Social Construction of Disease: Depression and Antidepressants

Ian Hacking discusses in The Looping Effects of Human Kinds what he refers to as the “looping affect of human kinds.”  He believes that there is an understanding that we “acquire knowledge of humanity by replacing human kinds by physiological or mechanical or neuro-electrical or bio-mechanical ones (Hacking, 353).” He entertains the notion that we have tried to organize (in order to understand) the human kind into scientific categories, rather than personality traits or emotional variables. He lays out several criteria that constitute a human kind, and by defining what it is that he means by a kind. In effect, he means the variations between people rather than the people exactly. These truths are to be used to create truths about people (Hacking, 252). He spends a great deal of time explaining these kinds, however, more importantly for the purpose of this course is his direct hypothesis of the “looping effect.” Hacking postulates that  “a causal understanding, if known by those who are understood, can change their character, can change the kind of person that they are. This can lead to a change in the causal understanding itself (Hacking,351).” In other words, once a person is classified a certain way, and are made aware of those classifications, then it might change the way they behave.  As a result, Hacking advocates a separation between the human and natural sciences, because humans, as opposed to nonhuman animals or bacterium, are influenced by what is being said about them.  This separation would be important to the study of mental health illnesses because we need to recognize the malleability of the human psyche, and therefore approach the human sciences (that is the science of human kinds) differently than the natural sciences (Hacking, 360).

Taking this concept and developing off of it, David Healy’s article, Shaping the Intimate: Influences on the Experience of Everyday Nerves” focuses on the shifts we have seen within the healthcare system concerning mental health issues. It focuses in particular, on certain influences that pharmaceutical companies  engage in to shape mindsets of physicians and patients alike, to be in their favour.  Not surprisingly, these influences are achieved by carefully planned marketing mechanisms, such as celebrity endorsements, and sponsoring educational events (Healy, 222,223). As of recently, these influences have extended into the academic realm, where interested pharmaceutical companies endorse ghost written scientific papers  and biased clinical trials (Healy,230). What Healy seeks to express through his article is this exact influence on the “domain of nerves” as he calls it, or rather simply the domain of mental health illnesses such as anxiety, panic attacks and depression. Furthermore, he postulates that the powerful experts in this field may not be aware, or fully understand the underlying influences they are being exposed to.

Andrew Lakoff takes a similar stance on the issue, describing the way in which market research firms influenced doctors, therefore the prescribers of such medicines, in Argentina  in 2001, amidst their financial crisis. It started with an information campaign encouraging people to seek consultation about the possibility of they themselves having an emotional disorder (Lakoff,248). The campaign repeatedly referred to  insecurity as being a prime factors in the sudden emergence and popularity of the illness. Obviously, this comes as no surprise given the country’s present turmoil. The campaign was predictably successful, with a drastic rise in numbers of patients complaining about symptoms of stress. However, the campaign itself was sponsored by a pharmaceutical firm called Bago. Selling SSRI’s to the general public in Argentina is illegal, so in order to increase their brand, they had to increase the market in search or need for what their brand produced (Lakoff, 248), and so, the Bago firm did their best to create a paranoia and epidemic of depression.  Furthermore, his article speaks to the difference between North American prescriptions of the drug and ones in Argentina. In Argentina, prescriptions for antidepressants were based more so on a general feeling of emotional distress caused by the social situation rather than a scientific hormone deficiency. Most importantly, it uncovers an important hidden truth about the prescribing of SSRI’s in Argentina. Lakoff expresses great concern in his paper because he reveals that pharmaceutical companies often gifted their physicians, as well as audit firms with fancy vacations or other “perks” for prescribing or giving inside information to the pharmaceutical companies (Lakoff, 253).  This highly unethical manoeuvre encourages physicians to prescribe more of a certain medication, especially under the careful eye of audit firms.

The Irving Kirsch (et al) article presents their findings of their study which aimed to understand the relation between the initial severity of a given patients depression upon diagnosis and the efficacy of the drug (Kirsch). They wanted to extinguish the idea that SSRI’s only had a minutely better result than a placebo in trials, suggesting that the benefit of SSRI’s are too minimal to be significant. Their findings were that patients with severe depression did not respond to the placebo, while they had a bigger response to the medication (Kirsch). This suggests that it is important to take how initially depressed a patient is into account when coming to a conclusion about the effectiveness of a given SSRI. The research team concludes that SSRI’s should only be prescribed to those who are severely depressed (Kirsch). Of course, given the previous information, one could see how even this study may be produced by a company and aims to protect the financial interests of the pharmaceutical companies

Lastly, the Erick Turner et al article talks about how some publications of trials are often selectively published, which creates a biased representation of the truth concerning the benefits and effects of SSRI’s (Turner).  The research group collected reviews from the FDA for 12 separate antidepressant drugs.  They performed a comparative analysis between published outcomes of trials with the  FDA reports.  Their conclusion is simple; regardless of the mannerism in which the bias comes to exist, it can have negative consequences because it creates an error by omission of all facts (Turner).

A few general conclusions can be taken from this grouping of readings. The Hacking article illustrates for readers the looping effect, that when applied to the discussion of mental health illnesses, may help account for the shifts in mental health that Healy goes on to describe in his article, as well as the general Argentinean public. As people become aware of the classifications that surrounded mental health illness, Hacking would suggest, they would morph themselves to better fit those classifications. Perhaps, one could imagine that a depressed person, coming to learn the “typical” characteristics of a depressed person, would adopt abnormal sleeping patterns, become increasingly negative, change their eating habits, etc. This accounts for the dramatic rise in numbers of patients exhibiting signs of depression that both Lakoff and Healy describe.  These two authors go about describing the mechanisms used to incite these looping effects – extensive marketing, biased research, and arranged prescription agreements. The Kirsch and Turner articles are reminders of how dangerous omitting information can be, but how the reality is that that is often the case.

The main point to be taken away from these articles is that the arena of SSRI’s is one which is deeply driven by economic reward. Pharmaceutical companies are the ringleaders, so to speak, of this arena. They are responsible for the upsurge in the depression epidemic, because they have such a strong influence on the public, physicians and academia alike. Their “disease marketing”, to borrow Healy’s term,  creates a type of depression paranoia, only to be reinforced by ghost written research papers,  labelled with key psychiatrists in the field, among a plethora of other mechanisms. Physicians of course, may not be aware of the influences upon to, and so they continue to prescribe SSRI’s (or like in the case of Argentina, they do so because of the “economy of gifts”).

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