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We're All Mad Here: Pharmaceutical Advertising and Messaging About Mental Illness

Advertising is as much a part of pop culture as deliberately created works of art. Here in the United States, one of the most lasting contributions to perceptions of mental illness in society has come courtesy of the pharmaceutical industry, which spends an estimated $2.5 billion annually on reaching the public through advertising. Most people who have televisions or magazine subscriptions in the US have encountered pharmaceutical advertising, sometimes for products so vaguely described and marketed that viewers aren't actually sure what they are for.

There is considerable controversy over the practice of marketing pharmaceutical products through direct-to-consumer advertising and this practice isn't legal in all regions of the world. In Canada, for instance, drug companies cannot place TV ads for their products. The widespread ubiquity of television advertising for pharmaceutical products here in the US plays a big role in how people think about mental health and appropriate treatments for mental health, especially depression.

A Prozac print ad, in a dyptich. Depression is a closed blind and dark wall, Prozac is an open blind with flowers visible through the window and a bright wall.

I'm sure I'm not the only one who remembers early Prozac® ads, featuring characters engaging in heavy-handed metaphors like opening the blinds to "let the sunshine in." Or the series of cheery, upbeat ads for Zoloft® where mental illness is turned fuzzy and cute as the advertisement simplistically explains what the drug does and how it's supposed to benefit you.

Many of these ads start with a depression-as-tragedy narrative; a sad-faced character mopes across the screen with woeful piano music as a background while the voice over talks about the benefits of the medication. Once the character gets the medication, the sun comes out, baby animals frolic, the clouds go away. They rely on a lot of very basic metaphors for mental illness, depression in particular, that make it seem like a very uniform experience. People with depression spend all their time being sad, and are never, ever happy, in the world of pharmaceutical advertising.

Still from a Prozac ad, showing a blurred, sad person on the beach with caption 'Life got you down?'

One consequence of framing depression the way we do is that when depressed people have good days or happy periods, it is assumed that they are faking. This can have very real consequences when it's your insurance company looking at your Facebook page and deciding that you are obviously not depressed, and thus don't need benefits. There's an expectation of depressed people that they perform sadness at all times, or they will be met with suspicion.

This advertising also suggests that pharmaceuticals provide an instant cure for the symptoms of mental illness, voice over warnings about increased suicidal ideation in patients on some classes of medications aside. For people who seek medications to manage their mental illness, the lack of instant results can be frustrating for those expecting a TV commercial experience. The endless dosage adjustments and switches between medications that may be necessary to find a balance point in real life aren't shown in pharmaceutical advertising. For patients, it can feel like you're doing it wrong when the medication doesn't work as promised; no tiny birds show up to sing you to work in the morning, you don't suddenly feel more confident at parties.

Zoloft ad, showing little bubble characters at a party with smilies on

And for people around a person with mental illness, the failure of the medication to work as expected can also become a source of tension and frustration. When the patient starts taking the drug, there may be an assumption that she should be "fixed" now, and no further work is necessary. Family and friends may push the patient; why do you still need therapy? How come you're mopey today, I thought you were taking drugs to prevent that? Why isn't the drug working yet? Are you sure you're really depressed?

This can translate to lack of support. Patients should just take a pill to treat their mental health conditions, according to the narrative in pharmaceutical advertising, when the truth can be more complicated. Many people need, or can benefit from, therapy, for example, yes, even while taking medications. Others may discover that medications just don't work for them, or they don't like the way they feel on medications. And all patients need support from friends and family, because everyone experiences bad days and setbacks. Medication can be an incredibly valuable tool, but it is not the only tool, and it doesn't work uniformly.

The understanding of mental illness mediated by pharmaceutical advertising tends to be simplistic, as though it can be something easily resolved: If you need fresh paint for the bathroom, go to Sherwin Williams; if you need treatment for your depression, pop a few pills. In a bootstrapping culture like the US, this can be a dangerous precedent to set, as it creates the idea that taking medication is "easy" and that people who want to use medications as part of their treatment plans aren't willing to work hard to get better. This attitude undermines the complexity and variation of mental illness and it also contributes to the culture of shaming that surrounds pharmaceuticals and other forms of therapy. People who choose to use medications are "taking the easy way out" while people who do not should "just take some pills." There is no way to escape this damned if you do, damned if you don't double bind.

