Dan Carlat MD has just come out with a book on American psychiatry that has got a lot of people talking. In Unhinged: The Trouble With Psychiatry – A Doctor’s Revelations About a Profession in Crisis Dr. Carlat describes the practices of the typical psychiatrist. In order to generate the most income, most of the appointments are 15 minute “med checks,” and the treatments are based on psychopharmacology and the biological psychiatry model. Patients are fed the pharma marketing explanations of how psychotropic medications work, providing solace for all involved, although there really isn’t good evidence for the explanations. Meanwhile, psychiatrists have farmed out therapy to the other professions, and have adopted a herd em through mentality toward their patients.

A July 13, 2010 interview about the book with Dr. Carlat on NPR’s “Fresh Air” show (which you can listen to here) has evoked some controversy. Giovanna Pompele wrote a critique on the Beyond Meds blog that takes him to task for his comments. She feels that by describing these practices and not apologizing for them, or implying that they still go on, that he is committing an offense. He also had some people throw some rocks about the implication that psychiatric training did not place a high value on therapy training.

I’m not sure I really see it that way. I think it is good that he is bringing this stuff out into a public discussion. I too used to give “drug talks” (see “Confessions of a Psychnetter“) but at the time I deluded myself into thinking that I was providing a useful “education”. However when they wouldn’t let me pick my own slides I realized I was doing nothing more than paid ads for the drug companies, and they dropped me for being difficult. I didn’t like it anyway, because the conversations with the psychiatrist attendees were like “I gave her Zoloft, and she got sleepy, so I gave amphetamines, and she developed… what should I do now?” Years later, the situation has degenerated to the point where my academic physican colleagues openly bemoan the fact that they can’t give “promotional talks” (yes, they actively call them that now). As for clinical work, I refuse to do the 15 minute med check thing, and restrict my clinical work to doing one hour evaluations. The part about telling patients that antidepressants increase serotonin in the brain is kind of a joke, because that is just marketing PR, and researchers like myself who have spent a lot of time reading the primary literature know it is a joke. However I’n not sure how much psychiatrists in the community have read that literature.

The idea of prescription medications like psychotropics being used to treat chemical imbalances has been burned into the public consciousness. Just take the example of Lindsay Lohan, who is on trazodone, Zoloft, Adderall and dilaudid, mixed with alcohol and cocaine, just one in a string of celebrity disasters to bite the dust on these lethal combinations. And when I pointed that out on TV last night, a caller practically took my head off, and there was a general discussion about her “depression” and how she needs to keep her meds in jail. How do we know she has real depression until all those drugs get out of her system? You don’t throw prescription meds at people who are actively abusing drugs (oopes, unless they are a Hollywood celebrity, of course).

I also see a little bit of the reaction to the acadmic psychiatist speaking the truth syndrome which is like “get him!” The whole psychiatry field has been perpetuated by myths and disttortions for so long that when someone talks frankly everyone freaks out.

By way of disclosure Danny wrote thispost in my support last year. I mention this as as a disclosure of my potential bias.

Interview of me by Neil Shulman MD about my experiences with the pharmaceutical industry. Exclusive footage you won’t see on the mainstream media.

Part 1

Part 2

Part 3

Part 4

Part 5

I was listening to the Howard Stern show the other day when I heard Tila Tequila talk about the death of her “wifey”, socialite and Johnson & Johnson family heiress Casey Johnson. I was like, whoa, these celebrities are dropping like flies! What they all have in common is a death related to prescription medications. These are not suicides, either. Often they are taken at prescribed doses. So I thought I would do some more research for a speech I gave at the Emory International Medical Volunteerism Conference this weekend. Casey was taking a string of prescription medications, including Oxycontin, Klonopin, Valium, Xanax, and Ativan. She was also using marijuana, cocaine and ecstasy, and had diabetes. She died at the age of 31 in the guest house of a friend while her friend was out partying, and she wasn’t found for several days. Actor Heath Ledger died from prescription medications including OxyContin, Hydrocodone, Valium and Xanax, and the sleep aids Restoril and Unisom. Anna Nicole Smith died at 39 while on choral hydrate, Klonepin, Ativan, Benadryl and Topamax. This occurred just a few months after her son Daniel died from a combination of Zoloft, Lexapro, Serax, Valium, and methadone. Another young actress, Brittany Murphy, died at 33. She had pneumonia, but she got tipped over from her combination of prescribed medications including hydrocodone, acetominophen, methamphetamine, and chlorpheniramal. Here she is:

