Many physicians assume they are immune to the advertising and marketing strategies of  pharmaceutical companies.
Physicians are confident in their own knowledge and judgment and believe that they will not be overly influenced by a presentation sponsored by a pharmaceutical company  promoting a specific medication.
Physicians believe they are resilient enough to see through the ruse of being offered a reasonably good meal in exchange for sitting through a biased presentation.
These beliefs overlook the more subtle aspects of marketing tactics.
Marketing is not  primarily about the manipulation of evidence. Rather Marketing is informed by more basic implicit psychological processes:  leaning theory, cognitive priming, attachment theory.
Advertising connects the  brand name of a drug  with positive  emotional stimuli, pictures of happy patients in pleasing surroundings.
Marketing strategies engage the physician in a way that promotes positive emotions and  memories that are associated with the drug name. It is done through direct detailing and  the development of positive attachments between the physicians and the drug reps. It is is done by the provision of gits and financial incentives.
But there are less obvious and more intricate strategies that large companies and affiliated physicians may use. For example companies may work to expand the indications for a particular medication. This can be done in two ways:  
i) claim specific mechanisms of action of a drug that target specific symptoms thus creating a niche market.
ii)  broaden diagnostic criteria for a condition by lobbying for changes to DSM.
This may  include the creation of new diagnostic entities and changing diagnostic thresholds.
This is made a lot easier when the pharmacological company itself provides assistance to physicians in making the diagnosis. The company will happily provide  brief diagnostic checklists that allegedly offer a cut off point that implies the prescription of the new medication.
The checklist replaces a comprehensive biopsychosocial assessment.
Some of these strategies have led to quantum increases in the prescription of antipsychotic medications across a range of diagnoses. Antipsychotic medications have been promoted to augment antidepressants in the treatment of depression and anxiety in the early stages of treatment while the risks of metabolic syndrome and tardive dyskinesia are downplayed.
There is even an effort underway to change the name “antipsychotic” to make the use of these medications in a broad range of conditions more palatable to patients and physicians (1). This would also make it less apparent that these medications can cause metabolic syndrome and tardive dyskinesia.
Wakefield has stated:
“A major pressure unique to psychiatric research today,


and one that has detrimentally affected the quality of journal


editing, is the push to publish articles that provide real or


apparent support for proposed changes in the DSM.


Links between DSM diagnosis and reimbursement, research funding,


and approval of pharmacotherapies create non-scientific


motives for justifying additions to DSM and thus for making


claims that stretch or go beyond or against the evidence.” (2,3)
“Entire research programmes (e.g. on complicated grief disorder,


or binge eating disorder) are pursued with the goal in mind of justifying


entry into DSM, with researchers interpreting their data and reviewers


evaluating submitted manuscripts through the lens of DSM.

This appears to have occurred with the new and somewhat absurd inclusion in DSM-V of a depressive mixed mood state. In DSM 5 under “specifiers” for depressive disorders there is a category for depression with mixed features which consist of at least three of the following:

elevated, expansive mood
inflated self-esteem or grandiosity
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
increase in energy or goal-directed activity
increased or excessive involvement in activities that have a high potential
for painful consequences such as buying sprees, sexual indiscretions
or bad business decisions
decreased need for sleep while still feeling rested.
But these specifiers are core symptoms of bipolar disorder and that should be the diagnosis!  There appears to be no scientific evidence for or need to invent a new category of mixed depression. This was very puzzling until I attended a presentation promoting the use of the antipsychotic medication Lurasidone for “mixed states”.
1. Zohar J, Allgulander C. Antipsychotics in anxiety disorders: An oxymoron or a reflection of   non-adequate nomenclature? European Neuropsychopharmacology, 21, 6, p.427-428, June 2011.
2. Wakefield J.  The editor’s dilemma: how DSM politics are
turning psychiatry into a pseudoscience. Acta Psychiatrica Scandinavica 132,

6  p.415 – 502, December 2015.

3. Rosenheck R. Second generation antipsychotics: evolution of scientific knowledge or uncovering fraud. Epidemiology and Psychiatric Sciences (2013), 22, 235–237.

Alan Eppel

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