Q&A with Dr. Daniel Carlat: Finding an independent voice in a pharma-sponsored world

Even in his infamy, Dr. Daniel Carlat, founder of The Carlat Psychiatry Report, is popular with drug companies. Carlat was invited recently by Schering-Plough to help promote a new drug. The company called him "a recognized thought leader and well-respected healthcare professional among your peers." I spoke with Carlat about how he is trying to lead the thinking about psychiatry and other medical disciplines in a direction away from one-pill-fits-all. The first part of our conversation was posted last week. The second part appears below. It has been edited for space and clarity.

Q: You wrote your 2007 article for The New York Times Magazine talking about promoting Effexor for Wyeth and then quitting when you started to feel you were compromising your ethics. What was the reaction from your colleagues and from the drug companies?

A: For the most part the reaction has been very positive. Most of the emails either from colleagues or from patients who have taken Effexor or who have been in psychiatric care have said it was a courageous article. "I'm so glad to have read this. Everybody knows this happens all the time." This has been the feeling particularly from other doctors who have done speaking engagements in the past. They said, "I had exactly the same experience. I spoke for Wyeth about Effexor, and I felt the exact same pressures." Maybe 10 percent were very angry people saying, "You're a hypocrite. You are basically cashing in. You've made $30,000, and now five years later you are using that experience to cash in on it by getting all this publicity. You are basically kind of a media hound." [Editor's Note: Antidote contacted Carlat after he was mentioned by Dr. Adriane Fugh-Berman during an earlier Q&A.]

Q: Was there any truth in that criticism, in that the article did raise your profile?

A: I had written a couple of op-eds about these kinds of issues before that. I had started my blog before The New York Times piece. I was already kind of on the radar screen as a reformer. But the article definitely supercharged that. They say that the easiest way to get a book deal is to get an article published in The New Yorker and the second easiest is to get an article published in The New York Times Magazine. In fact, I had already had a book agent who had contacted me way before any of this happened based on the fact that his wife is a psychiatrist who subscribes to The Carlat Psychiatry Report. He read it and told his wife, "This guy is an academic psychiatrist, but he makes a lot of sense to the lay reader. I bet he has a book in him." I had been talking to him for a year or so before the New York Times piece came out. After it came out, the pace of our conversations picked up because it was clear that having a magazine article in one's portfolio makes it easier to approach publishers and get a book deal. So we did approach publishers, and I did get a book deal with Simon & Schuster, tentatively titled Unhinged.

Q: What does "unhinged" refer to?

A: It refers to the fact that over the years the psychiatry profession has sort of disconnected itself from what its mission ought to be, which is to take care of patients. Over time, other influences have tainted that mission, one of them being the allure of riches from drug companies. But I plan to cover many other issues, such as the excessive use of medications to the detriment of psychotherapy and the ways in which the DSM has affected psychiatric practice.

Q: What is your sense of the extent of the influence of company-sponsored continuing medical education versus independent CME like yours?

A: It's hard to say. Just by the dollars, a little bit less than half of all money going into CME is industry money. In terms of how that translates into how much drug companies are influencing the actual education, it is very hard to say. That's up to every individual doctor. It is clearly true that over the last few years this issue is more on doctors' minds. Doctors are becoming more savvy and realizing that there are many CME programs that are essentially promotional programs dressed up as CME. The huge levels of CME funding have led to a problem of redundancy in the industry-sponsored CME world. I see course after course and article after article funded by the same few companies and saying the same things. Prescribe Cymbalta. Prescribe Zyprexa.

Q: In an article in the Boston Globe in 2007, a fellow Tufts professor, Dr. Jerome P. Kassirer, said that "psychiatrists are among the most conflicted of the medical specialties." Do you agree with that?

A: I agree with that to the extent that the numbers appear to bear it out. In Minnesota and Vermont, the only states that have enough experience with having a history of requiring disclosure, we can see that is the case. In those states, psychiatrists have been number one in the amount of payments received from drug companies. Whether that is going to be true throughout the rest of the country, I have no idea. In the sense that the amount of money being paid to doctors is a gauge of how conflicted they are, you could say that they are the most conflicted.

