Harvard Book Store; WGBH Forum Network; Daniel J. Carlat: The Trouble with Psychiatry

This and on behalf of Harvard bookstore It's my pleasure to welcome you to this evening's event with Dr. Daniel Carlock on the current state and future of psychiatry and his new book Unhinged The trouble with psychiatry. A doctor's revelations about a profession in crisis. Although our summer event schedule is a little bit lighter than the rest of the year we still have a lot of exciting events coming up. Tickets are on sale now at the registers for our Monday evening event with Sebastian Junger. His new book War tells the story of the months that he spent embedded with a platoon in Afghanistan and about the complex lives lived by today's soldiers. He'll be speaking at Monday evening at the Brattle Theater at 6 p.m. and $5 tickets are on sale now. We also have events next week with foreign correspondent Stephen Kinzer. Novelist and Bidi and behavioral economist Dan Ariely. So for more information about those events or other upcoming events please pick up an events fire on your way out this evening the yellow flyers by the door or visit us online at Harvard dot com. And now it's my pleasure to introduce Daniel Carlat. Dr. Carla is a practicing psychiatrist who also serves as an associate clinical

professor of psychiatry here at Tufts University and is an active mental health journalist. She is the editor in chief of the Carlotta Psychiatry Report a peer reviewed newsletter on psychopharmacology and his blog The Carlock psychiatry blog has received an award for outstanding mental health journalism and he has also written for Psychology Today the Psychiatric Times and The New York Times. His new book unhinged takes aim at his profession and asks the question is psychiatry fulfilling its essential purpose while the goal of psychiatry and its related fields ought to be to understand and heal mental illness. Dr. Croat argues that overemphasis on prescription drugs and de-emphasis of talk therapy have shifted the goal from the simple to the simple treatment of symptoms. After his talk this evening we will have time for questions followed by a signing here at this table. As always I'd like to thank anyone who purchases a copy of the book here this evening. By doing so you're supporting both a local independent bookstore and this author series. And now please join me in welcoming

Dr. Daniel Karla. Thank you very much for coming out tonight and as Rachel was talking about all the blogging that I've done I it's I was browsing I saw a book that that's what the Internet does to your brain and I'm thinking wow this is really what the Internet has kind of done is creating this book is what the Internet has done in my brain. So I was at the new I was in New Orleans recently at the EPA meeting the American Psychiatric Association annual meeting and I got a taste of just how how angry it's possible to make some people that are in your field when you are critical. I mean there's been a lot of books out that have been somewhat critical of psychiatry. And typically they have not been written by psychiatrists when you're a psychiatrist and you become critical of your field. You you're in for a kind of special retribution. And so I was

walking around the caboose the publishing booths at the APEC meeting and there was a woman who is quite a big wig in the field she has written textbooks and child psychiatry and she's used to it used to. One of the journals in child psychiatry and I just I went up to her to introduce myself because I just started a newsletter in Charlotte because I wanted to just sort of show it to her and see what she thought. So she took one look at I said Hi Dr. Carla Nice to meet you and she took one look at my name tag said Oh I know you. And there was something in her face that was a little bit hostile. So I said in a good way or a bad way and she said well in a bad way to tell you the truth you in your new York Times article would trash your training at Mass General Hospital and then you said you came to this realization that you had to understand your patients. Meanwhile you're writing these articles in order to sell your books and your newsletters.

This is all high volume with about 20 people waiting at the table. Meanwhile of course she's signing her own books. I don't know what that was that was lost on you. So. So I walked away and one of the women who was waiting in line stopped me and whispered to me I get your newsletter and really like it. She was wearing that much anyway. So in this in the small world anyway of of those of my fellow psychiatrist my fellow psychiatry this type of book and the type of articles that I've written generate a lot of controversy because essentially what I'm arguing in this book is that we as a field are providing substandard care to our patients even though there is a hierarchy in psychiatry just like there's a hierarchy and in authors you know Sebastian Younger guy gets paid $5 and you got to go to the theater I'm here for free but I just just like there is a hierarchy there in psychiatry there's a hierarchy you have the psychiatrists

who prescribe the medications for those who who don't know the difference between a psychiatrist psychologist psychiatrist the ones that go to medical school and prescribe medications. And the psychologists are the ones that go to psychology graduate school and are not able to prescribe medications. So for years now people in my field have developed something of an elitist attitude. These are the those who are in other fields who are the therapists and that kind of attitude is something that I I think I absorbed by osmosis while I went to do my residency. I did my residency nearby here at Mass General for psychiatry. I did medical school in San Francisco but it was something that I kind of absorbed by osmosis. Having started my residency in 1992 which was shortly after Prozac came on the scene and this was a time when the medications were coming out at a dizzying clip and there was a sense in which we

