My father, he was a psychiatrist. He loved the
field. When he was training in the 50s, it was
a pretty different field in the sense that most
of the training revolved around psychotherapy.
When I started my newsletter, it was just a single
newsletter, and I was doing literally all of
the work from doing the initial graphic design
of the logo to writing all the articles, editing
the articles. Paxil was very new, and it was
all about Use Paxil for your patients who are
anxious and have insomnia. You recently launched
an AI. clinical tool called Ask Carlette. Any
information that you get from Ask Carlette AI
is going to come directly from, you know, the
23 years or so of hundreds and hundreds of articles
and textbooks. Deprescribing is not something
that's terribly new. It's been the idea that
we over -medicate patients and that we end up
chasing our tails with having a patient be on
a med that causes a bunch of side effects. There's
definitely something to be said for these new
books that have come out and for us to really
study deprescribing as its own discipline. Welcome
to another episode of No Prior Off. This week,
I'm sitting down with Dr. Daniel Carlatt. Dr.
Carlatt is the founder of an industry -independent
CME newsletter that a lot of you already read,
The Carlatt Psychiatry Report. He wrote a New
York Times magazine piece called Dr. Drug Rep
about getting paid by Wyeth to promote Effexor
and then walking away when the data didn't hold
up. That article turned into a book called Unhinged,
which argues that psychiatry traded the therapeutic
relationship for 15 -minute med checks. His medication
fact book is in its eighth edition. His podcast
has over 564 episodes. This is someone who has
spent two decades asking hard questions about
how we train prescribers and how the pharmaceutical
industry shapes what we prescribe. Let's get
into it. Hi, Dr. Carlatt. Hey, Lindsay. How are
you? Great to see you and talk to you. Good to
see you, too. Thanks for being on. We've been
working together a little bit and collaborating.
It's been a lot of fun. It really has been. Yeah.
Couldn't believe that it took me five years into
my psych NP career to find your resources. That
floored me. Although I will say I did have this
book in school, but I didn't know about your
medication fact book and all of your other resources
until that long into my psych NP career. And
I was like, man, I really could have used this
in school. So I want more people to know about
your resources. I'm very passionate about that.
To kick off, I would love to ask you kind of
what got you into the field of psychiatry to
begin with. Yeah. So I am the son of a psychiatrist.
My father, Paul Carlett, who continues at his
age, he's now 95, and he just retired from his
practice a few years ago. So he was going strong.
And he's still going strong to the extent that
he was just asking me if he could subscribe to
the Carlet Geriatric Psychiatry Report, even
though he's not practicing anymore. He gets a
lifelong subscription, obviously. At any rate,
he went to University of California, San Francisco,
which is for medical school, which is where I
ended up going as well. And he did his psychiatric
residency at Langley Porter. So he was a psychiatrist.
He loved the field. When he was doing it, when
he was training in the 50s, it was a pretty different
field in the sense that most of the training
revolved around psychotherapy and psychodynamic
therapy. And there were some medications out,
but this was the age when the main medications
that were used for depression were nipramine
and the main medications for psychosis were thorazine
and then a little bit later, Haldol. and there
weren't too many other meds out there. So he
always really knew the value of combining psychotherapy
with medications. And as I grew, I went through
high school and college, I became Just sort of
naturally, I naturally gravitated toward psychology
topics. This was all in San Francisco during
the sort of tail end of the human potential movement.
So I was also doing yoga and Zen Buddhism and
like all the rest of my peer group. So, you know,
interested in self -help and psych stuff. So
I ended up going to college at UC Berkeley. and
then was trying to decide what I wanted to do.
Was I going to be a psychologist, like a PhD
in clinical psychology, or a psychiatrist? At
that point, my dad gave me some, in retrospect,
pretty good advice, which is that while he worked
a lot with clinical psychologists and found them
to be extremely smart and extremely effective
in their field, He noted that they were often
frustrated because they were not able to use
these very powerful tools, i .e. the medications
that were so helpful when combined with therapy.
So he didn't want me to go through that same
level of frustration. And so I took his advice
and applied to medical school and ended up going
to medical school to become a psychiatrist. That's
great. That's awesome. You live in Boston now,
correct? Just north. Okay. And you have two adult
children. I do. Is that right? Did either of
your children ever consider going into the field
of psychiatry? Not really, no. They followed
different paths. So for whatever reason, they
never really decided that the medical or the
healing paths were for them. Okay. And you have
a private practice where you live now? I did.
