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Monday, 18.11.2019

Daniel J. Carlat. Unhinged. New York, London, Toronto, Sydney Free Press; 2010

Barry Blackwell’s Review

 

        This is a tardy review of an important book published nine years ago subtitled "The Trouble with Psychiatry - a Doctor's Revelations about a Profession in Crisis.” Its cover comments Unhinged is a "searingly honest and articulate account of modem psychiatry's failure to think outside the box of psychopharmacology in treating patients."

        To review a book published almost a decade ago requires an explanation and justification. In 2015 the INHN website published my essay "Corporate Corruption in the Pharmaceutical Industry” (Blackwell 2016), the viewpoint of a psychopharmacologist who began residency training at the Maudsley Hospital in London in 1962. It was based on personal experience and a review of nine books by different authors that regrettably did not include Unhinged.

        Daniel Carlat's book is an account of the impact and outcome of events that evolved in the productive first three decades of psychopharmacology (1949-1980) written by a practicing psychiatrist who began residency in 1992 at Massachusetts General Hospital (MGH) and whose experiences reflect the modem era (1980 to the present).

        Our experiences and opinions, garnered 30 years apart, are remarkably compatible; where they differ somewhat as to causes and potential solutions will be commented on after reviewing the book.

        Unhinged is just under 250 pages long with 10 chapters thematically linked, supplemented by end notes, references and a comprehensive index. Its style is articulate, poignant and personal within a framework of anecdotes, including patient encounters, told in a manner accessible to the general reader.

        Chapter 1 lays a solid foundation for the general thesis that medication and therapy have been artificially divorced from each other in a manner damaging to the patient and our profession.

        Daniel introduces this theme in an encounter with a patient that reveals his own shortcomings and the common practice of the time. He takes a history from Carol, makes an inventory of her symptoms and matches them up with a recipe from the current version of the Diagnostic and Statistical Manual (DSM), then hands her a prescription. Despite four years of medical school at Harvard and three years of residency at MGH he does not do a medical exam. To Carol's surprise he recommends therapy but not by himself; like nine out of 10 contemporary psychiatrists he shuns integration of drugs with therapy because he "received little training and it isn't economical." His training model made him "enthralled with medication and diagnosis" at the expense of "understanding the mind." He makes more money doing 15-minute med-checks than the old fashioned 50-minute hour on the couch.

        Daniel's personal behavior is reinforced because "psychiatrists have become obsessed by pharmacotherapy and the endless process of tinkering with medication, adjusting dosages and piling on more medication to treat the side effects of the drugs we started with." This satirical disparagement of practice patterns is supported by cataloguing the shortcomings of research supporting biochemical theories of etiology after which he also castigates the tendency of industry to over inflate the benefits of "me-too" drugs despite the better benefits of older and cheaper generic drugs, demonstrated by federally-funded effectiveness studies like the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) (Lieberman, Stroup, McEvoy et al. 2005).

        Daniel introduces a second patient, Linda, who he treated for more than a year with a variety of medications in an attempt to match her diagnosis with the right drug, a goal undermined because drug choice is more an art than science and vulnerable to "disease mongering" by pharmaceutical representatives who provide him with food and drinks, as well as spurious drug data, on routine visits to his office.

        The chapter ends with a synopsis supporting the book's title. "Pulled by both drug companies and consumer demand to provide immediate drug fixes to life's difficulties the field of psychiatry has become unhinged, pried away from its original mission - to discover the causes of mental illness and to treat those causes and not just the symptoms.”

        Chapter 2 begins with Daniel's decision to become a psychiatrist on a dual basis. His father was a psychiatrist who collaborated with psychologists frustrated by the inability to prescribe so he felt medical school would be best for his son. Meanwhile his mother suffered from recurrent depression with paranoid symptoms and hypomania. Divorced when Daniel was five she looked after him until she committed suicide when he was 20: "cementing my desire to go into psychiatry."

        Medical school was a challenging rite of passage Daniel found boring and distasteful until his psychiatry rotation in the final year when was "riveted by the clinical work but disappointed the underlying science was in a shockingly primitive state in comparison with the rest of medicine."

        In 1992 Daniel began his psychiatric residency at MGH looking after five patients on the inpatient unit. It was a time of increasing enthusiasm for psychotropic medication: "America was becoming "Prozac Nation." Many key clinical trials were performed by faculty who "commanded millions of dollars in grants from both drug companies and government sources and walked around the hospital with a confident swagger."

