Carlat's Unhinged

Well he's not. Actually, I haven't met him, so it's always possible. But what he certainly has done is written a book called Unhinged: The Trouble with Psychiatry.

Daniel Carlat's best known online for the Carlat Psychiatry Blog and in the real world for the Carlat Psychiatry Report. Unhinged is his first book for a general audience, though he's previously written several technical works aimed at doctors. It comes hot on the heels of a number of other recent books offering more or less critical perspectives on modern psychiatry, notably these ones.

Unhinged offers a sweeping overview of the whole field. If you're looking for a detailed examination of the problems around, say, psychiatric diagnosis, you'd do well to read Crazy Like Us as well. But as an overview it's a very readable and comprehensive one, and Carlat covers many topics that readers of his blog, or indeed of this one, would expect: the medicalization of normal behaviour, to over-diagnosis, the controversy over pediatric psychopharmacology, brain imaging and the scientific state of biological psychiatry, etc.

Carlat is unique amongst authors of this mini-genre, however, in that he is himself a practising psychiatrist, and moreover, an American one. This is important, because almost everyone agrees that to the extent that there is a problem with psychiatry, American psychiatry has it worst of all: it's the country that gave us the notorious DSM-IV, where drugs are advertised direct-to-the-consumer, where children are diagnosed with bipolar and given antipsychotics, etc.

So Carlat is well placed to report from the heart of darkness and he doesn't disappoint, as he vividly reveals how dizzying sums of drug company money sway prescribing decisions and even create diseases out of thin air. His confessional account of his own time as a paid "representative" for the antidepressant Effexor (also discussed in the NYT), and of his dealings with other reps - the Paxil guy, the Cymbalta woman - have to be read to be believed. We're left with the inescapable conclusion that psychiatry, at least in America, is institutionally corrupt.

Conflict of interest is a tricky thing though. Everyone in academia and medicine has mentors, collaborators, people who work in the office next door. The social pressure against saying or publishing anything that explicitly or implicitly criticizes someone else is powerful. Of course, there are rivalries and controversies, but they're firmly the exception.

The rule is: don't rock the boat. And given that in psychiatry, all but a few of the leading figures have at least some links to industry, that means everyone's in the same boat with Pharma, even the people who don't, personally, accept drug company money. I think this is often overlooked in all the excitement over individual scandals.

For all this, Carlat is fairly conservative in his view of psychiatric drugs. They work, he says, a lot of the time, but they're rarely the whole answer. Most people need therapy, too. His conclusion is that psychiatrists need to spend more time getting to know their patients, instead of just handing out pills and then doing a 15 minute "med check" - a great way of making money when you're getting paid per patient (4 patients per hour: ker-ching!), but probably not a great way of treating people.

In other words, psychiatrists need to be psychotherapists as well as psychopharmacologists. It's not enough to just refer people to someone else for the therapy: in order to treat mental illness you need one person with the skills to address both the biological and the psychological aspects of the patient's problems. Plus, patients often find it frustrating being bounced back and forth between professionals, and it's a recipe for confusion ("My psychiatrist says this but my therapist says...")

This leads Carlat to the controversial conclusion that psychiatrists should no longer have a monopoly on prescribing medications. He supports the idea of (appropriately trained) prescribing psychologists, an idea which has taken off in a few US states but which is hotly debated.

As he puts it, for a psychiatrist, the years in medical school spent delivering babies and dissecting kidneys are rarely useful. So there's no reason why a therapist can't learn the necessary elements of psychopharmacology - which drugs do what, how to avoid dangerous drug interactions - in say one or two years.

Such a person would be at least as good as a psychiatrist at providing integrated pills-and-therapy care. In fact, he says, an even better option would be to design an entirely new type of training program to create such "integrated" mental health professionals from the ground up - neither doctors nor therapists but something combining the best aspects of both.

There does seem to be a paradox here, however: Carlat has just spent 200 pages explaining how drug companies distort the evidence and bribe doctors in order to push their latest pills at people, many of whom either don't need medication or would do equally well with older, much cheaper drugs. Now he's saying that more people should be licensed to prescribe the same pills? Whose side is he on?

In fact, Carlat's position is perfectly coherent: his concern is to give patients the best possible care, which is, he thinks, combined medication and therapy. So he is not "anti" or "pro-medication" in any simple sense. But still, if psychiatry has been corrupted by drug company money, what's to stop the exact same thing happening to psychologists as soon as they got the ability to prescribe?

I think the answer to this can only be that we must first cut the problem off at its source by legislation. We simply shouldn't allow drug companies the freedom to manipulate opinion in the way that they do. It's not inevitable: we can regulate them. The US leads the world in some areas: since 2007, all clinical trials conducted in the country must be pre-registered, and the results made available on a public website, clinicaltrials.gov.

The benefits, in terms of keeping drug manufacturer's honest, are far too many to explain here. Other places, like the European Union, are just starting to follow suit. But America suffers from a split personality in this regard. It's also one of the only countries to allow direct-to-consumer drug advertising, for example. Until the US gets serious about restraining Pharma influence in all its forms, giving more people prescribing rights might only aggravate the problem.