Thursday, July 15, 2010

Carlat on NPR's "Fresh Air"

For those who are interested in topics dwelt on in this blog and in my book Unhinged, please check out my interview on the NPR show Fresh Air, which was aired on Tuesday July 13, and is available on the NPR website here. Give it a listen. Hopefully I was fairly articulate, although it's hard to know when you are sitting alone in a studio with a giant microphone staring you in the face and an engineer cheering you on behind a window in the control room!

I found the host, Dave Davies (who was filling in for Terry Gross), extremely informed and I am perpetually impressed by the quality of programming on NPR. Today I was on another NPR show called Radio Boston, hosted by Meghna Chakrabarti (listen to it here) and again was amazed at the production quality and the intelligence of the questioning. Next time pledge week comes around for your local NPR affiliate, I urge you to pony up.

I must admit to some irritation when I think: why didn't you see this before? Why doesn't everyone see this? How can anyone practice this way, not really talking with their patients? How can anyone do these 15 minute u-know-whats? How can anyone believe the Pharma propaganda?

But no matter. Let's move forward.

Now that you're reformed, maybe you could start a movement. Really change things. You could be the messiah. :)

Years ago, I bought a used Triumph sports car. I did not have it long before a connecting rod broke. I saw a reputable mechanic who told me I needed the engine rebuilt. I asked him if he could just repair the cylinder with the broken rod so I could sell the car. He looked me in the eye and said, "I don't do patch jobs." He had too much integrity to practice his craft any other way.

That said, Liberty N. Justice really takes off at Dr. Carlat in a comment to the post below this one. The one embedded point he makes in his diatribe that appears to hold true is that Dr. Carlat has written a book denouncing psychiatric "patch jobs" but then rationalizes practicing essentially that way by maintaining a list of hundreds of patients.

I dunno. I don't walk in Dr. Carlat shoes or have any knowledge about how he practices psychiatry. However, while Liberty N. Justice's splenetic denunciation of Dr. Carlat is not a conviction, it unfortunately sort of rings true as an indictment.

I hope Dr. Carlat considers that as his professional sensibilities evolve.

""But on the other hand, 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.

I mean no disrespect but that is the most insulting thing I have ever heard a medical professional say.

Patients want honesty, not lies.

Maybe you shouldn't be prescribing medications that you can't come up with a truthful answer for.

""DAVIES: But that's pretty close to the truth?

Dr. CARLAT: Unfortunately, it is close to the truth. We're in a paradoxical situation, I think, where, you know, we prescribe medications that do work, according to the trials, and yet as opposed to essentially all other branches of medicine, we don't understand the pathophysiology of what generates mental illness, and we don't understand exactly how our medications work.""

I have seen no evidence whatsoever that these meds work even short term. The study that is most cited as this evidence, the Star D study, is completely flawed and nowhere near the 67% success rate that is cited.

""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.

Dr. 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. ""

No, no, no. It isn't reasonable to lie to patients. Why you and alot of your colleagues think that is ok is mind boggling.

I do applaud you for being honest about this. At least you haven't tried to sugar coat things. But it is still disgraceful that you think it is ok to lie about the serotonin issue.

""But on the other hand, 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.

I mean no disrespect but that is the most insulting thing I have ever heard a medical professional say.

Patients want honesty, not lies.

Maybe you shouldn't be prescribing medications that you can't come up with a truthful answer for.

""DAVIES: But that's pretty close to the truth?

Dr. CARLAT: Unfortunately, it is close to the truth. We're in a paradoxical situation, I think, where, you know, we prescribe medications that do work, according to the trials, and yet as opposed to essentially all other branches of medicine, we don't understand the pathophysiology of what generates mental illness, and we don't understand exactly how our medications work.""

I have seen no evidence whatsoever that these meds work even short term. The study that is most cited as this evidence, the Star D study, is completely flawed and nowhere near the 67% success rate that is cited.

""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.

Dr. 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. ""

No, no, no. It isn't reasonable to lie to patients. Why you and alot of your colleagues think that is ok is mind boggling.

I do applaud you for being honest about this. At least you haven't tried to sugar coat things. But it is still disgraceful that you think it is ok to lie about the serotonin issue.

I tried to respond to various comments you made but I am sure it went though as it said my comment were too long to process.