had finally gotten it and there was a sense in which psychiatrists what we could do is just prescribe the medications because we had understood the biochemistry of the brain. And for those messy messy issues that people have to deal with that could not be dealt with with medications. We could just refer them to people like social workers and psychologists. So there was a sense in which aren't we lucky that now now that we have been able to figure out the biochemistry we we don't have to do that stuff anymore. So this is sort of the the culture that I was trained in and it's a culture that I think a lot of people as lot of psychiatrists actually are thinking twice about these days. And the article in The New York Times magazine that that was sort of prelude to this book was called Mind over meds and it was basically an article saying you know psychiatrists prescribe too many meds and we don't do enough therapy.

And it was really uncontroversial. Surprisingly so and many many psychiatrists which was surprising to me wrote me email me or left comments on your Times Web site saying essentially Bravo I agree with you. In fact I'm one of the psychiatrists that still do a lot of therapy and there are many that are maybe some in this audience that do and there are many psychiatrists out there that still are able to do plenty of therapy in their practice. But the latest figures these were from about 2005 were that only 29 percent of all psychiatry visits entails psychotherapy and only 11 percent of all psychiatrists offer therapy to all their patients so something has happened over the past several years in which we have given up therapy and we're doing most of the medications. But let me read a bit from just chapter one of the book which I read from. Mostly because if there was sort of an

awakening that I had in my gradual shift from being a psychopharmacologist which is the type of doctor to prescribe meds to becoming more of an integrated practitioner this woman Carol was the type of patient that that helped me to shift my way of thinking. So Chapter one is called The Trouble With psychiatry for the past for the last 15 years I practice psychiatry in a small town north of Boston. Newburyport Actually it is a solo private practice I see mostly middle class patients who come to me with depression anxiety substance abuse and occasionally more severe problems such as bipolar disorder or schizophrenia. Like most psychiatrists my generation I've specialized in prescribing medications and have referred patients in need of treatment to speak to a psychotherapist during my training at Mass General I was taught that we were on the threshold of understanding the biochemistry of mental illness and also say that the 1990s were the decade of the brain so there was

this feeling that in IMH too or that we are about to kind of unlock all the secrets. After I graduated from residency I worked hard to keep up with the explosion of neuroscience knowledge absorb the intricacies of how to use the new drugs as they poured forth from the drug companies by harnessing these powerful meds. I thought I was providing my patients with the best psychiatric treatment possible. But a couple of years ago I saw a patient who made me question both my profession and my career. So Carol in her mid-thirties had short brown hair and strikingly green eyes always remembered that were filled with despair. Once we were seated in my office I asked her how can I be of help. My father was killed in a car accident she said choking back tears. How awful I said. When did this happen. Last month Carole told me that she had been in the car with her father who was driving. They came over a rise in the road and another car was just pulling out of a driveway in front of them. Her father tried to swerve but it was too

late. They collided with the other car and her father who was not wearing a seat belt was killed instantly. Miraculously Carol was not seriously injured. Since then she told me she had recurrent dreams about the accident and couldn't prevent herself from replaying the scene throughout the day over and over again. The events were unreal themselves like a movie in front of her. And often she would start sobbing uncontrollably. These were typical symptoms of post-traumatic stress disorder she said that she experienced. I asked her a series of questions she experienced symptoms. She said her life was so constricting in word. She said she drove rarely avoiding especially the road where the accident had occurred. Are you avoiding anything else I asked. I won't watch TV. I can't read the newspaper. I never realized how many stories there are about car accidents in the news. I asked her about symptoms of depression and she reported that she had some she had insomnia poor motivation

but luckily no suicidal ideation. The worst thing she said is how guilty I feel. Why guilty I asked. It was my fault that we crashed. I got him upset. Her eyes began to well up. I was telling him that he shouldn't be drinking. He was drinking and driving. She nodded. I told him I could smell it on his breath and that he shouldn't be driving. He got mad started yelling at me and then he floored the gas pedal said something like my driving good enough now and that's when it happened. I could see that this was going to be more than just a simple case of PTSD. If there really are such cases that are simple Anyway she would have complicated feelings about her father to wrestle with grief regret and eventually a good deal of anger. I then told her that I thought she had PTSD. I wrote out her a couple of prescriptions of medications Zoloft which is a

