Saturday, April 24, 2010

New York Times Magazine: Mind over Meds


This weekend’s Sunday New York Times Magazine carries my article, “Mind over Meds,” in which I argue that psychiatrists should reclaim the skills of psychotherapy. Compared to many of my writings, the article is not particularly controversial, and I think most readers would agree with the main points.

However, the following statement from the article has generated a number of indignant e-mails:

“Like the majority of psychiatrists in the United States, I prescribe the medications, and I refer to a professional lower in the mental-health hierarchy, like a social worker or a psychologist, to do the therapy. The unspoken implication is that therapy is menial work — tedious and poorly paid.”

Several psychologists have pointed out that their work is just as valuable as the work of psychiatrists, and that they are surprised that I would consider then “lower” in the hierarchy. Actually, my point here got muddled, and it was just the opposite. Many psychiatrists have an elitist attitude toward psychologists, falsely believing that therapy is somehow less valuable than psychopharmacology. This view is reinforced by the fact that insurance companies pay less for therapy than for psychopharm visits. The view also stems from the fact that some psychiatric illnesses, such as schizophrenia, respond much more robustly to medication than therapy.

However, for most psychiatric problems, the dichotomy between therapy and medications is overblown. Both meds and therapy are crucial. The ultimate mental health practitioners, in my view, should be equally skilled at both psychopharmacology and psychotherapy. Unfortunately, there are very few practitioners who can offer the full package. Because of this, most patients have to see two professionals, one for therapy and one for meds. That’s a crazy system, and Unhinged (the book upon which this article is based) expands on this problem and offers a menu of solutions for solving it.

106 comments:

DrBransfordMD said...

I found your article extremely enlightening & in accord with my own person and professional experiences. My father was a Harvard Trained MD, then WWII, and 14 yrs of General Practice before moving from a small only doc town in central Illinois to Minneapolis, MN and entering his psychiatric residency training at the U of MN. I was abt 12 in the late 1950s. Thorazine was being introduced, but most of the emphasis was psychoanalysis. I followed his footsteps with med school and psychiatry at U of MN. Psychopharm exploded, as Managed Care took over the State. I have been in private practice since 1977 in Northern MN, and refuse to be a 'pdoc' med checker. Split therapy is not acceptable to me I see my patients x 1 hr with meds and psychotherapy. Just turned 63 and will not change my practice style. Your article was most inspiring, David Bransford MD

Gustavo said...

First of all, congratulations for your shaking this controversial issue: it's always good to review any settled opinion. Anyhow, as a licensed clinical psychologist, I'd like to point out what might be an oversimplified notion of psychotherapy: there's no such thing, but in plural. Actually, I believe it's hard enough to get skilled at half the main streams of psychotherapies. Considering these equal to single format (a manualized view of CBT, for instance) is to really miss the point: psychotherapies are at the time an extremely complex field, far away from sufficient integration, as to be able to master all options in order to be a good-for-all practitioner. If taking care of our body -let's leave nervous system out- requires and accepts different specialties, why would our mind require a single practitioner? Do you imply it's simpler? I believe the answer to our limitations is not mixing it all up; it's rather getting to understand deeper and better each tool (which we don't do yet), and how to match every type of help available to every particular case, and coordinate those options efficiently.
Nice controversy, anyhow.

Cheryl Fuller, Ph.D. said...

That hierarchy is the basis for the turf wars. Each professional group zealously holds on to whatever function is unique to it. And the implicit assumption, albeit mostly unconscious, is that psychiatrists, because they are MDs, are the "real" doctors and every other group is less than or lower on the ladder.

Psychologists see social workers as lower on the ladder and social workers see counselors as below them. And few even think about psychiatric nurses.

I would also question the assumption that most patients need medication. That is a relatively new assumption, one that has come with the rise of psychopharmacology and one, I would argue, that is another piece of the turf war.

I quite agree with you on the desirability for some kind of common training for all, but so long as these status differences exist, I think it will be very difficult to bring into reality.

marydodds said...

Psychiatric consumers require different balances of medication and therapy. They are all unique. It is not a question of the doctor's style of practice or turf wars. It is that particular consumer's needs.

Seroquel Susie said...

Visit my blog to see how meds (in particular Seroquel) has affected my life. http://www.google.com/profiles/seroquelsusie

Anonymous said...

On an off topic note before I get to my main point, I wanted to mention something that has bugged me for quite awhile.

Why do people when they post, provide a link that leads me to believe it is to their blog, only to find there is nothing there? Kind of like when you click on a web page only to be told, "Page under Construction".

To Dr. Carlat's article - If you agree that 3/4 of the antidepressant response is due to the placebo effect, it seems to me that except in very extreme cases, that doesn't justify the prescribing of antidepressants.

I know that you can't ethically prescribe a placebo. But if psychotherapy works just as well, which you seem to be acknowledging in your article, why wouldn't that be tried first?

I realize your practice may not be set up to strictly do psychotherapy. But when you see patients for medication evaluation, do you tell them these results so they can make a fully informed choice. Did you do this with JJ?

Please understand that if the patient still decides they want medication, that is their right. But in my opinion, they need all the facts which I feel many psychiatrists (not all) don't provide.

Dr. Fuller, I am a big fan of yours and I thank you profusely for what you have posted.

AA

James said...

I found you article very thoughtful and in keeping with some of my own experiences. I'm a psychiatrist in private practice and currently in psychoanalytic training. Of note, seven of the eight other members of my psychoanalytic class are psychiatrists. I did my residency at UCSF from 1996 to 2000. There was a lot of exposure to psychotherapy of various forms (long and brief psychodynamic, CBT, IPT, etc), but my experience has been that it is important to deepen my skills and get additional training post-residency.

Despite our training, many of my residency classmates have opened practices which focus on medications only. I believe that this is largely due to the financial incentives you mention in your article. Also, psychotherapy skill development is a long, murky, and expensive process. Whatever type of therapy you learn (CBT, etc) really requires additional supervision to master the skills.

About 2/3 of my patients are on medications, prescribed by me. Some of my patients are in intensive psychotherapies, others are in infrequent supportive psychotherapies. I think that because I have multiple clinical tools at my disposal I am less likely to put every patient on medications. On the other hand, because I am a psychiatrist many people come to me wanting a medication from the outset.

I consider combined treatment a "specialty" and I try to be discriminating about whether the patient is suitable for the tools that I employ. For example, I often refer out to a CBT provider for patients with significant OCD. I can treat many borderlines effectively, but if I'm not getting anywhere then I refer to the local DBT program. Although I can't provide those treatments skillfully (CBT and DBT) I try to keep up enough to know when to refer.

I realize that I probably sound like I'm lost in the 50's, but I still find that for many of the people I evaluate psychoanalytically informed psychotherapy is a highly effective broad spectrum intervention that addresses both DSM symptoms and patients overall level of adaptation.

RebeccaMD said...

Thank you for your article.

Like "James", I am a psychiatrist, and a psychoanalytic candidate. I treat most of my patients with a combination of psychoanalytically oriented psychotherapy and medications (and I'm assisted in staying up-to-date by The Carlat Report, thanks again).

Shortly after finishing my residency, in 2004, I realized that what I had to offer my patients was very limited, which is why I embarked on the arduous process of analytic training. It has been an invaluable tool in treating my patients. As you noted, it tends to pick up where the meds leave off. I find this is true even for patients who I see only for medication.

It has also been a source of frustration, as psychotherapy, and especially psychoanalysis, have become such disparaged treatment modalities.

My hope is that your article in the NY Times will get people to begin to reconsider their perspectives about therapy. As things stand, it is near impossible to get patients to believe that twice a week therapy could be more helpful to them than medication alone, and that they will ultimately end up paying less for a more intensive treatment that takes less time overall, than a watered down therapy, or none at all. Oh, and that their lives will be better for the effort, and they'll be happier.

pacificpsych said...

Glad you woke up. I've always felt that these so called 'medchecks' are unethical, and the fact that THIS specialty out of all specialties, the very one that is supposed to deal with the psyche, has this "check" "meds" thing, and has it as the standard of care, and in any employed non-academic position as the only thing you ate allowed to do, well, I find that ludicrous and incomprehensible. Seems everyone has been caught up not only in doing these "medchecks" but in mumbling thoughtlessly bureaucratic lingo that should be offensive to any thinking person. Time to wake up. I just wrote a post about this the other day in case anyone's interested. http://www.pacificpsych.com/psychiatry/the-15-minute-medcheck/

moviedoc said...

I agree with Gustavo and Marydodds.

Just how far would you take this notion that your pejoratively labeled "split" treatment is inferior. Perhaps we should just have primary care docs do everything from colonoscopies to insulin management to brain surgery, and yes even psychotherapy, so we can really have one provider do everything.

Absurd.

Dr Shock MD PhD said...

Very important topic. In The Netherlands residents are both trained to become a psychiatrist and a psychotherapist although this last option is under attack. If a psychiatrist wants to do psychotherapy additional training is often required. Mostly psychiatrists are the ones doing screening. Should this patient be on meds. therapy and meds or just psychotherapy.
Myself I find working solely with psychophramacology very restricted, love doing both. Thnx for this discussion, take care Dr Shock

Anonymous said...

Dear Cheryl Fuller, Ph.D. ,
Fear not. I am a patient and I do not see psychiatrists as "real doctors" at all, even WITH the M.D. after their names. After seeing one for more than a decade... one who has never asked which other medications I take and one who relies on me to bring up any new medical conditions I have (rather than actually asking me)... one who gives a medication recommendation without bothering to mention risks and benefits unless I ask about them... I do not see this man as a physician. I see him as a legally sanctioned drug pusher. When I picture him in my mind, I picture a prescription pad. An unfortunate use of an Ivy League education. So there's nothing to worry about... patients really don't view psychiatrists as real doctors after all. While I do not see a psychologist because I would not be able to miss that much work, I have to say that I respect psychologists far more than I do psychiatrists. At least psychologists give a crap about human beings and not just about the money-making machine.

Anonymous said...

I am neither a psychiatrist nor a psychiatric patient, so read the NY Times article as a matter of general interest. I had two immediate reactions. First, I was stunned to find out that the idea that it's important to get to know one's patients as human beings and provide something other than prescriptions is apparently a daring statement; to me, it seems obvious. Second, I was reminded of how I have been treated by doctors I consulted about severe headaches: it was all about putting my symptoms into pre-established boxes, then prescribing medications according to some flow chart, without regard to my individual situation, concerns and responses to the drugs. (I have largely cured myself through a nonmedical, nontraditional approach called the Alexander Technique.) Perhaps the problem stems from our medical system's overall approach to patient care - it does not seem unique to psychiatry.

M said...

I read your article this morning, and was very relieved to find your blog post here. I too, as a graduate student getting my PhD in clinical psychology, felt my feathers ruffled when I read "lower on the mental health rung." I thought about the psychiatrists I've worked with -- often when dealing with clients with developmental disabilities (my current job is working with DD clients) -- who have prescribed medications without ever once seeing them, and often based on one symptom.(Such as one client, T., who became inexplicably psychotic, and who, because of one mention of "he's not been sleeping at night" and ignoring the "so he falls asleep in his chair all day" diagnosed him bipolar and put him on some profoundly useless medication. This especially angers me, as these are clients who cannot advocate for themselves.) And I've been frustrated with this idea that the Almighty M.D. has no need for input from the rest of us, and that much of that is caused by the perception that we are "lower" on the hierarchy.

I think the best outcome would be for psychiatrists and psychologists, instead of viewing each other competitively, is to help each other. I'm amazed at how many clients I work with that I end up as a go-between with them and the psychiatrist. Several times I have had a client express dissatisfaction to me about their medication (either because it's not working or it has side effects they feel are not worth it), but they are unwilling to tell their psychiatrist -- because how can they tell their doctor that he did something that didn't work? Much of my time with these clients is spent educating them on being willing to speak up for their own rights, and telling them that a good doctor of any kind should listen to their complaints, that they deserve to be heard, and if they feel their doctor isn't doing that, they have a right to switch. It's amazing how therapeutic that in itself is for them!! Sometimes being perceived as "lower on the ladder" makes our clients more willing to open up to us and voice complaints than with psychiatrists, who they are often intimidated by.

We also, as I'm sure you know, have very different training than MDs. MDs spend most of medical school learning a little bit of everything, and then narrowing it down near the end. We spend 4 years of undergrad, and 4-6 years (on average) of grad school learning, practicing, working in the community, researching, etc, nothing but psychology. Then we go on internship for a year, THEN we get our PhD, THEN we have to do 1-2 years of post-doc before we can be licensed. So we end up with about as much education time as MDs, and in some ways with a more in depth knowledge of our 1 subject. We are also more focused on research, generally.