To sum up what I said, it is disgraceful that you think it is ok to lie to patients about the Serotonin deficiency issue. If you can't come up with an honest reason to prescribe a medication, maybe you shouldn't be prescribing it.

Would you go to a surgeon who said he/she had no idea how this operation would turn out but the track record is excellent? I don't think so.

But for some reason, people with mental health labels are expected to accept care that would never fly in the rest of the medical arena. Somehow, with that label, we become less of a person and less deserving of respect.

That needs to stop.

I do applaud you for your honest and not sugar coating things. But lying to patients is not acceptable plain and simple.

Re: Anonymous It is still disgraceful that you think it is ok to lie about the serotonin issue.

I've thought the same thing. Psychiatrists are obviously trying to leverage the placebo effect by explicitly amplifying the supposed efficacy of a drug to a patient and downplaying side effects. Which on its face makes clinical sense.

However the practice is only ethical for prescriptions that are essentially benign like Omega-3 or St. John's Wort or even taking a walk around the block. With prescription psycho-pharmaceuticals though, the ethical boundaries are transgressed by what the physician does not tell the patient because of the potential nocebo effect.

Along with the placebo inducing nudge, should the physician also tell the patient that he could be trashed by a drug like Cymbalta or an antipsychotic, so that he can make a fully informed decision to take the medication?

I know the clinical instruction involves a complex therapeutic trade, but in the end, a physician who can't answer that question affirmatively probably shouldn't be in the business.

I routinely tell my patients that we have no idea how these medications work. I point out to them that there are hundreds of known compounds that affect mood and brain function. I also point out that the research data is completely contradictory regarding effects of medications.

I find that my patients welcome this information. And they are also willing to try a medication and often benefit from the medication I prescribe. Why? I don't know, but I find that the patients I have who are willing to try medications do much better than those who are not willing, even if they do not stay on the medications.

Regarding the studies on medication effectiveness. It is impossible to to scientific research on human subjects in this field. Real scientific research requires rigorously controlled experiments. There is no way of running such an experiment with human beings in a natural setting. What researchers do is make attempts to control for a few variables, and then they assume (or pretend) that the rest of the variables do not matter. That is not science.

When working with a patient I am working with someone with a unique genetic makeup, one that has never existed before and will never exist again. Furthermore, that person has been shaped by unique environmental events and lives in a unique environment now. There is not and never will be a controlled study on that person.

All the research data can give me are some rough guidelines. So I make recommendations for medications, supplements, therapy, behaviors, etc based on what I think will do the least harm, and give the most benefit. (Even exercise can be harmful so there is no risk-free approach). I then make sure that I follow patients closely and listen to what they tell me so that I can adjust what I am doing if it is not working or causing problems.

If each patient is treated as unique, then the potential for harm is much less. It is not the medications that are the problem, it is that providers use a cookie-cutter approach based on data that is meaningless and contradictory. Note that this applies to therapy as well. I have seen patients who were traumatized by therapists insisting they were sexually abused as a child because the therapist had a cookie-cutter approach to therapy.

Look forward to listening, did hear it publicized on NPR on many occasions before it aired. Thank you for moving forward the debate, which beyond fringes or some of us mental health Non-MD's, it seemed to not be brought up much. Biological reductionism and determinism has its appeal I suppose, one piece of the puzzle does not the puzzle make.

Some good comments here, SteveM rightly points out that Placebo effect may very well be a great thing for patience, but not when the drugs have many well known side effects some quite serious--particularly in the case of the Atypicals which in my practice I've seen turn many children into bloated lethargic kids with no real effect on their problems--perhaps because sedating children that AREN'T Manic-depressive/psychotics should be unethical. If you want a kid to sleep, give them sleeping pills.

Unfortunately like all the other scripts out there, Patients seem to want to walk away with pills, although I don't see this as often in the mental health field--its usually someone with power--schools/parents/group home's/social service that want the children to take the drugs.

I don't want most of the psychiatrists I've met to be doing psychotherapy, most have no real training in it, and exude a simplistic biological reductionism, especially behind closed doors that seems demeaning and irrational. Clearly the BioPyschoSocial theory integrates the various components to the complexity to brain development. After study after study about environmental factors needed to turn genes on and the like, I still see some treat neuroscience as if everything is predetermined and human's somehow don't actually LEARN both consciously and unconsciously through their lives.