        Daniel devotes 15 pages to a detailed description of patients he cared for and supervision by both psychopharmacologists and psychotherapists. He states: "The main thing you learn in psychiatric residency then or now is how to write prescriptions. The clinical work involves talking to the patient looking for a pattern of symptoms that matches up to a medication's profile of effectiveness." A process he describes as "a combination of guesswork or personal preference... or whether the patient strongly requests a certain agent, commonly in response to a TV commercial."

        Daniel is respectful of insights offered by faculty who were analytically oriented: "learning to do therapy was, by comparison, a complicated and mysterious endeavor. It was like sailing without a compass... I learned quickly that one of the crucial skills for therapy is the ability to shut up and listen."

        His synopsis of residency is: "I like many of my fellow residents became a psychopharmacologist, focusing on fifteen to twenty minute medication visits. While I now regret having started my career like this it was, in some ways, inevitable. The stars were aligned. Therapy was mysterious and often frustrating. Prescribing medications was clear-cut, more lucrative and reinforced my self-image as a "real" doctor. Only later did I realize how crucial are the skills of psychotherapy, even for those whose main practice is prescribing medication."

        Chapter 3, titled the "Bible of Psychiatry," is an intelligent person's review of how the DSM system evolved and has been revised through three editions, with an analysis of its strengths and weaknesses. It begins with a lucid dissection of a real patient's symptoms. At the time DSM IV had a menu of nearly 400 diagnoses. "As I listened to Lorraine it was clear to me she had one of the anxiety disorders, but which one?” Of twelve options he whittles it down to Panic Disorder. “This provides a ‘what’ answer inviting a drug but not a ‘when’ clue to identifying thoughts, feelings or behaviors that trigger the episodes, amenable to therapy.”

        In order to better understand the need for and structure of the DSM system Daniel describes a congenial visit with Robert Spitzer and learns it was a move away from both the psychoanalytic framework of DSM II, as well as the European system of diagnosis developed by Kraepelin and others based on the nosology and natural history of disorders like melancholia and schizophrenia. Spitzer convened a select group of experts who reviewed the literature to assemble categories of symptoms associated with each specific diagnosis; disagreements were resolved by committee vote. Inevitably, through three revisions in more than 30 years, the number of disorders has multiplied, creating controversies. Some categories are poorly distinguished from normality such as Social Phobia (shame) and Menstrual Dysphoria (discomfort). The most recent revision, DSM V, made the ambitious claim it linked some disorders to neuropathic etiology.

        These changes have been categorized as "a wholesale imperial medicalization of normality that will trivialize mental disorders and lead to a deluge of un-needed medications - a bonanza for the pharmaceutical industry but a huge cost to the new 'false positive' patients caught in the excessively wide DSM V net."

        Daniel concedes some benefits to the DSM system including the rationale that brought it into existence. He likens it to "a GPS system that allows me to find the basic location of a patient but are we making the patient's journey easier?"

        On the debit side "it has de-emphasized psychological mindedness and replaced it with an illusion that we understand our patients when what we are doing is assigning them labels." Last, but not least, Daniel notes that the DSM books have become best sellers for the APA.

        Chapter 4 tells how "medications became the new therapy." For example, between 1996 and 2005 the number of Americans taking an anti-depressant increased from 13 to 27 million. In no uncertain terms Daniel contrasts "pseudoscientific psychobabble with the complex realities of the central nervous system and the depth of our ignorance. In virtually all the psychiatric disorders the shadow of our ignorance overwhelms the dim light of our knowledge. Psychopharmacology is primarily trial and error, a kind of muddling through different candidate medications, until we hit on what works.”

        Daniel wastes no time before indicting the pharmaceutical industry in bringing about this state of affairs: "At the same time we are trying to kick the habit of always reaching for the prescription pad we are increasingly confronted by the juggernaut of pharmaceutical promotion. Where there is a scientific vacuum drug companies are happy to insert a marketing message and call it science. Psychiatry has become a proving ground for outrageous manipulation of science in the service of profit."

        Chapter 5 is the logical sequence describing how industry sells psychiatrists on its products. As a case study he examines how Warner Lambert boosted the sales of Neurontin. Introduced in 1993 as a weak anti-epileptic, marketing research predicted a modest estimate of only $500 million over the life of the patent compared to the industry average of $11 billion a year for a typical "blockbuster."

