The Emperor’s New Clothes

You know the aforementioned  story. Here is the first salvo from me about the “new clothes” of psychotropic medicines and the profession behind them. I don’t think many pastors have read Prozac Nation, House of Cards, The Antidepressant Era, or The Crisis in Psychiatry and Religion, and Anatomy of an Epidemic. This last I didn’t read either; I had a son of mine do it for me. Below is a transcript of a 2010 NPR broadcast on this topic. Let’s hear from someone in the field about these things. WARNING IF YOU DON’T WANT TO HEAR THE ‘OTHERSIDE’ OF THE PSYCHATRIC DRUGS DEBATE READ NO FURTHER. I AM NOT EDUCATED, TRAINED, OR LICENSED IN THE FIELD OF PSYCHIATRY LET ALONE MEDICINE. YOU ARE FREE TO IGNORE ME AS A KOOK. CONTINUE AT YOUR OWN RISK.

If you do go all the way to the end, you’ll find a 2020 article titled “Was Freud Right About Anything?”. For almost 40 years, I’ve been saying he wasn’t. The book mentioned above, The Crisis in Psychiatry and Religion, authored by one who rejects Christianity (147), has been saying he wasn’t for almost 60 years. Moreover, he cites a 1956 secular work documenting Freud’s satanic pact in a paper he gave at Ohio State University and University of Minnesota in 1959 (116). What secular authorities have been rejecting as bunk science for almost half a century, the church has been bowing down to. What? You mean that guy is walking down the street naked? By the way, the title of this blog is also a 1985 title on a book on psychology by William K. Kilpatrick which I have read and can recommend: The Emperor’s New Clothes/the Naked Truth About the New Psychology  

< A Psychiatrist’s Prescription For His Profession

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Heard on Fresh Air from WHYY

July 13, 2010 – DAVE DAVIES, host:

This is FRESH AIR. I’m Dave Davies, in for Terry Gross.

Two years ago, a psychiatrist created a stir in his profession with a piece in the New York Times magazine called “Dr. Drug Rep,” in which he told his story of being paid to push the antidepressant Effexor to his colleagues.

The psychiatrist, Daniel Carlat, joins us today to talk about his new book called “Unhinged: The Trouble with Psychiatry.” But it isn’t just about the influence of drug companies in the profession. Carlat believes in prescribing medication, but he says too many psychiatrists have all but abandoned talk therapy, leaving in-depth interaction with patients to others while they pursue medical fixes for mood problems and mental disorders.

Daniel Carlat was trained at Harvard and is on the faculty of the Tufts Medical School. He edits a monthly newsletter called The Carlat Psychiatry Report.

Well, Daniel Carlat, welcome to FRESH AIR. I thought we’d begin by talking about one of the critiques that you have of psychiatry as it is currently practiced. And you open your book with a description of a patient named Carol(ph) that kind of illustrates this problem. Maybe you could just tell us her story briefly.

Dr. DANIEL CARLAT (Tufts Medical School): Sure. Carol is a woman that came into my office, just north of Boston, and she came in with a really terrible experience in which she was in the car with her father. Her father was driving. They got into an accident. They crashed. Her father was killed instantly and she was uninjured. And as I spoke to her, it developed that she had been noticing that her father had been drinking. She had smelled alcohol on his breath, had criticized him about that, and he got angry and said, well, am I driving fast enough for you now, and he gunned down the accelerator, and that’s what caused the crash.

So it was a case of post-traumatic stress disorder in the sense that Carol was having these symptoms of nightmares and flashbacks, but it was really even more complicated than that because of all the feelings of guilt and anger that I knew that she was going to be developing.

DAVIES: And you did what for her?

Dr. CARLAT: Well, so I told her what I thought her diagnosis was, and I explained to her what post-traumatic stress disorder is, and I explained to her some of the treatments, which in psychiatry, among psychiatrists, typically those treatments involve medications.

And I gave her a prescription for Zoloft, which is a serotonin reuptake inhibitor like Prozac, and Klonopin, which is a tranquilizer, and then I said, you know, Carol, I think you’re also going to need some psychotherapy, and I’d like to refer you to a colleague of mine.

And I remember distinctly the disappointed look in her eyes, and she said to me: I thought you were going to be my therapist. And I explained to her that my practice was very full and that generally what I did was psychopharmacology and that I referred to some trusted colleagues for therapy.

