2/01/2004: Talking back to Prozac
5/14/2005: MGH psychiatry funding questioned
12/03/2006: Defending big pharma
NEWBURYPORT -- There are names for what Dr. Daniel J. Carlat once was, and he does not hesitate to use them: "Drug whore," he suggested calmly. "Hired gun."
"There's really no nice way to say it. If you're being paid to offer an opinion you're not all that confident that you believe, you're corrupt," he said.
Six years ago, Carlat, a psychiatrist and textbook author who trained at Massachusetts General Hospital, found himself in demand by drug companies. Like a great many prominent psychiatrists, he was offered generous sums to give instructional talks about medications at lunches and dinners with his colleagues: $500 or more per "lunch-and-learn," $1,000 or more per dinner. He did it for about a year, speaking mainly about antidepressants, for a total of $30,000 or so beyond his salary of about $120,000.
But then his conscience rebelled. A drug salesman chided him one day for showing "less enthusiasm for our product" than usual and "I had a kind of epiphany," said Carlat, also on the faculty of the Tufts University School of Medicine. "I realized the obvious -- that I was being paid to say good things about drugs, regardless of what my actual opinions were."
He not only walked away from the extra money and perks, he resolved to fight what he saw as an increasingly pernicious influence on psychiatric practice.
These days, operating from an old brick building in this quaint seaside town, he sees patients and puts out The Carlat Psychiatry Report, a monthly newsletter on psychiatric developments that aims to be more aggressively free of drug-company influence than any other, from its content to the financial ties of its writers.
Potential conflicts of interest are a growing concern in all of medicine, from cancer doctors who own scanning centers to cardiologists who prescribe specific blood-pressure drugs while accepting payments from companies that make them. Several states have recently passed laws mandating that drug-makers report such ties, but the great majority of payments remain undisclosed.
By all indications, "psychiatrists are among the most conflicted of the medical specialties," said Dr. Jerome P. Kassirer , a Tufts University professor and author of "On the Take," a book about what he describes as medicine's complicity with big business. With new drugs available for common conditions such as anxiety and depression, the pharmaceutical industry has been recruiting armies of psychiatrists to market them in recent years, he said.
He has met Carlat, Kassirer said, and "I'd say he's the real thing. He honestly believes that psychiatry has gone too far, and by the way, so do I."
Not everyone agrees that company payments are a problem in psychiatry. Like many doctors, psychiatrists who accept money tend to argue that they are not about to be swayed by the consulting fees or research grants they get from companies.
From the industry point of view, drug companies are simply paying the market rate for bona-fide services and the expertise that prominent psychiatrists can provide, said Scott Lassman , a spokesman for PhARMA, the national trade association for pharmaceutical companies.
"The people who are doing this are professionals and care a lot more about their reputation in the community than about whatever money they're making by providing these services," he said. "I don't think they're going to say anything that they don't believe, and the companies certainly wouldn't want them to."
In psychiatry, Carlat said, one drug tends to be much like another, and a psychiatrist may -- as he once did -- rationalize that it does no harm to patients to push one drug over another.
But when he started to look around at the bigger picture of drug companies' influence on psychiatry, "I said, 'This is unbelievable! Our field as a whole is progressively being purchased lock, stock, and barrel by the drug companies: this includes the diagnoses, the treatment guidelines, and the national meetings."
Perhaps worst of all, Carlat said, drug companies have come to sponsor so much of continuing medical education -- the courses that doctors must take to retain their licenses -- that the companies can set much of the agenda.
"Instead of getting educated about psychotherapy, about how to better manage our practices, about epidemiology and the public health concerns of underserved populations, what we're getting is lecture after lecture about how to diagnose depression and use antidepressants to treat it; how to diagnose insomnia and use sleeping pills to treat it; how to diagnose bipolar disorder and use mood stabilizers to treat it," he said.
In particular, Carlat said, he is appalled that his prestigious former employer, Mass. General, has chosen to accept millions of dollars of drug-company money to sponsor its continuing psychiatry courses. MGH says that its pharmaceutical sponsors have no input on the courses.
Carlat's newsletter is by no means anti psychiatry; it is meant for psychiatrists and their patients. Nor is it anti medication; Carlat himself prescribes drugs in his private practice all the time, he said, "because they work."
But it aims to cut through layers of drug advertising and studies sponsored by drug companies to a relatively spin-free bottom line.
The Report might warn, for example, that a new drug is merely a tweaked version of an older drug whose patent is about to expire -- meaning the new drug is probably not worth its sticker price.
In 2004, the Report concluded that a new anti depressant, Cymbalta, offered no significant advantages over existing drugs, and that its maker, Eli Lilly, was massaging the data to make it look better than it was. The article and its headline, "Cymbalta: Dual the Reuptake, Triple the Hype," drew a lengthy complaint from Eli Lilly, replete with 24 footnotes that Carlat then published on the Report's website, with his own rebuttal.
The Report (online at thecarlatreport.com) does carry interviews with psychiatrists who have financial ties with drug companies, Carlat said, but only because it is simply impossible to find prominent psychiatrists without such ties. He asks experts to disclose any financial ties in print.
Carlat seems to have struck a nerve. From a tiny 2002 start-up, the newsletter has grown to a circulation of 2,300 -- almost enough to begin paying himself a salary for his three days a week of writing and editing, Carlat said. Subscriptions range from $89 a year for individuals to $149 for institutions.
Dr. Steven Sharfstein , immediate past president of the American Psychiatric Association, the field's major professional group, said he believes that Carlat may be part of a larger movement, "a change in sensitivity and sensibility" about pharmaceutical industry involvement in psychiatry.
Sharfstein said he has no hard data, "but I believe there's a trend that people are moving away." His own hospital, Sheppard Pratt Health System near Baltimore, has stopped letting drug companies sponsor lectures.
"So now we just don't have fancy snacks," he said. "It just didn't feel right."
Carey Goldberg can be reached at email@example.com.