And so, yeah, I mean, like a lot of psychiatrists
and nurse practitioners, the trajectory of my
career has really been variable. I mean, for
many, many years, I did have a private practice,
which was crucial for teaching me how to be a
healer. Absolutely. You need to have some kind
of outpatient practice at some point in your
career. to really learn your craft, which I did
right after residency. For many years, continued
that as I also did some inpatient work and eventually
got into the publishing work that I'm doing now.
And then probably the last major clinical stage
of my life was working as vice chair of the Department
of Psychiatry at Tufts Medical School. where
I sort of oversaw a lot of the community psychiatric
work that Tufts does with various area hospitals.
So I was essentially being medical director or
chair of departments of psychiatric hospitals
or of psychiatric emergency rooms of hospitals.
And about two years ago, I retired from the clinical
stuff so that I could dive more deeply into the
publishing, the editing, and the writing. Yeah.
Did you ever see... Carlap Publishing kind of
becoming what it is today? No, I mean, I definitely
had no idea that I would be continuing to work
within it and to grow it. It's really, I founded
it in 2003. It has grown little by little over
that time. But, you know, from little acorns,
mighty oaks grow, right? I mean, you just sort
of have to stick with it. And when I started
My newsletter, it was just a single newsletter,
and I was doing literally all of the work from
doing the initial graphic design of the logo
to writing all the articles, editing the articles,
doing the marketing, opening the checks when
they finally started to come in. And it really
took a long time for it to become successful
enough where I could say, well, this is an actual
business. that could actually sustain itself.
And then eventually I hired some people. We're
still small, but eventually I did hire some great,
great employees, many of whom are still with
me from some of the early days. It has grown,
definitely grown more than I thought it would,
but that's been a good thing. Yeah, yeah, that's
awesome. How has not working with pharma impacted
your career, making that decision? Yeah, I mean,
it was interesting when I was doing my residency.
So I graduated from medical school in 91. I did
an internship in San Francisco, a medical internship.
And then I went to do my psychiatric residency
for 92 to 95. And I was a mass general in Boston.
So that was a time when the pharmaceutical industry
and academia were very, very closely intertwined
for better or worse. But it was certainly, if
there's anybody listening to this podcast that
is as old as I am and that can remember being
in training back then, I think you'll be nodding
your head with memories of how many drug reps
there were in academic medical centers, how many
lunches were being offered and sponsored by drug
reps and how much the drug industry was really
insinuating itself into the education. And I
remember very clearly George the Paxil guy who
would bring in bagels to the psych emergency
room at Mass General. And we loved our morning
bagels. He would provide us, you know, with the
mugs and the pens and all that. And his educational
pitch at that point, Paxil was very new and it
was all about use Paxil for your patients who
are anxious and have insomnia. But, of course,
he didn't emphasize all of the many side effects
of Paxil, such as sedation, which obviously does
help insomnia, and sexual side effects, and subcognitive
side effects, etc. So those were the kinds of
things that we were sort of undergoing on a day
-by -day basis during my training. And then there
was more sort of drug company involvement. after
training was over as well. Gotcha. Gotcha. What
does your dad think of your career? I know you
guys just recently attended APA together. Is
that correct? Yeah. So I just got back from the
APA meeting in San Francisco. My dad is no longer
going to APA meetings. He still follows the field.
The APA, the education that you can get from
going to the meetings from just wandering through
the exhibit hall is still something that i recommend
everybody i i don't go to every meeting it's
a little bit overwhelming not all the lectures
are top -notch these are academics who haven't
necessarily trained in how to give talks but
they're very smart people they know their stuff
yeah gotcha so When I look online to find any
like video media of you, it's very hard to find
any. Are you like a pretty private person? Are
you introverted? Or did you do more of the public
facing stuff at one point? Oh, yeah. I mean,
you know, I think as I was coming up through
media, it was all mainly print media and sort
of. print in HTML that was then published online.
So that's kind of how I cut my teeth journalistically.
And then, yeah, multimedia came on the scene.
We got to a point where you just had to have
podcasts. You had to have webinars to stay relevant.