And you know, she did follow up with therapy, but it was really after that, and after not just her but a number of patients like her, when I began to reevaluate: Does this type of treatment really make sense? Is this the kind of treatment that we want to be delivering for our patients in the United States? And why has it come to this sort of split model of treatment?

DAVIES: Well, let’s talk about that. So essentially, you and many, many other psychiatrists really aren’t in the business of providing therapy. You are in the business of doing what?

Dr. CARLAT: We are in the business of making diagnoses using the DSM, which is the official diagnostic manual for the psychiatric disorders of the American Psychiatric Association.

We make our diagnoses, and then we usually prescribe medications. And psychiatrists used to, in the past, also do a lot of talk therapy, and they used to combine drugs with talk therapy, although frankly, in the more distant past, maybe 30 years ago, before there were effective medications, we just did psychotherapy, which oftentimes was not terribly effective.

DAVIES: So what we have now is a situation where someone who is getting ongoing therapy, which includes psychological medications, will see a therapist who is not a psychiatrist – might be a social worker, might be a psychologist -regularly sees them and then goes to a psychiatrist like you – what, once a month, for essentially a 15-minute med check?

Dr. CARLAT: Well, essentially that is the story in most psychiatric practices, although there are certainly exceptions, and there are still many psychiatrists out there who do enjoy doing therapy and devote more time to it.

But I’d say the sort of default type of practice is exactly as you mentioned.

DAVIES: There’s this startling statistic in the book about how often psychiatrists really provide therapy.

Dr. CARLAT: Right, right, and that’s data that came out of Columbia University just a few years ago based on a survey of psychiatrists throughout the United States.

And it turns out that only 11 percent of all psychiatrists now offer therapy to all of their patients. So essentially one out of 10 psychiatrists are really doing psychotherapy on a regular basis.

DAVIES: And are a significant number offering therapy to at least some patients, or do we know?

Dr. CARLAT: Well, we know that in that study 29 percent of all psychiatry visits involved some amount of therapy, and that was down from 1997, when that figure was 44 percent. So essentially it went from nearly half of all psychiatric visits including therapy to, in 2005, when the study was published, about – well, less than a third of visits involved therapy.

And now in 2010, I’m guessing, based on my knowledge of my colleagues and anecdotal reports, that figure has gone down even further.

DAVIES: So if you’re seeing patients for a relatively short session, relatively infrequently, how do you know what to give them and whether it’s working?

Dr. CARLAT: And that’s really one of the key questions. It’s very hard to make a psychiatric diagnosis, and we’re not talking about a diagnosis for which we can get a blood test or where we can get a brain scan or an X-ray.

At this point, all of those types of things are all research tools, although we certainly hear a lot about them in the media. We do our diagnoses based on the kind of interaction that you and I are having right now.

We have a conversation, and I ask my patients questions about how they’re feeling, how they’re thinking, how they’re sleeping, what their concentration level is, what their energy level is, and I put all those pieces of information together and then I come up with a diagnosis based on the DSM guidebook that we have.

And then once I have a diagnosis, essentially I match those symptoms up with the medication. So modern psychiatry is really a conversation, a series of symptoms, and then a matching process of medication to these symptoms.

DAVIES: Now, meanwhile, the patient is likely having much longer, more detailed conversations with a therapist, in which they’re really talking about what’s going on in their life in a much more detailed way. How much information do you, the psychiatrist who prescribes the medications, get from the therapist who hears so much more?

Dr. CARLAT: Well, that’s what’s really concerning to me, is that often we really don’t get that much information. I mean, presumably the psychiatrist and the therapist would be communicating frequently on an ongoing basis, but I have many examples in my practice – for example, the case of a woman who I was prescribing sleeping pills to – an elderly woman, actually, I was prescribing sleeping pills for.

And then I learned about a year later from her therapist that she had been drinking large amounts of alcohol every night, combining them with the sleeping pills, which could be quite dangerous.

Or another patient who I found out from the therapist had been abusive toward his wife. I had been diagnosing him with bipolar disorder, thinking that his attacks of mania or irritability were due to a kind of biological condition, whereas in fact they may have been due entirely to his abusive nature and a dysfunctional, you know, relationship between him and his wife. So, these are – these kinds of situations come up with alarming frequency when you split the treatment up between a psychopharmacologist and a psychotherapist.

