| Boston Psychiatrist says "NO!" to
Big-Pharma
Date: 7 May 07
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 rwww.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." |
