CoachBri’s Blog

Editor’s note: Dr. Carl Elliott, an M.D. and Ph.D., is the author of “White Coat, Black Hat: Adventures on the Dark Side of Medicine” (Beacon Press, 2010).

(CNN) — If you want to understand the way prescription drugs are marketed today, have a look at the 1928 book, “Propaganda,” by Edward Bernays, the father of public relations in America.

For Bernays, the public relations business was less about selling things than about creating the conditions for things to sell themselves. When Bernays was working as a salesman for Mozart pianos, for example, he did not simply place advertisements for pianos in newspapers. That would have been too obvious.

Instead, Bernays persuaded reporters to write about a new trend: Sophisticated people were putting aside a special room in the home for playing music. Once a person had a music room, Bernays believed, he would naturally think of buying a piano. As Bernays wrote, “It will come to him as his own idea.”

Just as Bernays sold pianos by selling the music room, pharmaceutical marketers now sell drugs by selling the diseases that they treat. The buzzword is “disease branding.”

To brand a disease is to shape its public perception in order to make it more palatable to potential patients. Panic disorder, reflux disease, erectile dysfunction, restless legs syndrome, bipolar disorder, overactive bladder, ADHD, premenstrual dysphoric disorder, even clinical depression: All these conditions were once regarded as rare until a marketing campaign transformed the brand.

Once a branded disease has achieved a degree of cultural legitimacy, there is no need to convince anyone that a drug to treat it is necessary. It will come to him as his own idea.

Disease branding works especially well for two kinds of conditions. The first is the shameful condition that can be destigmatized. For instance, when Pharmacia launched Detrol in the late 1990s, the condition the drug treated was known to doctors as “urge incontinence.” Patients called it “accidentally peeing in my pants” and were embarrassed to bring it up with their physicians.

Pharmacia fixed the problem by rebranding the condition as “overactive bladder.” Whereas “incontinence” suggested weakness and was associated mainly with elderly women, the phrase “overactive bladder” evoked a supercharged organ frantically working overtime.

To qualify for a diagnosis of “overactive bladder,” patients did not actually have to lose bladder control.” They simply needed to go to the bathroom a lot.

The vice president of Pharmacia, Neil Wolf, explained the branding strategy in a 2002 presentation called “Positioning Detrol: Creating a Disease.” By creating the disease of “overactive bladder,” Wolf claimed, Pharmacia created a market of 21 million potential patients.

Another good candidate for branding is a condition that can be plausibly portrayed as under-diagnosed. Branding such a condition assures potential patients that they are part of a large and credible community of sufferers. For example, in 1999, the FDA approved the antidepressant Paxil for the treatment of “social anxiety disorder,” a condition previously known as “shyness.”

In order to convince shy people they had social anxiety disorder, GlaxoSmithKline, the maker of Paxil, hired a PR firm called Cohn and Wolfe. Cohn and Wolfe put together a public awareness campaign called “Imagine being allergic to people,” which was allegedly sponsored by a group called the “Social Anxiety Disorders Coalition.”

GlaxoSmithKline also recruited celebrities like Ricky Williams, the NFL running back, and paid them to give interviews to the press about their own social anxiety disorder. Finally, they hired academic psychiatrists working on social anxiety disorder and sent them out on the lecture circuit in the top 25 media markets.

The results were remarkable. In the two years before Paxil was approved for social anxiety, there were only about 50 references to social anxiety disorder in the press. But in 1999, during the PR campaign, there were over a billion references.

Within two years Paxil had become the seventh most profitable drug in America, and Cohn and Wolfe had picked up an award for the best PR campaign of 1999. Today, social anxiety disorder, far from being rare, is often described as the third most common mental illness in the world.

It is hard to brand a disease without the help of physicians, of course. So drug companies typically recruit academic “thought leaders” to write and speak about any new conditions they are trying to introduce. It also helps if the physicians believe the branded condition is dangerous.

When AstraZeneca introduced Prilosec (and later Nexium) for heartburn, for example, it famously repositioned heartburn as “gastroesophageal reflux disease,” or GERD. But it also commissioned research to demonstrate the devastating consequences of failing to treat it.

