# Lentis/Mental Health as a Pharmacological Growth Market
## Direct-to-Consumer Pharmaceutical Advertising

The average American watches nine pharmaceutical commercials per day for a total of sixteen hours worth of drug advertisements each year. These commercials, and all other attempts to market pharmaceuticals directly to a customer, are examples of direct-to-consumer pharmaceutical advertising (DTCPA). DTCPA is illegal in every "developed nation" except Canada, the United States, and New Zealand. In Canada, DTCPA can include either the product's name or its intended use, but not both. DTCPA in the United States and New Zealand can include both of these pieces of information.
The most common example of direct-to-consumer advertising is the "product claim ad", which makes specific claims about a product's indication, safety, and efficacy. In the United States, product claim advertisements are subject to regulations defined by the Food and Drug Administration's (FDA) Division of Drug Marketing, Advertising, and Communications (DDMAC). Regulations written by DDMAC require that product-claim ads include a "major statement" on the drug's most important risks and either a "brief summary" of the drug's prescribing information or "adequate provision" of such information. When they write their "major statement" and "brief summary", pharmaceutical companies are "encouraged to use language [that] consumers can easily understand". Product claim ads must also give a "fair balance" of information about a drug's risks and benefits.

### Arguments Against DTCPA

Critics of DTCPA argue that FDA regulations are too vague to adequately protect the consumer and cite "content analysis studies [that] have found that most DTC ads emphasize drug benefits over risks". Critics also blame DTCPA for creating unrealistic expectations of drug performance and for "contributing to the 'medicalization' of natural conditions, cosmetic issues, or trivial ailments, resulting in an overmedicated society".

### Arguments in Favor of DTCPA

Proponents of DTC advertising claim that it "reduces underdiagnosis and undertreatment of conditions". A study administered by Harvard University and Massachusetts General Hospital found that "25% of patients who visited their doctor after seeing DTCPA received a new diagnosis." Most importantly, advocates contend that DTCPA "educates patients and allows them to take charge of their health".

### Potential Ban on DTCPA

A ban on DTC advertising is unlikely, regardless of how the risks compare to the benefits. The Central Hudson test, which is used to determine "whether a ban on commercial speech is permissible," examines whether an advertisement is misleading, whether a ban would promote a "substantial government interest", and whether the government's interest could be promoted through some other means. Because the Central Hudson test has been used to overturn bans on alcohol, tobacco, and prescription advertisements, legal scholars expect that a ban on DTCPA would be declared unconstitutional.

## Attention-Deficit Disorder
#### Origin

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder most commonly diagnosed in children. Symptoms of ADHD include hyperactivity, impulsivity, difficultly focusing, and forgetfulness. These symptoms can be intensified by a person’s surroundings, such as a hectic home-life or a strict classroom. ADHD is diagnosed as either inattentive type, hyperactive/impulsive type, or a combined type. Similar to many other psychiatric illnesses, there is no conclusive way of testing for ADHD. Instead, it is diagnosed based on a symptom checklist. According to the American Psychiatric Association, ADHD only affects 5% of children, but 15% of children are diagnosed.

#### Pharmaceutical Market Expansion

According to a New York Times article published by Alan Schwarz, the number of children on ADHD medication has increased from 600,000 in 1990 to 3.5 million in 2013. This statistic suggests that ADHD has reached epidemic levels. According to Dr. Keith Connors, a psychologist and professor at Duke University, the increase in ADHD diagnoses is “a concoction to justify the giving out of medication at unprecedented and unjustifiable levels”. The surge in prescribed ADHD medication appears to have resulted from a 20 year campaign by pharmaceutical companies to publicize the mental disorder to doctors, educators, and parents.
In their advertising campaigns, pharmaceutical companies have exploited the qualitative nature of ADHD symptoms. Drug companies have expanded the image of ADHD to include relatively normal behavior like carelessness and impatience, and have even overstated the benefits of their medication. Since 2000, the FDA has cited major ADHD drug manufacturers including Shire Pharmaceutical (Adderall, Intuniv) and Janssen Pharmaceuticals (Concerta) for false advertising. The 2005 People magazine cover featured an advertisement for Adderall XR by Shire Pharmaceutical. The ad showed a mom hugging her son and had the caption, "grades that finally match his intelligence". This advertisement appealed to a mother's desire to have successful children.

