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Virtual pushers: Antidepressant internet marketing and women
Women’s Studies International Forum 28 (2005) 304 – 314 www.elsevier.com/locate/wsif
Virtual pushers: Antidepressant internet marketing and womenB Delanie Woodlock Monash University, Clayton, Victoria, Australia Available online 6 June 2005
Synopsis Women are diagnosed with bmental illnessesQ, such as depression, at twice the rate of men. The basis of women’s mental distress is often seen as biological, but many feminists believe society strongly influences women’s mental health. Despite this, in recent years treatment for women’s mental distress has often come in the form of antidepressants. While direct to consumer marketing of prescription medications is illegal in most countries, pharmaceutical companies use the internet as a global marketing tool for their psychotropic medications. In this paper I describe and analyse several antidepressant websites and examine whether these sites are marketing their products specifically to women. I will also ask if these sites are attempting to market their drugs to women already diagnosed as mentally ill, and/or creating new markets for their drugs by trying to convince more women they have a mental illness. D 2005 Elsevier Ltd. All rights reserved.
The medicalisation and pathologising of women has long been an area of concern for feminists. Feminists have researched the way in which medicine has exploited women in such areas as reproductive technologies and psychiatry (Chesler, 1989; Raymond, 1993; Klein, 1993) but a feminist analysis of women and antidepressant drugs is a relatively unexplored area. While feminist scholars have done much investigation of the mental
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This article is a condensed version of my unpublished honours thesis, Marketing Madness: An exploration of women and antidepressants, Deakin University, Geelong (Woodlock, 2003). Due to space limitations I could not include in this article what I believe to be one of the most comprehensive theories on women’s psychology, Dee Graham’s Societal Stockholm Syndrome. For more information see Graham (1994). Loving to Survive: Sexual Terror, Men’s Violence, and Women’s Lives. New York: New York University Press. 0277-5395/$ - see front matter D 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.wsif.2005.04.015
billnessQ industry, antidepressant drugs are usually only mentioned in passing. I believe this is a serious omission as studies have shown that women make up 70% of those prescribed antidepressants1 (Stoppard, 2004, p. 29). This information is a great cause for concern and my intention in this article is to explore how marketing may be a factor in the prevalence of psychotropic drug use among women. The basis of mental illness has been largely attributed to biology. As women are consistently seen as suffering from mental distress at twice the rate of men,2 the psychiatric industry has looked to the ways in which female-specific biology is responsible for women’s mental pain. Conversely, some feminists (Chesler, 1989; Graham, 1994; McLellan, 1995) have seen that the fact that women are diagnosed with more mental illnesses than men as evidence of the serious
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emotional damage that living in a male dominated society can mean for women. Despite this, the modern treatment for women’s mental anguish is not a move to ending women’s oppression. Instead a pill is seen as the way to cure women’s pain. The marketing of antidepressants to consumers is a fairly recent occurrence. Advertising of prescription drugs to the general public (direct to consumer adverting) (DTCA) is illegal in most countries. In general, the advertising industry has long been critiqued by feminists for creating low self-esteem in women and for the ways in which advertising convinces women they need products that are actually damaging to them.3 The marketing of mind-altering drugs opens up a massive area for potential exploitation and manipulation of women. Will pharmaceutical companies try to reach an existing market of women who are seen as mentally billQ or will they try to create new markets by attempting to suggest to women they are ill in order to sell their product?
Aims and methodology In my research I was most interested in the marketing of antidepressant drugs specifically to women, and how this marketing may play a part in the rate of drugs prescribed to women. Because of drug marketing restrictions in Australia, I decided to do an analysis of a cross section of the different classes of drugs on the market. I chose to analyse the antidepressant websites of: Prozac (http://www.prozac.com) marketed by EliLilly, Effexor XR (http://www.effexorxr. com) marketed by Wyeth Pharmaceuticals, Paxil (http://www.paxil.com) marketed by GlaxoSmithKline, Zoloft (http://www.zoloft.com) marketed by Pfizer and Xanax (http://www.xanax.com) marketed by Pfizer.4 In examining these websites I was particularly interested in the sort of messages the sites are conveying about women, mental billnessQ and drugs. What these sites are saying about the drugs they are marketing–the ways in which the drugs are supposed to work and their bsideQ effects–was also of importance to me. I also investigated whether women were a particular focus of the pharmaceutical companies’ marketing campaigns. For instance, are the mental billnessesQ the drug is supposed to cure billnessesQ suffered by women at a higher rate than men? And
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do the websites have a special appeal that might speak to women more than to men? The effects of advertising and the messages it gives to and about women have long been of interest to feminists. Kilbourne (1999) examined advertising through content analysis of hundreds of magazines, billboards, TV commercials and internet sites. Her findings on advertising provide insights into the powerful effects of marketing. She states: Advertising encourages us not only to objectify each other but also to feel that our most significant relationships are with the products we buy. It turns lovers into things and things into lovers and encourages us to feel passion for our products rather than our partners. Passion for products is especially dangerous when the products are potentially addictive, because addicts do feel they are in a relationship with their substances. I used to joke that Jack Daniels was my most constant lover. The smoker feels that the cigarette is her best friend. Advertising reinforces these beliefs, so we are twice seduced—by the ads and the substances themselves (Kilbourne, 1999, p. 27). Kilbourne’s statement is particularly pertinent in the context of advertising psychiatric drugs, which are marketed as bhappy pillsQ. Unlike advertisements for McDonalds which promote the message that their food will create happiness–for example the McDonalds slogan bCome in my friend and share the happinessQ5–pharmaceutical companies are actually selling products that can be seen as the ultimate way to be joyful: through altering your brain chemistry. It is my contention that the advertising of drugs by pharmaceutical companies via websites offers fertile ground for feminist content analysis. It is my intention to contribute, albeit in a small way, to new knowledge in this area. I now turn to the different theories on women and mental billnessQ.
Theories of mental distress The chemical imbalance theory of mental distress is one of the main theories that currently dominates psychiatry. This field of study is also called biological psychiatry (or biopsychiatry) and has been most influential over the past few decades particularly in the
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area of drug therapy (Breggin & Ross-Breggin, 1994; Stahl, 1996; Kornstein & Wojcik, 2002). In an effort to understand mental distress, biopsychiatry looks to the brain to discover abnormalities. Biopsychiatry is related closely to neuroscience, which is the study of the brain and neuronal functioning. Much of what is known about the brain and chemical neurotransmission comes from neurobiological investigations and experiments on non-human animals. It is from this kind of research that the definition of what is bnormalQ brain functioning emanates. Biopsychiatry uses such neurobiological evidence of bnormalQ brain function as the comparison when investigating abnormal brain functioning in people who are suffering from mental distress. Most of what is known of the brain chemistry supposedly involved in mental distress has been discovered by looking at the effects of drugs on the brain. That is, biochemists know how certain drugs behave and how they act on particular receptors and enzymes. If a drug produces an effect on the symptoms of a person’s mental distress then it is hypothesised that the symptom must be linked to the same receptor or enzyme that the drug is known to be targeting. Stephen M. Stahl, an expert in the area of psychopharmacology, explains the implications of this on understanding mental distress:
cology were found by serendipity. . . or by empiricism, that is, by probing disease mechanisms with a drug of known action but no prior proof that such actions would be necessarily therapeutic (Stahl, 1996, p. 74).
In general contemporary knowledge of CNS [Central Nervous System] disorders. . . is largely predicated upon knowing how drugs act on disease symptoms, and then inferring pathophysiology by knowing how drugs act. Thus, pathophysiology is inferred rather than proven, since we do not yet know the primary enzyme, receptor or genetic deficiency in any given psychiatric or neurological disorder (Stahl, 1996, p. 74).
Feminists have challenged the medical views on mental billnessQ and instead have urged the mental billnessQ industry, and women themselves, to look to external factors as to why women suffer from mental distress. In the next section I will introduce these feminist perspectives on mental billnessQ.
It seems outrageous that despite this lack of concrete knowledge, psychotropic drugs continue to be prescribed at an alarming rate, particularly to women (Hamilton & Jensvold, 1995, p. 10). Psychiatrist Peter Breggin, one of the most prominent long-term critics of psychiatry, has written of the faulty reasoning of biochemical theories. He clarifies: Ever since antidepressants were discovered, it has been assumed they work because of their effect on nerve transmission in the brain. It has also been assumed that, because they work, there must be something wrong with the nerves they affect. This assumption is commonly used as the major reason for searching for biochemical causes of depression and other psychiatric disorders. It goes like this: The drugs work, the drugs affect the brain, so there must be something wrong with the brain. But this is faulty and unscientific reasoning. Many well-known drugs, such as caffeine and alcohol, affect the mind and brain in the absence of any underlying defect in the brain (Breggin & Ross-Breggin, 1994, p. 29).
