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In other words, Carlat had been trained to talk about Effexor's weakness in a way that would reflect best for the drug and encourage doctors to try it out. “This did not mean the company ever told us to deny these side effects exist,” said Carlat, “only that you just had to talk about the side effects to physicians in a way that wouldn't alarm them. And you'd also have to couch them in a way that would convince doctors that Effexor was worth trying even before, in some cases, safer medications had already been tried.”

The disagreement forced Carlat to acknowledge that he was spinning the study's results in the most positive way possible while playing down the limitations of the data. “I thought to myself,” said Carlat frankly, “that I'm ultimately doing more of a disservice by discussing the data in simplistic terms than I am serving these doctors in educating them about the drug.” His style had to change. He would have to be more upfront.

Then came the second event. “I decided in one talk to say that the studies of Effexor were very short, and that if they'd been longer it's feasible that the competitors of Effexor may have caught up. But when I made that point in front of the doctors, the drug reps did not look very happy. The next day I had an unexpected visit from the district manager of Wyeth, who said the reps had told him that in my last talk I didn't seem so enthusiastic about his product. He then looked at me closely and asked, ‘Have you been sick?' I was shocked. It was as if the only possible way I could not be enthusiastic about his product was if I were somehow ill—not on my game.”

That encounter was decisive for Carlat. “It laid bare for me my role from the standpoint of the company, which was to be a marketer for their drug. And to the extent that I said anything that was in any way negative or not glowingly positive about their product, I was less and less useful to them, even if what I were saying was accurate. That was the tipping point when I decided to stop giving promotional talks.”

When I asked Carlat whether he believed his talks influenced the prescribing habits of the doctors he addressed, he was unequivocal. “I would be astonished if my talks did not significantly affect their prescribing behaviors. And the reason I say that is I was talking to primary care doctors and family practitioners who are not specialized in psychiatry. To them I was an expert simply educating them about the benefits of Effexor. So they just assumed, well, as he's saying it, it must be true and I should try prescribing it.”
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This, indeed, was the intended effect. And if “Key Opinion Leaders” like Carlat didn't achieve this effect, there would be tangible consequences. As Kimberly Elliott, who handled Key Opinion Leaders for a number of pharmaceutical companies, put it: “Key opinion leaders were salespeople for us, and we would routinely measure the return on our investment by rating prescriptions before and after their presentations.” She continued, “If that speaker didn't make the impact the company was looking for, then you wouldn't invite them back.”
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There are many startling things about the case of Dr. Carlat, most of which go without saying. But one strategy that I think is essential to how the pharmaceutical industry markets its pills does warrant mention. This involves exploiting the highly hierarchical nature of the medical profession, in which an almost caste-like system of professional rank arranges the relations between its various “orders.” Junior doctors defer to registrars, who defer to consultants, who in turn bow to their more senior consultants. This pyramid of ascending seniority sees each rank sitting atop and enjoying authority over the ranks below.

Companies therefore know that if they are to convert the pyramid's base, they must first convert those at the top. They must recruit senior psychiatrists like Dr. Michael Thase and Dr. Norman Sussman to convince less senior doctors like Daniel Carlat to spread the message to the wider ranks of medical students, junior doctors, primary care physicians, and GPs.

This latter group is especially important because the vast majority of antidepressants are not actually prescribed by senior psychiatrists, or even by psychiatrists at all, but by family doctors and GPs who listen carefully to the advice psychiatrists provide.
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After all, your kindly and overworked local GP has little time to scrutinize all the research relevant to every drug that he or she daily prescribes, and so is reliant on what more senior people like Thase impart through medical journals and on what less senior doctors like Carlat impart during their visits.

This strategy of paying “Key Opinion Leaders” like Thase and Sussman to ensure that community preferences align as closely as possible with company interests sheds a bit of light on why Senator Grassley found so many senior psychiatrists receiving eye-popping amounts of industry money. An endorsement from a top researcher at a senior university will benefit your brand far more than a thousand company reps could ever do. This is especially the case if their endorsement is itself published in a journal of high repute, which has often led companies to brazen excesses to get the recruit journal support.

And I am not just talking about providing financial incentives for editors to publish company-sponsored research (chapter 8), or designing, conducting, and writing research to which academics then merely put their names (a practice known as ghost-writing), but about strategies that go even further: One recent case saw the drug giant Merck, for example, pay an undisclosed sum to the international academic publishing house Elsevier to produce several volumes of a publication that had the look of a peer-reviewed medical journal but actually only contained reprinted or summarized articles, most of which, unsurprisingly, presented data favorable to Merck products.
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While feeding the top of the food chain is a crucial company marketing strategy, this does not mean that the junior ranks are left alone. They are not only visited by pharma reps and by speakers like Carlat (albeit perhaps in fewer numbers than in Carlat's day), but they too can be invited to all-expenses-paid conferences or “continuing medical education” events where experts discuss new treatments. They are also regularly sent free drug samples in the hope that their prescribing habits will alter, and are sometimes asked to find patients for drug trials while being offered strong financial inducements. At the same time, they are subjected to a barrage of adverts for psychiatric drugs placed in medical journals.
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Company marketing directives should therefore be a matter of serious concern for the general public, not least because it would be naïve to suppose that marketing campaigns have played no role in inflating prescriptions (the 46.7 million NHS antidepressant prescriptions in 2011 cost the British taxpayer over a quarter of a billion pounds last year).
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After all, if these marketing strategies did not work, you'd hardly expect pharmaceutical companies to keep investing in them.

