Pharmaceutical Company Power Over the SSRI Prescription Habits of Physicians in the United States

Candidate Number: W09855
7SSHM612 Pharmaceuticals and Society
Pharmaceutical Company Power Over the SSRI Prescription
Habits of Physicians in the United States
Final Essay
MA Bioethics & Society
May 04, 2016
Word Count: 3,499

Introduc)on
Selec%ve Serotonin Reuptake Inhibitors (SSRIs) are a class of pharmaceu%cal drugs used for
the treatment of depression and have existed on the American market since the 1980s (Gorman,
1997, p. 90). The popularity of SSRI prescrip%ons in the United States has steadily increased since
their introduc%on, and they remain the most popularly prescribed class of an%depressant today
(Harris et al., 2009, p. 37; Kantor et al., 2015, p. 1829). Despite their popularity, many medical
professionals and academics have argued that there is liPle to no scien%fic evidence that SSRIs are
an effec%ve treatment for most forms of depression. If the evidence indeed demonstrates that
SSRIs are not effec%ve, how is it that SSRI prescrip%ons remain so popular in the United States?
In this essay, I will analyze the popularity of SSRI prescrip%ons in the United States using
“power as causa%on” theory, which explains social events or trends in terms of a cause-and-effect
rela%onship between actors exer%ng power over each other (McFarland, 2015). I will examine the
actors involved in the SSRI prescribing process, analyze how power is exerted by one actor over
another, and examine observable instances of how exer%ons of power can influence the SSRI
prescribing trends. I will narrow my focus to two actors— doctors and pharmaceu%cal companies
— and examine how pharmaceu%cal companies exert power over doctors in the prescribing
process. I will also sort my research of these power dynamics into three manifesta%ons of power
over the SSRI prescribing process: power over the depression narra%ve, power over informa%on,
and power over brand loyalty. I will conclude with arguing that while prescribing prac%ces have a
variety of influences, pharmaceu%cal companies have a significant amount of power over the
prescribing process. Understanding the power of pharmaceu%cal companies may help physicians
and policymakers overcome these influences to ensure pa%ents receive the best recommended
treatment for their depression.
Depression and SSRIs
Candidate Number: W09855; 7SSHM612 Pharmaceuticals and Society; Final Essay
2

The World Health Organiza%on (c2016) defines depression as a common mental disorder
than can have a range of emo%onal symptoms and be mild, moderate or severe in form.
Depression is commonly thought to be caused by low levels of the neurotransmiPer serotonin in
the brain (Goldacre, 2012, p. 256). An informa%onal leaflet (Eli Lilly and Company Limited, 2016)
for the SSRI Prozac (fluoxe%ne) explains that SSRIs are believed to relieve depression by increasing
the levels of serotonin. While this biochemical model remains the commonly understood cause of
depression, many health resources assert that the actual cause of depression is s%ll unknown
(Chwas%ak, 2003, p. 1304; Centers for Disease Control, 2016). It is also argued that the
biochemical model of depression and the significance of serotonin levels is fundamentally flawed
(Goldacre, 2012, p. 256; Healy, 2003 cited in Moynihan and Cassels [2005, p. 23]). Research also
suggests that clinical trials have failed to prove that SSRIs are effec%ve in relieving mild to
moderate depression because the SSRIs barely outperform placebos (Chwas%ak, 2003; FDA 2008
study cited in Healy [2009, p. 56]). Because SSRIs can also cause a variety of unpleasant symptoms,
the research that argues that SSRIs are no more effec%ve than a placebo in trea%ng mild and
moderate depression suggests that these drugs may not be a benefit to most pa%ents.
SSRI Prescrip)ons and Power
Despite the evidence cas%ng doubts on SSRI efficacy, the number of SSRI prescrip%ons in
the United States has con%nued to grow since SSRIs were first introduced. SSRI use in the United
States grew 147.5% during the 1990s (Skaer et al. 2000 study cited in Clarke and Gawley [2009, p.
91]). Between 1999 and 2012, SSRI use doubled and became the most popular prescrip%on for
trea%ng depression (Kantor et al., 2015). If a doctor’s duty is to prescribe the best possible
medica%on for a pa%ent, and the effec%veness of SSRIs are so seemingly ques%onable, what could
cause the con%nual popularity of SSRI prescrip%ons in the United States?
I will examine this phenomenon through “power-as-causa%on” theory, which seeks to
explain social trends or events in terms of a cause-and-effect rela%onship of actors exer%ng power
3

