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Daniel J. Carlat

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Unhinged: The Trouble with Psychiatry - A Doctor's Revelations about a Profession in Crisis Hardcover – May 18, 2010

by Daniel Carlat M.D. (Author)

4.4 123 ratings

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IN THIS STIRRING AND BEAUTIFULLY WRITTEN WAKE-UP CALL, psychiatrist Daniel Carlat exposes deeply disturbing problems plaguing his profession, revealing the ways it has abandoned its essential purpose: to understand the mind, so that psychiatrists can heal mental illness and not just treat symptoms. As he did in his hard-hitting and widely read New York Times Magazine article "Dr. Drug Rep," and as he continues to do in his popular watchdog newsletter, The Carlat Psychiatry Report, he writes with bracing honesty about how psychiatry has so largely forsaken the practice of talk therapy for the seductive—and more lucrative—practice of simply prescribing drugs, with a host of deeply troubling consequences.

Psychiatrists have settled for treating symptoms rather than causes, embracing the apparent medical rigor of DSM diagnoses and prescription in place of learning the more challenging craft of therapeutic counseling, gaining only limited understanding of their patients’ lives. Talk therapy takes time, whereas the fifteen-minute "med check" allows for more patients and more insurance company reimbursement. Yet DSM diagnoses, he shows, are premised on a good deal less science than we would think.

Writing from an insider’s perspective, with refreshing forthrightness about his own daily struggles as a practitioner, Dr. Carlat shares a wealth of stories from his own practice and those of others that demonstrate the glaring shortcomings of the standard fifteen-minute patient visit. He also reveals the dangers of rampant diagnoses of bipolar disorder, ADHD, and other "popular" psychiatric disorders, and exposes the risks of the cocktails of medications so many patients are put on. Especially disturbing are the terrible consequences of overprescription of drugs to children of ever younger ages. Taking us on a tour of the world of pharmaceutical marketing, he also reveals the inner workings of collusion between psychiatrists and drug companies.

Concluding with a road map for exactly how the profession should be reformed, Unhinged is vital reading for all those in treatment or considering it, as well as a stirring call to action for the large community of psychiatrists themselves. As physicians and drug companies continue to work together in disquieting and harmful ways, and as diagnoses—and misdiagnoses—of mental disorders skyrocket, it’s essential that Dr. Carlat’s bold call for reform is heeded.

Editorial Reviews

Review

"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)

About the Author

Daniel Carlat, M.D., is on the faculty of Tufts Medical School and did his psychiatric training at Harvard Medical School and Masschusetts General Hospital, where he was chief resident of the inpatient psychiatric unit. He has published several professional books and articles, and is currently the editor-in-chief of The Carlat Psychiatry Report (www.thecarlatreport.com), a monthly newsletter read by clinicians throughout the United States. He is also an occasional contributor to The New York Times Magazine, where he has published articles on psychiatric and medical topics. He lives in Newburyport, Massachusetts.

Product details

ASIN ‏ : ‎ 141659079X
Publisher ‏ : ‎ Free Press; 1st edition (May 18, 2010)
Language ‏ : ‎ English
Hardcover ‏ : ‎ 272 pages
ISBN-10 ‏ : ‎ 9781416590798
ISBN-13 ‏ : ‎ 978-1416590798
Item Weight ‏ : ‎ 15.2 ounces
Dimensions ‏ : ‎ 6 x 1 x 9 inches

Best Sellers Rank: #819,513 in Books (See Top 100 in Books)
- #1,548 in Medical Psychotherapy TA & NLP
- #1,612 in Popular Psychology Psychotherapy
- #3,680 in Medical General Psychology

Customer Reviews:
4.4 123 ratings

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Customers find the book insightful and educational, providing important information in a clear, easy-to-understand manner. They describe it as an interesting read that is worth their time. The language is straightforward and not overly technical, making it suitable for both doctors and lay readers.

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Insight Readability Language

17 customers mention "Insight"17 positive0 negative

Customers find the book insightful and educational. They say it's an eye-opener with important information written in a layman's way. Readers appreciate the author's honesty and wisdom, finding the ethics chapters interesting. The book provides a great look at psychopharmacology from a doctor's perspective.

"...it's not ground-breaking material for those in the know, it's important information written mostly in layman's terms...." Read more

"...In conclusion, this book is a well-written, honest account of systemic problems in psychiatry written by someone with an insider's perspective on..." Read more

"...I have some disagreements with Dr. Breggin, but he is ethical and honest, and lives what he believes...." Read more

"...A great statement of the facts mixed with the authors opinions and personal experiences. A must-read for anyone who has long-term medical conditions...." Read more

12 customers mention "Readability"12 positive0 negative

Customers find the book engaging and interesting. They say it's worth reading and should be required reading for everyone in America.

"...has literally saved people's lives and it should be mandatory reading for everyone in America." Read more

"...I found it to be a very interesting book, I had trouble putting it down!" Read more

"Overall very good book. I really enjoyed it...." Read more

"...3. So we do the best we can. Good read." Read more

11 customers mention "Language"11 positive0 negative

Customers find the book's language readable, sensible, and helpful. They say it's well-written, honest, and perfect for doctors. The language isn't overpowering, so the lay person can understand better. It spells out how psychiatry devolved from interactive diagnosis to systemic treatment.