Feminist perspectives on women’s mental distress In other words, drugs are given to humans who are deemed mentally billQ with disorders that are not medically proven or even known. Stahl laments this practice, but nevertheless further explores the use of drug therapy: It would be advantageous for new drug development to proceed from knowledge of pathophysiology to the invention of new therapeutics, but this must await the elucidation of such pathophysiologies, and this is largely unknown. Virtually all drugs that have been discovered to this date to be useful in psychopharma-
While mainstream psychology often looks to internal reasons to locate the cause of women’s mental billnessQ, feminists have put the focus on women’s external circumstances. One of the earliest feminist critiques of psychology’s preoccupation with women’s inner world was the work of Naomi Weisstein. As she explains: In order to understand why people do what they and certainly in order to change what people psychologists must turn away from the theory of causal nature of the inner dynamic and look to
do, do, the the
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social context within which individuals live (Weisstein, 1970, p. 211). Following on from Weisstein’s analysis, Phyllis Chesler argued that women’s mental disorders are a result of society’s stereotypes and expectations of them. Chesler states that . . . women who are psychiatrically labelled, privately treated, and publicly hospitalized are not mad. . .they may be deeply unhappy, self-destructing [and] economically powerless—but as women they’re supposed to be (Chesler, 1989, p. 25). Betty McLellan expands on Chesler’s notion that women are made bmadQ. In Beyond PsychOppression (1995), McLellan argues that it is only by recognising how oppression impacts on women’s mental health that society can start to make sense of women’s mental billnessesQ. McLellan clarifies b. . .without an acknowledgement of women’s collective and individual oppression it would be impossible to understand the real depth of women’s pain and anguishQ (1995, p. 34). She goes on to identify several methods of oppression that are the causes of most women’s mental distress. These include: violence in the home, rape, reproductive technologies, sadomasochism and pornography. In sum, feminist critiques of women’s bmadnessQ look at the social conditions in which women live. They examine how external factors, such as rape, violence and oppression, impact on women’s mental health. The fact that women are seen as suffering from mental billnessQ at a greater rate than men is, for many feminists, further evidence of women’s oppression. The use of drug therapy, however, to btreatQ women’s mental billnessQ implies that women’s distress is biological, a premise that many feminists resist. In an attempt to provide some answers to the question of why women are prescribed antidepressants at a greater rate than men, I now focus on the marketing of psychotropic drugs, in particular on drug marketing via websites.
Website marketing In order to gain insights into the question of why women are prescribed psychotropics at a greater rate than men, I explored the ways in which antidepressants
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are marketed. The marketing of prescription drugs is highly controversial, so much so that it is illegal in most countries, including Australia. The use of the internet for marketing is a new form of direct to consumer advertising (DTCA). In the US, where all the sites I examined are based, there are no specific regulations for internet marketing, but they are expected to conform to the same guidelines set out for any DTCA (i.e. clearly state the drugs’ adverse effects). My aim was to investigate what messages these sites are distributing about women, mental billnessQ and drug therapy. In particular I wanted to know if these sites are marketing to women who were already diagnosed as mentally billQ, or if they are trying to create new markets. The design of the site, colours, images, meta tags and layout were of special interest to me as they could perhaps indicate if these sites are intended to be more female-oriented. The kinds of mental bdisordersQ the sites focused on and the prevalence of the discussed billnessesQ in women were also important. As antidepressants are believed to have many adverse effects6 I also wanted to examine if the sites were forthcoming with this information.
Direct to consumer advertising (DTCA) In Australia the marketing of any prescription or non-prescription medication is governed by the Therapeutic Goods Act, 1989, Therapeutic Goods Regulations, 1990 and the Therapeutic Goods Advertising Code (TGAC). In terms of marketing prescription medications, the advertising code does not allow direct to consumer advertising. DTCA is defined as brand specific marketing that can be expressed through a variety of media, including television and radio. A company may promote a drug in Australia in commercials, but it is prohibited to give the name of the drug promoted (http://www.tgacc.com.au). In order to circumvent this prohibition drug companies bsponsorQ websites that are marketed as resources for depression and anxiety. Two examples of this are Eli Lilly’s bdepression adviceQ7 website (makers of Prozac), and Wyeth’s byes to lifeQ8 site (makers of Effexor XR). Australia is not alone in this kind of regulation on the marketing of prescription medications. Legally DTCA is exclusive to New Zealand and the United States (Eagle & Kitchen, 2002, p. 293); no other
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countries allow DTCA. DTCA was introduced in the US in 1997. The Federal Drug Administration (FDA) relaxed its regulations on specific product/brand promotion and as such opened the floodgates to a billion dollar market (Wilke, 1998, p. 2). In New Zealand DTC advertising has been legal since 1981. The main criticism of DTCA is that it interferes with the doctor–patient relationship. If patients can get their information about prescription drugs, and illnesses, from the media, they might self-diagnose. This has proven to be true in the US where it has been found that women, in particular, ask their doctor for a particular brand of drug. Eighty-five percent of them leave the doctor’s office with this drug (O’Meara, 2001, p. 10). A study in New Zealand found that of the 1600 GPs who participated in the study, 90% said they had consultations generated by advertising, and 68% felt consultations were often unnecessary. More than 40% said they had either started patients on advertised drugs or switched drugs at their patients’ request even though they felt such drugs offered little new benefit (Gamble, 2003). Given the nature of advertising, some also believe that the emotive persuasion used in the marketing may not be backed by clear empirical evidence; and also that advertising increases the cost of drugs (Eagle & Kitchen, 2002, p. 294). DTCA of antidepressants Feminists have previously researched the advertising of psychotropic drugs. Two studies in particular have found that advertising of psychiatric drugs, in medical journals, overwhelmingly focus on women (Hansen & Osborne, 1995; Lo¨vdahl, Riska, & Riska, 1999). The Swedish study, headed by Ulrica Lo¨vdahl, concluded that . . . advertisements for antidepressants in medical journals currently construct depression as a female symptomatology, as was the case with advertisements for tranquillizers in the 1970s. This trend in drug advertising also revives the tendency towards biologicalization and overmedication of women’s symptoms of mental distress (Lo¨vdahl et al., 1999, p. 27). An in-depth academic study DTCA of antidepressants and the focus on women is yet to be conducted.
Internet DTCA The most recent debates on DTCA have been centered on the use of the internet by pharmaceutical companies. Since there are no formal regulations on DTC marketing via websites, pharmaceutical companies are embracing new technologies as a means to promote their products (Eagle & Kitchen, 2002, p. 293). A study conducted in 1999 on consumers in Sweden–a country without direct-to-consumer advertising–looked at how these consumers used a pharmaceutical company’s website. Although the small sample number of websites studied limits the results, the study found that: Pharmaceutical Web sites perform a variety of important functions, particularly in countries where there is no legal DTCA [direct to consumer advertising]. In developed societies where educated consumers are taking charge of their own health care and leveling the balance of power between physician and patient, the pharmaceutical site can be a primary destination for patients seeking information about diseases, diagnoses and medications (Maddox, 1999, p. 495). Given the growing influence and importance of DTC advertising via websites, I decided to conduct research into the marketing of psychiatric drugs via the internet.
Website design The designs of all the websites I investigated look very similar. The sites appeared to be professionally designed and were easy to navigate. The major links on each page are mostly associated with an billnessQ such as Generalised Anxiety Disorder (GAD) and Post Traumatic Stress Disorders (PTSD). When clicking on the link, a sub-menu usually opens where the web user can find out more about the particular billnessQ, including quizzes that can tell you if you may have the bdisorderQ. The colours most frequently used on the sites are a variety of hues of blue and yellow, with green also prominent on the Effexor XR and Zoloft sites. Studies of the use of these colours in marketing and advertising claim that the colour blue suggests security and
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authority and yellow conveys feelings of happiness and warmth. Green is used to convey health and healing (Garber & Hyatt, 2003, p. 313). Next I examined the meta tags used in the sites. This can be done by viewing the html sources of each site. Meta tags are keywords that web users enter into a search engine. The kinds of meta tags used can be an indication of what sort of people the website creators want to attract to their site (Raeder, 1997, p. 67). There have been criticisms of the way in which meta tags have been used, for example, on pornography sites. Pornographers use words that children may look up, such as singer bBritney SpearsQ. They have even been known to misspell words, as a child might, to attract younger viewers, i.e. bBrittanie SpheresQ. The kinds of meta tags, used on the drug websites I studied, are fairly similar. All web creators used the mental bdisorderQ labels that the drugs are approved for as key words, such as Generalised Anxiety Disorder, anxiety and depression. The names of the drug are always used, with Effexor XR, Paxil and Zoloft also including possible misspellings such as Efexor, paxel and zolof. The symptoms of the billnessesQ are included in most meta tags with words such as worry, trembling, chest pain, sorrow and despair. The Zoloft site also includes tags labelling events that may have caused trauma such as domestic violence, physical attack, child abuse, sexual abuse and rape. Each site displays similar images of women, except for the Zoloft site that uses cartoon images of pill shaped characters. The vast majority of these images are of women looking either happy or sad. Men are also used in some of the images, but mainly in the same pictures as the women, looking like they were enjoying life with their partners. Women are usually white, young to middle aged, and look affluent. There are some images of Asian, African-American and Hispanic women. None of the images are of lesbian couples, and all women look stereotypically heterosexual (usually long hair and make-up). User interaction One of the key differences between website marketing and other forms of advertising is the ability to interact with consumers. All of the websites have features that encourage users to participate in the site. The most common features are mental billnessQ
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quizzes. The web user can fill in a short quiz, which will indicate if s/he has certain mental disorders. For example, on the Zoloft website I filled in the quiz for depression. The introduction to the quiz states: If you think you may be suffering from the symptoms of depression, this Self-Quiz can help you discuss your concerns with your doctor. Just print this page, answer the questions to the best of your ability, and take the completed Self-Quiz to an appointment with a doctor or other qualified healthcare professional. Your answers can help your doctor determine if you have symptoms of depression. An example of one of the questions asked is whether you are bfeeling tired or having little energyQ. You have the option of selecting answers on a scale of bNot at all, Several days, More than half the days, Nearly every dayQ. After filling in the quiz a response is returned suggesting that if the person filling in the quiz had checked bseveral daysQ or more for questions 1 or 2 and some of the other problems, s/he print out the results and take them to her/his doctor. The print out clearly shows the name of the drug so that the doctor can be helpfully informed about what kind of drug you could be prescribed.
