AMA Journal of Ethics^®

Marketing research consistently shows that pharmaceutical advertisements entice patients to ask for particular medications and physicians to prescribe them [1]. How do these advertisements work?

Supporters of pharmaceutical advertisements argue that the ads provide patients and doctors with important information about new medications in ways that help both parties make informed treatment decisions [2]. Critics meanwhile contend that pharmaceutical ads help drug companies “create new disease markets” and “expand market share” [3].

Both sides of the argument overlook an important point: in addition to creating new markets or providing new information about medications, ads also tap into existing cultural attitudes and beliefs. Pharmaceutical ads identify, reflect, and even distort prevailing popular sentiments about such matters as race, gender, politics, and class and then posit prescription medications as treatments for “social” problems as well as medical ones. Of course, many types of advertisements work by identifying social anxieties and desires. It would seem particularly important that physicians be aware of these tensions, so that they can best differentiate cultural expectations and biases from actual information about medications and diseases when they make treatment decisions. To do so, doctors need to become competent, not just in the effects and side effects of pharmaceuticals, but also in the nuances of cultural manipulation on which ads for these pharmaceuticals often depend.

The history of doctor-directed pharmaceutical advertising from American psychiatric journals presents an object lesson in the ways drug ads reflect and distort cultural stereotypes. As is well known, starting in the 1950s, advertisements played off of popular attitudes about gender, and specifically about women’s roles as mothers and wives, to promote branding of antidepressants [4]. Scholars have now begun to examine the ways in which themes regarding race and racial politics inflected the marketing of antipsychotic medications in psychiatric journals over the same time period.

As a pedagogically useful example, consider a shocking advertisement for the antipsychotic medication Haldol that appeared in the May 1974 edition of Archives of General Psychiatry. In the ad, an angry African American man shakes his fist menacingly. The man wears the street clothes of ignominy, complete with a ruffled shirt and a wide collar, and stands in an urban scene. The man sneers, and the image distorts his features in a manner that makes him appear particularly threatening to the psychiatrists who were the assumed audience for the ad. The text above the image then literalizes the scene. “Assaultive and belligerent?” the text asks above an angry black man constructed as exactly that. “Cooperation often begins with Haldol” [5].

One could argue ad absurdum that the ad provided psychiatrists with information about a relatively new butyrophenone-class antipsychotic medication—Haldol was released in 1967. A more likely response is to wonder how McNeil Laboratories, the makers of Haldol, could have promoted their medication through such blatantly discriminatory imagery.

“Racism” is an answer that comes to mind as we look in horror at the ad from nearly 4 decades ago. And, to be sure, racism seems an apt descriptor for an ad that sells neuroleptics by depicting a problematic stereotyped man who appears to be a cross between a pimp and the Godfather of Soul.

But perhaps there is more to the story. The ad appears overtly problematic from the perspective of the present day, but was it seen that way when it was produced? Moreover, were the racial assumptions in the ad volitional, and if so, on the part of whom? The advertisers? The Archives publishers? The journal readers? Did these actors perform acts of racism knowingly, by creating particular images, or buying particular journals? Or was it also the case, and more troublingly so, that anxieties about belligerent, psychotic black men were embedded into acceptable public discourse in ways that defied recognition at the time?

Addressing these questions requires that we critique the ad as visual historians. Doing so involves focusing less on our immediate emotional response to the image. Instead, we would attempt to place the Haldol ad in historical context by uncovering how it connects to larger 1960s- and 1970s-era mainstream American cultural assumptions about race and insanity, in order to better understand the conditions that might have allowed such an image to appear in a mainstream psychiatric journal.

For instance, we might contend that the ad reflects era-specific cultural anxieties about race politics and racial protest. The man in the image presents a laden political gesture from that era: a clenched black fist (see image 1) [6].

Of course, the fist became a symbol of the Black Power Movement. And, while that movement was often popularly misrepresented as promoting violence, the fist connoted the opposite—solidarity, resistance, and joined struggle. Olympian Tommie Smith (see image 4) [7], whose raised fist at the 1968 Mexico City summer games set off a wave of controversy, later explained the gesture as a “salute” to “human rights” [8]. The Haldol ad appears to play with this popular misperception by inverting the fist in a way that suggests that the politicized figure—indeed a figure who is expressly not pictured in a treatment setting—will assault the assumed viewer of the image if not given Haldol immediately.