        Sleazy marketing techniques, nominally banned by the FDA, succeeded beautifully by achieving $2.7 billion in sales in 2003, primarily by training representatives to promote ‘”off label” use for bipolar disorder, migraine, neuropathic pain and hyperactivity in children. They were advised to downplay side effects and to keep no records of their activities.

        Using these strategies the profits of the top 10 pharmaceutical companies exceed the combined profits of the other 490 companies.

        In almost a decade (1995-2004), "industry diverted its resources from bona fide research to marketing wizardry" promoting me-too compounds; from $30 million on discovery to $60 million on marketing.

        Another 15 pages are spent on how drug companies treat doctors like royalty with "finely titrated dosages of friendship, (average 4 visits and 6 gifts a year), because we hold the key to their kingdom and riches." Industry is expert at extending patents by inventing new formulations and reps are equipped with data sold by pharmacies (prescription data mining) to target "high and low" prescribers.

        The chapter ends by noting that several US states have banned prescription data mining and that some companies are limiting expensive gifts and meals.

        Chapter 6 moves from industry tactics directed toward practicing psychiatrists in the trenches to highly paid "hired guns" benevolently known as Key Opinion Leaders (KOL's) or denigrated as "drug whores." Here Daniel speaks with knowledge from experience having served in that capacity for Wyeth, promoting Effexor to primary care practitioners at $750 for a brief talk - almost six times what he earned in practice. Also included was an expensive trip with his wife to Manhattan for a "Faculty Development Conference" where he listened to top tier KOL's touting their own research and received training in how to present the company's slides.

        The estimated number of KOL's in America is 200,000, double the number of pharmaceutical reps. Merck calculated their value in promoting Viox to be twice that of reps - a drug that caused 140,000 cases of serious heart disease before FDA withdrawal.

        Daniel frankly tells how his talks on behalf of Wyeth were "insidiously shaped by the approval or otherwise of reps in the audience. I was lying, not the bald faced lie that gets you sued ... it was a more sophisticated high class lie, what you might be more charitably called spin.” When he had made $30,000 in one year he realized he had become "a drug rep with an MD. I was willing to dance around the truth in order to make the drug reps happy. The money had become an addiction." Once he eventually decided he would "no longer tweak the truth," within days of straight talk the dissatisfied reps reported him to their District Manager who asked, "have you been sick?" before terminating his role as a KOL. Five years later Daniel described his experience in the New York Times Magazine that went “viral,” leading to a discussion of the pros and cons of the KOL role in which he "put his reputation and prestige at great risk."

        Chapter 7, titled "A Frenzy of Diagnosis," deals with the problems created by the DSM system and addresses the controversy surrounding Attention Deficit Hyperactivity Disorder (ADHD), particularly in children.

        His concern focusses on MGH, his residency alma mater and the child psychiatry team led by Joseph Biederman that "allowed itself to become a research factory for various drug companies." In 2005 alone they received $40 million in research funds from industry. The team inflated the diagnosis of bipolar disorder in children 40-fold between 1994 and 2003 largely as a result of adding the target symptom “irritability” to make the diagnosis. In 2008 a leading journal exposed the problem, noting that Biederman "did not adequately declare over a million dollars he received from pharmaceutical companies as consulting fees, calling into question the credibility and impartiality he brought to several of the trials he guided.” Although MGH temporarily barred him from industry-related activities, he was otherwise allowed to continue his academic activities.

        Cartlat goes on to discuss the dramatic increase in the diagnosis and use of stimulants in children and adults. In 2006 one in 10 10-year-old children and 1.5 million adults were taking stimulants for ADHD.  Support for this increase came from unsolicited newsletters with attention-getting titles issued by "Academic Councils," many of whose members were MGH faculty. "When our most esteemed colleagues have essentially joined the marketing teams it makes it that much harder to practice our craft responsibly. The resulting frenzy of psychiatric diagnosis has damaged the credibility of everyone in the field. Who, after hearing the stories of such behavior, can trust a psychiatrist again?"

        Chapter 8 explores the seductive influence of technology on the profession. In medicine a physician's income and that of any health care corporation or hospital he/she works for is directly related to a specialty's ability to perform technical procedures. Excluded from this club are the "talking disciplines" of which psychiatry has only one technique: electroconvulsive therapy (ECT), available since 1938. An effective, last-ditch treatment for melancholia when medications fail and the patient is often suicidal, it entails inducing seizures by passing an electric current through the brain while the patient is anesthetized and paralyzed.