Some psychotherapists as well I think go too far the other direction and discount or don't consider medical ailments from tumors, cancer, thyroidism, TBI's and the like. I had one particularly 'horrible' client that after being in the system finally got MRI's, they found massive lesions in his frontal cortex...perhaps this explained why both psychotherapy and 15 years of medications had only minimal effect.

Customized care should be the goal for psychotherapy and psychotropics. But many clients I have seen clearly have health issues that effect their mental health and functioning, and poor folks and those with horrible parents deserve a chance to grow up without automatically having their brain altered by years of drugs approved by TPTB.

The most telling thing for me was the study in 2005, that single best predictor of if someone was going to be on psychotropic drugs was not if both parents had severe mental illnesses, but rather if a child/adult was in the foster care system.

Looks like Big Pharma won over the Health Care Bill, Americans will continue to pay the most of drugs of all types, as the same companies sell them cheaper in foreign and competitive markets. I don't remember what year it was, but Prozac made 5 Billion one year alone in PROFIT, that drug must have been amazingly effective to sell like that eh? Maybe when R&D is the largest portion of monies spent, and Marketing is limited to Doctors rather than the public at large that knows more American Idol contenstants than Presidents, I'll give up on my pessimism.

"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."

DR.C: So why don't you just tell your patients that the man in the moon caused their depression? Really, this crap about a chemical imbalance being THE CAUSE of depression is just plain absurd. There is NO research supporting this position. NONE. So why do you lie to your patients?

I listened to you on NPR and I felt compelled to find your blog. I must tell you, not everyone in your profession is as greedy and unprincipled as you are. I see a Jungian analyst for hour long sessions once a week and he has only ever showed the highest degree of professionalism towards me. I can't imagine a reputable analyst not wanting to hear about a patient's personal life, in order to get to the next ten minute consultation. That is not practicing psychiatry, that's not practicing medicine, that's not even doing a decent job of being a human being. The banality of the way you talk about your work is shocking. It doesn't even sound like you have any more knowledge of how the mind works than the average guy on the street, yet you make a high income dispensing drugs to unwitting patients. I can't believe you still have professional credentials.

To those who think we have to know exactly how a drug works in order to take it: We still don't know exactly how aspirin works for headaches. Ever take one?

To say that no psychiatric drug works for any psychiatric condition is not consistent with reality. Just because a lot of them are used inappropriately on misdiagnosed patients without monitoring the patient for side effects, does not mean we have to throw the baby out with the bathwater.

Unfortunately, there is an epidemic of misuse by reductionistic psychiatrists of some potentially very toxic medications. I get referred patients damaged by this sort of thing all the time.

On the other hand, we don't need even more schizophrenics living on the street in cardboard boxes or languishing in jail instead of a hospital.

""To those who think we have to know exactly how a drug works in order to take it: We still don't know exactly how aspirin works for headaches. Ever take one?""

Actually, I don't since it is ototoxic and I already have a hearing loss and tinnitus from taking psych meds. From what I have read, once you develop an ototoxic reaction from taking meds, you're more susceptible to developing the same type of reactions from any med that has similar properties.

Anyway, you're missing the point. Dr. Carlat was criticized by several of us for being dishonest about the Serotonin deficiency issue. If he had been honest about not knowing how these drugs work, that would have been perfectly acceptable. He wasn't as he stated that he felt patients expected doctors to know how these meds work.

However, I will add that comparing aspirin to a psych med is like comparing an apple to chocolate. Yes, many psych meds like aspirin have ototoxic properties.

But I think anyone would take the side effect profile of aspirin over a psych med any day. So if a doctor doesn't know how aspirin works, at least the risk isn't nearly as great as taking a psych med.

I just think if doctors don't understand how meds that have horrific side effects work, that doesn't make me feel confident about taking the med. I think Dr. Carlat realizes this and that is why he feels the need to use the Serotonin theory even though he knows it is false.

""To say that no psychiatric drug works for any psychiatric condition is not consistent with reality. Just because a lot of them are used inappropriately on misdiagnosed patients without monitoring the patient for side effects, does not mean we have to throw the baby out with the bathwater.""

Again, you misinterpreted what I said. I said they don't work for a majority of people which is a big difference from stating they don't work at all.

