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Drug Companies Create Their own Markets.

By Chris Rangel MD ⋅ December 5, 2003 ⋅  Email this post ⋅  Print this post ⋅ Post a comment

Drug Companies expand scope of illness to increase market - So the other night I was watching TV and I see the Zoloft “blob” pretending to have “social anxiety disorder” (SAD) and advertising the use of the antidepressant Zoloft (sertraline) for the treatment of this “disorder”. It’s not so unusual that antidepressants (esp. the newer seritonin reuptake inhibitors - SSRIs) are used to treat various anxiety disorders. What is getting to be more worrisome is that many drug companies are beginning to market their SSRI antidepressants medications for uses beyond that of severe depression or anxiety.

Social anxiety disorder is also known as “Social Phobia” because - to point out the obvious - it is a “phobia”. A phobia is defined as “A persistent, abnormal, and irrational fear of a specific thing or situation that compels one to avoid it, despite the awareness and reassurance that it is not dangerous.” There are many phobias from heights, to air travel, bugs, and fear of the elastic in underpants but what is needed to distinguish a simple “fear” from a full blown phobia is that as indicated above, the fear is not only abnormal and irrational but it also significantly and adversely effects a person’s life. For example; an actor who has such severe “stage fright” that he can’t perform, a business traveler who is afraid to fly, a doctor who is afraid of blood, or someone who has such severe social phobia that he/she leads a very lonely and solitary life because of such a strong fear of public and social situations and meeting new people.

The American psychological Association’s publication Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) lists the following criteria for the diagnosis of a “social phobia” (emphasis added);

A. A marked and persistent fear of one or more social and performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(S) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

Notice that the emphasis is on the “anxiety” that these situations cause. This anxiety often takes the form of various physical symptoms such as palpitations, tremors, sweating, gastrointestinal discomfort, diarrhea, muscle tension, blushing, or confusion in addition to feelings of severe dread and impending doom that often impairs functioning (in extreme cases this is known as a “panic attack“). Now compare this definition with the information about “social anxiety disorder” that is on the Pfizer-Zoloft web site;

If you have social anxiety disorder, you often get very nervous around other people. It feels like everyone is watching you and judging you. You?re afraid of making a mistake, or looking like a fool. You will do all you can to keep that from happening. You may even avoid certain people, places or social events.

If you have to do these kinds of things, you may, Blush, Sweat, Tremble, Have a fast heartbeat.

Even though the DSM-IV is written for physicians and the Zoloft web site information is written for the general public there is still quite a difference in tone between these two definitions of social anxiety disorder. The Zoloft site never even mentions the word “anxiety” in its information except to identify the disorder. In fact, the site mentions that people with this disorder may get “very nervous around other people” but even lay people know there is a difference in degree between being “very nervous” and being “anxious”.

Semantics aside, the Zoloft site definition of social anxiety disorder makes it seem like anyone who as ever felt “nervous” in a social situation could qualify as having social anxiety syndrome and that just about includes everyone. What a market this would be if you could expand the definition of an anxiety disorder to include the common but not dysfunctional feelings that almost everyone feels at one time or another in their lives. But we don’t need to take medication for this. Nervousness and even anxiety are normal parts of our lives. It’s only when they cause serious dysfunction that a disorder or phobia is considered to exist but you would never understand this from reading the Zoloft web site.

Part of the problem is the fact that currently pharmaceutical companies can advertise in nonmedical media intended for general audiences. Even though they can’t make false or blatantly misleading claims, all too often these drug ads are heavily geared towards selling to the patient as consumer who may know far less about their disease or condition than their physician. In short, the patient may be the end user of these products but the patient is not really the “consumer”. The consumer is the physician who by definition is the one who is most qualified to make informed decisions on the use of various medications (in theory at least - not always in practice).

By marketing directly to patients the drug companies are creating a thorny situation where people are “encouraged” to informally diagnose themselves using the criteria set forth in these drug ads and then carry this influence to their doctor. A patient who sees the ad for Zoloft to treat social anxiety disorder suddenly makes a connection with how he fears his boss at work. This patient goes to his doctor saying that he saw this ad and realizes that he has this disorder and asks for a proscription for Zoloft so he can finally stand up to authority figures and improve his standing in the company. However, the real reason he fears his boss is because his boss is a major asshole who uses fear and intimidation to keep his employees in check. Does this patient really have a social phobia or does he have a crappy job?

But this problem is not solely the fault of the drug companies or the easily swayed public. The sad truth is that this kind of advertising works because so many doctors can be influenced (or pressured) by their patients who have seen these ads. There are many reasons for this. Some physicians may not be any smarter than their patients. However, most of the reasons have to do with patient pressure on their doctors and the doctor’s desire to be accommodating to their patient’s wishes. Another reason is that many physicians who proscribe SSRI medications are not psychiatrists and so have less experience and less expertise in the diagnosis and treatment of psychiatric disorders (including phobias). The patient in the above example goes to his general internist, describes his problems at work and his desire to start an SSRI. His doctor thinks, “What the heck. Zoloft is safe and has few side effects and besides, if I refuse or try and send him to a psychiatrist then he might not continue to be my patient” and wahhhhlllaa . . a new Zoloft consumer is created based on nothing more than advertising.

This is how the drug companies can increase business through advertising to the general public. It is very effective but it also has the potentual to create diagnostic problems and result in the inappropriate use of these medications for conditions that either don’t exist or don’t really need medical treatment. Besides, there is mounting evidence that these SSRI medications may not be all that effective for the treatment of psychiatric conditions they were designed to treat!