over each other. Ben Goldacre, in his book Bad Pharma (2012, p. 240) acknowledged the role of
power in the prescribing process when he described how the actors involved “exert pressure” on
one other. The poli%cal scien%st Robert A. Dahl (1957, pp. 202-203) defined power as: “A has
power over B to the extent that he can get B to do something that B would not otherwise do.” If
prescribing SSRIs can be construed as something a doctor “would not otherwise do” in light of the
evidence against SSRIs, the consistently high SSRI prescribing trends could be explained in terms of
actors exercising power over the prescribing process if a cause-and-effect rela%onship can be
established.
In my analysis of influences of power on the prescribing process, I will focus on the power
rela%onship between doctors and pharmaceu%cal companies, as they are the actors that form two
essen%al components of a prescrip%on; pharmaceu%cal companies manufacture the medica%on
for the prescrip%on, and doctors write the prescrip%on. I will examine the extent to which
pharmaceu%cal companies may have power to cause doctors to do something they “would not
otherwise do” (prescribe an ineffec%ve treatment). To analyze any kind of power rela%on, poli%cal
scien%st Andrew MacFarland (2015, p. 760) writes: “A statement of power then implies
observa%ons of instances of A changing B’s behavior. . . One first has to observe the causal
rela%onship; then one analyzes how power was wielded.” I have categorized my findings into three
expressions of power over doctors and the prescribing process: (1) pharmaceu%cal company
power over the depression narra%ve, (2) pharmaceu%cal company power over informa%on, and (3)
pharmaceu%cal company power over brand loyalty.
Pharmaceu)cal Company Power Over the Depression Narra)ve
Researchers Juanne Clarke and Adele Gawley (2009, pp. 94-99), in a review of ar%cles from popular
magazines between 1980 and 2005, found that the percep%on of depression in the United States
was not consistent within that 25 year period; in the 1980s, depression was viewed as “many
things” and its cause was “linked to normal events and social life” but in the 1990s, they found that
4

“depression becomes defined as biomedical” and “the vast majority of explana%ons were
scien%fic, technical, or physical explana%ons.” This rise in the cultural percep%on that depression is
biologically caused may be linked to the growth of an%depressants and how they were marketed
for the biochemical model of depression (Clarke and Gawley, 2009, p. 100; Moynihan and Cassels,
2005, p. 22-23). Ben Goldacre argues in favor of this theory:
The story of the serotonin hypothesis for depression, and its enthusias%c promo%on by
drug companies, is part of a wider process that has been called ‘disease mongering’ or
‘medicalisa%on,’ where diagnos%c categories are widened, whole new diagnoses are
invented, and normal variants of human experience are pathologised, so they can be
treated with pills (2012, p. 258).
Pharmaceu%cal companies that manufacture SSRIs have a vested interest in medicalizing and
propaga%ng a biochemical narra%ve of depression, because any alterna%ve explana%ons of the
cause of depression (such as nega%ve circumstances) that challenge SSRI sales will challenge
profits.
Pharmaceu%cal companies can influence the depression narra%ve through marke%ng. Large
pharmaceu%cal companies invest heavily in marke%ng and typically spend more money on
marke%ng than on research and development (GlobalData 2013 study cited in Anderson [2014]).
Pharmaceu%cal companies invest heavily in marke%ng because it is proven to work (Chew et al.
2000 study cited in Schweitzer, [2007, p. 85]; Spurling et al. 2010 systema%c review cited in
Goldacre [2012, p. 271]). Marke%ng can target the populace through direct to consumer
adver%sements (which is permiPed in the United States), and pharmaceu%cal marke%ng can also
target doctors through visits from pharmaceu%cal representa%ves, direct-mail promo%ons, medical
journal adver%sing, or con%nuing medical educa%on programs (Schweitzer, 2007, pp. 87-92).
How does influencing the dominant depression narra%ve influence the prescribing process?
If the widespread understanding of depression is biochemical causes, and SSRIs are marketed to be
the best treatment for these causes, pa%ents will be more likely to seek SSRIs as treatment for
5

