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Another reason to follow the money: the globalization of mental illness

In its latest issue, New Scientist magazine reports on a troubling trend being witnessed by medical anthropologists:

Drug companies, with the aid of the U.S. medical establishment, are exporting a western interpretation of mental illness — and not always for altruistic reasons.

“Our western conception of depression is being promoted by multinational drug companies who profit mightily when other cultures adopt the idea and then buy their antidepressants,” writes science writer Ethan Watters.

“[M]ental illnesses are not evenly distributed globally,” he reports, “and do not take the same form from place to place. Unfortunately, mental health professionals in the U.S. who dominate the global discussion about how mental illnesses are categorized and treated, have often ignored or dismissed these differences.”

As an example, Watters describes how GlaxoSmithKline (GSK) launched the antidepressant paroxetine in Japan in 2000.  A front-row observer to this marketing event was Laurence Kirmayer, MD, director of the division of social and transcultural psychiatry at McGill University in Montreal, Canada, and an expert on how cultural beliefs affect mental illness. Writes Watters:

The challenge GSK faced in the Japanese market was formidable. The nation did have a clinical diagnosis of depression— utsubyo — but it was nothing like the US version: it described an illness as devastating and as stigmatizing as schizophrenia. Worse, at least for the sales prospects of antidepressants in Japan, it was rare. Most other states of melancholy were not considered illnesses in Japan. Indeed, the experience of prolonged deep sadness was often considered to be a jibyo, a personal hardship that builds character. To make paroxetine a hit, it would not be enough to corner the small market for people diagnosed with utsubyo. As Kirmayer realized, GSK intended to influence the Japanese understanding of sadness and depression at the deepest level.
“What I was witnessing was a multinational pharmaceutical corporation working hard to redefine narratives about mental health,” Kirmayer said. “These changes have far-reaching effects, informing the cultural conceptions of personhood and how people conduct their everyday lives. And this is happening on a global scale. These companies are upending long-held cultural beliefs about the meaning of illness and healing.”
Which is exactly what GSK appears to have accomplished. Promoting depression as a kokoro no kaze — “a cold of the soul” — GSK managed to popularize the diagnosis. In the first year on the market, sales of paroxetine in Japan brought in $100 million. By 2005, they were approaching $350 million and rising quickly.

Globalizing PTSD

Watters also discusses how, “[i]n our rush to treat the psychic wounds of traumatized people, we seldom ask if PTSD [post-traumatic stress disorder] can be usefully applied everywhere”:

Giathra Fernando, a psychologist at California State University, Los Angeles, … found culturally distinct psychological reactions to trauma in post-tsunami Sri Lanka. By and large, Sri Lankans didn’t report pathological reactions in line with the internal states making up most of the west’s PTSD checklist (hyperarousal, emotional numbing and the like). Rather, they tended to see the negative consequences of tragic events in terms of damage to social relationships. Fernando’s research showed the people who continued to suffer were those who had become isolated from their social network or who were not fulfilling their role in kinship groups. Thus Sri Lankans conceived the tsunami damage as occurring not inside their minds but outside, in the social environement.

Because of these very different cultural reactions to trauma, medical anthropologists “worry whether counsellors can be effective if they don’t know the local idioms of distress,” reports Watters. “Arthur Kleinman, a medical anthropologist at Harvard University, says that although most disasters do not occur in the west, ‘we come in and pathologise their reactions. We say “you don’t know how to live with this situation.” We take their cultural narratives and impose ours. It’s a terrible example of dehumanizing people.’”

Haitians and PTSD
Of course, I immediately thought of Haiti, and wondered if our mental-health efforts there in the wake of the devastating earthquake will be culturally sensitive. The media is already reporting on how Haitians are going to be needing treatment for PTSD.

Haitian-born psychologist Marie Guerda Nicolas of the University of Miami told Health.com that she expects to see PTSD among some of the earthquake survivors, but that Haitians will turn to their lakou, or extended social network, for support and solace.

“I think it’s important to realize that we don’t experience things the same way,” she added. “We express what we feel differently. There may be a lot of crying and wailing. They might faint; they might fall down. All of that is part of responding to the trauma — but it doesn’t mean they’re not able to cope and function. A person in a state of shock may look like they’re going to fall down or faint, and then an hour or so later they’re fine. This is one of the remedies for dealing with that sense of shock. It’s not part of the Haitian mentality that we’re not able to do for ourselves. There’s always the sense that bad things happen in Haiti and to Haitian folks, but that we have the ability to overcome and get through it.”

Comments (2)

  1. Submitted by Susan Lesch on 01/25/2010 - 11:25 am.

    Watters goes on to say, in his book, that GlaxoSmithKline sales of Paxil reached $1 billion in Japan in 2008. Come to think of it, I don’t know that GSK is part of a Justice department suit in the U.S. (but the “world’s most respected company” Johnson & Johnson is, and of course Pfizer and Eli Lilly have been convicted of criminal marketing).

  2. Submitted by Bernice Vetsch on 01/25/2010 - 03:58 pm.

    There is a movement toward outlawing direct-to-consumer drug sales by manufacturers.

    I believe Tammy Baldwin (D-WI) has written federal legislation and that Senator John Marty of Roseville has included a Minnesota ban in his Minnesota Health Act.

    The companies can now count on increased sales as millions of patients rush to ask their doctors, “Is ….. right for me?” The ads most frequently feature the newest and most expensive drugs available to treat a condition, but say nothing about the BEST drug available.

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