How the pharmaceutical industry changed psychiatry

What’s happened to psychiatry over the last 15 to 20 years? That’s a big subject, discussed in many recent and excellent books. One of those books is by Daniel Carlat, author of Unhinged: The Trouble with Psychiatry – A Doctor’s Revelations about a Profession in CrisisHow the pharmaceutical industry changed psychiatry.

One of the problems Carlat readily acknowledges is that psychiatry is excessively focused on psychopharmaceuticals at the expense of other effective treatments. Not only is there too much focus on drugs as treatment. There’s so much money flowing from the pharmaceutical industry to psychiatrists that it makes one wonder if the profession can be objective.

Evidence of financial ties was documented by clinical psychologist Lisa Cosgrove. She considered those psychiatric experts who were responsible for the diagnostic criteria in the DSM, the bible of psychiatric disorders. Of the 170 psychiatrists who contributed their expertise on mood and psychotic disorders, 100% had financial ties to drug companies.

Carlat asks, “Why do psychiatrists take more money from the pharmaceutical industry than other doctors?” His answer:

Our diagnoses are subjective and expandable, and we have few rational reasons for choosing one treatment over another. This makes us ideal prey for marketers who are happy to provide us with a false sense of therapeutic certainty, as long as that certainty results in their drug being prescribed. Furthermore, psychiatrists feel inferior and less ‘medical’ than other specialties. Working at high levels with drug companies gives us a sense of power and prestige that is otherwise missing.

The education of a psychiatrist

Part of that sense of feeling inferior starts in med school. Carlat offers a number of reasons why medical school is not good for psychiatrists:

  • It creates an excessively biomedical view of problems that actually have many other sources (like conditions of daily life).
  • Psychiatrists feel inferior to other doctors. (In the medical school pecking order, only the failures go into psychiatry. See Sandeep Jauhar’s comments in Intern: A Doctor’s InitiationHow the pharmaceutical industry changed psychiatry.)
  • Psychiatrists feel superior to other mental health workers because they went to medical school.
  • The time and effort spent on medical school could be much better spent on activities directly related to what psychiatrists go on to practice. (They won’t be called on to deliver babies or perform surgery, for example.)

The med school experience explains, in part, why psychiatrists are antagonistic to colleagues in related disciplines, such as psychotherapists or clinical psychologists. What’s also going on there, however, is that psychiatrists feel a need to protect their own turf. Studies that show therapy or cognitive behavioral training is as effective as drugs are not in the interest of psychiatry.

The felt need to be scientific and biomedical – to be more “medical” than thou – is unfortunate. Psychiatry deals with the human condition, the human soul. When psychiatrists feel a need to insist that they are just as “medical” as other MDs, they no longer acknowledge that psychiatry is and should be essentially different from other medical pursuits.

The biological basis of psychiatric disorders

Modern psychiatry seems to believe that every deviation from “normal” can be explained exclusively by neurological activity in the brain and can be treated by drugs that modify that activity – depression being the main disorder that gets treated these days. Carlat, despite offering criticism of his profession on many counts, subscribes to this view wholeheartedly. “How could mental illness not be, ultimately, biological?” he says. And again, “Undoubtedly, there are both neurobiological and genetic causes for all mental disorders.”

It seems to me there’s a distinction between biological effects and biological causes. Childhood abuse and the trauma of combat may have a biological effect on the brain, but should a psychiatrist offer treatment only after the biological damage has been done? If the only tool the psychiatrist has is psychopharmaceutical modification, then the answer is yes.

Something has happened to psychiatry in recent years that’s not good for either practitioners or patients. Something needs to change. The “bar room brawl” (as Carlat calls it) over revising the next edition of the DSM is probably the best thing that could happen to psychiatry.

Jan Henderson is a historian of medicine who blogs at The Health Culture.

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  • http://davidbeharmdejd.blogspot.com David Behar, MD,EJD

    1) The bashing of modern psychiatry has its roots in well funded insurance company campaign to deny dark skinned people on Medicaid brand name medications. They will pocket the $9.90 they will save per pill if patients are diverted into therapy or generic medications costing !0 cents a pill, instead of $10. Yet, none of these psychiatry bashers would allow their dogs on these generics.

