I originally wrote this paper for a graduate level drugs class in 2015. My teacher suggested I turn it into a blog post and so now I’m doing just that but shaping it a little to sharpen my points and make it more readable. It was originally written in APA format and I have retained some of that formatting in my sources while changing other citations to include embedded URLs.
Further reading: Still in a Crib Yet Being Given Antipsychotics
Propaganda in the Helping Professions
Psychiatry Under the Influence
Bias in Psychiatric Diagnosis
One of the best selling drugs of the past few years in the United States is the antipsychotic medication Abilify, made by pharmaceutical behemoth Otsuka and co-marketed by Bristol-Myers Squibb. During 2013 it reached the highest sales of any drug--$6,460,215,394. To be clear, this does not mean it was the most prescribed, only that it had taken in the most cash (Brooks, 2014). According to the Abilify website, it is an antipsychotic and finds “use as add-on treatment for adults with depression when an antidepressant alone is not enough.” It also treats manic or mixed episodes of bipolar 1, schizophrenia, and “irritability associated with autistic disorder”. If Otsuka’s marketing bylines are to be trusted, this drug cuts a wide swath across the psychotropic spectrum, and this must be one of the reasons why it has been so popular.
Medco Health, a pharmacy company, reported that, as of 2010, 1 in 5 Americans are on some sort of psychotropic medication. This was up 22 percent from 2001. This means that more and more Americans are becoming comfortable with offering their brain chemistry and well-being up to the gods of medical advice and corporate medicine.
Surely drugs do not sit in a pharmacy and sell themselves. People, both doctors and laity, have to know about them and make the sometimes dubious and painful choice to inject, patch, or swallow the thing that they believe will help them. In order to sell a product, it follows that there must be some sort of marketing, some convincing of the customer, and in this case, also the person between the product and customer, the doctor.
This article will examine aspects of this marketing as well as some of the consensus reality of the drug Abilify. Abilify is an important drug to honestly investigate because of its multiple uses and its incredible popularity. Understanding reality versus marketing and even propaganda is ever more important in an information and spin saturated era where there are so many choices regarding mental health. Also, given the absolute complexity of the human brain and psyche, a drug that purports to do so much should not go unscrutinized.
Abilify, or aripiprazole, originally approved for the treatment of schizophrenia, is the sixth second-generation antipsychotic to be brought to market. Second generation antipsychotics are newer but not necessarily overall better in terms of side effects than the first generation (Leucht et al, 2008).
In an early literature review on the drug, Deleon, Patel, and Crismon (2004) concluded that Abilify “was effective in significantly reducing symptomatology associated with schizophrenia-related disorders compared with placebo” (p. 649). Its effects were comparable to risperidone and haloperidol. Very importantly, the report shows that Abilify seems to have a low tendency to cause problems with side effects such as weight gain and glucose dysregulation, a key concern with antipsychotics. Interestingly, one of the authors, Dr. Patel, had received grants from two large pharmaceutical companies and another author, Dr. Crimson, has received numerous grants, speaking related fees, and board memberships from various pharmaceutical companies. This sort of conflict of interest was very common across my literature review for this article.
Abilify is one of a few antipsychotics approved as a kind of adjuvant to strengthen antidepressants (Mcintyre et al, 2013). One report concludes that “the majority of individuals starting antidepressant treatment will require either an adjunctive treatment strategy or a switch to a different treatment avenue, which may include initiating and combining different pharmacological agents...” (p. 6) Though they also admit to the “absence of replicated controlled trials demonstrating the superiority of this approach over placebo” (p. 6). However, a few months later in an analysis Stewart et al (2014) conclude that “the current data suggest that adjunctive aripiprazole is effective in patients who have failed to respond to a prospective trial of an SSRI or SNRI…” (p. 24). A disclaimer towards the end of the paper indicates that Bristol-Myers Squibb and Otsuka “supported this study and funded editorial support for the preparation of this manuscript” (p. 24) These hopeful findings are difficult to fully ingest with the painfully honest disclaimers.
Theoretically, Abilify works by acting on both the postsynaptic dopamine receptors and presynaptic autoreceptors and displays partial agonism and antagonism at serotonin receptors (Deleon et al, 2004). Think of this as a carpet bombing approach to brain chemistry. Dopamine and serotonin are two favorite variables to play with in the continuous, scorched-brain chemical warfare against schizophrenia. As an example of the long scientific search to link brain chemicals to schizophrenia, I can find as far back as 1973 (Wise and Stein) a peer-reviewed article detailing the theoretical connection of dopamine to schizophrenia. Also, a 1958 article (Feldstein, Hoagland, and Freeman) attempts to make some connection from schizophrenia to serotonin. There is something vaguely alchemical in this search for the golden chemical that makes or breaks mental illness.