And I never really got into it. Personally, I
am generally an introvert and I am generally
a private. person. So I'm sure if I were a gregarious
extrovert, I probably would be doing a lot more
multimedia than I am now. Yeah, that makes sense.
I am too, actually, which is kind of funny that
I have a podcast and whatnot, but I am pretty
introverted myself, so I can relate. Do you think
that you will retire at some point, or do you
think that this is something that you just love?
want to continue doing for as long as possible?
I'm sure I'll retire at some point, but I have
no plans. It is something that I love. Not every
single aspect of it. So as the president CEO
of the company, I have about seven regular payroll
employees. And then I work with probably at least
50 contractors who do different things for the
publication. So The aspect of having to manage
and oversee all of that complexity is not my
favorite thing. But luckily, I have a great COO,
Jeff, who I know you've met, who keeps things
running on a day -to -day basis so I don't have
to do all that stuff. What really gets me up
in the morning and gets me revved up is project
work. So I love coming up with a new product,
a new project. whether it's helping you with
your work with your boot camp and with nurse
practitioners or meeting somebody on LinkedIn
and coming up with a new book project and helping
them to develop it and helping to do sort of
high -level developmental editing, or now with
AI overtaking everything, trying to figure out
how to bring AI into our... publication so that
we can more efficiently provide some great, great
education for people. Absolutely. Speaking of
AI, you recently launched an AI clinical tool
called Ask Carlette. Can you tell us a little
bit about what it does, what it's not allowed
to do? Just tell us a little bit more about it.
Yeah, yeah. So Ask Carlette AI is sort of a large
language model type of AI tool. And, you know,
I think we're all pretty familiar these days
with what LLMs are, but basically they're, you
know, filled in the blank, very elaborate, filled
in the blank kind of tools that are trained on
lots and lots of articles where the software
program reads the articles and then learns how
to answer questions based on that content. It
has no native intelligence, but it's basically
just learning in a very complicated way how to
move from the first part of a paragraph to the
next, to answering it with the next part of the
paragraph. So I think the difference with the
LLM that we have in Carlat Publishing is that
it's not affiliated with any of the large frontier
LLMs, such as Anthropics Cloud or OpenAI's ChachiPT
or Gemini, et cetera. So it has its own sort
of very limited universe. It's not going to go
outside of Carlet. So any information that you
get from Ask Carlet AI is going to come directly
from, you know, the 23 years or so of hundreds
and hundreds of articles and textbooks and material
from our webinars and from podcasts even that
we published. So it's, yeah, it's a work in progress.
And, you know, in some ways we felt like we had
to put out an AI, I mean, a chatbot. I mean,
kind of many, many publishers are feeling the
need to do that because our audience is assuming
now and expecting that most publishers are going
to have some sort of a chatbot to help them better
consume the information or more efficiently.
Yeah. Yeah, I think it's great because so many
of the practitioners I talk to are using open
evidence or some type of AI. And so to know that
there's a non -biased resource out there, too.
playing around with it and i really love the
answers how in -depth they are and just kind
of i mean it's in line with your what you teach
clinically and it makes sense and it's digestible
and kind of easy to apply so i think nurse practitioners
especially are going to be really excited about
this tool in clinical practice that's great and
i hope you and any of the mps that test it will
let us know when they ask an answer that should
they ask a question that should provide an answer
but it's not providing the right answer because
we're we're constantly tweaking it and refining
it yeah that's great yeah um i remember you know
the the nei prescribe app was kind of like my
go -to as a new grad as far as a resource that
i could have pulled up that i could easily get
to information on a medication you know while
I'm with clients sometimes even so I think just
having an accessible resource like that that
has access to all of your clinical information
that you've put out there is going to be really
really incredible so yeah you guys should you
guys should try it out if you have not already
what do you have in the works right now as far
as like upcoming projects anything that you're
excited about that you could share with us? Absolutely,
absolutely. And some of it I've shared already
on LinkedIn posts. So, you know, there's nothing
secretive. I think we have four or five books
in various stages of production currently, all
of which are going to be published sometime in
the fall, this fall timeframe, around October,
November, December. Probably of most interest
to your listeners would be, number one, a book,
a fact sheet on alternative, complementary and
alternative and lifestyle remedies in psychiatry,
whether that's the Mediterranean diet, exercise,
saffron for anxiety and depression, various other
herbal remedies. And Chris Aiken. who a lot of
people know from the Carlyle Psychiatry Podcast,
is the author of that. He's had a long interest
in complementary and alternatives, mainly clinically,
because his patients have always wanted to learn
more about them, and he realized there just weren't
that many good resources. That's coming out soon.
