By Giovanna Pompele PhD who teaches Women and Gender Studies at the University of Miami.
On July 13, 2010 Fresh Air, a program I very much like but which has repeatedly proven glib on mental health issues, aired an interview with psychiatrist Daniel Carlat This interview is jaw-dropping on a variety of levels, and since these levels are important, I’m going to detail them.
For the regular Joe, who unproblematically believes in the provability of biomedical explanations of mental illness, considers psychiatrists real experts in the field of helping people who suffer from inner pain, and has as much trouble with the concept of psychiatric medication as he has with the concept of anti-inflammatory drugs, the show was probably jaw-dropping in that it alerted him to the facts that psychiatrists know much less than he believed and the vast majority of them are entirely in the thrall of pharmaceutical companies. Regular Joe was probably not disturbed by Carlat as a professional but by what he revealed about his field.
For the educated Jane, who knows about Big Pharma’s shenanigans especially in relation to psychiatric drugs and is convinced that most psychiatrists are callous charlatans who pretend to have solid knowledge about things about which there is no solid knowledge to have, the show was jaw-dropping both with respect to Carlat himself as a professional and with respect to psychiatry in general. Concerning the former, she might have been shocked to learn that Carlat, now a professor of psychiatry at Tufts University, pimped for pharmaceutical companies and appears to feel no shame whatsoever about it. She might also have been disturbed to learn that he knowingly lies to patients and, similarly, seems to have no qualms at all about it.
For the super-informed Jan, an activist who tears her hair out everyday over the appallingly sorry state of mental health care in the US, the show was absolutely jaw-dropping not because of what Carlat said, but because of the glib and breezy way in which he said it. It felt to her as if someone had just confessed on the radio to breaking into the Pentagon and the State Department and passing on their secrets to terrorists, and nothing happened.
Here is a summary of the hair-raising things Carlat said. Some pertain directly to his own beliefs and practices, while some pertain to the state of the profession, though clearly there is no exact line between the two, as he is a fundamentally uncritical practitioner of his profession:
He diagnoses people in the course of very short sessions basing his judgment solely on the DSM; to Carlat, the patient represents, not a complex human reality, but a cluster of symptoms. His job is to match these symptoms directly to those listed in the DSM in order to come up with a diagnosis. This diagnosis is, to him, a fact about the patient. Check out the following statements:
CARLAT: We are in the business of making diagnoses using the DSM, which is the official diagnostic manual for the psychiatric disorders of the American Psychiatric Association. We make our diagnoses, and then we usually prescribe medications.
DAVIES: If you’re seeing patients for a relatively short session, relatively infrequently, how do you know what to give them and whether it’s working?
CARLAT: We have a conversation, and I ask my patients questions about how they’re feeling, how they’re thinking, how they’re sleeping, what their concentration level is, what their energy level is, and I put all those pieces of information together and then I come up with a diagnosis based on the DSM guidebook that we have. And then once I have a diagnosis, essentially I match those symptoms up with the medication. So modern psychiatry is really a conversation, a series of symptoms, and then a matching process of medication to these symptoms.
He sees patients for no longer than 15 minutes and makes it a policy to avoid getting into any depth at all about what ails them (he called it the “don’t ask don’t tell” approach to psychiatry). When he needs to learn about patients, he prefers to do so from their therapists rather than from the patients themselves:
There’s kind of an unofficial policy among psychiatrists, at least among some, which is the don’t-ask-don’t-tell policy, which is that we have our patients coming in, we know we have 15 or 20 minutes to see them. We want to learn a certain amount about how they’re doing, obviously, because we want to make sure that our medications are working and that we know if we need to increase the dose or add something else. But on the other hand, we don’t want to ask too many questions because if we start to hear too much information, then we’re going to run into a time issue where we’re going to have to kind of push them out of the office perhaps just at the point where they’re about to reveal something that could really be crucial to understanding their treatment.
