A Defacto Placebo Effect?

After reading the Greenslit piece, I wonder if the way a drug gets packaged can influence that drug’s efficacy. I.e., might there be a placebo effect from taking a drug with certain “inessential” characteristics versus taking a chemically identical drug with different “inessential” characteristics?

To illustrate, let us imagine an experiment. You give a group of people supposedly suffering from “PMDD”aesthetically different, but chemically identical, treatments: some get the green-and-white “Prozac,” while others get the pink-and-lavender “Sarafem.” If one treatment yields better results, I would conjecture that we are witnessing a “placebo effect” of sorts. I.e., while no “actual placebos” are involved, there are characteristics like “pill color” that may not affect the chemical or biological processes involved in a treatment, but do influence a patient’s psychological well-being and contribute to a treatment’s efficacy (especially if we are talking about psychiatric or mood disorders) .

Now, I do not have empirical evidence to justify that there is in fact a placebo-like effect when active ingredients get packaged in one way versus another; this is just a hypothesis that needs to be researched. However, if I am right, my hypothesis has implications for the discussion and debates surrounding pharmaceutical rebranding. Firstly, we might say that re-branding can be medically, and not just commercially, justified. Further, from a normative standpoint, we might say that regulatory bodies should require pharmaceutical companies to rebrand drugs for certain disorders, but not be to maximize the commercial value of a drug (as is the status quo), but rather to find which package or “brand” maximizes a particular drug’s effectiveness as treatment for a disease. Most often than not, I expect commercial and medical effectiveness of a drug’s branding will coincide, but in this way, rebranding can at least become a boon to public health.

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The business of rebranding

In Nathan Greenslits’ article “Depression and consumption: Psychopharmaceuticals, Branding, and New Identity Practices”, he focuses on how our ideas about mental health are produced by pharmaceutical companies and are inevitably consumed by the public. Throughout the article, he uses the example of Sarafem and how it has been recycled from Prozac (antidepressant) to treat premenstrual dysphonic disorder (PMDD). I want to focus my attention on the section titled “Markets, Molecules, and Meanings”, where he demonstrates that pharmaceutical companies have a vested interest in branding their product to match the particular illness as well as rebranding. He does this by showing us that while Sarafem has the same chemical make up as Prozac, the public only associates it with PMDD.  This is important for drug companies to establish as the public would not want to associate depression and PMDD together, therefore a rebranding must occur.

While I have never given branding with respect to pharmaceutical drugs much thought, they have done quite an incredible job. For example, if a physician recommends that I take Viagra for any medical issue I may have that is not related to sexual dysfunction, I would most definitely be skeptical, let alone “shocked and angry” as the article points out. The stigma associated with Viagra is so directly related to sexual dysfunction that if it were assigned for any other medical illness, it would definitely have to be rebranded. Marketing for drugs is an important business, but rebranding must be regarded as equally important as well as the task is quite substantial. 

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Prozac & Sarafe- Identical but different


Nathan Greenslit’s “Depression and Consumption: Psychopharmaceuticals, Branding, and New Identity Practices” examines a case where two chemically identical pharmaceutical drugs are branded and marketed as different, serving different purposes.  Fluoxetine Hydrochloride, under the brand name Prozac is marketed as an antidepressant, while the very same drug is marketed as a treatment for premenstrual dysphoric disorder (PMDD).  Both are developed, manufactured, and marketed by the Eli Lilly drug company.  Although these drugs are chemically identical, they have different social histories and identities.  ‘Sarafem’ is associated strictly with “the drug that treats PMDD, and ‘Prozac’ is associated with the distinct description “the drug that treats depression’.  Greenslit posits that the language that is formed in association to these drugs intentionally associates them to a disease, rather than each other, even though they are identical, so that consumers remain unaware that they are taking a drug that is also used for a different medical condition.  With this strategy, pharmaceutical companies can independently profit from two identical drugs.

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The New (Improved..?) Roles of Drugs

Greenslit’s article raises interesting questions about the ways both institutions and individuals appropriate drugs for their own use and to achieve a variety of ends. In their growing new role as consumer products, it seems to some extent unavoidable that the purpose of drugs will stray from its origins as a direct treatment to a specific health issue requiring treatment. This trend has created many of the questions we have been attempting to answer regarding how to determine which uses of drugs are ethical and how we should regulate them to ensure their use stays limited to these ways – or if we should do so at all. Greenslit demonstrates the particular danger posed for our conceptions of mental illnesses, which by nature are extremely vulnerable to the external influences such as marketing and branding that are increasing as drugs become a commodity. Further, as seen previously in the course, the greatest blockbuster drugs are rarely even treatments for life-threatening or –altering health problems; the amount of the industry’s focus, money, and time that is wasted on constantly developing new ‘diseases’ from minor, commonplace complaints in order to sell profitable drugs to treat them is one clearly unethical result of this process. The transformation of medicine into an increasingly accessible market product, being used for differing purposes within myriad personal and public discourses, has facilitated the loss of a single genuine aim and ethic for the healthcare system to strive for. Whether this is something we should embrace or resist remains a contestable subject from many angles. 