Mental billnessesQ and their prevalence in women All the bdisordersQ described on the websites are classified as bneuroticQ conditions. McLellan (1995 p. 34) lists these conditions as including depression, anxiety, eating disorders, low self-esteem and selfhatred. These bdisordersQ differ from the other main class of mental billnessesQ known as bpsychoticQ conditions, and are sometimes defined as bnon-psychotic mental disordersQ.9 What mainly differentiates these conditions is the cause of the billnessesQ—bpsychoticQ conditions are seen to have a biological cause, whereas bneuroticQ type conditions are seen as more emotionally based (McLellan, 1995). However these differences are no longer so clear, as it is currently widely believed that all bdisordersQ result from a chemical imbalance. The websites I studied focused on the following billnessesQ; depression, panic disorder, social anxiety disorder, obsessive compulsive disorder, generalised
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anxiety disorder, post traumatic stress disorder and bulimia. The descriptions of the bdisordersQ varied slightly from site to site, with most focusing little on the possible social reasons for mental distress and instead basing their information on biological models. Some gave very little information at all about the bdisorderQ, such as the Prozac site, and focused mainly on how the drug can help alleviate the billnessQ. Each of the billnessesQ on the sites are believed to be more common in women. Using the information provided on the sites and from recent studies on mental billnessQ in women I will now give a very brief overview of the prevalence of the following billnessesQ in women. Each of the billnessQ on the sites are believed to be more common in women. International studies have consistently shown that depression is twice as prevalent in women than in men (Kornstein & Wojcik, 2002, p. 147). The Effexor XR site states that nearly twice as many women (6.5%) as men (3.3%) suffer from depression each year. On the Paxil website it is mentioned that 25% of women suffer from depression serious enough to seek treatment at least once in their lifetime, versus only 0.9% of men (Pigott, 2002, p. 195). Social Anxiety Disorder (SAD) is believed to be one of the third most common mental bdisordersQ in the US and is diagnosed in 16.4% of women as compared to 11.2% of men (Pigott, 2002, p. 195). The Zoloft and Paxil websites both state that Obsessive Compulsive Disorder (OCD) is equally as common in men and women, but I have found studies which have shown that it is slightly more prevalent in women, 3.1% in women compared to 2.0% in men (Pigott, 2002, p. 195). Women are much more likely to be diagnosed with Generalised Anxiety Disorder (GAD). Research has shown that around 7.7% of women will suffer from GAD compared to 2.9% of men (Pigott, 2002, p. 195). Post Traumatic Stress Disorder is said to occur twice as frequently in women compared with men. An explanation as to why it is more prevalent in women is provided on the Zoloft site. It is stated that . . . doctors believe that women may have a higher prevalence of PTSD because the types of traumatic events that they experience are more likely to be associated with personal violence (such as rape and sexual molestation) than the events that men usually report. Also, the types of traumatic events that women
experience often tend to happen repeatedly, especially in childhood. Eighty percent of people diagnosed with Bulimia are women (hhtp://www.prozac.com).
Disclosure of adverse effects and information about drug withdrawal Each of the sites I examined disclosed adverse effects that may occur when taking their drug. Most websites state that adverse effects are not common, and that most people do not need to stop taking the drug because of negative reactions. Only two of the sites, Paxil and Xanax, mention withdrawal effects or so-called breboundingQ effects. The Effexor XR site contains a somewhat vague caution about bdiscontinuation symptomsQ. Adverse effects Each site is careful to include the basic information about adverse effects their drugs may cause. The websites for all five drugs also emphasise that the adverse effects are minimal compared to the benefits of the drugs. The Prozac site makes great efforts to prove that their drug is safe. The web authors begin by giving the following information: Some people experience mild side effects like nausea, difficulty sleeping, drowsiness, anxiety, nervousness, weakness, loss of appetite, tremors, dry mouth, sweating, decreased sex drive, impotence, or yawning. These tend to go away within a few weeks of starting treatment and, in most cases, aren’t serious enough to cause people to stop taking Prozac. The text continues with claims that due to its popularity and its continued prescription around the world, Prozac must be safe: Today, Prozac is one of the world’s most widely prescribed antidepressants, having been prescribed for more than 40 million people in more than 90 countries, including more than 22 million people in the United States. For more than 14 years, the safety and effectiveness of Prozac continue to be demonstrated worldwide
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through scores of clinical studies and patient success stories. . .The safety and effectiveness of Prozac have been thoroughly studied in clinical trials with more than 11,000 patients. There have been more than 3500 publications on Prozac in medical/scientific journals. The Zoloft site follows a similar pattern. Adverse effects are mentioned, but they are portrayed as being minimal and rare. For example: Some people taking Zoloft may have side effects. The most common side effects include upset stomach, having trouble sleeping, diarrhea, dry mouth, sexual side effects, feeling unusually sleepy or tired, tremor, indigestion, increase of sweating, feeling agitated, and decreased appetite. In clinical studies with Zoloft, few patients were bothered enough by side effects to stop taking their medicine. Tell your doctor about any side effects you may be experiencing. Your doctor may be able to adjust your treatment plan to help you feel better. The Xanax site, while more forthcoming about some adverse effects, nevertheless still minimises the harm that can be caused by taking Xanax: Side effects, if they occur, are generally observed at the beginning of therapy and usually disappear upon continued use. The most commonly reported side effects in clinical trials were drowsiness, fatigue, impaired coordination, irritability, light-headedness, memory impairment, insomnia, and headache. The web authors continue by giving information about the serious effects that can occur when a person takes more than 4 mg a day: At doses greater than 4 mg per day, XANAX has the potential to cause severe emotional and physical dependence in some patients and these individuals may find it exceedingly difficult to terminate treatment. Similar to the other sites, the Paxil website is cautious about overstating adverse effects. When examining the list of adverse effects, however, it seems they can be quite serious, such as injury and infection (what kind of injury or infection is not stated). As serious as these adverse effects are, even more severe effects may occur when people actually try to stop taking these drugs.
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Withdrawal effects The Paxil and Xanax sites are the most explicit in detailing the withdrawal effects people may experience when discontinuing drug btreatmentQ. The Effexor XR site does mention ddiscontinuation symptomsT but there are no details as to what these bsymptomsQ are. The Paxil site gives some information in its Q&A (question and answer) section. Under the question bWhat do I need to know about stopping Paxil?Q the answer is: Don’t stop taking Paxil before talking to your doctor since symptoms may result from stopping the medication or from your original condition. Some patients experience the following symptoms on stopping Paxil (particularly when abrupt): dizziness, sensory disturbances (including electric shock sensations), abnormal dreams, agitation, anxiety, nausea and sweating. The difficulties of withdrawal from Paxil have been documented recently, with a law suit currently being filed in the US against Paxil manufactures GlaxoSmithKline for downplaying the seriousness of the withdrawal effects,10 and it is my belief that the information on the Paxil website diminishes the seriousness of discontinuing the drug Paxil. The Xanax site is more forthcoming with information about serious adverse effects that can be caused by withdrawing from the drug. Xanax is a benzodiazepine, which is a class of drugs that have been criticised especially regarding extreme withdrawal effects. The site gives the following information: When taking a benzodiazepine like XANAX, the individual should also be aware of the possibility of brebound anxietyQ (also, sometimes called btransient rebound anxietyQ) when discontinuing therapy. Rebound anxiety is a temporary condition whereby the symptoms that led to treatment return upon discontinuation of the medication. It may be accompanied by other reactions including mood changes, anxiety or sleep disturbances, and restlessness. Since the risk of discontinuation symptoms and rebound effects is greater after abrupt discontinuation of treatment, most physicians usually prescribe a gradual tapering of dosage. Given the seriousness of adverse effects and withdrawal, it does seem extraordinary that these drugs are
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readily prescribed to women. The next section will provide a brief analysis of the information I gained through researching the antidepressant websites.
