Unhinged: The Trouble With Psychiatry—A Doctor's Revelations About a Profession in Crisis

The book Unhinged, by Daniel Carlat and subtitled The Trouble with Psychiatry—A Doctor's Revelations About a Profession in Crisis, has created something between a brouhaha and a verbal tsunami since its publication.

Those who have read this book as an attack on organized psychiatry have, I think, misread. Unhinged is an autobiographical coming-of-age account in psychiatry at the turn of the 20th century, much as David Viscott's The Making of a Psychiatrist was the coming-of-age story of psychiatry for the end of the 1960s (1).

Unhinged does not seem all that “out there” in most of its content. Carlat's point that psychiatrists have become overly focused on the endless process of tinkering with medications, adjusting dosages, and then adding medications to treat the side effects of the initial drugs is not exactly radical thinking. The belief that we are “still far away from a true understanding of the biological causes of PTSD, depression, and the range of other mental illnesses” is not a deviation from what virtually any psychiatrist would ascribe to.

Carlat tackles many thorny issues, but the foundation of his perspectives is rooted in contemporary psychiatric training that would allow a resident to become subspecialized in psychopharmacology before building a base of knowledge that draws from all aspects of psychiatry. Carlat makes the point that he himself was ill prepared to be a psychiatrist who could conduct any form of psychotherapy.

Carlat describes his experiences in medical school and wonders whether he took the right course of action by choosing medical school over clinical psychology. This experience is one common to many individuals who knew early in their medical school career that psychiatry was their future. Looking back on his early years in psychiatry, Carlat reports falling into what he refers to as “the trap of DSM think,” in which the psychiatrist is too focused on fitting their patients into categories. This rings true for most residents.

Carlat's description of the pharmaceutical companies' process of putting out new medications by “tinkering” with the structure of existing medications certainly fits what we all have observed in the proliferation of psychotropic medications. Carlat sticks close to the script when he describes bipolar disorder and the high lifetime risk of suicide from that disorder. His ensuing discussion about psychopharmacologic intervention for bipolar disorder is an accurate reporting of that history.

Carlat's discussion of the process of recruitment and inclusion or exclusion of participants for psychopharmacologic research studies is a perspective shared by all psychiatrists I know in community psychiatry. Namely, the patients whom we treat in community psychiatry are never found in any of these studies. As Carlat puts it, “To get into a study, patients have to meet a series of criteria more exclusive than those of an Ivy League college.”

Most reviews of Unhinged have ignored the fact that much of Carlat's book is mainstream, focusing instead on his opinions that diverge from it. Carlat indicates in this book, as he has in writings before and after Unhinged, that he believes that one efficacious method to deal with the shortage of psychiatrists is to allow prescribing privileges among other health care professionals, including nurse practitioners, physicians' assistants, and—what is most controversial—psychologists. One needn't endorse this perspective, but one ought to at least be informed about how a thoughtful psychiatrist could come to this conclusion. How better, then, to refute the arguments if one believes, for example, that a psychologist prescribing would be harmful to patients.

The focus of Unhinged, however, should not be lost. The prescribing-privileges question is a small piece of this book. The focus for psychiatry should be an examination about how, in 2011, we train psychiatrists and whether or not we need to alter the approach that we have been using for the past two to two-and-a-half decades. For me, that was the fundamental question raised by Unhinged, and it really is why Carlat was unhinged when he exited his residency. Even if a psychiatric resident thinks that he or she wants to become an expert psychopharmacologist, it should be academic psychiatry's responsibility to require the resident to achieve proficiency across the spectrum of the skills a contemporary psychiatrist ought to have. The degree to which specialization is instituted too early is the same degree to which it will be easier to marginalize psychiatrists.