Prozac like drug a serotonin reuptake inhibitor and the tranquilizer clonopin. Then I reached in my file cabinet and handed her a business card and this is a good therapist who I often work with. I told her I recommend that you give her a call and set up an appointment. Medication works better when you're also seeing a counselor. She looked confused. Aren't you my therapist. I shook my head. Unfortunately I don't have time in my practice to do the therapy. I usually refer my patients to a psychotherapist I can trust here in the community. So am I going to see you again. Yes I said we'll schedule another appointment in about a month to see how the medications are working. But in the meantime I hope you'll have had a couple of sessions with this other doctor. Carol still didn't look at all happy about this. But aren't there any psychiatrists that do therapy. She said there are a few I said but not many. They're hard to find these days.

So Carol left my office and after she left I finished writing her note. I closed my chart put my pen down and looked. Looked out my office window at the White steepled Unitarian church that's right across the street and there was nothing really unusual about my encounter with her. As I was reflecting this is a few years ago I did what most psychiatrists do when they encounter a new patient. I sat comfortably in my red leather chair wearing my suit and tie. I asked her a series of diagnostic questions her answers fit neatly into a recipe book of psychiatric diagnosis called the DSM 4 which has our list of mental disorders. I pieced together a diagnosis that made sense to me. I then reached over to my desk wrote out a prescription and handed this to her. Pondering this typical appointment what struck me most was what I did not do. I am an M.D. and it really was not fun going to medical school I can tell you. Basically you know medical school is 12 years of training when you

when you include the pre pre-med courses in college. So I did my my grueling medical internship in a general hospital my three years of psych residency at mass general but like most psychiatrists I did little to take advantage of those years of training. I did not do a physical exam nor did I take Carol's pulse or blood pressure. Typically what we do in psychiatry is we have we got the patients primary care doctors records to establish that they don't have a physical cause to their distress. Indeed the only times that I stirred from my chair were to meet her in the waiting room at the beginning and to show her my secretary's office to make a follow up appointment at the end just as striking to me as the lack of typical Doctor Lee activities and psychiatry is the dearth of psychotherapy. Most people are under the misconception better to appointment with a psychiatrist will involve counseling probing questions and digging into the psychological meanings

of one's distress and my sense is the problem here in Cambridge that's not so far from the truth it's probably fairly easy to find a psychiatrist here who can't who does to do more therapy. But it's not only is it hard to find that type of psychiatrist in most of the places it's hard to find psychiatrists at all it's usually a three to five month waiting list. If you can find someone but the psychiatrist or psychotherapist is an endangered species. In fact according to the data from Columbia University as I mentioned only one out of 10 psychiatrists offers therapy to all their patients doing psychotherapy doesn't pay well enough. I can see three or four patients per hour. If I focus on medication such psychiatrists are called psychopharmacologist but only one patient in that time period. If I do therapy and that income differential is a powerful incentive to drop therapy from my repertoire of skills and psychiatrists have generally followed the money

while while Carroll's case was it was traumatic and quite tragic her treatment I found was not particularly dramatic in the sense that her story illustrated a kind of a typical treatment approach for modern day psychiatry. And her story illustrated for me about the triumphs and the failures of modern psychiatry. So with that over the last 30 years we've constructed a reliable system for diagnosing mental disorders and we have created medications that work well to treat a range of psychological symptoms but these very successes have had unpredictable consequences. And psychiatrists have become enthralled with diagnosis and medication. We've given up the essence of our profession. Which is understanding the mind. We have become obsessed with psychopharmacology and its endless process of tinkering with medications adjusting dosages and piling on more medications to treat the side effects of the drugs. We started with. We've convinced ourselves that we have

developed cures for mental illnesses like Karel's when in fact we know so little about the underlying neurobiology of their causes that our treatments are often a series of trial and errors. So that was one of a series of patients as I look back on the last five years or so who taught me something about what I felt I was doing wrong. And you know in this case I thought to myself after the 12 years of training that I have what do I really have to show for the psychiatrists. Essentially what I do day to day is I prescribe medications. That's not me. Good. And I prescribe I prescribe medications I write write out prescriptions and when I have a patient like Carol who may or may not benefit from one of the medications and actually post-traumatic stress disorder is unfortunately one of those conditions that doesn't necessarily