Discussion In order to discover if internet marketing was indeed a factor in high numbers of women using antidepressants, I investigated whether the sites focused on women. I explored, in particular, whether the pharmaceutical companies are marketing their drugs to women who are already diagnosed as mentally billQ and are taking antidepressants, or are also attempting to market their products to women who are not (yet) currently taking drugs. I reasoned that while the first strategy would not increase the number of women taking antidepressants (although some might decide to change brands), the second strategy would create new markets and hence further increase the number of women on antidepressants. There were several other reasons why I wanted to look at antidepressant web marketing, such as examining if the sites are upfront about the adverse effects that their advertised drugs cause, and also, if the pharmaceutical companies are circumventing direct to consumer adverting (DTCA) laws by advertising globally on the internet. In order to determine if the sites are attempting to market to women, in particular to women who are not currently taking antidepressants, I looked at several aspects of the sites. I conclude that there are numerous indicators that the websites are indeed focusing on women. The images on the sites consist mainly of females, with the Paxil site featuring (at the time of this study, May to August 2003) over twice the number of women in its images. Having more images of women could be a technique to allow a woman web reader to identify with the mentally billQ women on the site, perhaps enabling her to see herself in these images. I was also interested in the meta tags on the sites as these are website tools that are a key factor in how people search for sites. The majority of terms that I found are related more to the general symptoms of the billnessQ than the names of the drugs. This seems to signify that the drug companies are hoping that people searching the internet for mental illness information
will be directed to their site. One extreme example of this might be a woman looking in a search engine for sexual abuse resources. The Zoloft meta tags included terms such as brapeQ and bsexual abuseQ, meaning that a woman could find herself on the Zoloft website in her search for information about sexual assault—surely not the best resource to access after the trauma of rape. I would also argue that the ways in which the sites are disguised as mental billnessQ resources, rather than as advertisements, is very misleading. The clearest example of this is the Xanax site which is entitled banxietyinfo.comQ and can also be found using the URL bhttp://www.anxietyinfo.comQ. The quiz sections of the sites were particularly illuminating. While there are cautions not to treat the mental billnessQ quizzes as a diagnostic tool, the fact that each site suggests that the web user print out their results and take it to their doctor seems to be further evidence of these companies’ aim to convince people, particularly women, that they are ill and need drugs. The symptoms of most of the bdisordersQ on the sites, such as Generalised Anxiety Disorder (GAD), are so vague and general–for example unsatisfying sleep–that almost any person, at any given time, could be diagnosed with GAD. DTCA has been shown to influence women when they are asking their doctors for particular brands of drugs (O’Meara, 2001, p. 10). Doctors have also reported that due to the influence of DTCA they sometimes prescribed patients with advertised drugs that they believed offered little new benefit. They did so acting on the patients’ direct requests (New Zealand Herald, 2003, p. 15). Considering these facts as well as my own research findings, website marketing of antidepressants can appear to be designed to convince women to switch brands of drugs and also to persuade women not (yet) on medication that they are mentally billQ and therefore need drugs. The bsideQ effects of the antidepressants studied are outlined on each of the sites, but in my view the seriousness of the adverse effects is minimised by comments claiming that it is rare for users to suffer any ill effects. The lack of information on the dangers of withdrawing from some of these drugs is to be deplaned. I do see the sense in such an omission though, as pharmaceutical companies may not want potential consumers to know how hard it is to withdraw from their drugs.
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Of note is also the very fact that I was able to access these sites while living in a country where DTCA is illegal. While some of the sites did have a note that they were designed for US, there was no real preventative measure from allowing me to view the websites. While I am unsure of what can be done to stop non-US residents from viewing these sites, it is clear that these websites now can be used by anyone with internet access, in any country, as source of information on psychotropic drugs.
to help ease mental distress, and that pharmaceutical companies should not be seen as a primary resource for mental health information.
Conclusion
Endnotes
The question as to why women are prescribed psychotropic drugs at a greater rate than men cannot be answered simply. My brief study on website marketing of antidepressants has barely scratched the surface as to the reasons why so many women are taking antidepressants. I suggest that more extensive research needs to be conducted on the topic of psychiatric drugs and women. In-depth interviews with women who have been prescribed drugs could be one method. Discovering the reasoning behind why women were prescribed the drugs in the first place, why they decided to take them and what motivated them to stop taking the drugs (if they did), would be very useful. It could also be important to look at other ways in which drug companies are marketing their drugs to women, to examine not only the direct advertising but also the influence pharmaceutical companies exert on doctors. Particular emphasis could be placed on looking at young women and examining the problems that lead to their medicalisation via antidepressants.11 Further studies could also scrutinise the marketing of psychiatric drugs to women in majority world countries by pharmaceutical companies. To conclude, I believe that the findings of my research have uncovered yet another layer of the medicalisation of women. Instead of acknowledging, for example, the impact that abuse can have on women’s mental health, biopsychiatry theorises that it is women’s biology that is at the root of mental billnessQ. The antidepressant industry then capitalises on this ideology, focusing their marketing on women with the result that profit arises from women’s mental anguish. I suggest that women need to be given unbiased information about all the options available
Acknowledgements I would like to thank Renate Klein for her insightful editing and thoughtful comments on this article. Thanks also to Kent Karlsson for the title of the piece.
1
With the latest Australian Government’s Women’s Health and Wellbeing study showing that depression is the leading cause of bdisabilityQ in women, it can be expected that this area is bound to grow (Victorian Department of Human Services, 2002). The World Health Organization (2001) estimated that by 2020 depression will be the highest-ranking cause of burden of disease in the developed world. 2 See Kornstein and Wojcik (2002, p. 147). 3 See Jean Kilbourne’s (1999) Deadly Persuasion: Why Women and Girls Must Fight the Addictive Power of Advertising, for more information. 4 These sites were analysed between May 2003 and August 2003. 5 McDonalds advertisement aired on TV3, November 2002 in Sweden. 6 For comprehensive information on adverse effects of antidepressants see Healy (2004). Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression. New York: New York University Press; Glenmullen (2001). Prozac Backlash: Overcoming the Dangers of Prozac, Zoloft, Paxil, and Other Antidepressants with Safe, Effective Alternatives. New York: Simon & Schuster; Breggin and Ross-Breggin (1994). Talking Back to Prozac. New York: St. Martin’s Press. 7 Site can be found at http://www.depressionadvice.com.au. 8 Site can be found at http://www.yestolife.com.au. 9 Astbury (1999) makes mention that non-psychotic mental disorders are also known as common mental disorders (CMD) because of their high incident rate (p. 5). 10 See The Salt Lake Tribune, b30 Utahns Sue Maker of Antidepressant PaxilQ, June 4, 2004. 11 At the time of writing (2004), I am engaged in PhD research examining young women and their experiences of antidepressants.
References Astbury, Jill (1999). Gender and mental health. Harvard University: Gender and health equity project. Breggin, Peter, & Ross-Breggin, Ginger (1994). Talking back to Prozac. New York7 St. Martin’s Press. Chesler, Phyllis (1989). Women and madness. Florida7 Harcourt Brace Jovanovich.
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Eagle, Lynne, & Kitchen, Philip (2002). Direct consumer promotion of prescription drugs: A review of the literature and the New Zealand experience. International Journal of Medical Marketing, 2(4), 293. Gamble, Warren (2003, 2 March). Direct advertising an uneasy pill to swallow. New Zealand Herald (p. 15). Garber, Lawrence, & Hyatt, Eva M. (2003). Color as a tool for visual persuasion. In Linda M. Scott, & Rajeev Batra (Eds.), Persuasive imagery. New Jersey7 Lawrence Erlbaum Associates. Glenmullen, Joseph (2001). Prozac backlash: Overcoming the dangers of Prozac, Zoloft, Paxil, and other antidepressants with safe, effective alternatives. New York7 Simon & Schuster. Graham, Dee (1994). Loving to survive: Sexual terror, men’s violence, and women’s lives. New York7 New York University Press. Hamilton, Jean, & Jensvold, Margaret (1995). Sex and gender as critical variables in feminist psychopharmacology, research and pharmacotherapy. In Hamilton Jean, et al. (Eds.), Psychopharmacology from a feminist perspective. New York7 Harrington Park Press. Hansen, Finy, & Osborne, Dawn (1995). Portrayal of women and elderly patients in psychotropic drug advertisements. In Jean Hamilton, et al. (Eds.), Psychopharmacology from a feminist perspective. New York7 Harrington Park Press. Healy, David (2004). Let them eat Prozac: The unhealthy relationship between the Pharmaceutical Industry and Depression. New York7 New York University Press. Kilbourne, Jean (1999). Deadly persuasion: Why women and girls must fight the addictive power of advertising. New York7 The Free Press. Klein, Renate (1993). Reproductive technology, genetic engineering, and women hating. In Cheris Kramarae, & Dale Spender (Eds.), The knowledge explosion: Generations of feminist scholarship. New York7 Teachers College Press. Kornstein, Susan, & Wojcik, Barbara (2002). Depression. In Susan Kornstein, & Anita Clayton (Eds.), Women’s Mental Health: A comprehensive textbook. New York7 Guilford Press.