What’s really concerning to me, is that often we really don’t get that much information. I mean, presumably the psychiatrist and the therapist would be communicating frequently on an ongoing basis, but I have many examples in my practice – for example, the case of a woman who I was prescribing sleeping pills to – an elderly woman, actually, I was prescribing sleeping pills for. And then I learned about a year later from her therapist that she had been drinking large amounts of alcohol every night, combining them with the sleeping pills, which could be quite dangerous. (Writer’s note: Why on earth didn’t Carlat talk to his patient long enough to find out that she was drinking on top of her pills?!)
Or another patient who I found out from the therapist had been abusive toward his wife. I had been diagnosing him with bipolar disorder, thinking that his attacks of mania or irritability were due to a kind of biological condition, whereas in fact they may have been due entirely to his abusive nature and a dysfunctional, you know, relationship between him and his wife.(Here is what’s wrong with this statement: 1) Someone can be bipolar and be abusive and have a dysfunctional relationship with this wife at the same time; those states are not mutually exclusive; 2) Carlat probably didn’t spend enough time with the man to know that he was, indeed, bipolar, because 3) he didn’t spend enough time with the man to know that he was violent and had a crappy relationship with his wife; 4) there is no such thing as an “abusive nature.”)
He has hundreds of patients.
Certainly what happens is that in order to maximize my income, I want to fit as many patients into an hour as I can. So if I see four patients in an hour, I’m obviously going to make more money than if I see three or two or one.
He express no ethical qualms, regrets, or remorse about pimping for pharmaceutical companies.
He regularly lies to patients.
What we don’t know is we don’t know how the medications actually work in the brain. So whereas it’s not uncommon – and I still do this, actually, when patients ask me about these medications, I’ll often say something like, well, the way Zoloft works is it increases the levels of serotonin in your brain, in your synapses, the neurons, and presumably the reason you’re depressed or anxious is that you have some sort of a deficiency. And I say that not because I really believe it, because I know that the evidence isn’t really there for us to understand the mechanism. I think I say that because patients want to know something, and they want to know that we as physicians have some basic understanding of what we’re doing when we’re prescribing medications. And they certainly don’t want to hear that a psychiatrist essentially has no idea how these medications work.
He prescribes drugs he claims to have no reason to have solid faith in.
A lot of the public doesn’t realize how sophisticated the marketing techniques have become, really over the last 10 years, to the point where essentially when a pharmaceutical company gets FDA approval for a drug, their marketing department can assure their bosses that they are going to be able to sell the drug, really whether the drug is effective or not.
DAVIES: “And it can be reassuring if you’re prescribing a medication to tell someone, well, there’s really a biological origin of your difficulty here, and we can treat it with – by treating the biology.”
CARLAT: Right, which is exactly why I still tell patients that at times. But I think, you know, one thing that has happened is that because there’s been such a vacuum in our knowledge about mechanism, the drug companies have been happy to sort of fill that vacuum with their own version of knowledge so that usually, if you see a commercial for Zoloft on TV, you’ll be hearing the line about serotonin deficiencies and chemical imbalances, even though we don’t really have the data to back it up. It becomes a very useful marketing line for drug companies, and then it becomes a reasonable thing for us to say to patients to give them more confidence in the treatment that they’re getting from us. But it may not be true.
And the problem is that we don’t have any direct evidence that depression or anxiety or any psychiatric disorder is actually due to a deficiency in serotonin because it’s very hard to actually measure serotonin from a living brain. And any efforts that have been made to measure serotonin indirectly, such as measuring it in the spinal fluid or doing postmortem studies, have been inconclusive. They have not shown conclusively that there is either too little or too much serotonin in the fluids. So that’s where we are with psychiatry.
And the really, to me, the astounding information that came out in that trial was that about 50 percent of all of the articles published about Zoloft over a certain period of time were actually ghostwritten by medical writers who were not MDs. And the company actually would pay big name psychiatrists a thousand dollars or $2,000 to have their names put on these journal articles in order to lend them some kind of scientific credibility.
DAVIES: How common is the practice? Do we know?
CARLAT: We don’t know, actually. Although, recently a study came out indicating that as many as 10 to 20 percent of articles in the major journals are still being ghostwritten… You would think that there would be repercussions like that. However, there have not been any such repercussions.”