benefit very well from medications and benefits very well from psychotherapy. I can't do it. So 12 years of schooling and I can't do basic basic therapy techniques. One of the pieces of feedback that I've gotten from some psychiatrists who have been critical of of the of the book in my thesis is that you're selling yourself too short. And psychiatrists actually do therapy. And it really depends on what you mean by psychotherapy if you mean 15 minute appointment where you prescribe medication and give some words of advice. And if you call that therapy then yes maybe we are doing therapy but there actually are very specific psychotherapeutic techniques like cognitive behavior therapy or psychoanalytic therapy which I was just writing about mindfulness based therapy which are specific techniques that can be used to treat specific illnesses. And typically what happens is that I

will see a patient who has a panic disorder. There are very good medications to treat panic disorder but typically patients will only get about 50 percent of the way better and then the cognitive behavior treatments that are required to get them all the way better are not. Not in my repertoire. And they're very hard to find it's actually very hard to find anybody that can do that kind of treatment. So that was sort of sort of the awakening that I began with that I began the book with and and then I go through. And then the rest of the book I sort of ask how do we get to this point. How did we get to the point where we as a field have become so fixated on medications and there are many different answers to that one of them is simply consumers consumers come in consumers hear that these medications work very well often and they want them. And if you if you've ever taken an anti-depressant and you've benefited from it you'll know that you probably can't believe

how much better you felt how much less irritable you were maybe to your kids after you've been on it. If you're one of the lucky people that response and then you might tell someone else and then they'll come to a psychiatrist and try to get on it. But there are these meds you know may work for 60 or 70 percent of patients to a certain degree but they need more than that and medications don't do a good job of solving basic life problems. So another piece of the puzzle is of course the insurance companies and the incentives to see more patients in an hour. But then another big piece of the puzzle and something that I know about because I used to do a fair amount of speaking for the drug companies is the effect of the pharmaceutical industry and for a year in 2002 I spoke for why pharmaceuticals pushing Effexor which is one of the antidepressants and I learned about how

sophisticated some of the techniques are not only for getting you as consumers to come to your doctor after seeing a commercial for a bill of fire or well and asking for it right. But even more so how drug routes are able to come to doctors offices and convince us that they have the next big drug and I will see how much time do I have. Yeah I have a little bit of time left to talk a little bit about some of the techniques that the companies have used over the last several years and I'm happy to say that we now are understanding some of these techniques and that there is some legislation in place that's going to curb some of these abuses but in Chapter 5 how companies sell psychiatrists on their drugs. I talk about neurontin which is a drug some you may have heard of. Neurontin was a drug that when I went to New York City with why a fly my wife and I to New York City to go to what

they call the Faculty Development Conference which was basically an indoctrination for about 100 psychiatrists where they flew in the best and the brightest psychiatrists to teach us about Efexor their drug. They gave my wife and I. Broadway tickets and that at the end of the conference I got an envelope with a thousand dollars a thousand dollar check just just for being such a good person. So and then I went off and did a series of drug talks over the next year till I got sick of it. So Neurontin it was this medication that was originally approved for the treatment of epilepsy and it was really just a very specific drug for the treatment of adjunct of use in epilepsy that wasn't adequately treated with other drugs. And the company that made it Warner-Lambert later bought out by Pfizer estimated that they could make about 500 million dollars over the drugs patented lifetime and a patented lifetime is 20 years. But it's usually about 10 years after they've gotten through the FDA process. So 500 million dollars may seem

like. And here I'm reading it may seem like good money to you and me but it is positively mediocre for drug companies which define very successful drugs as those bringing in $1 billion and more in sales per year. We're not talking over that patented lifetime per year. A billion here and there and you're starting to talk about real money eventually. And the the companies the kind of startling statistic that's a little out dated now was that the top 10 drug companies in the Fortune 500 list of companies made more in profit than all 500 other companies in the Fortune 500 combined. And I think they've been surpassed by maybe banks but now they're probably had banks again after what's happened. But at any rate the executives didn't like the idea of only having to make $500 million over the course of the patented lifetime. So they come up with a new marketing plan. They have found that a small number of studies a case series

had shown that Neurontin might be effective for several other conditions such as bipolar disorder migraine headaches neuropathic pain and ADHD and it was often used for things like many my colleagues and I in fact used it often for sleep and for bipolar disorder. And based on these small step studies the evidence was poor and it did not meet the FDA criteria for proof of effectiveness. And maybe the question of answer we'll find out that the FDA has bar for proof of effectiveness is one of the lowest bars you could imagine. But the executive decided to try to convince doctors to prescribe it for these disorders anyway. After all doctors are free to prescribe medications for anything they want even if there is no official indication. And this is called off label prescribing nothing wrong with it. Most doctors do it all the time. Warner-Lambert was well aware however that it is illegal for drug companies to explicitly market their drugs for off label uses. Nonetheless according to a

