In Donuts for Doctors, our cover story this month, Alan Cassels provides a chilling look at how the world’s largest pharmaceutical companies are turning healthy people into patients. Employing sly marketing campaigns that convince people they have something wrong with them, Big Pharma creates niches for drugs it hopes will become blockbusters. Critical to the commercial success of these drugs is the cooperation of the doctors who wield the power to write the prescriptions. So it is that billions of warm donuts – and free drug samples – are gifted to doctors and their receptionists across the world, compliments of the drug detailers, the sales reps whose job it is within the pharmaceutical empire to ensure that doctors prescribe these magic bullets to their patients.
Cassels, a drug policy researcher at the University of Victoria, has written extensively about the pharmaceutical industry. In his just released, Selling Sickness, he explains that the intention to target healthy people is anything but new. Thirty years ago, Henry Gadsen, chief executive of Merck (the company currently facing more than 4,200 lawsuits over its once immensely popular Vioxx), told Fortune magazine that he was upset that the company’s potential markets had been limited to sick people. It had long been his dream to make drugs for healthy people. Then, Merck would be able to “sell to everyone.” The late Henry Gadsen’s dream has now come true. Cassels notes, “With promotional campaigns that exploit our deepest fears of death, decay and disease, the $500 billion pharmaceutical industry is literally changing what it means to be human.”
In March of this year, Murray Aitken, senior vice president of corporate strategy at IMS Health – the word’s leading provider of information to the pharmaceutical and healthcare industries – stated, “For the first time, global pharmaceutical sales surpassed the $500 billion threshold.” That’s a lot of drugs being peddled worldwide.
The aroma of fresh baking spills out of Michael Oldani’s car, as the door swings open and he jumps out to retrieve a large box from the trunk of his blue Oldsmobile. He lifts out a box of drug samples and stacks two boxes of donuts on top, which are festooned with stickers bearing the name of the popular antidepressant Zoloft. As one of an 11,000-strong army of detailers working in the US for industry giant Pfizer, Michael greets his morning bearing a beguiling gift – donuts.
The donuts are good icebreakers, a way to get a smile from Joyce, the receptionist, when he walks through the door of the clinic, and maybe the key to snagging a few minutes of the doctor’s time. Because he knows Joyce likes apple fritters, those gooey bits of dough and apple may be what get him an unscheduled appointment with one of the doctors, even if it is only for a few seconds. That’s all it takes, just a few seconds. Today he’s not so lucky; the docs are too busy and already running behind, so he can’t squeeze in any face time with a prescriber. With military efficiency, he quickly refills the clinic’s sample cupboard, putting his products front and centre so they’ll be the first thing the docs see when opening the cupboard. On his way out, he stops to chat with Joyce.
A businesslike, yet charming, manner can be a detailer’s main asset. Michael’s jet-black hair and dark Italian good looks may also help open a few doors. Whether it is his charm, or his fritters, he walks away with a few juicy bits of intelligence, gathered from Joyce. He found out which anti-depressant the doctors in the clinic seem to be favouring lately – Prozac – and why they aren’t using his antibiotic – too expensive and hard to dose. Not a bad return for the price of a box of donuts.
“Now, is that why they call us detailers?” he muses, as he records these items in his electronic scheduler, which contains a database of extraordinarily detail. In it are the likes, dislikes, and habits of specific physicians in his sales area, even down to such minutiae as the birthdays of the doctors’ kids, and the kind of wine their spouses prefer – and, of course, what drugs they tend to prescribe. Knowing what motivates individual physicians, and which products they tend to favour, gives the detailer incredible power in honing a hallway sales pitch: “Oh, Dr. Jones, did you know your colleagues are seeing a lot of agitation in their Prozac users? Is that something you’d like to avoid in your depressed patients?” Michael knows that using and exploiting the side effects of a competitor can steer physicians in the desired direction. “Won’t you try your next patient on Zoloft. Just to see how it works? ”
The world of marketing drugs and disease revolves largely around the verbal exchange of information, caressed by the giving of gifts. Drug marketers have known for decades that the dominant weapon in the arsenal of persuasion is gifting – the donuts, free samples, pens, and free meals bestowed on physicians by drug reps thousands of times a day around the world. This activity is intensely interpersonal, largely hidden from public view, and highly effective. In fact, people like Michael Oldani would say that these gift-greased exchanges lie at the heart of what constitutes a physician’s ongoing education about prescription drugs – and about illness.