Overall, I'm totally with you on the fact that psychiatrists NEED to learn about the clients, build rapport, and truly listen, rather than just view them as a bunch of symptoms. (Environment is just as -- if not more -- important than brain chemistry!) I think that psychologist and psychiatrists should learn to view each other as equals working together to help a client have the best quality of life as possible, instead of BOTH sides (and yes, psychologists are just as condescending towards psychiatrists as vice versa) viewing each other as incompetent competition. And I think that ultimately, we all need to focus one what research has shown to be best for the client -- be it medication, therapy, or a combination of both, and try to provide the best quality of care for our clients that we can.

After all, isn't that why we got into the mental health field -- for the clients?

Sorry for the incredibly long post -- as you can tell, I'm passionate about my work, and I often get so frustrated that the in-fighting and jostling for position between and within mental health fields often slows down our progress, and often to the detriment of our clients.

FunPsych said...

Anonymous said: To Dr. Carlat's article - If you agree that 3/4 of the antidepressant response is due to the placebo effect, it seems to me that except in very extreme cases, that doesn't justify the prescribing of antidepressants.

I know that you can't ethically prescribe a placebo. But if psychotherapy works just as well, which you seem to be acknowledging in your article, why wouldn't that be tried first?


That's a really good question, and I think unfortunately the answer is a sad one. It's the same reason why many Americans, if given a choice between exercising for an hour a week versus taking a weight-loss pill, would choose the pill.

Furthermore, Americans are already overworked and feel pressured to work even more. At least half the patients that I've seen that I want to do therapy with just don't have time for it.

Of course, psychotherapy is more time consuming for the psychiatrist, and as Dr. Carlat's article stated, most are trained to think meds first. But I do believe that this reason is secondary to the primary one I listed above. It should be a good psychiatrist's job to not just push meds, and to recommend psychotherapy when it's appropriate.

However, clinical psychologists are facing many of the same pressures that psychiatrists are, in that insurers are pushing for the use of evidence-based solutions like time-limited CBT, which does work well, but are geared towards addressing specific symptoms (cognitive distortions, maladaptive schemas, avoidant behavior, etc) rather than the core issues a person may be facing.

-Funpsych

Mina said...

I have been a "consumer" of psychological "products" for years. I work in the field of early intervention and am unusually close to families and children with severe stresses. My own daughter had a terrible drug problem, 3 stints in rehab and 3 years later, she finally just quit doing anything except once a week therapy for her PTSD and every other week family therapy to rebuild the relationships and help us make the changes we all need. None of us is on medication. She is in college with a 4.0 average, my blood pressure is normal, her father's adult ADD went away and she has a wonderful set of friends: finally.

I think, and hope this doesn't sound insulting, but while psychiatrists may refer down line work with attending bias, I want to point out that most people think psychiatrists are snake oil salesmen, way crazy themselves, and highly suspect in their competency, including the prescribing of drugs.

I know this sounds horridly condemning, but I am attempting to support your point of view. It is time for psychiatrists to review themselves and their "helpfulness".
I have nothing to offer a family except support, but in 30 years of working with families, who would have an expected divorce rate of 50 percent plus, I rarely even have one divorce a year. For ten years in a row, I had none.

People need support. The more my daughter understood her decline into drugs,the more she understood life on life's terms. Don't even get me started on seroquel.

Medicating people to stick with the same ole same ole is rather more like chemical restraint than growth and progress.

I admire your stance and want to encourage you to keep on. We need more people who can think like you.

Steven Reidbord MD said...

Excellent writing as usual, Dr. C. I wrote a sort of rebuttal on my blog, while noting that your "hierarchy" line was probably misinterpreted. I know you have a lot of respect for psychologists and other mental health professionals.

The bigger point is one alluded to by Gustavo and James above. Your article makes it sound like psychotherapy consists of spending an hour and listening to one's patient, as opposed to rushing them through a med-check. Actually, that's just called "listening" — it's vitally important, but it's not psychotherapy in and of itself. The "golden" generation of psychiatrists were/are psychodynamically informed even when prescribing meds. It's this perspective or framework that seems to be lacking in many colleagues now, even some who see patients for 45 or 50 minutes, and charge for it.

Joel Hassman, MD said...

I saw a psychologist for therapy while I was in residency, and she made a very astute observation that is true today, just a different goal of the pursuit by our colleagues: psychiatry has been rather rigid and inflexible in its alleged focus of providing for the public, and it at times does act like a cult. When I was in residency, it was the constant dismissal of other psychotherapy techniques outside of psychodymanmic interpretations (thus why I saw a CBT trained therapist), and now that this line of thinking has been dumped in the trashheap per reimbursement access, the replacement is psychotropic administration alone as the cureall.

The problem our colleagues have is they just grab onto the first proverbial life preserver when the first loses it buoyancy, and now this one is sinking fast!

And, there is not another to grab and I don't see a lifeboat on the horizon the way the profession is staying afloat!

Good luck with book sales.

Daniel Carlat, M.D. said...

So many fantastic comments. I particularly appreciate M's perspective as a psychologist who works closely with psychiatrists and perceives the mutual animosity and distrust that so common. As he says:

"And I think that ultimately, we all need to focus one what research has shown to be best for the client -- be it medication, therapy, or a combination of both, and try to provide the best quality of care for our clients that we can."

Amen!

Daniel Carlat, M.D. said...

Steve, I agree with your rebuttal, and I'll post something over on your great blog. http://blog.stevenreidbordmd.com/

Danny

Jack Walsh said...

Given the recent exposure of data concerning antidepressants, I am sure that "evidence-based" treatment will no longer include these worthless meds. Anyone caught prescribing antidepressants by, say, July 1, should have his/her license suspended. We just can't tolerate this kind of malpractice on such a large scale; it is unconscionable.

And, I must say, the comments part of the Times mag let you off the hook pretty easily. Very little is made of the "cocktail" approach, in which a slew of meds is hurled at the patient. No one has any idea what one of the meds actually does, let alone a bunch of them at one time. Ah, progress in medicine marches on.

Perhaps you might think of becoming an internist. My internist listens to me more than you apparently listen to your patients.

tomassosan said...

Your article sheds light on the sad state of psychiatric care in this country.
From a cost perspective, conveyor-belt psychiatry is very expensive. NPs and Psychiatrist do not have the time to perform the careful assessment that you described in your article (the use of Ritalin for a patient with ADD). In the world of the 15 minute med check, this patient may have been prescribed multiple, ineffective and expensive medications. The cost in financial terms and human suffering is obvious.
Thanks again, for being one of the few relevant and sane voices in psychiatry.

Noel said...

Dan,
I am one of the 11% who do psychotherapy with each visit. I trained at Mass. Mental Health in the 1960's in adult and child psychiatry and we did both. I was so please with your NY Times Magazine article today. I had begun to despair that we would ever get the brain and psychi back together in "MIND" again. It was heartening. I still treat my very first patient maybe once a year. Dr. Semrad taught us to listen and the patient will tell us what is needed. At least the Mass Mental Health Gang found refuge at Cambridge Hospital. How does anyone know how to use medications without knowing the psychodynamics and what processes will be affected. Meds don't work the same in any two people.
I back you in the revolution. When I started only psychiatrist did psychotherapy.
Raymond C Yerkes, M.D.
Newburyport, MA

George Halasz said...

I add my congratulations to your article. As a child and adolescent psychiatrist from Down Under (Australia) where we sadly also follow the DSM based match the 'mind to meds' philosophy as you describe, but having been trained in the early 80's in the UK at the tail end of the 'golden' generation of psychiatrists whose focus was the total patient, I am surprised that your case study, as you were getting to know Jane', the health care administrator in her 40's led you to consider her distractibility as adult ADD.

Of course as a performance enhancing drug, Ritalin will focus the mind and make most people feel better. These are not surprising outcomes.

On a recent trip to the US I was amazed to see on large yellow billboards in LA, Chicago and NY airports asking if you felt 'distracted? frustrated? impulsive? UNFOCUSED? FORGETFUL? disorganized? ...it could be ADHD and to text or call a number.

Given the thrust of your excellent article is the need to assess moods in the context of the life of our patients, I have found that the same approach often highlights how the symptoms of ADHD are just that, (not a disease in the DSM, merely symptoms, often reified as a disorder).

The beginning of therapy, with the patience and care your recommend, the causes of distractibility etc. emerge like the causes of sadness.

In my case I was irritable and distracted after my long 18-hour flight from Ozziland. It settled soon after .

George Halasz MBBS MRCPsych FRANZCP

Robert Gladstone said...

I did understand your comment as you meant it, as not demeaning to psychotherapists, but the opposite. As a psychiatrist in practice for decades, I have long since found psychotherapy far more rewarding and productive than medication for real healing, not just providing a Band-Aid to allow my patients to function rather than struggle to control feelings.
I do disagree with your implication that psychotherapy is necessarily "arduous". For those therapists who are very comfortable with emotions, I believe psychotherapy is rich, engrossing and filled with love and connection, almost never boring or arduous - adjectives I would apply to routinely medicating people.
You call "mental illness" a "brain disease", a statement that tends to distort the emotional roots of the problems we are treating, and is a product of the intellectualization of emotional life that actually creates those problems. Also, I believe that much of what you claim is unknown in this area, (e.g,, why placebos work, and the mechanisms of most of the "mental Illness" we treat) is not unknown to those who practice psychotherapy adeptly, but does appear mysterious to psychiatrists who comprehend only the grossly deficient biological model. Unfortunately, time and space precludes discussing this further here, but although I feel grateful to you for going as far with this subject matter as you have, there is much more to be said about the real nature of "mental Illness" and the potential benefits of psychotherapy over medication. I do hope your book encompasses a larger perspective than your article in the Times.

Robert Gladstone said...

With all due respect, another look at your NYTimes article reveals that you are aware of only a fraction of the power of expert psychotherapy. Jane's story, for example, is not necessarily an argument for medication: Her "ADD" really entailed a struggle to control emotions which was making her unable to focus. I would routinely help someone with Jane's difficulty get comfortable with her emotions by helping her focus inwardly, relating to her with deep empathy. That process not only would have allowed her to regain focus in her life, but would have enriched her experience of life in many other ways - and not have tied her to medication. If Jane was very disabled, I might have employed Ritalin as a temporary measure to improve her functioning while we had a chance to let psychotherapy work, but it would only have been a stopgap, one I have rarely felt a need to use. In a situation like your mother's in her last months, I would feel confident that I could break through the paranoia and depression with psychotherapy. (I would be pleased to say more about how and why that would have worked if you are interested.)
As you would probably agree, the problem is not simply that psychopharmacologists do not have the time to spend with patients, but that in general they do not have the emotional ease and awareness to relate well and promote emotional healing. I have at times regretted that I trained to be a psychiatrist rather than a psychologist or social worker, since patients too often want me to provide medication initially when I know it can only provide an inferior "solution" to that afforded by psychotherapy. Generally they are easily persuaded to go the route of psychotherapy, but the discussion takes time away from our most productive activity. Although it is sometimes useful to have the ability to prescribe medications, I'm not sure the distraction it often causes is worth it. But your bottom line, that psychiatrists should be adept psychotherapists, is undeniably valid.

Mike said...

I appreciated your beautifully chronicled journey as a psychiatrist who came to value psychotherapy as a treatment for psychiatric distress. But I couldn't help wondering why, in your article, and in the journey you have taken in your career, you stopped yourself from taking the next logical steps in acknowledging the problems in how most psychiatrists view and treat psychiatric distress. You write that "Clearly, mental illness is a brain disease, though we are still far from working out the details." I would suggest that there is a reason the details aren't worked out. Modern psychiatry assumes that the brain is at the center of psychiatric disease, but we know that social and cultural circumstances play at least an equal role to the brain in the development and expression of DSM categories of disease. This doesn't mean there aren't brain manifestations of psychiatric disease; it just means that we can't rely on explanations that see the brain as the origin of all psychiatric disease. The DSM categories themselves skirt this problem by being symptom lists absent of any theoretical explanation of how disorders come into being. Why continue to elevate the brain as being the "real cause" of what you have decided to treat in so many cases through psychotherapy, a social encounter (rather than a chemical intervention), capable of altering your patients experiences of distress? Mike K, psychology resident in psychiatry

Anonymous said...

Fun psych, thank you for responding to my comments about why psychotherapy isn't tried first if most of the antidepressant response is due to the placebo effect. It makes sense that due to the insurance reimbursement system, that meds would still be tried first.