""On the other hand, we don't need even more schizophrenics living on the street in cardboard boxes or languishing in jail"

I hate to tell you Dr. Allen but there are people with schizophrenia living successful lives without being on meds. So this is not an either or situation.

Unfortunately, they will never be studied because many of your colleagues don't want to hear success stories about people who are succeeding without being on meds.

And even if someone goes off meds but needs to be on them doesn't mean those gloom and doom scenarios you report will occur.

You all are always talking about destigmatizing mental illness but giving gloom and doom scenarious like that is definitely stigmatizing people with schizophrenia.

An off hand comment made to a small cohort of eccentric readers like us to support a non-profit is analagous to wining and dining doctors who will only get re-wined and re-dined if they continue to aggressively prescribe specific drugs?

Moreover, Dr. Carlat is an academic who lives in Massachusetts for crying out loud! Of course he supports NPR. That's what academics in Massachusetts do!

And he probably recycles, reads the NY Times, eats Ben and Jerry's, shops at Whole Foods and grocery co-opts and uses sea salt when he cooks.

Dr. Carlat is being perfectly consistent with his station in life by promoting NPR. And he's doing a nice job of professional mortification by posting the comment bombs that are tossed at him about the stuff that really matters.

He probably doesn't recycle and doesn't shop at a co-op. He drives 40 when the going is good, 80 in snowstorms. He drinks coffee at Dunkin' Donuts. But he does shop at Whole Foods. His proceeds from the book will buy him one shopping trip there.

Steve: Say his appearance helped to sell 100 books. Say his reminder has 10 people subscribe to NPR. The stated aim of the appearance is to inform the public. However, the real aim is to sell books and to increase subscriptions.

Say, a doctor has 100 patients on a medication. He is called for a meeting at a nice resort. The stated aim is to give feedback to the company. The real aim is to comp prescriptions, comp as in a Vegas casino. Drop $10 million they will buy you a Rolls Royce, as a token of their gratitude. Drop $100, your drink is for free.

These transactions are all structured the same. They have a pretextual stated aim but a hidden financial agenda.

I am not just interested in having Dr. Carlat make a self-criticizing disclosure. I am more interested in his recognizing his unintentional hypocrisy.

In none of these cases is any harm done to others. So, people should be left alone. In the case of medication prescriptions, patients are benefited by modern brand name medications that the doctor would give to himself or a family member.

When patients do well, the doctor's life is heavenly. When patients do poorly, life is hell. No comp could induce a doctor to not do as best as he can for his patients.

Dr. Carlat, thank you. The fact that you question your practice and that of your colleagues suggests you have a level of medical curiosity not shared by many in your field. By talking about the flaws of your field you are helping clients everywhere to make informed choices, something that I believe is actively discouraged by mental health professionals.

Psychiatry is not the only branch of medicine that flat out lies to it's consumers, but it is the one that can get away with it most easily. A lot of people here are very angry and for good reason. But rather than attack Dr. Carlat for participating in practices which I will admit disturb me greatly (particularly the "don't ask, don't tell" bit), I think we should encourage his critical thinking, his pioneering spirit, and his interest in at least showing people what they're getting up front. Therefore, once again, thank you. I invite you to look at my blog, http://psychsystem.blogspot.com if you'd like to read a patient and nurse's perspective (albeit and angry and I may say bitter one).

I agree with you about one point: I never tell my patients that we know exactly what causes certain psychiatric disorders or exactly how the drugs work. All I can tell them is that the meds stand a good chance of helping for the particular symptoms they have, and that most of the time side effects are mild and can be managed.

All medicines have potentially toxic side effects for some people, dearie. Maybe you wouldn't take an aspirin quickly if you had a heart attack, and maybe you'd die because you did not.

Obviously if aspirin hurts your ears, under most circumstances you shouldn't take it. That doesn't change the fact that most of us have no problem with it at all, and we would rather take it than suffer with a tension headache.

It's always a matter of weighing risks versus benefits. If you think risks always outweigh benefits in psychiatric meds, you have absolutely no idea what you're talking about.

Not taking psych meds when they might be helpful can also be fatal.

Yes, there are mild schizophrenics who do ok without meds; people just consider them eccentric. They often don't even come to psychiatric attention. To compare them with more severe cases means that you are the one who is comparing apples to chocolate.

