How Ethical are Anti-Depressant Marketing Practices?

Evaluating the Design of SSRI Marketing

What are SSRIs?

Selective serotonin reuptake inhibitors (SSRIs) are a widely used class of drugs in the treatment of depression and other mood disorders.¹ These medications work by blocking the reabsorption of serotonin back into neurons, thereby increasing serotonin levels in the brain and improving depressive moods.² Despite their wide usage and promotion, debates about their effectiveness have gained prominence. Recent studies suggest that SSRIs are no more effective than placebos in treating mild to moderate depression, casting doubt on their pharmacological efficacy. Additionally, the precise mechanisms by which SSRIs affect brain chemistry are not fully understood, further complicating the debate.³

Figure 1: Depiction of different SSRI pill brands.¹⁰

Recently, SSRI marketing has faced intense scrutiny for utilizing tactics such as disease mongering and targeted advertising, particularly towards women. Disease mongering involves expanding the boundaries of medical illness to increase markets for treatments. It can take many forms, including framing risk factors as diseases, portraying mild problems as severe pathology, and widening existing definitions of specific illnesses.⁴ SSRI companies have also targeted their advertising towards specific consumer groups, particularly women, even though there is not a higher prevalence of clinical depression in this population.

These marketing strategies are highly unethical, as they promote over-prescription and misuse of SSRIs. Such tactics erode public health and take advantage of certain populations, especially women, exacerbating problems within the mental health landscape.

The History of SSRI Marketing

A significant shift in pharmaceutical marketing, most notably within the SSRI industry, occurred when direct-to-consumer advertising (DTCA) of prescription drugs was approved by the Food and Drug Administration (FDA). Before August 1997, the FDA required advertisements to include detailed prescribing information, often taking up much of the actual advertisement’s airtime. In 1997, regulations changed to require ads to mention only major side effects and to direct consumers to additional information elsewhere. Pharmaceutical companies could now simplify their advertisements and focus on the benefits of the drugs rather than the exhaustive list of potential side effects the drugs could cause.⁵

Figure 2: Prozac pill, manufactured by Eli Lilly.¹²

The Direct Impacts of SSRI Marketing

The impact of the DTCA on SSRI marketing strategies is very controversial. Some argue that it educates and empowers consumers, thus making them more active in their healthcare decisions. A study conducted by Calfee (2002)⁶ shows that DTCA increases consumer knowledge of therapeutic options and may, therefore, lead to better discussion between consumers and healthcare providers. Others contend that the consumer-driven demand facilitated by the DTCA translates into higher prescription rates of SSRIs, often to populations that are not medically in need. A study by Mintzes (2002)⁷ shows that DTCA can lead physicians to prescribe SSRIs due to patient demand, even when they are not the best treatment option. Often, this can lead to over-prescription and misuse and raising questions about the ethical responsibilities of the FDA.⁸

Figure 3: The Pharmaceutical Marketing Process.⁸

Do SSRIs Maximize Goodness?

To assess the ethicality of the marketing practices of SSRIs, we can utilize the philosophical framework of consequentialism. Consequentialism is an ethical framework that evaluates an action based on its ability to maximize goodness and looks at the results of an action rather than how the result is achieved. From a pro-marketing perspective, the goal of SSRI marketing is to maximize the number of people receiving antidepressants. It justifies the means of aggressive marketing if it leads to more people receiving treatment. Since the effectiveness of SSRIs has proven to be of similar efficacy to a placebo, this approach is problematic. If the benefits of SSRIs do not outweigh the benefits of a placebo, the marketing strategies may not maximize the overall good of the population. Instead, it may add to the over-prescription and misuse of such drugs and add additional negative outcomes such as side effects, dependence, and increased healthcare costs.

Marketing tactics such as disease mongering can also lead to an abundance of misdiagnosis and misuse throughout the population. As mentioned before, disease mongering is the process of widening the boundaries that define medical illness to expand markets for those who deliver and sell treatments. It can take many forms, including framing risk factors as diseases, portraying mild problems as severe pathology, and constructing whole new categories of medical illness. It is utilized by SSRI companies to market the ups and downs of ordinary life into the symptoms of treatable conditions, producing much iatrogenic illness and wasting many resources.⁴ Those who are convinced of illness through unethical marketing practices may seek medication for common human emotions such as feeling intermittently sad, which does not necessarily call for medication. Yet, others may counter-argue this and suggest that through extended outreach, there is the possibility of increasing overall happiness by giving the general population hope for their emotional conditions and the ability to choose a medicative alternative. This, however, unethically markets SSRIs as a “happy pill” or an easy solution to suppressing heavy human emotions, which is being offered to a population that does not necessarily have clinical depression.⁵

Further ethical concerns about the marketing designs of SSRIs are accentuated by taking advantage of vulnerable populations, particularly women. In a recent study, it was seen that SSRI advertisements heavily target the female population, as it was found that 82% of the ads feature women, in comparison to only 10.1% featuring men. Targeted marketing would be justified if clinical depression was more prevalent in females, yet this condition is found in 21% of women and 15% of the male population. Had this prevalence of depression been reflective of the ad gender distribution, it would have shown 58.3% for women and 41.7% for men. In addition, these ads present stereotypical settings where women, who appear depressed and helpless in their inability to tend to their husbands or children, appear as what American society might argue is an “idealized woman” after taking the drug. The depiction of women in these advertisements showcases outdated stereotypes of female hysteria, resulting in increased self-diagnosis of viewers.⁹

Click here to watch an example of a Prozac Ad portraying these concepts.