But as I mentioned in my initial comment, don't psychiatrists have an obligation to disclose this to patients when they seek meds? This isn't an issue about a med having a rare side effect which would not beg for disclosure unless the patient asked.

Also, I wanted to take issue with Dr. Carlat for claiming that SSRIs restore brain chemistry. Please see this article by Jonathan Leo who has done extensive research disproving this theory:

http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020392

AA

Anonymous said...

Dr. Carlat: The most disturbing aspect of your article was your discussion of patient "Jane" who you treated "for many years" for depression. She relapsed. And you wrote: "This time, rather than simply adjusting her medication, I asked her what was going on in her life." Are you kidding me? Was this the first time you took the time to ask this person about events in her life that might be related to the onset of symptoms? Have we trained generations of psychiatrists who no longer ask such questions or who deem such knowledge unimportant to understanding the causes of suffering? This is very unsettling. But you are right: Psychiatry has literally lost its mind.

Anonymous said...

Dear Dr. Carlat,

I live with with bipolar II. For readers who aren't familiar with it, bipolar II is the mild form of bipolar disorder. For more than 10 years, the psychiatrists I consulted were convinced that I suffered from depression and nothing else. Then, I received what I feel is the correct diagnosis from a very patient doctor who did just as you recommend: spent extra time with me.

Somehow, this doctor didn't make me feel as if the clock were ticking, and often allowed our sessions to run up to 40 mintues if we had something substantial to discuss. During one of these sessions,I revealed something I did which I consider to be outrageously inappropriate behavior. He was not in the least bit judgemental of me. And on hearing about this deed which we both felt was out of character, the doctor said something like, "You don't have depression, you have bipolar disorder and spend much of your time at the depressive end of the scale of moods."

I can't tell you how grateful I was to hear a doctor finally acknowlege that I didn't feel "depression" was completely accurate. In my mind, I had long sensed that there was another huge piece of my experience that falls outside of the label "depression". He changed my medicine completely: from Serzone to Lamictal. Others may think it works as a placebo for me. I beg to differ. Once in a great while, I forget to take my medicine. On that day, the darkness creeps back in a very ugly way. Then I realize what I've done, and redouble my effort to take my medicine every day.

So, my former psychiatrist agrees with you, and his patient listening and true engagement with what I was telling him was a sea change for me. I can't ever thank him enough for his perceptiveness: he changed my life.

Thank you for publicly advocating this common sense approach to psychiatry. I hope more doctors start using it and discover that it can make an enormous difference to at least some of their patients.

Leslie

Anonymous said...

Interesting, as a "counselor" I do find that there is a pecking order and sometimes MD's are brought into testify, rather than Psychologists who are actually trained in psychometrics--for issues that are not psychiatric.

The evidence based movement and pushes toward cookie cutter/manualized treatments are to some degree based on the ease of research. It's very difficult to research complex spontaneous psychodynamic flavored therapies, compared to more concrete CBT--which I find many say they do, but few really do beyond working on discrete symptom reduction.

I find the field to be becoming the "tower of babel" to some degree based on the economic incentive of people 'creating new therapies' and writing books, seminars etc. Linehan's DBT is a prime example, its all the rage--and people are trying to use it for everything now, not just Borderline. New research shows that it's not even more effective anyway. http://psychcentral.com/news/2010/01/26/psychodynamic-psychotherapy-is-beneficial/10964.html

Ultimately, the meta-analyses research data continues to show that the 'therapeutic relationship' is the key component to treatment outcomes and that it really doesn't matter as much for most clients if you focus on insight/behavior/environment/family as long as you are helping them using therapy as a template for change/insight/relationship improvement and the like.

We don't really have a mental health system, its a patchwork where most don't talk to each-other within the 'heirarchy'. I've tried to consult with MD's about some clients, when concerned about severe reactions to meds. I had one child who gained almost 100lbs during the year I worked with him, much of it clearly endema--when put on seroquel, he became diabetic, and started to show jerking movements. Two months later they scheduled a phone consult with me, and it ended up being with a nurse who basically asked why I wanted to talk to the Psychiatrist. She took notes and said she would pass the info along.

My former job working with poor clients, and overworked Psychiatrists treating them, showed a clear trend toward putting them on atypical anti-psychotics--really to just try and get them tired since they had behavioral problems--most of them not even diagnosed with Bi-polar etc.

It seems like there is little oversight when some MD's look down on their clients, or view them only through the prism of biochemical causation--rather than considering many of these children were raped, had no viable adult role models etc and perhaps this changed their brains--its always an interplay of both.

Ultimately, if I can't even get to talk to MD's about clients, when severe symptoms arise--then my guess is its going to take major litigation to change some of the trends--such as medicating massive amount of children with atypicals really just to sedate them. I didn't see this type of behavior by psychiatrists when I worked with college population and they had more informed consumers and parents that were likely to litigate, but with the Medicaid population--10minute med checks is about all I've seen. Hell, no one even takes blood serums anymore even when the clients are showing clear signs of diabetes and have massive weight gain--i find it sad and abusive--but what can be done, there are far too few Psychiatrists and the push is to have them medicate the behavioral problem children, pushed by schools, parents, and the vested interest of financial feasibility and expediency.

S said...

"At least half the patients that I've seen that I want to do therapy with just don't have time for it." (FunPsych)

"I want to point out that most people think psychiatrists are snake oil salesmen, way crazy themselves, and highly suspect in their competency..." (Mina)

Interesting for me to read these two comments in juxtaposition. I've seen FunPsych's statement echoed by many practitioners in various forums, and i'm sure it's true. But it's hard for me to reconcile this fact with my experience, as a patient, of having medications pushed on me by every psychiatrist i've seen, and of having learned (eventually, and thank goodness) to be very firm in refusing them.

Sarah

Herb Klein said...

I am in sympathy with “one-stop shopping” in psychiatric treatment, as distinct from the split that often occurs between prescribers and talk therapists. (This problem was also discussed in T. M. Luhrmann’s book “Of Two Minds.” )

I wish to suggest a new training paradigm with attendant economies, to wit, doctoral programs that teach both talk therapy skills and prescribing skills but are less demanding than the traditional psychiatry path. It would entail features of the training of psychologists and of physicians. I don’t mean to minimize the amount of training that is appropriate, but budding therapists don’t need obstetrics rotations, for example. A similar philosophy informs the training of dentists, i.e. sticking to the essentials.

A good venue for launching such a program might be the Uniformed Services University of the Health Sciences, because the military likely has the power to validate a new approach and because many soldiers need good psychiatric treatment.

(I'm a physician, but not a psychiatrist.)

JB said...

I have a question about the placebo effect theory.

Is it correct to assume that the placebo "cured" those 30% folks, or that depression does wax and wane, and "wait and see" would have also cured 30%? I've had several serious depressive episodes, and they did "go away" on their own. Had I been in the study, I'd have been a placebo or a medical cure, whichever group I'd been in.

Also, is the 40% who are helped by meds understated? In actual practice, dosages are adjusted and combined in an attempt to find the right "bullet" for a specific patient. Apart from the episodes mentioned above, I suffered from a chronic low mood. I finally decided to try medication, after lots of therapy that left me a very mature and self-aware depressed person. Several meds did not work for me. Each time I gave up and figured this is just the way it is for me, only to try again a couple of years later. 3rd try I found Celexa (now generic) that literally changed my life. So that 40% (or 25% --10% helped over placebo divided by 40% total helped) helped in studies is a lucky shot in the dark that they were put on a med that worked for them at the study-prescribed dosage. Other meds would work for some of that unlucky 60% who got no relief.

I think the studies are limited by what studies do: set up a very rigid structure so that results are reliable. So only an incremental 10% were helped by a certain antidepressant, not by "antidepressants" in general.

I fear that the "Antidepressants don't really work, it's all placebo" meme is not only inaccurate, it is dangerous at it gives people a reason not to take that scary step, to go see a professional about a serious mood problem.

And depression can be fatal, right? So if a cancer treatment may have terrible side effects but increases your odds of survival by 25% we stampede to it. Depression can be as serious as cancer, and maybe we should look at it that way.

Anonymous said...

Most of my former clients being medicaid clientele--showed one of the major problems with the 'system' that is utterly lacking. IF MD's are the top of the heirarchy per say, shouldn't information pertinent to talk therapy be passed along--what their hopes for titration are and the like?

Not many MD's want to work the social service sector--you get tons of quantity of clients, but lower pay-rate. Again, after 9 years as a therapist in multiple venues, I only spoke to MD's on a few occasions (actually 3 times). I attempted to do so about 15 times, in the past decade--always concerning notable health-concerns. I only was ever actually able to speak to one in person--got the run around, or left messages the rest of the time.

In the past few years, roughly 1/3rd of all the clients I saw were on an atypical--the oldest client being 16years old. Only one client didn't show noticeable weight gain. And I want to see the research that shows its OK to amphetamine a kid all day through school, and then give them 300mg of seroquel only for the purpose of 'tiring them out'. The amount of "off label" usage for behavior treatment, for kids who clearly aren't bi-polar/psychotic etc, but are typically depressed and anxious is amazing.

I'm all for psychotropic treatment, like any medical treatment when done with care, and with consideration of cost/benefits.

I think its going to be quite scary when a generation of children on amphetamine and atypicals show liver damage, tardive dyskenesia, PFC shrinkage, type II diabetes, heart disease etc. Meds certainly have their place, but in a fast food market with no real oversight by anyone who has the 'credentials' to be on parity--the MD's who spend 30-60mins/year with patients, and likely could never remember their name are going to be shown to do a lot of harm as well. Or perhaps, not, since we know have a system where research is done primarily by funding sources from those vested in outcome data that promotes their 'cure'.

But its hard to push back against the lack of oversight, overmedication, and lack of biometric testing being done for the new in drugs--namely the atypicals being used for off label usage. Let's be clear blood tests for sugar, white blood cell counts etc are not very expensive--and some of these drugs are well known to cause permanent harm, and of course they are being given to 8 year olds now--even though officially only for 18years and older, its pretty sad. Again, Lawsuits seem the only way this trend is going to change with the billions of dollars in play, and with MD's basically being forced to only prescribe and make for short visits in many areas.

Aqua said...

Without a psychiatrist who is well versed in medication management and psychotherapy I am not sure I would still be here.

As a patient with severe and persistant MDD or (maybe BPII?)that has been extremely resistant all medication trials (antidepressants (all kinds), mood stabilizers, antipsychotics,
stimulants etc., and ECT...the journey trying to help myself has been very difficult going.(understatement!)

Periodically, some of the meds have helped with some symptoms, but my pdoc's caring and consistent therapy has helped me both keep trying to help myself, and grow my soul in a way I never thought possible.

I am extremely grateful that my pdoc is well versed in, and practices, both psychotherapy and pharmacotherapy.

Dan said...

Dr. Carlat,

Given that your point of view is one that "none MDs" have been screaming about for years in growing frustration, I found myself reading your article with a mixture of gratitude and anger. For many of us, what you have belatedly come to understand is hardly news. Psychiatrists have long been reaping the benefits of their alliance with pharmaceutical and insurance companies with heavy financial incentives to continue the harmful, and untruthful status quo. I am glad for you that you have come to this realization, and even gladder for your patients. I also applaud your willingness to provide a public mea culpa, and not to simply keep it silent. But please also remember that psychotherapists (and their patients) are still struggling to make our voices heard, and to make an increasingly tenuous living because of the very lie that you have "uncovered."

Dan Livney

Anonymous said...

Thank you for your inspirational article. I am hoping to be accepted to medical school and given the opportunity to practice just as you have described. As a mental health worker with a degree in Psychology, I am grateful for the experience I have had building relationships with my clients.

pacificpsych said...

Unless you change the state of psychiatry outside of self pay private practice in wealthy areas, you've done nothing. Show me one job in the entire US (that is not some academic niche for which an exclusive few might qualify), that entails psychiatrists doing therapy. The entire system consists of psychiatrists being forced to medicate, as well as them being controlled by insurance, UR people, nurse admin, non nurse admin...Show me the clinics or hospitals where you can get a job doing anything else but medicating patients. Until that changes, and I don't believe it will change, nothing will change. Having a minute percentage of psychiatrists, in wealthy educated urban areas, succeed in maintaining a psychotherapeutic practice does not a profession make.

Sara said...

