What Is a Psychiatrist, Anyway?

If psychiatry is to help patients make knowledgeable choices about their treatment, it will need to rebrand in a way that makes sense not just to the mental health community, but to the public.
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Don't pretend to know everything about how psychiatric medications work, psychiatrist Daniel Carlat urges his colleagues in his new book, Unhinged: The Trouble with Psychiatry - A Doctor's Revelations About a Profession in Crisis. Be open with patients about how much doctors and scientists still don't understand about the biology of mental illness and how to treat it. And for Pete's Sake give therapy a try.

Those might not sound like the revelations the book's subtitle promises. But in examining psychiatry up close, Unhinged reveals something more important to the average reader: It hints at just how insanely confusing it is to try to navigate the landscape of mental health care in America.

Carlat is mostly concerned about how the profession of psychiatry has transformed from one that emphasized talk therapy to one that focuses on dispensing pills, even though evidence shows that a combination of the two often works best. He includes the rather unsettling statistic that only 11 percent of psychiatrists provide psychotherapy at every visit.

To prospective patients, though, the more immediate problem is figuring out what they're getting into; the term "psychiatrist" has come to mean everything and nothing. It indicates that the person went to medical school and can prescribe medication, but it doesn't say anything about the doctor's actual approach to treatment. Throw in clinical psychologist, social worker, counselor and therapist, not to mention some other specialty terms, and you have a thoroughly confusing mess of monikers within the mental health profession.

We'll probably argue for decades about the relative importance, value and efficacy of different forms of therapy, different kinds of medication and various combinations of the two. That debate is absolutely worth having, especially if it prompts more and better research. In the meantime, though, many people already hold strong opinions about what kind of mental health treatment they want for themselves and their kids. It's just hard to know which caregivers will actually provide that kind of treatment.

Carlat notes early in his book that he spent the first part of his career as a psychopharmacologist, which meant he went to medical school, did a psychiatric residency and then focused his practice on prescribing medication. As such, he limited his appointments to 15- to 20-minute "med checks" in which he asked patients about symptoms and side effects and adjusted dosages accordingly.

Most psychiatrists today arguably are psychopharmacologists; they just don't necessarily self-identify as such. The term has its downsides. It's a mouthful, and critics of medication-only treatment often use it derisively, as one self-identified psychiatrist pointed out in response to Carlat's recent article in The New York Times Magazine.

"In our field psychopharmacologist has just become a code for doctors who are uncomfortable 'dealing' with patients. Untrained in therapy, uncurious about people they worry about having little to offer people beyond a pill."

Some patients, though, aren't seeking anything beyond a pill. Perhaps they're uncomfortable discussing their private thoughts and feelings with a virtual stranger. Maybe they already have a therapist they love and just need someone to supervise the medication aspect of their treatment. Or maybe their insurance won't pay for enough mental health visits to make regular therapy feasible (a situation the federal mental health parity law is designed to fix). One can criticize any of these scenarios as providing less-than-optimum care; Carlat believes that splitting treatment between a therapist and a psychopharmacologist shortchanges patients and duplicates efforts -- but patients make decisions based on their actual situations, not some idealized view of best practices.

More precise terms would help patients make informed decisions about their treatment. With a psychopharmacologist, patients know that their appointments will likely be short and that treatment will focus on monitoring medication dosages, side effects, and interactions. If they want someone who is able both to prescribe medication and counsel them extensively about their worries, relationships, habits or ambitions, they should go elsewhere within the psychiatric profession.

But where should they go, given that most psychiatrists don't provide therapy? It's not clear. In Unhinged, Carlat advocates that psychiatrists should aspire to be "psychological healers" who focus more on their patients than on the latest neuroscience findings. Calling for an individualized, integrated approach to treatment, Carlat may have chosen the amorphous "psychological healer" because he's reluctant to pigeonhole himself and his peers. But if psychiatry is to help patients make knowledgeable choices about their treatment, it will need to rebrand in a way that makes sense not just to the mental health profession, but to the public at large.

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