    2) Ironic. Dr. Carlat would like us to return to the primitive psychiatry that failed to prevent the suicide of his mother, after extracting massive expenses for prolonged, worthless, anti-scienitific treatments. Today, she would be alive and no longer suicidal on modern medication.

    3) My psychiatric colleagues were among the most intelligent in their classes. If some had low grades, it was due to lack of interest in subjects unimportant to them. The same was true of the poor performance in psychiatry of future surgeons.

    4) The sincere value of a service or product is its market price. As practiced today, psychiatry is among the highest netting of all medical specialties. The biological orientation is driven by the public willingness to pay more for it, not by anything else. Why would the public do that? Because, psychiatry has the highest rate of return on investment of any possible human activity. For a few med checks a year, with total costs of $500, one returns to a job making $50,000. That is a guaranteed 10,000% return on investment with no risk of loss of investment, year after year of adherence to treatment. Not even crime has that kind of return.

    • http://www.TheHealthCulture.com Jan Henderson

      Psychiatry is a much more abstract subject than hands-on medicine, so I’m not surprised to hear that your psychiatric colleagues were among the most intelligent. Carlat complains at length about the parts of med school that are of no interest or value to psychiatrists.

      Even though there are books written about how SSRIs are nothing more than a placebo (The Emperor’s New Drugs), I – like many others – have seen dramatic changes in patients who use them. There’s a good article on this http://bit.ly/fKNyYK.

      As a historian, I’m interested in how psychiatry – like any science — has changed over the years. Undoubtedly it will continue to be in flux. I wouldn’t be surprised if the recent biological orientation gave way to a more holistic approach at some point in the future. Anthropological studies show that the way mental illness is regarded and treated in the community makes a huge difference. See, for example, the chapter on schizophrenia in Zanzibar in Ethan Watters’ Crazy like us: The globalization of the American psyche.

  • Greg

    As a primary care doctor (Internist) working at a University hospital, I couldn’t disagree more with this post. Dr. Henderson may be describing psychiatry 15 years ago, but now, in 2010, the psychiatrists are highly respected in our practice, especially since at least half of what we do in primary care is psychiatry, and their advice on both pharmacological AND non-pharmacological treatment of mental illness has been valuable to me on many, many occasions.

    The poster suggests that nowadays psychiatrists just do drugs, and don’t do therapy? Since when? Every single psychiatrist at our hospital has therapy-only patients. Every single one. How do I know? They’re MY patients that I referred to them.

    As for the accusation that psychiatrists are not the best doctors, as someone involved in an internal medicine residency training program, I’ve lost a bunch of good potential residents to psychiatry. Psychiatrists have the luxury of 45 minute psychotherapy visits with patients, for which they are paid reasonably well, while we primary care docs have to do with 15 minutes, if that (usually more like 10). Many of my best and brightest medical students have gone to psychiatry in lieu of other medical specialties, so that they can practice medicine the way they want, without worrying about the stupid stuff like RVUs and filling out endless insurance forms and other B.S. like I have to. I don’t blame them, honestly.

    • http://www.TheHealthCulture.com Jan Henderson

      I’m really happy to hear that and appreciate getting a more balanced perspective. I certainly got the impression from Carlat’s book that – after the initial visit — psychiatrists primarily do 15-minute visits to adjust the patient’s medication. I’ve also heard wonderful reports of psychiatrists who do monthly hour-long (well, 50 minute) sessions where they primarily listen to the patient.

      In the health system I’m familiar with (an HMO), primary physicians refer to psychiatrists rather than prescribe themselves, and it’s not difficult for patients to see psychiatrists, even without a referral.

      There does seem to be evidence of a close relationship between psychiatrists and the pharmaceutical industry. Lots of well paid thought leaders – more than just the few bad apples who get all the publicity.

  • http://davidbeharmdejd.blogspot.com David Behar, MD,EJD

    Jan: The left would like to think the trend is driven by industry payoffs. It cannot face the fact, the trend is driven by what patients value.

    Dr. Carlat feels free to tell clinicians and their patients what is best for them is not what they are choosing to pay for now. At the peak year, industry pay ran all the way up to 2% of my gross. On every talk, I lost money compared to charges for clinical care. These talks were sacrifices done to share experiences and to profit from the experience of peers.