DAVIES: You know, you mentioned almost in passing, toward the back of the book, that you have a practice of hundreds of patients. Is that right?

Dr. CARLAT: That’s true, and it seems like a lot. And it – it is a lot. I think many of my colleagues have practices with four, five, six hundred patients. And people are surprised when they hear those numbers, but when you’re seeing patients for 15 or 20 minutes every month, every two months, sometimes every six months, or once a year, quite frankly, that you can imagine how you could have that many patients.

DAVIES: Right, and I guess what’s troubling about it is that if you – it seems to me that if you have that many patients, you know you’re just not going to get enough real communication with the patients’ therapists to know at least what you’d like to think that you would want to know about what’s going on in their lives.

Dr. CARLAT: It’s true, and there’s kind of an unofficial policy among psychiatrists, at least among some, which is the don’t-ask-don’t-tell policy, which is that we have our patients coming in, we know we have 15 or 20 minutes to see them. We want to learn a certain amount about how they’re doing, obviously, because we want to make sure that our medications are working and that we know if we need to increase the dose or add something else.

But on the other hand, we don’t want to ask too many questions because if we start to hear too much information, then we’re going to run into a time issue where we’re going to have to kind of push them out of the office perhaps just at the point where they’re about to reveal something that could really be crucial to understanding their treatment.

DAVIES: Boy, that’s kind of unsettling, isn’t it? For heaven’s sakes, don’t get to the bottom of your problem in my presence.

Dr. CARLAT: We don’t want to open the Pandora’s box, in a sense, and I certainly can remember patients who just at the point where they had their hand on the doorknob turned around and told me – for example, one woman told me that she was using drugs, and she was cheating on her husband, and that was really why she was depressed, none of which had come out during our very brief session, where I had simply increased her medication to treat her depression. And then at that point it was like, well, you know, I’m going to have to allow my next patient to wait in the waiting room a little bit, and you have to sit down, we need to talk about this a little bit more.

DAVIES: What’s driving this, this separation of therapy from psychopharmacology?

Dr. CARLAT: Well, there are a lot of factors. You know, this is one of those issues where there’s no one villain, and I think, you know, we have certainly with the late 1980s, when Prozac came on the scene, that ushered in an avalanche of new medications, many of which, to be fair, are very effective.

And then there is also, of course, the influence of the pharmaceutical industry, where they have come up with very sophisticated – and a lot of the public doesn’t realize how sophisticated the marketing techniques have become, really over the last 10 years, to the point where essentially when a pharmaceutical company gets FDA approval for a drug, their marketing department can assure their bosses that they are going to be able to sell the drug, really whether the drug is effective or not.

DAVIES: To what extent are insurance reimbursements driving this tendency of psychiatrists not to provide therapy?

Dr. CARLAT: Well, that’s, you know, kind of another leg of the stool, as it were. Certainly what happens is that in order to maximize my income, I want to fit as many patients into an hour as I can. So if I see four patients in an hour, I’m obviously going to make more money than if I see three or two or one.

So when insurance companies reimburse more for a 15 or 20-minute visit than they do for the equivalent one-hour psychotherapy visit, that’s yet another factor playing into what I would consider to be, you know, the overvaluation of the medication approach and the undervaluation of the let’s-understand-what-makes-our-patient-tick kind of approach.


DAVIES: Now, it’s clear – you’re certainly – there are some, there are some who are very skeptical of much – many of the medications that are prescribed. You are not opposed to medications. You prescribe them all the time, right?

Dr. CARLAT: Uh-huh. I do.

DAVIES: How much do we know about how psychological medications actually work?

Dr. CARLAT: Well, we know both a lot and very little, and the way in which we know a lot is that through clinical trial studies, in which patients are randomly assigned to a medication versus a placebo sugar pill, we know how effective these medications are, in other words how much of an advantage medication has over a placebo.

And that varies from medication to medication. It tends to be a very minimal advantage for antidepressants when treating depression. It tends to be a higher advantage when treating schizophrenia.

