Psychiatrist and fellow PT blogger Daniel Carlat has some startling advice for his colleagues in the latest issue of the New York Review of Books. During a feisty exchange over Marcia Angell's recent two-part essay, "The Illusions of Psychiatry" and "The Epidemic of Mental Illness: Why?," he writes: "as psychiatrists, we should stop overselling ourselves as possessors of a sophisticated neurochemical knowledge."
If psychiatry has been overselling itself in this respect, what exactly has the public overbought?
Before I get to that question, let's focus on the exchange itself, which makes clear that Angell's review, on which I blogged just over a month ago, hit a very obvious nerve with the psychiatric establishment. Defensive rejoinders come from such figures as John Oldham, President of the American Psychiatric Association; Richard A. Friedman and Andrew A. Nierenberg of, respectively, the Weill Cornell Medical College and the Harvard Medical School; and Carlat himself, whose book, Unhinged: The Trouble with Psychiatry—A Doctor's Revelations about a Profession in Crisis, had received a largely favorable review.
With the exception of Carlin, the other psychiatrists complaining about Angell's essay offer knee-jerk, seemingly prewritten responses, pretty much regardless of the facts and evidence she reported. Indeed, that pattern is quite familiar to commentators on psychiatry—we see the same "moves" whenever criticism of the profession starts to bite. If researchers can show that too many Americans are medicated for conditions for which only a fraction of them meet the criteria, for instance, opponents cry foul, insisting that one-in-ten Americans (more than thirty million) on antidepressants is far too few, and that Americans in general are undertreated and undermedicated. If the critique of psychiatry is on-target but unfavorable, opponents quickly claim that it is "unbalanced" and try to change the subject. If the critique comes from one of their own, or relies substantially on insider concerns and disagreements, a common strategy is to try to discredit the messenger or reviewer. And if the focus is on the drugs themselves, including whether they work and why they so often generate side effects, the response is often to ignore the latter completely or, when that isn't possible, to pretend that the drugs' effectiveness makes the side effects more or less irrelevant.
In the latest exchange, however, to which Angell responds ably, it's striking—perhaps even a curious sign of progress—that the psychiatrists aren't in the least on the same page themselves. Oldham opines that the NYRB "chose to review three books that are highly critical of modern psychiatry," as if the periodical were responsible for the books' content and should somehow ignore their negative findings until books more favorable of psychiatry can be coaxed into print. But Carlat credits Angell with pinpointing exactly what Oldham, Friedman, and Nierenberg profess to disbelieve: "Her argument is correct in its essentials," he states (my italics). "Psychiatrists often overdiagnose disorders of questionable scientific validity, they have become overly fixated on medication solutions to life's problems, and many have accepted a steady flow of drug industry money, creating so many conflicts of interest that it is impossible to know who we can trust."
There are quite a few notable admissions in that statement. What does Carlat expect the public to do with such revelations, including that it's impossible to know whom to trust, given psychiatrists' rampant conflicts of interest, their frequent overdiagnosis of ailments, and their "fixation" on drugs to treat them? And why is he unhappy with the review when it reported his position both accurately and fairly?
"Missing from [Angell's] review," he writes, "is an unequivocal if perplexing truth about psychiatric drugs—on the whole, they work" (his emphasis). Ignoring recent international controversy about the findings plaguing each of the sets of drugs in question, Carlat presses on: "Antipsychotics for schizophrenia, stimulants for ADHD, hypnotics for insomnia, benzodiazepines and SSRIs for anxiety disorders—in all these cases, drugs are robustly more effective than placebos in double-blind controlled trials." To take this unwise and wildly inaccurate statement on trust, we must not only ignore that large numbers of infants have been prescribed antipsychotics for conditions other than schizophrenia, with rapid weight gain, increased risk of diabetes, and shortened life expectancy just three of the many side effects routinely noted. We also must ignore the vast amounts of evidence pointing to chronic, well-documented withdrawal syndromes from both benzodiazepines and SSRI antidepressants—again, factors affecting the millions who take them.
As for the "robustly more effective than placebos in double-blind controlled trials" part: That is, in large part, the oft-cited myth among psychiatrists that Angell's two-part review did so much to discredit, in part through detailed examination of Irving Kirsch's meta-analyses and his careful assessment of the placebo effect. Using widely agreed-upon criteria, Kirsch calculated that the effect accounts for up to 82 percent of the drugs' performance, rendering their pharmacological contribution "clinically meaningless." As Angell reported at length, he also studied the "enhanced effect" of placebo in trials that have not sufficiently adjusted for it.
With Carlat's insisting otherwise about the drugs, it's as if he simply ignored that extended discussion in the review, in hopes that readers also didn't notice it. He resorts to insisting that the drugs work when the evidence suggests that what is working, in terms of treatment, is not owing to the drugs at all.
Carlat, remember, openly concedes in his book that "our diagnoses [as psychiatrists] are subjective and expandable, and we have few rational reasons for choosing one treatment over another" (my italics). In the book he is also quick to burst "the illusion that we understand our patients when all we are doing is assigning them labels... To a remarkable degree, our choice of medications is subjective, even random. Perhaps your psychiatrist is in a Lexapro mood this morning, because he was just visited by an attractive Lexapro drug rep."
Yet after being quoted with these statements in the review, here he is in his letter to the NYRB: "Dr. Angell makes much of the fact that we do not understand the mechanism of mental illness, nor of the drugs we use to treat it. While this is true, it does not mean that the drugs are ineffective—only that as psychiatrists, we should stop overselling ourselves as possessors of a sophisticated neurochemical knowledge of our craft."
This is an extraordinary statement, especially when presented as backhanded criticism of Angell. For starters, why wouldn't she elaborate on the massive implications of Carlat's own point, given its consequences for the public at large, especially when his point is so rarely acknowledged by his colleagues? Second, his remarkably frank admission about psychiatrists' failure to understand both the illnesses and the drugs they use to treat them does of course put in question the widespread prescription of such treatments, both because of the principle enshrined by the Hippocratic oath, First, do no harm, and because, by Carlat's own admission, the drugs' role in such treatment has been massively oversold.
After Peter Kramer's highly selective "Defense of Antidepressants" in the New York Times, itself a broad exercise in mischaracterization, Robert Whitaker posted on his PT blog that we desperately need "an honest discussion about what science is telling us about the drugs." In Kramer's essay, he added, "the American public has been treated to yet another dose of misinformation."
The same, alas, is true of most of the responses to Angell's review essay. Indeed, Carlat's advice—that psychiatrists "should stop overselling ourselves as possessors of a sophisticated neurochemical knowledge of our craft"—is better directed at his colleagues, including the other letter writers to the NYRB, who have sent in prepared answers to problems they know are more serious and more troubling than they can publicly admit. They cite an imbalance in argument without any real regard for the highly inconvenient facts that Angell reported.
"The Illusions of Psychiatry: An Exchange" (including Angell's response) can be found here.