    Example. Abilify is history’s best anti-aggression medication. I never addressed anyone about it. Across the nation, 500,000 children were placed on Abilify, and kept on it by desperate parents. Why? Because it works. Academics and the FDA approval process caught up to that clinical advance many years later.

    The idea is that Dr. Carlat knows what is good for them better than they do. That is the message of the left wing, officious intermeddler. Do pointless psychotherapy over many years, as your family is destroyed by an out of control monster. If you do that long enough, patients will just age out of their symptoms. Meanwhile, you have taken people’s money for advice and help they could get from a neighbor for free.

    • http://www.TheHealthCulture.com Jan Henderson

      When talking about psychiatry and psychotherapy, I think it’s useful to distinguish – in a common sense way, not the DSM way – between patients who are mentally ill (schizophrenia, bipolar, severe depression) and patients who are struggling with the painful dissatisfactions of modern life. Scientifically we may not yet understand why, but certain pharmaceutical drugs can change the functioning of the mentally ill so that they are less of a threat to themselves and their behavior is less inconvenient for those in their environment. The dissatisfactions of modern life, on the other hand, should be understood as a social problem – that is, what type of a society do we want to live in – not a medical problem.

      I’m afraid this may sound very left wing, but the pharmaceutical industry has a vested interest in turning ordinary behaviors into treatable conditions. And the American Psychiatric Association has been complicit. In DSM-II (1968), the APA asserted that certain maladaptive patterns of behavior were “determined primarily by malfunctioning of the brain.” Obsessive-compulsive disorder went from being “unquestionably one of the rarest forms of mental disorders” in 1973 to one of the top four mental disorders in the world, affecting anywhere from three out of a hundred to one in ten. This happened in less than 30 years. What happened? Did our brains change?

      My point is simply that human behavior responds to its environment, a large part of which is the authority of the medical profession. With the assistance of psychopharmaceuticals, many aspects of life which were previously outside the jurisdiction of medicine are now understood as medical problems. This is a choice society makes, though I’m not convinced we make it consciously. I found no acknowledgment of this aspect of mental health in Carlat’s book.

  • http://davidbeharmdejd.blogspot.com David Behar, MD,EJD

    Jan: We have much common ground, which I want to make more explicit. Environmental factors and normal stress reactions are always in the differential diagnosis, especially in non-psychotic conditions. Anti-depressants for bereavement are disruptive, not helpful, give a bunch of side effects. Their main effect, helpful in the depressed, the leveling of mood or even numbing, is disruptive in the bereaved, never mind their side effects.

    The analogy is diabetes. It requires medication. It requires environmental measures, dieting and exercise. Prior to medications, the remedy was drastic, starvation.

    If you are advocating some triage, we agree entirely. Most colds are managed by patients. A bad flu or a pneumonia should be managed by a family doctor. A pneumonia requiring a ventilator in ICU requires a pulmonary specialist. Psychiatrists are like the pulmonary specialist, best suited for the extreme of mental pathology. Medications are their tools. Even the most severe of pathologies will have some environmental factor. That should not be neglected.

    This hierarchy of care is driven by the paying public, not by any drug company. The public runs the show. And, there is nothing wrong with that setup.

    • http://www.TheHealthCulture.com Jan Henderson

      Dr. Behar – Yes, I see we are more in agreement than not. The analogy with diabetes is excellent — medication AND environment. I remember an episode of Marcus Welby MD – which was only 40 years ago – where a patient was diagnosed with diabetes and told the only treatment was diet.

      I wrote a post recently on the APA’s debate about whether or not to consider bereavement a Major Depressive Episode. (http://bit.ly/frBwDs) I find discussions among psychiatrists about issues such as this both interesting and satisfying. Psychiatrists are inclined to be more holistic than reductionist, which is what I find missing in highly specialized modern medicine. They are dealing with a person, not an organ, cell, or molecule.

      And yes, I would agree that the hierarchy of care is driven by the paying public, not the drug companies. But I’m troubled by what the drug companies do drive. It’s only natural that individuals desire enhancement. The public learned that Prozac would make them feel better than well, and who doesn’t want that?

