by Shankar Vedantam
Washington Post Staff Writer
The Washington Post, July 16, 2001
About two years ago, newspaper, magazine and television news stories began popping up across the country about a little-known malady called social anxiety disorder. Psychiatrists and patient advocates appeared on television shows and in articles explaining that the debilitating form of bashfulness was extremely widespread but easily treatable.
The stories and appearances were part of a campaign, coordinated by a New York public relations agency, that included pitches to newspapers, radio and TV, satellite and Internet communications, and testimonials from advocates and doctors who said social anxiety was America's third most common mental disorder with more than 10 million sufferers.
So successful was the campaign that according to a marketing newsletter, media accounts of social anxiety rose from just 50 stories in 1997 and 1998 to more than 1 billion references in 1999 alone. And about 96 percent of the stories, said the report in PR News, "delivered the key message, 'Paxil is the first and only FDA-approved medication for the treatment of social anxiety disorder.' "
The plug for a drug was no accident. Cohn & Wolfe, the public relations agency coordinating the campaign, did not serve at the pleasure of the doctors and patient advocates who participated in' the education campaign. Instead, the agency worked at the behest of SmithKIine Beecham, the pharmaceutical giant now known as Glaxo SmithKIine, which makes the antidepressant Paxil.
The campaign was supplemented by a multimillion-dollar marketing and advertising blitz that pitched the drug to doctors, audiences of television shows such as "Ally McBeal" and readers of magazines such as Rolling Stone. Sales of Paxil, which had been lagging those of Prozac and Zoloft, jumped, rising 18 percent last year alone.
The education and advertising campaigns have raised concerns that pharmaceutical companies, traditionally in the business of finding new drugs for existing disorders, are increasingly in the business of seeking new disorders for existing drugs. Critics accuse the companies of recruiting patients by teaming up with doctors and patient advocates - with all the attendant conflicts of agenda and conflicts of interest.
"Pharmaceutical companies who are marketing psychopharmacological treatments have gotten into the business of selling psychiatric illness," said Carl Elliott, a bioethicist at the University of Minnesota, who studies the philosophy of psychiatry. "The way to sell drugs is to sell psychiatric illness. If you are Paxil and you are the only manufacturer who has the drug for social anxiety disorder, it's in your interest to broaden the category as far as possible and make the borders as fuzzy as possible."
BLURRING THE LINES
Blurring the line between normal personality variation and real psychiatric conditions can trivialize serious mental illness, some experts said.
"Some marketing seems to imply that huge proportions of the population need pharmaceutical intervention for relatively common problems, and in the long run, I am concerned that that may undermine the credibility of the concept of serious mental illness," said Rex Cow-dry, medical director of the National Alliance for the Mentally Ill, a patient advocacy group.
Glaxo SmithKline did not make company officials available for comment, despite repeated requests. 'But doctors and advocates associated with the company's campaign defended the effort, saying it informed thousands of people who previously did not know they were suffering from the disorder, spurring many to seek needed help.
"When I talk to family physicians, I don't hear them saying I have all these people who are asking for medicines they don't need," said Murray Stein, a psychiatry professor at the University of California in San Diego. "They say this patient said she had social anxiety and I've been treating her for years and I never thought to ask about it. What could be negative about that?"
ADVOCATES HAIL ATTENTION
Although many of the participants said they served as paid consultants or scientific investigators for the company, they rejected any notion that they were manipulated by the pharmaceutical industry. Most said they had spent years toiling on social anxiety disorder and were delighted when SmithKline offered a way to get their message out.
"I know there's lots of concern about, 'Are we medicalizing normative things and is the pharmaceutical industry trying to put SSRIs in the water,' " Stein said, referring to the class of drugs known as selective serotonin reuptake inhibitors, which includes Paxil. "The people I see talking about that have not seen these patients."
Patients with social anxiety disorder aren't the shy people who hang out at the edges of parties. Those truly suffering from the condition are profoundly debilitated, refusing promotions or taking jobs as night guards because they can't stand to be around people. Some cannot open the door to a handyman because that would mean conversation.
"Would somebody who is not having problems take a medicine that is costly and has side effects?" Stein asked. "I don't think too many people would do that. The idea that this is cosmetic psychopharmacology I find offensive."
The advocacy organizations that participated in the campaign - the American Psychiatric Association, the Anxiety Disorders Association of America and a Long Island-based group called Freedom From Fear - said that the only way for nonprofit groups to get out a potent public health message is to team up with a pharmaceutical company with deep pockets. Moreover, the groups demanded and received full control over the editorial content of the education campaign, said John Blam-thin, an APA spokesman.