Many people might say, “What’s the problem? My physician can see through the marketing spiels.” Yet the data says something very different. In 1998, Toronto drug policy researcher Joel Lexchin reviewed the literature on detailing by pharmaceutical industry representatives and found a very strong link between inappropriate prescribing and contact with drug reps. In fact, Lexchin found that the more frequently prescribers saw industry detailers, the more prone they were to use pharmacotherapy versus non-drug therapy, and the more likely they were to use more expensive medications when cheaper, and equally effective ones were available.
Evidence proving the success of drug education by reps is everywhere. The chemical cures for mental illness is a market of gargantuan size. The drugs provided for various forms of depression, particularly Prozac, Paxil, and Zoloft (selective serotonin reuptake inhibitors, or SSRIs) or Effexor (a serotonin and norepinephrine reuptake inhibitor) comprised a market worth $14.3 billion in 2002. In fact, the global antidepressant market has grown 50 percent since 1994, mainly due to rising sales of SSRIs. And, as the market continues to expand, there is no end in sight. By 2008, it is expected to reach $18.3 billion.
Some argue that the phenomenal growth of the antidepressant drug market is due to the simple fact that more people are depressed. Since Eli Lilly’s Prozac was approved in the US in 1988, the number of cases of depression has nearly doubled from 14 million to 25 million in 2001. Some say the key to this remarkable rise is due to improved diagnoses of people undergoing mental distress. Others blame our increasingly frenetic, stressful lifestyle and lack of social cohesion. Others say the newer SSRIs are used more often because they are more effective than the older antidepressants.
All these factors may be somewhat relevant, but no one can argue that a major factor in getting people to think about depression in the right way – as a chemical imbalance – was driven by the marketing imperatives of all the major antidepressant manufacturers. In one sense, this is remarkable when you consider that there is scant scientific evidence that such a chemical imbalance actually exists in depressed people. In fact, those who have seen secret company documents, uncovered in SSRI litigation, go further, saying the explanation of chemical imbalance causing depression is little more than a clever advertising gimmick, which, through marketing research, has been proven to be an effective means of getting consumers to reach for a bottle of Prozac, or Zoloft, or Paxil. Regardless of how you view the promotional tactics of drug companies, serious clinical depression is, of course, an undeniable major health problem with sometimes devastating consequences. And some people do respond to SSRIs, some even miraculously.
Compared with the drug manufacturers’ marketing campaigns, which push the more lucrative chemical views of depression, alternative views of illness and treatment get short shrift. And with drug reps constantly parading in front of doctors, the chemical views of illness are shaped and reinforced where nobody sees them – behind closed doors, or in clinic hallways. With a ratio in the US of one drug rep for every four doctors, and with drug reps averaging one visit per day, per doctor, Joyce is likely to see a parade of reps. Why should we be surprised that the dominant paradigm of mental healthcare has largely been reduced to the tweaking of neurotransmitters and serotonin levels with patented drugs?
Over half the drug marketer’s budget is allocated to detailers and free drug samples (over eight billion per year in the US). The cartons of free drug samples lugged around the US by more than 60,000 detailers like Michael Oldani represent the promise not just of a gift of new products – but of new knowledge. They are effective because they tap into physicians’ primal motivations – wanting to appear on top of new advances in medicines and keeping patients happy with samples that show how much they care. But free samples also enforce, promote, and reinforce the dominant view of disease that a drug is designed to treat – in this case, the neurotransmitter model of mental health.
As the world’s biggest drug companies battle over markets for their new antidepressants, key allies and key opinion leaders are drawn from the field of psychiatry (known as KOLs in the marketing world) to help educate fellow doctors about both the drugs and the diseases. These KOLs are often just ordinary members of the medical community who can make easy money by giving lunchtime talks to their colleagues. Unfortunately, few of those KOLs come with unbiased opinions. In fact, when Dr Marcia Angell, former editor of the New England Journal of Medicine, wrote her now famous article Is Academic Medicine for Sale? she expressed alarm that in searching for potential contributors for articles on depression, her journal could only find “very few” senior psychiatrists without financial ties to the pharmaceutical companies who make anti-depressants.
