medical writing and was a finalist for a Pulitzer Prize. Whitaker is in the tradition of Michael Pollan, Eric Schlosser, and other investigative reporters who get taken seriously. A decade from now, nobody will remember Unhinged, but Whitaker's Anatomy of an Epidemic may do what Rachel Carson's Silent Spring was able to do - wake up an entire nation to the dangers of the arrogance of another chemical industry.
13 of 16 people found the following review helpful
on August 7, 2010
Something is rotten in the state of psychiatry today, and Daniel Carlat shows you, with brutal honesty, what the problem is. He shows the influence of the drug companies over doctors--even over himself at one point, which I give him credit for admitting. Several big names in psychiatry--including Daniel Amen--are shown to be quacks. Studies funded by drug companies turn out to be--shockingly!--biased and unreliable. Yes, as many reviewers have pointed out, drug company influence over doctors is hardly breaking news, but sometimes an important message needs to be repeated over and over again. At the end of this book, you'll like Dr.Carlat, but you may be weary of that Paxil pill your doctor just prescribed. If you're a mental health professional or patient, you need to read this delightful book.
28 of 38 people found the following review helpful
on July 13, 2010
Breath taking ! Shocking. Put as many adjectives you want still it wont be enough to describe the merits of this book. The unholy nexus between the doctor and the pharmceutical industry has been brilliantly portrayed. Unless the author has some personal grouse - I trust the author to be unbiased - this book brings to the fore some disturbing facts. He shows how the doctors are persuaded - rather one may even say bribed - by the salesmen of the big corporations to peddle their ware and how the doctors succumb to such soft tactics. The genuine issues of the profession - of psychology - are brought forth like the overwhelming number of patients that the shrink has to attend to and the impossiblity to give required therapeutic attention to the patients. But in my opinion, that is no excuse. A senate hearing should be held just on the basis of the reports in this book. The story telling is quite vivid. That too straight from the horse's mouth. The nefarious connection between the medical profession and the pharmaceutical industry.. The falsehood behind the statistical studies and the subsequent results published as if having the expert's approval . The innocent victims who think the ads to be gospel truths . Oh the shame of it ! We are reminded of the old saying " Statistics can prove anything ". Bravo ! It takes a lot of guts to come out into the open through his book with facts like this - even though the author himself belongs to the same profession. The lifeless souls that come out of such drug treatment bereft of their personality - the products of mind altering drugs. In the corporate world the evil nexus that existed between the auditors and the clients was substantially eliminated by laws like Sarbanes Oxley etc. But what about this ? Is there any way to tackle this problem at all ? Mind you, the issues at stake are much more serious - one of human health. But sadly no laws exist. Our bodies have become the profit machines for the pharmaceutical industries. Though the author admits that many drugs are really miracle cures . But still the situation is dicey. To realize that all this is happening under the guise of paracticability. The betrayal of the Hippocratic oath - the oath that the doctors have to take once they enter this profession . Can it be termed the hypocritical oath ? Going by this book, there are sufficient grounds for saying so. If the author had written it in a form of novel, this could be a Dickensonian classic.
15 of 20 people found the following review helpful
on August 3, 2010
While I appreciate Dr Carlat's book, and feel that it effectively covers what he wanted to say, I was particularly interested in the chapters "The Hired Guns" and "A Frenzy of Diagnosis" because of my own vocation. For the past 23 years I have worked in the field of Substance Abuse Treatment and for the past 13 years as a Director of 3 private oupatient programs. Nothing in this book is new stuff but most it is not talked about enough. Because I always see the back side and the negative impact of mis-diagnosis and overzealous pharmacological treatment, several things frustrated me as I read this book. I often wonder if any physician or therapist who is quick to catagorize a child or adolescent bipolar or ADHD ever considers the psychological impact this label can have on this young person's life going forward. Additionally, I wonder the if this unrgency to diagnose, label, and to treat with medication is ever considered an impediment to a patient's ability to deal effectively with life's day to day problems. I know Dr Carlat acknowledges this, and that he is advocating psychotherapy, but mostly with concurrent use of what is perceived in my field to be dangerous addictive medications. Early in his book he describes a client who retreats from his depression into alcohol and drug abuse. My question in cases like this is "how often would an individual like this be assessed for genetic pre-dispostion to alcoholism?", and if that be the case "how much would it affect the prescribed treatment?" I understand that I am taking the purpose of this book off topic but in my field prescription drug addiction, particularly opiods and benzodiazapines, is epidemic and the majority of the dealers are not on the streets but in physicians offices. And even more discouraging is that because of the reasons Dr Carlat describes in his book, this epidemic is being funded by all of us through our health care industry.