series of stories written by New York Times journalist melody Peterson such legal technicalities didn't seem to bother this ethically challenged company. Petersen interview David Franklin who is a former Warner-Lambert employee turned whistleblower who detailed his former company's systematic off label marketing campaign. Franklin recounted a meeting at which John Ford a senior executive exhorted reps to pitch in ront and to doctors for a long list of disorders. None of them adequately researched quote according to the executive. That's where we need to be holding their hand and whispering in their ear. He's talking now about the drug groups talking to the doctors. Ford said referring to the doctors Neurontin for pain Neurontin for monotherapy Neurontin for bipolar Neurontin for everything. He went further encouraging reps to get doctors to ramp the dose up higher than the FDA has recommended maximum of 8500 milligrams per day. I don't want to hear that safety crap either he said. Have you tried Neurontin. He's talking to the

drug reps now. Every one of you should take one just to see that there's nothing. It's a great drug. Warner-Lambert kept pushing the envelope of ethics to the point that it was eventually torn to shreds. According to Petersen's reporting drug reps were explicitly instructed to not leave a paper trail according to one of the executives anything you write down can be audited. So don't write anything down. But they were sued anyway because of David Franklin. The company rewarded doctors who are prescribing high amounts of Neurontin with free trips dinners or cash essentially bribing doctors to use more of the drug. The company hired marketing firms to ghostwrite articles pushing Neurontin and goes by ghostwriting basically this meant that the company had hired a writing firm in medical writing firm. And then the medical writers wrote up the articles and then they were hired doctors for about a thousand dollars to put their names on it to make them seem legitimate. And then that way they could get them into the top journals and then psychiatrists like I would be able to read them believe that it was written by

by an academic when in fact it was written by the company. And then I would prescribe more Neurontin for example one memo from this marketing firm read quote draft completed. We just didn't author unquote minor detail right. The company paid doctors to allow reps to read patient charts and to shatter doctors during visits. In some cases reps convinced doctors to prescribe Neurontin for off label uses during the so-called preceptors ships. These sleazy techniques worked beautifully. The drug became a blockbuster earning $2.7 billion in 2003 alone. Almost all of that income was from off label uses. In 2004 experts estimated that 90 percent of Neurontin prescriptions were for disorders not approved by the FDA. Eventually due partly to David Franklin's revelations. Pfizer which had since bought Warner-Lambert pleaded guilty to criminal charges

and agreed to pay $430 million in fines which was a pittance in comparison with the billions the drug was earning per year. So for Pfizer It was simply another business expense and a fairly minor one at that. So you can see that with the the ways that the companies are slapped on the wrist essentially a 400 million dollar fine is amounts to the amount of money that a company might make in a week or two so that it doesn't really do anything to prevent these practices from occurring. And since Neurontin and some of you may have been reading papers I mean these stories are starting to come out a lot. Zyprexa has paid Lilys has paid $1.3 billion fine to settle allegations of off label marketing of Zyprexa which is an anti-psychotic that causes one pound of weight gain per week in many of my patients anyway so that you have a normal person sort of starting the medication and then they blew up or over

the next couple of months and it can also cause diabetes. So the process here of us becoming largely pill pushers is one is a complicated one. Right. It doesn't. It's not just one thing. It's not just that the evil drug companies are causing us to prescribe drugs. It's not that the insurance companies are messing up our reimbursement. It's not just that the patients are coming to us. It also relates to something within our profession. And when I think about my training and the people that trained me I remember that we were very very proud to be Andie's and part of the issue here is that the only way that we can really prove to ourselves that we went to medical school is by prescribing a medication. And the other chapter in the book where I talk about some of these talismans of M.D. hood is where I talk in a chapter called

the seductions of Technology where I talked about a very successful treatment called easy t which actually former Governor Michael Dukakis his wife Kitty Dukakis had and she responded to wonderfully. She wrote with her I think with Larry tie a book called shock and after. It's not often that you got an e-mail from Michael Dukakis but I got an e-mail from Michael Dukakis after having written the New York Times article. Mind over meds and he was concerned actually that I not say so many quote bad things about the biological option that I steer people away from certain things that that worked at it. And I've seen Michael and I seen kids speak and their story is very very poignant. So some of these things work. But the the new the new machines such as vegas nerve stimulation or transcranial magnetic stimulation have been approved by the FDA

with very very little evidence that they actually work and in some cases these machines that are sometimes implanted. Other times we're simply like a big dental dental chair on steroids like that. The magnetic stimulation therapy really don't work any better or not demonstrable better than placebo How am I doing here should we stop kind of questions are getting pretty close. OK. Well let let me open it up for questions now and we can kind of go through and talk about some of the other issues for example some of the issues that I haven't touched on. Here is a chapter called a frenzy of diagnosis which gets into the whole DSM and the by the bible of psychiatry which at the New Orleans meeting was interesting because I went to a presentation where a psychiatrist actually I think she's a Catholic Kathleen Philips has come up with a new diagnosis called

