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A Psychiatrist's Prescription For His Profession

Two years ago, psychiatrist Daniel Carlat wrote a piece in the New York Times Magazine called Dr. Drug Rep, in which he told his story of being paid to push the anti-depressant Effexor to his colleagues.

Carlat joins Fresh Air contributor Dave Davies today to talk about his new book, called Unhinged: The Trouble With Psychiatry. But the book isn't just concerned with the influence of drug companies in the profession.

Carlat believes in prescribing medication, but he says too many psychiatrists have all but abandoned talk therapy -- leaving in-depth interaction with patients to others -- while they pursue medical fixes for mood problems and mental disorders.

"Based on a survey of psychiatrists throughout the United States [conducted by Columbia University], it turns out only 11 percent of all psychiatrists now offer therapy to all of their patients," he explains. "So essentially, 1 out of 10 psychiatrists are really doing psychotherapy on a regular basis."

He says time and billing constraints have also made it difficult for psychiatrists to integrate in-depth sessions back into their practices.

"I have hundreds of patients. And if I start to do one-hour therapy sessions with most of my patients, I am going to have to kick patients out of my practice because I won't have time to see them," he says. "So it's been difficult and I've had to do creative things where I don't do one-hour therapy sessions, I might do 45-minute therapy sessions or half-hour therapy sessions so I can still fit a fair number of people into my practice while performing what I would consider a better quality of psychiatry."

Daniel Carlat was trained at Harvard and is on the faculty of the Tufts Medical School. He edits a monthly newsletter called the Carlat Psychiatry Report.

Interview Highlights

On what Dan Carlat does

"We are in the business of making diagnoses using the DSM -- the official diagnostic manual for the psychiatric disorders of the American Psychiatric Association. We make our diagnoses. And then we usually prescribe medications. And psychiatrists used to, in the past, also do a lot of talk therapy and used to combine drugs with talk therapy -- although frankly, in the more distant past, maybe 30 years ago -- before there were effective medications, we just did psychotherapy which, often times, was not terribly effective."

How a diagnosis is made

"It's very hard to make a psychiatric diagnosis and we're not talking about a diagnosis where we can get a blood scan or a brain scan or an X-ray. At this point, all of those types of things are research tools although we certainly hear a lot about them in the media. We do our diagnoses based on the kind of interaction that you and I are having right now. We have a conversation and I ask my patients questions about how they're feeling, what they're thinking, how they're sleeping, what their concentration level is, what their energy level is, and I put all of those pieces of information together and then I come up with a diagnosis based on the DSM guidebook that we have. And then once we have a diagnosis, I match those symptoms up with a medication. So modern psychiatry is really a conversation, a series of symptoms and then a matching process of medication to these symptoms."

On communication between a patient's psychiatrist and therapist

"Often we don't really get that much information. Presumably the psychiatrist and the therapist would be communicating frequently on an ongoing basis but ... these situations come up with alarming frequency when you split the treatment up between a psychopharmacologist and a psychotherapist.

On the length of visits

"There's kind of an unofficial policy among psychiatrists, at least among some, which is the 'don't ask, don't tell' policy, which is that when we have our patients coming in, we know we have 15 or 20 minutes to see them. We want to learn a certain amount about how they're doing, obviously because we want to make sure our medications are working and if we need to increase the dose. But on the other hand, we don't want to ask too many questions because if we start to hear too much information, we're going to run into a time issue where we're going to have to push them out of the office perhaps at a time that they're going to reveal something that could really be crucial to understanding their treatment."

On conclusive evidence in psychiatry vs. other fields

"We don't have any direct evidence that depression or anxiety or any psychiatric disorder is due to a deficiency in serotonin because it's very hard to actually measure serotonin from a living brain. Any efforts that have been made to measure serotonin indirectly -- such as measuring it in the spinal fluid or doing post-mortem studies -- have been inconclusive. They have not shown conclusively that there is either too little or too much serotonin in the fluids. So that's where we are with psychiatry. ... In cardiology, we have a good understanding of how the heart pumps, what electrical signals generate electricity in the heart. And due to that understanding, we can then target specific cardiac medications to treat problems like heart failure or heart attacks. Again, based on a pretty well worked out knowledge of the pathophysiology -- again not perfect, but pretty well worked out."

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