Hi guys. This is an interview I did a few years ago with psychiatrist Daniel Carlat, M.D, when I served as editor in chief for The Alternative Mental Health News. Since the questionable efficacy of antidepressants is in the news (again) and “anti-psychiatry” is trending ( again), I thought it was timely to share. In fact, it’s like we are in the same spot all over again, which is both suspicious and discouraging, considering rates of mental illness are increasing around the globe yet the medications haven’t improved. A couple reasons I shared my crazy, embarrassing experience in Manic Kingdom was to show people the ambiguity of diagnosing mental illness and how frustrating that can be for the patient ( me in this case) and ( albeit through a bizarre, dangerous, mad, somewhat romantic encounter with a stranger) show how dedicated lifestyle modifications can make a significant impact on the mind, while a hasty antidepressant prescription can prove deleterious. The below interview with Dr. Carlat reinforces our need to improve our mental healthcare system; to invest in research that makes the ambiguous more clear, and to prescribe more prudently, without drug companies filling the pockets of key stakeholders and manipulating the sacred relationship between doctor and patient.
Dr. Carlat is on the faculty of Tufts Medical School, and completed his psychiatry training at Harvard Medical School and Mass. General Hospital. He’s published many books and peer-reviewed articles and is currently editor-in-chief of The Carlat Psychiatry Report, a monthly newsletter read by clinicians throughout the US. He’s been a contributor to The New York Times Magazine and authored a great read, UNHINGED: The Trouble with Psychiatry- A Doctor’s Revelations about a Profession in Crisis.
Erin: I read UNHINGED…, and you talk a lot about the 15-minute patient-psychiatrist encounter, which is being pushed by insurance companies over a longer encounter, because it’s more profitable. You also talk a lot about the lost skill of psychotherapy. How dangerous are those trends, considering psychiatric diagnoses are made by talking to people?
Dr. Carlat: There are potential dangers, because you can’t really have medication without understanding, and you have to understand what someone is going through psychologically in order to make the appropriate medication decisions. For the most part. I mean obviously there are always some people who can take Prozac or Klonopin and do great on them. And that’s it. There’s a certain percentage of patients in everyone’s practice who respond to medication and that’s it. They just take their medication every day and feel better, but it’s certainly a minority. The majority will take a medication, will get somewhat better, or maybe not better at all. There has to be tweaking. The regime will be to talk more: Either more time with me as a psychopharmacologist and more therapy or maybe go to another person for more in depth therapy. What I’m really advocating in my book is that we have more people who are trained to do both. It’s ideal, from both the standpoint of the patient and the doctor, to go to one person for 25 minutes to an hour and to understand that person beyond their symptoms. There are other ways aside from the medication approach that can really help them. That’s pretty much the gist of the argument in my book: that we need to find a way to train more integrative health practitioners, whether that is through current training via nurse practitioners, psychologist and psychiatrists, or whether that is adding a new type of training like a college of psychiatry, which would be a dedicated school for people who are interested in combining therapy with psychopharmacology but don’t want to go
to medical school.
Erin: In the American Psychiatric Publishing Textbook of Psychopharmacology, it concludes that “The central question of what variables drive the pathophysiology of mood disorders remains unanswered,” yet you hear many psychiatrists tell their patients that mental disorders are caused by a chemical imbalance. Drug companies imply it through marketing, and you often hear a diagnosed person talk about his or her chemical imbalance. Would you say that’s a big lie?
Dr. Carlat: I certainly don’t think it’s a lie. I think that it probably is some type of biochemical…well let’s put it this way: I think it’s clear that any kind of thinking and emoting we do is the consequence of some kind of biochemical reaction. I don’t think anyone would argue that’s not true. So if somebody is having significant emotional dysfunction or problems there probably is, eventually, going to be some way of tracking that or finding biochemistry that has gone awry. But, we certainly don’t know what that is yet. In other words, is there a chemical imbalance underlying psychiatric problems? Undoubtedly some day we’ll find that, but the simple story that it is all to do with the serotonin depletion or norepinephrine depletion is, at the very least, extremely overly simplistic and possibly with faults, but we just don’t know at this point. I think it’s a convenient, short-cut kind of explanation that doctors tend to use, because it provides a rationale for why they are choosing the drug they are choosing to prescribe. But I think that we do tend to oversell our knowledge of the biochemistry of mental illness.