Factory r o r s of factory reference syndrome which is a diagnosis of people who believe they smell terribly believe that terrible body odor or have terrible mouth odor bad breath. But they actually don't. And so she was able to find a case study of about 20 people who suffered this problem and she presented data to show that these people suffered terribly and they became suicidal at times because their problem was so bad. And we were joking that the worst problem is people that don't know that they smell but I actually do smell. Maybe that should be a Diosa diagnosis. But I think and I think that there really are I'm sure people that have olfactory referenced syndrome and do suffer. But I think this points to the reality that psychiatry is a funny field where since we don't have objective criteria we don't have a blood test. We don't have x rays to make our diagnoses.

We use these symptoms and we can kind of corral and mix and match certain symptoms in different ways in order to create these labels. And the DSM which is our list of disorders has gone from about 180 different diagnoses in 1968 to roughly around 400 disorders. With the next edition which is DSM 5 which will come out in 2013. Any questions. Yeah. Yeah I mean and anybody here who who is is a psychiatrist or who knows someone who has heard about the training will know that in fact in all psychiatric programs there is a large psychotherapy component. And what that typically means is that you are really thrown

in to the room. It's like kind of like being thrown into a lion's den is how it feels when you're first doing therapy because you have no idea what to say. You're basically thrown into a room with a patient and you wallow around a bit and you try to be as helpful as you can and then you leave and you talk to a supervisor and you learn that way certainly happened. They did a lot of that at Mass General which is kind of ironic that I was yelled at for for trashing Mass General about not teaching therapy because in fact they did a pretty good job of teaching therapy. But the problem is like any skill and probably more so therapy than almost any skill I know it takes a lifetime to master. And so that the typical psychiatrists will leave a program like that I will have learned the relatively easy skill of prescribing medications and then will do mostly that for the rest of their career. And if you don't to vote a certain large amount of your time and your practice to doing therapy with patients you just ain't

going to learn it. You'll never be good at it. So yeah. Right. Right. And that that's an interesting. It was a you know it was an article in New York Times and also a boy was based on a book which is anybody know the name of you know me crazy like us. Yeah. Yeah I haven't read the book but I know that Times article is excellent. But yeah there are certain diseases that are either much more common in the United States than they are in other countries or they're treated very differently and the outcomes of the diseases are very different

in other countries. And the anorexia is is one of them. But then what happens is that as the kind of the export the exportation is not just exploitation of other disease. There's an expectation of scientific expertise to other countries as well. So as the psychiatric epidemiologists epidemiology being the study of the prevalence of disease sort of get their hands on these other countries I've been seeing they've been able to produce research showing that the rates of some disorders apparently are the same in other countries. For example there's a 1 percent and often cited 1 percent prevalence rate of schizophrenia. And you can get your hands on studies in many different countries where you'll see that it looks real looks like there is a 1 percent prevalence of schizophrenia implying that maybe it's a biological disorder. And the same is true of ADHD ADHD attention deficit hyperactivity disorder sort of that's the kind of one

of the defining disorders of apparently kind of a manufactured disorder of a frenetic American society right. I mean this is where everybody comes into my office and says they can't concentrate and they want to help. They want to have been diagnosed with ADHD because they can get speed which is the treatment for ADHD to be quite frank. So but even ADHD which early research had indicated was much more common in the United States and other countries. Now I've started to see some research showing that possibly it isn't any more common in the United States. Again hard to know sometimes who you can trust because some of the research research is doing some psychiatric studies are funded by the pharmaceutical industry being funded by companies doesn't mean they're going to lie about your research but it does mean that you're sort of being selected out by the pharmaceutical industry to be because you're that type of person who happens to believe in their syndrome and you're the kind of person the kind of man or woman who's going to do the research it's going to

be sort of most convenient for the for the company. So yeah. That makes human beings not fall for that. The drug talks right. How do you how do you know what to prescribe.