But on the other hand, what we don’t know is we don’t know how the medications actually work in the brain. So whereas it’s not uncommon – and I still do this, actually, when patients ask me about these medications, I’ll often say something like, well, the way Zoloft works is it increases the levels of serotonin in your brain, in your synapses, the neurons, and presumably the reason you’re depressed or anxious is that you have some sort of a deficiency.

And I say that not because I really believe it, because I know that the evidence isn’t really there for us to understand the mechanism. I think I say that because patients want to know something, and they want to know that we as physicians have some basic understanding of what we’re doing when we’re prescribing medications.

And they certainly don’t want to hear that a psychiatrist essentially has no idea how these medications work.

DAVIES: But that’s pretty close to the truth?

Dr. CARLAT: Unfortunately, it is close to the truth. We’re in a paradoxical situation, I think, where, you know, we prescribe medications that do work, according to the trials, and yet as opposed to essentially all other branches of medicine, we don’t understand the pathophysiology of what generates mental illness, and we don’t understand exactly how our medications work.

DAVIES: And it can be reassuring if you’re prescribing a medication to tell someone, well, there’s really a biological origin of your difficulty here, and we can treat it with – by treating the biology.

Dr. CARLAT: Right, which is exactly why I still tell patients that at times. But I think, you know, one thing that has happened is that because there’s been such a vacuum in our knowledge about mechanism, the drug companies have been happy to sort of fill that vacuum with their own version of knowledge so that usually, if you see a commercial for Zoloft on TV, you’ll be hearing the line about serotonin deficiencies and chemical imbalances, even though we don’t really have the data to back it up.

It becomes a very useful marketing line for drug companies, and then it becomes a reasonable thing for us to say to patients to give them more confidence in the treatment that they’re getting from us. But it may not be true.

DAVIES: Right. Well, I certainly want to talk a lot more about what drug companies do to market their products, but, you know, help us understand the distinction between the kind of scientific knowledge we have about the brain and its reaction to psychological medications, as opposed to, you know, treatments for cardiac disorders or vascular disease.

Dr. CARLAT: Sure. And – so for example, I’ll take the example of a medication like Zoloft, which is in the class of SSRI, which is specific serotonin reuptake inhibitor.

And as the name implies, what we think these medications do is they prevent the neurons of the brain from sort of vacuuming up the excess chemicals and neurotransmitters that the neurons generate so that if the depression or anxiety disorder is due to a deficiency of a chemical, a reuptake inhibitor would act by pumping out or allowing the neuron to pump out more neurotransmitter, thereby famously balancing the chemicals.

And the problem is that we don’t have any direct evidence that depression or anxiety or any psychiatric disorder is actually due to a deficiency in serotonin because it’s very hard to actually measure serotonin from a living brain.

And any efforts that have been made to measure serotonin indirectly, such as measuring it in the spinal fluid or doing postmortem studies, have been inconclusive. They have not shown conclusively that there is either too little or too much serotonin in the fluids. So that’s where we are with psychiatry.

And then your other question was: How does that differ from some of the other medical fields? Well, for example, in cardiology we have a good understanding of how the heart pumps, what electrical signals generate activity in the heart.

And due to that understanding, we can then target specific cardiac medications to treat problems like heart failure or heart attacks, again based on a pretty well-worked-out knowledge of the pathophysiology – not perfect, but pretty well worked out.

DAVIES: Whereas – to draw an analogy to psychiatry, it might be like saying, well, if nitroglycerin eases your chest pains, then we conclude that your heart problem is a deficiency of nitroglycerin.

Dr. CARLAT: Exactly, or if we find that opiate medications treat pain in general, we might conclude that pain is a opiate or narcotic-deficiency illness, whereas in fact we know that pain is not an opiate-deficiency illness. It’s a symptom that can be caused by many, many different pathologies throughout the body.


DAVIES: Well, let’s talk about how drug companies market their products. I mean, this is a subject that you write a lot about. And one way is through manipulating publishing in medical journals. And you have a fascinating story in here about a series of seemingly respectable articles about the benefits of the antidepressant Zoloft. What was really happening in these publications?

Dr. CARLAT: This was information that came out over the course of the trial in which Pfizer was being sued for its antidepressant Zoloft possibly causing suicidal ideation. And over the course of that trial, it came out that there was a publication marketing plan that the marketers of the company had developed. And the way it worked is that, rather than going directly to physicians, psychiatrists, researchers and asking them to write up studies about their medication; instead they went to what was essentially an advertising firm. And they asked them to see to it that studies complimentary toward Zoloft were published in the major medical journals of the United States.