Erin: You talk a lot about the drug companies in your book. You mention that in 1999 they spent around 1 billion dollars on direct-to-consumer marketing, 5 billion in 2008 and it’s probably even more now. What do you think about that? Is that unethical or is that just business being business?
Dr. Carlat: I think it’s sort of a complicated issue. Most of me thinks that’s not a good idea. Marketing directly to consumers is somehow implying that consumers have enough medical training to be able to judge the pros and cons of medication, when they just don’t. They are not going to be able to make those kinds of judgments. What the commercials are trying to do is to get it so the consumers have the name of the product in their heads so that they mention it when they go to their doctor. And the doctors will usually prescribe what their patients ask them for.
Erin: And that leads into my next question: A lot of people will see a drug on TV, go to their doctor’s office and not only ask for it, but demand it. Is the prescription pill craze more a symptom of a fast society that wants and needs a quick fix and doesn’t want to put time into therapy?
Dr. Carlat: It’s not simple. The consumers are partly responsible, because they come to us and they ask for medication. But they’re not unreasonable when they request medication, because the fact is they do work. They may not work as well as we wish they did, and they may cause more side effects than we lead people to believe, but for a lot of people they do work to some degree and help them move on with their lives more functionally. So, that’s certainly okay. People are entitled to feel better quickly. I don’t see anything necessarily wrong with taking a pill if it does help you. But they should also be given complete disclosure that there are costs as well as benefits to these medications. There’s sexual dysfunction, weight gain, jitteriness, all these things. Many of the side effects might be considered to be less serious if you’re not the ones experiencing them, like the doctors prescribing them. Sexual dysfunction or not being able to sleep well can be a pretty serious thing. They have to live with that day in and day out.
Erin: That’s almost more depressing than depression.
Dr. Carlat: Yes.
Erin: When you say the medication works…in a lot of the recent studies I’ve read the placebo effect seems to play a major role. Especially in the case of antidepressants. They seem to work for a while, and then they stop working. How much of the medications’ effect, do you think, is due to placebo and does it matter?
Dr. Carlat: A lot of it is placebo, and it matters but it’s hard to say how much it matters. Take people with depression. That population is particularly sensitive to placebos, so maybe 70% or more of the drug’s effect is due to the placebo effect or due to the hope of wanting to getting better. On the other hand, it’s very hard to imagine how one can harness the power of a placebo without prescribing something. Part of the whole placebo process is writing out a prescription, having a patient take a pill every day and believing that it works. So it’s easy to say that a large part of these drugs’ effectiveness is due to placebo, but it’s hard to come up with a good alternative. What are we going to do other than give them pills that are going to really take advantage of the placebo effect?
Erin: In your book, there’s not much mention about alternative therapies for mental illness…
Dr. Carlat: I didn’t really mention that. I was more focused on the difference
between conventional medications and psychotherapy rather than different conventional medications and alternative, natural medications and dietary supplements. And I don’t really know a lot about how effective alternative remedies are in psychiatry. Saint John’s Wort, Omega 3s…it’s always been my impression that there hasn’t been enough research to be very clear about how effective these things are, but that, on the other hand, most of them don’t cause much in the way of side effects so it’s probably perfectly fine to take them, and it might help them just as much or more than medication.
Erin: Right. And I don’t know if a lot of them don’t work, or if the research isn’t there, because there’s just no funding available for the appropriate studies. Getting back to the prescription pill craze, you see a lot of kids being prescribed things today. What are your thoughts on this? Do you think it’s safe and is there really that many mentally-ill children running around?
Dr. Carlat: Yes, I think it’s become a little faddish to prescribe medication to children. For a long time, no meds were prescribed for kids, and I think that was probably wrong as well. There are adults who suffer from schizophrenia and bipolar disorder and they were children once and had at least the beginnings of these illnesses when they were younger. It would certainly be illogical to say that children should never be treated for psychiatric disorders, but on the other hand, just because a medicine is effective for an adult doesn’t necessarily mean it’s going to be effective for a child. And I think in psychiatry there is that assumption of “why don’t we just go ahead and give that medicine to children since it’s been effective in adults?” And I think, in some cases, we’ve gone overboard. I think in Attention Deficit Disorder we’ve gone overboard with that, I think in bipolar disorder, and I think antipsychotics have gone a bit overboard. And now we’re finding out how many side effects these meds do cause, especially the antipsychotics.