And then of course there is the death of Michael Jackson, which I wrote about before, another victim of prescription medications.
These drugs include pain medications (Hydrocodone, Oxycontin), benzodiazepine sedatives used for anxiety or insomnia (Valium, Klonepin, Ativan, Serax, Restoril)
Deaths from prescription medications are now more common than deaths from illegal drugs. When is this going to stop?

I just saw this review published in Activities, Adaption & Aging by Leo Uzych. Thanks guys!
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Abstract:Reviews the book Before you take that pill by J. Douglas Bremner (2008). Before You Take That Pill critically examines a multitude of commonly prescribed medicines and alternative medicines (including vitamins and herbs) within the analytic framework of data gleaned from research studies. To the reader’s likely great edification, Bremner displays a fierce determination to unearth data embedded in the research literature germane to making scientifically valid conclusions and recommendations about potentially harmful effects of medicines. But the cascade of information flowing profusely from the book, focusing especially on the harmful effects of drugs, is a boon to the reader with any drug exposure. The book’s scientific rigor may also strongly attract the keen interest of readers with professional backgrounds tethered to medicines, including medical clinicians, scientists, and ethicists; public health professionals; health policy makers; and members of the pharmaceutical industry.

I justed posted a guest blog on the Dear Thyroid website, which is a advocacy group for patients with thyroid disease here.

A local FOX Atlanta show, you can see me and read about it here.

Reported By: Beth Galvin | Edited By: Leigha Baugham

Nearly 20 percent of American doctors get paid by drug companies to be consultants or speakers, and in some cases, they’re making quite a lot of money. So does that influence the decisions your doctor makes about your care?

Doctors earn money by giving professional talks to their peers about the latest research and the practice is pretty common.

For years it’s been unclear how much money physicians were actually earning for these speeches. Now, three major drug companies are going public revealing who is on their payrolls and how much money they’re making.

On Eli Lilly’s website, the company lists faculty on the drug company’s payrolls, including educators, advisors and contractors.

Nearly 200 Georgia doctors are on the list and they pulled in over $2.2 million dollars last year.

Some of Georgia’s highest paid physicians on the list are Emory urologist Dr. Muta Issa, who earned $ 91,000 from GlaxoSmithKline. Atlanta endocrinologist Dr. David Robertson cashed in over $78,000 from Eli Lilly and Roswell psychiatrist Dr. Michael Banov banked over $68,000 from Eli Lilly.

Some healthcare providers are earning much more by working for several companies at the same time.

“It’s common, that people who are very active, can make several hundred thousand dollars or more,” said Emory psychiatrist, Dr. Doug Bremner.

“We don’t sell medications. We simply educate physicians about data, and they make their own mind up,” said Dr. Banov.

Dr. Banov, a private practice psychiatrist, was paid over $68,000 by Eli Lilly. The Roswell doctor said he gives speeches for about five companies with competing medications.

“I think my patients welcome the fact they have a doctor who is meeting other doctors, actively involved in research, actively communicating with other physicians, someone who’s on top of the game,” Dr. Banov said.

Dr. Banov said the drug company, not him, creates the materials used in his speeches, and he also said there’s a reason for that. “We are only able to present the data. We’re not able to present our personal opinions, our personal preferences, how we use the medication off label, any of that. So we’re held to a very tight standard by the FDA.”

Emory’s Dr. Bremner said he thought paying doctors to speak for drug makers was a bad idea. Bremner said he used to do it, until he got a wakeup call about six years ago.

“I was going out to give a talk and the sales, the marketing guy like, slapped me on the back and said, ‘Go on out there and sell some,’ I’m not going to say the name of the drug. ‘Sell some of that drug,’” said Dr. Bremner.