I have to agree with a small minority of other commenters that the fact you are making "news" with this revelation/realization is a sorry comment on the state of psychiatry today. Yes, I appreciate your honesty. I like the direction you're moving in but I still find it shocking that it's taken over a decade of seeing patients for you to realize the importance of asking them about the circumstances of their lives and to attributing some causal role to them. Worse than that it appears you are still using those facts to "diagnose" and pigeon hole and then decide on some different medication to do the trick. I'm dismayed that it's still back to business, back to finding that magical combo of medication and therapy that's going to do the trick, and believing that it takes both together to do the job. You still have a long way to go to understand just how toxic and disabling a lot of these meds are over the long term (and sometimes just over the short term). They may be miraculous for short periods of time. I don't deny it but "buyer beware" -- the devil is going to make you pay.

Claudia M.Gold said...

Hi Danny

I admire you for having the courage to not only question the standard of care in your chosen profession, but to change the way you practice and write intelligently about the subject.( I wrote something like this in a letter to the Times, but in case they don't publish it I put it here as well!)
The solution to the problem may be complex,involving "turf wars" etc., but the bottom line is, in my opinion, a need for our culture to recognize and value the healing power of human relationships.
As you know I write about this issue as it relates to children on my blog.

Anonymous said...

I am a phd psychologist who practiced in the psychiatry dept at MGH in the late 1970s at the time when great numbers of psychiatrists were making the decision to "go biological." At MGH, I practiced with the author of "The Anxiety Disease" which became the bible for psychiatrists making the switch from psychology to biology. Over the years I have practiced with some truly gifted psychiatrists and avoided the psychopharmacologists. Your NYT article is encouraging to those of us who would like to see a restoration of balance between psychology and biology in the field of mental health. However,I hope that psychiatrists will take your suggestions seriously and not see them as simply a way of getting business back from the primary care physicians who now prescribe the majority of the psyhcotropics. It would be unfortunate if psychiatrists continued to rely primarily on medications and just threw in a little token talk therapy to distinguish themselves from the primaries in the eyes of the payors in order to win back some of the lost business.

Anonymous said...

As a patient, I think it's interesting that there are few "patients" responding to this article and a "ton" of experts it seems arguing over this issue. It makes me wonder if you experts have for a second, turn off your ego, cover your diplomas, and really listen to your patient(s)? And for those patients who come in and choose a "quicker" way out (pills versus "long sessions") - then you are probably getting what you pay for. We live in such "hurried lives" and want things quick! As an "80's HIV Survivor" and having lost friends who were "purely" dependent on meds - I learned or was reminded quickly that everything is about balance - not just to rely on meds - that I had to do my part, mentally and physically as well as emotionally -

I went thru my "depression" time and opted to see a therapist and invested time towards my mental health - I didn't want a "Band-Aid".

Sure I take pills because I have to keep my viral load down etc - but that's just part of it - I think it's the doctor's responsibility also to remind patients that they have to do their part... as "AA" stated:

"Please understand that if the patient still decides they want medication, that is their right. But in my opinion, they need all the facts which I feel many psychiatrists (not all) don't provide."

MM

Thomas Tharayil LCSW, BCD said...

Your article was refreshing. It left me wondering if psychiatrists have been relegated to assessing, diagnosing, and prescribing, then what distinguishes them from any other physician? Couldn't a competent psychiatric nurse, psychologist, and clinical social worker do the same with additional training and pharmacological supervision?

Also I found it interesting that some in our profession would think of providing a meaningful engaging therapy relationship as more menial and mundane than spending days assessing, diagnosing, and writing prescriptions.

BookingAlong said...

Excellent article. I would argue that too many patients are given drugs without truly getting to know them. I have walked into a therapist's office and basically been given a diagnosis in 15 minutes, simply by filling out a questionnaire. At no point was I asked about recent events in my life (several losses, deaths). The depression was normal and temporary and yet I could have been medicated for awhile, with no doctor asking about recent events.

By the way, I'd like your take on ADD meds and college students. I've written about that. Link on my blog

Kyle Arnold, PhD said...

I'm a licensed psychologist and the correction of the controversial remark reminds me of many experiences of psychiatrists claiming to supposedly view me as a valued colleague but really, taking a dictatorial stance to someone on a lower rung. In my experience, even psychiatrists who claim to see psychologists as equal colleagues typically do not understand the length and difficulty of training involved in becoming a psychologist. Does Carlot truly, really, see psychologists as equals? If so, why make the lower rung remark in the first place?

Anonymous said...

Sometimes, the meds cause more problems than the mental health issues.
Many of the drugs you prescribe cause high cholesterol, weight gain, and the worst one of all, TARDIVE!
I got tardive from Zoloft.
I got high cholesterol from Seroquel, and I was prescribed such high doses, that my eyesight was affected until I stopped taking it.
No one gave me blood tests or any test which is supposed to be given when taking Seroquel.
Five years of trying every drug on the market and now I am drug free and only go to monthly therapy.
Some people are drug resistant.

Sorry....the ssri's can also cause some people to be impulsive.

And EVERYONE feels better on those ADD drugs.

They were used as diet drugs for women in the 50's and 60's and were taken off the market because so many women were becoming addicted to them.

Amphetamines are amphetamines.

It's insanity in the medical profession.

Martha Eichler said...

I recommend, if you haven't done so already, that you read Dr. Rita Charon's HONORING THE STORIES OF ILLNESS. Her concept of Narrative Medicine underlines the importance of listening to patients and writing about their medical illnesses for optimum treatment. The resultant "parallel charts" are then discussed for greater understanding in collegial meetings. She has been introducing this concept into medical education. Her book and ideas confirm that, no matter what the illness, empathic listening to a patient is primary in the healing process. Her ideas illuminate that the disconnect between mind and body is, as you say, a "fallacy." Mind/body is a continuum, and it is about time that psychiatrists with their medical education have come to see that listening to patients' stories is of utmost importance in addressing any diseases.

Anonymous said...

I congratulate you for exploring the possibilities outside of the conventional psychopharmacological approach and for beginning to understand the significance of establishing humanistic relatedness with your patients.

The article leaves the distinction that it is the events in the individual's life that are at the root of the problem and the ability to help unearth them is significant in pursuing effective treatment. I suggest it is the connection that you have established with your patient that is considerably more significant. Your simple act of taking the time to listen to what has been burdening her has made a real difference.

Courtenay Harding's Vernont study is illuminating. Her 20 year follow up on patients diagnosed with schizophrenia revealed that of those who recovered fully none complied with medication long term. This suggests that even for conditions thought of as grave as schizophrenia that the answer lies elsewhere.

The article suggests a real transformation in your understanding of "mental illnesses" and it is remarkable that you have accomplished this despite the significant influences of the profession and the pharmaceutical lobby. I will suggest however that promoting that "Clearly, mental illness is a brain disease, though we are still far from working out the details." is pure speculation and conjecture and lacks scientific scrutiny.

I will promote that clearly mental illness is the manifestation of maladaptive behavior permeating from the unconscious mind in the presence of representative environmental stimuli. It is a human response. It is a human condition. It represents human beings doing the best they can notwithstanding the limiting effects their past experience has provoked with them.

Your centrist approach, to my mind, is considerably better than the conventional approach that discounts the value associated with psychotherapy in favor of psychiatric drugs. It will undoubtedly inspire opposing sides of the argument to suggest that one or the other, and not both must be correct. Akin to "you cannot be both fish and fowl".

Good Luck!

Dr. Darryl L. Townes said...

I would like for you to address whether you believe that medical psychologists, i.e. a clinical psychologist with two years of postdoctoral clinical psychopharmacology training culminating with a postdoctoral Master of Science degree can prescribe psychotropic medications with the same record of safety as a physician, nurse practitioner, physician assistant, or even a psychiatrist?

Anonymous said...

As a NYT subscriber, I was pleased to see yet another article on mental illness featured within its covers. Dr. Carlat raises interesting questions where as a consumer I have been taught to attribute my mental illness to a fundamental imbalance in the biochemistry of my brain which only a combination of ever changing medications will address. Of course, the specific imbalance in my singular brain has yet to be shared me.

I do hope psychiatric professionals can think more broadly beyond psychiatry versus psychotherapy alone or in combination and how they should be delivered. Is it too much to ask that psychiatric professionals of all stripes occasionally try put themselves in the place of the very consumers they treat? For example, try to imagine that your life has fallen apart or you've never had a life but merely a fragile existence. Consider the resources, services, and and supports you would need to regain or realize one and then consider what is available. How much could you achieve in the Era of Wellness & Recovery? How far could you travel when your resources are largely limited to medications and/or talking to a therapist (too often absent any recognized therapeutic approach) when there is little else to facilitate and foster those things you might value most? Would you end up thriving or joining the ever growing population on disability by virtue of mental illnesses?

Just an chronic who spent his childhood in the mental health system and has forever been medication compliant. I am Lexapro, Lamictal, Xanax and now Seroquel adjunctively. I can only apologize for failing a mental health system which putatively afforded me every opportunity for success.

James M. La Rossa Jr. said...

It should come as no surprise that not all psychopharmacologists are well versed in psychotherapy. Is a cardiologist who is expert in the treatment of heart disease using ACE inhibitors less a physician if he/she has a nominal grasp of eating disorders and addictions — the dominant underlying causes of so much heart disease? Why are we more willing to follow faithfully the enormous biological advances in antihypertensive medications and the cardiologists who prescribe them, for example, while being so dismissive of antidepressant medications and those psychopharmacologists who are most expert in the use of psychotropics? Excuse my over-simplicity, but the dismissal of the importance of psychopharmacolgy in so many comments shows an inherent lack of respect for the enormous advances in biological psychiatry and psychiatrists, which other specialists (who may also rely solely on medications) do not suffer.

I also concur with many postings which express a profound importance in psychotherapy. Like Dr. Carlat, one of my early influences was a depressed, paranoid and suicidal mother. And while I can't tell you who helped her more — her therapist or her psychopharmacologist — I was glad to have the expertise of each. Both were instrumental in keeping her well and cared about her deeply. They eased her dark journey; a fascination with their science helped set me on my professional journey. Psychiatry should not be an "either-or" proposition, but a specialty as rich in science as it is in case histories. Best regards.

James M. La Rossa Jr.
Medworks Media
Los Angeles

Anonymous said...

I consider myself a psychopharmacologist and I always strive to know my patients very well, and consider supportive psychotherapy key to good psychopharm practice. I don't think you can practice psychiatry and not know your patients. I am confident that many "psychopharmacologists" would share this opinion. I don't think what you are saying is new, and you seem to imply that it is a unique viewpoint, which is condescending to others who go to work every day and try to do right by patients.

David M. Allen M.D. said...

The appallingly unprofessional prescrition of atypical antipsychotics to non-psychotic patients without even following their blood sugar, cholesterol, and triglycerides is malpractice, plain and simple, even if that is all the patient expects.

Ditto a doctor making no attempt to separate out psychological/environmental triggers versus limbic system dysfunction in order to figure out why patients are responding they way they are to treatment.

A lot of psychotherapists do not pay attention to family and other interpersonal factors creating behavior problems and focus on simple and inappropriate "social skills training," so today's horrible practice trends are hardly limited to psychiatrists alone.

Very few people seem to be willing to work on their personal and interpersonal problems any more and expect a quick fix. They are easy prey for the Joseph Biedermans of the world who preach that every behavior problem is a brain disease, so it's not only the mental health profession that is to blame for today's sad state of affairs.

There is plenty of blame to go around.

Anonymous said...

Thank you so much for your openness, and your honesty in the NYT and in this blog.

It's tempting to write a very long comment raising pointed questions about psychiatry, things I simply do not understand but let me just say: It's unbelievably unpleasant to be on the other side, to be the person needing help. The odds of even seeing a doctor for many people are low (because of insurance barriers and costs). The odds of actually being helped once one sees a doctor remain slim. For the sick person, psychiatry holds out the brass ring of health but only the really lucky person manages to attain it. Please do look deeper into the effectiveness of the medicine you prescribe, at the diagnostic practices, at the real efficacy of treatments. You are beginning to do this. I hope you won't stop raising these questions because, as you know, the suffering of the mentally ill is among the most extreme forms of human suffering.

How many people--those lucky enough to be treated--are really helped by the kind of psychiatry you describe, in the final account? Please don't doubt my questions as unscientific. I doubt the science will actually move forward unless the current paradigm is more robustly challenged. But it is hard to challenge the paradigm when the interested parties all hold medical degrees or pharmaceutical stock and the many who suffer from inadequate treatment are considered crazy and unreliable.

Alas, I now sound like a crank. I admit that psychiatry is better than nothing for most people. But it just seems that with the resources it has, it could do much more.

Anonymous said...

