How Drugmakers Influence Our Beliefs About Mental Illness

The downside of some “greater awareness” campaigns and other pharmaceutical marketing tactics.

Nothing burns itself into memory quite like public humiliation. Even now, 20 years later, I can vividly recall the embarrassment I felt the day I tried — and epically failed — to play the guitar in front of my high-school classmates.

It was my junior year. A couple of friends and I were giving a presentation to our Western Civ class, and my part included playing the intro to Led Zeppelin’s “Over the Hills and Far Away” — a riff I’d mastered and had played countless times at home. But performing it in a quiet classroom, watched by my teacher and two dozen peers, proved too much for me. My hands trembled and my fingers seized up. I “played” some unrecognizable mush and turned fire-hydrant red.

I still think about that day every time I have to appear in front of an audience, which fortunately isn’t often. I’ve improved with practice, but public speaking still makes me sweat and messes with my sleep. It wasn’t until recently that I learned, to my surprise, that I may have a mental illness.

According to the latest Diagnostic and Statistical Manual of Mental Disorders — a.k.a., the DSM-5, which mental health professionals use to identify and diagnose disorders — I meet all of the principal criteria for social anxiety disorder (SAD). I experience a “marked fear of one or more situations” where I’m exposed to scrutiny by others. The DSM-5 explicitly includes “performance situations” in that group, and prescription drugs (primarily SSRIs) are considered a first-line treatment for my condition.

I’m not making light of stage fright; I know firsthand how rough it can be. But it’s difficult for me to make sense of its DSM inclusion. Researchers have found that one-third of the general population feels “excessive anxiety” when speaking in front of an audience. Some surveys have found that a fear of public speaking is even more prevalent than a fear of death, and evolutionary psychologists have proposed that this fear is so old and widespread that it must have some utility for our species. How can such an ordinary and natural human experience be a disorder?

Some experts say it’s not. They argue that labeling stage fright a disorder is an example of a broader movement to shunt any and all unpleasant or uncomfortable feelings (shyness, sadness, worry, fear, even grief) into illness categories. This “psychiatrization of society,” some academics contend, is leading to overdiagnosis and overtreatment, and it’s an open secret that this trend is partly engineered and funded by the pharmaceutical industry.

Many people right now are struggling. I think it’s worth asking whether branding them “disordered” and giving them a drug is the best way to help them get better.

How predictable and commonplace does an emotional experience have to be to avoid a disorder label? And what are the consequences of defining an ever-expanding range of experiences as “illnesses,” and therefore candidates for drug-based treatments?

These are complex questions with nuanced answers. But it’s undeniable that a huge swath of the American public is now taking prescription drugs for conditions that, not long ago, were considered well within the range of “normal.” It’s also undeniable that drugmakers spend billions of dollars to shape and promote our understanding of these conditions.

“It’s become quite common for pharmaceutical companies to take a common symptom and make it into a disease in order to condition brand a specific drug,” says Adriane Fugh-Berman, MD, a professor of pharmacology and physiology at Georgetown University.

I wasn’t familiar with the term “condition branding” until I read some of Fugh-Berman’s work. The tactic, in a nutshell, involves marketing a disease in order to sell more of its treatment. For example, a drugmaker might pay for a highway billboard that highlights the burden of a mental illness for which it makes the primary medication. (In a lot of cases, the drugmaker and its product aren’t even mentioned.)

‘Unfortunately, pharmaceutical companies control every source of information physicians have.’

One well-documented example of condition branding involves social anxiety disorder and the drug Paxil, made by GlaxoSmithKline.

Social anxiety disorder first appeared in the DSM — to some controversy — in the 1980s. After the FDA approved the drug paroxetine (Paxil) for the treatment of social anxiety disorder — something made possible by a broadening of the DSM’s diagnostic criteria — GlaxoSmithKline spent more than $92 million in the year 2000 to market SAD to therapists and to the public. That’s according to the work of Christopher Lane, PhD, a professor at Northwestern University who has written extensively (including in his award-winning book Shyness) about the expansion of the DSM and the “medicalization” of commonplace emotional experiences.

GlaxoSmithKline’s marketing campaign for SAD was centered around ads with the tagline, “Imagine Being Allergic to People.” Lane writes: “[The] campaign did not mention Paxil — it didn’t need to, since it was the only pharmaceutical remedy approved for the disorder at the time.” Many of the ads themselves did not even mention GlaxoSmithKline. Instead, they referenced organizations such as the Anxiety Disorders Association of America, which GlaxoSmithKline was helping to fund. In 2001, the year after GSK launched its campaign, doctors wrote 25 million new prescriptions for Paxil. All of this was, and is, legal.