I'm being facetious obviously. Right. So but that's what I understand. I understand right now I'm absolutely right. Right. Absolutely yeah. And so the the the statistics are again a little hard to be certain of. But there was a study done by a group at the Mass General Institute of Health Professions. ERIC CAMPBELL It showing that while the sensational part of the statistics was that quote 90 percent of physicians take something from drug companies. But it turned out that most of that was free samples and that doesn't really qualify because I Isel think for example and a lot of people take free samples and because we think it's probably good for a lot of our medication for our patients who are poor. But the more telling statistic was that

25 percent of all physicians participated in some way in the marketing of drugs. And that was not just speaking for pharmaceutical companies. Some of that was doing what it called phase four clinical trials which are not real scientific clinical trials but they're just kind of ways of doing research to increase sales of the drug. So there's a lot of physicians out there that treat that do choose to do it. And there's a lot of physicians who choose not to do it. And the question of it's a very thorny question of psychologically how to differentiate the two. When I go to the AOPA meetings and I used to be on the AOPA assembly which is sort of the governing body I would find so many of my colleagues who were livid that I would suggest that they could possibly be influenced by thousands of dollars that they were being paid. I absolutely love it. And you know you laugh but these are people who really really believe

that they are invulnerable to marketing and many of them believe that they're doing is doing a great service to the profession actually. You know because it's a win win win win win proposition. They make a lot of money. But the drug company makes money through more sales and the doctors that they're educating get education. And maybe that maybe it's for wins maybe the patients win too. So there's a will there's a lot of ways of rationalizing any you know any kind of behavior you know in my opinion it is behavior unbecoming of someone in the medical profession to become a paid marketing rep essentially for for a company. That's not what our patients want us to be doing. And yet you know rationalization lives on. It's like saying you know it varies about $300 an hour for three or four medication

visits and maybe $150 an hour for therapy more or less. So you're going to make about half as much money. Yeah. So but $150 an hour is not bad either but it takes your whole life to be at school. Yeah. Yeah. Yeah. When you're brilliant. You got it. Bingo. Yeah right.

Yeah it is. And this is you know kind of fades into the issue of direct to consumer advertising and I'm I personally am ambivalent about it because I think there are some patients who have come to me after having seen a commercial about depression or anxiety who really never knew that what they had was a condition could be treated and come in and get some treatment and feel better. All right. On the other hand there are many others who come in asking for specific medication that they probably should not be on. And then I have to have a whole discussion about why that's actually the wrong medication for you as in Abilify being apparently now a medication for depression but it's an anti-psychotic medication. Originally from schizophrenia and bipolar disorder. So it's a tough issue but I would I would say that I'm I'm not slandering anyone but I would say that you should be careful of web M.D. because you know like any medical web site you know they have to support themselves with advertising.

And so no there's no problem with that. But they go a little bit beyond that and they allow drug companies to actually rent entire resource areas of their sites so that you know like the ADHD resource area might be rented out or paid by Schier I don't know if that's true. Just as an example and that's where the line between editorial and marketing really starts to blur badly. Yes. Right.

Right. Right. So the question is that there are there are there are there apparently are some people who develop emotional problems triggered by events and others who just seem to come in without any trigger and maybe it is a chemical imbalance or who knows what it is. Right. And so in my experience in my own practice I'd say that there's maybe 30 percent or so of people to whom I prescribe a medication and they just gets to get better. And it's almost miraculous for that 30 percent. When one patient said it's like he when he takes his Zoloft or whatever it is every morning it's like he's bowing at the altar. I mean literally is how he put it it was like a sacred event because it helped him so much. But you know the rest of the patients may get a little bit better with meds and they may not. And it's very very hard to know what to do in those cases. And I think that's the way that the training of psychiatrists has done such a disservice to patients because

what happens is that we are so focused on the biological diagnosis the notion that these these illnesses are essentially biological illnesses that when we are evaluating people who were on that kind of another zone where we can is this biological Is this due to events. Does this person need meds does this person need therapy. Psychiatrists are utterly unequipped to be able to make those kinds of decisions because we're not trained to make those decisions. And psychologists are also fairly unequipped to make those decisions because they haven't learned about how to prescribe medications. So what we have is this crazy fragmented system of mental health where we don't have the sweet spot. You know we don't have the right practitioner who really knows the medications and who really knows the therapy and who can therefore make those judgments that really take up most of my time. Those subtle judgments of how much is environmental and how much is biological in the back.

