Reprinted from the "Medications" issue of Visions Journal, 2007, 4 (2), pp. 21-22
Jason* first went on antidepressants at age 18 when his girlfriend left him. It was his idea: he felt bad and wanted help. His parents agreed. They were concerned, because after the breakup he had sometimes been coming home drunk. Jason’s doctor asked if he’d felt bad for over two weeks. He had, so the doctor prescribed the antidepressant.
The story is so familiar that it’s unremarkable. We all know someone who is unemployed, divorced, stressed out or lonely who ends up on antidepressants. Sadness from a relationship breakup or a job layoff is an understandable human reaction. But is it really a medical problem?
Should we use medicines for normal life problems?
There are three main concerns about taking a medicine for a normal life event. First, the medicine is being prescribed for an untested use, for which it may not work. The same medicine that treats symptoms of major clinical depression may not provide relief for normal sadness after an upsetting event. This is an untested off-label† use—or unapproved use—of a medicine.
Second, any decision to take a medicine is a balancing act, because all medicines have side effects. The likelihood of benefit needs to be weighed against the likelihood of harm. With conditions like AIDS or a heart attack, the decision is easy. Even severe side effects may be worth risking, if the untreated disease is life threatening or is much worse than the side effects—which can also be the case with mental illnesses. However, if you don’t have a health problem in the first place, a medicine won’t help, and no side effect, no matter how mild, is worth risking.
Third, treating a life problem as a medical problem can distract from real solutions. Jason wanted help. He was offered a medicine as a gesture of help. But perhaps he needed help in learning to feel better about himself and finding his way in life. A person—not a medicine—can provide this kind of help.
A strong advertising message: Ignore the context for your problem
Advertisements for prescription medications are illegal in Canada, but we are still exposed to them because of the number of American television programs and magazines we see every day.
Advertising medicines blurs the boundaries between normal life and medical problems. The late American journalist Lynn Payer coined the term “disease-mongering” to describe attempts to “convince essentially well people that they are sick, or [to convince] slightly sick people that they are very ill” in order to sell treatments.1
Ads for antidepressants don’t just sell drugs. They also sell the idea that depression “may be related to the imbalance of natural chemicals between nerve cells in the brain,” and that the drug “works to correct this imbalance.”2 These biological explanations remove the social or personal context, even for mild problems or for distress that is clearly related to an event.
Researchers Jeffrey Lacasse and Jonathan Leo recently reviewed the evidence on the link between depression and brain chemistry. They found no scientific articles to support this theory; in fact, they state even more broadly: “There is not a single peer-reviewed article that can be accurately cited to directly support claims of serotonin deficiency in any mental disorder...”3 When the United States Food and Drug Administration (FDA) allows companies to say in ads that depression “may be related” to a chemical imbalance, “may” is the key word. However, these ads—often accompanied with scientific-looking diagrams of chemicals and receptors—can be made to look misleadingly scientific.
Antidepressants do affect brain chemistry, but that doesn’t mean depression is caused by an imbalance of brain chemicals. A beer or a glass of wine can help shy people loosen up, but nobody claims that shyness is caused by alcohol deficiency. Effects on brain chemistry are thought to be the reason that antidepressants can improve mood and symptoms of depression. Published studies of patients with depression in primary care (family doctors’ offices) have found that around six out of every 10 patients who took an antidepressant felt considerably better, as compared to four out of 10 patients on a placebo (or ‘sugar pill’).4
“Millions of sufferers . . .”
Promotional messages aiming to sell drugs often exaggerate how common or serious a condition is. This is not limited to mental health. Dartmouth University researchers Steve Woloshin and Lisa Schwartz tracked US news reports over a two-year period when the first drug for restless legs syndrome was being launched. Restless legs is defined as an unpleasant urge to move the legs that gets worse at rest. Symptoms are usually mild, but a few people are more strongly affected, most often experiencing difficulties sleeping.
Two thirds of news stories included exaggerated reports of how many people are affected, with statements such as ‘12 million Americans’ or ‘1 in 10’ are affected. These estimates were based on a single flawed study, which used a positive answer on a single question to classify people as having restless legs syndrome, rather than the usual use approach to diagnosis, which involves at least four symptoms. Most news stories also described the experiences of an extreme sufferer. They didn’t explain that most people are much less troubled. The drug was often presented as a ‘miracle cure,’ although only one in eight users do better on the drug than on a placebo.5
Promotion—not science—is the name of the game
When public relations companies get a new drug into the news, readers don’t always realize this is not neutral reporting, but part of a promotional campaign. The problem is that these ads have been shown to affect prescribing. And unnecessary use of a medicine can lead to serious harm.
The same companies that advertise Coca Cola or Budweiser are creating these ads. The image of the happy, treated patient—like the glowing housewife in 1960’s “whiter than white” detergent ads—has little to do with what the product is like, and everything to do with making it look like something you need.
Anxiety sells. Although prescription drug advertising is illegal in Canada, drug companies are allowed to run ads that don’t mention product names. We had ads for a cholesterol-lowering drug that didn’t mention its name, but featured a tagged toe of a corpse. The message was that without testing and treatment, you can die of a heart attack at any time. That’s not true for most people. The same is true of ads saying that your mild sore throat may be the sign of a more serious condition.
Ads like this should make you pause and remember who’s telling you this and why. The best cure may be a little healthy skepticism.
About the authorBarbara is an Assistant Professor in the Department of Anesthesiology, Pharmacology & Therapeutics at UBC. She has researched the effects of direct-to-consumer advertising on prescribing and, with the Therapeutics Initiative, systematically reviews drug effectiveness and safety. She works with women’s health and consumer groups, including Women and Health Protection and DES (diethylstilbestrol) Action Canada.
Payer, L. (1992). Disease-mongers: How doctors, drug companies, and insurers are making you feel sick. New York: John Wiley & Sons.
Zoloft ad, Shape magazine, August 2004.
Lacasse, J. & Leo, J. (2005). Serotonin and depression: A disconnect between the advertisements and the scientific literature. PLoS Medicine, 2(12), e392. medicine.plosjournals.org/archive/1549-1676/2/12/pdf/10.1371_journal.pmed.0020392-L.pdf.
Arroll, B., Macgillivray, S., Ogston, S. et al. (2005). Efficacy and tolerability of tricyclic antidepressants and SSRIs compared with placebo for treatment of depression in primary care: A meta-analysis. Annals of Family Medicine, 3(5), 449-456.
Woloshin, S. & Schwartz, L.M. (2006). Giving legs to restless legs: A case study of how the media helps make people sick. PLoS Medicine, 3(4), e170.