"We have never, ever promoted any drug," said Jerilyn Ross, the founder of the Anxiety Disorders Association of America. "If you look at our materials and on our Web site, we have never mentioned a drug." Ross said that she even got into "fights" with SmithKiine because she frequently told the company's marketers, " 'We can't do this, we can't do that.' "
But if the experts did not want to be boosters for Paxil, the arrangement with the public relations firm - and the marketing campaign for Paxil, which offered journalists interviews with some of the same experts - made that confusing. Cohn & Wolfe emphasized in its calls to the media that it spoke on behalf of doctors and nonprofits - not the pharmaceutical company that was paying its bills.
The Cohn & Wolfe Web site, however, made no secret of the fact that it is in the business of marketing, not public health: On a previous campaign to promote coverage about the 10th anniversary of Prozac's launch in Britain, the agency said it successfully helped drug maker Eli Lilly spin coverage. The strategy? Offer journalists interviews with "independent Key Opinion Leaders" - doctors, advocacy groups and patients with "suitable debate."
Cohn & Wolfe declined to talk about its role in the Paxil campaign, calling the information "proprietary and confidential."
BUSINESS OF EDUCATING
Marcia Angell, a former editor of the New England Journal of Medicine, said that pharmaceutical companies could not be expected to act solely in the interest of public health: "They are no more in the business of educating the public than a beer company is in the business of educating people about alcoholism."
The expensive ad and education campaign paid off in the crowded antidepressant market: Glaxo SmithKline's 2000 annual report told shareholders the drug "became number one in the U.S. selective serotonin reuptake inhibitor market for new retail prescriptions in 2000."
Barry Brand, Paxil's product director, told the journal Advertising Age, "Every marketer's dream is to find an unidentified or unknown market and develop it. That's what we were able to do with social anxiety disorder." Several experts, including some who treat social anxiety disorder, worried whether such marketing was in the public's best interest.
"When the pharmaceutical companies focus on broadening the market, you miss out on the fact that there is a proportion of people for whom mental illnesses are truly disabling," said Cowdry, who formerly headed the National Institute of Mental Health. "I have the same reaction when I hear that one in three Americans have a mental illness. The problem with that kind of data is that it undermines credibility - it doesn't pass the laugh test."
SIZING UP THE PROBLEM
Two experts who were assembled by the American Psychiatric Association to write the definition of social anxiety disorder for the psychiatrist's manual said they admired the campaign for alerting patients suffering in silence. Still, they had concerns.
"I don't think the ads make the distinction between social anxiety and shyness," said Edna Foa, a professor of psychology at the University of Pennsylvania who served on the APA committee. "One gets the impression from the ads that if you are shy and you have some diflicul-ties and you want to be outgoing, then take Paxil. You are promoting medication when it is unnecessary."
There were other instances where the social anxiety marketing campaign diverted from the message of medical experts - including experts who were part of the education campaign - or quoted the experts selectively.
The campaign said that more than 10 million Americans suffered from social anxiety disorder, making it the most common mental disorder after depression and alcoholism - and that 13 percent of Americans are affected by social anxiety disorder. But the National Institute of Mental Health says only about 3.7 percent of the U.S. population has social anxiety disorder. The American Psychiatric Association says rates vary between 3 percent and 13 percent. Stein of UCSD said he preferred the 3 percent to 4 percent estimate.
Although Paxil has been specifically approved by the Food and Drug Administration for the disorder, many psychiatrists said there is probably little difference between Paxil and similar medicines such as Prozac or Zoloft in treating social anxiety. There are also other of drugs available for treating other forms of anxiety.
And although the campaign mentioned a psychological therapy called cognitive behavior therapy, it did not stress that the therapy is as effective as medication, has no side effects, such as sexual problems and fatigue, and does not require patients to stay on treatment indefinitely.
"In my opinion, social anxiety is not a chemical problem with the brain," said Jonathan Abramowitz, a psychologist at the Mayo Clinic in Rochester, Minn., who worked on the psychiatrist's manual. "I see it as a problem with normal thinking and behaviors that have gone awry."
Cognitive behavior therapy, he said, takes 14 weeks: "It's like learning to ride a bike. You are practicing these skills over and over. No one can take them away from you the rest of your life. The long-term benefits of cognitive therapy is better than medicine because with medicine, when you stop, the symptoms come back."
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