Bipolar Expeditions (26 page)

Second, new FDA guidelines now allowed products to be directly linked to brand names. Early in my research, Sam Giosa, a physician who works as medical director for an advertising agency, explained to me,

Previously, the FDA legislated that the pharmaceutical companies could use ads to show the drug name or the condition it treated, but they could never link the two. If they did, they had to present the entire product information statement. This would take so much time on TV and cost so much that the companies didn't want to do it. They could link them in print, but they had to include the whole product fine print about side effects, etc. Now there is a trial period where they are allowed to link the two, if they make a “major statement” at the end, so the public won't be misled.
⁵

In part because of DTC advertising, the market for psychotropic drugs grew rapidly. In the United States, sales reached $2.5 billion in 1990, $6.6 billion in 1995, about $7.6 billion in 1996, and then over $15 billion in 1999.
⁶
Academic studies documented that the proportion of visits to a doctor in which a psychotropic medication was prescribed increased from 5.1 percent to 6.5 percent between 1985 and 1994, an increase that can be accounted for by the three new Selective Serotonin Reuptake Inhibitors (SSRIs): fluoxetine in 1988, sertraline in 1991, and paroxetine in 1992.
⁷

DTC ads are intended to tap into consumers' emotions, but what happens when the consumer's emotions are disordered? Can a manicdepressive person, say, be a good consumer? On the one hand, we might think that people labeled “irrational” by virtue of mental illness would be considered ripe targets for these ads. Since irrationality is often defined as emotions getting beyond the control of reason, “irrational” people might seem especially susceptible to advertising's emotional appeal.
⁸
On the other hand, however, the point of the ads is to get the consumer to consume: to decide he needs the drug, to seek a doctor who will prescribe it, and so on. “Irrational” people might not seem reliable in following through all the way to the act of consumption. When I asked my pharmaceutical interlocutors about this puzzle, they were as confounded as I was.

Katherine Holmes:
It's something that I think all the drugs that have indications for mental illness have to consider, especially the antidepressants. Depression is more common and the patients are generally more functioning than, let's say, a schizophrenic or a bipolar. The patients, it's hard to reach them, since they are not really necessarily aware of what they are doing, they are not going to respond to … [Her voice trails off.] Prozac is trying to do direct-to-consumer [marketing] for their drug, and Zoloft is considering it. It doesn't seem like they've really been that successful. So it's more like public relations than it is like direct advertising to these people because I think … it's just … [hesitating] because of their illness they're not necessarily … they're not going to respond and go ask their doctor for the medication.

Emily Martin:
Is that partly an issue of noncompliance? (When patients do not take drugs a doctor has prescribed for them?)

Katherine Holmes:
Right, I used to work on that issue, too. Yeah, a lot of this is much more educating the doctors and the caregivers, the families around these people, than it is the person, because these people sometimes really cannot … it's not even … like if you presented them with a 1–800 number? [Shrugs.]

Jason Marshall, who worked as a sales rep at the beginning of his career in marketing, talks about the difficulties of advertising to patients for Drug S, used for schizophrenia and bipolar disorder.

Emily Martin:
Did the company do any DTC advertising?

Jason Marshall:
No, there was no DTC for Drug S. I'm just taking a guess about why that was, but first of all it's not a huge market. Psychiatric disorders in general and especially schizophrenia can't be more than a couple million patients. Most of the DTC advertising you see is for physical disorders, which are very common, so it's easy, you know, if you are doing Propicea, because 20 percent of the audience could experience baldness. To advertise directly to people with psychosis … [He trailed off with a dubious expression.]

Or you
can
specifically target people with schizophrenia, but that's probably not a good way to advertise something … and I'll be willing to bet that as much as doctors are upset about direct-toconsumer advertising with products for asthma and hypertension, they'll be
very
upset with us if we tried to influence a patient with a psychiatric disorder.

Jane Fuller has worked on a number of ad campaigns for psychotropic drugs and so I asked her whether advertising for psychotropic drugs is ever directed to patients who are deemed mentally ill. She thought that doing so would be contradictory because such patients might not have enough self-awareness to act on their own behalf by seeking the drug. But she thought that if a patient took the drug and began to feel better, he or she would “engage,” and might begin to complain about weight gain or sexual side effects. With increased awareness, such a patient might be able to behave like a good con sumer, that is, behave rationally, and actively seek out the best drug on the market.

The advent of DTC advertising has brought the uneasy and volatile status of the mentally ill directly into the advertising process. A patient who is not regarded as functioning rationally enough to be an appropriate target for a drug ad might still be able to “feel better” with the aid of the drug. Earlier in this chapter we saw how pharmaceutical employees imagine indirect relationships with patients by reaching through the materials provided to doctors. Now we can see that forms of advertising sent directly to the mass of consumers fall short of people who are thought to be “less aware.” The relationships in question are almost always one step removed from actual patients, but they live vividly in the imagination of pharmaceutical employees. People with some forms of mental illness are thought to lie outside even this imagined social landscape.

Living with Drugs

If drugs, like other commodities, are given the particular kinds of life I have just described through marketing and advertising, how do people who take the drugs make sense of this thing that now literally takes up residence inside them? Does the drug seem alive to them the way a person or a spirit would be? Does the personality advertisers intend to create for the drug take hold in their imaginations?

Before tackling these questions, we must remember that since psychotropic drugs are a commodity and, as such, carry a price, everything we say about them should be framed in political economic terms. Who can afford to buy them? Who has knowledge to use them? Who has access to physicians or others who can monitor their effects and suggest adjustments? In the United States, these basic questions are determined mostly by where one is in the hierarchy of resources. Whether one is encouraged or required to take psychotropic drugs in a welfare office, never offered the choice in a remote rural or underserved inner-city setting, given them in a one-off way by a doctor in a clinic, or carefully monitored over months or years of minute adjustment: these are more often matters of what one can afford and what one is in a position to know than what one prefers. At the high end of the scale, a psychiatrist in New York City told me that her patients take cell phone calls during their consultations with her about their psychotropic medications. Overhearing them say proudly, “I am with my psychopharmacologist,” she commented, “I feel like a Prada bag; everyone has to do this to be up to the minute.”

