Psychiatrist Dr. Daniel Carlat is a compelling storyteller. One especially compelling story, Dr. Drug Rep, was told in the pages of the New York Times Magazine about his own very brief career moonlighting as a Big Pharma drug rep.

Once upon a time, he explained, on a blustery fall New England day in 2001, a friendly sales manager from Wyeth Pharmaceuticals came into his medical office and made him an offer he found hard to refuse.

“He asked me if I’d like to give talks to other doctors about using Effexor XR for treating depression. It would be pretty easy. Wyeth would provide a set of slides and even pay for me to attend a speaker’s training session.

“I would be paid $500 for one-hour Lunch and Learn talks at local doctors’ offices, or $750 if I had to drive out of town. I would be flown to New York City for a ‘faculty-development program,’ where I would be pampered in a midtown hotel for two nights, and would be paid an additional honorarium.”  

Dr. Carlat was familiar with the drug Effexor XR and had read some studies in medical journal articles showing that Effexor might be more effective than SSRIs, the most commonly prescribed antidepressants: the Prozacs, Paxils and Zolofts of the world.

SSRI stands for selective serotonin reuptake inhibitor, referring to the fact that these drugs increase levels of the neurotransmitter serotonin, a chemical in the brain involved in regulating moods.

Effexor, on the other hand, was being marketed as a dual reuptake inhibitor, meaning that it increases both serotonin and norepinephrine, another neurotransmitter. The theory promoted by Wyeth was that two neurotransmitters are better than one, and that Effexor was thus more powerful and more effective than SSRIs.

Some time later, as promised, Wyeth flew both Dr. Carlat and his wife to New York, put them up in a luxury hotel for two nights (along with about 100 other psychiatrists from across the country), presented them with the schedule for the Effexor training day, invitations to various gala dinners and receptions, and two tickets to a Broadway musical.

At the end of the intensive training presented by prestigious American psychiatrists, Dr. Carlat received another Wyeth envelope – this one with $750 inside, and a note wishing him and his wife a great time in New York City.

But even then, Dr. Carlat recalled having niggling doubts about some of the Effexor ‘facts’ that had been presented during that Wyeth training day.

“Was I swallowing the message whole? Certainly not. I knew that this was hardly impartial medical education, and that we were being fed a marketing line. But when you are treated like the anointed, wined and dined in Manhattan and placed among the leaders of the field, you inevitably put some of your critical faculties on hold.”

At the time, Dr. Carlat said he didn’t know exactly how many physicians like him were on Big Pharma payrolls to help increase drug sales, but he estimated at least 25% of all U.S. doctors receive drug money for lecturing to physicians or for helping to market drugs in other ways.

“I actually felt quite flattered to have been recruited, and I assumed that the rep had picked me because of some special personal or professional quality.”

Dr. Carlat also described being anxious about doing a really good job during his early talks, and relieved when he received positive feedback from the Wyeth drug reps who organized his presentations for him.

He dove into each talk, going through a handout based on the official Wyeth slide deck. He discussed the importance of depression remission, the advantages of Effexor, how to dose the drug, the side effects, and everything else he had learned at the Wyeth training in New York – and then added a very quick review of the other common antidepressants available.

He was very pleased when the number of his speaking invitations increased, and his reputation among Wyeth drug reps grew.

“As the reps became comfortable with me, they began to see me more as a sales colleague. I received faxes before talks preparing me for particular doctors.

“One note, for example, informed me that the physician we’d be visiting that day was a ‘decile 6 doctor and is not prescribing any Effexor XR, so please tailor accordingly. There is also one more doc in the practice that we are not familiar with.’  The term ‘decile 6’ is drug-rep jargon for a doctor who prescribes a lot of medications. The higher the ‘decile’ (in a range from 1 to 10), the higher the prescription volume, and the more potentially lucrative that doctor could be for the drug company.”

