Neurology Center

Just wanted to let everyone know about a blog called 1 boring old man, which is a very poor name as it isn't boring at all.


I don't know if it's written by an old man or not, one can only assume so, but whoever writes it, it has got a lot of extremely good stuff about psychiatry and psychiatric drugs. Fans of Daniel Carlat's blog or even former readers of the now seemingly defuct Furious Seasons will find it extremely interesting.

It's actually been going since 2005, but for some reason I've only just found out about it (many thanks to regular Neuroskeptic commentator Bernard Carroll).

So apparently: Left wing or right wing? It's written in the brain

Last week I was at a discussion about New Media, and someone mentioned that they'd been put off from writing content online because of a comment on one of their articles accusing them of being "stupid".

I found this surprising - not the comment, but that anyone would take it so personally. It's the internet. You will get called names. Everyone does. It doesn't mean there's anything wrong with you.

I suspect this is a generational issue. People who 'grew up online' know, as Penny Arcade explained, that

The sad fact is that there are millions of people whose idea of fun is to find people they disagree with, and mock them. And they're right, it can be fun - why else do you think people like Jon Stewart are so popular? - but that's all it is, entertainment. If you're on the receiving end, don't take it seriously.

If you write something online, and a lot of people read it, you will get slammed. Someone, somewhere, will disagree with you and they'll tell you so, in no uncertain terms. This is true whatever you write about, but some topics are like a big red rag to the herds of bulls out there.

Just to name a few, if you say anything vaguely related to climate change, religion, health, the economy, feminism or race, you might as well be holding a placard with a big arrow pointing down at you and "Sling Mud Here" on it.

The point is - it's them, not you. They are not interested in you, they don't know you, it's not you. True, they might tailor their insults a bit; if you're a young woman you might be, say, a "stupid girl" where a man would merely get called an "idiot". But this doesn't mean that the attacks are a reflection on you in any way. You just happen to be the one in the line of fire.

What do you do about this? Nothing.

Trying to enter into a serious debate is pointless. Insulting them back can be fun, just remember that if you find it fun, you've become one of them: "he who stares too long into the abyss...", etc. Complaining to the moderators might help, but unless the site has a rock solid zero-tolerance-for-fuckwads policy, probably not. Where the blight has taken root, like Comment is Free, I'd not waste your time complaining. Just ignore it and carry on.

The most important thing is not to take it personally. Do not get offended. Do not care. Because no-one else cares. Especially the people who wrote the comments. They presumably care about whatever "issue" prompted their attack, but they don't care about you. If anything, you should be pleased, because on the internet, the only stuff that doesn't attract stupid comments is the stuff that no-one reads.

I've heard these attacks referred to as "policing" existing hierarchies or "silencing" certain types of people. This seems to me to be granting them far more respect than they deserve. With the actual police, if you break the rules, they will physically arrest you. They have power. Internet trolls don't: if they succeed in policing or silencing anybody, it's because their targets let them boss them around. They're nobody; they're not your problem.

If you can't help being offended by such comments, don't read them, but ideally you shouldn't need to resort to that. For one thing, it means you miss the sensible comments (and there's always a few). But fundamentally, you shouldn't need to do this, because you really shouldn't care what some anonymous joker from the depths of the internet thinks about you.

Well he's not. Actually, I haven't met him, so it's always possible. But what he certainly has done is written a book called Unhinged: The Trouble with Psychiatry.

Daniel Carlat's best known online for the Carlat Psychiatry Blog and in the real world for the Carlat Psychiatry Report. Unhinged is his first book for a general audience, though he's previously written several technical works aimed at doctors. It comes hot on the heels of a number of other recent books offering more or less critical perspectives on modern psychiatry, notably these ones.

Unhinged offers a sweeping overview of the whole field. If you're looking for a detailed examination of the problems around, say, psychiatric diagnosis, you'd do well to read Crazy Like Us as well. But as an overview it's a very readable and comprehensive one, and Carlat covers many topics that readers of his blog, or indeed of this one, would expect: the medicalization of normal behaviour, to over-diagnosis, the controversy over pediatric psychopharmacology, brain imaging and the scientific state of biological psychiatry, etc.

Carlat is unique amongst authors of this mini-genre, however, in that he is himself a practising psychiatrist, and moreover, an American one. This is important, because almost everyone agrees that to the extent that there is a problem with psychiatry, American psychiatry has it worst of all: it's the country that gave us the notorious DSM-IV, where drugs are advertised direct-to-the-consumer, where children are diagnosed with bipolar and given antipsychotics, etc.

