A Psychiatrist's Prescription For His Profession

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A Psychiatrist's Prescription For His Profession

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 re-
evaluate: 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
it.

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 involve 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 a
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 don't
really 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 is a lot. I think many
of my colleagues have practices with four or 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 when 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
sessions, 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: We're speaking with psychiatrist Daniel Carlat. He publishes a monthly
newsletter called the Carlat Psychiatry Report, and he has a new book that's
critical of the current practice in psychiatry. It's called "Unhinged: The
Trouble with Psychiatry." We'll talk more after a short break. This is FRESH
AIR.

(Soundbite of music)

DAVIES: If you're just joining us, our guest is psychiatrist Daniel Carlat. He
has a new book called "Unhinged: The Trouble with Psychiatry."

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 or 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 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 post-mortem 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: Daniel Carlat's book is called "Unhinged: The Trouble with Psychiatry."
He'll be back in the second half of the show. I'm Dave Davies, and this is
FRESH AIR.

(Soundbite of music)

DAVIES: This is FRESH AIR. I’m Dave Davies in for Terry Gross. We're speaking
with Dr. Daniel Carlat. He's a practicing psychiatrist whose new book
"Unhinged" argues that drug companies have too much influence in his profession
and too many psychiatrists have all but abandoned talk therapy.

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 happing in these publications?

Dr. CARLAT: And 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 creditability.

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, et cetera. 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, is 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
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 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: We're speaking with psychiatrist Daniel Carlat. His new book is called
"Unhinged."

We'll talk more after a short break.

This is FRESH AIR.

(Soundbite of music)

DAVIES: If you’re just joining us, our guest is Dr. Daniel Carlat. He's a
practicing psychiatrist. He writes a monthly newsletter called the Carlat
Psychiatry Report and he's the author of a new book that's critical of the way
psychiatry is practiced these days. It's called "Unhinged: The Trouble with
Psychiatry."

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 doctor's
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 specialist 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 the 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, as 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 was 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?

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 a 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 doctor 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 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 you 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
you 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 minutes 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 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, freshair.npr.org.

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

This is FRESH AIR.
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Robert Randolph: A Gospel Guitarist's Secular 'Road'

DAVE DAVIES, host:

Robert Randolph and the Family Band have been recording for about a decade,
mixing soul, gospel, R&B and rock. Randolph emerged from a gospel music
tradition, playing steel guitar in the so-called sacred steel style of a
certain African-American Pentecostal churches. His move into secular music has
now been furthered by a new album, "We Walk This Road," produced by T-Bone
Burnett and featuring both original songs and songs of covers from Bob Dylan,
Prince and John Lennon.

Rock critic Ken Tucker has a review.

(Soundbite of music)

Mr. ROBERT RANDOLPH (Guitarist, Singer): (Singing) We walk this road. We're on
our way. But when we get there, no one can say. No one can say. No one can say.

KEN TUCKER: The high, plaintive wail of the pedal steel guitar and the warmly
rough voice that follows close behind it define Robert Randolph's sound. In the
past, and occasionally on this new album "We Walk This Road," Randolph's
mixture of soul, gospel, R&B and rock is reminiscent of another group that came
out of a similar tradition: Sly and the Family Stone.

At once a seasoned gospel prodigy and a newcomer to secular music, it's no
surprise that Randolph has ended up working with producer T-Bone Burnett, the
musical polymath who likes to pair musicians with songs that might not
otherwise occur to the artists. So it is with Randolph's cover of the Peter
Case song "I Still Belong to Jesus." It begins with an intro that sounds like
something off a 1970s Fleetwood Mac album, and then moves into Randolph's
searching soulfulness.

(Soundbite of song, "I Still Belong to Jesus")

Mr. RANDOLPH: (Singing) Someone else woke up today and saw it all in a brand
new way. But I still have to turn my head. I still belong. Something saved me
long ago. How it happened, I don't know. You say it doesn't make much sense.
Still, I know it's no coincidence. My life has changed.

TUCKER: Randolph and Burnett listened to loads of music, from the turn of the
century to the present. Like doctoral students footnoting their scholarship,
the album includes snippets of some of the original texts from which they
derived inspiration. Listen to the way this bit of "If I Had My Way" from Blind
Willie Johnson leads to a glorious rearrangement of the song by Randolph,
Burnett and the great eccentric Los Angeles singer-songwriter Tonio K.

(Soundbite of song, "If I Had My Way")

Mr. RANDOLPH: (Singing) Well. Delilah was a woman fine and fair. Her pleasant
looks-a, her coal black hair. Delilah gained old Samson's mind. A-first saw the
woman that looked so fine. A-well went Timnathy, I can't tell. A daughter of
Timnathy, a pleased him well. A-Samson told his father, I'm going. Help me
Lord. If I had my way I'd tear this building down. If I had my way, I'd tear
this building down. Tear the building down. Tear the building down.

Daniel, Daniel in the lion's den, wondering where have you been. Like Delilah
fine and fair, diamond eyes and coal black hair. Like Delilah put me out, too
much sorrow, so much doubt. Love is painful. Love is blind. Never know what
you're going to find. If I had my way...

TUCKER: Backing Robert Randolph and the Family Band on that track is drummer
Jim Keltner, who's played on so many crucial albums by everyone from Eric
Clapton to Bob Dylan. Speaking of Dylan, his song "Shot of Love" receives a
radical reworking on this album, and not for the better. The title song from
what is generally considered the last of Dylan's born-again Christian period,
"Shot of Love" featured Keltner on the original.

There's another connection here, too: It's was widely reported that T-Bone
Burnett was one of the people who escorted Dylan into evangelical Christianity
in the late '70s - all the more reason, therefore, to be startled at how
miscalculated Randolph's version of the song sounds. I'd call it a travesty if
the original material merited such a shocked term.

(Soundbite of song, "Shot of Love")

Mr. RANDOLPH: (Singing) Don't need no shot of heroin to kill my disease. Don't
need a shot of turpentine, only bring me to my knees. Don't need no shot of
codeine to help me to repent. Don't need no shot of whiskey to help me be
president. I need a shot of love.

TUCKER: And so this album "We Walk This Road" is certainly uneven, but always
interestingly so. The urgency in Randolph's singing propels every song forward,
even when everyone's headed on either a wild detour or in the wrong direction.
But he also keeps both the high road and the mainstream in sight.

Randolph knows that what his gospel past and his pop music future have in
common is a desire to communicate to the widest possible audience, to have you
feel and share in his passion for every kind of music that embodies his hopes,
his desires and his dreams.

DAVIES: Ken Tucker is editor-at-large for Entertainment Weekly. He reviewed "We
Walk This Road" from Robert Randolph and the Family Band. You can hear three
songs from the album on our website: freshair.npr.org.
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