But as the months went by, he began to suspect that Effexor was turning out to be an antidepressant that might have only a very slight effectiveness advantage over SSRIs  – but one that caused well-documented problems like high blood pressure and seriously prolonged withdrawal symptoms.  These had not been disclosed during his New York training, and were casually dismissed by Wyeth drug reps.

He described one particularly uncomfortable presentation in which his Effexor side effect ‘facts’ were repeatedly challenged by another psychiatrist in his audience.  His Wyeth-scripted answers failed to convince the challenging doc. He felt rattled, and he never forgot the look on that other psychiatrist’s face – a “mixture of skepticism and contempt”.

Dr. Carlat began to wonder if his colleague was seeing him for what he feared he had become — a drug rep with an M.D.

“I began to think that the money was affecting my critical judgement. I was willing to dance around the truth in order to make the drug reps happy. Receiving $750 checks for chatting with some doctors during a lunch break was such easy money that it left me giddy. Like an addiction, it was very hard to give up.

“I was highlighting Effexor’s selling points and playing down its disadvantages, and I knew it. I realized that in my canned talks, I was blithely minimizing Effexor’s known hypertension risks, conveniently overlooking the fact that hypertension is a dangerous condition and not one to be trifled with.

“I didn’t mention any of this in my talks, partly because none of it had been included in official company slides, and partly because I was concerned that the reps wouldn’t invite me to give talks if I divulged any negative information.

“But I was beginning to struggle with the ethics of my silence. “

As this “ethical struggle” continued, he gave a presentation one day in which, for the first time, he told his audience that SSRIs were possibly just as effective as Effexor, yet without the same side effect issues. He recalled that he felt “reckless” at the time, but had left the physician’s office that day with a “restored sense of integrity”.

That “restored sense of integrity” did not go unnoticed by the alarmed Wyeth drug rep who had accompanied Dr. Carlat to the luncheon presentation.

Several days later, he was visited by the same Wyeth sales manager who had first offered him the speaking job. Pleasant as always, the manager said: “My reps told me that you weren’t as enthusiastic about our product at your last talk. I told them that even Dr. Carlat can’t hit a home run every time. Have you been sick?”  Dr. Carlat’s response:

“At that moment, I decided my career as an industry-sponsored speaker was over. The manager’s message couldn’t be clearer: I was being paid to enthusiastically endorse their drug. Once I stopped doing that, I was of little value to them, no matter how much ‘medical education’ I provided.”

Dr. Carlat not only stopped speaking on behalf of Big Pharma drugs, he went one step further. These days, operating from an old brick building in the quaint New England seaside town of Newburyport, he sees patients, teaches psychiatry at Tufts University School of Medicine, writes in his blog, 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.  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, for example, The Report concluded that a new antidepressant, 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, complete with 24 footnotes that Dr. Carlat then published on The Report’s website along with his own rebuttal.

His current worry is that potential conflicts of interest are a growing concern in all areas of medicine, from cancer doctors who own scanning centres to cardiologists who prescribe specific blood pressure drugs while accepting payments from the companies that make them. The great majority of these payments remain undisclosed.

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, says:

“Psychiatrists are among the most conflicted of the medical specialties.”

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, says Dr. Kassirer.

According to an interview in the Boston Globe, Dr. Carlat 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 influence includes the diagnoses, the treatment guidelines, and the national meetings.”

Perhaps worst of all, Dr. Carlat told the Globe, pharmaceutical companies have come to sponsor so much of continuing medical education – the CME 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.”

Read Dr. Carlat’s entire article, Dr. Drug Rep, originally published in the New York Times Magazine.

See also:

• Harvard Cozies Up with Big Pharma
• Harvard’s Ethical Ultimatum to Doc: Give Up Big Pharma Moonlighting Jobs, or Lose Harvard Teaching Post
  
• Same Old Duet: Drug Companies and Psychiatry
• Is Your Doctor a “Thought Leader”?
• Bad Doctors Earning Good Money from Big Pharma
• Pfizer Paid For Doc’s Helicopter Speaking Tour to Push ‘Off-Label’ Drugs