This is essentially a whistle blower reporting on the corruption of psychiatry by Big Pharma. Dr. Carlat went to UCSF med school in 1985 as psychiatry was rapidly transiting to psychopharmacology. He is practicing at Massachussetts General Hospital (MGH) where many of the key drug trials had taken place and where faculty members had received millions from Big Pharma to conduct such trials. He also used to accept Big Pharma's money ($30,000 in total, a very small amount relative to others) to lecture to pitch its drugs until his conscience regained the better of him. Thus, he had a front seat and was an active participant in psychiatry's' corruption. His confession is very insightful.
Carlat feels that psychiatry is in a state of crisis, as it has lost much credibility with the public. He mentions a recent Gallup poll that uncovered that only 38% of Americans trust psychiatrists, on par with chiropractors (36%) and even bankers (37%) and way below regular physicians (69%). There are several themes to Carlat's analysis of psychiatry devolution.
First, psychiatrists have given up on understanding their patients. They don't do psychotherapy anymore. They essentially just prescribe drugs (mainly anti-depressants). They now call themselves psychopharmacologists instead of psychotherapists. For psychotherapy, you have to go to a psychologist (who got a graduate degree in psychology, but did not go to med school, and is not allowed to prescribe drugs).
Second, psychiatrists overdiagnose their patients. Way too many children are overdiagnosed with ADHD and even bipolar disorder (the latter being often meaningless for young children). From 1994 to 2003, children and adolescent treated for bipolar disorder rose by 8,000%! The majority of cases are misdiagnosed. The psychological troubles are related to complex sociological problems the psychiatrists make no effort to understand. And, way too many adults are overdiagnosed with ADHD, social anxiety, and mild depression for what are often normal responses to the challenges of daily life.
Third, psychiatrists are overdrugging their patients. Psychiatrists too readily prescribe anti-depressants and stimulants to treat just about any small psychological discomfort that could better be resolved through just a few therapy sessions.
Fourth, the efficacy of most drugs are highly questionable because they are based on an unproven scientific hypothesis: the brain chemical imbalance theory (called "monoamine hypothesis"). Carlat states that chemical imbalance is a myth perpetrated by the profession. Depression is explained by a deficiency in the neurotransmitter called serotonin. The problem is that the causal link between serotonin level and depression has never been proven. Actually, several studies attempting to prove this link ultimately served to disprove it. Therefore, SSR anti-depressants aimed at boosting serotonin levels work no better than placebo. In 50% of drug trials, the drugs do not beat placebo. Another outstanding book on this subject is: The Emperor's New Drugs: Exploding the Antidepressant Myth.
Fifth, psychiatrists understand very little regarding the human brain. Its functioning at the neurobiological level remains a mystery. Additionally, "to a remarkable degree our choice of medication is subjective, even random" acknowledges Carlat.
Sixth, so far technological innovations within psychiatry have failed. Innovations such as the vagus nerve stimulator, transcranial magnetic stimulation have been complete failures. Yet, they have been approved by the FDA only to be rejected by more serious studies.
All those themes have a common root: economic conflict of interest. About three decades ago, psychiatrists noted that they could make a lot more money by prescribing drugs instead of conducting therapy. A therapy session takes an hour. During this same hour, a psychiatrist can see three patients, quickly diagnose them and give them a prescription. As a result, psychopharmacology is far more lucrative and efficient than psychotherapy. The increased efficiency translated into lower claim cost per patient. Therefore, insurance coverage became more generous for drugs than for therapy. This only accelerated the transition to psychopharmacology.
Carlat suggests there are two major problems with this transition to psychopharmacology. First, it does not work that well. Many studies have confirmed that psychotherapy works often better than drugs and with no side effects. The relapse rate is lower as patients learn lifelong solving skills. And, second psychopharmacology has turned psychiatry into the marketing arm of Big Pharma. Now, over 27 million Americans are on anti-depressants that work little better than placebo but with side effects. Big Pharma spends twice as much on marketing as research. Carlat states that all the "new" drugs work no better than the original ones of 50 years ago. They are just a lot more lucrative because they are under patent. Antidepressants often bring in between $1 billion to $5 billion in annual revenues.
The conflict of interest in psychiatry have reached a critical level whereby the credibility of the profession is being questioned. Dr. Carlat covers the practice of drug reps and leading psychiatrists receiving millions of dollars from Big Pharma to give speeches to other doctors pushing their drugs and even testing their drugs in clinical trials. Psychiatrists lead the pack of specialties receiving the most money from Big Pharma. How can a clinician objectively evaluate a drug when he is paid a fortune by the developer of that drug? This is an egregious conflict of interest resulting in poor science and perpetrating the ignorance of psychiatrists. How can they figure what really works since they can't trust the original studies.
In the last chapter, Carlat makes recommendations to reform the field of psychiatry. He feels psychiatrists should not be trained through traditional med schools. They waste several years learning everything they will never need (radiology, surgery, delivering babies, ER training, etc...). And, they learn very little of what they really need such as therapy. Instead, he refers to a prototype program in San Francisco that offered a special degree in mental health that combined extensive training in therapy and pharmacology. It prepared students far better than the long curriculum of med school. Yet, the program was killed by the psychiatry lobby. Carlat, similarly, feels we should license all psychologists to prescribe drugs after providing them additional training in pharmacology. He also feels that all psychiatrists should conduct therapy as they did in the past.
Carlat's recommendations make sense. But, the psychiatry lobby will resist all such proposals to protect their income. Nevertheless at the risk of becoming ostracized by colleagues, Carlat is really courageous for stating what is necessary to restore integrity to his profession.