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While the prescribing figures in the UK are high, in the United States they are higher—not by much, mind you, only in fact by around 13.5 percent. To put this figure into perspective, this means that in 2011 there were around 746 prescriptions for antidepressants per 1,000 people in the UK, while in the United States there were around 843 prescriptions per 1,000 people. This amounts to a difference of around 100 prescriptions.
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Naturally many sociocultural factors contribute to why doctors in the United States prescribe more antidepressants, but once again we cannot dismiss the role of marketing. After all, the United States is the only country (with the exception of New Zealand) where direct-to-consumer advertising of psychiatric drugs is permitted. This means that in the United States adverts for antidepressants can be placed freely in public locations—on trains and buses, on stations and billboards, in magazines, on television, and on the Internet.

The pharmaceutical industry takes this form of advertising very seriously, spending billions of dollars on it every year.
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And it justifies this huge expenditure both in terms of its being a wise investment and in terms of its providing an important public service—one that increases public awareness of undiagnosed disorders such as depression, and one that therefore alerts people to problems that may otherwise go untreated. Countries that reject direct-to-consumer advertising often offer the counter argument that the education of patients and physicians is surely too important to be left to the pharmaceutical corporations, whose ability to produce unbiased information can't be guaranteed. Consider, for example, the following series of US adverts all of which make scientific-sounding claims that don't stand up to serious scientific scrutiny.

In a recent advertising campaign for a drug called Abilify, which is prescribed to people diagnosed with bipolar disorder and depression, a commercial claimed that it works in the brain “like a thermostat to restore balance.”
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Its print advertisements also claimed that “When activity of key brain chemicals is too high, Abilify lowers it. When activity of key brain chemicals is too low, Abilify raises it.”

Another example was the widely televised Zoloft commercial, which again plays on the chemical imbalance idea. It states that “Prescription Zoloft works to correct this imbalance,” even though not a single piece of research has ever confirmed what a so-called “correct” chemical balance looks like.

Then there is the advert for Paxil that reads “Just as a cake recipe requires you to use flour, sugar, and baking powder in the right amounts, your brain needs a fine chemical balance in order to perform at its best.”

Advertisements for other big-selling antidepressants such as Prozac and Lexapro have made similar claims, again in the absence of scientific support.
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One of the first direct-to-consumer pamphlets produced by Eli Lilly for Prozac, for example, stated that: “Prozac doesn't artificially alter your mood and it is not addictive. It can only make you feel more like yourself by treating the imbalance that causes depression.” The fact that the chemical imbalance theory has never been proven does not seem to matter to these corporations, which have made their public assertions as though they were based on scientifically established certainties.
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In these cases it is clear that pseudoscientific claims are being misused to sell the idea that our problems are largely biological in origin and so best remedied with costly bio/chemical solutions. In 2011, I encountered a particularly brazen example of how far such misinformation will go. In a video promoting antidepressants on the APA's website, we overhear a father reflecting upon his son's depression and how it led to a catastrophic end. The father says:

“I did not understand that depression was a disease. If he'd been a diabetic, I'd have gotten him insulin. I told him ‘get over it, you'll feel better later.' I used to think medication was mind control. When he stopped his therapy, he got worse. When maybe he could have been helped …”

The most chilling part comes at the end of the video when the father turns to his other son and says forlornly, “I have got some bad news about your brother …”—implying that his untreated depressive brother had finally taken his own life
.
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The promotional video drives home a number of misleading messages that play on public fear and confusion around mental health issues while exploiting the viewers' trust of medical experts. These messages imply that depression is a disease like any other physical disease (a view research doesn't support), that medication is really the only solution (another unsupported view), and finally that not giving your child medication may lead to their death (a gross overstatement by all accounts). This video therefore taps into our anxiety that if we don't defer to drug treatments, then we may only have ourselves to blame if tragedy ensues.

This kind of pseudoscientific scaremongering should have no place in respectable medicine and even in medical marketing, but research now indicates such tactics are used in adverts for psychiatric drugs more than in adverts for any other type of medication.
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It is not just scientific authority that has been misappropriated to sell pills. Any authority will do—including the authority of celebrity. In a popular commercial for the antidepressant Paxil, the British company GlaxoSmithKline paid the American football player Ricky Williams a huge figure to discuss his “social anxiety disorder.” Elsewhere, GlaxoSmithKline has Williams saying, “It's amazing at how much I've grown and how much I've changed and how much I went through. And of course I owe a lot of that to Janey, my therapist, and Paxil.”
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So it seems that Paxil not only corrects your chemical imbalance but also helps you to grow into a better person. The irony is that while this advert was being disseminated, GlaxoSmithKline was busily burying data about Paxil's ineffectiveness for certain groups.

What should concern Americans more is that all the adverts above were approved by the Food and Drug Administration (FDA). But even when the FDA has to step in to ban a particular drug advertisement (as they eventually did with the even more misleading commercials for Sarafem), those adverts will still be aired. This is because, contrary to what many people believe, the FDA does not assess pharmaceutical advertisements before they are released. Instead, it only monitors advertisements once they are disseminated, which means that fraudulent messages can still do the rounds (and so do their work) before they are axed.
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While many doctors are savvy about the cozening claims of “pharma fraudulence,” the evidence is that they still have a significant impact on doctors' prescribing habits as well as expanding the antidepressant market.
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This is because consumers are influenced by the adverts and go to their doctors to demand the promoted pill, which doctors in turn prescribe. An innovative study published in the
Journal of the American Medical Association
demonstrated this by gathering together a group of pseudo-patients who were trained to behave as patients. They were sent to different primary care physicians to see what would happen if they asked for a particular drug.