Related Reading:

This is Your Brain on Ads: Morgan Spurlock's Greatest Movie Ever Sold
We're All Mad Here: Case Studies in Pop Culture Therapy

Previously:

We're All Mad Here: Sucker Punch Tackles Abuse in Asylums, We're All Mad Here: Crazy Ladies in Batman: The Animated Series

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Comments

14 comments have been made. Post a comment.

Oh wow. These videos and

Oh wow. These videos and images are really, really bizarre to me. Presumably this is because I do in fact live in Canada.

I just...the idea of advertising for prescription medication just seems really peculiar. And I can well believe it has the effects on perception you describe! (Though certainly at least a few of them--in particular people asking why my medication hasn't "fixed" me--do still happen here)

Thanks for this look into USA pharmaceutical culture--I actually had no idea this was a thing.

Oh Advertising

Infomercial Hell:
http://www.funnyordie.com/videos/626737c84a/infomercial-hell

Three Men in a Boat:
http://www.forgottenfutures.com/game/boat/boat.htm

"It is a most extraordinary thing, but I never read a patent medicine advertisement without being impelled to the conclusion that I am suffering from the particular disease therein dealt with in its most virulent form. The diagnosis seems in every case to correspond exactly with all the sensations that I have ever felt.

I remember going to the British Museum one day to read up the treatment for some slight ailment of which I had a touch - hay fever, I fancy it was. I got down the book, and read all I came to read; and then, in an unthinking moment, I idly turned the leaves, and began to indolently study diseases, generally. I forget which was the first distemper I plunged into - some fearful, devastating scourge, I know - and, before I had glanced half down the list of "premonitory symptoms," it was borne in upon me that I had fairly got it.

I sat for awhile, frozen with horror; and then, in the listlessness of despair, I again turned over the pages. I came to typhoid fever - read the symptoms - discovered that I had typhoid fever, must have had it for months without knowing it - wondered what else I had got; turned up St. Vitus's Dance - found, as I expected, that I had that too, - began to get interested in my case, and determined to sift it to the bottom, and so started alphabetically - read up ague, and learnt that I was sickening for it, and that the acute stage would commence in about another fortnight. Bright's disease, I was relieved to find, I had only in a modified form, and, so far as that was concerned, I might live for years. Cholera I had, with severe complications; and diphtheria I seemed to have been born with. I plodded conscientiously through the twenty-six letters, and the only malady I could conclude I had not got was housemaid's knee.

I felt rather hurt about this at first; it seemed somehow to be a sort of slight. Why hadn't I got housemaid's knee? Why this invidious reservation? After a while, however, less grasping feelings prevailed. I reflected that I had every other known malady in the pharmacology, and I grew less selfish, and determined to do without housemaid's knee. Gout, in its most malignant stage, it would appear, had seized me without my being aware of it; and zymosis I had evidently been suffering with from boyhood. There were no more diseases after zymosis, so I concluded there was nothing else the matter with me."

The DSM-V, the next

The DSM-V, the next publication of the Diagnostic and Statistical Manual of Mental Disorders, is supposed to be even more broad in it's definition of what constitutes "mental health" diagnoses. I mentioned the conflicts of interest in the mental health industry in my other reply, and such conflicts spread to the DSM, which is used to determine (in the USA at least) who has what mental health labels. The pharmaceutical companies have played a large role in the creation of the DSMs, and will continue to do so for the next one, due out in 2013. The broader the requirements for mental health problems equates to an excuse to label more people with mental health problems, and thus put more people on (pharmaceutical, government-approved, usually expensive and long-term) medications. "Mo' Money, Mo' Problems"? Nah: "Mo' Problems, Mo' Money".

There has also been research into the idea that placebos often work just as well as many psychiatric medications. One of the problems with many double-blind studies put out by the pharmaceutical companies is that the patient can usually tell (subconsciously or not) whether they have been given a placebo or not by whether or not they experience side effects. Research, though minimal, has shown that when those people are given placebos that don't work on their mental health problems but do add negative side effects (such as weight gain), the efficacy of the real medication is found to be on-par or very close to the placebo.

"I just...the idea of

"I just...the idea of advertising for prescription medication just seems really peculiar."

If it weren't for advertizing, I wouldn't know that depression was a mental illness or that there were medications to treat it.