Q: In The New York Times recently, Gardiner Harris wrote about how Forest Laboratories had created CME programs for physicians in order to increase market share for its drug Lexapro. Forest outlined in a marketing plan how it was going to hire writers from publications like CNS News, The Psychiatric Times, and the Journal of Clinical Psychiatry to write about the drug. You have written for The Psychiatric Times. Does knowing that the journal is considered a friendly outlet by the industry worry you about the reliability of its content?

A: To some degree it does, but the way that most of these journals work is that they try to separate content between the regular journal and the supplements. So, for example, The Psychiatric Times has the regular journal, but then many issues come with a supplement or two, which are CME supplements funded by the pharmaceutical industry. So they go to great pains to point out that the supplements are created by different companies, and they have very little involvement with the content of the supplements. They try to convince readers that you can trust everything in the editorially-controlled pages but not necessarily in the supplements.

There are other journals, like the Journal of Clinical Psychiatry, that are much less up-front about the fact that the supplements are advertisements for drug companies. You look at their supplements, and they look much more like the journal. And I think they do that in order to be able to charge a premium to the drug companies that are funding their supplements. The more legitimate a supplement looks, the more easily the readers are going to be fooled by it. By the same token, the regular content of the Journal of Clinical Psychiatry is pretty trustworthy.

Q: What do you think about the argument from PhRMA that doctors would not risk their reputations and would not say anything that they did not believe just to earn some money for CME classes or from doing what you did, promoting a particular drug?

A: I agree with that. I don't think that any doctor is going to say anything that they know to be untrue in any lecture or any publication just to make some money. That's not the way it works. What they do is that they say things that are true, but they might neglect to say good things about a competing company's product, or omit inconvenient truths about the disadvantages of the supporting company's product. That kind of tweaking or omitting of facts is not something that you can easily point to or accuse somebody of.

Q: Since you wrote your piece, there have been more cases exposed about doctors who have been taking payments on the sly or doctors who have used ghostwriters paid by drug companies. Also, it seems there are more doctors coming forward and saying that they either worked with a company or ghostwriters or took money to teach classes like you. Is that your impression?

A: It would be hard to quantify that. But that seems to be the case to me, too. There is a kind of momentum that everybody has noticed. As stories hit the press, people who have thought about blowing the whistle for a long time are realizing that now is the time to do so. Whistle blowing is a tough business because it makes you a pariah among your colleagues for many years. You may or may not win the case, and may end up in poverty. In the Pfizer case, about $115 million went to four whistle blowers, but that's an exception. There's also more and more interest among academics in pursuing these questions. Thus far, not a lot of changes have occurred, but I'm proud to say that in the American Psychiatric Association, quite a bit of reform has occurred. We have decided to stop industry funding of CME symposia at our annual meeting and a work group has created new guidelines for how psychiatrists should relate with industry. The APA has not yet formally adopted these guidelines, and it is a work in progress, but as an elected member to the APA Assembly, I'll get a chance to push for strong guidelines.

Q: What is so wrong about teaching doctors how to better diagnose mental illness and target it with specific drugs? Don't doctors need to understand how to use the most powerful tools at their disposal?

A: That's true. And they have typically gotten that information through non-industry sources, through grand rounds at their hospitals, or through various journals that have the nitty-gritty articles or the secondary journals that describe and summarize the articles that come out. There's a plethora of non-industry funded ways of getting up-to-date information. I have no problem with a doctor talking to a drug rep to learn about that product. Just as I would have no problem talking to a car salesman to learn about the horse power and mileage of a car I'm thinking about buying. But if I wanted to decide which of several different cars I should buy, it would be foolish for me to rely on a Honda salesman for such advice. Analogously, it's foolish for me to talk with a Wyeth hired gun to get unbiased information about which of the 20 or so antidepressants I should prescribe. We certainly do need the education, but we need to be much more discriminating about the sources of that education.

