A Drug a Day Keeps Depression Away: How Direct-To-Consumer Advertising Influences Our Perception on Antidepressants

Direct-To-Consumer (DTC) advertising is a form of marketing where pharmaceutical companies advertise their products through raising awareness about health disorders. Fueled by the Patients’ Right Movement and Consumer Civil Rights Movement in the 1980s, which enabled individuals to take more control over their healthcare decisions and be aware about treatment options, the first DTC advertisement was Merck’s advertisement for Pneumovax in 1981.[1] This drove the U.S Food and Drug Administration (FDA) to officialize DTC advertising in 1997 under the conditions that the information was presented in a true and balanced manner[2] Currently, the U.S and New Zealand are the only two countries where DTC advertising is legalized.

However, DTC advertisements have typically under-emphasized risks and glorified the use of medications over other interventions.[3] For example, an immunotherapy drug named Keytruda® was promoted on the basis that it offered a longer lifespan than chemotherapy but failed to mention that more than 50% of patients in the trial did not respond this way.[4] Furthermore, a study analyzing the quality of information across 97 DTC advertisements aired between 2015 and 2016 revealed that a low proportion of companies provided information regarding efficacy and risks.[5] In this regard, DTC advertisements have been a topic of controversy for misrepresenting information.

Specifically, biased DTC advertisements have had a significant impact on society’s perception of antidepressants.

DTC advertisements have failed to capture the complexity of depression by minimizing it to a “simple” chemical imbalance in serotonin that can be “fixed.”  Zoloft® is an antidepressant that belongs to a group of medicines called serotonin reuptake inhibitors (SSRIs). Zoloft® advertisements portray the effect of SSRIs by showing the transition of a sad looking blob to a happy looking one. It also establishes depression as a “serotonin imbalance" and proposes that Zoloft® works to “correct this imbalance.” This may influence viewers to think that taking a single drug may alleviate all negative emotions and turn them into a “happy blob” as shown in the commercial. As a result, it may cause the target audience to view antidepressant medication as the only solution when it may not be in their best interest.

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The question remains—is a mere serotonin imbalance the cause of depression? The serotonin hypothesis is contradicted by a study that compared serotonin levels in blood and brain fluid between people with and without depression which discovered that there is no difference.[6]  More importantly, an article focusing on the causes of depression beyond chemical imbalances and genetics associated depression with slower brain waves, inflammation, poor gut health and hormones apart from serotonin, highlighting that there are other causes of depression.[7] These studies show that there are multiple causes of depression and raises the concern that DTC advertisements have presented a simplistic perception to their target audience that the cure to depression is simply fixing a chemical imbalance.

DTC advertisements also leverage neurobiology jargon to sound more convincing, diminishing the possible role of non-biological factors in depression treatment. The advertisement for Lexapro® explained the process of how serotonin is transferred from one neuron to another and how the drug works to help with this process[8].

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While such advertisements provide tangible proof that the drug works and therefore sound more convincing, studies have shown that administering placebos—a treatment that has no active properties and provides mental relief rather than elicit an actual effect--were as effective in administering actual antidepressants.[9] This was further evidenced in clinical trials for Zoloft® which suggested that patients who were administered the actual drug did not perform much better than those who were administered the placebo.[10] This raises doubts as to whether biological treatment is the only cure for depression. To delve deeper, research has shown that factors such as good support systems and enforcing healthy and positive behavior are equally important as medication, and sometimes more effective, in recovering from depression. This suggests that there are both biological and non-biological factors in curing depression, but DTC advertisements fail to present a fair balance between both. Consequently, such advertisements are platforms to present the use of medication as the only effective solution.

While DTC advertisements have played a crucial role in destigmatizing mental health conditions and propagate treatment seeking, such marketing encourages individuals to overly depend on medication and self-diagnosis, at the cost of misunderstanding the side-effects and risks. A study has highlighted that that 55% of individuals in the study requested brand-specific antidepressants from their physicians because of seeing it on a DTC advertisement.[11] Additionally, DTC advertisements influence the prevalence of depression in society by pathologizing normal sadness as depression, leading to over-diagnosis of the condition.

