What's wrong with psychiatry? One shrink's view

Psychiatry has lost its soul.

That's how grimly Dr. Daniel Carlat, a psychiatrist in private practice outside of Boston, characterizes the state of his profession.

"Over the last 20 to 30 years, psychiatry has really transformed itself from a profession in which we try to understand people and understand their psychology - and talk to them and help them that way - into a profession in which we diagnose diseases, and we medicate those diseases," says Carlat.

"So over that time, we have in a sense, and this is really alarming to me, we've lost our sense of psychological curiosity," he says. "And that's kind of the very soul of psychiatry."

Exactly what's wrong, and how to fix it, was the topic of discussion last Thursday, when Reuters Health spoke to Carlat about his new book Unhinged: The Trouble With Psychiatry - A Doctor's Revelations About a Profession in Crisis (Free Press, May 18, 2010). (See live-blogging from the conversation)

The slide started, says Carlat, when psychiatric blockbusters like Prozac (fluoxetine), a so-called selective serotonin reuptake inhibitor, or SSRI, was approved in 1988. Thanks to Prozac and its cousins such as Zoloft and Paxil, and their relatively limited side effects, prescriptions grew to the millions.

Borrowing the words of late Harvard psychiatrist Dr. Leon Eisenberg, psychiatry went from being "brainless" to being "mindless," Carlat says. Today, psychiatrists spend 20 minutes with a patient every few months, in essence adjusting medications, compared to an hour or more each week trying to understand what was wrong.

Some argue that reflects a more mature science, one that pays off faster and more efficiently. But that's not necessarily true, says Carlat. He cites an example from his clinic: He had been prescribing Ambien, a long-acting sleeping pill, to one of his patients for a while. At the same time, however, the patient was complaining to his therapist that he felt overly sedated and couldn't get up in the morning.

"One of his psychological issues was that he had such low self-esteem that he felt that he wasn't worth enough as a person to come to me - the more intimidating doctor figure - to ask me to do something about it."

As a result of the gap between psychology and psychiatry, the man had nodded off at the wheel during a business trip, barely avoiding an accident.

With the change in psychiatry also came a shift in the way we think and talk about mental problems. In the case of depression, for instance, doctors often refer to a deficiency in the neurotransmitter serotonin. While this makes sense at first glance, all it means is that SSRIs can treat depression; it does not mean we understand what's going on in the brain. In fact, nobody has ever found proof of a serotonin deficiency, according to Carlat.