Erin: One of the psychiatrists you talk about in your book is Dr. Biederman [a Harvard medical school professor and recipient of the American Psychiatric Association’s Blanche Ittelson Award for Excellence in Child Psychiatric Research who, in 2008, was caught not disclosing about 1.6 million dollars received from drug companies]. Honestly, I couldn’t help but laugh reading about how he labeled 2-year-olds as bipolar, because, to me, that’s almost what the definition of what being a 2-year-old is. One minute they’re happy and the next minute they’re crying their heads off. As I read it, I wondered how he slept at night.
Dr. Carlat: From his perspective and the perspective of his supporters, he’s a pioneer in the field of focusing on the inner workings of a very young child’s brain. I think not only does he sleep well at night, I think he’s very proud. I think he thinks he did a great service to humanity in helping children who are very disturbed and finding some medication that works for some of them.
Erin: Can you really label a child that young as mentally ill?
Dr. Carlat: It’s very young, and it’s hard to imagine how you can diagnose someone who’s 2 or 3 or 4 with a psychiatric disorder unless they have severe developmental delay or something, but yes, if we’re talking about something that has to do with temper tantrums, outbursts, exhaustiveness, it’s very hard to distinguish normal childhood behavior from pathological behavior. It’s very easy to misdiagnose children who are just demonstrating the extremes of normal behavior as pathological.
Erin: In your book, and this is happening in a lot of areas of medicine, you talk about, what I’ll call, the manipulation of science. Drug companies fund their own drug studies and the results of those studies are almost always in favor of the drug; they fund the construction of research centers in academic settings; they ghostwrite research articles and then pay doctors to sign their names as authors, even though they don’t write anything. You mention the Hired Guns, doctors drug companies pay to speak on behalf of a drug, and the practice of prescription data mining, where drug reps can purchase from the pharmacy a list of drugs any doctor is prescribing to help with their marketing strategy. Then there’s the FDA that doesn’t require drug companies to publish failed studies, and there’s often a lot of them, and, as mentioned in your book, there’s the overwhelming drug-biased research articles that get published in medical journals. All that said, how are we supposed to know what good evidence is?
Dr. Carlat: Yes, how do you know? And it’s especially hard to trust academics when they are supposedly who we should be able to trust, because they’re the ones who have the most training and who have done the most research. Yet when you look at their disclosure statements, often there are dozens, literally dozens, of pharmaceutical companies that they have received money from. And so it’s very hard to know, when they write something or publish a study, if they are being completely honest about the results of the study or are they responding to some kind of financial incentive to tweak the results in a way that they know their sponsor will find favorable. So it’s …I guess I’m just restating what you just told me….but it’s tough these days to know who to trust.
Erin: What’s your opinion on the FDA? In your book you point out both good things that they’ve done and bad things. For example, they approved transcranial magnetic stimulation and Vagus nerve stimulation for treatment resistant depression when the results weren’t there at all?
Dr. Carlat: Yes, I think they are under pressure to approve medications, because they do get a lot of money from the pharmaceutical industry to be able to do their work. They’re also under pressure from doctors and patients too – to allow new treatments to get out there in the public. So decisions about medications that are made may tend to be rushed by the FDA, and they may not be the best decisions. You can always find examples of decisions…poor decisions that were made and a lot of medication that is not effective is allowed to be prescribed.
Erin: What are your thoughts on the DSM?
Dr. Carlat: The DSM is just a field guide to recognizing mental disorders. For me and for many of my colleagues, including psychiatrists, psychologists and social workers, we tend to use the DSM manual more as a bureaucratic way of fulfilling certain insurance company requirements rather than as a textbook for helping understanding patients. And that varies from doctor to doctor obviously. I tend to look much more at symptoms which are not really listed as disorders in DSM – just something trying to categorize people as specific disorders which are really just specific patterns of mental illness. I tend to see a lot of patients who seem unhappy, anxious, have mixed depression and anxiety, you know, depression and insomnia, mania and psychosis. None of these are DSM V disorders, but they’re all symptoms that find their way into various disorders. That’s kind of the way I look at my practice and how I tend to make decisions, both medications and therapy. What kind of therapy is going to treat this kind of insomnia? Often times that’s not going to be a medication, but is something you have to cure via lifestyle changes.