        Daniel describes his own use of ECT in a patient, managing a machine that "looks like a jetliner's cockpit." Although effective, "we have no idea of how or why; the seizure seems to re-boot the emotional machinery of the brain, in the same way that pressing Control-Alt-Delete on the computer can produce a fresh start." He notes the public unpopularity of the procedure dating back to when it was given without anesthesia or muscle relaxants, as shown in the 1975 academy award winning movie One Flew Over the Cuckoo's Nest; it is also a technique castigated by the Church of Scientology in its anti-psychiatry movement.

        Perhaps, not surprisingly, Daniel has given up ECT in favor of full-time office practice and believes the procedure could be safely provided by a technician under medical supervision. This would reduce the cost of treatment, make it more accessible and shorten the wait time due to a shortage of psychiatrists willing to provide ECT. "However this would be another insult to our sense of being part of the community of physicians."

        This leads Daniel to discuss how the device market is being flooded with machines and surgical procedures for mental disorders: "These devices are either ineffective or only marginally helpful. But the companies producing them have rushed them to the market with the complicity of psychiatrists who are eager to cloak themselves in medical legitimacy, not to mention the financial rewards."

        He proceeds to describe three technologies in detail and outlines the lack of convincing evidence for their efficacy, despite which they have been endorsed by KOLs and approved by the FDA, even after being voted down by its own advisory committees.

        The first of these is the use of a device surgically implanted under the skin to electrically stimulate the vagus nerve for 30 seconds every 5 minutes: Vagal Nerve Stimulation (VNS) is approved for the treatment of resistant depression, defined as having failed three antidepressants and ECT. The cost is $25,000 per procedure. Daniel’s review of the literature suggests the response is no better than placebo and he cites an investigative conclusion: "If the FDA's reasoning for approving VNS was simply there were no other treatments they might as well approve sticking a fork into the shoulder for a depressed patient. There's as much evidence for that as there is for VNS."

        The second dubious procedure he describes is Transcranial Magnetic Stimulation (TMS): "The machine looks like a futuristic dentist's chair. Every day for 4 to 6 weeks the patient sits down and a powerful electromagnetic coil is placed on his scalp, radiating a magnetic field into the brain tissue for a half hour. The magnetic field induces a mild electrical current in the neurons, stimulating a particular brain region. Generally, practitioners aim at the left frontal cortex because some scan studies suggest this area is under-reactive in patients with depression. TMS is billed as a gentler version of ECT that uses magnetism to nudge neurons into action. No seizure or anesthesia is required and there are no side effects." There are two problems with this procedure: research data showed no significant benefit as a whole, but was marginally significant in patients who had failed one antidepressant; oddly, patients who had failed more than one antidepressant also failed TMS. Another problem is the expense. To recoup the cost of the equipment psychiatrist's charge $300 to $400 per procedure, totaling $10,000 for a complete treatment.

        The third technology is a brain imaging technique called the Single Photon Emission Computed Tomography (SPECT) scan which Daniel equates with "peering into the brain" before describing an interview with a psychiatrist who charges $3,000 for such a study. The claim is that specific areas of brain activity are correlated with clinical symptoms. Daniel was unable to elicit any "evidence of benefit... he would shift to anecdotal stories rather than citing studies and statistics."

        For unknown reasons FDA requires "far less scientific evidence to prove devices than medication."

        Chapter 9, "The Missing Skill," is where Daniel makes his case about the reduction in psychotherapy.  Citing a 2008 study reported in a psychiatric journal, he notes: "The percentage of visits to psychiatrists that included psychotherapy dropped from 44% in 1996-1997 to 29% in 2004-2005. The percentage of psychiatrists who provided psychotherapy at every visit decreased from 19% to 11%. This decline in therapy was closely correlated with the growth of medication treatment and decreasing insurance reimbursement for psychotherapy."

        Although public response was variable, the media implied it was "a major new finding" while experts differed, noting that unlike medications there was "no marketing for psychotherapy"; others "saw it as part of the progress as seen in other fields of medicine." The public found it "surprising psychiatrists do not do therapy and they want to know why." Even among psychiatrists "opinions are split about whether the trend is good or bad."