Yeah. Right. Well direct to consumer advertising is unique to I believe two countries the United States and it's either unusual in Australia or maybe I mean I keep turning to one of my experts here in New Zealand you know Robert Australia I think there's two countries that allow commercials like that the U.S. and Australia but you know there's commercialism in different ways in many different ways and in many many countries and where in countries that don't allow drug companies to advertise may have much looser

laws regarding marketing on the part of the pharmaceutical industry for example in many Asian countries the laws are much looser. So either way that they kind of get you with the commercialism part of it over here. Yeah. Right.

Right. Right. So and it's a good point and there are many institutions like Kaiser in California that have that model where basically it's a salary model where they pay physicians a salary and so that the idea there is that you don't have an incentive to squeeze more and more patients into an hour because you're going to get paid the same amount per hour anyway and that and therefore the incentive is going to be to provide excellent care to patients. So this is definitely one of the models that was discussed I think given some speeches by President Obama actually as one of the solutions to the country's healthcare crisis. I think in psychiatry that is probably likely to be helpful but that won't really address the culture of the medical model having kind of taken over the psychiatric mind. So yeah I have but you know the trials and tribulations I've gone through in changing it I

think speaks to how difficult our system is set up for other psychiatrists to change their model. So when you start out seeing a psychopharmacology practice you quickly build up a lot of patience so I probably have 500 to 1000 patients that I that I am responsible for. And so I gradually change my system where I'm seeing more. Years to be a 50 minute hour it's now 45 minute hours that it keeps shrinking. So I'm seeing more patients in the 45 minute sessions and I'm also rather than seeing 15 or 20 minute sessions I'm seeing too many patients in a 45 minute time period which a few extra minutes actually does help in understanding them. But if I do that too much I'm going to have to kick patients out of my practice. So I'm I'm stuck. And a lot of others like which I think are in a same situation where it is tough to transition from a psycho farm kind of practice to a more integrative practice. Oh sure.

Yeah. Yeah. Right.

Right. Right. Right right you may have you you have a Friday and whereas you want to a cognitive behavior therapist that's all tied with right. You have no idea. Right. Right. So there are there are there are certainly some psychiatrists that do ascribe to certain kinds of theories of therapy. I'd say the majority of them these days would say that they're quote eclectic. Eclectic is the term used where they would say that they pick and choose from whatever the technique they think is most effective. Yeah I do. I mean I think that the average kind of therapy done by most psychiatrists is eclectic maybe verging a little bit more on the Freudian which is now term psychodynamic

instead of Friday. But then as far as the MRI question mostly that's charlatanism. And so I and I have in my chapter on the seductions of technology I talk about Daniel Eyman who who is you know I think a very good psychiatrist a very good writer. He has several books bestselling books primeness bookstore and I did I once did an article for Wired magazine where I submitted myself to some of his brain scans to see if they worked. And I felt that they were basically what they were. The information that you could derive from such scans was valueless in my opinion. And obviously he has a different opinion. We're all we're all entitled to our opinions. OK. Go ahead. Sorry.

The people who do. OK. So what is their role in this whole issue of. Well one of the things that I recommend for the field as a whole is to think think seriously about physician extenders and psychiatrist extenders and so just as we had a whole series of turf wars around nurse practitioners and primary care doctors in the 1960s and now probably most people in this room see a nurse practitioner I know I do typically if I could see my doctor and she does a great job usually she. I think that the next frontier in that is going to be a psychologist seeking prescriptive authority prescriptive privileges which they already have and in all branches of the military and New Mexico Louisiana it's kind of a state by state thing. And so for my money that's really the ideal mental health practitioner because that's somebody who has trained basically and what we do day to day

which is psychology. That's mostly what I do is I'm I'm I'm having mind to mind contact with people trying to understand them and then they would have an extra couple of years of psycho fire masters training to be able to prescribe the basic medications. So that would be my baby the ideal. But it's very controversial most most psychiatrists would disagree with that. So one more question someone who hasn't asked one yet. Right. Yeah. It's kind of the central question

of the really of this entire talk I think in some ways is how did we move into the drug culture and how can we kind of get away from it in a way that doesn't say no to all drugs because some of them work for some people right. And again you know it's a question of culture. I mean if I am trained in a medical culture that is a medical model chances are not very good that I'm going to be reading a lot about diet and exercise and it's going to take something for me to have an incentive to start doing that. It's going to take research and the research money isn't there because no one can really patent exercise for example. But I think the you know the overall point is that we do I believe overmedicate people in general and that we haven't tried another strategy which is to try to wean people either off of medications or just to take them for it down from five to four from four to two or whatever or from one to the lower dose because we're not trained to do that.

And I think that that really the training the entire training system would need to be revamped for that to happen. So your point is well-taken. Thank you