A Response by Daniel Carlat

From my standpoint as the author of Unhinged, Dr Haldipur’s review is both good news and bad news. The good news is that he thinks I’m talented and erudite. The bad news is that he doesn’t like the book, summing it up as a “book of scandals and debates, and a polemic of sorts-a ‘trahison des clercs’-rather than an intellectual discussion about psychiatry.” Erudite or not, I had to look up “trahison des clercs.” It means “a compromising of intellectual integrity, especially for political reasons.” Ouch.

Well, I can agree with Dr Haldipur on one thing. Unhinged is not an intellectual discussion about psychiatry. Instead, it is a call to arms-an effort to shake us out of our complacency and to get us thinking about solutions.

There is an old joke about 2 elderly women who are at a resort in the Catskill Mountains. One of them says, “Boy, the food at this place is really terrible.” The other says, “Yeah, I know; and such small portions!”

In psychiatry, we are unfortunately in a similar situation. Psychiatrists are now primarily 15-minute psychopharmacologists, rushing patients through the office to increase reimbursements. This is insufficient time to properly evaluate and treat patients with medications, much less
to squeeze in some psychotherapy. Thus, the care we are providing, while not descending to the level of the food at the Catskills resort, is often suboptimal.

We can do much better.

You can see the punch line coming a couch away.

The second problem with modern psychiatrists is that there aren’t enough of us. The Health Resources and Services Administration recently documented a “critical shortage” (meaning that only half of patient needs are met) of psychiatric prescribers in 75% of all counties in this country. The shortage will worsen-because psychiatrists are relatively old and are retiring faster than they can be replaced, and because health care reform will add some 30 million new patients to the insurance rolls.

These 2 problems constitute the “Trouble with Psychiatry” to which I refer in Unhinged. It is not something that I made up, nor is it a problem that I publicized for fame and fortune, as implied by Dr Haldipur. It is the elephant in the middle of the room, and psychiatrists are studiously ignoring it.

Most of Unhinged is my effort to detail these problems in language understandable by the general public. It is a mashup of memoir, historical research, and strongly held opinion. In the last few pages of the book, I offer a list of solutions. Much has been made of the fact that I included prescribing psychologists on that list. But actually, the solution that I endorsed most forcefully is to tweak psychiatric training so that it is shorter and more relevant to what we actually do.

It is time for us to be honest with ourselves and to admit that most of us use only a fraction of our medical training in our day-to-day work. Few of us do physical exams after residency. When we discover a possible medical problem during our interviews, we don’t deal with it ourselves-we turf the patient to a primary care physician for evaluation and treatment. For most psychiatrists, medical school and internship is a 5-year lesson in medical triage. We learn all our psychopharmacology and psychotherapy during our 3 years of residency and during our years of psychiatric practice.

Dr Haldipur points out correctly that there are exceptions. Some psychiatrists, especially in the public sector, keep up with their medical skills and treat their patients’ basic medical problems. There will always be such medically oriented psychiatrists, and there will always be a need for some psychiatrists to go through the entire traditional medical training process.

But we must provide another option for psychiatric training . . . one that is tailored specifically for the skills that we use on a daily basis. What would that training look like? Like colleges of dentistry, optometry, and podiatry, it would likely be a 4-year postgraduate program, with the option of additional subspecialty training. It would certainly involve a thoughtful integration of psychology, psychopharmacology, and medicine. Creating such a program would be a complicated task. The first step would likely be an exploratory committee formed within the American Psychiatric Association. The committee might even include the participation (horror of horrors!) of our psychology colleagues from the “other” APA.

Dr Haldipur begins his review of Unhinged with the story of a medical student who chooses psychiatry because he is so impressed with our willingness to debate controversial issues. I pray that we will not disappoint that student now.

Click here to read the review of Unhinged: The Trouble With Psychiatry-A Doctor’s Revelations About a Profession in Crisis by Dr Haldipur