Dr. Bremner said he worried that even the most independent doctor can get hooked on all that extra cash coming in. “Doctors are human, and once you get into this routine of making outside income, you become dependent on it.”

When asked how receiving money from the drug companies could from influencing how a doctor treats a patient, Dr. Banov said, “When I close that door, and I’m with a patient, my 100 percent interest is in getting that patient better.”

Last fall, Emory University’s School of Medicine banned staffers from making promotional talks for drug companies after congressional investigators accused the school’s chief of psychiatry, Dr. Charles Nemeroff of failing to report to the university over a million dollars he got from pharmaceutical and medical device manufacturers.

Dr. Nemeroff resigned his chairmanship, and has since left the school.

Another Emory staffer, urologist Dr. Issa listed his earnings as $91,000 in the first three months of 2009 from GlaxoSmithKline. Dr. Issa declined to comment on this story. A school spokesperson said Dr. Issa left the speaker’s bureau when Emory changed its policies.

Atlanta diabetes specialist Dr. David Robertson, who earned $78,000 for giving 47 promotional talks for Eli Lilly, said he only speaks about medications he actually prescribes.

“I think a presentation a physician makes should represent their own practice,” said Dr. Robertson. The doctor did admit that some physicians spend too much time promoting too many products. “That’s bad for everyone. That’s bad for the pharmaceutical companies, that’s bad for physicians as a profession and that’s bad probably for physicians as recipients of information because they become mistrustful.”

So are public lists like this a good thing?

Doctors on both sides say yes.

“I think it’s gotten to the point where the public is looking at it for what it is and they’re saying, ‘What’s going on here?’” said Dr. Bremner.

“Why not let the public know? There is nothing to hide. There is no shame. We’re not doing anything illegal,” said Dr. Banov. “I think it’s terrific. [It] should be completely open.”

So far, GlaxoSmithKline, Eli Lilly and Merck have published online lists of who’s on their payroll. Pfizer will be doing the same this spring.

Related Links: statements and public registries for Eli Lilly, Merck (also see here) and

GlaxoSmithKline (also see here).

Complete statement from Emory University School of Medicine regarding its new Conflict of Interest policy.

“In June of 2009, Emory’s School of Medicine adopted a comprehensive new policy governing faculty relationships with industry. The policy meets the recommendations of the Association of American Medical Colleges, the Association of American Universities, and the Institute of Medicine. Professors Issa, Pacifici, and Schulman are respected faculty members who are in compliance with that policy. Dr. Nemeroff resigned his position at Emory in fall of 2009 to become chair of psychiatry at another medical school.”

This week the traveling road show is in Barcelona, where we are attending the annual meeting of the European Society of Cardiology. Immediately upon arrival at the convention center we were greeted by a 30 feet high banner from Novartis Pharmaceuticals that admonished us to “Aim Higher”, in reference to one of their newer high blood pressure medications. It wasn’t clear whether the reference was to aiming at higher drug costs or higher levels of blood pressure control, but we all know that what Novartis really wants is the former, although they might try and convince you that they are interested in the latter.

I noticed that the line for cabs was about 200 cardiologists long, while there were hardly any cabs pulling up. I personally prefer taking public transportation in foreign cities as you get a better idea of the city and it is, well, cheaper and better for the environment. With the metro stop right next door it makes you wonder what lengths those cardiologists will go to to avoid mixing with the rabble.

Anyhoo upon passing the snaking line of cardiologists I was handed a card by a young lady as I entered the convention center. I thanked her and looked at the card as I walked in. Surprisingly it was for the El Cabaret Strippers Club in Barcelona. I immediately twittered the news and received various feedback including laughter and being accused of being a misogynist. As I continued following the signs to the hall where Mrs. Bremner was to lecture on Non-obstructive coronary artery disease in women, or Syndrome X, the signs routed me directly through the cavernous exhibit hall where drug and device manufacturers tout their wares. After freaking out about a 40 foot high model of a person with pulsating veins suspended from the ceiling, I tried to scuttle past the vendors averting their eyes and looking for the ephemeral lecture hall. I couldn’t help but be distracted, though, by the Medtronics booth, who I wrote about a while back in reference to their picking up the tab in the VIP room of the Platinum Club strippers place in Memphis for a bunch of surgeons who were brought in to learn more about Medtronics spinal devices. Inhibiting the urge to ask them if they were picking up the tab for the ESC meeting too, I continued on to the lecture, where we learned that 50% of women who undergo diagnostic catheterization do not have evidence of coronary artery obstruction, versus 20% of men.

