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To be clear, I am also a social anthropologist (a profession from which I earn my living), and as an anthropologist I have never taken an either/or position with respect to psychiatry and psychotherapy. I have been critical too of psychotherapy's limitations and excesses—something my previous academic work makes clear.
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After all, my professional aim has never been to put the interests of a single professional group within the mental health industry first, but only ever the interests of patients. Furthermore, although I have worked as a psychotherapist in organizations like the NHS, I have never received any money for the clinical work I have undertaken. So far I have preferred only to work voluntarily.
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Once I reached the Lincoln Memorial, I stood for a moment pilgrim-like at the foot of an icon. Lincoln has always fascinated me ever since reading his letters as a teenager. He had always been conflicted by power—reluctant to assume it, watchful of those wielding it, and consummately observant of its potentially corroding effects. As I sat in a shady area on the memorial steps, looking back soberly toward the Capitol, one of Lincoln's sayings came to mind. “Nearly all men can stand adversity,” he had written, “but if you want to test a man's character, give him power.” This quotation now seemed so thoroughly apposite to what Grassley had just revealed only moments ago: a psychiatrist warrants criticism to the extent his or her character has failed the test of power. But I also knew that this general notion applies to institutions as well as to individuals—institutions that, for one reason or another, have similarly failed the test of power.

As to how this notion applies specifically to psychiatry is a matter I shall explore next.

WHEN SCIENCE FAILS, MARKETING WORKS

I
n the years following the release of Prozac in 1988, the pharmaceutical industry fractured into ever deeper warring fragments. The ensuing battle concerned what company would gain the greatest share of a rapidly emerging market opportunity: the demand for a brand-new wave of antidepressants believed far superior to earlier psychiatric drugs. This market would be worth billons of dollars annually to any company able to convince doctors and the wider public that it manufactured the most efficacious pill. As company after company charged in to win its market share, different versions of this new antidepressant arrived year on year—Prozac, Effexor, Seroxat, Lustral, Cipramil—each claiming to be better than the last.

Given the vast amounts of money at stake, it is little surprise that companies developed increasingly sophisticated marketing techniques to persuade people that their drugs worked best. In places like Britain, where the pharmaceutical industry was prohibited from directly advertising its pills to the public, it had to rely solely on what is generally called physician-directed marketing. This meant that GPs, psychiatrists, academic researchers, and psychiatric nurses all became targets of elaborate promotional exercises by which the profile of a particular drug could be raised and the number of prescriptions increased.

The seriousness with which companies took these marketing offensives is illustrated by the vast amounts of money they spent. At the height of the marketing war, the industry invested twice as much money in promoting its pills as it did in researching and developing them. For instance, in the mid-2000s companies were spending $2.52 billion on drug promotion in Britain each year. This investment is evidenced by how quickly marketing departments in the pharmaceutical companies expanded. The ex-editor of the
British Medical Journal
stated, for example, that between 1995 and 2004 there may have been a 59 percent increase in the number of employees working pill promotion, while jobs were actually cut in drug research.
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Because a large proportion of these vast resources were used in promoting antidepressants, it's safe to say that during the 1990s and 2000s the British public's escalating familiarity with these drugs was largely a product of the pharmaceutical marketing machine.

What kinds of strategies did companies use to promote their pills so successfully? In what kinds of tactics did they so heavily invest to achieve their financial goals? How did the pharmaceutical industry, in other words, manage to transform an obscure set of SSRI antidepressants in the early 1990s, which really didn't work too well and were dangerous in many ways, into one of the most widely prescribed species of drug in medicine today?

2

In early 2001 Daniel Carlat, like thousands of other psychiatrists at the time, became embroiled in this drug marketing war.
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The particular battle in which he got tied up concerned a new antidepressant called Effexor, developed by the pharmaceutical company Wyeth. During the early 2000s, the company was on a promotional offensive to convince practitioners across Europe and the United States that Effexor was superior to its competitors. Unlike the existing SSRI antidepressants, which just targeted serotonin levels, Effexor was rather a “dual reuptake inhibitor,” which meant it targeted two neurotransmitters (serotonin and norepinephrine). Wyeth claimed that Effexor's dual action rendered it superior to its SSRI-only competitors. And so this was the message Wyeth reps sold wherever they entered doctor's offices whether in Birmingham, Nottingham, Manchester, or London; in Washington, Boston, Philadelphia, or New York, the sales reps worked the same simple objective: convince doctors you visit that Effexor is the best.

