Advertising Depression: The Case of Paxil

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A brilliantly written, insightful and informative essay on -

Advertising Depression: The Case of Paxil ( with images from campaigns)

Cristina Hanganu-Bresch, University of Minnesota
Advertising Depression: The Case of Paxil
Writing about advertising and the “therapeutic roots of consumer culture,” T.J. Jackson Lears (1983) points out that advertising relies on a historical shift to a “therapeutic ethos” that occurred some time around the turn of the century, and which is characterized by “the fretful preoccupation with preserving secular well being, the anxious concern with regenerating selfhood.” This new ethos shows, through various cultural institutions such as advertising, “an almost obsessive concern with psychic and physical health defined in sweeping terms” (1). My premise here is that the recent proliferation of psychiatric advertising in both specialized and popular journals is an arguably even more transparent medium for Lears’ thesis; and it is more so for two reasons. First, as Barthes (2002[1964]) emphasized, advertising an obvious target for semiotic analysis because it is “undoubtedly intentional,” “frank, or at least emphatic” (34). Second, psychiatric advertising offers a more direct view at our fears and desires as framed by the scientific and popular discourse on health because it unequivocally refers to an ideal of normality. I am therefore going to attempt a semiotic analysis of a contained and relatively comprehensive sample of the images used in print ads for a particular antidepressant--Paxil.

I must make clear that it is NOT my intention to contest the reality of mental illness. R.D. Laing and antipsychiatry have long been proven wrong: schizophrenia or depression are, undoubtedly, illnesses, not social constructs. I also do not contest the usefulness of psychiatric drugs, when judiciously administered. I applaud recent progress in removing the stigma of mental illness. We are more and more today seeing mental illnesses as illnesses, on a par with others, and we try to treat them as such.

However, language and our own practices betray our best intentions. Words like “insane, nuts, crazy,” label both behavior that we disapprove of and behavior of people with a mental illness. We also sometimes have a hard time distinguishing between everyday angst and an illness that requires medication; well, for that matter, trained psychiatrists might experience some difficulty in that area, too. The symptoms of mental illness, as often advertised, are usually non-specific enough to qualify for general malaise sometimes, and in that case, it becomes impossible to see the difference between illness and normality. In short, it’s becoming difficult today to tell when we need Oprah, Freud, or Nurse Ratchett. Psychiatric diagnoses are oftentimes subject to interpretation, and difficult to get falsified (failing the Popperian criterion for science).

This is where ads sometimes come to help: by describing mental illness symptoms, by showing us how they look, by labeling them, they claim to educate and even empower both doctors and patients. Their imagery tells a story, conveys a message, helps fix or sometimes change our mental map in that particular area. Before I go on to talk about the semiology of psychotropic drug ads, let me first mention, alas too briefly, a few factors that have shaped the way we struggle to construct mental illness, visually and not only, today:

- The status of psychiatry as the least regulated, least “professionalized” field within the medical sciences; as a result, the ads try to build ethos for the psychiatrist, either by using “scientific realism” (graphs, charts, chemical processes), or by emphasizing the humanity of their patients when overwhelmingly relying on photographic portraits.

- The split between a biological and a psychoanalytical model of treating mental illness, with the overwhelming success of the former (today, there is hardly a hint, or zero, toward combining the two methods; in the 60’s the ads still emphasized the complementary role of the drugs as aids in therapy, but not as replacements)

- The rise of the psychotropics—and the discovery of the SSRI drugs, with the ensuing “cosmetic psychopharmacology” trend;

- The gradual transition from a doctor-patient model to a highly commercialized model of provider-consumer; from the individualized visit to the managed-care system. In this context, the psychiatrist has once again lost prestige within the mental health system as she is often employed as a technician rather than a caregiver and supervisor.

- The rise of the DTC trend (direct-to-consumer advertising) in the US, and our daily bombardment with symptoms of mental illness that can be miraculously cured with a drug. This trend has been extensively criticized in literature for medicalizing everyday human condition and challenges, playing with basic emotions and human desires for the purpose of profit. Clients have been transformed, some argue, into salespeople for the drug companies. Many studies have shows that more advertising “leads to more requests for advertised medicines, and more prescriptions.” For Mintzes et. al, “If DTCA opens a conversation between patients and physicians, that conversation is likely to end with a prescription, despite frequent physician ambivalence about treatment choice.” (2003). For others, “The constant barrage of DTCA contributes to the “medicalization” of normal human experience by which the authority of medicine and our modern inability to accept the normality of illness and death has turned us into ‘two-legged bundles of diagnoses.’” Conversely, the trend has been defended as being educational and empowering consumers in a managed care system where there are no longer close relationships established with doctors and consumers must be responsible for their own care. There are more pressures on physicians, too (they have to see more patients every day, and spend less time with each). Patients take charge of their own health and are aided in that task by an explosion of new drugs being approved by the FDA weekly.