˚ sa, & Riska, Elianne (1999). Gender Lo¨vdahl, Ulrica, Riska, A display in Scandinavian and American advertising for antidepressants. Scandinavian Journal of Public Health, 27(4). Maddox, Lynda M. (1999). The use of pharmaceutical web sites for prescription drug information and product requests. Journal of Product & Brand Management, 8(6), 488 – 497. McLellan, Betty (1995). Beyond psychoppression: A feminist alternative therapy. North Melbourne7 Spinifex Press. O’Meara, Kelly (2001, 30 April). Misleading medicine. Insight on the News, 10 – 14. Pigott, Teresa (2002). Anxiety disorders. In Susan Kornstein, & Anita Clayton (Eds.), Women’s mental health: A comprehensive textbook. New York7 Guilford Press. Raeder, Aggi (1997). Promoting your web site. Searcher, 63 – 67. Raymond, Janice (1993). Women as wombs: Reproductive technologies and the battle over women’s freedom. North Melbourne7 Spinifex Press. Stahl, Stephen M. (1996). Essential psychopharmacology. Cambridge7 Cambridge University Press. Stoppard, Janet (2004). Feeling blue? Herizons, 17(3). Victorian Department of Human Services (2002). Women’s Health and Wellbeing Study. Retrieved October 1, 2002, from http:// www.women.vic.gov.au Weisstein, Naomi (1970). Kinder, Kuche, Kirche. In Robin Morgan (Ed.), Sisterhood is powerful: An anthology of writings from the women’s liberation movement. New York7 Vintage. Wilke, Michael (1998). Prescription for profit. Advertising Age, (2). Woodlock, Delanie (2003). Marketing Madness: An exploration of women and antidepressants. Unpublished Honours thesis, Deakin University, Geelong. World Health Organization (2001). The World Health Report 2001: Mental Health, New Understanding, New Hope. Retrieved August 1, 2003, from http://www.who.int/whr2001/2001/main/en/ index.htm
Virtual pushers: Antidepressant internet marketing and womenB Delanie Woodlock Monash University, Clayton, Victoria, Australia Available online 6 June 2005
Synopsis Women are diagnosed with bmental illnessesQ, such as depression, at twice the rate of men. The basis of women’s mental distress is often seen as biological, but many feminists believe society strongly influences women’s mental health. Despite this, in recent years treatment for women’s mental distress has often come in the form of antidepressants. While direct to consumer marketing of prescription medications is illegal in most countries, pharmaceutical companies use the internet as a global marketing tool for their psychotropic medications. In this paper I describe and analyse several antidepressant websites and examine whether these sites are marketing their products specifically to women. I will also ask if these sites are attempting to market their drugs to women already diagnosed as mentally ill, and/or creating new markets for their drugs by trying to convince more women they have a mental illness. D 2005 Elsevier Ltd. All rights reserved.
The medicalisation and pathologising of women has long been an area of concern for feminists. Feminists have researched the way in which medicine has exploited women in such areas as reproductive technologies and psychiatry (Chesler, 1989; Raymond, 1993; Klein, 1993) but a feminist analysis of women and antidepressant drugs is a relatively unexplored area. While feminist scholars have done much investigation of the mental
B
This article is a condensed version of my unpublished honours thesis, Marketing Madness: An exploration of women and antidepressants, Deakin University, Geelong (Woodlock, 2003). Due to space limitations I could not include in this article what I believe to be one of the most comprehensive theories on women’s psychology, Dee Graham’s Societal Stockholm Syndrome. For more information see Graham (1994). Loving to Survive: Sexual Terror, Men’s Violence, and Women’s Lives. New York: New York University Press. 0277-5395/$ - see front matter D 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.wsif.2005.04.015
billnessQ industry, antidepressant drugs are usually only mentioned in passing. I believe this is a serious omission as studies have shown that women make up 70% of those prescribed antidepressants1 (Stoppard, 2004, p. 29). This information is a great cause for concern and my intention in this article is to explore how marketing may be a factor in the prevalence of psychotropic drug use among women. The basis of mental illness has been largely attributed to biology. As women are consistently seen as suffering from mental distress at twice the rate of men,2 the psychiatric industry has looked to the ways in which female-specific biology is responsible for women’s mental pain. Conversely, some feminists (Chesler, 1989; Graham, 1994; McLellan, 1995) have seen that the fact that women are diagnosed with more mental illnesses than men as evidence of the serious
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emotional damage that living in a male dominated society can mean for women. Despite this, the modern treatment for women’s mental anguish is not a move to ending women’s oppression. Instead a pill is seen as the way to cure women’s pain. The marketing of antidepressants to consumers is a fairly recent occurrence. Advertising of prescription drugs to the general public (direct to consumer adverting) (DTCA) is illegal in most countries. In general, the advertising industry has long been critiqued by feminists for creating low self-esteem in women and for the ways in which advertising convinces women they need products that are actually damaging to them.3 The marketing of mind-altering drugs opens up a massive area for potential exploitation and manipulation of women. Will pharmaceutical companies try to reach an existing market of women who are seen as mentally billQ or will they try to create new markets by attempting to suggest to women they are ill in order to sell their product?
Aims and methodology In my research I was most interested in the marketing of antidepressant drugs specifically to women, and how this marketing may play a part in the rate of drugs prescribed to women. Because of drug marketing restrictions in Australia, I decided to do an analysis of a cross section of the different classes of drugs on the market. I chose to analyse the antidepressant websites of: Prozac (http://www.prozac.com) marketed by EliLilly, Effexor XR (http://www.effexorxr. com) marketed by Wyeth Pharmaceuticals, Paxil (http://www.paxil.com) marketed by GlaxoSmithKline, Zoloft (http://www.zoloft.com) marketed by Pfizer and Xanax (http://www.xanax.com) marketed by Pfizer.4 In examining these websites I was particularly interested in the sort of messages the sites are conveying about women, mental billnessQ and drugs. What these sites are saying about the drugs they are marketing–the ways in which the drugs are supposed to work and their bsideQ effects–was also of importance to me. I also investigated whether women were a particular focus of the pharmaceutical companies’ marketing campaigns. For instance, are the mental billnessesQ the drug is supposed to cure billnessesQ suffered by women at a higher rate than men? And
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do the websites have a special appeal that might speak to women more than to men? The effects of advertising and the messages it gives to and about women have long been of interest to feminists. Kilbourne (1999) examined advertising through content analysis of hundreds of magazines, billboards, TV commercials and internet sites. Her findings on advertising provide insights into the powerful effects of marketing. She states: Advertising encourages us not only to objectify each other but also to feel that our most significant relationships are with the products we buy. It turns lovers into things and things into lovers and encourages us to feel passion for our products rather than our partners. Passion for products is especially dangerous when the products are potentially addictive, because addicts do feel they are in a relationship with their substances. I used to joke that Jack Daniels was my most constant lover. The smoker feels that the cigarette is her best friend. Advertising reinforces these beliefs, so we are twice seduced—by the ads and the substances themselves (Kilbourne, 1999, p. 27). Kilbourne’s statement is particularly pertinent in the context of advertising psychiatric drugs, which are marketed as bhappy pillsQ. Unlike advertisements for McDonalds which promote the message that their food will create happiness–for example the McDonalds slogan bCome in my friend and share the happinessQ5–pharmaceutical companies are actually selling products that can be seen as the ultimate way to be joyful: through altering your brain chemistry. It is my contention that the advertising of drugs by pharmaceutical companies via websites offers fertile ground for feminist content analysis. It is my intention to contribute, albeit in a small way, to new knowledge in this area. I now turn to the different theories on women and mental billnessQ.
Theories of mental distress The chemical imbalance theory of mental distress is one of the main theories that currently dominates psychiatry. This field of study is also called biological psychiatry (or biopsychiatry) and has been most influential over the past few decades particularly in the
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area of drug therapy (Breggin & Ross-Breggin, 1994; Stahl, 1996; Kornstein & Wojcik, 2002). In an effort to understand mental distress, biopsychiatry looks to the brain to discover abnormalities. Biopsychiatry is related closely to neuroscience, which is the study of the brain and neuronal functioning. Much of what is known about the brain and chemical neurotransmission comes from neurobiological investigations and experiments on non-human animals. It is from this kind of research that the definition of what is bnormalQ brain functioning emanates. Biopsychiatry uses such neurobiological evidence of bnormalQ brain function as the comparison when investigating abnormal brain functioning in people who are suffering from mental distress. Most of what is known of the brain chemistry supposedly involved in mental distress has been discovered by looking at the effects of drugs on the brain. That is, biochemists know how certain drugs behave and how they act on particular receptors and enzymes. If a drug produces an effect on the symptoms of a person’s mental distress then it is hypothesised that the symptom must be linked to the same receptor or enzyme that the drug is known to be targeting. Stephen M. Stahl, an expert in the area of psychopharmacology, explains the implications of this on understanding mental distress:
cology were found by serendipity. . . or by empiricism, that is, by probing disease mechanisms with a drug of known action but no prior proof that such actions would be necessarily therapeutic (Stahl, 1996, p. 74).