And the really, to me, the astounding information that came out in that trial was that about 50 percent of all of the articles published about Zoloft over a certain period of time were actually ghostwritten by medical writers who were not MDs. And the company actually would pay big name psychiatrists a thousand dollars or $2,000 to have their names put on these journal articles in order to lend them some kind of scientific credibility.

DAVIES: So let’s get this right. A marketing firm – an advertising firm -writes an article. They find a psychiatrist, pay them money, the psychiatrist’s name then appears on the article, it’s then submitted to a respectable journal which then publishes it?

Dr. CARLAT: That’s what happened in about half of all the articles published about Zoloft. And these were in journals such as the New England Journal of Medicine, the Journal of the American Medical Association, the American Journal of Psychiatry, etcetera. So essentially all the top journals that doctors read were publishing – unbeknownst, I’m sure, to the journal editors – ghostwritten articles written by an advertising firm, essentially pushing the benefits of Zoloft, and they were being paid to do this by Pfizer.

DAVIES: How common is the practice? Do we know?

Dr. CARLAT: We don’t know, actually. Although, recently a study came out indicating that as many as 10 to 20 percent of articles in the major journals are still being ghostwritten. And I think that the practice, as it has become disclosed, it’s becoming less common and there are more guidelines being put into place particularly by the associations of journal editors who, of course, felt that they were hoodwinked by these practices, as indeed they were.

DAVIES: Right. I mean if in fact you’ve been told that someone wrote this that didn’t write it, I mean wouldn’t you ban that person from ever appearing in the journal again? I mean, isn’t this a serious credibility issue?

Dr. CARLAT: Yeah. You would think that there would be repercussions like that. However, there have not been any such repercussions. All that has happened is that the issue has come out into the open, which is great, and now many of the top journals have regulations in place in which they require that there be a disclosure of exactly who wrote what, in addition to disclosures of whether the authors have received any funding from pharmaceutical companies.

DAVIES: You also write about a number of fairly well-publicized cases where very nationally prominent psychiatrists and researchers have, you know, been embroiled effectively in scandals where they got hundreds of thousands of dollars from drug companies and essentially hid it, despite policies which would have required their disclosure. Have things changed? I mean, are there reforms that are curbing these practices?

Dr. CARLAT: There are many reforms that are curbing these practices. Partly, this is due to the actions of Senator Charles Grassley, who has been at the forefront of transparency. And actually, in the recent health care reform bill that was passed, hidden within that reform bill was a package called the Physician Payment Sunshine Act. And what that’s going to do is – it’s going to be phased in gradually – but by 2013-2014, all drug companies are going to be forced to publish on publicly accessible websites, all the money, all the payments that they make to doctors, including exactly what the payments are for. So that we will be able to find out, if we see an article that looks a little bit fishy, if we’re wondering if the doctor was paid by a drug company. We’ll be able to look on the website, and find out, not only whether the doctor was paid by a drug company, but the exact monetary amount and whether that payment was for writing an article, whether it was for giving a promotional talk to a group of doctors or for doing a certain kind of research study.


DAVIES: One of the other ways that drug companies market their products is at the retail level, through physicians who play the role of hired guns. Tell us about that.

Dr. CARLAT: And this is something that I know a lot about because I was involved personally. In 2002 a rep from Wyeth Pharmaceuticals, which has since been bought by Pfizer, but at that point they were marketing an antidepressant called Effexor. The rep came to my office and asked me if I would like to be on their speaker’s bureau. And what that meant was that I would go to doctors’ offices, I would be paid about $750 for a half-hour to an hour of my time, and I would sort of accompany the drug reps who would provide sandwiches to the doctor and the doctor’s staff, and then I would give them a little mini lecture about how to treat depression.

It sounded reasonable at the time; although, you know, I realized that there was obviously going to be some kind of a marketing intent here, I figured that it would be interesting work and that I wouldn’t necessarily be influenced by the pharmaceutical company and I could go in there and help doctors learn about depression and its treatment.