Why do pharmaceutical companies choose to advertise medication the way they do? The answer is simple: profits over patients. After being launched in 1991, Zoloft® has made over a $30 billion profit simply by convincing target audience that the drug was effective in treating depression by focusing on specific aspects of the clinical data that played in their favour, disregarding other factors that would diminish the efficacy of the drug.[12] Similarly, Nexium® generated an annual revenue of $3.8 billion by claiming that their drug was a “more effective” version of Proton Pump Inhibitors (PPIs), a class of drugs, when this was not backed up by sufficient data. Privatization of healthcare in U.S has led to viewing healthcare as a commodity to keep up with rising demand and costs, luring pharmaceutical companies to focus on generating profits—and to do so, target vulnerable groups through DTC advertisements by glorifying medication as the cure to all their problems.

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Over the years, the regulations for DTC advertising have become more stringent, requiring companies to present side effects and risks in a clear and neutral manner. However, concerns over companies overemphasizing branding and profits over the welfare of patients persist. In a roaring capitalist society, there is a naturally increasing association between pharmaceutical companies and profits, but it is only ethical for DTC advertising (or any form of marketing) to be driven towards the best interest of society and not profits. In this regard, advertisements should promote antidepressant medication while acknowledging that depression is a complex disorder and requires a highly personalized, specific combination of biological and non-biological interventions. As a result, society could seek more appropriate and regulated help and take ownership over their healthcare decisions.

[1] Julie Donohue, 'A History of Drug Advertising: The Evolving Roles of Consumers and Consumer Protection' (National Library of Medicine, Dec 2006) https://pmc.ncbi.nlm.nih.gov/articles/PMC2690298/#:~:text=The%20goal%20of%20the%20patients,help%20businesses%20market%20their%20products accessed 26 November 2024

[2] Ibid.

[3] Nathan P Greenslit, 'Antidepressants and Advertising: Psychopharmaceuticals in Crisis '(National Library of Medicine, 29 March 2012) <https://pmc.ncbi.nlm.nih.gov/articles/PMC3313530/> accessed 26 November 2024

[4] Natasha Parekh and William H Shrank, ‘Dangers and Opportunities of Direct-to-Consumer Advertising’ (Journal of general internal medicine, May 2018) <https://pmc.ncbi.nlm.nih.gov/articles/PMC5910355/> accessed 21 November 2024

[5] Ibid.

[6] Ucl, ‘No Evidence That Depression Is Caused by Low Serotonin Levels, Finds Comprehensive Review’ (UCL News, 21 July 2022) <https://www.ucl.ac.uk/news/2022/jul/no-evidence-depression-caused-low-serotonin-levels-finds-comprehensive-review> accessed 21 November 2024

[7] Suruchi Chandra, ‘Causes of Depression: Beyond Chemical Imbalances and Genetics’ (SURUCHI CHANDRA M.D., 28 May 2024) <https://chandramd.com/what-causes-depression-chemical-imbalance/> accessed 21 November 2024

[8] Jeffrey R Lacasse and Jonathan Leo, ‘Serotonin and Depression: A Disconnect between the Advertisements and the Scientific Literature’ (PLoS medicine, December 2005) <https://pmc.ncbi.nlm.nih.gov/articles/PMC1277931/> accessed 21 November 2024

[9] Irving Kirsch, ‘Antidepressants and the Placebo Effect’ (Zeitschrift fur Psychologie, 2014) <https://pmc.ncbi.nlm.nih.gov/articles/PMC4172306/> accessed 21 November 2024

[10] Zoloft No Better than Dummy Pill, Says Lawsuit’ (Medical News Today) <https://www.medicalnewstoday.com/articles/255782#2> accessed 21 November 2024

[11] Richard L Kravitz and others, ‘Influence of Patients’ Requests for Direct-to-Consumer Advertised Antidepressants: A Randomized Controlled Trial’ (JAMA, 27 April 2005) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3155410/> accessed 21 November 2024

[12] Ibid.