In general contemporary knowledge of CNS [Central Nervous System] disorders. . . is largely predicated upon knowing how drugs act on disease symptoms, and then inferring pathophysiology by knowing how drugs act. Thus, pathophysiology is inferred rather than proven, since we do not yet know the primary enzyme, receptor or genetic deficiency in any given psychiatric or neurological disorder (Stahl, 1996, p. 74).
Feminists have challenged the medical views on mental billnessQ and instead have urged the mental billnessQ industry, and women themselves, to look to external factors as to why women suffer from mental distress. In the next section I will introduce these feminist perspectives on mental billnessQ.
It seems outrageous that despite this lack of concrete knowledge, psychotropic drugs continue to be prescribed at an alarming rate, particularly to women (Hamilton & Jensvold, 1995, p. 10). Psychiatrist Peter Breggin, one of the most prominent long-term critics of psychiatry, has written of the faulty reasoning of biochemical theories. He clarifies: Ever since antidepressants were discovered, it has been assumed they work because of their effect on nerve transmission in the brain. It has also been assumed that, because they work, there must be something wrong with the nerves they affect. This assumption is commonly used as the major reason for searching for biochemical causes of depression and other psychiatric disorders. It goes like this: The drugs work, the drugs affect the brain, so there must be something wrong with the brain. But this is faulty and unscientific reasoning. Many well-known drugs, such as caffeine and alcohol, affect the mind and brain in the absence of any underlying defect in the brain (Breggin & Ross-Breggin, 1994, p. 29).
Feminist perspectives on women’s mental distress In other words, drugs are given to humans who are deemed mentally billQ with disorders that are not medically proven or even known. Stahl laments this practice, but nevertheless further explores the use of drug therapy: It would be advantageous for new drug development to proceed from knowledge of pathophysiology to the invention of new therapeutics, but this must await the elucidation of such pathophysiologies, and this is largely unknown. Virtually all drugs that have been discovered to this date to be useful in psychopharma-
While mainstream psychology often looks to internal reasons to locate the cause of women’s mental billnessQ, feminists have put the focus on women’s external circumstances. One of the earliest feminist critiques of psychology’s preoccupation with women’s inner world was the work of Naomi Weisstein. As she explains: In order to understand why people do what they and certainly in order to change what people psychologists must turn away from the theory of causal nature of the inner dynamic and look to
do, do, the the
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social context within which individuals live (Weisstein, 1970, p. 211). Following on from Weisstein’s analysis, Phyllis Chesler argued that women’s mental disorders are a result of society’s stereotypes and expectations of them. Chesler states that . . . women who are psychiatrically labelled, privately treated, and publicly hospitalized are not mad. . .they may be deeply unhappy, self-destructing [and] economically powerless—but as women they’re supposed to be (Chesler, 1989, p. 25). Betty McLellan expands on Chesler’s notion that women are made bmadQ. In Beyond PsychOppression (1995), McLellan argues that it is only by recognising how oppression impacts on women’s mental health that society can start to make sense of women’s mental billnessesQ. McLellan clarifies b. . .without an acknowledgement of women’s collective and individual oppression it would be impossible to understand the real depth of women’s pain and anguishQ (1995, p. 34). She goes on to identify several methods of oppression that are the causes of most women’s mental distress. These include: violence in the home, rape, reproductive technologies, sadomasochism and pornography. In sum, feminist critiques of women’s bmadnessQ look at the social conditions in which women live. They examine how external factors, such as rape, violence and oppression, impact on women’s mental health. The fact that women are seen as suffering from mental billnessQ at a greater rate than men is, for many feminists, further evidence of women’s oppression. The use of drug therapy, however, to btreatQ women’s mental billnessQ implies that women’s distress is biological, a premise that many feminists resist. In an attempt to provide some answers to the question of why women are prescribed antidepressants at a greater rate than men, I now focus on the marketing of psychotropic drugs, in particular on drug marketing via websites.
Website marketing In order to gain insights into the question of why women are prescribed psychotropics at a greater rate than men, I explored the ways in which antidepressants
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are marketed. The marketing of prescription drugs is highly controversial, so much so that it is illegal in most countries, including Australia. The use of the internet for marketing is a new form of direct to consumer advertising (DTCA). In the US, where all the sites I examined are based, there are no specific regulations for internet marketing, but they are expected to conform to the same guidelines set out for any DTCA (i.e. clearly state the drugs’ adverse effects). My aim was to investigate what messages these sites are distributing about women, mental billnessQ and drug therapy. In particular I wanted to know if these sites are marketing to women who were already diagnosed as mentally billQ, or if they are trying to create new markets. The design of the site, colours, images, meta tags and layout were of special interest to me as they could perhaps indicate if these sites are intended to be more female-oriented. The kinds of mental bdisordersQ the sites focused on and the prevalence of the discussed billnessesQ in women were also important. As antidepressants are believed to have many adverse effects6 I also wanted to examine if the sites were forthcoming with this information.
Direct to consumer advertising (DTCA) In Australia the marketing of any prescription or non-prescription medication is governed by the Therapeutic Goods Act, 1989, Therapeutic Goods Regulations, 1990 and the Therapeutic Goods Advertising Code (TGAC). In terms of marketing prescription medications, the advertising code does not allow direct to consumer advertising. DTCA is defined as brand specific marketing that can be expressed through a variety of media, including television and radio. A company may promote a drug in Australia in commercials, but it is prohibited to give the name of the drug promoted (http://www.tgacc.com.au). In order to circumvent this prohibition drug companies bsponsorQ websites that are marketed as resources for depression and anxiety. Two examples of this are Eli Lilly’s bdepression adviceQ7 website (makers of Prozac), and Wyeth’s byes to lifeQ8 site (makers of Effexor XR). Australia is not alone in this kind of regulation on the marketing of prescription medications. Legally DTCA is exclusive to New Zealand and the United States (Eagle & Kitchen, 2002, p. 293); no other
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countries allow DTCA. DTCA was introduced in the US in 1997. The Federal Drug Administration (FDA) relaxed its regulations on specific product/brand promotion and as such opened the floodgates to a billion dollar market (Wilke, 1998, p. 2). In New Zealand DTC advertising has been legal since 1981. The main criticism of DTCA is that it interferes with the doctor–patient relationship. If patients can get their information about prescription drugs, and illnesses, from the media, they might self-diagnose. This has proven to be true in the US where it has been found that women, in particular, ask their doctor for a particular brand of drug. Eighty-five percent of them leave the doctor’s office with this drug (O’Meara, 2001, p. 10). A study in New Zealand found that of the 1600 GPs who participated in the study, 90% said they had consultations generated by advertising, and 68% felt consultations were often unnecessary. More than 40% said they had either started patients on advertised drugs or switched drugs at their patients’ request even though they felt such drugs offered little new benefit (Gamble, 2003). Given the nature of advertising, some also believe that the emotive persuasion used in the marketing may not be backed by clear empirical evidence; and also that advertising increases the cost of drugs (Eagle & Kitchen, 2002, p. 294). DTCA of antidepressants Feminists have previously researched the advertising of psychotropic drugs. Two studies in particular have found that advertising of psychiatric drugs, in medical journals, overwhelmingly focus on women (Hansen & Osborne, 1995; Lo¨vdahl, Riska, & Riska, 1999). The Swedish study, headed by Ulrica Lo¨vdahl, concluded that . . . advertisements for antidepressants in medical journals currently construct depression as a female symptomatology, as was the case with advertisements for tranquillizers in the 1970s. This trend in drug advertising also revives the tendency towards biologicalization and overmedication of women’s symptoms of mental distress (Lo¨vdahl et al., 1999, p. 27). An in-depth academic study DTCA of antidepressants and the focus on women is yet to be conducted.
Internet DTCA The most recent debates on DTCA have been centered on the use of the internet by pharmaceutical companies. Since there are no formal regulations on DTC marketing via websites, pharmaceutical companies are embracing new technologies as a means to promote their products (Eagle & Kitchen, 2002, p. 293). A study conducted in 1999 on consumers in Sweden–a country without direct-to-consumer advertising–looked at how these consumers used a pharmaceutical company’s website. Although the small sample number of websites studied limits the results, the study found that: Pharmaceutical Web sites perform a variety of important functions, particularly in countries where there is no legal DTCA [direct to consumer advertising]. In developed societies where educated consumers are taking charge of their own health care and leveling the balance of power between physician and patient, the pharmaceutical site can be a primary destination for patients seeking information about diseases, diagnoses and medications (Maddox, 1999, p. 495). Given the growing influence and importance of DTC advertising via websites, I decided to conduct research into the marketing of psychiatric drugs via the internet.