One name you will frequently run across in drug-related research is that of the polyphemic, controversial science and medical publisher Elsevier (Goldacre, 2009). According to its website, Elsevier publishes over two thousand journals, including the prestigious Lancet and Cell. It would seem logical that a publishing company as big as this has significant influence in the direction that mental health care takes. Drugs and ostensibly scientific opinions towards mental illness do not magically appear from a vacuum, they at least have the potential to be subtly or overtly shaped from central sources that have enough money, connections, and publishing power to sway conclusions. It is important to remember this and not accept whatever comes out from behind the curtain as being somehow mysteriously virtuous.
Drug companies typically spend more on advertising and promotion than on actual research and development (Gambrill, 2012). This fact makes it important to be aware of the psychological tactics used in marketing drugs as it could indicate an emphasis on salesmanship and sophistry over science and holistic ethical considerations.
Abilify is a good example of very successful and purposeful marketing. In 2003 the Senior Director of Abilify Marketing at Bristol-Myers Squibb was given a Marketer of the Year award by the Medical Marketing Association for “successfully positioning and championing a unique branding campaign for Abilify…and putting it on track to become a blockbuster agent for Bristol-Myers Squibb and Otsuka.” This Senior Marketer is lauded for her “commitment and aggressive tactics”. The sports language, “positioning and championing” and “on track” as well as using a term originally connected to bombing, “blockbuster”, are indicative of a mentality that is vainly disconnected from the realities of the customer’s experience with their product.
The Abilify website features soothing blue and orange tone and visitors are immediately offered an Abilify savings card. There is also a section for family and friends (taken down since I wrote this) of those taking Abilify. People are encouraged to make sure their loved one is taking Abilify as directed. There are several reminders to make sure this patient talks to their doctor before ending or modifying their dose, reminding you that “your loved one’s body may need time to adapt.” In a somewhat Orwellian turn, you are also encouraged to keep the doctor informed about the loved one’s progress with Abilify.
Now we will examine two consumer-oriented Abilify commercials that have been aired on TV. I will demonstrate some of the sophistication engineered into the images and words. For the purposes of brevity, I will not describe the whole commercial but only the parts that seem to be important to this discussion.
Our first commercial, set to pleasant guitar strummings, opens with a cartoon image of a dowdy looking young woman standing on a green landscape that ominously drops off behind her. A middle-aged voice says, “Here’s me and here’s my depression…” A black hole opens in the earth next to her and out comes a small black cloud with eyeballs that morphs into a ball and chain. She is eventually sucked into a feminine-looking opening in the earth. This is a potent, archetypal image despite its simplistic rendering.
The voice essentially explains that one antidepressant wasn’t adequate until she talked to her doctor, a paternal, smug looking fellow with a huge, oddly positioned tie that Freud might have chuckled at. The doctor helps her out of her hole and gives her and her black depression avatar an odd lecture where he stands by a screen but his image lectures from the screen. A very pleasant male voice then warns of the many potential problems and side effects of Abilify. During these warnings, the heroine switches from a pea green shirt and blue dress to a light red shirt and blue pants, symbolic of her new, more confident attitude. She is walking in the countryside and carrying a blanket, upright with a smug, determined expression. Her depression flies low to the ground behind her. A large-nosed, slouching male with a wooden walking stick, and younger, grinning female follow dutifully behind her. In the background, a road leading from the top of a hill is magically drawn. These characters are miraculously unperturbed by the god-like voice reading over them. Interestingly, the characters begin to sit down on the blanket as soon as the narrator mentions “dizziness upon standing”. As anyone who has watched drug commercials knows, there is almost always this bizarre, somehow pleasing contrast between the images and the legally-required side-effect inventory.
In a close-up shot, our cartoon heroine tells us how depression used to define her until her doctor added Abilify to her antidepressant. Her voice sounds slightly deeper than it did at the beginning of the commercial, as if it comes from a more authentic place. The road motif appears again beside and behind her and segues into the Abilify logo. Overall, the ad seems to treat the viewer as a childlike primitive who finds salvation through a doctor and a magical remedy.
A second commercial cleverly personifies a young woman’s antidepressant as having “worked hard” but not quite being up to the task. A little yellow pill helps a woman through her day, dutifully moving things around for her and nudging her. This is induced magical thinking at its finest.