Q: As you have gotten farther away from your time working for Wyeth, how have your prescribing habits changed?

A: That's a tough thing to say. I don't keep close track of my prescribing patterns. Two years ago before I published The New York Times article, I asked one of the companies that tracks these things about obtaining information about my own prescribing practices. They said, "You can get this much information for $10,000." They were looking at me like a drug company. So I didn't get the information. I generally favor generic medications because I want to keep costs down, and I tend to favor medications that have been out for a long time because I have a lot of experience dosing them and I know a lot more about the side effects. When a new drug comes out, I will be a bit skeptical that it might be just a me-too drug or a tweaked version of an old drug, like many of them have been in psychiatry.

Q: How do you monitor the conflicts of interest in the contributors to your newsletter?

A: I send them a disclosure form, and I say, "Please tell me about any health care companies that you have had any kind of financial involvement with and, for each type, whether it's speaking or consulting or research, what company you did it with and the name of the product and the approximate amount of money you made."

Q: How do you deal with ghostwriting, where there isn't really money exchanging hands?

A: That's an authorship disclosure. In those cases, you require that anybody who sends in an article has to disclose exactly what their involvement in the article was. Did you write the piece? Were you paid for it or not paid for it? If you didn't write the piece, who wrote the piece and how were they paid?

Q: Has a ghostwritten piece ever been submitted to you?

A: No. The writers who write for me have typically been either residents who are in the last stage of their training or early-career psychiatrists who have read my blog or newsletter and have bought into my whole philosophy.

Q: How do you figure out whether journal articles that you are discussing are free of company influence?

A: All you can do is trust that the journal has done a good job with requiring disclosure, even though there have been plenty of instances where authors have chosen not to disclose certain things and the journal ended up with egg on its face. It's extremely time consuming for a reader to Google and investigate all these authors before they read an article. Every time you look at an article, you try to judge the possibility of bias by following the trail of money. If the entire article and research was funded by the pharmaceutical industry, my skepticism meter is lit up higher than if the authors have their own disclosures but the research itself was funded by the NIH. And then you determine by reading the methodology and results whether they followed scientific protocol. Often company funded research follows good scientific protocol and can produce good research.

Q: You mentioned that the climate is ripe for these stories to come out. What can health writers do to reveal more of these cases of tainted research or tainted experts?

A: As we get more information released through court cases, we begin to understand which companies and which journals are involved and which academics are involved. Names are being named. It's important to not just report on the fact that Forest outlined a promotional plan involving CME. That's news in itself. But the nitty-gritty details are also important. The fact that they mentioned names of people and journals they've used. It's time to go back into the literature and connect the dots. What was funded by Forest and did something bad happen as a result of these promotional practices? It's one thing to say the makers of Lexapro spent millions of dollars on CME. But if nothing was produced that was biased information, then it's hard to really fault the company. That's the hard work of investigative reporting. Probably the best example of that kind of reporting is through the Milwaukee Journal Sentinel and the investigative team, particularly John Fauber. What he and his colleagues have done is looked at CME on specific topics like HRT and the use of testosterone and the use of Chantix for smoking cessation and asking experts in the field to look at these programs and say whether they are biased.

It's been very interesting to read those articles because they establish a very clear pattern of bias. The final step is whether you can prove that any patients have been harmed. In order to demonstrate that, you'd have to be able to get access to a whole lot of patients and their medical records and compare patients who have been treated by doctors who have been in the CME programs funded by industry and those who have not. The effects may be real, but they are probably going to be small effects. You probably have to get thousands and thousands of patients to consent to these studies. I don't see any investigative journalists having the resources to do that kind of study. It's almost an impossible thing to prove. All you can really do is say things like, "We know that Eli Lilly settled for $1.4 billion for misleading marketing of Zyprexa and studies have shown that Zyprexa causes 30 to 40 pounds of weight gain in some patients and we know that obesity leads to heart disease. You do the math. Can we prove that the Lilly-sponsored CME led to deaths? That's almost impossible to demonstrate.