Apart from running these sorts of ads, pharmaceutical companies also give financial support to advocacy groups that do this sort of promotion for them.

Last month, as anyone spending time on the internet was sure to hear, was Mental Health Awareness Month. Mental Health America, the non-profit group that first launched Mental Health Awareness Month, receives money from pharmaceutical companies; in 2020, its list of “platinum” donors included Pfizer, Bristol Myers Squibb, and drug subsidiaries of Johnson & Johnson, among other drugmakers. The National Alliance on Mental Illness, or NAMI, is one of the country’s largest mental health non-profits and also one of the loudest megaphones for Mental Health Awareness Month. A mid-2000s congressional investigation found that three-quarters of its funding came from pharmaceutical companies.

For this piece, I spoke with a marketing professor who has studied condition branding and does paid consulting work for drugmakers. He asked that I not include his name here. “You can’t sell a product for which there is no problem,” he told me. “Condition branding identifies and defines the problem.”

Based on figures he provided me, pharmaceutical companies last year spent about $7 billion on direct-to-consumer advertising. Of that total spend, he says a little more than 8% went toward “disease awareness” campaigns and other unbranded advertisements, meaning ads that did not mention a drug.

How we interpret what we’re feeling — and how much that interpretation distresses us and shapes our self-image — depends in part on what society is telling us to think about our experiences.

Pharmaceutical companies also spend billions to ensure that health authorities and medical professionals recognize new conditions and associate them with a particular drug treatment. Fugh-Berman says they can do this in lots of different (and legal) ways: they can fund favorable research studies; they can host luxurious medical conferences in which “key opinion leaders” (paid doctors) deliver lectures that support their narratives; they can produce continuing education materials for healthcare professionals that emphasize the prevalence and severity of a condition; and they can make donations to teaching hospitals or non-profit advocacy groups.

“Unfortunately, pharmaceutical companies control every source of information physicians have,” she says. “Even physicians who don’t go to industry-funded events are still being influenced by industry-funded information.”

Based on current diagnostic criteria, SAD will affect up to 30% of Americans at some point in their lifetime. Up to 20% of young people will develop social anxiety or a related phobia, and the median age of onset is 11. That’s according to a 2020 guideline paper from the American Academy of Child & Adolescent Psychiatry.

It was not always so.

When I spoke to Northwestern University’s Lane, he told me that up until the 1980s, SAD (which was initially called social phobia) was not formally classed as a disorder. When it did land a disorder classification, it was initially tightly defined so that it encompassed only a small subset of the population. But then, in its revised 1987 version, the DSM “radically adjusted” its definitions of SAD so that many, many more people met its diagnostic criteria. Overnight, the number of people with SAD moved “from 1–2% of the population to something closer to 1 in 5 people,” Lane told me.

Last year, a study in The Lancet Psychiatry pointed out that more and more adolescents are taking prescription drugs (primarily SSRIs) to manage SAD and other conditions despite persistent unknowns about the long-term effects of these drugs on a young person’s psychological and neurocognitive development.

To be sure, some people who experience severe anxiety in social situations have benefited from increased public awareness of their challenges, and maybe also from improved access to drug treatments. The marketing professor I spoke with says he believes that the benefits of pharmaceutical condition-branding practices outweigh the harms of overtreatment or overdiagnosis. More people who need these drugs are able to get them, he told me, and the expansion of diagnostic criteria means that insurance companies will pay for treatment in a broader group of patients.

But our emotional experiences are always, to some extent, suggestible. How we interpret what we’re feeling — and how much that interpretation distresses us and shapes our self-image — depends in part on what society is telling us to think about our feelings.

Labeling commonplace fears, anxieties, or other challenging emotions as “illnesses” or “disorders” may provide some comfort by validating what a person is going through — by acknowledging that, yes, what you’re dealing with is real and difficult. But there may be a cost to this sort of validation, including the risks of prescription psychiatric drugs, all of which may cause serious adverse effects and may not promote long-term mental health benefits or improved outcomes. It’s possible to acknowledge a person’s pain and give them support without calling them “disordered.”

Put another way, labels matter — especially when being assigned a label means being prescribed a drug.

“Making people feel that their normal variant of eating or sleeping or feeling is abnormal is not helpful to them,” Fugh-Berman says. “It leads people to pharmacological treatments when what they’re experiencing is better dealt with in non-pharmacologic means.”