On a nondescript afternoon in 2001, one of these sales reps would confidently stride into Dr. Daniel Carlat's office with an enticing offer in hand. Would Carlat be willing to give some talks about Effexor to other doctors? Sure, he'd be paid for the talks (between $500 and $750 per hour), and sure, he'd receive some training. But the training really wouldn't take long—and he'd be paid for that too. All he needed to do was turn up at a hotel in New York in a few weeks' time and attend a two-day crash course on Effexor. Then he'd be ready. His stay would also be very comfortable—all expenses paid, of course. What's more, he needn't leave his wife at home. Her ticket was paid for too.

“I was extremely flattered by this offer,” Carlat confessed to me as he recounted the drug rep's visit, “especially since I'd been out of the academic setting for so long working in a small community.” Indeed, since finishing his psychiatry residency a few years earlier, Carlat's career had remained decently modest. “I'd been working half-time in an inpatient unit and half-time in my own private practice,” said Carlat. “I was just spending my time enjoying meeting patients and learning my craft.”

Carlat enjoyed no glitzy pharmaceutical links or perks even though he knew lots of other psychiatrists had been enticed by them, something he first noticed when still training as a psychiatrist at medical school. “I realized back then there were a lot of doctors and academics who were doing work with pharmaceutical companies, either doing research or just jetting around the country or even the world, giving different kinds of presentations. Their lifestyle appeared very glamorous. And there was an unspoken sense among the psychiatry trainees that this was the lifestyle to one day chase after too.”

Perhaps a seed had been sown back then, because a few weeks after the Wyeth rep stepped into Carlat's office, Carlat and his wife would step off the plane in New York. They would then make their way to a luxurious hotel in the heart of Manhattan, where a Wyeth attendant with a dazzling smile would greet them. She would hand Carlat a conference pack containing a schedule of talks as well as invitations to various dinners and receptions and, surprisingly, two tickets for a Broadway musical. Despite the pang of conscience Carlat felt at having so much money lavished on him, he couldn't help but feel, well, kind of special. How very distant his small-town practice now suddenly seemed from the glamorous world into which he had been invited.

In between the various dinners and entertainment events, Carlat eagerly attended the talks, which were delivered by some leading lights in antidepressant research. First, there was Dr. Michael Thase from the University of Pittsburgh. He was the global authority on Effexor and one of the most respected psychiatrists in the United States. Thase's task was to report the findings of his huge meta-analysis, which included studies covering more than two thousand patients. Thase's results were so impressive that Carlat soon understood why they were taking the world of psychiatry by storm.

Effexor achieved a remarkable 45 percent remission rate, which in layperson's terms meant that 45 percent of patients experienced a complete disappearance of symptoms. With results like these, Effexor far excelled the existing SSRIs (whose remission rate was only 35 percent) and placebos (remission rate 25 percent). If these figures held true, then for the first time in modern psychiatry one antidepressant stood out from all the rest. Not only would this revolutionize what doctors would prescribe, but it would also increase Wyeth's profits by literally billions of dollars a year. Could Thase's results be trusted?

Thase was determined they could. And to prove this he would spell out carefully to the crowded room of psychiatrists the main objections to his research so he could impressively rebut each in turn. The first objection he addressed was that Wyeth had funded his meta-analysis. Did this not create a conflict of interest that may have potentially biased his study? Thase was sanctimonious. He and his team had consulted all the data and not cherry-picked the results most favorable. They had abided by the strictest scientific standards, ensuring that their objectivity could not be purchased. It was as simple as that.

Another objection was that Effexor had only been compared to one SSRI—Prozac. So presumably other SSRIs may perform better. Thase was ready for that one, too. Since the original study, he had analyzed data about Paxil and other SSRIs. And as luck would have it, these also showed similar advantages for Effexor. Case closed.

The final objection concerned why Thase had chosen to measure “remission” rates over the more usual “response” rates. The difference was subtle but important. For instance, a “response” is achieved when a patient experiences a 50 percent improvement on the Hamilton Scale (e.g., moving from 30 points before treatment to 15 points after treatment), while “remission” is defined as complete recovery (in Thase's study this meant achieving a score of 7 or below on the Hamilton Scale). Had Thase chosen to measure remission over response because it would make Effexor look superior? Carlat couldn't work it out until Thase addressed the issue head on: no matter where you put the cut-off rate for remission (7 points, 6 points, 9 points, etc.) Effexor always came out on top. With each rebuttal the audience grew more convinced.

