by Julie Donahue*

Studies suggest that about half the people with depression receive no treatment. A key variable influencing decisions by those with depression about whether to seek help is the perception of need.

Many patients with depression (and other mental health problems) do not think they need treatment. One study explains:

they believe the symptoms are temporary or not serious…because they do not recognize their problem as a mental health problem, do not know that appropriate help is available, believe that treatment will not help, do not find services accessible, are embarrassed about seeking help, or fear stigmatization.

Stigma has been frequently cited as an important barrier to seeking treatment for depression and other mental disorders. Perceived stigma is high among individuals with depression and its likelihood increases with severity of the condition

At the same time, the pharmaceutical industry spends millions promoting psychotropic drugs to consumers with depression and other mental disorders. In 2005 alone, pharmaceutical manufacturers spent approximately $120 million on direct-to-consumer advertising of antidepressants. Much more than that ($900 million) was spent on advertising and other promotions to psychiatrists, primary care providers and other physicians.

A possible direction
So my question is this: can pharmaceutical advertisers play a role in reducing stigma and increasing awareness of symptoms of depression?

I must confess that I am an iconoclast when it comes to direct-to-consumer advertising of prescription drugs. I think that drug ads have the potential to do some good. I do have a plea, however, for the pharmaceutical industry: spend more money on ads that discuss the symptoms of and risk factors for depression, the value of treatment in general, and the need to adhere to treatment, and spend somewhat less on ads that promote specific drugs.

Some may point out that pharmaceutical firms are "for profit" not "public service" organizations. They are accountable to their shareholders and need to demonstrate that their promotional activities are generating sales. Evidence suggests, however, that shifting some of the advertising budget away from specific products to disease-awareness ads may not hurt and perhaps will even help pharmaceutical firms' bottom lines.

First, studies show that advertising designed to reach consumers increases sales to a class of medications as a whole but does not have an effect on individual product market share. In marketing parlance, it direct-to-consumer advertising generates positive "spillovers" from one brand to another (Zoloft's advertising boosts sales of Lexapro as well as Zoloft).

Put another way, direct-to-consumer advertising encourages people to seek treatment for health conditions. But once they are in the doctor's office, it is the doctor's preference for Drug A over Drug B that matters most, not the patient’s request for a specific medication. So if the primary effect of direct-to-consumer advertising is treatment-expanding rather than market share-shifting then why not emphasize this more in the ad content?

Second, experimental evidence suggests that general requests for treatment are better received by physicians than drug-specific ones. One study trained actors to present symptoms of mild or severe depression to learn about the effects of patients requests for antidepressants on physician prescribing. Researchers asked if the likelihood of receiving a prescription for an antidepressant varies depending on whether the patient’s request for medication is brand-specific or general. They found the probability of receiving medication was the highest among those making general requests (76 percent) compared with those making brand-specific requests (53 percent) or no request for medication (31 percent). So at least for major depression, requests for general treatment appear to be more productive from the pharmaceutical firms' perspective than brand-specific ones.

I find it encouraging that approximately half of direct-to-consumer advertising spent for antidepressants in 2005 was not tied to a specific product but was aimed instead at disease awareness. I would like to see more of this for depression as well as for other conditions.

To improve general awareness of symptoms and treatments, drug companies could air ads that discuss the symptoms of depression and anxiety disorders or depression with substance use disorders. Individuals with these co-occurring mood and substance disorders are less likely than those with mood disorders alone to think they need help.

The direct-to-consumer ads should also discuss the wide range of treatments available for depression, the importance of adherence for preventing relapse, the appropriate duration of treatment, and the importance of patients informing their doctors if they have discontinued their medications.

Studies indicate that physicians generally do a poor job of communicating with their patients about the medications they are taking and patients who are non-adherent often do not tell their doctors. Pharmaceutical marketers should recognize that their profit margins are affected by the poor levels of adherence with medication therapy and focus some of their advertising budgets on addressing this public health problem.

In addition, ads could be targeted at specific groups where rates of under-diagnosis and under-treatment are higher. This would be the case for older men. Because men with depression tend to report irritability, stress, somatic complaints, or cognitive dysfunction instead of depressed mood or sadness, men (and their providers) may not recognize the symptoms of depression. To address this problem, the National Institute of Mental Health (NIMH) recently launched a campaign to reach out to men with depression called Real Men, Real Depression Targeted ad campaigns that address this difference in depression symptoms could benefit public health. And a nationwide campaign, Men Get Depression, is just getting underway.

The public image of the pharmaceutical industry is at an all-time low and its marketing practices are under close legal and regulatory scrutiny. FDA officials have stated repeatedly that they support the industry's use of disease awareness ads. Perhaps using Madison Avenue firms to design public health campaigns in addition to pushing the latest SSRI would make everyone better off.

*Julie Donohue received her Ph.D. in health policy at Harvard University and completed a post-doctoral Fellowship in Pharmaceutical Policy Research at Harvard Medical School. At the University of Pittsburgh Graduate School of Public Health, she has an appointment in the Department of Health Policy & Management and the Department of Psychiatry.