A convention of psychiatrists gathered for a scientific meeting offers the ideal place to see how new definitions of mental illness are shaped. It is also where opinion leaders go to hear about the newest new thing. The American Psychiatric Association (APA) 2004 conference in New York City is electric. More than 20,000 visiting health professionals and physicians from all over the world attend this annual scientific conference. This year it’s entitled: Psychotherapy and Psychopharmacology: Dissolving the Mind-Brain Barrier. In the exhibition halls, thousands of doctors are enthusiastically enjoying the delights of the drug company displays, gawking at the soaring high-tech screens promoting the latest medications. It takes a lot of money to attract 20,000 health professionals to a meeting, and most of the APA annual conference is underwritten by the drug industry. A 10-foot square in the exhibit hall goes for $2,400, and scientific sessions are for sale at around $50,000 each. This is the place where capitalism and healthcare meet.
At Eli Lilly’s depression stand, yellow, red, and purple lights flash the words “Where does it hurt?” There are no obvious drug names. Why advertise without mentioning a specific product? Because Lilly is advertising a disease, not a drug.
The “Where does it hurt?” sign flashes alternately with “What four little words could give your patient a better chance to achieve remission?” Lilly’s new drug Cymbalta, a serotonin and norepinephrine reuptake inhibitor whose only rival, so far, is Effexor, has been proven in a recent clinical trial to show some efficacy in treating the physical symptoms (e.g. fatigue, back pain and aches) that often accompany depression. But in a crowded antidepressant market, your drug has to do more than treat depression – it’s gotta’ do something else. But what? Associated symptoms, that’s what.
Lilly has spent more than a year selling the hurt to physicians in journals such as the American Family Physician with an ad that reads: “What did 69 percent of patients diagnosed with depression say? I hurt.” An earlier two-page document about depression, which seeded the ground for Cymbalta, shows a bicycle wheel with the slogan: “We’re not reinventing it. We’re just taking a closer look.”
What is happening in the APA exhibit hall, however, is exactly that: reinvention. Drug companies are reinventing depression by promoting niches which drugs in the pipeline may someday fit, drugs that aren’t even on the market yet. And they are taking existing drugs and colonizing whole new areas of treatment. This drug is now good for agitation. This one works well for pain. This one is for anxiety or tiredness. Lilly is looking to Cymbalta to be its bedrock product in the depression market. Some analysts are already calling it the “next blockbuster antidepressant,” and, no doubt its alleged dual action on emotional hurt and physical pain is the key marketing factor. There’s no better way to get Cymbalta’s sales curve climbing early than pounding that message into the physicians’ heads – long before the drug is approved.
Meetings like the annual APA fulfill a crucial marketing role – part of a “pre-launch awareness campaign.” As Dr. David Healy notes in his latest book Let Them Eat Prozac, the market development for a drug doesn’t just involve scientists, but depends on public relations and communications companies. The goal is to make the new drug have impact and brand presence in the mind of prescribers. David Healy is one of a few high-profile physicians who are critical of the way pharmaceutical companies have shaped physicians’ behaviour. In 1998, in a high-profile resignation from the APA, Dr. Loren Mosher called the American Psychiatric Association a “drug company patsy,” adding, “Psychiatry has been almost completely bought out by the drug companies.” The merchants of the chemical definition of mental illness rely on a key aspect in the practice of medicine: the power of expert opinion. That’s why you won’t find many David Healys or Loren Moshers speaking at an APA conference where new depression niches for drugs like Cymbalta are being created and promoted.
No one could argue that people suffering acutely with depression or mania shouldn’t have the best treatment available. But how many people fit this description? It is a reverberating refrain in the disease-selling business that there are huge – sometimes grossly inflated – estimates of how many people are suffering from the disease, and rather few whom are being treated. This is the gap that propels the marketing of the disease by public and private agencies. Promoters of the undertreatment paradigm are found even among those without drugs to sell. The World Health Organization states that 121 million people worldwide are affected by depression. It projects an increase in mental disorders up from nearly 12 percent of all diseases worldwide to almost 15 percent by the year 2020. The WHO uses the term “treatment gap,” and points out that fewer than 25 percent of those affected have access to effective treatments. Other groups such as the National Institute of Mental Health say that one in five adults in the US, or 22 percent of all adults suffer from a diagnosable mental disorder in a given year.
What is lost in those statistics, however, is that they very much depend on the diagnostic criteria used by researchers. In Australia, professor Ian Hickie led a major campaign which claimed that 30 percent of people who walked into doctors’ offices had an undiagnosed mental illness. As a paid consultant for drug manufacturer Bristol Myers Squibb, Hickie was using and promoting the use of an instrument to diagnose depression – one of those classic screening tools that seems to catch nearly everyone, because the symptoms are so common. A few years later when academic researchers rigorously evaluated Hickie’s instrument, they found it totally inadequate, and were disturbed by the huge numbers of false positives – people who ended up with a label for depression who weren’t in fact depressed.