You've probably never even seen a severe melancholic depression, because nowadays hardly anyone gets to that point without being treated. To say that antidepressants "don't work" without asking for whom and for what is just plain ignorant.

Joanne: I agree that you should try to avoid psychiatric inpatient hospitalization. You should also avoid going the cardiac intensive care unit where the torments are all day, physical, mental, and spiritual.

I have a suggestion. Try to adhere to your outpatient treatment so that you never return to the inpatient service. About half of adverse patient events come from non-adherence to treatment. Only a tiny minority of patients who commit suicide have any medication in them. Half are over the legal limit for blood alcohol level. Getting people to stop getting drunk and high would cut the psychiatry budget in half, as well as close most hospital psychiatric beds.

That being said, the strong medicalization of psychiatry was forced by the HMO's in the 1990's. That brought the specialty completely in line with all other chronic disease specialties. Its diagnoses are as reliable as those in cardiology. Its treatments are as effective as those in pulmonology and gastroenterology, with fewer risks and side effects.

Dr. Carlat wants a return to the atavistic practices of the 1970's, which were a type of cult fraud. When you add the pretextual attacks on drug companies, from all sides, here is the real agenda.

Insurance companies, not idealistic Boston left wingers, evil insurance companies want dark skinned people on medicaid to receive only generic drugs. They do not want them to get expensive brand name medications that Dr. Carlat would take himself, or give to a loved one. I would like Dr. Carlat to cite a single patient he ever harmed by taking drug company fees to speak or to go on trips. On the other hand, I want to come over to your and his houses to give your dogs Haldol 1 mg. Is that OK with you? If it is not OK, explain why it is OK to give to dark skinned folks.

Joanna makes a good point about Dr. Carlat's critical thinking. It is refreshing in a field that seems to be particularly weak in the area of self reflection. Nevertheless there was a lot in the NPR interview that was of dismay and concern. Here's a write-up that "nails" it on a blog that makes for some cautionary reading by anyone who thinks diagnoses and psych drugs can be used in a cavalier and offhand manner without proper disclosure of the dangers, including death and disability. http://bipolarblast.wordpress.com/2010/07/19/daniel-carlat-md-on-fresh-air-discussed-by-giovanna-pompele/

If you appreciate the perspective that Dr Carlat is taking with his book and this blog, he really is taking on a sizeable entrenched group in our profession, and he risks being ostracized and minimized by said cronies. Having been there, in much smaller size and scope, it ain't fun, but, if you are an advocate and ally to responsible and ethical health care interventions, you do what is right, not what is easy and convenient. I just find some of his censoring at this site to be a bit frustrating, especially since the Schwarberg incident last year.

Hey, if a reader makes a critical but reasonable criticism or rebuke of someone mentioned in the blog posting, that is on us, especially if we use our name that can be traced back! It is only the defenses of the narcissist and/or antisocial that claim you the blog author are guilty for others' comments.

Put a disclaimer in the blog or at the end of the comment. DVDs do it all the time!

I can only echo what many here have said: lying--or rather grossly oversimplifying what we do and do not know about the mechanisms of action of psychotropic drugs--is flatly unethical. Or does Dr Carlat propose some kind of utilitarian defense of such behavior? I'd be curious.

None of this is to say that we shouldn't be prescribing psychotropic drugs, but we, as physicians, should fully disclose what we know about their risks and benefits (and there are, obviously, quite significant risks) AND the risks and befits of non-pharmacological interventions, and allow and encourage patients to make a truly informed decision. The paternalistic attitude you display in the NPR interview ('I know better than my patients and therefore feel no qualms about misleading them for their own good') astounds me. Not that I haven't seen it before... (Perhaps the real shocker is that you're supposed to be the face of reform.)

Supremacy Claus: Why do people resent the book Dr Carlat wrote? Are you saying that since the book isn't free, he's making as much money as he would, if he became a spokesman for a drug?Go see the book page on Amazon. As a writer I know all too well how easy it is to buy book reviews. He's not a sleay marketer and never resorted to sensationalism (have you seen how Dr Perricone promotes his 'cure'?) THAT is marketing for money. Have you seen Dr. Mehmet Oz on Oprah? Does this guy seem to be doing anything remotely similar?I have seen your other comments where you had less restraint. You're trying to sound reasonable because the other way didn't work.Well nice try, but get a life will you?