Erin: How influential do you think the power of suggestion is? When you’re asking a patient – say screening them for depression – and asking them about sleep issues, appetite changes, anhedonia and such, do you think a person can think too hard in the moment and come up with something?
Dr. Carlat: Yes, like trying to almost please me?
Erin: Yes, and also because people want answers and want to know they’re going to be okay. So when you ask them a question, do they brainstorm and think-well now that you mentioned it!
Dr. Carlat: And that’s actually one of the arguments in favor of diagnosis because, while it’s really symptoms we end up treating in psychiatry, patients sometimes really like a label. And they like it when you can organize the chaos of their stress into a nice, neat package and say, for example, you have bipolar disorder, this is what it is, you’re not alone, there are a lot of people like you and we have treatment for it. And JUST saying that really can be immensely relieving to a lot of people. But yes, the question comes up, do we encourage our patients to say, “Yeah, yeah, I got that…, yeah, yeah, I got that,” and then they get a label. But then how meaningful is a label, and, ultimately, aside from making them feel like you’ve diagnosed them with something and relieved them that way, ultimately how useful is that label for their treatment is often an open question.
Erin: Right. I think sometimes, too, and not sure if you agree with me or not, but when you give a person a label, my fear with it is you choose medication based on what label you give a person. An artful clinician might take time to assess the full picture of a patient but another person might be like, “Well, I think you might have had a manic phase so instead of an antidepressant I’m going to give you Lithium.” That’s where I’m always a little scared of psychiatry, because that label, even though it can be therapeutic…, it also dictates what medication you’re going to get.
Dr. Carlat: Yes, yes, it does, and it works the other way around, too. The fact that we have medication that is approved for certain labels and diagnoses encourage doctors to look for those diagnoses and look for those particular symptoms. It does kind of work ways, and if it’s true that there is an artificially inflated prevalence of mental disorders, an epidemic of mental disorders, you know, like Bob Whittaker talks about in his book, An Anatomy of an Epidemic, if that’s true, part of the reason is because we’ve been seized upon these treatments partly because they work and partly because we’ve been waylaid by the pharmaceutical industry into believing what they have to offer. We tend to seize all treatments, and then we tend to look for patients to diagnose in order to deliver those treatments. That puts us at risk of overdosing, and not even consciously -sometimes it’s just a question of how severe is this? Is this depression? Is this unhappiness or is this insomnia? Is there enough for inclusion and a list of criteria to lead to a diagnosis?
Erin: Have you ever read the book The Hypomanic Edge?
Dr. Carlat: No, I have not.
Erin: Well, it talks about how hypomania, which qualifies as a Type 2 Bipolar diagnosis, can work for you and help you succeed in life. So sometimes I wonder if a lot of symptoms are just idiosyncrasies – you know, are you medicating the brain chemistry of an eccentric person or somebody who might be different than
Dr. Carlat: Yes, and you’re also hitting on something that is a source of a lot of disagreement within psychiatry. A lot of these discussions end up sounding like psychiatry is a model entity where all the doctors believe in the diseases, and they all
believe in the medication, but actually if you go to meetings and you read the literature, you’re finding a lot of fractures within the field. In the case that you brought up about bipolar disorder and hypomania- whether it’s over-diagnosed or under-diagnosed is a source of huge controversy and a rancorous disagreement amongst psychiatrists. You have some saying there’s a spectrum, where some say we should diagnose many more people with bipolar disorder and get them on mood stabilizers and others saying that’s ridiculous and you’re just overmedicating them. So you get the whole spectrum of viewpoints in the field as well.
Erin: My last question has to do with solutions. You mentioned a different kind of education for psychiatrists, like a new medical school of sorts, and more talk time with patients. What are some other ways to make the system work better?
Dr. Carlat: That and as far as the pharmaceutical industry goes, more regulation about preventing ghost writing, preventing them funding medical education and preventing them from deceptively manipulating science. There are disclosure laws that have been passed and now we can get on websites and see how much money any doctor has received from drug companies. That will be helpful.