She goes to her doctor, a confident-looking, short haired woman with a pleasant sky framing her visage. The doctor introduces her and her antidepressant to a tall (compared to the yellow antidepressant), happy looking “A” that strides out from behind a clipboard. The narrator says, “Having Abilify and an antidepressant working for me, it just made sense. I wish I’d talked to my doctor sooner.” Note the deliberate use of poor sentence structure. In a tangential way, this is the equivalent of the cliched car commercial where the viewer is breathlessly told to ‘Come on down now!” to the dealership.
Next we see the required "money shot' of pleasant scenes set to narrated drug side-effects. The heroine is seen walking down a hall in an office with a young man striding to catch up to her. A slightly shorter woman follows behind her gesturing about something. The heroine is now in charge of a meeting, her orange shirt standing out against the grey of the office surroundings. She has transcended. Then she is at home with her family, her husband giving her a subtly longing glance as she walks by him. Her antidepressant and Abilify are off to the side and behind her, watching over her like two happy little superheroes. Like the previously discussed advert, it ends with an enjoinder to look into a free trial of Abilify.
Both of these ads are strangely comforting and numbing to watch. The gently rendered cartoons evoke a simpler time of childhood and easy solutions to problems offered by wise guides. Parental figures help us find the answers and anthropomorphized concepts and objects are pleasantly made made digestible, approachable, and ultimately desirable. Both ads are also ninety seconds long which gives them plenty of time to draw out a narrative and engender a subtle participation mystique, a mystique that is at once modern and archaic. This combination is all-important in contemporary marketing.
Drugs and marketing are not inherently objectionable or evil, they are neutrals that can easily go any direction. However, after this brief inspection, the energy and calculation poured into Abilify’s marketing and scientific campaign appears to be cynically manipulative and deceptive. At the end of the line, past all the science and marketing, is the “consumer”, an actual human being who is not a cartoon or a statistic. Will a depressed or psychotic person carefully consider all the complex behind-the-scenes maneuverings that bring ideas about drugs into their pained reality?
One apparent problem with public discourse and marketing about depression (not to mention other mental “illnesses”) is that depression is separated from the human being and turned into a separate element that can be dealt with like a problem. The mystery is drained away and a game of chemical Tetris is played to square everything off. Drop in the right chemicals in the right way and, poof, it is banished to the ethers. This disembodying of the experience we call depression can make for inhumane decisions, whether from a doctor or consumer, because we forget all the connecting implications and complications.
How will millions of people who are on psychotropic medication ultimately affect the rest of the biosphere? Could a populace that is becoming numbly, dysfunctionally disenthralled due to pharmakeia be ripe for authoritarian control? I’m not sure these questions can be meaningfully engaged within a cyclopsian science industry but they should be considered by those in the helping professions and, most importantly, by those who consider taking drugs. A slickly marketed drug may not just alter the mind but ultimately the course of an individual's destiny, not to mention that of a species. Drugs make just as effective a gulag as barbed wire and guard towers, perhaps more so.
Further, what does it mean if a drug “works”? Does it objectively make a human’s life better to be rid of symptoms? For instance, if I am depressed and my dysfunctional relationship with my dysfunctional mother is a prime part of the etiology of my depression but then I feel better after adding on Abilify, will I further accept this toxic relationship as the pain turns into a calm haze? Who could I have become if I had stayed with my pain and allowed it to transform me as part of a natural, evolutionary process?
Depression, once called "melancholy" and personified by great artists such as Durer was formerly considered an indication of spiritual struggle (Gambrill, 2012). Depth psychologists such as Carl Jung (2006) and James Hillman (1964) have worked against the materialist and reductionist agenda of our scientific era and emphasized the experience and inner, empirical reality of human depths. Ideas such as theirs and the patience required to rework ones inner life will never make billions of dollars for a corporation though, nor will they fit into our contemporary, manic need for quick, magical solutions.
Switch on the TV and soon you will be greeted by glittering invitations to join a pharmaceutical revolution. Open a magazine or browse a news site and smiling people invite you to talk to your doctor. Beyond even health, an existential victory beckons from the tiny space of a nicely shaped pill.
In 1976, the CEO of Merck told Fortune Magazine that he regretted that their markets had been limited only to the sick. He wanted to be more like Wrigley’s and “sell to everyone” (Moynihan, Cassels, 2005, p. ix). While Abilify is made by a different company and this comment was made almost forty years ago, it is hard to not see this kind of cynicism in the marketing for a drug like Abilify and others around the industry. Unfortunately, this enjoined marketing and scientific push is so clever and comprehensive that it is automatically ruling out any sense that depression and other problems might be a positive sign of inner life and something to embrace rather than chemically subvert.
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