As someone who's been treated for depression and anxiety for 11 years (since I was in high school), I know the feeling of being handed yet another prescription by a psychiatrist or GP when I needed more than that. I know that medications can do wonders for many, and SSRIs/SNRIs can lessen the severity of my symptoms. However, I've also been put on mood stabilizers that caused frequent vomiting, hives covering the palms of my hands and soles of my feet, and debilitating dizziness. Some SNRIs gave me tinnitus and made my hands shake. All the SSRIs/SNRIs I've tried have caused sexual side effects. I've had severe "withdrawal" when I try to stop taking these drugs or switch to a new one, however gradually. In other words, sometimes the treatment is almost as bad as the disease for me.

Last week I bit the bullet and went back to therapy. It's uncomfortable. It's difficult. But I'm tired of taking a pill every day for so long that I don't know who I am without the medication -- and honestly, even with the medication, I've still managed to develop a eating disorder and lapse back into serious depression. I haven't given up on medication forever, but I agree that therapy deserves more attention.

pacificpsych said...

To the last Anon: I must reiterate - even psychiatrists who are completely opposed to the current system have no power to change it. They are trapped, unless they are in private practice and doing well there. YOU, yes YOU need to help us. Go to the administrator of the clinic, call the health insurance/medicare/medicaid administrator, call your senator and congressman. Demand that you get proper treatment. That means spending as much time with your psychiatrist as you and your psychiatrist feel is necessary. Fifteen minutes is in almost all cases a sham. It's only acceptable if the patient feels very uncomfortable with longer visits - then it could be OK.

That also means doing psychotherapy with your psychiatrist if you so choose - real therapy, not just a few supportive words as medications are handed out. You and all other patients need to take a stand against insurance companies and against the mental health system as it is run and change the way things are. We can't do it - we have less power than you! Surprising, isn't it?

Jack Walsh said...

This is all starting to annoy me. The "we have no power, the insurance companies rule" is only true if we let it be. I am a psychologist, was in a practice for 20 years, and stopped accepting insurance payments when it became clear that I was not in charge of either the treatment or the information that was entrusted to me by the patient. Seems to be we rolled over for the insurance companies in the late '80s and early '90s and haven't regained our dignity and self-respect. There are other ways to make a living, particularly for MDs.

My latest experiences with MGH and McLean have reinforced my belief that these are inept people of little accomplishment or consequence. My bad was not realizing at the outset what I was dealing with; only later on did I remember that these folks were the psychosurgery, ECT and med kings of the universe. Eye of toad, ear of newt, indeed. Gimme the screwdriver, Charlie, we're goin' in. Sounds like a joke, but this has gone on for 60+ years, and they have never paid for the damage they have done.

I still want someone to tell me why we shouldn't accept the evidence that antidepressants are no better than placebo.

No rush; I'll wait.

David M. Allen, M.D. said...

Pacifipsych, you could not have said it better. All people in the profession like us can do is write books (like the one Dan has coming out, and one I have coming this summer)and hope people read them and take action.

There are some organizations fighting the good fight with Big Pharma like Community Catalyst, but that doesn't help us with the insurance companies. And the drug companies have become incredible propagandists.

Astra Zenica just got nabbed for off-label promotion of Seroquel, but it won't stop them. As I've seen as a former residency director for 16 years, it's amazing what we're up against.

Anonymous said...

The comment here by an anonymous psychopharmacologist to the effect that Dr. Carlat is saying nothing new, nothing more than that all psychiatrists should "know their patients" and perform "supportive psychotherapy", illustrates the problem with leaving psychiatrists ignorant of the nature of life-changing psychotherapy. Such therapy, which heals depression and anxiety disorders through deep emotional understanding and connection is worlds away from simply knowing, respecting and supporting ones' patients, qualities that every good physician, like Anonymous, practices routinely. I wish that Anonymous, rather than finding Dr. Carlat's comments demeaning, was able to see that his/her psychiatric education lacked something vital. I am a psychiatrist, and am saddened by the profound inexperience of most of my peers with psychotherapy capable of healing emotional dysfunction, inexperience that even hampers their nuanced interpretation of psychopharmacological results and research.

Judy Mauer said...

One of my friends forwarded me one of your articles which has landed me on your blog. I am a BSW level generalist counselor

As you will probably know Social Workers are trained in a holistic approach. We are trained in case management. We are trained to view the whole picture and make referals for intervention.

And, it is not surprising to me that psychiatry would become such a specialized and seemingly disconnected profession--human nature mandates this as a natural evolution resulting from the way that we are seemingly "hard wired" to compartmentalize, judge and create hierarchy in our attempts to "fix" human suffering.

I realized early on in my psychological studies that all of the fore fathers of the varying disciplines in psychology all had an invaluable piece of the puzzle.

While over the years we have broken the puzzle apart, I am tickled by the break through you have made to get back to viewing the human being as a complex whole where medication can assist and yet is not be the sum total of the "fix".

However, it is my belief that the psychiatric community can not be expected to diagnose and treat the biology and at the same time become the expert in psychotherapeutic interventions--The only thing that is needed in my opinion is for the psychiatric community to take interest in teaming more intricately with the other helping professionals to create cohesive, whole systemic approaches.

I have been to several appointments with my clients with psychiatrists and other mental health professionals and to date only one of them has been interested in engaging me in the conversation for the purpose of creating a holistic plan for healing and recovery.

I am tickled that you are broaching this subject.

Anonymous said...

It's interesting that on nightly news last night they brought up lawsuit b/c of Seroquel being given to children off label--and being pushed by it's maker for this very purpose.

It's no big 'coincidence' that the Atypicals magically became 'effective for treating resistant depression' after they lost their patent protections--so they go out and push it for other uses. So how again is the D2 receptor site, supposedly integral to depression?

Again, I have seen the atypicals given--often in mega dosages to children increasingly in the past 4 years--to the point, where 1/3rd of my clients were on atypicals, with only one being diagnosed as bipolar II rule out diagnosis. The real reason they were given this drug, was to sedate them, and often to sedate them after amping them up with ADHD amphetamines all day.

I had one client, given blood tests in the last 4 years that was on these Atypicals, and it was because I made a huge deal of it--to caseworker, group home, and the parent. The girl gained 40lbs, as soon as her dosage was amped from 200mg/to 800mg--clearly in an attempt to sedate her--right after they placed her in a group home. She had endema, and started getting facial twitching within a couple weeks after. It took a half a year of me complaining, before they finally took her in for blood sugar, cholesterol readings--the refused to do any of the 'expensive' testing on her.

Again, her mood didn't improve from the titration, and her health and self-esteem dropped massively as she become sullen and tired--although supposedly this was to help her with her bipoloar rule-out--even though the Psych Eval, labeled her R.A.D. which makes much more sense given her history and symptoms, but the MD, only had 10mins, and wasn't talking with me (the therapist) nor the consulting Psychologist.

This is just one example, I've seen many children now--become so obese, that this becomes a major health concern, this is not a rare symptom of the atypicals, and why the hell can't they look into facial twitching etc--most of these caseworkers are clueless to the side-effects possibly being permanent or even fatal--and the parent's of the medicaid population are even more so. Most who don't want their kids on drugs, don't have a coherent reason why--and they cow-tail to the MD's who again, are overwhelmed with cases--and financially taking less money via M.A. so probably feel like they are doing charity work anyway. The MD's couldn't take more time if they wanted, they book them with 2-3 clients an hour typically, from what i've seen, re-scheduling appointments for clients often take a couple months. They often send kids to Hospitalization if severe enough--and get re-evaluated there. I've had 100% of aggressive children come back from one Psych Hospitalization diagnosed Bi-Polar and put on atypicals. Let's be clear, children can act out and be aggressive without it being indicative of a manic episode!

James M. La Rossa Jr. said...

The rather brilliant Anonymous psychiatrist who suggests that "rather than finding Dr. Carlat's comments demeaning, [we should] see that his/her psychiatric education lacked something vital," gives us a wonderful opportunity to bridge the CME controversy presently raging on this blog. If the presentday training in psychiatry is (sometimes) inadequate to field a group of therapist/MDs — as so many of you have powerfully suggested — perhaps the best way to bolster expertise would be through largescale, "required" CME geared specifically to psychotherapy.

As the current trend continues to discourage industry-sponsored CME (which is oriented toward drug therapy), it might be high time to adopt (in a big way) therapy-directed CME. I submit that there is very compelling evidence for the APA et al to direct and support its members in this direction (assuming, arguendo, that the APA can overlook its obvious industry ties).

There is no doubt that research into biological psychiatry will continue at a brisk pace — even if psychiatry makes a shift toward psychotherapy "capable of healing emotional dysfunction." The "trend" which Dr. Carlat outlines in his NYT article, along with the regulatory market forces raging around CME, may provide the very opportunity which so many of you espouse. BACK TO THE FUTURE anyone? Regards.

Harry D. Corsover, Ph.D. said...

I am a psychologist in private practice with over 37 years of experience, and I'll comment on something Dr. C and M wrote:

"So many fantastic comments. I particularly appreciate M's perspective as a psychologist who works closely with psychiatrists and perceives the mutual animosity and distrust that so common. As he says:

"And I think that ultimately, we all need to focus one what research has shown to be best for the client -- be it medication, therapy, or a combination of both, and try to provide the best quality of care for our clients that we can."

Amen!"

Well, what's the opposite of "amen?" First, M is not a psychologist, but a doctoral psychology student, who no doubt is being exposed to only part of the story regarding "evidence-based practice" in psychology.

Secondly, research simply does not show what's best for the client we are treating, except on very rare occasions. At best, it offers some information about how a narrowly defined group responded to a narrowly defined intervention. As anyone knowledgeable about statistics knows, group statistics offer only a statement about the probability of something occurring in a large-enough group. If our client is not a good match for the study cohort, it may offer very little of value to guide our treatment.

Research studying the efficacy of specific interventions, in most cases, carefully selects people who present with a single clearly defined problem (something, by the way, that I have seen about twice in my practice over the last 37 years), defined by the DSM (itself not a scientific document), provides a single manualized intervention over a pre-determined number of sessions, often using "naive" therapists (so they are less likely to very from the manual) and often uses only a relatively short time period for follow-up (if at all).

I have written an article in a recent issue of The Independent Practitioner (published by the Division of Independent Practice--Division 42--of the American Psychological Association) pointing out the many problems and issues regarding underlying evidence-based practice in psychology, especially given the current state of our science.

The article can be downloaded here: (if the URL does not appear here, see the one in my signature)
and provides a lot more detail about this.

While evidence-based practice may make a lot of sense in some areas of medical practice, in the context of psychotherapy it is far from the panacea many believe it is.

Harry D. Corsover, Ph.D.

moviedoc said...

I'm intrigued by Mr. LaRoss's idea of required CME in psychotherapy for psychiatrists. Training in just one method of psychotherapy, however, requires many hours of supervision, far beyond even a week long CME activity. What would be feasible, however, would be a course in differential psychotherapeutics that would increase our competence in matching the treatment to the patient's clinical needs. The problem then becomes how to identify a psychotherapist who can skillfully deliver that modality to the patient in the community. Not to mention that mandating CME probably must originate with the state licensing board.

pacificpsych said...

Thanks, David. About EBM in psychiatry: newsflash, it's mostly bunk. In response to Dr. Corsover's post, I simply must post my latest rant hoping it's not off topic. http://www.pacificpsych.com/psychiatry/the-dsm-is-it-the-truth/

Andrew said...

Daniel Cartlet writes in his article

"focusing on a complicated combination of medications like Effexor, Provigil and Xanax. "

And you're wondering why the patient still had problems with a combination of Effexor, Provigil, and Xanax? Those are three intense drugs the short half life alone on Effexor makes you start shaking like you are coming off of heroin after missing 1 dose. Not to mention all the other side effects. It sounds like you were just throwing so many drugs at the patient so they couldn't feel anything, instead of actually trying to heal them.

You then pretend that you are taking a new step and talking to clients to find out what is wrong. but you immediatly perscribe amphetamines. The fix it drug of the 50's. And after 30 days they feel better???? Well that is beyond obvious. Anyone feels better after 30 days on amphetamines. Talk to someone after they take amphetamines for a year and many are just more irratible and need it to complete any simple task.

If you represent the enlightened in psychopharmacologist then I am very scared for those with mental differences in America.

Harry D. Corsover, Ph.D. said...

Sorry -- the link to my article didn't show up. Here's the proper link:
<a href="http://dl.dropbox.com/u/5981212/Good_Intentions_Paving_HDC-IP.pdf/>The Good Intentions Paving Company</a>

Harry D. Corsover, Ph.D.

Arthur said...

