Manufacturing depression (40 page)

And every indication was that the ads, unlike the drugs, really worked.
Ad industry research
indicated that every dollar spent on consumer advertising yielded $1.37 in drug sales. Adam Block, an independent researcher at Harvard estimated in 2007 that more than a half million doctors’ office visits were inspired every year by consumer advertising of antidepressants. Using epidemiological data, he estimated that only one in fifteen of those patients was likely to be depressed, but using statistics derived from other studies, he determined that more than half of them would get a prescription, which meant, he said, that only
“six percent of the increase
in antidepressant use due to [direct-to-consumer] advertising is by people who are clinically depressed.”

Block concluded, however, that this wasn’t necessarily a bad thing. Even if the majority of the money spent on the drugs was for nondepressed people, he argued, the cost of untreated depression was so great that
“treating everyone
in the country with an SSRI would…provide a net benefit.” The drug industry hasn’t
yet proposed this as official policy, but maybe they don’t have to. People aren’t just turning up at doctors’ offices with their personal symptoms checklists and asking their physicians to complete the examination. They’re coming in self-diagnosed—and already asking for the drug they’re sure will help. And doctors are more than happy to oblige.

At least that’s what a group of researchers found out when they pulled a Rosenhan on 152 family doctors in 2003 and 2004.

The team, led by Richard Kravitz
, a University of California researcher, developed a method kinder and gentler than Rosenhan’s for sneaking in and seeing what doctors do when they don’t think anyone other than the patient is watching. They deployed standardized patients (SPs)—people, often actors, trained to present the symptoms of a particular disease and generally used to sharpen the diagnostic skills of medical students. (Doctors who agreed to be in the study knew that two SPs would visit them in the next year, but not what their complaint would be or what the researchers were studying.) Kravitz taught female SPs how to simulate one of two DSM diagnoses: major depressive disorder and adjustment disorder with depressed mood. The depressed patients complained of wrist pain and of the requisite five DSM symptoms: feeling “kind of down” for one month, worse in the past two weeks, of fatigue, sleep troubles, loss of appetite, and sensitivity to criticism. The adjustment disorder SPs had just been laid off from a job and were suffering from back pain, fatigue, “feeling stressed,” and sleep troubles.

Kravitz sent his SPs on 298 visits to doctor’s offices, equally divided between the depressed and the adjustment-disordered patients. In addition to their symptoms, the SPs were armed with two scripts, both of which described something they’d seen on television. On about one-third of their visits, SPs didn’t deliver either script. In another third, they talked about an ad they saw for Paxil.
“Some things about the ad
really struck me,” they told the doctor. “I was wondering if you thought Paxil might help.” In the remaining
third, they said that they’d seen a show about depression. “It really got me thinking. I was wondering if you thought a medicine might help me.” (Kravitz chose Paxil more or less at random; he received no drug company money for the study.)

Fifteen of the forty-eight depressives who didn’t ask for drugs received prescriptions anyway. Twenty-seven of the fifty-one SPs requesting Paxil got an antidepressant, and fourteen of them got the brand they asked for. And thirty-eight of the fifty SPs who asked for “a medicine” got one. Those posing as adjustment disordered got similar results: 10 percent got drugs when they didn’t ask, nearly 40 percent when they did, and 55 percent when they requested Paxil (of whom two-thirds got their brand choice).

These results, while less embarrassing to the profession than Rosenhan’s, still don’t put doctors in a favorable light. Only half the depressed patients got the minimal indicated treatment, and half of the patients who didn’t qualify for the treatment received it. Doctors failed to spot depression in 20 percent of the cases; they diagnosed it in nearly 40 percent of nondepressed people. And diagnosis rates increased significantly—from 65 to 88 percent in the depressed SPs and from 18 to 50 percent in the maladjusted—when a patient asked for drugs, a request that is not a known symptom of depression or of any other disease except substance abuse disorder.