Website design The designs of all the websites I investigated look very similar. The sites appeared to be professionally designed and were easy to navigate. The major links on each page are mostly associated with an billnessQ such as Generalised Anxiety Disorder (GAD) and Post Traumatic Stress Disorders (PTSD). When clicking on the link, a sub-menu usually opens where the web user can find out more about the particular billnessQ, including quizzes that can tell you if you may have the bdisorderQ. The colours most frequently used on the sites are a variety of hues of blue and yellow, with green also prominent on the Effexor XR and Zoloft sites. Studies of the use of these colours in marketing and advertising claim that the colour blue suggests security and
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authority and yellow conveys feelings of happiness and warmth. Green is used to convey health and healing (Garber & Hyatt, 2003, p. 313). Next I examined the meta tags used in the sites. This can be done by viewing the html sources of each site. Meta tags are keywords that web users enter into a search engine. The kinds of meta tags used can be an indication of what sort of people the website creators want to attract to their site (Raeder, 1997, p. 67). There have been criticisms of the way in which meta tags have been used, for example, on pornography sites. Pornographers use words that children may look up, such as singer bBritney SpearsQ. They have even been known to misspell words, as a child might, to attract younger viewers, i.e. bBrittanie SpheresQ. The kinds of meta tags, used on the drug websites I studied, are fairly similar. All web creators used the mental bdisorderQ labels that the drugs are approved for as key words, such as Generalised Anxiety Disorder, anxiety and depression. The names of the drug are always used, with Effexor XR, Paxil and Zoloft also including possible misspellings such as Efexor, paxel and zolof. The symptoms of the billnessesQ are included in most meta tags with words such as worry, trembling, chest pain, sorrow and despair. The Zoloft site also includes tags labelling events that may have caused trauma such as domestic violence, physical attack, child abuse, sexual abuse and rape. Each site displays similar images of women, except for the Zoloft site that uses cartoon images of pill shaped characters. The vast majority of these images are of women looking either happy or sad. Men are also used in some of the images, but mainly in the same pictures as the women, looking like they were enjoying life with their partners. Women are usually white, young to middle aged, and look affluent. There are some images of Asian, African-American and Hispanic women. None of the images are of lesbian couples, and all women look stereotypically heterosexual (usually long hair and make-up). User interaction One of the key differences between website marketing and other forms of advertising is the ability to interact with consumers. All of the websites have features that encourage users to participate in the site. The most common features are mental billnessQ
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quizzes. The web user can fill in a short quiz, which will indicate if s/he has certain mental disorders. For example, on the Zoloft website I filled in the quiz for depression. The introduction to the quiz states: If you think you may be suffering from the symptoms of depression, this Self-Quiz can help you discuss your concerns with your doctor. Just print this page, answer the questions to the best of your ability, and take the completed Self-Quiz to an appointment with a doctor or other qualified healthcare professional. Your answers can help your doctor determine if you have symptoms of depression. An example of one of the questions asked is whether you are bfeeling tired or having little energyQ. You have the option of selecting answers on a scale of bNot at all, Several days, More than half the days, Nearly every dayQ. After filling in the quiz a response is returned suggesting that if the person filling in the quiz had checked bseveral daysQ or more for questions 1 or 2 and some of the other problems, s/he print out the results and take them to her/his doctor. The print out clearly shows the name of the drug so that the doctor can be helpfully informed about what kind of drug you could be prescribed.
Mental billnessesQ and their prevalence in women All the bdisordersQ described on the websites are classified as bneuroticQ conditions. McLellan (1995 p. 34) lists these conditions as including depression, anxiety, eating disorders, low self-esteem and selfhatred. These bdisordersQ differ from the other main class of mental billnessesQ known as bpsychoticQ conditions, and are sometimes defined as bnon-psychotic mental disordersQ.9 What mainly differentiates these conditions is the cause of the billnessesQ—bpsychoticQ conditions are seen to have a biological cause, whereas bneuroticQ type conditions are seen as more emotionally based (McLellan, 1995). However these differences are no longer so clear, as it is currently widely believed that all bdisordersQ result from a chemical imbalance. The websites I studied focused on the following billnessesQ; depression, panic disorder, social anxiety disorder, obsessive compulsive disorder, generalised
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anxiety disorder, post traumatic stress disorder and bulimia. The descriptions of the bdisordersQ varied slightly from site to site, with most focusing little on the possible social reasons for mental distress and instead basing their information on biological models. Some gave very little information at all about the bdisorderQ, such as the Prozac site, and focused mainly on how the drug can help alleviate the billnessQ. Each of the billnessesQ on the sites are believed to be more common in women. Using the information provided on the sites and from recent studies on mental billnessQ in women I will now give a very brief overview of the prevalence of the following billnessesQ in women. Each of the billnessQ on the sites are believed to be more common in women. International studies have consistently shown that depression is twice as prevalent in women than in men (Kornstein & Wojcik, 2002, p. 147). The Effexor XR site states that nearly twice as many women (6.5%) as men (3.3%) suffer from depression each year. On the Paxil website it is mentioned that 25% of women suffer from depression serious enough to seek treatment at least once in their lifetime, versus only 0.9% of men (Pigott, 2002, p. 195). Social Anxiety Disorder (SAD) is believed to be one of the third most common mental bdisordersQ in the US and is diagnosed in 16.4% of women as compared to 11.2% of men (Pigott, 2002, p. 195). The Zoloft and Paxil websites both state that Obsessive Compulsive Disorder (OCD) is equally as common in men and women, but I have found studies which have shown that it is slightly more prevalent in women, 3.1% in women compared to 2.0% in men (Pigott, 2002, p. 195). Women are much more likely to be diagnosed with Generalised Anxiety Disorder (GAD). Research has shown that around 7.7% of women will suffer from GAD compared to 2.9% of men (Pigott, 2002, p. 195). Post Traumatic Stress Disorder is said to occur twice as frequently in women compared with men. An explanation as to why it is more prevalent in women is provided on the Zoloft site. It is stated that . . . doctors believe that women may have a higher prevalence of PTSD because the types of traumatic events that they experience are more likely to be associated with personal violence (such as rape and sexual molestation) than the events that men usually report. Also, the types of traumatic events that women
experience often tend to happen repeatedly, especially in childhood. Eighty percent of people diagnosed with Bulimia are women (hhtp://www.prozac.com).
Disclosure of adverse effects and information about drug withdrawal Each of the sites I examined disclosed adverse effects that may occur when taking their drug. Most websites state that adverse effects are not common, and that most people do not need to stop taking the drug because of negative reactions. Only two of the sites, Paxil and Xanax, mention withdrawal effects or so-called breboundingQ effects. The Effexor XR site contains a somewhat vague caution about bdiscontinuation symptomsQ. Adverse effects Each site is careful to include the basic information about adverse effects their drugs may cause. The websites for all five drugs also emphasise that the adverse effects are minimal compared to the benefits of the drugs. The Prozac site makes great efforts to prove that their drug is safe. The web authors begin by giving the following information: Some people experience mild side effects like nausea, difficulty sleeping, drowsiness, anxiety, nervousness, weakness, loss of appetite, tremors, dry mouth, sweating, decreased sex drive, impotence, or yawning. These tend to go away within a few weeks of starting treatment and, in most cases, aren’t serious enough to cause people to stop taking Prozac. The text continues with claims that due to its popularity and its continued prescription around the world, Prozac must be safe: Today, Prozac is one of the world’s most widely prescribed antidepressants, having been prescribed for more than 40 million people in more than 90 countries, including more than 22 million people in the United States. For more than 14 years, the safety and effectiveness of Prozac continue to be demonstrated worldwide
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through scores of clinical studies and patient success stories. . .The safety and effectiveness of Prozac have been thoroughly studied in clinical trials with more than 11,000 patients. There have been more than 3500 publications on Prozac in medical/scientific journals. The Zoloft site follows a similar pattern. Adverse effects are mentioned, but they are portrayed as being minimal and rare. For example: Some people taking Zoloft may have side effects. The most common side effects include upset stomach, having trouble sleeping, diarrhea, dry mouth, sexual side effects, feeling unusually sleepy or tired, tremor, indigestion, increase of sweating, feeling agitated, and decreased appetite. In clinical studies with Zoloft, few patients were bothered enough by side effects to stop taking their medicine. Tell your doctor about any side effects you may be experiencing. Your doctor may be able to adjust your treatment plan to help you feel better. The Xanax site, while more forthcoming about some adverse effects, nevertheless still minimises the harm that can be caused by taking Xanax: Side effects, if they occur, are generally observed at the beginning of therapy and usually disappear upon continued use. The most commonly reported side effects in clinical trials were drowsiness, fatigue, impaired coordination, irritability, light-headedness, memory impairment, insomnia, and headache. The web authors continue by giving information about the serious effects that can occur when a person takes more than 4 mg a day: At doses greater than 4 mg per day, XANAX has the potential to cause severe emotional and physical dependence in some patients and these individuals may find it exceedingly difficult to terminate treatment. Similar to the other sites, the Paxil website is cautious about overstating adverse effects. When examining the list of adverse effects, however, it seems they can be quite serious, such as injury and infection (what kind of injury or infection is not stated). As serious as these adverse effects are, even more severe effects may occur when people actually try to stop taking these drugs.