their depression and doctors will be more likely to prescribe them. In addi%on, the very act of
seeing a doctor to request a specific drug has been shown to influence the prescribing process.
Anthropologist Joseph Dumit describes this effect through a 2005 study (Kravitz et al. 2005 study
cited in Dumit [2012, p. 56]):
Actors posing as pa%ents visited doctors, presented symptoms of depression, and in
some cases men%oned seeing a direct to consumer commercial and asked for a drug by
name. The troubling result by these “standardized” pa%ents was a profound increase in
prescrip%on rates for an%depressants.
The causal rela%onship observed is the research that shows that doctors’ prescribing trends
can be influenced by the marke%ng strategies of pharmaceu%cal companies. The way that power is
wielded in this instance is through marke%ng a biochemical model of depression alongside SSRIs as
a treatment. By changing the narra%ve of depression from social or circumstan%al causes to
biochemical ones, SSRIs become viewed as first-line treatments by both doctors and pa%ents.
Pa%ents become more likely to ask for SSRIs, and doctors are more likely to prescribe them.
Pharmaceu)cal Company Power Over Informa)on
The data gathered on drugs during clinical trials to test safety and efficacy is an incredibly
important component of understanding the effects that a drug may have on a pa%ent, making that
informa%on very important to doctors. In the US, pharmaceu%cal companies are ac%vely involved
at almost every stage of a drug’s development, which places them in a posi%on of influence over
the informa%on that makes it to doctors.
One significant issue is that of missing informa%on. Clinical trials that produce nega%ve
results are not open published, which can misrepresent the safety or efficacy of a drug. A single
favorable study may make a drug appear effec%ve, but six addi%onal studies that produced
nega%ve results would make the drug appear ques%onable. Research shows that pharmaceu%cal-
funded trials are more vulnerable to this kind of manipula%on. In a 2010 study of five hundred
6

clinical trials, 85% of the pharmaceu%cal-funded trials were posi%ve, compared to only 50% of
government-funded trials (Bourgeois et al. 2010 study cited in Goldacre [2012, p. 1]). Ethicist
Leonard J. Weber references a specific example from the history of SSRIs:
In the FDA review in 2004 of the safety/risks of suicide related to the use of [SSRIs] by
teenagers and younger children, one of the most significant points that came to light
was that companies had not made public the results of some clinical trials showing a
link between the drugs and suicidal behavior. . . It is not enough to publish only the
posi%ve results of studies” (Harris, [2004] cited in Weber [2006, p. 102-103]).
The structure of a clinical trial can also be manipulated to produce a favorable result. The
size of the study, the types of par%cipants recruited, and the type of control group are all variables
that can be adjusted to produce a favorable result. In a 2009 study (Kendrick et al.) of SSRI efficacy
when used in conjunc%on with suppor%ve care, the results indicated that prescribing SSRIs in
addi%on to suppor%ve care was more effec%ve than suppor%ve care alone. On the surface, this
conclusion appears to demonstrate that SSRIs are effec%ve, but the structure of the study was not
able to rule out the placebo effect, as the control group was not administered a placebo. Other
prac%ces that can misrepresent or hide clinical trial data include inten%onally stopping an
unfavorable study early before it can be published, and failing to give researchers who are wri%ng
the study access to all of the data (Weber, 2006, p. 125).
It is important to note that it is impossible for any doctor to review all of the data available
for a par%cular drug (Goldacre, 2012, p. 242). Research by Coleman et al. (1966 study cited in Lilja
et al. [2008, pp. 259-260]) demonstrates that physicians are more likely to be informed by a
network of colleagues, with medical “opinion leaders” (expert physicians of influence) in the
center of the network. Researchers Lilja et al. (2008, pp. 260-262) argue that these opinion-leading
physicians can affect the prescribing habits of other doctors, which makes them a target for
pharmaceu%cal company influence. Opinion leaders can be used by a pharmaceu%cal company to
increase the adop%on of a drug by other doctors in different ways. Physicians could be paid to give
7