        It is worth noting at this time that another book, written by an anthropologist 10 years earlier, made the same point (Luhrmann 2010). However, while this book discusses changes within psychiatry and between disciplines in detail, it fails altogether to mention industry or the changing cultural Zeitgeist.

        Questions abound: “to what extent does psychotherapy work alone or combined with drugs and if the latter why are psychiatrists and insurance companied farming it out and to what effect? Psychotherapy itself is changing from traditional Freudian concepts including ‘free association’ and ‘transference’ which morphed into a modem version called ‘psychodynamic.’ Entirely new forms have evolved, principally cognitive behavior therapy (CBT).”

        Having set the stage Daniel switches to how his own conviction about the merits of combined therapy have evolved and are utilized in practice.

        Three years before his book was published Daniel boarded a small, under ventilated, over- heated commuter plane and began to feel trapped, fearing he might suffocate: "my chest felt tight, my pulse quickened, I hyperventilated and felt lightheaded." He recognized the symptoms of panic he would normally treat in his patients with Xanax; lacking medication he racked his brain, "trying to remember the CBT techniques for calming myself down." He told himself panic is an irrational fear reaction, began to regularize his breathing and distracted himself by reading the inflight magazine and "very gradually I begin to feel better."

        After returning home, this powerful experience "forced me to rethink how I was practicing my craft. Why was I not offering these techniques to my patients? Had I undergone eight long years of medical and psychiatric training just to be a pill pusher?”

        Daniel recognized the economic factors that influenced his use of time but also knew about studies showing that integrated medicine and therapy required fewer visits overall and sometimes reduced insurance costs (the so-called “medical offset”).

        Daniel found affirmation for his epiphany and decision to modify his pattern of care to accommodate integration from two major sources. A female colleague practicing in a rural area was treating "many patients who lived in poverty-stricken, oppressive life circumstances... miserable because of problems in relationships or difficulties coping.” After sharing her techniques, including 50-minute interviews and even her inevitable loss of income, she concluded by asking Daniel: "Why would you choose psychiatry just to give people psychotropic medication? I'm assuming if you go into psychiatry you're really interested in the mind."

        A second powerful influence came from Daniel's father. Trained in the analytic era in the 1950s he learned when few medications were available but when they became available he incorporated them, gradually modifying his 50-minute hour by creative scheduling. He chose 45-minute time slots during which he scheduled either two medication visits or one therapy visit. "Inspired by him I began experimenting with a similar type of schedule. As I began this new style of practicing, the first thing that struck me is that I had barely known many of my patients... I didn't know what made them tick as people." Daniel provides a case vignette of his successful integrative care: "a version of supportive therapy that I now try to weave into the fabric of all my sessions with patients, whether they are seeing me primarily for medication or for therapy."

        In a further insight Daniel notes: "The greatest disservice psychiatrists do is to encourage patients to open up and then slam the door shut when they are at their most vulnerable. This often happens during the first session, ostensibly devoted to generating a DSM diagnosis." He drives this home with a metaphor: "good therapists often say that it is vital to 'strike when the iron is hot.' But modern psychiatry is set to turn the heat up and then plunge the iron into cold water."

        Daniel concludes this chapter by commenting on the drawbacks of fragmented care. There are logistical difficulties - after opening themselves up patients are often reluctant to accept referral to a stranger and not a psychiatrist. Communication between therapists is not remunerated and may be difficult or impossible due to time constraints or their practices are on different provider panels. Worst still, "a therapist may even work at cross purposes with what I am trying to accomplish."

        Chapter 10 is Daniel’s conclusion in which he addresses the question of solutions to the problems he has previously identified.

        Appropriately, he expresses the need for our profession to develop a definition of an "ideal" psychiatrist. His version sees a person who understands that life's challenges include psychological problems and someone who possesses the skills to integrate medication and therapy to address and alleviate each patient's unique needs. This would include knowledge of the benefits and limitations of medication and an assurance that prescribing was not influenced by incentives from the pharmaceutical industry.

        How to accomplish this is less clear. He notes that the Accreditation Council for Graduate Medical Education (ACGME) requires all psychiatric residencies to include training in Cognitive Behavior Therapy (CBT) and the American Board of Psychiatry and Neurology's list of core competencies includes the ability to conduct a range of accepted models for individual, group and family therapy with an ability to integrate them in multi-modal therapy.

        Daniel notes that these stipulations have not prevented the gradual disappearance of psychotherapy in the last decade.