After Thase received eager applause for this impressive display, the next speaker made his way to the podium: a psychiatrist called Norman Sussman, a professor at New York University. Sussman was a typical front man, more charismatic and personable than the lithe and academic Thase. He was also an expert popularizer, demonstrating fluently to the psychiatrists gathered the most effective manner in which they could communicate the great news about Effexor to doctors up and down the country.

And so the talks continued, until by the end of the weekend, the attendees had been thoroughly dosed with a mixture of genuine education and effective sales techniques. If any lingering doubts remained, well, there was no need to dwell on them now. The last night of the conference had arrived, and what's more there was a surprise waiting: for Carlat it came in the form of a small envelope containing $750. “It was now time to enjoy the city,” as Carlat put it.
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When Carlat returned to his small practice in Newburyport, there were already two messages from Wyeth reps waiting on his answering machine. Obviously, the company wanted to begin its promotions in earnest. Carlat would deliver his talks once or twice a week during his lunch breaks. This time suited everyone, including the reps who could use the occasion to entice bigger audiences with offers of a free lunch. Sometimes there'd be just a small gathering of doctors and nurses, sometimes a crowded conference room, and at other times just Carlat and a single physician.

While each setting was different, one thing never changed. There was always a drug rep present, scrutinizing Carlat's performance and occasionally giving him notes after a talk: emphasize this, don't worry about that, enjoy yourself more, you're doing well. Before his talks the reps would also advise Carlat about the prescription habits of the various doctors he'd be addressing that day. They obtained this crucial information from data-mining companies that accessed prescribing data recorded at pharmacies. These data were repackaged and sold to companies like Wyeth so they could tailor their sales strategies accordingly. The whole operation was very slick, and Carlat was beginning to feel uneasy.

He soon realized that his $500 to $750 an hour came at a price. “When I was sitting in New York, I could never have imagined the huge pressure I'd be under to perform in those talks in a certain way,” Carlat said to me. “When you are being paid a significant amount of money to promote a pill, and when you know that the reps are going to decide whether to invite you back depending on whether the doctors will prescribe Effexor after your talk, the question is how that pressure affects you. Does it cause you to highlight the advantages inappropriately and to downplay the side effects? Did the promise of more money actually affect the content of what I was telling those doctors? I struggled with those questions.”

The struggle deepened as Carlat began to encounter more criticisms of Effexor. New data seemed to show that the remission rates for the drug were far less impressive than Thase had reported in New York—more like 5 percent better than SSRIs instead of the reported 10 percent. Also, Carlat realized that Thase's meta-analysis may have been a victim of some of the methodological games I discussed in chapter 8. For example, some patients enrolled in the original Effexor studies had taken SSRIs in the past and had presumably not responded well. This meant that the study population might have included patients who were already treatment-resistant to SSRIs, therefore giving Effexor an inherent advantage.

Finally, the majority of studies Thase assessed in his meta-analysis were fairly short-term—only six or eight weeks long—so there was a possibility that if the clinical trials had been longer (e.g., six months or a year), the response and remission rates of the SSRIs compared with Effexor's would have turned out to be the same.

Although Carlat knew that this crucial information invited “the kinds of methodological discussion that may really be important for doctors to hear,” Carlat kept this highly relevant information out of his talks. He feared that if he mentioned it, the reps wouldn't invite him back. But at the same time he also realized “by not mentioning them I was committing sins of omission.” Carlat began to struggle seriously with the ethics of his position—a struggle very soon deepened by two events.

The first occurred at a lunchtime meeting when Carlat was talking about Effexor to a group of psychiatrists. One psychiatrist took issue with Carlat's view that high blood pressure was relatively uncommon with low doses of Effexor, stressing that in his clinical experience Effexor's record on hypertension was pretty poor. Carlat was caught off guard and struggled to respond. Sure, back in New York Thase had actually briefly addressed the blood pressure problem. But Carlat was also aware that “while there are data to support the position that the drug is safe, when you really dig more deeply into the data, the full story isn't quite as cut and dried.”