One's standing in the hierarchy can also change over time. As health benefits run out, a job ends, savings evaporate, or the like, a person can drift down the scale. Kiki described this succinctly on a Web newsgroup: “Well—I saw my otherwise wonderful PDOC [psychiatrist] today for a reg. session to discuss meds and my symptoms, etc. In the past I would have liked to have seen her 1× week for meds and therapy, but she is not on my HMO's panel and I cannot afford $175/week—so I see her for meds ($90) and disability management about every three weeks since 4/30.”
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Kiki would prefer a therapeutic hour every week, but she can only afford fifteen minutes every three weeks.

In my many visits to support groups, the vast majority of people spoke of fifteen-minute appointments with county doctors once a month, where the doctor could do little more than just renew prescriptions. Hilary told one support group that she saw a doctor at a clinic who spent at most two minutes talking to her, and then “it is on to the next patient. She must see thousands of patients in a day; it is like you are on an assembly line.” This situation is no more the choice of doctors than patients. Speakers at conferences I attended for psychiatrists and for patient support groups alike regarded these kinds of constraints on physicians' ability to treat patients as deplorable.

As we have seen, one main goal of DTC drug advertising is to invest the drug with a personality. When people talk about the experience of taking drugs, however, the drug frequently does not survive with its own intended identity intact. Rather, the drug goes in the person, and a new person results. A woman spoke out at a support group I attended.

I am Hanna and I am manic depressive. I am a rapid cycler; I am either up or down, and I am not much in the middle, or at normal (if you want to call that normal). I realize I expected the pills to manage the manic depression, and now I see
I
need to manage it at all levels, including the spiritual.
I
need to learn more, to exercise more, to be active not passive. My shift in thinking is due to taking Depakote—it is like a new suit of clothes! I am a snake who has shed its skin, I am all new and shiny.

In another support group, Gail, a very thin woman in her thirties, whose long, dark hair shadowed her face, had been through four years of a lot of therapy and medications, all of which “came to nothing.” Worse than that, the medications she was given made her literally sick, to the point of vomiting. She had just been to see a new doctor who started her on a new drug, Tegretol, and she was feeling hopeful. But in spite of her hopes for the drug, she stated most emphatically that her social relations with other people were more important than the drug in moderating her behavior: “I go to these groups because I have a network of friends in them. I don't want to depend too much on my fiance to do things for me. Instead I would rather have feedback from my friends
and
my fiancé, because this would allow me to ‘modulate my own behavior.'”

Gail's emphasis on her network of friends and family does not mean drugs can come and go from people's lives without perturbation. Linda said she had gone for a second opinion to another doctor, who, the support group facilitator assured her, was a very good psychopharmacologist. This doctor told Linda the medications she was taking were terrible for her. He was so certain these drugs would not deal with her anxiety that he recommended she should taper them off and start a new combination of drugs. Linda was upset by this and told the group, “I want my old personality back. I know I look terrible, and I feel I am looking worse and worse. I am really alone, I don't know whether I lost the phone numbers of the group or just couldn't bring myself to call.” As she talked, several people passed her their numbers written on little slips of paper.

Marcy, a graduate student who initiated contact with me and traveled from another state in order to tell her story, described her deep dislike of switching drugs because switching changes one's identity and threatens the “magic” of the original drug.

If I take a new drug, even a new brand name of the same drug, like a different version of the same drug, I have to reshape my entire identity, like now I am not that person who took Depakote. If I have to go and take lithium, then I have to come up with an identity that takes lithium, and that's a lot of work for me, that's something I have to get used to, and so I have an aversion to doing it. It's the work of producing a new identity, it's like integrating something new into your old identity. This is a lot of work, and for what? It takes away from the magic of the first drug. And if the first one worked for you, then it has magical properties. You can only be cured if your medicine has a power beyond being medicine, well, beyond being a drug. What makes it a medicine instead of a drug are the magical properties that I associate with it.

Marcy's notion of “magic” made the drug sound like an impersonal force, but occasionally, others spoke of specific properties of the drug that seemed to give it human-like qualities. For example, at an East Coast support group meeting, Georgia said she told her doctor she wanted to take Zoloft because (holding out her hand as if to cup the pill)

it was like a little robin's egg, it has that blue color and it represents hope. Later the doctor added lithium. Still I was knocked down by depression every spring. Now I am on what my doctor calls an “ironclad defense” against manic depression: two mood stabilizers, lithium and Depakote, and two antidepressants, Wellbutrin and Zoloft. My friend said, “Oh, I wish he hadn't said that, ‘iron-clad defense,'” because it implies the defense could give way. It might break.

In this instance, which stands out from the usual way people spoke of their drugs, Georgia does see Zoloft as alive, like a little robin's egg filled with hope, but before long its hope fades as she finds it to be inadequate by itself to handle her needs.

Although most prescription drugs advertised directly to consumers have a rather amorphous identity in the eyes of patients, lithium, which is not advertised to patients, is granted so much consistent agency that it does have a kind of personality, albeit one with both positive and negative sides. On the positive side, many people felt that lithium was the most “natural” of all the psychotropic drugs, explaining, “It's just a salt.” Others referred to the mood-steadying effects of lithium as a boon. Sometimes people mentioned the lyrics of songs such as Sting's “Lithium Sunset,” in which lithium folds “obsidian darkness” into its “yellow light.”