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Both Hayden “Pharmaceuticals and the Politics of the Similar in Mexico” and Greenslit’s “Depression and Consumption” partly address how drug prescriptions give primacy to brand names over active substances.

Hayden reports how in 1998 the Ministry of Health in Mexico responded to a social-security crisis that drove up the cost of medicine by encouraging growth in the country’s generic pharmaceutical market.  The Mexican government enacted a policy requiring public sector physicians “to prescribe the active substance of a drug, rather than simply a brand name” (478).  The policy aimed to debase a “ ‘culture of the brand’, in which the foreign-made and expensive is seen as naturally superior” (478).

The qualities of being ‘foreign-made’ and ‘expensive’ reported by Hayden can be grouped with the dual titles and packagings of fluoxetine hydrochloride that Greenslit addresses.  They all belong to what Baudrillard calls the “ ‘inessentials’ of advertised commoditities” (Greenslit 480).  These qualities, superfluous to a drug’s physiological effects, might have beneficial effects for drug consumers: supporters of the Sarafem/Prozac distinction argue that a distinct and unique disease-drug relationship helps sufferers of PMDD psychologically by establishing a medical identity, and it seems equally plausible that selecting a more expensive, foreign-made drug over an equivalent, cheaper generic might lead a consumer to a better recovery because they believe they are receiving superior treatment.

This current emphasis on the inessential qualities of medicines, however, creates a climate where patients are informed more by marketing and politics than medical knowledge, where patients must be both a “savvy consumer and political activist.”

If doctors prescribed active substances rather than brand names, the climate would certainly change. Such a shift would make evident that few drugs are used to treat many diseases, and second, that our lack of finer, more specified substances reveals we sometimes know little about the interactions between drugs and bodies.

If diseases are no longer tied knee-jerk to a single drug in the public eye, it is possible this shift would slow down rather than speed up what Hayden calls the “pharmaceuticalization” of public health.  Words are powerful.  They become even more powerful when they represent the cures to our most intimate problems.  If we remove the brand name mask, then a drug becomes just a chemical, and seen as such, we might be less likely to take it as an all-in-one solution, favouring instead a broader conception of treatment.

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Greenslit article comment

Nathan Greenslit challenges us to think about our relationships with pharmaceuticals. I didn’t think the article was just about consumption and branding, but rather identity practices that place the reader/consumer in a state of being. This state of being may be described or framed in terms of a diagnosis but also in terms of a prescription.

Greenslit quotes Lauren Slater who suggests that “we are all “on” Prozac”, and I’m reminded of an episode of PBS Idea Channel where the host asks if there is such a thing as “offline”? That discussion focussed on the on-line/off-line distinction and how ambiguous it is. With respect to Greenslit’s article, we could debate the on/off prozac distinction. At what point are we considered “on Prozac?” It doesn’t seem as simple as orally taking Prozac. What dose? What strength? For how long? Is there a ramp-up? Is there a wash-out? These questions confuse the notion of being on Prozac. The distinction becomes less-so when we consider ourselves in a state of pre-Prozac and post-Prozac. In this sense, the state of being becomes a spectrum where it is quite conceivable that, to some extent, we are all on prozac.

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The Social Identification and Integration of Pharmaceutical Products

In ‘Depression and Consumption: Psychopharmaceuticals, Branding, and New Identity Practices,’ Nathan Greenslit suggests that the packaging, marketing and targeting of pharmaceutical products not only allows them to assume changing social lives, but allows them to represent various cultural messages that contribute to a key dimension of the social histories of mental illnesses. The product itself apparently has an identity that becomes crystallized in the context of social explanations. Following Baudrillard, Greenslit wonders if personalization with such a product identity is achieved through an emphasis on inessential aspects of a commodity, or aspects distinct from functional ones.

There lies a boundary between science and politics that arises from the relationship between medicine and culture. Marketing complicates what is considered real or bad science. Using the example of Sarafem, Greenslit explores how psychiatry medicalizes premenstrual experiences, and complicates concerns about how the pharmaceutical industry consequently capitalizes on premenstrual experiences. It appears as though drugs themselves change the social reality of mental illness, for the case of PMDD shows how the pharmaceutical industry medicalizes the condition as bodily rather than hormonal in order to eventually create new ideas about premenstrual symptoms.

Greenslit consequently emphasizes the ways in which the coproduction of illness categories with pharmaceutical treatments creates ways for people to speak about themselves as medical objects, and as experiencing themselves as subjects of medical discourse. Prescription drugs are produced not only as chemicals, but also as texts with social, cultural, and personal influences and interpretations.

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