G. Ficca, G. Barbato, M. Beatrice, G. Muscettola - Vol. 6, Marzo 2000, num.1
Articolo speciale/Special Article
G. Ficca* **, G. Barbato* **, M. Beatrice***, G. Muscettola**
* Department of Psychology, II University of Naples
** Department of Neuroscience, University "Federico II", Naples
*** Community for Therapy and Rehabilitation "Il Castello", Anversa degli Abruzzi, LAquila
Advertisement Psychotropic Drugs Gender Visual content
Pubblicità Farmaci Psicotropi Sesso Contenuto visivo
Drug advertising plays an important role in influencing daily medical practice; in past surveys, many physicians reported that their basic knowledge of current treatments is often provided by drug industries propaganda (1,2) .Also their prescribing habits were shown to be noticeably affected (3-5) .
In order to support the choice of a certain drug amongst physicians, advertisers have to pursue a subtle and ambivalent strategy. On one side, their aim is to manipulate the consumer, persuading him of new informations and ideas; on the other, if they dont want their message to be rejected, they cannot be too aggressive (6) ,in particular when the target of the campaign is a group (the physicians) who is supposed to have an expertise and "to know more". In a few words, they try to reshape the consumers beliefs on mental illness while pretending to adhere to their opinion, so that advertisements, as Neill suggested (7) ,would also be modified in their content and semantic structures by changes in the shared knowledge and stereotypes.
A meaningful example concerns the construction of patienthood: Lupton (8) ,considering advertising a two-way interaction between advertiser and consumer, stated that the verbal and visual portrayal of the patient reveals an already existant ideological profile of doctor-patient relationship.
Advertising may thus turn out to be extremely useful as a "mirror" of the common beliefs about mental distress and all other related aspects, including the conceptualization of those people who are involved in it (patients, psychiatrists).
Few studies in the past have moved from this perspective. Riska and Hägglund (9) conducted a survey on psychotropic drug advertisements in the major national journals of Denmark, Sweden and Finland. For each compound, the image content of its advert was referred to its market position. The use of metaphores, in particular when connected to the portrayal of a patient, was related to low sales of the drug, whereas a picture of a drug package was related to a stable market position. However, the results cannot be extensively generalized since it was, as in the intention of the Authors, strongly dependent on the geographical context of the study.
Neill (7) provided much information throughout his dynamic analysis of advertisements on a long period (1955-1980). His observations focused on the two different targets to which adverts were addressed (the institutional market, that is state hospitals and inpatient facilities, and the private practice market) and on the peculiar features of psychotropic drug advertising in the early years of psychopharmacology.
These studies date back more than fifteen years. The purpose of our study was to investigate recent changes of advertisements features, covering also the last two decades. Therefore, we examined quantitative and qualitative elements that could shed light on the concepts of mental illness and treatment.
Special focus was put on the image of patients and doctors: an attempt has been made to detect typical patterns in their portrayal and/or in their gender representation, since two studies, in the past, have reported either a females or males overrepresentation (10,11) .
Semantic features, such as the kind of images and of verbal message adopted, were finally analysed.
All questions have been assessed following the rules for content analysis (12) ,with the intention of providing quantifiable evidence to the subjective impressions elicited from the general overview of the adverts.
As source of the advertisements, we chose "Archives of General Psychiatry", on the basis of its high impact factor and wide diffusion in psychiatric field. A single issue (April) was randomly selected for the first year of the sample (1975). The same issue was then chosen also for the following years (1976-1994) in order to maintain a regular twelve months interval.
The advertisements were first classified according to the different groups of psychotropic compounds: 1) antidepressants, 2) benzodiazepines, 3) neuroleptics, 4) others, the latter group including mood stabilizers, vigilance-enhancers, non benzodiazepinic tranquilizers and so on.
The frequency of advertisements was measured both as the absolute number of insertions and as the percentage of advertising pages out of the total number of pages for each issue. For this calculation, the prescription page (usually the final one) has been not taken into account.
For each of the advertisements, we took into account the visual-analogic (non linguistic) content, represented by its picture. If more than one picture was present, the most relevant was identified according to its size, placement and connection with the main verbal message.
