Bipolar Expeditions (25 page)

The ground this appealing scenario leaves unexplored is the traditional ground of cultural anthropology.
¹⁶
Can a single individual create a social context with social meaning? Can we speak of a redeployment on the basis of a one-off gesture? Do not such acts depend on a context at least coming into being, an interest group, an identity group, meetings, organizations, publications, support groups, named entities, or at least informal associates who could corroborate an alternative description? In fact, in the case of mood disorders many such organizations and associations are flourishing.
¹⁷
In his book about depression,
Speaking of Sadness,
David Karp found that his American interviewees experienced the lack of language they had to describe depression as a profound loss, and that this loss increased their isolation.
¹⁸
We might imagine this loss being repaired by social movements that would enable those diagnosed as “mentally ill” to use DSM terms in their own ways or to speak in terms other than the DSMs. In such a context we might see the
emergence
of performativity in conjunction with the mobilization of new social movements and groups.
¹⁹

The crux of the difficulty with this scenario (practically speaking) is that mental illness, as a particular kind of stigmatized condition, is erroneously taken to rob the person it is attached to of her rationality, and therefore of her ability to make sensible observations about the world. Cast into an alien sphere, apparently removed from what is essentially human, how can such a person perform a “labor of self-definition”? Until this daunting situation changes, people in support groups for manic depression can continue to shelter behind and rest upon the soft fabric of the DSM categories.

CHAPTER SIX

 

Pharmaceutical Personalities

This is the idea of “person”
(personne),
the idea of “self” (moi)…. Each one of us finds it natural, clearly determined in the depths of his consciousness, completely furnished with the fundaments of the morality which flows from it. For this simplistic view of its history and present value we must substitute a more precise view.—Marcel Mauss, “A Category of the Human Mind”

D
rugs are inanimate products that cannot literally speak, think, or feel. Nonetheless, pharmaceutical marketers and advertisers attempt to invest psychotropic drugs with attributes that make it possible to think of them as “persons,” as if they were social beings with individual personalities and the ability to have nurturing relationships with the patients who take them. However, patients who take these drugs do not necessarily relate to them as friendly living “persons” who take up residence inside them. Patients are as likely to think of drugs as biological tools, whose potency lies in their specific line of action on something in their brains, and whose harmful side effects might need to be moderated by complex cocktails of different drugs.
¹
Despite the friendly imagery of advertising, both patients and pharmaceutical marketers and advertisers invest psychotropic drugs with deeply ambivalent meanings. Psychotropic drugs can help us, so it would seem, but they cannot do so without harming us at the same time.

Marketing a Psychotropic Drug

From my interviews with pharmaceutical employees, I learned that developing a personality for the drug begins early in the production phase. Two executives from the research and production departments of the same company told me with considerable exasperation how demanding and detailed the concerns of marketers about developing a drug's personality could be.

Marketers worry about having every possible dose form: tablets in different strengths, a liquid form for pediatrics. They want a form that is aesthetically pleasing, looks good, tastes good, and is not too big. Color is important to them also: you never use red for psychotropic drugs! It is said to be bad for psychological or psychiatric problems, signifying danger. Black and gray mean death. Sometimes blue is bad because it can mean poison and can be seen as cold. But then again, light blue or green can be good when you want calm, soothing colors. Kids' taste buds are different from adults, and different cultures have different associations with tastes. A wintergreen flavor we once used is associated in France with the scent of toilet bowl cleaners!

From the point of view of research and production personnel, the preoccupation of sales, marketing, and advertising personnel with the aesthetics of the tablet was understandable but frustrating. Their own work on the drug's chemical formulation was like building the “body” of the drug, and the rest was its “dress.” They would cooperate in making this “dress” comforting and comfortable, stylish and aesthetically pleasing, even though the effort seemed superficial to them in comparison with building the body of the tablet itself.

An e-mail from Sarah Taylor, who is widely experienced in pharmaceutical marketing, summarized the importance of investing drugs with specific personality traits, which could, in due course, be combined with each other.

The antidepressants in particular have capitalized on [different] effects or lack thereof in their competitive branding campaigns. “All the efficacy without losing sleep, sex, etc.” One psychiatric group (at Mass General, Boston) even offers their patients a “menu of reasonable choices.” This is a descriptive “menu” of all the antidepressants they could prescribe along with a description of the various side effect and efficacy profiles. This is as close to selecting a pill based on its personality as I can think of. Psychiatrists have reacted to these brand ing campaigns in a curious way. Instead of prescribing one antidepressant or the other, they combine the drugs into their favorite “cocktails.” In LA, one drug combination became so popular it is called the Hollywood cocktail. It's popular because it utilizes Serzone (somewhat sedating, yet without weight gain, sexual dysfunction, or sleep loss) and Effexor (activating, pep you up so you can “get out of bed in the morning”). This hypermanagement of symptomology to a state that is better than normal or baseline seems like a new kind of medicine to me. In the case of the Hollywood cocktail, the psychs [psychiatrists] are actually inducing a sort of mania or hyper-alertness (at least compared to the person's previous state).

Physicians' readiness to combine the character traits of drugs to optimize a patient's mental state should alert us that however person-like they may seem, drugs are not exactly like persons. Their personality traits are more thing-like than person-like because they can be bought and sold and combined on demand in many ways, more like the parts of a motor or the ingredients of a cake than the personality traits of people. Acknowledging this, an ad in a trade magazine for pharmaceutical marketing shows a plumber installing brands inside a person's head with a wrench.