The questions that often pop into my mind seeing these ads is, “Is illness a commodity? A need? And evil? Does ‘normalizing’ it or relentlessly pushing a list of symptoms enlarge the consumer basis of the prescription drug?” Many of the ads want us to believe there is a connection between the photograph and the way the illness works, and in turn, we believe we understand it: the images of difference or identity seem so straightforward that we take them for granted. They move us because we can superimpose our stories on the stories of the models. While once visuals in psychiatry were used to diagnose, today, they’re used, arguably, to self-diagnose, and, of course, to sell.

I’ll be looking at a small sample of psychiatric advertising: Paxil ads in the American Journal of Psychiatry and popular media, 1993-to date (1993 is when Paxil started to be marketed). If I want to decipher a certain Weltanschauung in these images, I have to be aware that there is no truth to be established except in the process of semiosis, in the act of seeing, interpreting, identifying, or signifying, in the way the beliefs of the producers of the ad and the beliefs of the groups targeted are interacting. “Reality is in the eye of the beholder” (Kress and Van Leeuwen). However, as these authors point out, "the eye has had a cultural training and is located in a social setting and a history." I’m also aware that ads, like most images, are polysemic; still, I believe with Stuart Hall that they produce a “preferred meaning”. And finally, according to Williamson (1978: 42), the adverts “invite us ‘freely’ to create ourselves in accordance with the way in which they have already created us.” In Gillian Rose’s words, “This sense of creative freedom is the most subtle form of adverts’ ideology […] because it deceives us into thinking that we can choose our social position through what we consume.”

Although it is very hard to generalize over a number of ads, a number of years, and a number of different audiences, I think it is important to at least attempt to apply these semiological foundations on a sample that is coherent at least thematically and tends to offer a multifaceted view of one product. I will rely heavily on Kress and van Leeuwen and Gillian Rose for the theoretical apparatus.


Modes of representation: scientific realism to naturalism

The Paxil ads move quickly from “scientific realism” to “naturalism” with some symbolic elements (such as the shadow, the dial, the serene blue water, the cluttered/disordered room vs. the bright outside, the down and up movements). After 1993, they are all photographs; more than that, high-modality photographs: they draw us in with the reality of the picture, with the implication that this is an accurate description of reality. The scientific pose is abandoned as the drug enjoys greater commercial success.

Main actor: women

All the American ads portray mostly women and seem to imply that a particular type of mental illness is overwhelmingly afflicting women. Actually, both Prozac and Paxil have been indicated for a constellation of mental illnesses centered around depression, including social anxiety disorder, post-traumatic stress disorder, eating disorders, and premenstrual dysphoric disorder. While I read some studies that indicate that indeed this disease tends to affect women mostly, one wonders about the cultural assumption at play in the diagnosis (see study*). In the Paxil ads, the woman is offered as a promise—and the female figure has cultural salience anyway (Kress and van Leeuwen). The ad “gives greater stress to the promise of the product than to the factual information it also offers,” as the frame of the ad divides the description of the ad (world of what “is”) and the world of the “what might be” (the picture).

1993 Paxil ad in AJP: note the use of graphs ("scientific" mode) as opposed to naturalistic photographs

1996 Paxil ad in AJP

1998 Paxil ad in AJP

1999 Paxil ad in AJP
Decontextualization

The ads in AJP and in People tend to blur or deemphasize the backgrounds; they are decontextualized. Nothing else is important: only the individuality of the person depicted takes center stage. The individual cannot, will not, or will not be allowed to connect with her milieu; strangely enough, it’s not connected even when the picture shows her in the “after” position. This may be a reflection of our current isolationist treatment of disease, including mental disease: it all rests with the individual. Society is not, cannot be implicated in the origins of the disease; at most it’s a passive, faceless environment whose presence the ads try to make us forget; the seat of the disease is not with the world, but with the person. The meds work to put that person back, in a role that is unquestioned. The young professional, the worried mother, the haunted woman, or the serene bodies offered in luminescent glow back to the world, are “fighting” (another confrontational model perpetuated in the ads) with something that is at once removed from their environment, but that also seems to be removed from them. Lack of socialization, consequently, becomes a function of pathology.

Case in point: Paxil ad in People Magazine

The restoration to a “normal” life is often questionable. For a mini-case analysis, let’s take the ad in People magazine stating “What’s standing between you and your life?” and claiming that Paxil offers the power of balance: “Feeling balanced, more like ‘yourself’, is within reach.” We recognize the oppositional pattern immediately: a woman (a metonymy for depression) is set in an oppositional role to her (one presumes) husband and son (a metonymy for “life” or “normality”). The woman’s gaze is vague, and her arms are wrapped around herself in a defensive stance. She obviously does not fulfill her role of wife/mother, as suggested by the pained, sympathetic look of the man and the stern, almost accusatory look of the little boy. At the same time, the male duo is presented as powerless in the face of depression: they cannot restore their wife/mother to “normal”; their hands are reaching down (the boy keeps them in his pocket) in a posture that suggests both rejection and helplessness. They are literally faced with a wall of symptoms (“Depressed Mod, Loss of Interest, Sleep Problems, Difficulty Concentrating, Agitation, Restlessness”) that keeps the family apart.