Hard to tell which was worse for me: taking Wellbutrin (Hellbutrin for patients in the know) and getting permanent tinnitus; or the response of the prescribing psychiatrist and his successors: get lost, buddy. Not our problem. If they knew what they were talking about and took some responsibility for the damage they do, that might be an acceptable course of action. But, unfortunately for patients (former patient) like me, when it comes to pdoc damage, they know nothing, do nothing, and care nothing.

Mina said...

This post broke my heart. My daughter had all the symptoms of "akathesia" except the physical ones. She was paranoid, aggressive and unable to fuction. Finally someone took her off of Seroquel and she was so different within 10 days.
A year later, she is back in college, has a boyfriend, got rid of her drug problem.

I do so worry about the sedative effects of this drug. I worry about people's lack of caring.
And I worry about their malice. At each settting all I had to do was ask about taking her off of Seroquel and her dosage would be doubled, I'd have to listen to a lecture on MY co-dependence, and she would end up picked up by the police for aggression and transefered to the psych ward which would then call me to take her home, telling me that it was street drug use that was causing this.

Anonymous said...

James La Rossa suggests a large scale CME effort to try to bring psychiatrists up to speed on psychotherapy. A good idea, but perhaps a difficult one to implement for a number of reasons. For one thing, it might be difficult to locate the best teachers. My own experience, having done my residency in a program known at the time for its emphasis on psychodynamic training (Beth Israel Hospital, Boston, in the early 1980's) was that my supervision was woefully lacking, tending to be overly intellectualized with psychoanalytic jargon, and performed by staff most of whom were themselves largely out of touch with the deeper emotions of patients (and their own!). I'm sure the situation has only worsened as the psychiatry staff at teaching institutions has become far more biologically oriented. So I submit that any CME effort would do best to look for teachers not found among the current psychiatry "experts" teaching in residency programs. Even among psychologists and social workers, there may be a tendency for those who do psychotherapy well to stay away from bureaucratic teaching institutions in favor of full-time private practice, and these practitioners are likely to be short on experience with the most troubled clientele who have usually been referred to psychiatrists.
A greater problem lies in the fact that becoming an expert therapist entails becoming at ease with one's own deeper emotional life. That is a rich, rewarding process, but one that is primarily experiential, not intellectual. Perhaps the most one could expect out of instructional CME programs would be some guidance about what the best psychotherapy entails, why it works, and how to go about learning it, rather than trying to teach the process per se. What I am suggesting here would be a very tough sell to the powers that be in psychiatry who typically have, I fear, little sense of what I am talking about because of their own emotional blockage that goes hand in hand with their intellectual/biological mindset. They would find a realistic description of how the very best therapists work and what they can achieve in cases of, say, severe anxiety and depressive disorders, unfathomable and unbelievable.

Yasser said...

Thank you for your article. It always amazes me when people attach lower cost to a profit-maker in the medical services chain as a supportive argument for a certain treatment. In no other country I am familiar with, no other culture, is health compromised for cost. A society must bear the cost of the best treatment to all its members, or it is not civilized. If it's not there yet, it should tend to go there, not argue for this or that treatment based on cost. Often throughout life's ups and downs I've been depressed or anxious, probably through an inherent weakness of the mind. However I never accepted to take substances to alter my brain from people, however much time they spent at school, who barely knew my name and spent no more than 15 minutes with me, most of it typing up stuff on a computer for record-keeping in case of a lawsuit. Thank goodness for my muslim faith which discourages me from messing with my brain through drugs or alcohol, which is the support of my being. Before subscribing to a regimen of mind-altering drugs, a patient should ascertain they are absolutely necessary and the right ones. This does not require the provider have a degree from Harvard or MIT, but rather on the contrary, the time, patience and ethics that come with a dedication to one's profession rather than its generous benefits.

James M. La Rossa Jr. said...

Thanks to both moviedoc and and the thoughtful anonymous writer for picking up the CME thread and running with it.

Imagine a specialty which "entails becoming at ease with one's own deeper emotional life." How seemingly grand. A group of highly self-idealized physicians sounds like just the folks to be able to cut through the hardened dogma that has put psychiatry in the cross hairs. Thanks and best wishes.

TracyM said...

The one thing that struck me as I read this article was how many medical conditions could be causing anxiety, none of which were "ruled out" in that 20 minutes. Hyperthyroidism, Hyperparathyroid, all kinds of things.

The reason I go to an MD rather than a Ph.D or MFT is that the Ph.D and MFT can't distinguish between an organic disorder and a general medical condition or toxicity.

There rule-outs are unfortunately rarely done properly.

Anonymous said...

Hey TracyM:
I have news for you: If I was concerned that a symptom I was experiencing had a medical cause, I sure wouldn't ask a psychiatrist to diagnose the problem! I would go to PCP first!

S said...

Anonymous who responded to TracyM above: I'm glad you're in a position in which you can evaluate your own condition and care, and determine when your symptoms warrant additional medical attention. But i think it's unfair to expect that level of insight from all patients.

Additionally, there are PCPs who, once they know you're under psychiatric care, will attribute any symptom to a psychiatric cause and who will try to refer you back to the psychiatrist. They don't want to deal with mental patients. And it's very easy to say, Get another doctor, but there are plenty of reasons why various people would consider that more difficult than it's worth.

I once called my PCP's office with palpitations and weakness and was referred to my psychiatrist (who prescribed Klonopin over the phone, which didn't help at all, so i still have most of the bottle, which is pretty sweet. It hadn't occurred to me to call the shrink initially, because i had recently had a tonic-clonic seizure and was still feeling wonky). A different PCP referred me to my psychiatrist when i called with questions about the antimalarial drug that he (the PCP) had prescribed.

Joel Hassman, MD said...

You might want to take a little time off and consider penning a column/blog posting after what I read in the April '10 Clinical Psychiatry News lead story: "Law Fuels Debate on Specialty's Future", http//www.clinicalpsychiatrynews.com , as I have been saying for months what this article now raises as a legitimate concern. Psychiatry will be irrelevant, and while all you antipsychiatrists will be up and cheering, it will be a short applause, as when you see what PCPs/Family Docs/Nurse Practs/Psychologists/and you watch, even Social Workers, will substitute, people will realize that psychiatrists, as stupid as we have been these past 15 years, still had the patients' interests more at heart than what our substitutes will provide.

This is the issue of 2010 now, and it can be ignored, dismissed, or rationalized, but, unchallenged, half my colleagues will not be practicing by 2015. And you can take that to the bank!

James M. La Rossa Jr. said...

After reading both Dr. Hassman's last comment as well Dr. Carlat's new book last night (thanks to your publisher for sending it ... superb job) I had a simple revelation which may cut through some of the dire predictions. Medicine needs psychiatry — it is still the last great frontier — and as long as psychiatrists are doing the majority of writing and research, the field can not advance without them.

What psychiatry has not seen in a while is a new "blockbuster" therapy (drug or talk), which could catapult psychiatry to the next level. The importance in how this new therapy is advanced will be enormous, and society will entrust it to be applied by psychiatrists — the very men and women who brought it to market. Perhaps all this fighting within the field is more boredom than anything else.

Anonymous said...

Dear "James" -
You said this:

"I can treat many borderlines effectively."

Shame on you for referring to patients as diagnoses. People HAVE borderline personality disorder. People ARE NOT borderline personality disorder. When will your profession learn this?

"He's bipolar." "She's borderline." No. Actually, he HAS bipolar disorder and she HAS borderline personality disorder.

For people who are supposed to have a shred of a clue about people and the importance of word choice, you certainly do tend to minimize personhood. It's really rather disgusting.

Anonymous said...

I have deeper and more therapeutic conversations with my endocrinologist than I do with the psychiatrist prescription-writer I see.

JHSmdjd said...

Sir: A friend from Med School sent md your NYT Magazine article and like Dr. Bransford I found many parallels with my own experience and feelings on the subject. But because I spent 25 years in the US Navy Iwas alllowed to continue to do psychotherapy almost without let or hindrance. No concern for insurance or the differential incentives to do primarily "med management".

As a civilian and Medical Director of a large system, I began to see a darker side of this "third party payment" derived dichotomy, a pattern of misdiagnosis. As I often heard in the USMC, "If the only tool you have is a hammer, then every problem looks like a nail." There was no refferral of patients for psychotherapy only the prescription of meds commonly with little or no result.

In no way do I mean to impugn the motives of the psychiatrists. I know from personal experience as a GP in a small town that when patients come to a doctor with a problem they expect to be treated, to be validated if you will. My much older partner explaine to me that meant they expected a prescription for something. I took that lesson with me to my residnecy in Psychiatry.

I started at MGH almost twenty years before you. We could easily not prescribe meds to patients because we could and usually did refer them for therapy. The majority of the patients I saw in residency were not prescribed meds initially unless the diagnosis was clear and meds required. Now most psychiatrists do little if any therapy. The reasons are, in my view, mostly economic in origin. But the residents I see in training today get less training in psychotherapy and seem less motivated to learn the skill, which suggests they are less likely to do it or even refer to others to do it.

As for the issue of hierarchy in mental health, your phrasing may have annoyed some, but it is true. At MGH, I had psychotherapy supervisors who were MD's, PhD's, and LCSW's and there skills as psychotherapists did not seem to be corollated with that identity. But as psychiatrists were the only ones who could "do it all", prescribe meds, perform ECT, and do psychotherapy they were at the top of the hierarchy. And they were paid more, significantly more. It was not an issue of disrespect for their skills. Psychotherapy is not menial, but it is a skill shared by many different "mental health professionals". Perhaps market forces play a role in setting payments. But there is a hierarchy in income if nothing else.
V/R: JHSmdjd

Anonymous said...

As a psychiatrist in practice for almost 30 years, I find myself dismayed by Dr. Hassman's statement here that "people will realize that psychiatrists... had the patients' interests more at heart than what our substitutes will provide." Perhaps his words do not accurately convey the point he intended to make. If he argued that psychiatrists were more equipped by their training to provide better care than other mental health care providers, that would at least be arguable, but "had the patients' interests more at heart"? I can see no conceivable justification for saying the motivation to provide quality care is stronger for psychiatrists than for those other specialities.
As for the point about psychiatrists being doomed to irrelevancy, that seems to me to be highly exaggerated. They may be placed in the position of being relegated to a secondary level of care provision, much as cardiologists or endocrinologists are with respect to internists, but that hardly seems to have hurt the status of those specialties. While it does seem that this might tend to decrease the demand for psychiatrists, mental health parity and increased insurance coverage will tend to increase demand, as the article cited by Dr. Hassman also noted.
I would argue that if psychiatry is going to remain wedded to psychopharmacolgy, its relegation to a second-tier specialty in the world of mental health provision would be appropriate. In general, the average mental health care practitioner in other specialties has a more balanced view of the appropriate role and effectiveness of medication vis a vis psychotherapy than does the average psychiatrist, the legacy of psychiatry having swallowed the bait of the pharmaceutical industry hook, line and sinker for decades, much in line with the point of Dr. Carlat's article.

pacificpsych said...

Here's a challenge for you Dr Carlat. Why not ride on the wave of publicity and do something to save the profession.

Open up a public clinic where psychiatrists will do therapy (along with psychologists and LCSWs), where you (or another psychiatrist) will be in charge, where the hiring will be based on the psychiatrist's qualities (empathy for example) and not on some ridiculous credentialling criteria (i.e. a secretary deciding how your paperwork looks to her).

Where pateints will be charged a fair fee, starting at zero for the truly indigent, to say 10/hour for anyone who has a cellphone to 50/hr for someone with a minimum wage job who has a cellphone. Make it nice, not shabby and bureaucratic like most MHCs. No paperwork. No mile thick charts. Just the real note, 4-5 lines.

I submit to you that you will not be able to do this. You will not be able to open even one nice clinic. It is impossible in our current system that is controlled by bureaucrats, jacho/medicare/medicaid/insurance regs with Big Pharma overseeing it all. It is not run by common sense and (nice) intellegent educated doctors.

You will not be able to create an employed position where psychiatrist do therapy. You will not be able to reintroduce humanism into the field. And thus, nothing will change in the world of mental health at large. Nothing at all. We have ceded control, and we will never get it back.

Anonymous said...

Biological reductionism + economic pressures + cultural pressures for medications + limited number of Psychiatrists + Big Pharma's massive influence over their profession, research results, advertising directly to consumers something that is actually quite complicated and nuanced = Pill pusher/Med Check role.

Many comments here have reflected the lack of ruling out other medical diagnoses (non DSM IV labels). I'm sure there are those who do due diligence, but my experience in various settings have shown an utter lack of follow through, almost no biometric testing--even when symptoms arise that could be due to diabetes, hypothyroidism, cancer, etc etc.