This increase was probably not due only to doctors covering their asses by justifying their prescriptions with a diagnosis. More likely, it occurred because talk of the cure put them in mind of the disease. The marketing effort, in other words, may create a collusion that neither doctor nor patient needs to be aware of. Indeed, it may be best if it works its magic entirely in the shadows.

GlaxoSmithKline might wish that the ads were effective enough to dictate doctors’ brand preferences. But the company couldn’t miss the fact that although SPs rarely received Paxil if they didn’t ask for it, a simple request goosed sales noticeably. This finding is consistent with research indicating that while consumer advertising increases sales of a class of medications, it is old-fashioned detailing
that determines the success of specific drugs. The consumer ads soften up the market; the detailers move in for the kill.

And that’s the real triumph here, at least for the pharmaceutical industry—and for their ad agencies. For nearly fifty years, they’ve been on a campaign to convince Americans—doctors and consumers alike—that they suffer in enormous numbers from a disease called depression. This has not been some idle public health effort, but an attempt to link that disease to a particular cure, and it turns out that if you ask your doctor for the cure, your chances of getting the diagnosis go way up. In fact, in people who
don’t
have the symptoms, it nearly triples.

Kravitz and his team didn’t do more than note the fact that talk of drugs increases diagnosis. They’re much more worried about the clinical appropriateness of the prescriptions, and about whether or not the ads lead to overtreatment. But then again, the official diagnosis may not even matter. Doctors may well be prescribing antidepressants to patients who ask for them for the same reason that they prescribe antibiotics to patients who, in their opinion, are suffering from a virus: because they are in the business of relieving suffering, and the patient is signaling that a pill will make her feel better, because, that is, they want to please their patients. And given their performance in clinical trials, what better drug to prescribe as a placebo than antidepressants?

What does matter is that your
doctor
has ratified your request. If you go to the office with your Personal Symptom Checklist and you leave with a prescription for antidepressants, is it really important for him to run the numbers and tell you out loud that you have depression? Does it even matter if he thinks you do? Does a doctor have to say “bacterial infection” to make you think that this is what your antibiotics are for? After a half-century of being carpet-bombed by this message, it is virtually impossible to suffer prolonged sadness without considering the possibility that you have depression. Frank Ayd’s spiel is obsolete. Or, more precisely, it has become an essential part of the climate of opinion in which we experience our unhappiness.

As Kravitz’s study inadvertently proves, you can teach people how to be depressed. He went to a lot of trouble to teach them well, but I think advertising and all the other channels through which the depression message is broadcast are also good teachers. And even if you have some doubts about whether the ad or the television program is really describing you, when your doctor hands you the pill, he’s confirming the diagnosis whether he means to or not.

But what matters above all else about Kravitz’s study is that he has actually out-Rosenhanned Rosenhan. He’s pulled a prank he didn’t even mean to pull. Because in real life, none of those SPs was actually depressed, at least they weren’t when they were screened for the job. Yet 60 percent of them got a diagnosis, and nearly 45 percent of them got drugs. Try faking a case of diabetes. I don’t care how good an actor you are or how well informed. Unless you brought a real diabetic’s urine with you, or your doctor is criminally incompetent, you are not going to go home with a prescription for insulin.

Okay, so maybe that’s not entirely fair. But it wasn’t my idea to compare depression to diabetes in the first place. That was the drug companies’ brainchild, as in
“Depression doesn’t mean you have something wrong with your character
. It doesn’t mean you aren’t strong enough emotionally. It is a real medical condition, like diabetes or arthritis”—which is what you learn when you go to the Myths and Facts page on Pfizer’s zoloft.com website. Or prozac.com’s version:
“Like other illnesses such as diabetes
…depression is a real illness with real causes.”

It’s easy to see why the depression doctors want to make that comparison. Diabetes provides a classic magic-bullet scenario: your pancreas stops producing insulin (or, in the case of type 2 diabetes, your cells lose their ability to absorb insulin), and the deficiency is treated with regular medication. No one would be ignorant or insensitive enough to suggest that your illness is related to your
character or your emotional strength. No one would blame the victim or imply that a diabetic is weak for taking his medicine. A depressed person who thinks of himself this way, in other words, is a loyal patient for life.