And then we have a book that is going to be called
The 20 -Minute Therapist, which is actually written
by a doctoral -level NP, Deb Granik, who I think
you may know. who is really has developed a great
way of teaching us all who are doing, you know,
30, many of us are doing sort of like 30 minute
medication visits and finding that, you know,
it really often only takes five or 10 minutes
to do the medication piece and that you have
a good chunk of time, 20 minutes potentially
left over to do therapy. And so she's developed
a framework for figuring out what modalities
to use for patients and which patients to use
them for. So those are, I think those are two
kinds of books that would have really helped
me if I had had them earlier in my training.
And so I'm excited about those. Yeah, I'm really
excited about both of those because I'm constantly
referencing Chris Aiken's website where he has
just a lot of great information on supplements.
I've even shared it with patients. And then,
yeah, Deb Granik's content, when I found her
stuff, I was like, man, I wish I could have heard
this masterclass while I was in school. Like
this would have helped me to make so much more
sense of the brief psychotherapy aspect of being
a psych NP. Yeah. And I think I'm not as familiar,
obviously, with the current training that psych
NPs are getting. But my impression is that there's
a lot of concentration on diagnostic techniques
and medication techniques in a typical master's
program. But by virtue of the limited amount
of time, there just isn't necessarily that much
on all of the different psychotherapy modalities.
So that's the thing that I think that a lot of
MPs will find helpful. Not as the only way to
learn therapy because the only way to really
learn it is by doing it over and over again,
but at least to have that mental framework for
understanding the techniques. Right. Yeah, no,
100%. Was this kind of the first book that kind
of took off as far as like people adopting it
and using it in residencies? Yeah, yeah. The
psychiatric interview book, that was something
that I developed when I was in residency at MS
General. During our last year of residency, during
the chief residency year, I was the chief resident
of the inpatient unit, which is in the Blake
building. It used to be in the Bullfinch building.
Blake 11. So I was in charge of teaching the
residents who were rotating through that. So
I had gotten to become friends with Sean Shea,
who some of you may have read some of his books,
but he has a wonderful book on the psychiatric
interview and on another book on the assessment
of suicidal ideation. Really charismatic lecturer,
great, great human being, and elegant writer
too. You read his books and you can't believe
you're reading a textbook because it's just,
you really want to finish it. He became my mentor
with the psychiatric interview, and I decided
to use some of his ideas to write what I thought
would be a somewhat more accessible version,
which was a very small sort of a handbook. And
that's how I developed it during my last year
of residency. And then soon after that, I began
to turn it into a book, and eventually it was
published. Gotcha. Gotcha. Gotcha. Yeah, I do
think that that is something that sets your resources
apart is what a great writer you are. Like this,
this book, for instance, look at all the stickies.
I have stickies like that and all of your resources.
It's kind of funny, but it's because so much
of it is stuff that we can actually use in clinical
practice, which is really. Nice. You know, there
are some books I have a hard time getting through,
academic books, like the deprescribing guidelines
is one of those that I'm trying to get through
right now. But I just I love how accessible you
make it. What do you think about deprescribing
and kind of everything going on in that realm?
Also, have you read this book? No, I haven't.
I've heard of it, though. Yeah, I've Stahl's
Deprescribing Guide. Yeah, there's the Bonsley
Deep Prescribing Guide. There's the Stahl Deep
Prescribing Guide. And then there was recently
a large article that came out in one of the major
psych journals from a group of mostly American
academics on deep prescribing. And then, of course,
there was RFK Jr.'s announcement that, you know,
at a national level, there would be more resources
put into helping patients to come off of medications.
which was controversial mostly because I think
a lot of people interpreted what he was saying
as encouraging people just to come off antidepressants,
which I don't know what was on his mind when
he was talking about that. But I think ultimately
that initiative will be a good thing because
it will put more more resources and more awareness
into psych treatment and into alternatives to
medications. But generally, deprescribing is
not something that's terribly new. It's been
the idea that we over -medicate patients and
that we end up chasing our tails with having
a patient be on a med that causes a bunch of
side effects, and then we're following that up
with other medications sometimes to treat the
side effects. or sometimes just to add additional
augmenting agents to treat the underlying symptoms.