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Withdrawal effects The Paxil and Xanax sites are the most explicit in detailing the withdrawal effects people may experience when discontinuing drug btreatmentQ. The Effexor XR site does mention ddiscontinuation symptomsT but there are no details as to what these bsymptomsQ are. The Paxil site gives some information in its Q&A (question and answer) section. Under the question bWhat do I need to know about stopping Paxil?Q the answer is: Don’t stop taking Paxil before talking to your doctor since symptoms may result from stopping the medication or from your original condition. Some patients experience the following symptoms on stopping Paxil (particularly when abrupt): dizziness, sensory disturbances (including electric shock sensations), abnormal dreams, agitation, anxiety, nausea and sweating. The difficulties of withdrawal from Paxil have been documented recently, with a law suit currently being filed in the US against Paxil manufactures GlaxoSmithKline for downplaying the seriousness of the withdrawal effects,10 and it is my belief that the information on the Paxil website diminishes the seriousness of discontinuing the drug Paxil. The Xanax site is more forthcoming with information about serious adverse effects that can be caused by withdrawing from the drug. Xanax is a benzodiazepine, which is a class of drugs that have been criticised especially regarding extreme withdrawal effects. The site gives the following information: When taking a benzodiazepine like XANAX, the individual should also be aware of the possibility of brebound anxietyQ (also, sometimes called btransient rebound anxietyQ) when discontinuing therapy. Rebound anxiety is a temporary condition whereby the symptoms that led to treatment return upon discontinuation of the medication. It may be accompanied by other reactions including mood changes, anxiety or sleep disturbances, and restlessness. Since the risk of discontinuation symptoms and rebound effects is greater after abrupt discontinuation of treatment, most physicians usually prescribe a gradual tapering of dosage. Given the seriousness of adverse effects and withdrawal, it does seem extraordinary that these drugs are
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readily prescribed to women. The next section will provide a brief analysis of the information I gained through researching the antidepressant websites.
Discussion In order to discover if internet marketing was indeed a factor in high numbers of women using antidepressants, I investigated whether the sites focused on women. I explored, in particular, whether the pharmaceutical companies are marketing their drugs to women who are already diagnosed as mentally billQ and are taking antidepressants, or are also attempting to market their products to women who are not (yet) currently taking drugs. I reasoned that while the first strategy would not increase the number of women taking antidepressants (although some might decide to change brands), the second strategy would create new markets and hence further increase the number of women on antidepressants. There were several other reasons why I wanted to look at antidepressant web marketing, such as examining if the sites are upfront about the adverse effects that their advertised drugs cause, and also, if the pharmaceutical companies are circumventing direct to consumer adverting (DTCA) laws by advertising globally on the internet. In order to determine if the sites are attempting to market to women, in particular to women who are not currently taking antidepressants, I looked at several aspects of the sites. I conclude that there are numerous indicators that the websites are indeed focusing on women. The images on the sites consist mainly of females, with the Paxil site featuring (at the time of this study, May to August 2003) over twice the number of women in its images. Having more images of women could be a technique to allow a woman web reader to identify with the mentally billQ women on the site, perhaps enabling her to see herself in these images. I was also interested in the meta tags on the sites as these are website tools that are a key factor in how people search for sites. The majority of terms that I found are related more to the general symptoms of the billnessQ than the names of the drugs. This seems to signify that the drug companies are hoping that people searching the internet for mental illness information
will be directed to their site. One extreme example of this might be a woman looking in a search engine for sexual abuse resources. The Zoloft meta tags included terms such as brapeQ and bsexual abuseQ, meaning that a woman could find herself on the Zoloft website in her search for information about sexual assault—surely not the best resource to access after the trauma of rape. I would also argue that the ways in which the sites are disguised as mental billnessQ resources, rather than as advertisements, is very misleading. The clearest example of this is the Xanax site which is entitled banxietyinfo.comQ and can also be found using the URL bhttp://www.anxietyinfo.comQ. The quiz sections of the sites were particularly illuminating. While there are cautions not to treat the mental billnessQ quizzes as a diagnostic tool, the fact that each site suggests that the web user print out their results and take it to their doctor seems to be further evidence of these companies’ aim to convince people, particularly women, that they are ill and need drugs. The symptoms of most of the bdisordersQ on the sites, such as Generalised Anxiety Disorder (GAD), are so vague and general–for example unsatisfying sleep–that almost any person, at any given time, could be diagnosed with GAD. DTCA has been shown to influence women when they are asking their doctors for particular brands of drugs (O’Meara, 2001, p. 10). Doctors have also reported that due to the influence of DTCA they sometimes prescribed patients with advertised drugs that they believed offered little new benefit. They did so acting on the patients’ direct requests (New Zealand Herald, 2003, p. 15). Considering these facts as well as my own research findings, website marketing of antidepressants can appear to be designed to convince women to switch brands of drugs and also to persuade women not (yet) on medication that they are mentally billQ and therefore need drugs. The bsideQ effects of the antidepressants studied are outlined on each of the sites, but in my view the seriousness of the adverse effects is minimised by comments claiming that it is rare for users to suffer any ill effects. The lack of information on the dangers of withdrawing from some of these drugs is to be deplaned. I do see the sense in such an omission though, as pharmaceutical companies may not want potential consumers to know how hard it is to withdraw from their drugs.
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Of note is also the very fact that I was able to access these sites while living in a country where DTCA is illegal. While some of the sites did have a note that they were designed for US, there was no real preventative measure from allowing me to view the websites. While I am unsure of what can be done to stop non-US residents from viewing these sites, it is clear that these websites now can be used by anyone with internet access, in any country, as source of information on psychotropic drugs.
to help ease mental distress, and that pharmaceutical companies should not be seen as a primary resource for mental health information.
Conclusion
Endnotes
The question as to why women are prescribed psychotropic drugs at a greater rate than men cannot be answered simply. My brief study on website marketing of antidepressants has barely scratched the surface as to the reasons why so many women are taking antidepressants. I suggest that more extensive research needs to be conducted on the topic of psychiatric drugs and women. In-depth interviews with women who have been prescribed drugs could be one method. Discovering the reasoning behind why women were prescribed the drugs in the first place, why they decided to take them and what motivated them to stop taking the drugs (if they did), would be very useful. It could also be important to look at other ways in which drug companies are marketing their drugs to women, to examine not only the direct advertising but also the influence pharmaceutical companies exert on doctors. Particular emphasis could be placed on looking at young women and examining the problems that lead to their medicalisation via antidepressants.11 Further studies could also scrutinise the marketing of psychiatric drugs to women in majority world countries by pharmaceutical companies. To conclude, I believe that the findings of my research have uncovered yet another layer of the medicalisation of women. Instead of acknowledging, for example, the impact that abuse can have on women’s mental health, biopsychiatry theorises that it is women’s biology that is at the root of mental billnessQ. The antidepressant industry then capitalises on this ideology, focusing their marketing on women with the result that profit arises from women’s mental anguish. I suggest that women need to be given unbiased information about all the options available
Acknowledgements I would like to thank Renate Klein for her insightful editing and thoughtful comments on this article. Thanks also to Kent Karlsson for the title of the piece.
1
With the latest Australian Government’s Women’s Health and Wellbeing study showing that depression is the leading cause of bdisabilityQ in women, it can be expected that this area is bound to grow (Victorian Department of Human Services, 2002). The World Health Organization (2001) estimated that by 2020 depression will be the highest-ranking cause of burden of disease in the developed world. 2 See Kornstein and Wojcik (2002, p. 147). 3 See Jean Kilbourne’s (1999) Deadly Persuasion: Why Women and Girls Must Fight the Addictive Power of Advertising, for more information. 4 These sites were analysed between May 2003 and August 2003. 5 McDonalds advertisement aired on TV3, November 2002 in Sweden. 6 For comprehensive information on adverse effects of antidepressants see Healy (2004). Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression. New York: New York University Press; Glenmullen (2001). Prozac Backlash: Overcoming the Dangers of Prozac, Zoloft, Paxil, and Other Antidepressants with Safe, Effective Alternatives. New York: Simon & Schuster; Breggin and Ross-Breggin (1994). Talking Back to Prozac. New York: St. Martin’s Press. 7 Site can be found at http://www.depressionadvice.com.au. 8 Site can be found at http://www.yestolife.com.au. 9 Astbury (1999) makes mention that non-psychotic mental disorders are also known as common mental disorders (CMD) because of their high incident rate (p. 5). 10 See The Salt Lake Tribune, b30 Utahns Sue Maker of Antidepressant PaxilQ, June 4, 2004. 11 At the time of writing (2004), I am engaged in PhD research examining young women and their experiences of antidepressants.
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