"...other works that can be easily dismissed, this book was written by a practicing psychiatrist who advocates (and practices) going back to the..." Read more

"...In conclusion, this book is a well-written, honest account of systemic problems in psychiatry written by someone with an insider's perspective on..." Read more

"Great easy to read book about the world of psychiatry and modern medicine in general...." Read more

"...Clear, vivid, and well-written, _Unhinged_ autobiographically tells of how the culture of psychiatric practice can put practitioners in a position..." Read more

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D. Baptista
We need more Dr. Carlats in the world
Reviewed in the United States on July 26, 2010
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A great criticism of the psychiatric profession and its incestuous relationship with Big Pharma. Unlike other works that can be easily dismissed, this book was written by a practicing psychiatrist who advocates (and practices) going back to the profession's psychotherapy roots. The language isn't too overpowering, so the lay person can have a better understanding of how psychiatry works (and how it doesn't. It debunks the many myths that unwitting patients have, e.g., that psychiatrists regularly practice therapy, that psychiatrists have more than half a clue when they prescribe a certain medication. While it's not ground-breaking material for those in the know, it's important information written mostly in layman's terms.

My biggest complaint is not with the book itself, but with the publishers, who set a higher price for the book.

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6 people found this helpful

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Arguably the most important book ever written in psychiatry
Reviewed in the United States on June 28, 2023
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This book has quite literally saved the lives of countless people that were either trapped or about to become trapped in the corrupted psychiatry system. Incidentally I have met many of the victims of the exact psychiatric system that Daniel wrote about. I cannot emphasize enough how important this book is. It has literally saved people's lives and it should be mandatory reading for everyone in America.

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Harry Magnet
A Psychiatrist Criticizes His Own Profession
Reviewed in the United States on September 24, 2011
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It's not news that the profession of psychiatry is in a crisis state. 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, 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.

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G. Ramirez
Interesting read
Reviewed in the United States on November 11, 2011
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Dr. Carlat discusses the breakthroughs and drawbacks of modern psychiatry. His main criticism is the shift from therapy to psychopharmacology within the field, in which doctors no longer offer hour-long therapy sessions for their clients, favoring the 15 minute "med check" model instead. Carlat also sheds light on the issue of drug industry influence on doctor's research and prescription habbits, including Carlat's own experience as a paid spokesman for Wyeth (makers of the Effexor antidepressant) and the pressure put on him by the company to influence other doctors' opinions about the drug.

I found it to be a very interesting book, I had trouble putting it down!

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C.C. Hoffman
Missing the point
Reviewed in the United States on August 19, 2014
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I have only read the first chapter so far, so maybe it is not fair for me to comment, but I was very annoyed with the good doctor. Fact is, shrinkery has become nothing but a system of pimping for the drug companies. The author has been colluding in this all along, instead of raising hell like Dr. Peter Breggin. I have some disagreements with Dr. Breggin, but he is ethical and honest, and lives what he believes.
The fact is, not every unhappiness and maladjustment has to be examined under a microscope for these high priests of nuerochemistry to pontificate about. I took birth control pills when they first came onto the market, and was poisoned. Part of the damage done to me by thiese highly touted and very profitable pills, aside from the obisity and hypertension they caused, was ...ta da...depression. Did I need big pharma to dope me up with an "antidepressant" ? No. I needed to stop ingesting oral contraceptives. My daughter went on a mission to never eat animal flesh again. After a few years, she was...depressed. Did my daughter need an antidepressant? No, she needed some protein, and when she ate some chicken, she was better within a few hours, and has stayed fine ever since, eating the small amounts of protein she needs. My husband spent twenty five years drinking heavily. Alcohol depletes the body of huge amounts of essential nutrients, and one of the consequences of that is "depression." A doctor would have him doped with pills that further deplete the body of nutrients, and do absolutely nothing to repair the damage he did to himself with alcohol. And yet, this author engages in the solipsistic notion that every negative feeling a human being can experience is the domain of the shrinks, who, as a group, are pretty much irrelevant, and should get a real job.

connsequences of that is "depression." What he needed was to stop drinking and have some intensive nutritional therapy.
wha

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Top reviews from other countries

DJ Barrow
The world's only book by a psychiatrist who went mad
Reviewed in the United Kingdom on October 26, 2024
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Psychiatry is an old boys club but most in psychiatric care have made a serious society misstep like a leisure suit Larry going past his ideal woman and throwing a tantrum its all about keeping your knickers on.

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Meg
Debunking myths of psychiatric medicine
Reviewed in Canada on December 15, 2012
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I loved this very frank and forthright book on the way psychiatry is practiced in the current age. To me there was an extra level of interest, since I myself trained in medicine, and I worked in general practice for eight years before having to stop working due to severe depression. I have to agree with everything Dr Carlat has written, especially as to how the profession now mainly treats sypmtoms rather than causes. I spent years on a merry-go-round of various pharmaceutical cocktails such as what is described in the book, without any psychiatrist actually getting at the root cause of my depression. The risks he describes are all true and shamefully little discussed by prescribing psychiatrists - this book is a gold mine of information for the unsuspecting patient and I would recommend it to anyone who is considering treatment with a psychotropic medication.

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Garden Mist
A very interesting book! A caring Psychiatrist thinks doctors should "talk" to their patients to help them get well!
Reviewed in Canada on March 22, 2014
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The author speaks with kindness and empathy about many of his patients and feels that psychiatry could do much more for the people who seek it's help other than just writing out a prescription. He seems to fell the art of listening has dies within the field of psychiatry and that people may get better from their illness if more Psychiatrists would actually "talk" to their patients. A very good book!

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LostinBooks
Outstanding!
Reviewed in Canada on January 17, 2016
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Daniel Carlat is a psychiatrist who loves his profession enough to expose its considerable weaknesses. Psychiatry will be better for this in the long run. In addition to dishing up some criticism, though, he takes time to show patients (and readers) how psychiatrists think, how psychiatric assessments are conducted, and how this profession has evolved. Warm, readable and memorable.

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