3 of 3 people found the following review helpful
on February 28, 2012
Format: HardcoverVerified Purchase
Daniel Carlat is no polemicist: He loves the field of psychiatry. This book, a convincing argument, appears to emerge from his commitment to a profession he sees as helpful to patients but burdened by financial and scientific conflicts as well as an outdated training model.
Clear, vivid, and well-written, _Unhinged_ autobiographically tells of how the culture of psychiatric practice can put practitioners in a position of dismissing patients' concerns and overvaluing the most cleverly marketed pills. Among Carlat's prescriptions: Stop training psychiatrists in medical schools and adopt a training model that focuses on mental health, encourage prescriptive authority among psychologists and nurse practitioners, and change psychiatric practice to emphasize psychotherapy as well as pharmacology. Carlat's recommendations are not popular in his field, but with medical students avoiding psychiatric specialities and with a shortage of mental health care in large parts of the U.S., following them would lead to greater access to better care for those suffering from mental health difficulties.
3 of 3 people found the following review helpful
on December 28, 2011
Format: HardcoverVerified Purchase
An eye opening reminder of what has become of the medical profession. It is a perfect representation of the evolution of what used to be a "helping profession" into one focused on making money in addition to dependent clients.
Highly recommended for anyone in or entering mental health, but I may also purchase a copy for my general practitioner as well!
2 of 2 people found the following review helpful
Author Daniel Carlat wrote in the first chapter of this 2010 book, "I will take you on a guided tour of the landscape of modern psychiatry. I will show you what we actually know about the mind---versus what we only pretend to know. I will argue that we psychiatrists spend our days splitting our patients into two: one is a repository of neurotransmitters, and the other is a person with relationships, a job, and aspirations. We treat the neurotransmitters, and we refer the person to someone else. The surprise is that our treatments are remarkably helpful to patients, even though we hobble ourselves in this way. Imagine how effective we could be if we embraced all the tools at our disposal." (Pg. 16)
He admits, "Most people are under the misconception that an appointment with a psychiatrist will involve counseling, probing questions, and digging into the psychological meanings of one's distress. But the psychiatrist as psychotherapist is an endangered species. In fact, according to ther latest data ... only one out of every ten psychiatrists offers therapy to all their patients. Doing psychotherapy doesn't pay well enough. I can see three or four patients per hour if I focus on medications... but only one patient in that time period if I do therapy... psychiatrists have generally followed the money." (Pg. 4-5) He adds, "There was a time when I thought this shift in the profession was a natural evolution. Why put patients through months and years of weekly therapy if simply taking pills worked as well if not better? As it turns out, we were wrong in two ways. We both exaggerated the effectiveness of the new drugs and gave psychotherapy a premature burial." (Pg. 12)
He states, "The tradition of psychological curiosity has been dying a gradual death... In the past... treatment entailed constructing elaborate explanations for how symptoms developed through early childhood experiences... The climax of treatment would be an 'interpretation'... Many such explanations were, no doubt, true, but unfortunately the truth did not necessarily set patients free. Symptoms stubbornly remained. Gradually, the profession became disillusioned with psychoanalysis, and turned to other methods, such as psychopharmacology." (Pg. 45-46)
He points out that "The idea that depression is a 'chemical imbalance' derives from how the drugs work. We have come to the theory through a process of deduction, reasoning backward from the effects antidepressants have on neurotransmitters. Antidepressants... treat depression. Ergo, depression must be caused by a DEFICIENCY of such neurotransmitters... But the problem is that there is no DIRECT evidence that a ... deficiency is involved." (Pg. 76-77) He adds, "The fact is that psychopharmacology is primarily trial and error, a kind of muddling through different candidate medications until we hit on one that works." (Pg. 83)
After noting the large number of drug study results that are suppressed and/or never published, he states, "If I relied on the published medical literature for information... it would appear that 94 percent of all antidepressant trials are positive. But if I had access to all the suppressed data, I would see that the truth is that only about half... of trials are positive... If there is only a fifty-fifty chance that an antidepressant drug study shows the drug to be effective, what does this mean for the patients taking these drugs? Is everybody taking a placebo, and only fooling themselves into believing that these drugs work?" (Pg. 117)
This is a fascinating, insightful, and controversial book that will be of great interest to anyone studying the pharmaceutical industry, modern psychiatry or psychology, or the medical profession in general---whether one always agrees with Dr. Carlat or not.