Informed consent is often a joke, clients are not told much at all about side effects--nor does the MD often have the time to do so. I do informed consent for 'talk-therapy' but find that most MD's don't even attempt to give much of a dumbed down version.

I think its pretty well established that the bio-psycho-social model of mental health, basically there is no nature vs. nurture but rather its always an interaction of biology/gene expression/lifestyle/and social neurological development is often dismissed by MD's at least in practice. At least the old MD's whom still study such as Adler, M.D. and the like still did psycho-social assessments--given back than Medications were more rudimentary in some respects.

With the current economic paradigm, I see no way for MD's to remove themselves from this economic reality. Psychiatry is suffering from it's deal with the devil with Big Pharma, and promoting the dumbed down "neuroscience" pushed by advertising.

Again we don't have a mental health 'system' we have a patchwork quilt of different camps--a "tower of babel" if you will that just continues to grow. I'm fine with making 40k as a therapist, and the MD's making 250k, they took on more debt and went to school longer then me. But I'm not fine with them, not taking time with clients, and treating clients as guinea pigs.

I for one typically don't see clients until they have already been on drug treatments for many years, sometimes a decade, and then they go to talk therapy. Let's be clear, meeting with someone for 15mins, is not a thorough psych evaluation--its a joke--but a bad one. But Psych's are more likely to continue to lose ground to other non-specialist MD's in the future, and I do believe we will see another backlash as N.M.S. and the like start to show up with the millions of children they have been putting on atypicals, and titrating them purely as a behavior control--again, why not just give them ambien, its nearly the same idea in many of these cases. I hope Psychiatry separates itself from Pharma and more begin to use their typically large intellects to add to psychotherapy as well--and promote wellness overall, since so many client's lifestyles are disturbingly unhealthy--self medicating with soda, chips, candy, and a whole host of things that aren't good for the brain.

Anonymous said...

I'm a patient. Here's what I think about the whole thing: How dare anyone presume that they could assess whether my problems warrant being put on potentially dangerous drugs in 15 minutes every 3 months? That is the epitome of arrogance. And as far as off-label prescribing is concerned, even more arrogance. My body is not your personal test subject. I'm going to have my internist prescribe for me. Why should I pay for specialty care that consists solely of writing a prescription? That's a waste of my time. It's also a waste of my money and the health "system's" money. I have better things to do than to use my hard-earned cash to feed, clothe and educate the children of psychiatrists.

lethaChristina Chamberlain said...

Dr. Calat, thank you for at least opening this can of worms so the public can begin to see the problems I (as a forty-year veteran, graduate-educated psychiatric RN, as well as "consumer") have seen/experienced over a rich lifetime of experiences/education/research. Now, myself, joining the army of mental heath professionals/survivors of psychiatry--am attempting system-wide changes to abuses of human beings through a multi-pronged approach. Such a huge endeavor has kept me very humble, in that there is such a complexity of issues real change will be slow. Each of us "putting in our two cents" makes valuable contribution". I would also like to note in these comments a lack of reference to spirituality--for which we as humans are also "hard-wired": even the atheists and non-believers... Transpersonal psychology statistics show 80% of psychiatric patients come in with these kinds of issues (either alone or in conjunction with other complaints.) Only whole-person considerations will do the healing so necessary. I also note the hundreds of thousands of people already with mental health "diagnoses" on the streets, permanently stigmatized. I am now wondering if these are often people who have been subjected to the "torture" (UN declaration) of forced treatment/neuroleptic administration/ECT from which now complicates problems to the point, they will never recover. The shame of these kinds of "treatments"--and the lack of response to so many requesting help, being rebuffed, then going to such things as police-killing, mass violence, and other terrorizing behaviors shows the general lack of real concern for people in our "throw-away people" society. I thank all those "in the trenches" posting here, showing that "psychiatry" right now is not the answer, but much more basic human LOVE and providing for dignified ways "out" of a very corrupted system (in spite of all the good people who try so hard to help). Thank you for allowing me this opportunity.

Eugene said...

i have been following the discussion with interest, and would like to pose a different slant. From my perspective, medical training is invaluable to my work as a psychiatrist. I don't find things like gross anatomy, pathology and other developments in medicine to be irrelevant. They help me understand differential diagnosis, when to refer to other specialists and how to understand medical conditions that many of our patients have. We would not want an obstetrician to learn only things relevant to obstetrics even though they never treat other conditions. I believe the same is true for psychiatry and that as medicine becomes more complex, an understanding of it (and hopefully the future biological basis of psychiatric conditions), knowledge of medicine and, as Nasir Ghaemi has suggested, a medical way of thinking about psychological problems makes great sense. And perhaps we should be trained in the future to be closer to primary care physicians because the conditions we treat are so often the reason for most visits for our patients.

Some of us have been fighting the meds or therapy battle with insurers for years. I quite agree that the split as now practiced makes little sense. However, it is important to define what "psychotherapy" is as much as the attention to "psychopharmacology". I have long felt that to limit my practice to a handful of patients seen for 1-2 hours per week would be a waste of my medical training. I have a large practice (probably 400-500 patients), heavily weighted with patients who have medical/psychiatric needs and don't see more than 2 an hour and do it mostly under insurance. It is possible to do and still make a living. Most do not want, need or can use traditional "psychotherapy"; I daresay it is 90%. The people that are interested and in need i am happy to refer for therapy of the more traditional type, which I see as a related service, but different from what I provide. For the other 90%, I believe that every contact is not just a medical contact but a psychological one. To me, it is akin to the relationship with the old time GP. Someone who knows you, knows your life situation, treats illness when necessary and who you can call in a pinch.

So as you think about the possibility of abandoning medicine, I'd suggest that you think about it also from the other end. We have definitely fallen into the trap of meds or therapy and we have to get out of that bind. To me, reinvesting in the value of the medical education and medical thinking in the care of patients is more productive than diluting it. This is not a matter of turf but of expertise. I do not believe that I do a variety of non-medical psychiatric tasks any better than any other professional. But I do believe that there is a critical place for full medical training in the delivery of high quality mental health services.

Jack Walsh said...

Oh, Eugene, you smooth talker!!

"I do not believe that I do a variety of non-medical psychiatric tasks any better than any other professional." Indeed. Well, guess what? I myself, despite lacking a medical license, am damn sure I could do the medicating better than 90% of the folks with medical licenses. They are a bunch of money-happy pill pushers, in the thrall of BigPharma. Try all you want. You're still the whiney kid on the playground who can't play well with others.

The real issue is that there is nothing you think anyone can do any BETTER than you do it...that psychotherapy stuff, pish, just a bunch of words. Stand aside, sonny, and let the real docs deal with the meds here.

Please, don't hide behind a pseudonym. Let us know who not to send any more patients to. Please.

Anonymous said...

The point I made earlier, about the utter lack of biometric testing--is something Eugene basically touched on. Back in the day Psychiatrists actually used to do physicals, and although allowed to do so--in practice don't act much like PCF.

If I have to basically bug people, to have simple blood-work done, that should be done anyway with some of the meds my clients are on--but are NEVER done around here--without a whole lot of trying to get caseworkers/adults/parents stand up for themselves and lose the Awe of the Psychiatrist. Asking three or four questions, "How have you been feeling since last time etc etc." that are done with the M.A. patients routinely is a joke. Hell I can ask them three questions, what about all that Medical training--I see all kinds of physical ailments that contribute directly to their brain functioning. Doesn't diabetes, thyroidism, obesity all produce symptoms that are fairly general despite the so called specificity of the DSM.

For example, what happened to the Anxiety disorders--aren't they hip anymore--so everything is Bi-Polar II and Depression/PTSD now adays? This stuff is so trendy sometimes its a joke.

I would LOVE to have MD's use their medical expertise to treat the whole person, medicate when needed (much less mind you--or at least tell some of these folks that some of these meds are to help 'take the edge off' and 'reduce' symptoms) and do some basic biometric tests--or demand to look at them.

My opinion of most Psychiatrists have diminished after watching time and time again, them totally disregarding new Psych Evaluations..and see some kids still getting treating for Bi-Polar ruleouts from years previous, even though they had thorough Psych evals with psychometric testing and the like and have been re-diagnosed R.A.D. or G.A.D. etc. Or they just don't bother reading the documentation, which I'm guessing is the case. Or again, they MAGIC ATYPICALS, are just given out to all these children as a sedative--basically, hell with the 25% diabetes rate, the massive weight gain/endema for many of them, the Tardive, N.M.S. for long term use etc etc.

I hope that Psychiatrists don't try to just do some talk therapy--but rather act like Medical doctors rather than a Pharmacist that happens to sign the scripts'

Anonymous said...

In your comment Eugene, You mention 90% don't want/need Psychotherapy?

Really, so do you work with only patients with severe shizophrenia/bi-polar I disorder?

Your going to have to wait a very long time for the the "Future Biological basis of Mental disorders". Perhaps your up on gene expresion and all the studies now showing Bio-Psycho-Social model to be the only one the truly captures the plasticity of the human brain and the genetics--and if they are expressed or not. So your a biological reductionist/Nurture person eh, Eugene? Perhaps that's what you believe of of your patients, that its simply bad genetics, I think some Psychiatrists back in the 1940's worked on that as well.

As a lowly Talk-Therapist, I advocate for some clients to get medicated or at least evaluated (which means they get medicated, since I haven't had ONE single person ever return without meds, unless they blatantly refused them.) Neuroscience is still in it's infancy, half of the things I studied in the 90's have since been proven wrong--or overstated dramatically. Now we know that there is neurogenesis beyond the Hippocampus.

Remember experience/thoughts/actions push dendritic growth---priming the synapses may help in that regard, but keeping Dopamine or Serotonin in the synapse longer--doesn't in itself re-wire the brain, thus client lifestyle/thought/actions typically need to change as well.

S said...

I see a lot of agreement here. Psychiatrists' medical training is invaluable. IF they use it. If the majority of psychiatrists acted like medical doctors and did thorough medical assessments of their patients, i don't think there'd be any reason to have this discussion.

Eugene said...

Re my comment 90% don't want, need, or can use traditional psychotherapy. Emphasis is on traditional, meaning one hour a week or more frequently. I would also add "afford" to the list.

I draw on psychodynamic understanding as much as on medical understanding in most every contact I have with a patient. I have never understood why "psychopharmacologists" don't know about their patients lives and rely on symptoms more than a global picture of functioning to guide them. But I have also not understand why patients who could truly benefit from medication are not referred or why the one size fits all 1-2 hours a week psychotherapy is prescribed as cavalierly by therapists as medication is prescribed by psychopharmacologists.

We have inherited a mindless "med vs therapy" paradigm first from community mental health and then from the insurance industry (with a vengeance). We must rethink the whole package so that patients get what they need on an individualized basis.

Anonymous said...

There is no "Med vs. Therapy" Paradigm in nearly every setting I've worked as a Talk therapist--pretty much 90% of all the clients I've ever worked with were medicated before I met them and had been for some time, or were medicated in short order. I'm being lenient with the 90% since I can only think of three clients in 8 years that were not medicated.

I think most of us Talk therapists, who spend a lot of time with clients (more than one hour a week in some of the non outpatient type settings) are more frustrated with the utter lack of communication, over-medication, and the seeming lack of care/follow through with biometric testing for some of the meds which have severe and dangerous side effects and possible toxic effects if the child/adults bodies aren't removing the drug.

So in response to Eugene's comment, I responded to him previously here. If biological reductionism is the conceptual framework, then it does become an "us vs. Them" to some degree since some therapists are perhaps to much on the side of environment--but many who pay attention to research and have a background in neuroscience understand it's usually a combination of both--thus the biopsychosocial model of mental health. Hell, even for many physical ailments lifestyle, diet, environmental stressors either cause/contribute/or turn on the genes to produce the pathology.

There is no "us vs. Them" in my opinion, because we don't even get as far as saying "hello, hey could we briefly consult on this shared case." This only happens in rare setting, perhaps hospitals, which I have never worked at--but in the social work-esque field, colleges and the like, M.D's and Talk therapists aren't chatting.

Talk therapy sometimes can be like the late great Carl Whitaker, M.D. said, "firing blanks". As a collaborative/cooperative endeavor--its pretty difficult to DO therapy to someone--even though as someone who has worked with many high-risk/court ordered clients both children/and adult--they continue to try to do this anyway. For some medications truly seem to alleviate suffering and sometimes allow talk therapy to be more effective, or at least help them to manage distressing symptoms--but for others (many children I've seen) it's just a way to try and use chemistry to manage behaviors---and use mental health Jargon/system to do it under the guise of helping. Again, for so many clients I've seen put on atypical in the past 4 years, with no regard for their drastic weight gain, ticks, endema, and the sedative effect (which is really why they put some of these angry kids on it) I say this is unethical at the least--and again, this is all off-label usage. I never say M.D.'s that worked with affluent college kids in a previous job--give them atypicals for anger management etc and they were rarely labeled Bipolar etc. even though this was supposed the age range when this occurs. Anyone else out there have experience working primarily with M.A. clients and seeing the amount of serious medicating that is involved with these children--regardless of actual symptom cluster.