DAVIES: Right. Now before this approach was made to you, you were familiar with the practice. How common is it in psychiatrists’ and other specialists’ offices, for, around lunchtime, a drug rep to show up with some takeout and free samples and helpful information?

Dr. CARLAT: Well, in any state that allows it, and there are some states that have actually banned the practice, but anywhere where it’s allowed you can bet that it’s happening. Now there are some academic medical centers recently that have banned it, such as the Harvard Hospital, Stanford, Yale. But essentially, doctors and their staff, you know, you and I like a free lunch; and so if the reps are allowed into a medical practice anywhere in the country they will try to get in there, and this is an integral part of their marketing of their drug.

DAVIES: So let’s talk about your experience. What did they do to get you oriented?

Dr. CARLAT: They flew my wife and I down to New York. Here I was, a small town, essentially, psychiatrist in a little town north of Boston. They gave my wife and I Broadway tickets. I was there with maybe 100 other psychiatrists that had been flown in from other cities and they brought in the biggest names in the field of psychiatry, all of them paid by Wyeth to do research and to give talks. And we sat in what was called faculty development – a faculty development seminar. Only later did I realize that this was really all about indoctrinating us into a marketing line, but at the time I was really in awe, sitting there seeing the greatest researchers in the field speaking directly to me and a few other psychiatrists.

DAVIES: And the drug you were falling in love here was Effexor, is that right?

Dr. CARLAT: Effexor was the drug. It is a drug similar to the Prozac and Zoloft drugs, but rather than being a serotonin reuptake inhibitor, it is a serotonin and norepinephrine inhibitor. In other words, it increases levels of two chemicals in the brain, rather than one. And that was one of the big marketing lines, of course, of the company, was that because the drug increases levels of two chemicals, it’s more effective than your typical Prozac and Zoloft type drugs.

DAVIES: And are they right about that? Is it more effective?

Dr. CARLAT: Well, it certainly seemed that they were right about that in 2002. The data that I was shown at the meeting in New York looked pretty good. But I did note that the data was limited, that it was limited mainly to comparisons with one drug, Prozac, and that they were, the trials that they were talking about were six-to-eight-week trials, which is a pretty short-term trial and, you know, even the advantages between the two drugs, the advantage of Effexor was relatively small, although it did seem to be significant.

It was only later, over the course of the last few years, that we have found as more and more studies have come out, that the advantage has whittled down to a smaller and smaller degree, such that now most psychiatrists would consider it to pose little if any advantage over other drugs. And, in fact, in some cases a disadvantage, because it has so many more side effects than the typical SSRI drugs used.

DAVIES: So you had this weekend in New York. What did you do then? What was your experience actually visiting offices?

Dr. CARLAT: In Newbury Port, which is where I practice, the drug reps would call me and they would ask me to accompany them to offices. And it was a sort of a dog and pony show, in the sense that I would come in, the drug rep would come in with a platter of goodies for the office staff, and then I would give my spiel, which was based on the slide set that I was given in New York.

And at first, you know, again, I couldn’t say that I was naive. I mean obviously I knew I was getting paid. I knew who was buttering my bread here. But I guess I had underestimated the kind of subtle pressures of the financial incentive. And so what I found, is that as I was giving these talks about Effexor, I was increasingly embellishing the advantages of the drug and I was minimizing the side effects of the drug.

And you have to understand that the drug reps are right there in the room with you. They’re hanging on your every word. You see them watching you just like everyone else is watching you, and you know that they’re the ones that are going to decide if you get invited to do another lunch and learn, as these were called, for another $750 the next week.

DAVIES: Did the drug company then monitor your performance? Did they have a way of judging whether you were effective in getting doctors to write more prescriptions?

Dr. CARLAT: They did. And the way that worked is something called prescription data mining, which is that the drug companies discovered that they were able to purchase information about doctors’ prescribing habits from pharmacies, and then they could funnel that information to their drug reps, eventually electronically, right into their laptops. So that when a rep would call on a doctor, he or she could open up the laptop and could find out whether Dr. Carlat was prescribing enough Ambien and whether he was still prescribing too much Trazodone for, you know, for insomnia, for example, and then they could use that information to direct their marketing pitch.