So Carlat is well placed to report from the heart of darkness and he doesn't disappoint, as he vividly reveals how dizzying sums of drug company money sway prescribing decisions and even create diseases out of thin air. His confessional account of his own time as a paid "representative" for the antidepressant Effexor (also discussed in the NYT), and of his dealings with other reps - the Paxil guy, the Cymbalta woman - have to be read to be believed. We're left with the inescapable conclusion that psychiatry, at least in America, is institutionally corrupt.

Conflict of interest is a tricky thing though. Everyone in academia and medicine has mentors, collaborators, people who work in the office next door. The social pressure against saying or publishing anything that explicitly or implicitly criticizes someone else is powerful. Of course, there are rivalries and controversies, but they're firmly the exception.

The rule is: don't rock the boat. And given that in psychiatry, all but a few of the leading figures have at least some links to industry, that means everyone's in the same boat with Pharma, even the people who don't, personally, accept drug company money. I think this is often overlooked in all the excitement over individual scandals.

For all this, Carlat is fairly conservative in his view of psychiatric drugs. They work, he says, a lot of the time, but they're rarely the whole answer. Most people need therapy, too. His conclusion is that psychiatrists need to spend more time getting to know their patients, instead of just handing out pills and then doing a 15 minute "med check" - a great way of making money when you're getting paid per patient (4 patients per hour: ker-ching!), but probably not a great way of treating people.

In other words, psychiatrists need to be psychotherapists as well as psychopharmacologists. It's not enough to just refer people to someone else for the therapy: in order to treat mental illness you need one person with the skills to address both the biological and the psychological aspects of the patient's problems. Plus, patients often find it frustrating being bounced back and forth between professionals, and it's a recipe for confusion ("My psychiatrist says this but my therapist says...")

This leads Carlat to the controversial conclusion that psychiatrists should no longer have a monopoly on prescribing medications. He supports the idea of (appropriately trained) prescribing psychologists, an idea which has taken off in a few US states but which is hotly debated.

As he puts it, for a psychiatrist, the years in medical school spent delivering babies and dissecting kidneys are rarely useful. So there's no reason why a therapist can't learn the necessary elements of psychopharmacology - which drugs do what, how to avoid dangerous drug interactions - in say one or two years.

Such a person would be at least as good as a psychiatrist at providing integrated pills-and-therapy care. In fact, he says, an even better option would be to design an entirely new type of training program to create such "integrated" mental health professionals from the ground up - neither doctors nor therapists but something combining the best aspects of both.

There does seem to be a paradox here, however: Carlat has just spent 200 pages explaining how drug companies distort the evidence and bribe doctors in order to push their latest pills at people, many of whom either don't need medication or would do equally well with older, much cheaper drugs. Now he's saying that more people should be licensed to prescribe the same pills? Whose side is he on?

In fact, Carlat's position is perfectly coherent: his concern is to give patients the best possible care, which is, he thinks, combined medication and therapy. So he is not "anti" or "pro-medication" in any simple sense. But still, if psychiatry has been corrupted by drug company money, what's to stop the exact same thing happening to psychologists as soon as they got the ability to prescribe?

I think the answer to this can only be that we must first cut the problem off at its source by legislation. We simply shouldn't allow drug companies the freedom to manipulate opinion in the way that they do. It's not inevitable: we can regulate them. The US leads the world in some areas: since 2007, all clinical trials conducted in the country must be pre-registered, and the results made available on a public website, clinicaltrials.gov.

The benefits, in terms of keeping drug manufacturer's honest, are far too many to explain here. Other places, like the European Union, are just starting to follow suit. But America suffers from a split personality in this regard. It's also one of the only countries to allow direct-to-consumer drug advertising, for example. Until the US gets serious about restraining Pharma influence in all its forms, giving more people prescribing rights might only aggravate the problem.

Ever wanted to crack the mysteries of the brain? Dreamed of discovering the cause of mental illness?

Well, now, you can - or, at any rate, you can try - and you can do it from the comfort of your own home, thanks to the new Stanley Neuropathology Consortium Integrative Database.

Just register (it's free and instant) and you get access to a pool of data derived from the Stanley Neuropathology Consortium brain collection. The collection comprises 60 frozen brains - 15 each from people with schizophrenia, bipolar disorder, and clinical depression, and 15 "normals".

In a Neuropsychopharmacology paper announcing the project, administrators Sanghyeon Kim and Maree Webster point out that

Data sharing has become more important than ever in the biomedical sciences with the advance of high-throughput technology and web-based databases are one of the most efficient available resources to share datasets.

Coded specimens are sent to researchers with the code varying from researcher to researcher to ensure that all studies are blinded. The code is released to the researcher only when the data have been collected and submitted to the Institute.