Psychiatry has lost its soul.
That's how grimly Dr Daniel Carlat, a psychiatrist in private practice outside of Boston, characterises the state of his profession.
"Over the last 20 to 30 years, psychiatry has really transformed itself from a profession in which we try to understand people and understand their psychology - and talk to them and help them that way - into a profession in which we diagnose diseases, and we medicate those diseases," says Carlat.
"So over that time, we have in a sense, and this is really alarming to me, we've lost our sense of psychological curiosity," he says. "And that's kind of the very soul of psychiatry."
Exactly what's wrong, and how to fix it, was the topic of discussion when Reuters Health spoke to Carlat about his new book Unhinged: The Trouble With Psychiatry - A Doctor's Revelations About a Profession in Crisis (Free Press, May 18, 2010). (See live-blogging from the conversation)
Started with SSRIs
The slide started, says Carlat, when psychiatric blockbusters like Prozac (fluoxetine), a so-called selective serotonin reuptake inhibitor, or SSRI, was approved in 1988. Thanks to Prozac and its cousins such as Zoloft and Paxil, and their relatively limited side effects, prescriptions grew to the millions.
Borrowing the words of late Harvard psychiatrist Dr Leon Eisenberg, psychiatry went from being "brainless" to being "mindless," Carlat says. Today, psychiatrists spend 20 minutes with a patient every few months, in essence adjusting medications, compared to an hour or more each week trying to understand what was wrong.
Some argue that reflects a more mature science, one that pays off faster and more efficiently. But that's not necessarily true, says Carlat. He cites an example from his clinic: He had been prescribing Ambien, a long-acting sleeping pill, to one of his patients for a while. At the same time, however, the patient was complaining to his therapist that he felt overly sedated and couldn't get up in the morning.
"One of his psychological issues was that he had such low self-esteem that he felt that he wasn't worth enough as a person to come to me - the more intimidating doctor figure - to ask me to do something about it."
As a result of the gap between psychology and psychiatry, the man had nodded off at the wheel during a business trip, barely avoiding an accident.
With the change in psychiatry also came a shift in the way we think and talk about mental problems. In the case of depression, for instance, doctors often refer to a deficiency in the neurotransmitter serotonin. While this makes sense at first glance, all it means is that SSRIs can treat depression; it does not mean we understand what's going on in the brain. In fact, nobody has ever found proof of a serotonin deficiency, according to Carlat.
"We do have a short-hand, "neurobabble" way of speaking to patients, and we usually use terms such as serotonin deficiency or epinephrine deficiency," he says. "I basically ask, do we know what the heck we're talking about when we even use those terms?"
Making tens of thousands as a 'hired gun'
While no one completely understands what's going on in the brain of a depressed person, drug makers have been quick to take advantage of the medical model of mental illness, pushing their own expensive medicines in dubious ways, Carlat says.
And he would know. In 2001, he was contacted by the pharmaceutical giant Wyeth, which offered him $750 to have a short lunch with primary care doctors. The basic idea: to tout the company's psychiatric drugs, such as Effexor. Wyeth, later bought by Pfizer, gave him slides and took him to expensive conferences, where key opinion leaders in the field would lecture on the newest drug trials. And each time he did his talks, drug reps would listen in.
"I knew that if I wanted to get another gig, and another phone call, another invitation for another $750 check, I was going to have to say some pretty positive things about their drug, and I was going to have to downplay some of the negative side effects," Carlat says.
Finally, after having made $30,000 and realising he was just a hired gun, he started talking frankly about the side effects. The next day, he said, a drug rep came by his office and asked him if he'd been sick, as if that was the only logical explanation for such behaviour.
Doctors won't deceive doctors
"Doctors usually are going to think that other doctors aren't going to try to deceive them about things, but unfortunately, that's not true," says Carlat, who later wrote about the experience in The New York Times Magazine. "Doctors are just as vulnerable to the allure of money, marketing and financial incentives as anybody else."
For example, in 2006, one prominent psychiatrist, senior National Institutes of Medical Health scientist Pearson "Trey" Sunderland, was sentenced to two years' probation for accepting about $300,000 in consulting fees from Pfizer without first obtaining approval and disclosing the funding. In response to this and other incidents, just last week, National Institutes of Health director Dr Francis Collins proposed new, more stringent rules about how to manage researchers' financial interests in companies whose work is related to their own.
As part of the new proposal, NIH-funded institutions would be required to post conflicts of interest on a public website.
"The public may not always understand the intricacies of rigorous science, but most individuals quickly grasp the concept of bias," Collins and a colleague wrote in the medical journal JAMA.
"Plain and simple," they added, "Americans do not want financial conflicts of interest to influence the federally funded research they hope will yield better ways to fight disease and improve health."
How to fix psychiatry
As important as minimising conflicts of interest is, it isn't going to give psychiatry back its soul. To start down that path, one of the solutions Carlat suggests in his book is a merger between talk therapy and psychiatry.
But there's a problem: Today's psychiatrists don't have the time to do much more than diagnose and medicate their patients. In fact, they don't even have time for that. Citing a new study, Carlat says 40,000 new prescribers of psychiatric medicine are needed in addition to the current 30,000 in order to fill the gap in US healthcare. Training that many psychiatrists would be hugely expensive.
The solution? Give psychologists a little extra training, and let them prescribe the most common drugs.
"We have something in the range of 80,000 to 100,000 psychologists in our country...who already know most of what you need to know to be a good psychiatrist," Carlat said.
Louisiana and New Mexico have already approved psychologist prescribing, and according to Carlat there hasn't been a single malpractice lawsuit there since 2002.
Not surprisingly, many psychiatrists are resisting the idea, says Carlat, adding that "this is just a good old-fashioned turf war and it's all about money."
But patients might benefit, such as the man who kept falling asleep because his sleeping pills were too strong. It almost took a car crash before he told Carlat, who immediately switched him to a lighter medication.
"If a therapist had been able to prescribe it, he would have gotten the drug right away and he wouldn't have risked having a potentially fatal car accident," Carlat says. - (Frederik Joelving/Reuters Health, May 2010)