The visual content could fall in five different subcathegories. The subcathegory "metaphor" indicates any symbol which is not directly related to the properties and/or action of the drug, but clearly resembles it, whereas the subcategories "before (illness)" and "after (recovery)" mean that the insertion portrays the patient in a definite temporal allocation, with the drug administration as zero time. When two or more images portray a patient both before and after the treatment, the ad was assigned to a distinct subcategory called "before-after". "Scientific" is anything related to mechanisms of action, dosages or research reports.
Further items, within the visual content, are those referring to the image of patient, doctor and/or the psychotropic drug itself: thus, other pictures besides the main one, when present, were also taken into account to determine if these elements were portrayed in the insertion. For each patient depicted, we considered sex, age (where identifiable) and whether or not he/she was portrayed in a definite context. The sex of the physician was also included in the list.
Two independent judges, who were blind of the hypothesis and aims of the study, separately rated all the advertisements on the previously described checklist. Any discrepancy was solved by consensus, and the reconciled attribution was used in data analysis.
The changes in the frequency of advertisements over the years were assessed by dividing the total sample in 5-year periods (1975-79, 1980-84, 1985-89, 1990-94).
Chi2 test was used for comparisons between different classes of drugs, within the total sample, and between different periods, within the same class.
In total, 219 insertions were included in the analysis.
As for the distribution by major drug groups (Tab. I), antidepressants and neuroleptics are in general more advertised than benzodiazepines. The number of benzodiazepines adverts, however, seems to be the most consistent over the years, apart from a slight rise from the first to the second period, whereas the number of adverts for neuroleptics increases consistently up to the period 1990-1994.
The group of other psychotropic drugs was represented only until 1984: after that year, no insertion for this group can be found. For this reason, this group was included in descriptive statistics, but not in the contingency table comparisons.
The mean number of pages for insertion was 2.3 (± 1.4) for the total sample, 2.4 (± 1.3) for antidepressants, 2.4 ± 2.0 for benzodiazepines, 2.0 (± 0.9) for neuroleptics and 2.4 (± 1.1) for the other drugs. Only 17 insertions (7.8%) contained 4 pages or more.
As for the visual content (Tab. II), the most frequent subcathegory in the total sample is that of "metaphor" (34.7%), but those images referring to scientific details about the drug are also well represented (26.9%): less frequent are images of illness (15.5%), of transition from illness to recovery (15.5%), of recovery (6.8%).
A similar ranking can be found for the single drug classes (Tab. II); actually, c2 analysis does not show any significant difference between classes, but only a relevant trend, related to the peak of "scientific" adverts for benzodiazepines.
The drug, as a package or in the shape of free pills, is present in 71 ads (32.4%), with no significant difference of representation in the three classes.
Seventeen ads (7.8%) depict a doctor, who is male in 96% of them, and almost equally represented in the three classes compared through c2. The patient is portrayed more often (56%), with an almost even gender distribution and a prominence of middle age in the total sample and in that of benzodiazepines. However, a significant difference was found, between the other two drug classes, both in sex distribution and in age, as more middle aged patients, and, in particular, much more women are portrayed in the insertions for antidepressants, whereas the young are more often the subjects in the adverts for neuroleptics, which also show an inverse M/F ratio.
Only in 28 pictures (12.8%) is the patient portrayed in a social or relational context; amongst them, 21 show a male patient. The ads for neuroleptics focus more on the work environment, the ones for antidepressants usually depict familiar or other personal relationships.
All data about patients, physicians and drugs are summarized in Table III.
Antidepressants and neuroleptics were more advertised than other compounds, suggesting an acceptance (and, of course, the attempt to reinforce this concept) of the leading role of pharmacotherapy for major psychiatric disorders. On the other hand, the low frequency of the adverts for benzodiazepines could be explained in light of a reduced marketing campaign in psychiatric journals as counterbalance of the more massive and expensive commercial strategy addressed to the entire medical field: in fact, benzodiazepines are one of the most prescribed class of drugs by general practitioners (13,14) ,and BDZ adverts are overrepresented in journals of general medicine.