I mean, these are the tools that we have had
mostly, and we may have overused them. So I think
there's definitely something to be said for these
new books that have come out and for us to really
study deprescribing as its own discipline. Yeah,
absolutely. I know one of your most recent...
addressed deprescribing to and had some really
great information. But it would be really cool
to have a deprescribing book from you, like one
of these small little, you know. So just throwing
that out there in case you're ever inspired for
a new project. I know you need more projects.
Sounds like a great one. You've been a long time
supporter of psych NPs. And I think that's one
of the things that we. really appreciate that
you've supported psych NPs kind of from the beginning.
It's felt authentic. What kind of, because I
feel like not all psychiatrists have that mindset.
So what, how did that kind of, I don't know,
support or approach come about for you? Yeah.
I mean, I think it really came about as I was
doing a lot of my inpatient work because I mean,
I know there's a lot of pathways now to become
a psych NP, but the traditional pathway, at least
in the past, was that you would first be an RN,
and you might then log some years under your
belt. Maybe some of those years would be in a
psych hospital where you'd get a lot of experience
working with psych patients, and then you would
move on to getting a master's and do some clinical
hours and supervision hours and then become an
independent psych NP. It was always apparent
to me that the engines of treatment in inpatient
units were the RNs, and they were the ones that
were really front and center dealing with the
psychosis, the agitation, all the things that
are really difficult but are really the symptoms.
that we need to be treating and we need to be
able to feel comfortable diagnosing. And we have
to be comfortable being with these people who
are hard to be with sometimes. So, you know,
the nurses were the ones who were doing it. I
was always learning from the nurses I was working
with. And then over the years, I think really
from maybe 2010 on is really when the field of
psych MPs really exploded. And we had... I think
we went from about 10 % of prescribers being
psych MPs in 2010 to about 30 % in 2020 is the
latest research that I've seen. You may have
more of those figures at your fingertips. So
there's been a lot more. And as I was doing my
work at Tufts, by far the majority of people
that I was hiring were psych MPs, in part because...
It has been very difficult to recruit psychiatrists
for roles because there's a shortage, and in
part because the psych NPs just have the experience
built from their prior roles, sometimes as RNs,
and they have that sort of natural compassion
that serves them very well when they're working
with psych patients. Yeah, absolutely. What do
you think needs to change about psych NP education?
There has to just be more of it. Your boot camp
is great. I mean, the thing that most people
say about psych MP education is that, you know,
you graduate from psych MP school and you do
not do a residency. Whereas when you graduate
from medical school as a physician, you then
do four years of structured residency training
in your field. And typically, The quote residency
training is the first job that you get as an
NP. And so what a lot of people are trying to
do is to create fellowships and residencies that
may not be four years, but even if you had a
six -month or a 12 -month residency slash fellowship,
that could be tacked on to your first job. I
think that would make a huge difference or even
more than one year, you know, maybe one year
of more intensive education and then maybe another
year of sort of gradually tapering less intensive
education. Yeah. Okay. Good to know. Where should
people who want to follow your work and what
you're doing, where should we send them to kind
of follow along with all these new exciting projects
coming out? What's the best place, would you
say? Yeah, the best place would just be to go
to thecarlatreport .com and to just Google Carlat.
And so from there, you can get to a number of
both paid and free resources. And a lot of people
I know have gotten aware of Carlat through Chris
Aiken and Kelly Newsom's podcast, which is free
to listen to and the way we monetize it. is,
is to charge people for getting CME credit if
they choose to. But that's, that's a great, that's
a great way to get it introduced. And then, you
know, on, on the website, we have a lot of sort
of special offers and free materials that you
can look at to get a feel for whether it's the
right product for you. Okay, great. And you're
on LinkedIn. You're pretty active on LinkedIn
too. Yeah, I'm active on LinkedIn. So I post.
sort of mini articles. Some of them are based
on articles that are published in the newsletter
or based on some chapters that are published
in some of our books to whet people's appetite
to kind of give them a sense of what's going
on with us. That's great. Have you ever thought
about starting a Substack? I just was curious
because, you know, I see other psychiatrists,
thought leaders on there, and I just was curious.