        Perhaps worse still the American Association of Medical Colleges ranks the medical school performance of students by the specialty they choose as well as their scores on the specialty boards. "Future psychiatrists consistently rank at or near the bottom in all measures."

        Faced with this discouraging data and his personal experiences Daniel presents "A Menu of Solutions" consisting of four possibilities.

        First is to continue the status quo, a proposal he negates by questioning the need for four years of medical school, followed by a year of general internships and finally three years of residency in psychiatry. Much of the content in medical school and internship is redundant and the major thrust, despite increases in psychosocial content, is directed toward the pathophysiology of medical disorders when "in psychiatry we do not know the pathophysiology of mental illness."

        However, Daniel acknowledges the need to learn the basic skill of medical triage and for courses in pharmacology, side effects and lab interpretation of results. He also identifies drawbacks that "make medical school the wrong place to train psychiatrists." Daniel names four: "It indoctrinates an excessively biomedical view of multidisciplinary problems. It gives psychiatrists a feeling of inferiority and less medical competence. It encourages a feeling of superiority among mental health professionals. It deprives us of precious time to earn more valuable skills relevant to our work.”

        With these disadvantages in mind he suggests three alternatives: “A realistic option would be to license psychologists to prescribe," but to ensure that psychopharmacology was integrated with psychological techniques throughout training. Another might be to expand psychiatric nurse practitioner training beyond two years. Plans at that time were to add a year of psychopharmacology to the curriculum but Daniel doubts if that would be enough.

        The final suggestion describes an actual experiment in California to build a new training program from the ground up: a "Doctorate in Mental Health, a hybrid of medical school and psychology graduate school." This was initiated in the 1970s and 1980s by a psychoanalyst, Chair of Psychiatry at the University of California at San Francisco, who recognized psychopharmacology was displacing psychoanalysis. The program consisted of the initial two years of pre-medical training in basic sciences followed by three years identical to a psychiatric residency.

        Fifteen years after the initial plans the first class graduated but they were never licensed to practice. "Both the California Medical Society and Northern California Medical Psychiatry Society lobbied against a bill to license the program. The arguments against were not based on empirical evidence that training was not sound or that we made clinical mistakes - it was all about the underlying guild issues."

        Daniel concludes this last chapter of his book with final thoughts and feelings about the status quo of psychiatry when the book was published in 2010: "There's nothing quite like being a psychiatrist. Sometimes, as I sit talking to patients about what is important to them, I have to pinch myself to realize I am actually being paid to do something that is so interesting and that is so helpful to people. But the question I have explored in this book is whether we are as helpful as we can be."

        His pleasure is expressed along with his purpose in writing Unhinged: "Over the past two decades psychiatry has gone astray. We have allowed our treatment decisions to be influenced by the promise of riches from drug companies, rather than by what our patients most need. We have fought pitched turf wars with our colleagues in related disciplines, instead of learning from them and incorporating their effective therapeutic tools into our arsenals. Finally we have unquestioningly sought to become just as 'medical' as other doctors, when we should embrace the fact that psychiatry is remarkably different from the rest of medicine."

        Commentary

        Daniel’s description of the “medicalization” of psychiatric treatment is accurately and colorfully illustrated, along with his skill and willingness to dissect his own practice patterns with patient vignettes. This makes his thesis accessible to lay and professional readers.

        It also reveals the striking rapidity with which not only psychoanalysis disappeared from training programs but so did any serious attempt at “understanding the mind.” Only two decades separate my own time as a faculty member at the University of Cincinnati in the early 1970s from Daniel’s time as a resident at MGH in the early1990s. This is a cogent example of “throwing out the baby with the bath water,” a 16th century German metaphor I use to unravel the contemporary muddied waters stirred up by the modern psychopharmaceutical industry (Blackwell 2017).

        During the heyday of psychoanalysis in Cincinnati my Anglo-Saxon pedagogy as a pioneer psychopharmacologist on the psychosomatic unit benefited from Freud’s insights but not enough to deter my analytic colleagues from warning the residents who rotated through that the experience “might ruin their careers” (Blackwell 2012c). This was a time when the appropriate conservative use of medication in patients not benefiting from therapy was interpreted as the resident’s sadistic impulse which would delay the patient achieving insight.

        In the final chapter devoted to finding solutions Daniel focuses on the education of trainees in different disciplines. With medical school he is concerned about the inadequacy of preclinical behavioral science to mitigate the influence of biomedical and technological life-saving content. He is willing to abbreviate that and eliminate the year of rotating internships.