Because marketers and advertisers make serious efforts to imbue drugs with person-like traits, they quite reasonably also try to foster person-like relationships between drugs and the doctors who prescribe them or the patients who take them. Through the important role of the pharmaceutical sales representative in marketing drugs, a great deal of drug advertising aims to build aesthetic and emotional links with doctors. Here, I will keep my focus on patients by discussing how some ads try to reach through the doctor to the patient. Margaret Connor told me about her experiences as a copywriter for an ad agency: “Pharmaceutical ads use artistic themes because psychiatrists are artistic and this would appeal to them. For Lithium-P,
²
we did a four-month calendar on a poster featuring a portrait of Beethoven and there was even a card you could send in to get a CD of the Ninth Symphony.” But she felt this kind of appeal would not be appropriate for consumers.

6.1. In this ad from a pharmaceutical marketing trade magazine, a plumber installs brand-name drugs directly in the brain. Reprinted with permission.
Guide to Pharmaceutical Marketing Services, MedAd News
21 (September 2002): 29. Courtesy of the Hal Lewis Group, Inc. All rights reserved.

For example, a client wanted Van Gogh on the cover of a brochure for patients. But you know he committed suicide at the age of thirtyseven! I resisted because [this would make] it sound like you take the drug or you are going to die like he did. In the end, although I resisted, they used the picture, but I did manage to soften the wording.

Margaret also thought it was an ethical problem to put creativity so in the forefront of the ad, because fear of losing creativity is one of the main reasons bipolar patients resist taking Lithium-P: “Why take the drug if you lose that? People enjoy the highs, they feel invincible, they get a lot of work done. We also don't want to scare people off (consumers, that is) about the side effects. So the letter that goes to doctors with the calendar is clear and blunt about side effects, while the consumer materials mute them.”

I asked where the idea for Beethoven and Van Gogh came from.

From reading Kay Jamison's book on genius manic depressives, Schumann, Van Gogh, Poe. Then we had another author (I guess he was a jealous academic) ask us why not use his book, which is on military leaders and manic depression, so they did one with Napoleon, with quotes from [military heroes] but they couldn't use Stalin and Hitler. They issued these for three years—they were wonderful!

Later, Jack Levy, medical director of an advertising agency, explained the general principle behind the effort: borrowed interest. Inside the mailing tube with the calendar would be a paragraph on the famous figure and then a full Lithium-P sell: “An example of borrowed interest would be using Cal Ripkin in an ad for a beta blocker. Cal doesn't take the drug, but we borrow his long duration and hope it sticks to the drug.”

From her perspective as a production manager, Katherine Holmes talked about how ads are tailored to patients who belong to different populations. Katherine illustrated how pharmaceutical advertisers share general cultural notions about particular mental conditions and funnel them back into materials designed to promote relationships between drugs and populations of patients.

The same drugs are used, but the populations are very different. Schizophrenia tends to be downwardly mobile. I mean when people get it, they could be from any background. But once you get it, you could end up homeless, with no job—people just cannot function. So the average schizophrenic will end up either in a hospital or without a job somewhere living on minimum wage. I mean there are a few, rare cases of people that are teachers, but it's not your average. Whereas with manic depression—those are creative people who are successful, and you wouldn't even know that they [were taking medication or had] the disease. So it's a very high-functioning group of people, which I think makes it even harder to treat them because they are smart, they are creative, and they don't like to take their medication. When they are on the high part of it they create, they produce, they do things, wonderful things. And it's just when they are in the depressive part that things are really bad.

The main “beam” [focus] of the creative for our drug was very artistic—the idea was [to move the patient] from chaos to control. Those aren't the words we used, but the ad would show a page with just a scribble on it and then it would turn into musical notes. And so the idea was that your mind goes from being confused and everything, to kind of understanding, and then up to creative.

Katherine went on to explain how these advertising materials build on the widespread cultural connection between manic depression and creativity.

A lot of the stuff that the advocacy organizations do is around arts—they have art shows. I think there's definitely an understanding that it is a creative person who might have that disorder. I don't think the agency exactly views the disorder as a good thing. Maybe it's more that we should realize it's just OK. Like with depression it's totally open: Mike Wallace is on Zoloft [for depression] and that's not at the level of being abnormal. Depression does have a very dark side, but I think manic depression still really has that other side to it. I'd use the word “crazy” but … you know, it's high energy, things are happening.

In devising ads for drugs used to treat manic depression, advertising designers take for granted cultural associations between manic depression and creative energy. The drugs they design for this condition must promise neither too much dampening, which would lead to loss of creativity, nor too little, which would leave the patient's chaotic thinking intact.

The Rationality of Consumers

Between 1998 and 2001, when I was doing fieldwork on the pharmaceutical industry, it was undergoing some important changes that bore on its ability to build relationships with consumers. First, DTC advertising had begun in earnest in 1997. Draft promotional guidelines from the FDA's Division of Drug Marketing, Advertising and Communications (DDMAC) in August of that year permitted pharmaceutical companies to advertise the benefits of prescription drugs by brand as long as they also made clear the product's most important negative effects.
³
The marketing and advertising budgets of the pharmaceuticals subsequently increased through 2000, adding fuel to critics' claims that high prescription drug costs resulted from pharmaceutical advertising.
⁴