Thank you all for your comments. I continue to be amazed at how difficult it is to predict what statement will provoke the most withering criticism. My words on Fresh Air about how I sometimes repeat the myth of the chemical imbalance to patients was meant to point out that this is a popular, though unproven explanation for how our drugs work in the absence of any more compelling explanation.

I don't lie to any of my patients. Here is how I actually phrase it, when I bring up the subject at all: "We have no idea exactly how the drugs help to cure depression. One theory is that there is a chemical imbalance, and that Zoloft [if that is what I am prescribing] somehow increases the amount of a chemical called serotonin. But the actual mechanism may be something else entirely. Someday, we'll figure out what's actually happening with these drugs, but the key point is that they do work."

Some would argue that antidepressants don't work at all, but I disagree with that and have explained my thoughts in various places, such as this blog and in Unhinged.

As to issues of self-promotion and making money--yes, I do promote myself and I do make money. Neither of these activities is unethical, and neither relates to deceiving the public and other doctors by engaging in clearly unethical activities such as certifying industry-funded educational programs as "CME", ghostwriting for commmercial concerns without disclosure, and using one's MD as a platform for promoting a specific company's drug.

Clearly, you didn't write your book or do this blog merely to make money--and its ridiculous that people would attempt to make such an argument. We live in a world where money is a requirement and the more you have the more freedom you have to say what you want--at least potentially.

Likely if economics weren't an issue more M.D.'s would come out of the woodwork as well in regards to the general theme of this blog.

The lack of integration within the 'mental health SYSTEM' is what has always been startling to me. I rarely get to talk with Psychiatrists even for the briefest consult, unless its in regards to forced hospitalization--which is an extreme rarity. I'm a firm believe in a holistic approach that doesn't really exist in practice. For many clients lifestyle changes are imperative for dramatic changes in their mental health, not only psychotherapy or medications.

I have found Anti-depressants to be one of the least effective class of drugs out there, particularly when its the only treatment. I again state that Psychiatry has become the cult of radical biological reductionism which i find to be demeaning to the complexity of the human/social condition. Telling a victim of abuse/trauma that they merely have 'chemical imbalances' is not even good dumbed down 'science'.

I hope that you make a lot of money, its how you use the money that is key--if you can leverage some wealth to advocate change and be a sorely needed voice in a system that harms as many people as it helps--mostly for the bottom line of Big Pharma, then by all means, make some money! As long as many M.D's feel the financial imperative to do what I have seen for years--15-20min consults asking questions about how they feel on their drugs and then titrating or giving them an additional drug and send them on their merry way--then there will be problems.

My experience shows that poor people get lousy treatment and are medicating with many more drugs, compared to wealthier clients I've seen that usually are only on 1-2 psychotropics. I've witnessed behavioral problem children routinely being given 4-5 medications, most clearly just to fatigue them. Amphetamines to make them alert during school, some Atypicals to tire them out, some anti-depressants to try and help them feel better about their abuse and lack of parents etc etc.

Perhaps its not SOMA that we need, but for the majority it remains the same thing that bothers the "non-mentally ill" money problems, relationship problems, trauma's and how various life experiences play out via their unique neural networks. I continue to advocate for children who have no real say, and whose livers and bodies are taking a beating by lifetime drug use--of the legal variety. -M

Every patient has it today. It can result in an analysis of a treatment, its pitfalls, and limits at the Nobel laureate level. The patient has the ability to read all scientific articles with abstracts by going to PubMed.

This duty to Google has eliminated all present and future litigation claims of lack of informed consent. Consent is a slow process of deepening knowledge and grasping of the effects of a treatment. Even a three hour discussion with slides and a sandwich provided by the drug company will not replace repeated research over weeks by the patient.

The chemical imbalance is a good lay simplification of otherwise complex and unknown drug effects. It carries a removal of responsibility from the patient for many of the symptoms. Diabetes (body is not making a hormone)is a better analogy than Parkinsons disease (imbalance between dopamine and choline). Almost all psychiatric disorders are disinhibited states. The mute, frozen depressed patient has good evidence of disinhibiition.

I have no criticism of promotion of a book, nor of a radio network. I am criticizing such promotion by folks who criticize such promotion by others, including drug companies. Promote away. But stop bashing others doing the exact same thing, especially based on race.