As I left the convention center attractive young women were seen walking around holding signs over their heads saying ‘Novartis’ and ‘GSK’, followed by laughing groups of cardiologists.

As I reflected on my experiences I wondered who in fact were the hookers and the patrons. Were the physicians the patrons of prostitutes, or was it the other way around, were the physicians prostituting themselves to device and drug makers?

I tried to get a picture of the El Cabaret but got the following message when I searched for it on the internet.

La página que desea visualizar ha sido filtrada por el sistema, ya que su contenido ha sido clasificado dentro de las categorías no permitidas.
	permite limitar el acceso a páginas web con contenidos no apropiados, eliminar la publicidad y controlar la descarga de determinados archivos. Si considera que ha habido un error, por favor, seleccione su caso en el siguiente formulario, pulse el botón enviar y si nos indica un email le daremos una respuesta una vez hayamos analizado su petición:

Accompanied by a pair of happy Catalonian children surfing the net. I guess they were too prudish in my apartment here to let me look up El Cabaret. I think the cardiologists at ESC should pick up some pointers from them.

Plos Medicine has just release over 1500 documents which you can peruse here on ghost writing which they obtained through legal action in cases on use of hormonal replacement therapy (HRT) in post-menopausal women. You can plod through the individual Tiff files but the always useful University of California at San Francisco Drug Document archive will soon be putting them up in indexed format here so you can soon be reading about Timothy Kuklo MD and all of your other friends like the guy from Columbia who published a fraudulent article on the power of prayer for in vitro fertilization who I found on there right away.

Speaking of Columbia, their medical school seems to be putting out their fair share of turds recently, to whit the professor who was quoted in the NYT article on ghost writing for prempro that it was “too much work” to actually look up and read all of the articles required for a review paper. She of course had a ghost writer do it for her, for which she got a pay check and a free publication, which helped her get academic promotion, and more “writing” gigs presumably. I find that particularly depressing since I have written numerous reviews for which I spent hundreds of hours and did painstaking research and didn’t have someone do it for me.

I have been amazed at how many physicians continued to write about the benefits of HRT even after (as I wrote in my book, see sidebar) studies like the Women’s Health Initiative (WHI) showed that they increased the risks of cancer and heart disease, rather than decrease them. Now I think I understand why, since Wyeth financed the writing of over 60 papers about HRT which they hired private “ghost writing” firms to write, and then recruited academic physicians to put their names on as authors to add prestige and credibility. It only leads me to the conclusion that my profession is filled with corrupt sociopaths and that the publishing companies who participated in this scam are part of the problem.  

Plos was able to get the judge in the HRT litigation to release these 1500 documents because he appropriately concluded that this practice was putting the public health at risk by creating a biased and at times fraudulent body of “scientific literature” that leads to misinformation.

As other bloggers have pointed out medical schools seem to have an inordinate amount of corruption and cheating. I think that is because MDs have a sense of entitlement and because so called non profit academic medical centers are really anything but. It is all driven by money, and many academic physicians use their record of publishing as a way of getting lucrative consulting and speaking gigs. Then the drug companies pay them to put their names on papers, which helps the drug companies, but also helps the academic physicians have longer publication records. Drug companies also help them make more contacts and in general become more successful so it is a win-win situation. We used to call these charmed individuals “shining lights”.

After I wrote this post yesterday called “Motherhood is Not a Medical Disorder” about the Mother’s Act, which advocates for widespread screening of moms for post-partum depression (PPD), something I don’t think is a good idea because it medicalizes a normal stage of life, increases the chances that people will be but on antidepressant medications that they may not need and that may have side effects, and represents yet another intrusion into privacy, I got this response from John Grohol at psychcentral (”False Claims by Bremner”).