Viewers are invited to contemplate this familial drama through the frontal angle of the photographic shot and through what Kress and van Leeuwen (2001) call the “offer” position of the subject. Kress and van Leeuwen identify several visual strategies that position the viewer in relation to the image; thus, the absence or presence of the gaze at the viewer would suggest an “offer” or “demand”—the subject of the image as passive offering to contemplation versus a demanding participation and involvement of the viewer through direct gaze or inviting gesture.

2002 People magazine ad (I apologize for the poor quality of the image)
The Paxil ad positions the viewer as spectator to the happy-ending drama of mental illness, while inviting her to take action to avoid the situation described in the images through the direct rhetorical questions. The drama unfolding in the Paxil ads also progresses from a spectacle of aloofness/detachment characterized by the long shots of the “before” picture (which invite an impersonal stance for the viewer, according to Kress and van Leeuwen) to one of intimacy with the viewer characterized by the close-up of the “after” picture. This suggests that while mental illness is something to be kept at bay, as far as possible, the new mental state granted by the magic of the pill allows social intimacy and the viewer can identify with the enabled woman in the ad. Indeed, in the “after” picture of the second Paxil ad, the woman smiles happily up (presumably at her husband?) while holding her equally happy kid close to her. She is thus recast in a socially acceptable role (mother, nurturer), while the order of the patriarchal system is restored.

Identity issues

In an interesting rhetorical move, the authors of the ad choose to put “yourself” within quotes: “Life is too precious to let another day go by feeling not quite ‘yourself’.” This may indicate some awareness of the difficulties related to ascribing a fixed identity to a subject; it may be a sign that the consumerist slogan machine acknowledges that identities are fluid, not pre-constituted or given, and there is no “core self.” Yet, despite this potential awareness, the ad still is a form of “prescriptive individualism” (Strathern, 1992), in the sense that there is no individualism and no self outside the choice of a product. The after-Paxil personality may be just one life option among many other choices; however, it is the desired “cosmetic” option because it operates a magical life make-over. The antithetical structure of the ads (before/after) suggests that, if drug-boosted life is “real” life, life off the drugs is actually death, negation of individuality.


Paxil ad, AJP, 2000




Paxil ad, AJP, 1999

Image created by the ads: the female yuppie?

However, we haven’t revealed yet what sort of “person” gets this complex of diseases treatable by antidepressants. If we examine the ads, we’ll see they are overwhelmingly women; they are overwhelmingly young and white, well coiffed, very attractive, thin, mostly with long hair, well-dressed, usually business-casual, or not dressed at all in some cases, heterosexual. Their bodies are slender, their smiles flawless; in most cases, as I just said, there are no clearly discernible props or settings, and where there are, they are a discrete metonymic presence connoting either panic (the “red ad,” the PTSD ad) or serenity (the canoe ad). No matter what—chased by the PTSD demons, overcome with anxiety—they must look good—they will look good for their doctors (the sexual overtones are hard to miss in some places—the doctors are sold not only a drug, but an attractive, desirable body, a magical promise of rescuing that body); these bodies will look good for the audience who will want to identify with their sorrow. Overall, the emerging image of the constellation of depression is that of a middle class woman in her prime, with a desirable body and an attractive face, relatively well off, and afflicted by a multifaceted adversary that is in no way in her, cannot be. They will also be, with rare exception, passive and disengaged: most of the images in the American journals are shown in a position of “offer,” as opposed to “demand,” disconnected from the viewer. The people in the Paxil ads almost never engage us directly. The ideal presented is socially aloof in comparison w/ the viewer, something to be yearned for, coveted, dreamed about.

It is remarkable the progress we’ve made to see what we used to call the “insane” as as the accepted neighbor next door, as the image of middle class America. However, as Michel Foucault said, “To respect madness is not to interpret it as the involuntary and inevitable accident of disease, but to recognize this lower limit of human truth, a limit not accidental but essential.” The ads, however educational in purpose, reveal the limits of our social construction of depression as, for the most part, a female heterosexual middle class white woman. Truth is, unless she goes into psychotherapy, the average psychiatrist employed at psychiatric hospitals, nursing homes, or long-term care residencies, is quite unlikely to see such patients. Her patients will often come from disadvantaged and minority groups, and their ages and genders will vary. Thus, the normality we crave and which is portrayed in these ads is telling through what is left unsaid—the often real face of mental illness. The manicured, Eddie Bauer generic middle-class people obscure the reality in the mental homes. The minimal differences between DTP and DTC ads in terms of imagery used (except for the sexual imagery) may have to do with leveling the field of practice, where the patient and the doctor will speak a common language of symptoms and will have an idea of how those look like. In other words, it may facilitate the commercial exchange in the end, as the psychiatrist will end up prescribing the pill the patients feels more comfortable with or more confident in as a result of a positive media campaign. And, interestingly enough, the sexual overtones are minimal in the DTC ads.