talks or meet with other doctors to discuss the merits of a drug (Moynihan and Cassels, 2005, p.
39). Physicians could also be hired to be an “author” of a clinical trial that they were not involved
in or to sign their name to a favorable report wriPen by a pharmaceu%cal company writer (Weber,
2006, p. 125). Easch of these examples are instances of marke%ng that are presented to physicians
as expert opinion or knowledge. This prac%ce extends into the psychiatric world, and Moynihan
and Cassels argue that the endorsements of opinion leaders has demonstrably influenced SSRI
prescribing prac%ces:
By any objec%ve analysis, one of the reasons the SSRI an%-depressants were embraced
by prescribing doctors so fulsomely all over the world for so long was because the hard
work of detailers [pharmaceu%cal representa%ves] was backed with the credibility of
psychiatrist thought-leaders in the pay of the drug makers (2005, p. 40).
Opinion leaders can influence the prescribing habits of other doctors because their knowledge or
exper%se is valued or respected. When pharmaceu%cal marke%ng is disguised as expert
knowledge, “informa%on” of the merits of a par%cular drug is misrepresented.
The type of power wielded by pharmaceu%cal companies in these instances is an ability to
misrepresent, hide, or manipulate the scien%fic data about drugs that the medical community
relies on for prescribing knowledge. The cause and effect rela%onship between the concealment or
manipula%on of data and prescribing trends is apparent; if the best available informa%on is
withheld or misrepresented to any individual, they will be unable to knowingly act according to the
best informa%on available. The cause and effect rela%onship between “opinion leader”
endorsements and prescribing prac%ces can be seen through the research showing that leading
physicians have a strong influence on the prescribing habits of doctors (Coleman et al., 1966 study
cited in Lilja et al. [2008, pp. 259-260]). The extent to which pharmaceu%cal companies can buy
endorsements from opinion leaders that are disguised as expert knowledge to influence other
physicians is an instance of pharmaceu%cal power over the prescribing process.
8

Pharmaceu)cal Company Power Over Brand Loyalty
The American Marke%ng Associa%on Dic%onary (c2016) defines brand loyalty as, “The
situa%on in which a consumer generally buys the same manufacturer-originated product or service
repeatedly over %me rather than buying from mul%ple suppliers within the category.” To translate
this defini%on to the prescribing process, the doctor would be the consumer, and brand loyalty
would be wri%ng prescrip%ons for the same product rather than prescribing with more variety.
True loyalty between two actors is something that can never be elicited through force, but the
ability to win an individual’s loyalty s%ll usually involves possessing a level of power or influence.
As an example, a farmer from a small US town who decides to run for president may have the
charisma to gain a following, but may never aPract millions of supporters the way that a senator
with resources and poli%cal influence might. Pharmaceu%cal companies cannot force brand loyalty
on doctors, but they do have resources that could increase the likelihood that doctors consistently
prescribe their product.
It is important to note that there are many reasons a doctor could choose to consistently
prescribe one type of drug that are not connected to pharmaceu%cal exer%ons of power or
influence. Doctors could favor a drug that is most cost-effec%ve or the drug that is proven to be the
best on the market for trea%ng a certain condi%on, which are all mo%va%ons in the best interest of
pa%ents. Power would only be linked to influencing the prescribing process if it could be shown
that a doctor consistently prescribed a brand for reasons that offered no direct benefit to pa%ents.
One pharmaceu%cal marke%ng strategy that can elicit brand loyalty is the provision of free
drug samples to clinics. In 2004, $15.9 billion worth of pharmaceu%cal samples were distributed to
physicians in the United States (Kaiser Family Founda%on, 2005 cited in Schweitzer [2007, p. 89]).
Free samples are supplied to give doctors and pa%ents the opportunity to “try out” a new drug,
and doctors are shown to distribute these free samples among themselves and their pa%ents
(Weber, 2006, pp. 82-83). Free samples can be understood to benefit doctors and pa%ents, but as a
marke%ng strategy, the sole purpose of free samples is to encourage pa%ents and doctors to
9