First he grumbles about my pointing out that the psychiatrist quoted in the Time article, Katherine Wisner, MD (you can follow the link to the Time article in yesterday’s post), was on the speakers bureau for Pfizer and Lilly (something not noted in the article but which I found on my own), makers of Zoloft and Prozac, respectively, which as a commenter pointed out are promoted as the two safest antidepressants for pregnant and lactating women. Being on a speaker’s bureau these days means giving “promotional talks”, which translates into working for the drug company to advertise to other doctors, and is relevant. In addition, the psychcentral website has paid ads, most of them for treatment (which includes medications), while this site has no ads. And don’t say I am trying to profit off my book, which now goes for a nickel on amazon.

Grohol further takes issue with my statement that women without a prior history of anxiety or depression are not at risk for PPD and therefore would not benefit from widespread screening. However in support of that he cites Ross et al 2009, claiming that history of abuse and alcohol or substance abuse are risk factors for PPD as well. However a perusal of Ross et al shows that a history of childhood abuse is not in fact a factor, rather only abuse during pregnancy. In addition, it is alcohol and substance abuse during pregnancy that is a risk factor, on the order of a pregnant woman drinking a six pack a day or actively abusing cocaine. That kind of substance abuse is a risk to the fetus, and needs to be stopped.

If you have a man beating his pregnant wife, or a woman snorting cocaine while pregnant, that it is a situation much more serious than PPD, and should be stopped. These extreme circumstances hardly justify mass screening for PPD.

I still say NO to the MOTHER’S ACT.

This recent article in Time Magazine discusses the Mother’s Act, legislation initiated in response to the story of Melanie Blocker-Stokes, who leaped to her death from her hotel room in Chicago three months after the birth of her daughter. Officially known as the Melanie Blocker-Stokes Post Partum Depression Research and Care Act, but referred to as the Mother’s Act, this legislation would require screening of all women post-partum for depression.

The problem with this is the attitude that being a mother is a risk factor for a psychiatric disorder. First of all, there is no evidence that women without a prior history of anxiety and depression have any increased risk of getting post partum depression. So to screen all moms as if giving birth is a risk factor for depression is ridiculous. And whenever you start screening the general population, you get into problems with over-identification of people and an increase in the number of people that go on antidepressants. I am opposed to mandatory screenings of the population, like Teenscreen, which are bonanzas for the pharmaceutical industry, but a major intrusion into the privacy and autonomy of American citizens. In the case of Melanie Blocker-Stokes, she had already been treated with multiple courses of psychotropic drugs and electro-convulsive therapy, so there is no reason to think that her life would have been saved by “screening”. This legislation is typical of much that comes out of an individual tragedy, that results in an intrusion into the personal lives of individuals and the further relinqueshment of individual freedoms to the government.

The article quotes psychiatrist Katherine Wisner MD as stating ”how can you be opposed to something that will help mothers?” But an examination of the fine print from one of her articles here shows that she is on speakers bureaus for Pfizer and Lilly, makers of Zoloft and Prozac, respectively. 

In it is quoted Amy Philo, a leader of the coalition against the Mother’s Act. Her experience was that after her baby choked on his vomit and needed emergency treatment, she became increasingly anxious about his health. Her doctor gave her Zoloft, telling her that it would make both her and her baby happier. After treatment with Zoloft, she started having alarming suicidal thoughts and thoughts about hurting her baby. When she weaned herself off of Zoloft she felt fine. This experience led her to start the United Non-Profits and Individuals for Truth and Ethics (UNITE), a coalition opposed to the Mother’s Act (click here to sign their petition). Time magazine recently corrected a statement that she had post-partum depression and developed thoughts of harm before taking Zoloft, which wasn’t true.

[update: read more on the debate that arose after this post here at Amy Philo's The Bitter Pill blog and my responses to John Grohol's attack on this post ("Bremner makes false claims...") here and here.]