I haven't done a literature search lately, but with true major depression, rest assured that there are many unbiased studies which show that antidepressants are extremely effective.

The Pharma studies actually understate the effectiveness of antidepressants. I don't have room here to totally explain why. (I discussed it on a website called Healthy Skepticism but you have to pay to join the organization in order to see it).

Mostly it's because research organizations overdiagnose major depression because they get paid per subject enrolled. There is a different type of depression called dysthymia which generally does NOT respond to antidepressants.

It is in Pharma's interest to blur the distinction so doctors will overprescribe. They only have to beat placebo by a little, and there are enough patients with true major depression in their studies to do that, so they don't mind including dysthymics. There is much overlap in symptoms but the two conditions are different.

Widespread clinical experience (which is not synonymous with "anecdote") by doctors who actually apply the diagnostic criteria and make good clinical judgments rather than relying on "symptom checklists" trumps any studies in my mind. I can tell you from thirty years of my own experience prescribing them, watching residents prescribe them, and working in a wide variety of clinical settings in two states, there is no question that the drugs work for the right patients - but not for misdiagnosed ones who really need psychotherapy.

If you are interested in a balanced viewpoint about what works and what doesn't work in psychiatry and psychology, I invite you to check out my blog at http://davidmallenmd.blogspot.com/

Those of you who really buy into the effectiveness of a/ds -- and I wonder what distinctions you make between short term effectiveness and long term disability -- should read Irving Kirsch's recent book The Emperor's New Drugs. I'd be interested in hearing how his argument fits in with your faith in the objective wonders of a/ds.

I really think that those of you who say that a/ds work miraculously for one particular kind of depression but don't for others and also that they "unmask" "bipolar disorder" instead of actually cause it by inducing mania are living in a dream world.

I also think you should be much more suspicious of clinical trial results because they are so manipulated in the case of psychiatric drugs and outcomes are measured in terms of weeks when real clinical practice keeps treatment going for months and often years. Half the people who are "on placebo" in trials are actually in withdrawal from prior treatment because clinicians are so cavalier and ignorant about withdrawal. This skews results in favor of the psych drugs. The people with the good results are really having their withdrawal treated, not their depression. This goes on in clinical practice too.

Well if I were you, I wouldn't say that antidepressants "work" until I know for sure they "work" for that patient. My blood still boils every time I remember my psychiatrist telling me yhat the treatments for bipolar were "good" when I spent the entire time in treatment completely fucking miserable... And come to find out, not even an honest review of the literature indicates treatments for bipolar are "good"

Let's be honest with ourselves and begin at the beginning. Please prove that these conditions are medical problems at all in the first place. In fact, every page in the DSM specifies that the "symptoms" must not be due to a medical condition, so what does that tell you? -kimbriel

I didn't say they always work, or that they work for every patient. Apparently I have to spell everything out for some people.

Many people who are diagnosed with bipolar disorder nowadays do not have it; the doctors ignore the established criteria, or in the case of pediatric bipolar, just make up their own.

Some DSM disorders are more clearly brain disorders while others are behavioral disorders. There are arguments in the field about which are which. The "proof" you request, which you would probably find fault with no matter what it was, is simply not possible considering out current knowledge base about neural networks. As someone said, if the brain were simple to understand, we would be too simple to understand it.

The medical exclusion requirement in the DSM refers to internal medicine conditions affecting other organ systems, not psychiatric conditions

In the meantime we have to settle for indirect evidence, which in certain disorders is quite massive and for other disorders almost non existant.

Until you have an actual objective, scientific lab test for the purposes of diagnosis, there is no way to talk about over diagnosis or under diagnosis of any psychiatric condition. It's all just guess work. -kimbriel

To a degree, psych diagnosis does involve educated guesswork. Of course, you are totally discounting a couple hundred years of clinical observations, epidemiology, and thousands of journal articles published every year(admittedly of varying quality, but there are good ways to judge quality).

When I say overdiagnosis or underdiagnosis, I am referring specifically to whether a patient actually meets the DSM criteria for a disorder. We can dispute many of the criteria and some of the disorders, and believe me I often do, but the DSM got a lot of it right. And the distinctions are often not very subtle at all.