#### Advertising to Parents

Pharmaceutical advertisements for ADHD drugs are typically targeted at parents, especially mothers, rather than the patients (children). This is because mothers are seen as impressionable consumers. According to Alan Schwarz, the author of ADHD Nation: Children, Doctors, Big Pharma, “Adderall suddenly wasn’t a medicine just for an ADHD child. It was for his mother, too, to make her child less of a pain, to improve her parental satisfaction of a job well done”. Similar advertisements leverage common values of parents, such having successful and competitive children. Pharmaceutical companies strategically market their ADHD products by exploiting social norms regarding parenting in the United States. Not only is it socially acceptable for parents to discuss their children's success, it is expected.
The direct-to-consumer advertisements from pharmaceutical companies not only cliam that their drugs will ameliorate ADHD symptoms, but they explicitly state that they will also improve personal skills. For example, Eli Lilly and Company released an ad for their ADHD medication, Strattera, that asked, “‘What can a child with ADHD gain? Control and Confidence’”. These advertisements also promise parents peace of mind if they medicate their children with these drugs. A 2003 Concerta ad promised that ADHD medication brought the “comfort of undeniable safety”.

#### Advertising to Physicians

Once parents are convinced that ADHD medication will improve their child's behavior and their parental satisfaction, they need a physician to prescribe the drug. Because of this, pharmaceutical companies attempt to gain physicians’ acceptance. They do this by claiming that ADHD medication can both help children avoid accidents and allow them "to experience life’s successes every day”. An ad for Strattera that was targeted at doctors shows a child about to skateboard into the street and asks “When could ADHD symptoms affect your patients?”. This ad shows that there is a thin line between treating those affected with ADHD and tempting healthy individuals. Since ADHD medications are stimulants that boost concentration and focus, it can be used less as a medicine and more as a performance-enhancing drug.

## Depression
#### Origin

Depression is a mental illness defined by feelings of sadness or dejection, often accompanied by a loss of interest in activities that were once enjoyed. Types of depression include psychotic depression, antenatal and postnatal depression, and melancholia. Humans have had a long and arduous relationship with the many forms of this illness. Ancient Romans would beat and shackle the afflicted, while Renaissance Christians would burn and drown the mentally ill to rid them of their “demons”.

#### Pharmaceutical Market Expansion

Biomedical depression treatment began in the 1950's with iproniazid and isoniazid. Though these drugs were originally used to treat tuberculosis at Sea View Hospital, they began to be used as an antidepressant when doctors noticed that they improved their patients' mood. Iproniazid grew in sales until the 1960's when it was recalled for toxicity. Since then, many other antidepressants have been developed that have altered the ways in which care is administered to psychiatric patients.
The first antidepressant to be widely accessible in the United States was Fluoxetine, or Prozac, manufactured by Eli Lilly and Company. This drug was approved for commercial use by the FDA in 1988. Before Prozac, antidepressants and other treatment such as electro-compulsive therapy were available only in psychiatric clinics. For this reason, Eli Lilly and Company funded large advertising campaigns to promote the idea that Prozac was non-toxic and could be used by anyone. The campaign was so successful that in its first five years of availability, Prozac instigated a 50% increase in antidepressant usage. By 1994, the drug was earning Eli Lilly and Company $1.2 billion a year worldwide. By 2011, antidepressants were second in prescription drug sales and accounted for an $11.9 billion industry.

#### Advertising to Women

Pharmaceutical companies have used DTC advertising to increase antidepressant sales by appealing to people, especially women, and their insecurities. It is possible that advertisements target women because, according to the MayoClinic, “women are nearly twice as likely as men to be diagnosed with depression”. This is due to complex hormonal changes, such as those associated with the menstrual cycle, pregnancy, and menopause, along with life experiences and inherited traits. Postpartum depression, for example, is described by feelings of sadness or anxiety after giving birth, and occurs in about 10 to 15% of women.
Antidepressant advertisements, such as Eli Lilly and Company's ad for Cymbalta,, frequently feature women that have overcome depression to enjoy their daily life. The Cymbalta print advertisement in particular highlights the smiling, happy face of a mother who is enjoying a tea party in a sunny field with her husband, daughter, and son. Magazines and television feature similar advertisements for Prozac, Pristiq, and Abilify. Pristiq commercials in particular show women with their “wind-up toy counterparts” to symbolize how depressed women “lose their willpower throughout the day”. In addition to promising increased happiness and confidence, antidepressant advertisements assure women that the drug will improve their ability to be a good mother or wife.
According to America’s State of Mind Report by MedCo Solutions, women are more likely than men to use antidepressants in every age bracket. Epidemiological studies by the Indian Journal of Psychiatry also indicate that excess antidepressant use occurs most commonly “among married women aged 25–45, with children”. This could illustrate the success of women-focused antidepressant advertising, but it could also indicate that women are more likely to suffer from depression, or to seek help for depression-like symptoms. Ultimately, it is probable that DTC advertisements are on cause of the epidemic-level rise in depression diagnoses since the release of Prozac in 1988.