exclusively use and prescribe these products. And providing free samples can influence the
prescribing process. One study (Chew et al,. 2000 study cited in Schweitzer [2007, p. 89]) found
that doctors will distribute samples even if it is not the drug they would have otherwise prescribed.
Physicians are also more likely to simply con%nue prescribing drugs that ini%ally began as a free
sample (Coyle, 2002 cited in Weber [2006, p. 84]). If pa%ents no%ce a favorable response using a
free sample, they are also more likely to request this drug from their physician in future
prescrip%ons (Schweitzer, 2007, p. 89).
Physicians can also be swayed when free samples create a gip rela%onship with
pharmaceu%cal companies. According to ethicist Leonard J. Weber (2006, p. 89):
Personally benefi%ng from sample medica%ons, like personally benefi%ng from other
gips, can compromise the physician’s independence and objec%vity. Gips of greater
value [drugs of higher costs] open have higher poten%al for giving rise to a sense of
indebtedness to the giver, and consequently, influencing and/or compromising behavior.
Moynihan and Cassels (2005, p. 24) agree: “Human beings have a natural tendency to want to
repay kindness, and the best way doctors can do that is by prescribing the products that the
detailers are pushing.” These are paPerns that exist throughout the clinical world, and are equally
true of SSRI samples on prescribing habits (Moynihan and Cassels, 2005, pp. 22-23).
Pharmaceu%cal companies spend billions of dollars on marke%ng strategies to elicit brand
loyalty prescribing from doctors. Providing free samples is one example of how pharmaceu%cal
power is wielded in this instance, as such tac%cs has been shown to influence prescribing habits.
This demonstrates a causal rela%onship between pharmaceu%cal exer%ons of power and the
prescribing process through marke%ng strategies to win brand loyalty.
Conclusion
Marke%ng and data misrepresenta%on are ways in which pharmaceu%cal companies can
wield power over the prescribing process. In the case of SSRIs and how doctors in the United
10

States con%nue to prescribe these an%depressants despite the academic and medical research that
asserts that these drugs are ineffec%ve at trea%ng depression, these prescrip%on trends can be
linked to these pharmaceu%cal company exer%ons of power. Pharmaceu%cal company marke%ng
has been argued to have had a profound impact on changing the narra%ve of depression into a
biochemical interpreta%on of depression that is best treated with SSRIs (Goldacre, 2012; Moynihan
and Cassels, 2005). This can impact the SSRI prescribing process by causing SSRIs to be viewed as a
first-line treatment, when in reality, other treatments may be more effec%ve. Pharmaceu%cal
company power over providing drug informa%on can also have a large impact on the prescribing
process, because incomplete informa%on prevents doctors from knowing what the best possible
treatment for their pa%ents may be (Goldacre, 2012; Weber, 2006). Efforts to market SSRIs under
the guise of “expert knowledge” through the hiring of “opinion leaders” further demonstrates a
level of pharmaceu%cal control over the kind of informa%on that is presented to doctors to inform
their prescribing habits. Lastly, pharmaceu%cal company power over brand loyalty can influence
the SSRI prescribing prac%ce by encouraging doctors to con%nually write prescrip%ons for the SSRI
drugs manufactured by the company. Through gip-giving or the provision of free drug samples,
these strategies have an effect on encouraging doctors to con%nue wri%ng prescrip%ons for the
medica%ons pushed by companies. This can cause prescrip%ons to be wriPen out of habit or upon
a pa%ent’s request rather than through serious evalua%on.
The power of pharmaceu%cal companies is not the only power that can exert influence over
the SSRI prescribing process, as pa%ents, government, and funders can also demonstrate a level of
influence (Goldacre, 2012, p. 240). However, the above cause-and-effect rela%onships indicate that
pharmaceu%cal companies have a fairly significant influence over the SSRI prescribing process, and
because pharmaceu%cal companies are mo%vated primarily by profits, the level of influence may
not always work in the best interest of pa%ents. Acknowledging the power that pharmaceu%cal
companies have over the SSRI prescribing process may help physicians and policymakers iden%fy
11

and overcome these inﬂuences to provide the treatment of depression that is best for the pa%ent,
according to the best evidence.
12

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