Major depression and dysthymia have been recognized as distinct in clinical presentation, time course, treatment response, and a bunch of other factors for a century or so. It used to be called depressive neurosis.

Typical cases of each look about as much alike as a cat and a dog. Those animals both have four legs, fur, a tail, two eyes and a nose. Still, we are somehow able to recognize the difference with a high degree of accuracy, and without running lab tests.

Maybe depressed people should see scientologists instead of psychiatrists and psychologists, so they can rid themselves of the space aliens and volcano gods that are the source of their trouble.

Dr Carlat was being honest. People took offense at how he used bs descriptions about serotonin to make people feel more comfortible about taking mind altering drugs. The people have spoken-- they don't want bs descriptions. So he wont do it any more. They dont want a psychiatrist who just does med checks-- he is going to try and move his practice more toward therapy. He said on his blog that he qualified his statements about neurobiology, but he didnt actually say that on the npr interview.

If a client is clearly depressed to a clinically significant level--they are suffering, plain and simple. If it's primarily biologically driven, or primarily environmental--usually this can be determined as well to some degree. We are biological beings who function socially in a complex world with unique neural networks derived from experience and our repetitive thoughts/beliefs about those experiences in addition to basic health considerations, and NT variances--that sometimes may be due to trauma/abuse even from the womb, and other time's due to perseverations/behaviors.

Asking more of Psychiatrists, going back to Psychosocial histories and Physicals, or at least reviewing this information from Primary Care Physicians would be key in gaining a clearer perspective on the individual patient. This is not really the system we have, and this is not the system the HMO's want either. They want the quick fix, and Big Pharma wants permanent lifetime customers.

Pediatric disorders and off label drugging has risen dramatically and as some noted, they likely don't actually fit the albeit lousy DSM criteria, but many stakeholders from some parents who romance the pathology, from schools, to Group home's, hospitals push these diagnoses on children. It's estimated that the average adult brain has a quadrillion synapses--so yes neuroscience research almost always overstates things. Hell, they found another--what 50 neurotransmitters since the 1990's, yet the conversation remains focused on Serotonin half the time.-M

"The duty to Google. Every patient has it today... The patient has the ability to read all scientific articles with abstracts by going to PubMed... This duty to Google has eliminated all present and future litigation claims of lack of informed consent."

Wow. You really need to do some CME credits on the issue of health (il)literacy.

Anonymouses: Doctors treat the distress of patients. They do not treat abnormal lab values.

*****

Give a three hour presentation with a 100 page handout on a treatment. Three hours later give the patient a brief quiz. They know almost nothing of what was presented to them. Was that lecture informed consent, when the patient knows nearly nothing about a treatment, a short time later?

So informed consent is a process of learning and retaining by repetition increasing amounts of information about a treatment. That can only be achieved by self-study over a long period.

Everyone in the USA has access to the internet, if only by going to a local library.

In case law, there is a beginning of a realization of the duty to Google. A client sued a lawyer for malpractice for failing to find and collect from a defendant after a trial award. The lawyer said, the defendant was impossible to find. The judge Googled the defendant on his laptop from the bench, and found a couple of listings and locations of the defendant. Case closed, that was legal malpractice, failure to Google in a collection action.

Maybe you could say Dr. C lies to patients if he really pretends to know meds work by increasing serotonin levels. I certainly tell my patients I don't have a clue, but I would classify his as a harmless white lie. What I find more interesting is that some of his patients probably read this blog and bring to visits a gamut of reactions or challenges, raising the question of whether he does the right thing by putting his name out here vs. my practice of anonymity. I believe each of us should have the right to choose.

Put up or shut up: If you really believe Dr. C lies to his patients, why not complain to the American Psychiatric Association, or his state medical board (MA?)? Sure, some will say they're all in this together, but you can't lose. If they let him off, you can criticize the APA or the licensing board for failing to act.

As one of those folks you told to put up or shut up, I am curious as to how you define a harmless white lie.

I will give you example of one I read about that I feel is harmless and actually was the right thing to.

A doctor came upon an accident and said to a dying mother's question about her children being ok, that they were in good hands. One child tragically died.

The anger you are seeing from people like me is it seems that many patients and doctors have a different view as to what constitutes a harmless white lie in many situations. Instead of telling me to report Dr. Carlat, which you know is a bunch of BS, I think it would be more productive to try and understand where the other person is coming from.