        I am sympathetic to these concerns based on my experience as Chair of Psychiatry in a community-based medical school, part of a Federal plan that established 30 such new schools throughout America intended to graduate  “humanistic physicians” willing to work in underserved urban and rural areas. Despite the fact my Vice-Chair was an analyst and the Director of medical student  education was a female cognitive behavioral psychologist, our innovative interdisciplinary curriculum failed to alleviate the meat-grinder of medical school or achieve the program’s goal (Blackwell 1985).

        Daniel also suggests adding psychopharmacology curriculum to graduate psychology and nurse clinical practitioner programs although he is rightfully cautious about the kind of “guild” concerns among degree-granting agencies that doomed an innovative California attempt to launch a “Doctorate in Mental Health.”

        I wonder if David’s ambivalence towards medical school is also influenced by the fact he entered it knowing that, like his father, he wanted to become a psychiatrist. My own experience was quite different. I knew almost nothing about the specialty and my decision was made late in my third clinical year based on an experience during the obstetric rotation. I was assigned a “primip” who could not account for how she became pregnant and was terrified of pushing her baby though the birth canal. My request for a psychiatry consult was rejected and the possibility of a caesarian section ridiculed on statistical grounds. The consultant ordered an intravenous drip to stimulate the uterus and I sat at the bedside while my patient screamed her way through labor. That week an obstetrician at another London teaching hospital published an article in the Lancet on “Human Relations in Obstetrics.” My letter to the editor describing my own impressions was published (Blackwell 2012a) which provoked retribution when I took my final exams three months later and an obstetrician failed me based on my poor performance doing a vaginal exam (Blackwell 2012b).

        After six months on a neurology unit I began my residency training at the Maudsley Hospital and Institute of Psychiatry, fortunate to be accepted because Aubrey Lewis preferred residents who had already obtained boards in internal Medicine, a criterion I did not meet but he felt necessary for training graduates most of whom became Chairmen of Departments throughout England and the colonies (Goldberg, Blackwell and Taylor 2015).

        Looking back I feel that despite irrelevant episodes and redundancy the totality of medical education served me well as a faculty member in psychiatry, medicine and pharmacology, in my role as a teacher in consultation-liaison medicine and as a therapist working with patients co-morbid for many medical disorders well as the medical side effects of what I was prescribing. Even so I was once guilty of pursuing obvious psycho-social conflicts in an attractive young woman until she visited a nearby emergency room and a neurologist diagnosed her multiple sclerosis. She was generous enough to forgive me!

        Daniel does not discuss the large number of political, social and professional factors of the contemporary Zeitgeist in which corporate corruption and medicalization are embedded (Blackwell 2016). This was beyond the purview of his patient-oriented book but involves concerns and issues he touches on in the Carlat Reports and Newsletters he has published regularly since his epiphany.

 

References:

Blackwell B, Wilkinson N. Human Relations in Obstetric Practice. The Lancet, Vol. 275, Issue 7134, 21 May 1960, pp. 1126-1127.

Blackwell B. Medical education and modest expectations. General Hospital Psychiatry 1985; 7, 1-3.

Blackwell B. Human relations in obstetrics. In Bits and Pieces of a Psychiatrist’s Life XLibris 2012a,102.

Blackwell B. Payback time. In Bits and Pieces of a Psychiatrist’s Life. XLibris 2012b, 105.

Blackwell B. Psychosomatic medicine. In Bits and Pieces of a Psychiatrist’s Life. XLibris 2012c, 257-261.

Blackwell B. Corporate corruption in the pharmaceutical industry. controversies.inhn.org. 01.09.2016.

Blackwell B. The baby and the bathwater. controversies inhn.org. 22.06.2017.

Blackwell B, Torem M. Behavioral science teaching in U.S. medical schools: a 1980 national survey. Am J Psychiatry. 1982 Oct;139(10):1304-7.

Goldberg, Blackwell B, Taylor DC. Professor Sir Aubrey Lewis, the Maudsley Hospital and the Institute of Psychiatry. biographies.inhn.org. 02.19. 2015

Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD, Severe J, Hsiao JK; Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med. 2005 Sep 22;353(12):1209-23.

Luhrmann TM. Of Two Minds. New York: Alfred A Knopf, 2000.

 

June 27, 2019