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Unhinged: The Trouble with Psychiatry - A Doctor's Revelations about a Profession in Crisis Hardcover – May 18, 2010
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"Unhinged is a searingly honest and articulate account of modern psychiatry's failure to think outside the box of psychopharmacology in treating patients." (Alison Bass, author of Side Effects: A Prosecutor, a Whistleblower and a Bestselling Antidepressant on Trial,winner of the NASW Science in Society Award for 2009)
“A psychiatrist looks deeply into the mirror and takes stock of his profession and what it has become. Whether you are a patient, student, trainee, clinician, or “KOL” (key opinion leader”), this frank and insightful book will definitely make you think.” (Erick Turner, M.D., Department of Psychiatry and Center for Ethics in Health Care, Oregon Health & Science University)
"Unhinged provides crucial insights for anyone who cares about the future of Psychiatry. Must reading for psychiatrists and patients alike." (Keith Ablow, MD, author of Living the Truth)
"Terrific book, terrific insights! Daniel Carlat is the kind of psychiatrist we wish we all had." (Manny Alvarez, MD, Senior Managing Health Editor at Fox News Channel)
Top customer reviews
I suspect such a book may not be popular among psychiatrists but truth is painful and it's high time someone came out to remind them what patients expect and deserve... real, humane treatment.
Kudos to Dr. Carlat... now we need more whistle-blowers to shed true insight into just how damaging many of the meds are and that continue to be prescribed at an alarming rate.
Daniel Carlat, in his book, 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. 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 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.
Carlat describes his own experiences as a target of the pharmaceutical marketing machine. Ambien, a sleeping pill marketed by Sanofi-Aventis, was going off patent soon. Safoni-Aventis wanted doctors to prescribe Ambien CR ("Controlled Release"), a longer-acting drug than the original. Carlat was skeptical of the science behind the new pill. Valerie, his drug sales rep, knew that he wasn't prescribing much Ambien CR. 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 talks about the overdiagnosis of psychiatric disorders. 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.
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 and older teenagers. 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. His diagnostic change led to a forty-fold increase in the number of children and adolescents treated for bipolar disorder.
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 assumes that drugs are effective. In his book, he gives a number of case examples of patients whom 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?
In conclusion, this book 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 efficacy.
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.