in fact no more selective than some older drugs. The term SSRI came from the marketing department of SmithKline Beecham as part of their effort to distinguish their Paxil from Lilly's Prozac and Pfizer's Zoloft, but all three companies used the term to create the appearance of a new class of drugs and provide a common platform from which to launch marketing efforts designed to marginalize older—and demonstrably more effective—treatments.35
To this day, the brand names of drugs do not feature in medical textbooks, but these same books all include sections on statins, SSRIs, and ACE (angiotensin-converting enzyme) inhibitors as though these are medical terms, when in fact they are brand-like names that replace medical terminology. Statins such as Lipitor are just one subset of lipid-lowering drugs that include equally effective older drugs such as nicotinic acid. Zestril and its sister compounds hit the market in the 1980s as “ACE inhibitors,” rather than simply as antihypertensives, and became bestsellers as the SSRIs did—replacing cheaper and more effective antihypertensives.
One of the most striking instances of the branding of a new drug class has been creation of the idea of a “mood stabilizer.” This once rarely used term was summoned up by Abbott Laboratories in the 1990s and pressed into use in the marketing of their newly patented Depakote. Depakote as we have seen was approved by the FDA in 1995. But it was only approved for the treatment of the manic pole of what was once called manic-depressive illness. Such approval was not surprising—giving any sedative to manic patients will produce a change that can be portrayed as a benefit. More surprising was the company's application for approval. There are comparatively few manic patients, and a lot of sedatives were already in use to manage their illness. If there was to be any serious money in Abbott's move, it had to lie in the much larger market of people whose moods could be portrayed as fluctuating unhelpfully, who were in need of “mood stabilization.” But Abbott's license did not include warrants to claim Depakote was prophylactic—they couldn't claim it would stop moods swinging—or indeed even that it was a treatment for manic-depressive illness.
However, from the start ads for Depakote carried a claim that it was a mood stabilizer. Had Abbott said prophylactic, indicating that this drug had been shown to prevent mood swings, they would have broken the law. The beauty of the term mood stabilizer is that it had no precise meaning. But what else would a mood stabilizer be if not prophylactic? And this verbal construction would lead prescription writers to use it for that purpose, even though no controlled trials have ever demonstrated Depakote to be prophylactic. Far from being a well-grounded scientific idea, the term mood stabilizer was an almost perfect advertising term— as successful a brand as the term tranquilizer had been in the 1950s and SSRI in the 1990s.
All of a sudden everyone seemed to know what a mood stabilizer was. There was an exponential increase in the number of articles in medical journals with this term in the title—from none in 1990 to over a hundred per year by 2000. Within a few years, all psychopharmacology books had sections on mood stabilizers. It was as if in the middle of a TV drama series like Buffy the Vampire Slayer the main character is given a sister she never knew she had. When it comes to entertainment we can accommodate developments like this without blinking, but it is not the kind of thing we expect to be happening in science or medicine without solid evidence.
The emergence of mood stabilizers coincided with increasing estimates of the prevalence of what, in another successful piece of rebranding, was now almost always called bipolar disorder. Up to the launch of Depakote in 1995, almost everyone had heard of manic-depressive illness but soon this term all but disappeared, replaced by bipolar disorder. By 2005 over five hundred articles per year in the medical literature referred to bipolar disorder in their titles, with almost none mentioning manic-depressive illness.
This rebranding reengineered the disorder from the ground up. Manic-depressive illness had been a rare and serious condition affecting ten people per million, who invariably had to be admitted to hospital. Bipolar disorder, in contrast, supposedly affects up to 50,000 people per million, and efforts are now underway to persuade primary care clinicians that a wide range of the minor nervous problems they see are indicative of underlying bipolar disorder rather than anxiety or depression, and that these patients should be treated with newer and more costly mood stabilizers, such as Zyprexa or Seroquel, rather than older and cheaper antidepressants or tranquilizers.36
Bipolar disorder became intensely fashionable with extraordinary rapidity, promoted by assiduous disease awareness campaigns through direct-to-consumer advertising on television in the United States, and patient educational material in Europe, encouraging patients to complete self-assessments and ask their doctor whether bipolar disorder might be the cause of their problems. It became fashionable to the point where clothes and accessories could be bought online celebrating the wearer's bipolarity.37 Within a decade, one of the most serious of mental illnesses had gone from being a devastating disease to being a lifestyle option.
Everybody, it seems, stood to gain—physicians, companies, and patients. Bipolar disorder could be portrayed as a genetic disorder—not a parent's fault. While no one likes to have a biological disease, this one was portrayed in pharmaceutical company sponsored booklets38 and ads as a disease linked to creativity that supposedly had affected major artistic figures of the nineteenth and twentieth centuries from Vincent Van Gogh and Robert Schumann to Robert Lowell and Sylvia Plath. Public authorities meanwhile could support screening programs such as Teenscreen, introduced in many American schools beginning in 2005, to detect the condition and trigger treatment as early as possible in order to avoid any number of social and individual ills such as suicide, divorce, career failure, crime, and substance misuse that might stem from a failure to detect and treat.39
For the specialists new journals appeared—Bipolar Disorder, The Journal of Bipolar Disorders, Clinical Approaches in Bipolar Disorders, and others. made possible by unrestricted educational grants from pharmaceutical companies. From 1995 onward a slew of societies and global conferences appeared as well—The International Society for Bipolar Disorders, The International Review of Bipolar Disorders, The International Society for Affective Disorders, The Organization for Bipolar
Affective Disorders, The European Bipolar Forum, The Australasian Society for Bipolar Disorders, and many others.
In just the same way impotence vanished and was replaced by erectile dysfunction, frigidity by female sexual desire disorder, boisterousness in children by ADHD. The skill lies in understanding the market and positioning a drug accordingly. In 1980, for instance, the newly created panic disorder was viewed as a severe form of anxiety; the marketing goal for Upjohn was to get Xanax on the market for panic disorder in the expectation that creating the perception that Xanax was good for severe anxiety would lead to leakage into prescriptions for other forms of anxiety also.40 As we shall see in later chapters, marketing like this can conjure diseases like osteopenia, restless leg syndrome, and fibromyalgia out of thin air. This is now called disease mongering. But even more alarming, an “opportunity cost” of marketing like this is that medical diseases with a pedigree going back two millennia, such as catatonia, can vanish if no company stands to make money out of helping medical or nursing staff to recognize its presence and as a result patients may die, when the means to treat them may be lying inches away.41
Once the addition of a branded drug to a doctor's arsenal was a minor addition to medical culture, but now the insertion of a Viagra or a Vioxx into the medical marketplace will often replace existing medical culture in an area of treatment, as the examples of mood stabilizers and bipolar disorders illustrate. Disorders that were once defined by patients' needs for medical services and doctors' perceptions of their pathology are now increasingly defined by the goals of marketers. Furthermore this now happens on a global basis. Whereas once the brand names of drugs differed from country to country and huge differences existed between Japanese and American medicine, say, and between French and German medicine, from the mid-1990s drugs like Zyprexa, Lipitor, and Viagra have been launched globally with essentially the same marketing in every country. Partly as a result of these onslaughts, differences in medical cultures