I mean, I could. I've always thought that, you
know, since we do publish newsletters, Substacks
are essentially newsletters. Some of them are
free and some of them people start charging for.
It's not even that new anymore. But I think when
I first heard about Substack, I thought, you
know, those are basically newsletters and we
already publish a bunch of newsletters. So why
would we get involved in Substack? But maybe
it's time. You tell me. Should we? I think so.
I think, you know, I think it would be in line
with just kind of giving people like a taste
of your content. And then it's like, if you want
more, this is where you can go to find it. You
know, I know I've subscribed to like Dr. Nasir
Ghami's sub stack and, you know, different thought
leaders like that. And it's been, it's been helpful,
you know, because I think, yeah, you're writing.
It's just. it helps a lot of people. It's accessible.
It makes sense. Again, one of the, I can't just
read clinical textbooks typically, you know what
I mean? But I can, I can read through a lot of
your books and be like interested to your point,
you know, Dr. Sean Shea's psychiatric interviewing.
That was one of the first ones too, that I really
like got a lot out of and was able to really
engage with on a meaningful level. So I think
it's really, Amazing how accessible you're making
this information for us. So we are very appreciative.
Anything else that you would tell psychiatric
nurse practitioners graduating in 2026? Any words
of advice? Yeah, I mean, one thing that was central
to my early career was looking at the influence
of the pharmaceutical industry on medical education.
Because, you know, like I said earlier, it was
such a big part of it. And what has happened
over the last 10 years or so is because the Open
Payments website, which provides transparency
to all payments to doctors for marketing purposes,
a lot of the drug companies have been going to
nurse practitioners to give those marketing talks.
And there are now a much higher percentage of
nurse practitioners, psychiatric nurse practitioners
giving. taking drug company money and giving
marketing talks then for psychiatrists. And in
part, that was because NPs were exempt from the
open payments website for many years until 2021,
when now they are reportable. Maybe you don't
know that. A lot of people don't know that. Yeah.
I would just, you know, if I were a nurse practitioner
coming up, I know that I would be approached
by a lot of drug company drug reps. Certainly,
you know, asking them to take samples, but also
asking them if they would like to give marketing
talks for doctors or for nurse practitioners.
My advice is just to think twice about doing
that because it ends up being a very slippery
road. At first, you think you're just getting
some money to say things that you already believe,
but it doesn't take too long for you to start
to... change your opinions or to start editing
the things that you say because you want to make
sure those checks from the drug company keep
rolling in. Think twice about being on a drug
company payroll if you're treating patients.
Yeah. Yeah. I'm in an integrative fellowship
right now. And even navigating some of that has
been tricky for me as far as like, you know,
lithium orotate and some of the stuff that's
recommended in there and wondering. What kind
of influence big wellness could have on some
of the things that were some of the interventions
we're talking about when we're talking about
integrative psych. And I like that I can kind
of go back to your resources to really vet, you
know, what has solid research behind it and trust
that it's non -biased. It's important for us
to keep it non -biased and to refuse pharmaceutical
money just so that. our readers know that they
can, they can trust what they're reading. Yeah.
I had done a little bit of work with pharma right
before I started collaborating with you more
closely. And I think it was just kind of meant
to be because I stepped away from that and it
just feels much more aligned and it feels, it
feels good that the content that we're creating
in my programs is, is non -biased. So I'd like
to, I'd like to keep it that way. Great. Yeah.
Thank you so much for taking the time out of
your busy schedule to be on the podcast. For
the AI tool, Carlat AI, is there a free trial
or is it just kind of a monthly subscription
for people wanting to check that out? There are
various offers that are going on. There is a
kind of a free trial offer, I think, for people
who have already purchased the toolkit. Uh, right.
The toolkit being the, with a web app that gives
you access to six of our textbooks and a bunch
of what actually it's, but you're attacking AI
onto that. There's some sort of trial going on
now. Okay. Awesome. Yes. Perfect. All right.
Well, we'd love to have you on again, maybe in
six months to hear what you're up to and yeah,
hear about. the two books too that you guys are
going to be releasing. So thank you so much for
being on. Oh, thank you so much, Lindsay.