## Conclusions and Future Work

Direct-to-consumer pharmaceutical advertising has caused the number of prescriptions for mental health drugs to increase dramatically. Pharmaceutical companies have successfully marketed their products by targeting the members of particular interest groups and appealing to their insecurities. Although pharmaceutical companies do this to ensure that their drug is available to people that need it, they sometimes overemphasize the benefits of their product for the purpose of making money. Future work should examine how pharmaceutical advertisements encourage teachers to monitor their students' mental health. It should also analyze whether medications for mental health disorders are less prevalent in countries where DTCPA is illegal. Finally, researchers can consider how pharmaceutical advertisements have changed over time and how these advertisements have shaped the public's view of mental health illnesses.

## References

* ↑ US FDA. (n.d.). Keeping Watch Over Direct-to-Consumer Ads [WebContent]. https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm107170.htm
* 1 2 3 4 5 6 7 8 Ventola, C. L. (2011). Direct-to-Consumer Pharmaceutical Advertising. Pharmacy and Therapeutics, 36(10), 669–684.
* 1 2 US FDA. (n.d.). Drug Advertising: A Glossary of Terms [WebContent]. https://www.fda.gov/Drugs/ResourcesForYou/Consumers/PrescriptionDrugAdvertising/ucm072025.htm#brief_summary
* 1 2 3 4 What is ADHD?" (2017). American Psychiatric Association.https://www.psychiatry.org/patients-families/adhd/what-is-adhd
* ↑ Attention-Deficit / Hyperactivity Disorder (ADHD). (2017, August 31). https://www.cdc.gov/ncbddd/adhd/diagnosis.html
* 1 2 3 4 5 6 7 8 Schwartz, A. (2016). ADHD Nation: Children, Doctors, Big Pharma, and the making of an American Epidemic.
* 1 2 3 4 Schwartz, A. (2013).The Selling of Attention Deficit Disorder. The New York Times.
* ↑ Beyond Blue Ltd. (2016). Types of Depression [WebContent]. https://www.beyondblue.org.au/the-facts/depression/types-of-depression.
* ↑ Nemade, M., Reiss, N.S., Dombeck, M. (2007, September 19). Historical Understandings of Depression. https://www.mentalhelp.net/articles/historical-understandings-of-depression/.
* ↑ Selikoff I.J., Robitzek E.H. (1952). Tuberculosis Chemotherapy with Hydrazine Derivatives of Isonicotinic Acid. Chest. 21 (4): 385–438.
* 1 2 Das, A. (2011, March). Pharmaceutical Industry and the market: The case of Prozac and other antidepressants. Asian Journal of Psychiatry, Volume 4.
* ↑ Newsweek. (1994, February 7). The Culture of Prozac. http://www.newsweek.com/id/113121.
* 1 2 Li, C. (2014, October 22). The Effects of Direct-to-consumer Antidepressant Advertising on Young Adults. Northeastern's Undergraduate Writing Program Journal.
* 1 2 MayoClinic. (2017). Depression in Women: Understanding the Gender Gap. https://www.mayoclinic.org/diseases-conditions/depression/in-depth/depression/art-20047725
* 1 2 Eli Lilly and Company. (n.d.) Cymbalta. http://www.herbmuseum.ca/files/images/v-cymbalta-ad1.jpg.
* ↑ MedCo Health Solutions, Inc. (n.d.). America’s State of Mind Report. http://apps.who.int/medicinedocs/documents/s19032en/s19032en.pdf
* ↑ Rao, T.S., Asha, M.R., Ramesh, B.N., Rao, K.S. (2008 April). Understand Nutrition, Depression, and Mental Illness. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738337/