stigma and barriers to care - Uniformed Services University of the ...

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
little while. This embarrassment is based, at least in part, on the perception of the
stigma associated with emotional disorders, the idea that it is shameful to have a
mental illness, and that it is a character flaw.
There is reason to think that some of these attitudes might be changing. For a
number of years now the General Social Survey has been monitoring attitudes about
mental illness and has documented an increase in the perception that mental illness
is attributable to biological causes, rather than a character flaw. There has been an
increase in the perception that biological treatment is likely to be the most effective
kind of treatment. Part of the reason for this, presumably, is that there has been a
massive increase in public information about mental illness since the early 1990s
when Prozac became the first prescription drug to be advertised on TV.
I do not know how many of you are familiar with this but it is really not coincidence
that in the last 15 or 20 years there has been this boom in understanding of
mental illness. I was, as it so happens, working as a graduate student at the National
Broadcasting Company in New York at the time that it became illegal to advertise
cigarettes on television. The television networks in their eagerness to improve public
health and also, as an aside, to get a little bit more money, decided that it was a terrible
thing that prescription drugs could not be advertised on television and started
something called the Prescription Drug Advertisement Coalition. They came together
with a bunch of pharmaceutical companies to lobby to make it legal to advertise
prescription drugs on television.
As it turns out there is some interesting economic evidence about this. Advertising
on TV for eyeglasses, which also require a prescription, is illegal in some states.
It turns out that when you look at the states where you can advertise prescription
eyeglasses on TV, the cost of eyeglasses is only about 60% as high as in the states
where you cannot advertise. The result is that all of these eyewear shops only go
into the states where they can advertise because they make their money on volume.
In fact, being able to get this information out has a positive impact on getting
people access. That is not always the case, though. If you look at over-the-counter
medications, like Bayer aspirin versus aspirin, the companies that spend most on
advertisement raise the prices of their products more.
It is not always true that giving people more information is a good thing. For one
reason or another, the networks and the pharmaceutical industry combined to convince
the FDA that there should be direct-to-consumer advertisement for prescription
medications. It just so happened that ruling occurred at exactly the time that Eli
Lilly developed Prozac, the very first drug that was advertised direct-to-consumer.
As you know, Prozac had this unbelievable uptake. The idea that depression is an
illness and that treatment was available was compelling. We now know that the
effectiveness of SSRIs and SNRIs is not that much greater than TCAs. There is a side
effect profile advantage. But the dramatic change in the number of people who were
getting treatment for depression was really unprecedented. It is hard to know which
was the horse and which the cart. It is true that direct-to-consumer advertising of
Prozac coincided with front page feature stories about Prozac on the covers of Time
and Newsweek, and all of a sudden we became inundated with Prozac.
Subsequently, we have had many front covers of Time and Newsweek that have
talked about PTSD, stress, trauma, and suicide in the Army. Various famous people
have gone on the Tonight Show to talk about their depression and their drugs and
how they overcame it. There are lots of tell-all books, etc. If you look at the mass
media archives, the number of stories about mental illness in the past 15 years has