Figure 4: SSRI advertisement published in the American Journal of Psychiatry in 2001.¹¹

In evaluating SSRI marketing design through the lens of consequentialism, it is largely unethical, as it does not promote the maximization of well-being within the female population. If such marketing design were ethical, it would instead involve diversifying advertisements to reflect the gender distribution of clinical depression. This would maximize goodness and would ensure that all individuals who might benefit from SSRIs will have equal access to information.

Figure 5: SSRI advertisement published in the Journal of the American Medical Association in 1967.¹¹

So… How Can We Fix This?

The current marketing strategies adopted by SSRI companies are unethical and raise significant concerns about the widespread misuse and abuse of such medications. Direct-to-consumer advertising, indirect marketing via online pharmacies, and direct marketing to health professionals have equally played a role in these unethical trends. These strategies, most of all those of disease mongering and gender bias, exploited vulnerable populations and compromised public health. Through the lens of consequentialism, it is evident that such marketing designs fail to maximize the overall good of the general population, as its net bad weighs heavily over its net good. Ultimately, comprehensive reform is necessary for SSRI companies to better align themselves with ethical standards and to maximize the well-being of their consumers.

The core of this problem can only be properly dealt with through more stringent governmental regulation on pharmaceutical companies, and an additional focus on educating consumer groups. In addition, it would be wise for large pharmaceutical companies to create positions dedicated to assessing the ethical and cultural repercussions of their marketing designs before they are released to the public. These changes could heavily aid in lessening the negative repercussions associated with SSRI advertisements and allow companies to reach their targeted audience in a much more ethical manner.

References

1. Dally, P.J., et al. “The Creation of the Concept of an Antidepressant: An Historical Analysis.” Social Science & Medicine, Pergamon, 5 Mar. 2008, www.sciencedirect.com/science/article/pii/S0277953608000129?via%3Dihub.
2. Spitzer, R. L. (1975). On pseudoscience in science, logic in remission, and psychiatric diagnosis: A critique of Rosenhan’s “On being sane in insane places”. Journal of Abnormal Psychology, 84(5), 442–452. https://doi.org/10.1037/h0077124.
3. Antonuccio, D. O., Burns, D. D., & Danton, W. G. (2002). Antidepressants: A triumph of marketing over science? Prevention & Treatment, 5(1), Article 25. https://doi.org/10.1037/1522-3736.5.1.525c.
4. Moynihan, Ray. “Disease-Mongering: Widening the Boundaries That Define Medical Illness.” Health Action International, 2 Mar. 2020, haiweb.org/encyclopaedia/disease-mongering.
5. Bhide, Amar, et al. “Case Histories of Significant Medical Advances: SSRIs and Non-SSRIs (through 1999).” Harvard Business School, Harvard, www.hbs.edu/ris/Publication%20Files/20-135_04bb2f82-66f0-4995-9b0f-112e2738039b.pdf. Accessed 1 June 2024.
6. Calfee, John E. “Public Policy Issues in Direct-to-Consumer Advertising of Prescription Drugs.” Sage Journals, The Journal of Public Policy & Marketing, journals.sagepub.com/doi/full/10.1509/jppm.21.2.174.17580.
7. Mintzes, B. For and against: Direct to consumer advertising is medicalising normal human experience: For. BMJ. 2002 Apr 13;324(7342):908–9. doi: 10.1136/bmj.324.7342.908. PMID: 11950745; PMCID: PMC1122842.
8. Buckley, Joan. “Pharmaceutical Marketing: Time for Change.” Academia, 1 Jan. 2004, www.academia.edu/84049655/Pharmaceutical_marketing_time_for_change.
9. Asadi, Lelia K, and Asim A Shah. “Gender Bias in Antidepressant Direct-to-Consumer Pharmaceutical Advertising.” Science Direct, Comprehensive Psychiatry, 9 Mar. 2023, www.sciencedirect.com/science/article/pii/S0010440X23000214.
10. Purse, Marcia. “What Are Selective Serotonin Reuptake Inhibitors?” Verywell Mind, www.verywellmind.com/list-of-ssris-380594. Accessed 1 June 2024.
11. Schumaker, Erin. “50 Years of Sexist Pharma Ads May Actually Affect Who Gets Treated for Depression.” HuffPost, HuffPost, 7 Dec. 2017, www.huffpost.com/entry/antidepressants-advertisements-women_n_7276906.
12. “Prozac.” Healthdirect, www.healthdirect.gov.au/medicines/brand/amt,2954011000036108/prozac. Accessed 1 June 2024.