So, I too knew this information because the drug reps, as they began to trust me more and more, would start to fax me kind of detail sheets about each doctor. And I would literally get a sheet saying Dr. Smith is prescribing 20 percent Celexa, 30 percent Zoloft, 40 percent Prozac and only 10 percent Effexor; so we really have to adjust our approach to him accordingly. And what that meant was that we had to really do a hard sell.

DAVIES: And then after you went to visits, would they look at what the doctors were then prescribing and figure out whether, I mean, your batting average, in effect?

Dr. CARLAT: I, you know, Dave, I don’t know if they did that, but I would be astonished if they did not do that. And it’s interesting when you say batting average, because just to jump ahead a bit, after a year of doing these talks, I became more and more disillusioned with the practice and really saw myself as being, you know, deceptive toward the doctors I was talking to. And I went to one of my lunch and learns, deciding, going into it, that I was going to tell the whole truth this time.

And I talked about how the studies that the advantage of the Effexor was based on were short-term studies and if they were longer-term, maybe the two drugs, would seem more equivalent. And the next day, the district manager of the company came to my office, the next day, and said, you know, Dr. Carlat, I heard from the drug reps that you don’t seem to be as enthusiastic about our product as you used to be. And, you know, and Dr. Carlat, I told them that even Dr. Carlat can’t hit a home run every time. Have you been sick?

(Soundbite of laughter)

Dr. CARLAT: So at that point, so that’s where your batting average thing – at that point I realized that I just couldn’t do this anymore. It was very clear that the only value I had to the company was as a salesmen and that I wasn’t really being expected to provide medical education. I was expected to get the numbers up.

DAVIES: We’re speaking with Dr. Daniel Carlat. He is a practicing psychiatrist. He writes a monthly newsletter called the Carlat Psychiatry Report and he’s the author of a new book called “Unhinged: The Trouble with Psychiatry.”

We began with your critique of the separation of therapy and the prescribing of drugs in psychology and so many psychiatrists these days are mostly managing medications while their patients go to someone else for therapy. Tell us about your practice now, how much therapy you do and whether you feel like you’ve got the skills to be a good therapist.

Dr. CARLAT: I’ve been trying to shift my practice so that I can do more therapy. And the problem that I’ve encountered is the problem that I think many psychiatrists are going to encounter over the next decade or so, and I think that this shift is going to be happening toward more therapy, which is that like I said, I have hundreds of patients. And if I start to do one-hour therapy sessions with most of my patients, I’m going to have to kick patients out of my practice because I just won’t have time to see them. So it’s been difficult and I’ve had to do kind of creative things where I don’t do one-hour therapy sessions. I might do 45-minute therapy sessions or half-hour therapy sessions so that I can still fit a fair number of people into my practice while still performing what I would consider a better quality of psychiatry.

DAVIES: You know, another way of changing the balance besides having psychiatrists who, of course, can write prescriptions for medications, in addition to having them do more therapy, is to permit people who do therapy to write prescriptions, most of whom are not legally entitled to right now, right?

Dr. CARLAT: That’s right.

DAVIES: But there are some changes afoot. Tell us about that.

Dr. CARLAT: There are some changes and I think that what we’re going to be seeing is a kind of reconfiguring of the professional landscape, which is the kind of thing we’ve seen in other professions, like in the 1960s, nurse practitioners came on the scene and now they can prescribe medications; podiatrists can do work that only orthopedists used to do, et cetera.

So what we’re beginning to see is that psychologists who are trained in psychology graduate programs – usually six-year-long programs or so – are gaining prescription privileges in certain states after they graduate from a two-year program in psychopharmacology. And so far, two states have awarded prescriptive privileges to psychologists, those are New Mexico and Louisiana; and essentially, all branches of the military also allow this to happen. But as you can imagine, there’s been a bit of pushback, especially from psychiatrists.

DAVIES: Well Daniel Carlat, I want to thank you for spending some time with us.

Dr. CARLAT: Thanks very much.

DAVIES: Daniel Carlat’s book is called “Unhinged: The Trouble with Psychiatry.” You can read an excerpt on our website,

Coming up, Ken Tucker on a new album from Robert Randolph and the Family Band.

This is FRESH AIR.

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About Paul Harris

Pastor Harris retired from congregational ministry after 40 years in office on 31 December 2023. He is now devoting himself to being a husband, father, and grandfather. He still thinks cenobitic monasticism is overrated and cave dwelling under.
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