Subsequent accounts reveal the extent of cooperation between psychiatric researchers and pharmaceutical company personnel in the development of antidepressants. Company scientists were involved in providing new compounds for psychiatrists to try and psychiatrists sometimes suggested leads for companies to follow. Nathan Kline subsequently claimed that the industry was sceptical about the market for antidepressants, and was only persuaded to collaborate in research by his own remonstrations.
However contemporary accounts suggest that by 1961 the industry was ‘launching an aggressive search for more antidepressant compounds’. It may be true that companies were initially reluctant to put their energies into marketing iproniazid, which had been associated with liver toxicity fairly early on, but it also appears that they soon threw themselves into the foray to find drugs for depression. In the British Medical Journal in the first two months of 1962, eight different companies placed one or two page adverts for antidepressants, involving seven different drugs or drug combinations. As early as 1961 antidepressant adverts appeared on the back cover of the British Medical Journal.
The early marketing campaigns for antidepressants had to establish the idea of depression as a common, medically treatable condition. In order to achieve this, Merck, who finally won the patent for amitriptyline, bought and distributed 50,000 copies of Frank Ayd’s book, ‘Recognising the Depressed Patient’. In this book, which can be seen as the first full exposition of the modern concept of depression, Ayd suggested that depression was commoner than was generally realised and that it often went undiagnosed. He claimed that one out of every ten people required some sort of psychiatric treatment in their lifetime and that ‘of all the psychiatric ills to which man is heir, depression occurs with the most frequency’.
He suggested that depression was most commonly encountered in General Practice, where it could be treated satisfactorily by the General Practitioner. He also suggested that many people who acquired other psychiatric diagnoses were in fact depressed. Like more recent marketing campaigns, Merck sought to create a concept of depression as a medical condition, amenable to drug treatment. The concept was also inherently fluid, allowing many more people than before to be pulled into the net of psychiatric treatment.
In the early 1990s, with the launch of the new range of antidepres-sants such as Prozac (fluoxetine), Lustral or Zoloft (sertraline) and Seroxat or Paxil (paroxetine), the pharmaceutical industry was involved in a number of similar campaigns about depression. The UK Defeat Depression Campaign, run by the Royal Colleges of Psychiatrists and General Practitioners but part-funded by Eli Lilly (makers of Prozac), is a good example and typical of other national depression campaigns. The main message echoed Ayd’s book, that depression is an under-recognised problem. The campaign sought to persuade General Practitioners that they should diagnose more people as depressed and prescribe more anti-depressants.
Campaign literature suggested that 5% of the population suffer from depression at any one time and that around 20% of General Practice attenders have symptoms of depression, with half of these needing treatment. The campaign also aimed to reduce the general public’s resistance to taking drugs for depression, stressing that antidepressants were not addictive and distancing them from the recently discredited benzodiazepines. The campaign was particularly concerned to dispel fears of addiction so that people would follow its recommendation that everyone treated with antidepressants, even those with a relatively minor first episode, should continue taking their antidepressants for a further 4-6 months after recovery.
Since most people treated in General Practice were thought to take medication for about three weeks only, this suggestion aimed to achieve a substantial increase in the quantity of antidepressant treatment used. Subsequent publicity about discontinuation effects of antidepressants, especially some Selective Serotonin Reuptake Inhibitors, has led to an acknowledgement of the difficulties of withdrawing from medication, but there has been no revision of recommendations about the benefits or length of treatment. As a result of the Defeat Depression Campaign and more general marketing, use of antidepressants soared during the 1990s. Between 1992 and 2002 the number of prescriptions issued for antidepressants in the United Kingdom increased by 235% from 9.9 to 23.3 million.
Many early advertisements referred to the specificity of antidepres-sants, referring to them as ‘specific’ and a ‘corrective’. But the industry was also concerned to capture the market for agents for anxiety that was perceived as a major problem in the 1960s. Therefore, the sedative or anxiolytic properties of antidepressants were often emphasised. Since the 1990s the pharmaceutical industry has promoted an unambiguous message about the biochemical nature of depression and how antidepressants rectify a chemical imbalance.
The industry has popularised the idea of antidepressants as a disease-specific treatment and greatly expanded their consumer base. Antidepressants have successfully captured much of the market of drugs for ‘everyday nerves’, previously occupied by the benzodiazepines. They are also colonising many other areas including childhood difficulties, eating disturbances and aspects of personality and behaviour such as compulsive shopping and difficulty controlling one’s temper, now diagnosable as ‘intermittent explosive disorder’.