If all drugs were harmless, disease branding would be relatively harmless, too. But no drug is completely benign.

For example, Detrol can make elderly people delirious and may cause memory problems. Paxil is associated with sexual dysfunction and dependence. It also carries a black-box warning for suicide in children and adolescents. Side effects like these are a part of every drug. But they are never part of the brand.

The opinions expressed in this commentary are solely those of Carl Elliott.

from http://cnews.canoe.ca/CNEWS/Canada/2010/06/10/pf-14356871.html

June 11, 2010

At graduation, Sara Carlin was a straight-A student who dreamed of becoming a doctor. (Photo courtesy the Carlin family)

Sara Carlin had everything to live for: She was smart, athletic, beautiful and pursuing her dream of becoming a doctor.

But on May 6, 2007, that bright future ended abruptly with a piece of electrical wire.

The promising 18-year-old had hung herself in her family’s Oakville basement and her grieving parents blame her suicide on the Paxil antidepressant she’d been prescribed more than a year before.

In emotional testimony that left many fighting back tears, Sara’s mother Rhonda told a coroner’s inquest that her daughter earned 90’s in school, played baseball and women’s hockey, held a part-time job at an optometrist’s office and tutored other kids in math.

“She was a pretty exceptional girl, she was absolutely loving and she was beautiful,” her mom proudly recalled Wednesday before the presiding coroner, Dr. Bert Lauwers. “She really was an exceptional daughter.”

But in the early part of 2006, Sara began to change. During the family’s March break vacation to Palm Springs, she wouldn’t get out of bed most days and got drunk at dinner. “It was so unlike her,” her mom said.

It was only later that she learned Sara had complained of anxiety and depression to her family doctor and had recently been prescribed Paxil, one of the antidepressants known as selective serotonin reuptake inhibitors (SSRIs).

“I said, ‘Why on earth, Sara would you be on antidepressants?’ I was astounded,” she recalled for the five-member jury. “Why, why would he be giving these to her? This was a wonderful, happy girl.”

While Sara lost her much older brother to a drug overdose in 2000, her mother believed her daughter had coped well with his death and never wanted the counselling she’d been offered.

So this need for antidepressants, she said, came out of the blue.

“She was very troubled, much more troubled than any of us knew,” her mother acknowledged.

While her parents repeatedly voiced their reservations about Paxil, Sara brushed them off, saying her doctor told her it would make her feel better. “I didn’t even know the horrific side effects of Paxil at that time,” her mom said. “I certainly didn’t know what I know now.”

Health Canada issued warnings in 2003 and 2004 that prescribing antidepressants to teens could lead to behavioural or emotional changes that might put them at increased risk of suicidal behaviour.

Over the next few months, Sara’s behaviour changed even more. She suddenly quit her job and stopped playing hockey. Her mom said she was unaware Sara was drinking and doing cocaine; she just knew she wasn’t herself.

“She was really lethargic and tired and pale. She’d lost weight. We were concerned. “

Just as she was starting her first year in health sciences at the University of Western Ontario, Sara was diagnosed with mononeucleosis. Her parents were almost relieved, hoping it explained the change in their daughter.

But her downward spiral continued at university to the point where she had drug debts, was missing classes and was eventually taken by ambulance to a London emergency room after mixing her prescription medications with alcohol and cocaine.

She withdrew from school and came home to Oakville.

It was the first time her mom learned Sara was doing coke and was now on four prescribed medications: Paxil, a second antidepressant, Ativan and a sleeping pill.

The night before her suicide, Sara held a pre-drink for friends in her basement and then headed to a local pub where she continued drinking. A friend eventually drove her home, but not before stopping at a home where he thinks she picked up drugs.

When her mom found her room empty the next morning, she just assumed Sara had gone out early for breakfast. As the day wore on, she and her husband Neil became increasingly worried when no one could locate her.

“Then I heard Neil just screaming, screaming and you could hear it all the way in the backyard,” she recalled, the tears rolling down her face. “Neil was screaming, ‘She hung herself.’”