Every October, National Depression Screening Day rolls across campuses, hospitals, and schools all over North America, asking the question, “Are you tired? Sad? Anxious? Stressed?” In BC in 2003, a one-day conference entitled Untreated Depression and Anxiety Disorders in the Workplace, organized by the Canadian Mental Health Association, was sponsored by the provincial health services, a few banks and credit unions, and Wyeth, Glaxo, Pfizer, Novartis – all manufacturers of antidepressants. This year, they’ve captured media attention with the presence of Premier Gordon Campbell, and what better way to focus the attention of the media and the masses than to use the magnet of a high-profile politician? His personal story is tragic – his father, an assistant dean of medicine at the University of British Columbia, suffered from alcoholism, was fired, and committed suicide in 1961. Yet this kind of story is a golden opportunity to raise the kind of media-piercing awareness the sponsors want for their event.
Using high-profile politicians to sell sickness is not new, and some might defend the practice, saying that raising awareness is vital to ensuring that people get the help they need. In the case of Premier Campbell, his personal story is used in neither a crass, nor distasteful, manner, yet it is disturbing how easily such a story can legitimize and promote the benefits of depression “screening” and treatment. It is definitely a coup for the drug companies who – providing almost the only available treatments – can simply sit back and allow public figures to do their marketing for them. Public facilities are being harnessed to the cause. The BC Ministry of Health sponsors the annual Depression Screening and Education Day as part of National Depression Month. Among the event’s “gold” sponsors is Wyeth, which makes a leading antidepressant, Effexor. This day is designed to cast a wide net, and what better place to stage the actual screening than in the main building housing employees of BC’s largest government ministry? Given recent government cutbacks and downsizing, there is no doubt a higher-than-normal level of angst in government. Hundreds pour in to get screened.
Wyeth’s marketing has not only invaded public health facilities, however. Effexor is a relatively new treatment for depression and in the same SRNI class as Lilly’s forthcoming Cymbalta, whose maker has been particularly interested in targeting the 15 million American college students. Wyeth funds a series of special events on campuses involving MTV stars like Cara Kahn (who takes Effexor). The seminar Depression in College: Real World, Real Life, Real Issues is held in order to raise awareness about depression and the drugs to treat it. Featuring free screenings for depression and celebrity speakers – be they Premier Campbell or Cara Kahn – it is all about creating impact.
Perhaps being screened for depression will help some people, but critics say that such screening only provides a platform for those who have something to sell. They say that public health agencies are being duped when they sponsor and promote screening for normal mental distress, and that they are becoming unwitting medicalizers of depression. Dr. Iona Heath, a general practitioner in London, England, maintains that the whole screening paradigm has never been evaluated, and there is the likelihood that pegging someone as in need of medical help may unnecessarily drag them into the maw of the medical system. While she says it’s important for doctors to diagnose and treat genuine mental illness, she is concerned that too many people with ordinary life experiences are being offered a label and a drug, including those who have lost a loved one, face the prospect of job loss, live in a damp cold home, or experience domestic violence. She writes in the British Medical Journal that the questionnaires used by medical researchers to “diagnose” depression are so broad that they may wrongly label people as sick far too often.
Heath takes the time to listen to her patients who, she maintains, largely reject the “culture of reductionism” which reduces their complaints to a mere problem with neurotransmitters. She sees the doctor-patient relationship in terms that don’t fit within the instant pill-for-every-ill model, where patients are characterized as broken, and the physician is there to fix them. She sees medical care more as a dialectic, a meeting of two experts: the doctor, an expert on disease, and the patient, the expert on his or her own aspirations. The goal is to come to a mutual agreement on the extent to which patients want to medicalize their lives. She also proposes treatments from a larger bundle of solutions, like prescribing exercise which she says is “evidence-based,” and shows benefit, although it is not heavily promoted in the same way as the biochemical approaches. She also gets people to write things down, to tell stories, and to take dancing classes – reverting to the traditional human solution of sublimation, the art of “distracting yourself from the imminence of death and suffering.”