Again let's be clear, anger is a basic primitive human emotion, it doesn't denote Bi-polar II, many of these cases previously were criminal justice type, but the mental health system and Big Pharma seem to have turned any purpposeful/learned human behavior into a "mental illness" especially if your poor and have less power in society--aka. Children.

Jennifer Bremer MD said...

Congratulations on the article!

Anonymous said...

If I had a therapist, I would not want him or her talking about me with my psychiatrist without my being present. If my psychiatrist wants to know something about me, he can ask me himself. That is his job.

I terminated a therapist relationship because there was a lot of "talking" going on without my knowing what was being discussed and why. I see this as laziness and/or greediness (refusal to spend an appropriate amount of time due to reimbursement) on the part of the psychiatrist. Frankly, if more therapists refused to discuss clients/patients with psychiatrists, maybe psychiatrists would actually start doing their jobs.

Who likes it when people talk about them behind their back? This is not the same as a surgeon discussing a case with an internist or specialist. That generally is strictly a medical discussion. No, I'm talking about discussing the things that are going on in my life - my problems, my interpersonal challenges, my failures. If he wants to know, he can ask and I may tell him. Or, I may not tell him because I don't necessarily trust that he won't just go off and discuss it with someone else without my knowing about it.

MD/therapist consults are not the panacea some here make them out to be. Patients like me might fire you for engaging in such behavior. What I say in a therapy room is private and personal. Private means private. It does not mean "private, except feel free to discuss it with my doctor who doesn't care enough to ask about it himself."

Perhaps the situation would have been different and I would not have minded so much if the therapist in question had not been so rabidly pro-medication. She approached the point of coercion at times and when I found out that this was generally around the time that she had had discussions with my psychiatrist, she was fired. How's that for promoting trust and strengthening the "therapeutic alliance"? Apparently, the alliance was between doctor and therapist, not therapist and patient. Gee, my psychiatrist can't even find the time to discuss possible new medications with me? He has to do it through my therapist? Lazy.

Anonymous said...

pacificpsych -
Wow. You really do play the helpless victim, don't you? It's not patients' responsibility to get you to do your job. You sign the insurance contracts. You set your schedule. You decide whether to write or talk. You have an established relationship with your own boss and/or administrator (BTW, your boss/administrator could not care less what patients think). You decide whether you want to make lots of income or less income. Exactly how is your refusal to do your job OUR problem? If you agree that changes need to be made, then make them and quit asking those who have less power than you to do it for you. I've never heard such complaining and impotence from the mouth of a physician. If there is blame to be laid, it is at your feet, not at the feet of your patients. We have no say in the way you CHOOSE to practice psychiatry. I assume you are an adult who has the ability to choose employers and practice arrangements. If you don't like yours, leave. That's what people do.

Anonymous said...

One of the letters to the editor in response to this article in the NYT said this:

"Learning how to practice the art of psychotherapy is much more difficult and anxiety-provoking."

The author was explaining why some psychiatrists might choose to focus only on pschyopharmacology. Since those who do 15 minute med checks, in my mind, are not doing their JOBS, the sentence above tells me that psychiatrists are not only worried about making as much money as humanly possible, but also how to do that while being LAZY.

Sure, a lot of jobs are difficult, complex and very challenging. So what? Suck it up and do your jobs, new grads.

It's all well and good that apparently so many programs still offer psychotherapy training, but it doesn't matter if the graduates don't use it. For example, my psychiatrist attended an Ivy League residency program that places a STRONG emphasis on psychotherapy, but he doesn't touch it with a ten-foot pole. I'm sure his Ivy League mentors would be quite proud of him for figuring out how to make so much money while not having to use very much energy thinking. Hell, if I could make that much money scribbling a sentence fragment on a notepad, I'd do it, too. The difference is, I would acknowledge my laziness and greed. Yes, I actually would. Probably because I would feel guilty about doing a half-assed job and still making so much money. But I am an over-achiever and I like to feel proud of my work. I guess all the med-checkers were over-achievers in med school and then discovered they could make lots of cash without engaging the same organ they profess to know so much about. Good for them. Bad for patients.

In fact, I think psychiatrists should stop calling their patients patients and call them what they really are: clients. That's right, they're clients. Why? Because they are buying your DEA number. And that's what you are selling.

Ro said...

Dear Dr. Carlat,

Your succinct piece in the Times touched a personal chord for me. My mother had been depressed since her angioplastic (even this procedure was probably unnecessary!) in January 2006. A woman who was 24/7 active became 24/7 inactive! Indeed, she was also treated by psychiatrists.

A highly intelligent and strong-willed woman, recently, she stopped all medication, including for her heart and is doing much better. She has even begun eating much better. Up until recently she hardly ate and stayed in bed almost all the time.

A trained musician she was teaching tens of students but now, the only music she religiously listens to is mine every day at a set time. She's not normal yet, but since she stopped all medication, she certainly has come a long way and finally, as her daughter and caregiver, I'm beginning to feel hopeful. I've taken her up as a project and I'm beginning to see results. Thanks for your total honesty in talking about your profession.

With all due respect to my psychiatrist friends, I must confess that I didn’t think they could cure her (they had no idea of her belief system nor her upbringing, which in my opinion contribute much to how one deals with life’s traumas), and they didn’t. One of them (not my friend) came across as a real quack, in fact. I’m not sure if she was a psychiatrist or from one of those sub-professions.

I felt very sorry to read about your mother’s suicide.

Ro.
www.yeahwhatif.blogspot.com

Jennifer Bremer MD said...

I like what Eugene said. I'm thinking I know you Eugene? If so, hi. If not, you sound like my fantastic teacher.

There are many of us out here who highly value an integrated approach and using meds with care and thought. I do not understand why somehow those who do not do as good a job are considered representative of the field? If a psychiatrist is not doing a good job, simply find a or refer to a new psychiatrist. I have many friends and colleagues who are superb and prescribe with care.. They are out there.

Anonymous said...

I was given your NY
Times article by one of my patients. She commented that I had been more than just a "prescriber" but was interested in developing an actual relationship with her. Now that I've read your article I understand what she was talking about. I am a Psych NP and find that NOT engaging with my patients is a foreign experience. Nursing is all about relationships. After working as a psych nurse for years, I left for over ten years when it became apparent to me that the psychiatric profession had seriously lost it's way. When I came back it was all about prescribing and little about treating the whole person. I'm glad to hear you are of the same mind. Treating only from the head up ignores everything below that can so often impacts the big picture. How can one possibly ignore the emotional life of our patients when it is at least half the picture? RS.

pacificpsych said...

To Anon up there: thank you for that little ad hominem. I don't have a boss. I see physicians with burnout and do other non medical work. I've never signed an insurance contract in my life and I've never done 15 minute visits. I've made my choice - cash only, talk only, because it's the only way to go. I think there's something wrong with this being the only way to do real work. I think you'll see more and more physicians (from all specialties) quitting the system and either setting up cash practices or quitting medicine altogether. Hope that helps!

Anonymous said...

I agree with PacificPsych in that the system is set up to make quantity of clients and "med checks" the norm in most areas--and the financially feasible means to be a Psychiatrist. I am friends with a couple older Psychiatrists and they have always taken cash clients, if they relied on that, they would still be paying off their student loans at age 60. Perhaps in some very affluent areas this is feasible, but clearly cash only practices mean making far less money in most cases--and simply most people can't afford to do this coming out of Med school with 150-200k debt.

In response to Dr. Bremer's recent comment, I'm sure you are aware this a national shortage of Psychiatrists. In my city, of 200k people, there are only 8 psychiatrists, last I knew--with 2 of them that I know, both in their mid 60's and looking to work part-time only. Around her it sometimes takes 2 months to get a meeting with a Psychiatrist if you are poor (M.A. client) since there are only a handful that work with thousands of patients.

I've had children that have clearly had liver problems and had resting heart rates that were in the 120's, have to wait weeks to see a Psychiatrist--and the parent's were told not to reduce dosage or take them off the pill without the MD's advice.

So around here there is no real choice, and the prescribe with care MD's have such huge caseloads that they can't possibly do due diligence even if they wanted to. And again, why are so many of my clients being put on atypicals for depression--someone again explain to me why the D2 receptor helps clinical depression? So far, I've seen no alleviation of symptoms with clients, quite the contrary these clients become more lethargic, tired, forgetful, fat, and are more flat and without energy than when they were on SSRI's alone. Does anything go then, even if there are no results, as long as the clients are too poor and uneducated to realize they are merely being sedated them to wellness?

Anonymous said...

One more thing, pacificpsych:

You ask patients to run and complain to their lawmakers and others. I don't know anyone who would jump at the chance to admit publicly that they see a med-checker and talk to their politicians about it.

It must offer you some relief to abdicate responsibility for your profession's own shortcomings and place all of the responsibility for fixing things on your patients, but that is not our job. Our job is to feel better. And we don't need the added stress of publicly admitting that we see a med-checker for a psychiatric condition. You, as a psychiatrist who professes not to be just a med-checker, should know that.

Maria said...

On 5th March 2008 a psychiatrist met my 17 year old son, Toran in a cafe to conduct a psychiatric assessment. He prescribed the antidepressant fluoxetine despite recording that Toran exhibited no symptoms of depression or any other mental disorder. On 6th March, Toran's file was update to record that diagnosis had been deferred. On 20th March Toran committed suicide. At the inquest, seven psychiatrists testified that Toran's 'care' represented usual practice in New Zealand. At the assessment I vehemently opposed the prescribing of antidepressants to my son and attempted to discuss the research on the risk of suicidality associated with the drugs. The Social Worker present at the meeting testified at Toran's inquest that the psychiatrist told me to "stop reading research and trust his professional judgement." I asked if we could trial CBT before medication and the psychiatrist said no. He said that legally I had no right to stop Toran's access to medication. The Social Worker testified that his attitude to both Toran and I was "aggressive and authoritarian." I was the person who found my son, my only child, following his violent suicide. I was involuntarily assessed by a psychiatrist who recorded that I suffered no mental disorder but exhibited 'normal bereavement' but sent me home with five different psychotropic medications. I overdosed on them the following day. In his brief of evidence, the psychiatrist said that when he was told Toran had committed suicide 15 days after he had given him the drugs, he couldn't really remember who he was. My son's life is ended and mine is destroyed but this is not a story about one family. It is a story that applies to thousands of families. You will understand my view that psychiatrists, with their well documented links to the pharmaceutical industry, are nothing but legalised drug dealers. All of those who testified at his inquest justified the actions of their colleague...

pacificpsych said...

Interesting comments. Good example of what leads to physician burnout (in all specialties). You're criticising the critic, have you noticed? Why not direct the anger at those who cause the problem? Perhaps because they're not here? Shoot the messenger, ay?

Admin (some highly paid kid with an MBA and a suit) sits in a leather chair far from the front line pushing paper all day and dictating to physicians how they will practice. But patients will always direct their anger at the physician and nurse who are treating them.

I understand it's unsettling to be faced with the possibility that physicians are not omnipotent. I'm amused that despite all the talk of the decline of paternalism and rise of patient empowerment, people still want physicians to do all the work for them.

These comments point to what is perhaps the biggest source of physician burnout, in all specialties. They are trapped in a system they don't control, whose rules are set by everyone but themselves. They are forced to practice in a manner incompatible with their professional standards. The only way out is to leave the system, something that is not always possible, to open a cash practice or leave medicine altogether. But when they do that, they are accused of abandoning ship...

Can't win!

Not happy with the way things are? Do something about it. Taking control is empowering. Most patients who see a psychiatrist are not completely debilitated. Even the severely mentally ill might have family or advocacy groups that can represent them. Not against the doctor who's treating you, but against the system that undermines your doctor's ability to give you proper treatment.

If you can write on this blog, you can write to the new head of the APA, to your congressman and to your insurance company with all your concerns.

Anonymous said...

Maria,

I am so sorry for your loss. I am speechless as to what happened to you.

I am stunned you were involuntary assessed after the death of your son and given 5 psych meds.

And people wonder why there is so much anger against psychiatry.

Again, I am so sorry.

AA