      But people are very suggestible. It’s like medical students suspecting they might have each new disease they learn about. Suggesting to people that they are sick — through direct to consumer advertising – seems morally questionable to me. But it’s a difficult issue. How does society draws a line between freedom of choice and protecting the public? Who makes that decision? An interest group with a vested financial interest?

      I can draw a line at outright deception, which the pharmaceutical industry – like the tobacco industry – doesn’t hesitate to practice

  • http://davidbeharmdejd.blogspot.com David Behar, MD, EJD

    One should add the biggest environmental factor in mental illness. Anyone can figure it out, and remedy it without any professional help.

    About a third of even extreme psychoses are caused by alcohol and illegal drugs. About 5% of conditions can be cured by cutting back on caffeine.

    • http://www.TheHealthCulture.com Jan Henderson

      Interesting statistic on caffeine. I hadn’t seen that.

      I think that in the amazing, life-saving ability of modern medical science to understand disease — at the level of cells, molecules, genes – we have lost the bandwidth to consider how the environment (both physical and mental) causes disease in the first place.

  • http://www.talktoyourunconscious.wordpress.com BobBapaso

    I went into psychiatry because I thought it was the highest calling in medicine, and as yet have no reason to doubt it. Understanding human nature is much more challenging than, say, the gallbladder. But, our understanding of brain physiology is still so primitive, drug company hype and money not withstanding, that its study is no more helpful to psychiatry than study of computer hardware and software is to learning Microsoft Word, which I also find challenging.

    • http://www.TheHealthCulture.com Jan Henderson

      I looked up the page in Sandeep Juahar’s book that prompted me to write about psychiatry’s place in the pecking order. I won’t repeat the details here, since it’s only an opinion of one of Juahar’s professors and it’s unnecessarily unflattering. (You can read it at http://bit.ly/iemTXA in Google books.)

      There’s no question in my mind that trying to understand human nature is much more challenging than understanding the gall bladder. Juahar, whose book is about his internship (which included a severe depression), says that his professors openly expressed disdain for psychiatry and psychiatrists. Was his experience exceptional? And if not, why would that be? Is it that understanding human nature is not a scientific pursuit?

      In my mind, it’s psychiatry’s attempt to compete with the scientific nature of medicine that has led it off track – throwing the baby out with the bath water over the last 40 or so years when it comes to treating patients. And clinical medicine’s attempt to compete with the hard sciences – while the discoveries and advancements have been truly amazing – has resulted in medicine no longer being the “healing art” for patients that it once was.

  • Kimbriel

    I don’t agree with David Behar. Most people I know on psychiatry’s miracle cocktails are on ssdi, not working. I had a 100k job before psychiatry intervened. Maybe in his practice he sees something different. I’m not a fan of psychiatry.

    However, this article was unnecessarily harsh. I suspect people go into psychiatry for a lot of different reasons. And some bright, some not so bright, most average,

    • http://www.TheHealthCulture.com Jan Henderson

      I agree that people undoubtedly go into psychiatry for many different reasons. I was surprised to read that there was disparagement of the profession along those lines. I don’t know if that attitude is an exception or if it’s relatively common. Perhaps it’s related to the relative prestige of diseases and specialties (http://bit.ly/fb8zpM). There was a nice post a while back on KevinMD about professional hierarchies, recommending that doctors avoid disparaging other professions. (http://bit.ly/hbEAsj)

  • kimbriel

    Well, not to be insulting, but psychiatry just isn’t… very medical. The majority of it is managing and watching for illnesses CREATED by the prescribed treatment. Most psych docs get REALLY sensitive if you point that out, but I have had major medical interventions throughout childhood, in addition to a so-called serious mental illness diagnosis in adulthood, so I speak from experience.

    My biggest frustration with the profession is that they seem unable to grasp the idea that the meds just do not work, and have nothing to offer you if they don’t – but YOU are labeled “non-compliant” or “treatment resistant” and just in general treated like a bad patient. I’m also not aware of any other medical specialty that considers treatment of symptoms to equal treatment of disease. Can you imagine going to an endocrinologist and he prescribes meds that stop constant thirst and urination and says your diabetes is being “treated”?

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