She is not alone in promoting the non-medication approaches to treating human distress. Some researchers might agree that perhaps screening is not such a bad thing, especially if there are large numbers of people who may be undertreated for mental illness. But they question whether antidepressant drugs are the best way to treat those people. Despite the enormous popularity for SSRI treatments for “just about everything,” David Antonuccio, a clinical psychologist and professor in the department of psychiatry at the University of Nevada, says bluntly: “The scientific data don’t support that popularity. From my perspective, there are alternatives that are just as effective and even have some advantages in terms of preventing relapses.”
After nearly 20 years of such research, Antonuccio is among the world’s experts on comparative efficacy studies, those studies that compare drug to non-drug treatments in the treatment of depression. In an article in 1994, he published a study that showed that non-drug treatments such as CBT, talk therapy, and even exercise, to be as effective in the short run, and possibly more effective in the long run than drugs. What happened next caught him off guard. “We got contacted by every media outlet you can imagine – CNN, USA Today. People from newspapers and TV from all over the world were calling us. And we were thinking: “What the hell is going on? All we were saying is therapy seems to be as good or effective as the drugs in the short run, and appears to be better in the long run.” He maintains that there is no new science to dispute those initial findings. In fact, he and his colleagues have been publishing variations of the same paper for the last decade. What he says is most disheartening – that this research can’t seem to pierce the all-pervasive worldwide view of mental illness as chemically caused and treated. “Look, I was watching Good Morning America this morning and they told me ‘your weather report is brought to you by Paxil.’”
The culture of antidepressant use has been beaten into our collective consciousness. Adverse effects associated with those drugs, however, do not seem to get much airplay. A growing chorus of people charges that there are some serious downsides to the entanglement of pharmaceutical manufacturers that are defining diseases, and physicians who are writing prescriptions. In early 2005, amid dramatic and emotional public hearings at the United States Food and Drug Administration, Karen Barth Menzies, a Los Angeles attorney, testified about the concerns relating to SSRI use in children. She cited evidence of unpublished company trials, which failed to show any benefit for several of the new pills. She noted: “The clinical researchers who did these trials on kids and the drug companies themselves, confirmed that there are multiple events of suicidality caused by the drug.” Several months after this testimony, the attorney general of New York State launched a lawsuit against GSK, alleging that the company fraudulently withheld data about Paxil’s safety. He noted that by “concealing critically important scientific studies on Paxil, GSK impaired doctors’ ability to make the appropriate prescribing decision for their patients and may have jeopardized their health and safety.”
With thousands of drug reps working clinics, hospitals, and conferences worldwide and drug-funded key opinion leaders working hotel meeting rooms, how can public health compete? How can we reclaim medicine from the marketplace? Several years ago, Bob Goodman, a New York internist started nofreelunch.org, a website dedicated to escaping the influence of practitioners. A group of physicians in Australia led by Dr. Peter Mansfield also runs a website called HealthySkepticism.org, which exposes the problems with market-based definitions of disease and treatment. Both Goodman and Mansfield are of the opinion that prescribing under the influence of marketing is like driving under the influence of alcohol.
Some say that we get the medicine we ask for. Antidepressants fit the single-pill solution that many of us expect, yet when the definitions of disease itself are being sold, and where the dangers inherent in using those pills are downplayed, how many physicians really have what they need to help their patients get through particularly tough times?
Meanwhile, Michael Oldani (who has since gone on to better things) has noted that a revolution occurred in the late 1990s when drug salespeople gained access to “script-tracking” software. No longer did reps need to schmooze the office receptionists like Joyce with apple fritters to find out what the doctor was writing. Now, with the help of computers, they could buy prescribing data, collected from pharmacies and tabulated, so that the reps could actually focus on the high prescribers and gain even more “face time” to promote products. The fact that they now had the real details about a doctor’s prescribing habits created what Michael refers to as a technology-induced “involution” where major companies could do even more of what works: swarm prescribers with even more representatives and gifts.
And despite the controversies, the mounting lawsuits, and the growing sense of unease about medicating depression, Zoloft generated $3.1 billion in sales in 2003.
Alan Cassels is a drug policy researcher at the University of Victoria. He has spent most of the last 10 years studying how clinical research about prescription drugs is communicated to policy makers, prescribers, and consumers and has produced several full-length documentaries for CBC Ideas, including Manufacturing Patients, which deals with the subject of selling sickness.
Alan Cassels presents a free talk in the authors’ tent at The Word on the Street Festival, Sunday, September 25, 11:20 am, Library Square (at Georgia and Homer). Book signing follows. For more info, visit thewordonthestreet.ca
Common Ground Publishing Corp.