The British Perspective

Since we, as modern human beings, have more and more difficulty accepting the normality of illness and death, the implication in the ads is that any signs of abnormality require immediate corrective action. Thus, stances that invoke rumination, anxiety, worry, or panic, are apriorically condemned as abnormal. This implication worried psychiatrists Phillip Thomas and Pat Bracken (BJP, 2001); they criticized an ad for Valproate semisodium, a drug for bipolar disorder, picturing Van Gogh’s “Self-Portrait with Bandaged Ear”—the implication being, had Van Gogh taken the drug, he might have ended up not removing part of his ear, and may have been out of the Saint Remy asylum in which he spent the last 18 months of his life. However, the authors point out, those were also the most creative months of Van Gogh’s artistic career, as that’s when he painted the some of his greatest works (60 paintings in total). The two psychiatrists deplored the type of drug advertisement that pushes a certain image of normality and attempts to force human experience into well-confined boundaries, controlled by drugs (or any other form of social control). The drug, they point out,


[…] can work for us too, in an age that has no use for anxiety, in which we lie etherised like Prufrock, sedated, becalmed, and tranquil, neither high nor low. No suffering no soul, no art. Yes, if Vincent had been on valproate he might still have painted. If he were alive today and on valproate Vincent would be driving around in a white transit van, painting houses battleship grey. But then at least the bandage wouldn't be necessary. Madness is okay, as long as it's kept in its place, on the canvas, in the asylum but, either way, under drugs.


Seroxat (Paroxetine, same as Paxil) ad, BJP, 1995


This kind of criticism and a steady trickle of articles against DTC advertising is characteristic of the British journal’s attitude towards psychiatric advertising. This, in conjunction with cultural factors creates a different picture of mental illness as portrayed in the British Journal of Psychiatry. First of all, the five distinctive ads for Paxil create a more subtle play with absence and difference. Only one of the ads has a full portrait of a woman. However, the two photographs, before and after, show little, if any change in the woman’s facial expression. Furthermore, she’s middle aged, her features not airbrushed, the full weight of her wrinkles plainly visible. The only indication of the “sinking” versus “surfacing” is the position of the framing—an external, graphic interpretation of “illness,” extraneous to the woman portrayed; almost to indicate that the framing of illness as illness is a social construct, or nothing more than a frame, nothing to do with her “selfhood.” Nature is not “cooked” or shown deficient; rather, the creator of the ad uses graphical cues that do not impose meaning to the body.


Some of the other ads speak mostly in metaphors and avoid the high-modality, naturalistic photography and especially portraits to make inferences about the face of depression. While there is clearly an oppositional system at place (messy room/bright outside, love and care/absence thereof, sinking/surfacing, panic attack/serenity), the BJP Paxil ads prefer to rely on visual puns and overt metaphors rather than on a direct representation of the human agents. At this point, I recognize that more study is needed to look at the possible cultural assumptions in place, shaped by a long history of the practice of psychiatry, in Britain as opposed to the US. I suspect that extending the study to other geographic areas (Germany, France) might reveal further cultural differences, but this is perhaps the topic of another paper.


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* Natalie Sachs-Ericsson and James Ciarlo (2002) cite extensive research that seems to indicate that women have higher rates of mental illness than men, but criticize these studies for the way they sample their population (based, for example, on clinical service utilizations rather than an objective sampling of the general population) or the way they define mental illness. The authors conducted a study on a large population (Colorado) to determine whether this is true, and find that the prevalence of mental illness is roughly the same in male and female population; however, women tend to have higher rates of depression and anxiety, while men seem to have higher rates of substance abuse and antisocial behaviors. The implication of the authors is that these may be different manifestations, culturally bound, of actually the same “disease.” To date, however, there is little or inconclusive research on whether men may react differently from women to the same malady because of the way they are acculturated.

Jimenez (1997) reviews the literature about women’s mental health in the American Journal of Psychiatry 1960-1994 and concludes we’ve reverted back to a psychological (moral) model. In lieu of hysteria there are other controversial diagnoses that apply primarily (sometimes only) to women: histrionic personality, borderline personality disorder, dependent personality disorder, premenstrual syndrome (premenstrual dysphoric disorder)—all of them culturally bound, vaguely described at best, and as of date insufficiently support

© Cristina Hanganu-Bresch, 2004