Borrowing a word from psychodynamics, a general "negation" of diseases emerges from the analysis of the adverts. The world of advertising has always been very reluctant to embrace anything related to illness (15) ,in view of an overdirect emotive impact. In the case of drug advertising, where illness is always the event underlied, there is no way to avoid the notions of pain and suffering except to try and soften them by means of particular linguistic or semantic expressions: a clear example is the massive use of metaphoric, or even surrealistic, images. Goldman (16) suggests that the larger use of metaphors in psychotropic drugs adverts implies their tendency to be more unscientific and less informative than other medical adverts. It may be argued that the so-called "referential" function of advertising (ie, providing information and details) is always supposed to be marginal when compared to the "fatic" (ie, eliciting emotions) or "imperative" one (17) ,and that this hypothesized "unscientificity" could simply reflect mental distress as being more frightening and perturbing than other pathologies.
Aimed at the same goal would be the attempt to purify the image of the patients from all its harshest and most repulsive elements: very few scenes of crisis or emergencies are shown and mental illness is rarely portrayed in its complete crudeness. The attitude of psychiatrists to keep illness at a safe distance could be the same reason why physicians are so seldom depicted in the ads.
Dichter (quoted in Packard, 1958) suggested that every marketing campaign for drugs should stress the importance of "doctors personal touch", in order to fulfill their narcissistic requests (18) .Judging from our sample of adverts, it seems that drug industries have not followed this piece of advice. The only advert where a crucial role is still given to the physician is one in 1989 for a benzodiazepine, with a slogan claiming " a unique structure to support your psychotherapy" and the corresponding image portraying a psychotherapist peacefully listening to his patient on top of a huge drug package. Anywhere else, the pill comes out as the real magic, the physician being just the unarmed witness of a process (the illness) not reversible but using drugs.
From the present analysis a quite impressive sexual bias concerning the portrayal of both the doctor and patient has emerged. In advertising, the physician dealing with mental illness is almost always a man (96%), although in U.S., for example, the percentage of women amongst psychiatric residents was 41% in 1988 (19) .Hence we should infer that the psychiatrists job is commonly associated with what people ideally consider "mannish" traits, such as strength, power and authority. This result is consistent with what reported by Walter (20) ,who found that 96% of the psychiatrists portrayed in American cartoons, in the period 1941-1990, were males.
As for patients, sex distribution in the adverts for antidepressant and neuroleptics is biased if compared to their actual sex ratio. In ads for antidepressants, females were three times more represented, whereas actual female / male ratio in major depression is 2:1 (21) .On the other hand, in advertisements for antipsychotic drugs, males were more represented, despite the 1:1 female/male ratio in schizophrenia (21) .In both cases, this attitude may reinforce already operating prejudices like a passive role for female, corresponding to the passiveness of depression, and the stereotyped association of males to the work context, which is mainly impaired by psychosis.
The bias reported by Thompson (11) ,ie a male overrepresentation in adverts for benzodiazepines, was not confirmed in our sample. However, Thompsons finding, which was probably related, as suggested by the author, to a marketing attempt to enlarge the use of antianxiety drugs to males, is not directly comparable, since it was from a single year sample and in general medical journals.
The results of our content analysis are consistent with what previously reported by Kleinman and Cohen (22) about a remarkable decontextualization of patients in the insertions. In most of the ads, all we can see is an expression on the patients face, which tells us about their mood, feelings, thoughts: but nothing is shown of their family, work, relationships and sociocultural background. The controversial message implied is that all these elements are secondary in the ethiopathology of illness as well as in the recovery process, since the only outer countermeasure against the "inner" disease is drug administration. The decontextualization is particularly evident for women: moreover, in those few cases when a context is shown around women, this is almost always home or the family environment.
In conclusion, our results suggest that quite many prejudices remain to give a fictional halo to the portrayal of mental illness in adverts: in particular, the role of sexual bias and its possible influence on sex role modelling in the clinical practice of physicians have to be furtherly clarified.
We wish to express our warm gratitude to Dr. Monica Ficca for her thorough rating of the insertions, and to Miss Lesley Arnold for her assistance in editing the manuscript.