The link on insurance

The link on insurance companies is very disheartening. Pharmaceutical medications never CURE mental health issues (there's no profit in healthy people). The most they can do is treat the symptoms, and even the pharmaceutical companies, scientists, and psychiatrists don't understand how, exactly, they work. In fact, the very concept that mental health problems stem from "chemical imbalances" is only a theory, a theory created when a drug was found to reduce symptoms (starting with medications like Thorazine, and then later your SSRIs and other meds) because it affected neurotransmitters. When this was discovered, there was a (very large) leap in logic that since the drugs affected neurotransmitters by either producing more or less of certain ones, the problem must then be that mental illness occurs because of an over- or under-adequacy of the neurotransmitters. Using this logic in regards to pain, which is often treated with opiates that activate the opiate receptors in the brain, the "cause" of pain must be due to a deficiency of opiates in the brain!

Medication is not the only treatment for mental health problems, and some mental health problems can actually be cured by alternative means, such as therapy (DBT, for one), which actually addresses the ROOT of the problem. Sadly, these therapies and alternatives don't have the funding behind them that the pharmaceutical industry does, and such solutions aren't a "quick fix" like medications are touted to be. Making the decision to not take medication can result in a lot of negative backlash, including the ones mentioned in this article and the ones linked, and also for those of us who obtain disability benefits, it can mean we must not "really" be disabled since we don't "need" medication anymore.

For those who do take the medication route, it can lead to a host of negative side effects. The "solution" for these is... to take medications (paying the pharmaceutical companies, of course) which counteract the negative side effects of the original medication(s)!

This reply doesn't even begin to get into the conflicts of interest between the pharmaceutical companies and the government agencies (such as the FDA) who promote these medications as being "safe" nor the mental health "advocacy" groups who get some of their funding from (or are otherwise tied into) the pharmaceutical companies.

lets not forget...

As someone who does struggle with depression, I can relate to a lot of this, but there is also the issue with the cost of all of this. I do have insurance, but it is not great insurance. It will cover the medication, but only 20 sessions of therapy a year. So, I can either pop a pill, (paying about $5.00 a month for the generics) or pay about $200.00 a month averaged out for what the insurance will not cover...not to mention finding time to go see one, when the culture is such that we should go to work every day all day and never call in sick, never leave early, never come in late, flexing time is a big no no... which option do you pick? Imagine how people who don't have insurance feel? It ends up being rock/hard place. Of course there is a LOT of pressure to pick the pills.

Definitely. This is a really

Definitely. This is a really important point. Even in Australia where we've enjoyed universal health care since before I was born, and much higher wages in many jobs than US residents, therapy and "lifestyle changes" can be incredibly expensive and inaccessible for people on low incomes.

It's even more disheartening when you consider how much both of our nations spend on imprisonment and war. (Of course, in my opinion, imprisonment of violent criminals is important, but putting people in jail for possessing small amounts of illegal drugs or stealing food to survive etc seems a terrible waste of resources when we could be using the money to help prevent homelessness, unemployment and mental illness.)

I've always interpreted the

I've always interpreted the ads to be about encouraging people to seek help, that this (whatever condition) is not necessarily normal (if you've lived a majority of your life with something, it's hard to know that you should mention it to your doctor) and that it is treatable.

Also

"One consequence of framing depression the way we do is that when depressed people have good days or happy periods, it is assumed that they are faking."

When I first saw this I thought you meant faking the happiness, something that I've done a great deal of. Holds true both ways though.

That's an interesting point

That's an interesting point you make about ads encouraging people to seek help. I hadn't thought of it that way. Where I live, prescription drugs are not advertised, although we do have (sporadic) public service announcements about mental illness, and almost every public bathroom has posters encouraging depressed/anxious/concerned people to seek help. The level of awareness isn't adequate anywhere that I know of, and we certainly don't have a good mental health system here, but I do think the strong medication focus that pharmaceutical company advertising puts on things can be problematic. However, any dialogue that encourages people to recognise and seek help for mental illness is a good thing.

Treatable?

That's actually very significantly not true, that mental illness- and depression in particular- are universally treatable. Far from it! That's another toxic myth that pharma advertising perpetuates, and it's pretty harmful to many of the people whose conditions available meds cannot "treat."

A little personal, but thank you...

This has put into words some of the things I've been trying to say to my family, friends, and coworkers to help them understand what I'm going through, which lately is a push-pull between what are medications "supposed to do" and what am I "supposed to do" personally by sheer force of will through diet, exercise, meditation, etc to balance my mental state. Drugs definitely don't work all of the time for all of the people, but healthy food and physical activity don't wash everything clean either.