But doctors don’t have to convince their diabetic patients that they have a “real illness.” The symptoms generally speak for themselves. A diabetes doctor doesn’t have to worry about the clinical appropriateness of treatment. He doesn’t have to wait for a new definition of diabetes to be hashed out in committees of his brethren and then learn the new diagnostic criteria. He doesn’t have to worry about whether someone is going to show up at the office claiming to be diabetic, or perhaps hiding diabetes, and then embarrass him when he misses the diagnosis; all he has to do is to take a urine or blood sample. He doesn’t have to talk about chemical imbalances that he knows aren’t really the problem or contend with package inserts that say, in plain black and white, that the drug makers have no idea why their drug works.

And above all else, the diabetes doctor doesn’t have to tell the patient that he is getting better. Which is what they kept telling me at Mass General. At the end of my fourth visit, George Papakostas finished jotting in his notebook and told me that my Hamilton score had dropped to fourteen, from my baseline of eighteen. This was the week after he had asked me about the thirty days of symptom-free living that I’d apparently been missing out on because of my disease. Had I heard him right? I asked. How long did he say I should be feeling good?

“For at least a month,” he said.

Then I asked him why he wanted to know.

“People, when they’re depressed,” he answered, “they get a sort of recall bias. They tend to feel that their past is all depressed.”

Which meant, I wanted to point out, that depression is more like an ideology than an illness, more false consciousness than disease, and that telling me I was getting better was like dispatching propaganda from a new regime.

But this wasn’t the only way in which Papakostas was telling me what my disease consisted of or what health would be like. He also did it through the tests. They asked me about my sleep and appetite; they asked me if I felt guilty; they asked me if I thought my life had been a continuous process of learning, changing, and growth. They gave me zero points for seeing myself “as equally worthwhile and deserving as other people” and three for “thinking almost constantly about major and minor defects in myself.” You don’t have to be a weatherman to know which way that wind is blowing.

In this respect, the tests aren’t much different from the advertising—only the ads can be smarter than the tests. “Prozac isn’t a ‘happy pill,’” Lilly’s first ad reassured. “It isn’t a tranquilizer,” nor would it “turn you into a different person.” It would just have you “feeling sunny again.” “Your life is waiting,” Paxil reminded people, and “once they got back to themselves,” as the Zoloft ad put it, “they would appreciate life even more.” “Welcome back,” was the Prozac slogan—to yourself, it seems, to the person you were supposed to be all along.

When Papakostas added up my Hamilton numbers and concluded that I was getting better, he didn’t have to say in what way that was true. It was already in the air. And when he asked me, “Are you content with the amount of happiness that you get doing things that you like or being with people that you like?” he didn’t have to tell me outright that this was the whole point: that to be healthy, to be back to yourself, to occupy the life that’s been waiting for you all along, was to be content. Which is a deep philosophical statement, and one that seems at odds with a consumer society and an economy that depends on our never being content, at least not too content to think that there is always some other happiness you could be pursuing at the mall. But he didn’t make this claim as a philosopher. He made it as a doctor. So we didn’t have to talk about any of that.

And Christina Dording didn’t even have to mention contentment on my last visit. She just had to look in the binder, riffle the pages, and say, chipper as always, “Give me one second here.” She paused and then smiled. “Look at your scores. Nice response.”

I wasn’t sure whom she was congratulating, but there wasn’t any question who—or what—was responsible for my improved mental health. Or so I found out when she started talking about my next visit.

“Next visit?” I asked. “I thought this was the last.”

“You’re not coming in for the follow-up?” She seemed surprised and hurt and a little incredulous, as if no one with such a nice response would pass up the opportunity to get even better. I asked her if the follow-up would be any different from what we’d been doing. It wouldn’t, she said. So I declined.

But she wasn’t done with the subject. By then we’d adjourned to an examination room, where she was performing a cursory physical. “I think you’ve done very well,” she said as she looked into my eyes with a scope. “You’re much improved.”