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 Crisis.

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 Initiation.)
  • 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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