Unfortunately, this narrative that advertising has created can alter patient expectations and how they attempt to navigate their own course of treatment too. This notion of performance hits home; every time I face the NP who prescribes and monitors my medications, I fret over how much to tell her. What degree of mood fluctuation is "normal?" What constitutes "out of balance?" I don't want to add another medication to my regimen or increase any dosages, but if I feel like something's not working, then what? Shouldn't I be "fixed" by now? It's been two years, c'mon now... What's hormones, what's not? Is my obsessing over this a symptom in itself? OH JEEZ...

Being female and under treatment for anxiety and depression, "have you changed your meds?" has replaced "are you PMSing?" as the obnoxious question when I'm having an angry or a weepy day. An argument gets dismissed as a side effect of my having had wine with dinner (while on meds), rather than a failure to communicate between me and my boyfriend.

And while many of my peers have sought or are currently undergoing treatment for both minor and major disorders, from counseling sessions with a social worker all the way to inpatient care, there's still enough of a stigma amongst my friends that I feel awkward and embarrassed to discuss it openly. It sucks, but it's like the TV tells me: I should be fixed by now.

I remember being shocked when

I remember being shocked when I picked up a copy of the New Yorker which my friend had brought back from a trip to the US and saw an ad for an antidepressant. It just hadn't occurred to me that drugs of any kind would be advertised to the public. I live in Australia and as far as I know, prescription drug advertisement isn't allowed here either. I agree with everything you've written, and I also think that it raises some serious ethical questions when patients are being encouraged to ask their doctors for a specific drug. Yes, there are also issues with doctors being courted by pharmaceutical companies to encourage them to sell more of one drug or another, but at the very least, doctors have the training and education to make their own educated decisions about these things...mostly, anyway.

I'm a little confused about

I'm a little confused about the whole 'no drug advertising on TV in Canada' thing. I live in Montreal and local TV runs Viagra and Cialis ads regularly. I thought the rule was that they could do TV ads for drugs as long as they didn't -talk- about the drugs (the Viagra ads are mostly wordless boner jokes with the word "Viagra" displayed at the end, for example). While it seems to function for products like Viagra with relatively simple messages (boner problems, see doctor), I can't recall any psychiatric drug ads. Harder to get mental health issues across with no words?

I mean I could see an ad with a woman looking sad and some dramatic music as she is staring down at her cold coffee, but they could use that for Viagra and Zoloft pretty interchangeably.

I can't speak for the drug market anywhere else, but maybe the fact that the various provincial governments regulate drug prices fairly tightly also lower the incentive for such ads.

From the inside...

Reading essays from outsiders about pharma marketing is so interesting to me, since I get an inside seat to it everyday. I love your essays se smith, and this one is no different! There are a couple of things that do happen in pharma that account for what you see in advertisement that I think people don't really know about.

1. All pharma advertising you see is an example of marketing by committee. None of these commercials was just done by an agency and approved by a marketing team. There are whole teams from other departments, reg/legal, medical, compliance, editorial with the marketing management constantly telling them that they can't do this or that. What that Zoloft commercial probably started out looking like is completely different. It's like playing telephone, except the messaging gets mushier and mushier until there are two dimensional, non-speaking characters. That's where you get the simplicity.

2. Pharma advertising is dependent on precedent. If you look at the first commercial ever for depression, you'll see the last commercial, because the argument is that if there is something someone else did and it didn't get a warning letter from the FDA, then we can do it, and that's usually how it nets out. The conspiracy is less to paint depression as one monolithic disease involving before and afters, and more a conspiracy to avoid warning letters by using messaging the FDA is okay with (which are the same types of images used over and over again). I also don't think there is anyone working in depression marketing that would ever say medicating depression is easy.

There is not one person working in Pharma that is not afraid of the FDA. If you are in any way responsible for a letter from the FDA (or, god forbid getting a product pulled), most likely it will kill your career, as well as get you fired. People are fired all the time in our industry for just saying the wrong thing once (even as hundreds are still being laid off). And I'm not saying it's a bad thing. I think industry should be worried about making sure that we are doing right by patients and doctors by conforming to a high standard. But I think any changes in how we approach depression from a marketing standpoint to make it better for people is going to be a tough road given the institutional pressure to do things in one exact way.