Image 1.

Image 2.

Similarly, the man seems to stand defiantly within an urban scene in which buildings and windows reflect an orange hue. We might contend that this color palate invokes connections to era-specific urban unrest. In the years preceding the ad, urban protests had spread across such U.S. urban centers as Detroit, Watts, and Newark. Popular representations of these revolts prominently displayed burning buildings. Nightly newscasts often described the scenes as “insane” while overlooking the unjust economic conditions that led to the protests in the first place. Tapping in, the ad troublingly posits Haldol as a clinical treatment for a social, political, economic, and of course highly racial “problem.”

A second historical point that we might make about the Haldol ad is that its imagery is consistent with broad transformations taking place in antipsychotic advertisements—transformations that revolved expressly around race and gender in depictions of psychosis and schizophrenia. A quick flip through journals such as Archives and the American Journal of Psychiatry reveals that antipsychotic advertisements began to appear with regularity in these journals in the 1950s. At that time, images such as the one seen in the Haldol ad simply never appeared. Early antipsychotic ads [9] instead showed docile white women treated with medications such as Serpasil. Or, as in the case of 1955 Thorazine ads, depicted white-only women’s wards [10].

Suddenly in the 1960s and 1970s, Africanized or African Americanized themes emerged in ways that now seem shockingly abrupt. Thorazine ads, for instance, suddenly shifted to depicting Africanized icons [11] of what it called “primitive psychiatry,” while ads for Stelazine suddenly featured tribal artifacts or masks [12, 13].

One might posit many reasons for this transformation, ranging from changed marketing techniques to altered cultural aesthetics. But this transformation also provides important supporting data for our hypothesis about the racializing of antipsychotic drugs in the 1960s and 1970s and a linking of that racialization to concerns about politics as well as about mental illness.

Finally, we might note that the transformation in antipsychotic advertisements reflects larger transformations in American popular and medical representations of psychotic and schizophrenic illness [14]. Here as well, a broad transformation occurred in which understandings shifted from docility to hostility, and often from white to black. For instance, through the 1950s, psychiatric journals and textbooks often depicted schizophrenia as a condition, manifest by “emotional disharmony,” that negatively impacted white people’s abilities to “think and feel.” Psychiatric authors frequently assumed that such patients were nonthreatening and were therefore to be psychotherapeutically nurtured by their doctors, as if unruly children, but not feared [15].

Meanwhile, through the 1950s, popular magazines such as Ladies’ Home Journal [16] and Better Homes and Gardens [17] wrote of unhappily married, middle-class white women whose schizophrenic mood swings were suggestive of “Doctor Jekyll and Mrs. Hyde”—a theme that also appeared in Olivia de Havilland’s infamous depiction of a schizophrenic housewife named Virginia Stuart Cunningham in the 1948 Anatole Litvak film, The Snake Pit, on which the earlier Thorazine ad appears to be based [18, 19].

American assumptions about the race, gender, and temperament of schizophrenia changed beginning in the 1960s. Many leading medical and popular sources suddenly described schizophrenia as an illness marked not by docility but by rage. Growing numbers of research articles from leading psychiatric journals asserted that schizophrenia was a condition that also afflicted “Negro men” and that black forms of the illness were more hostile and aggressive than were white ones. A 1968 article from the Archives of General Psychiatry asserted that this psychotic hostility emerged because black men listened to the words of Malcolm X, joined the Black Power Movement, or “espoused African or Islamic” ideologies—indeed, the same ideologies that seem to be referenced by the 1960s- and 1970s-era antipsychotic advertisements [20].

Meanwhile, mainstream newspapers in the 1960s and 1970s warned of crazed, black, schizophrenic killers on the loose. “FBI Adds Negro Mental Patient To ‘10 Most Wanted’ List” warned a Chicago Tribune headline in July 1966, above an article that advised readers to remain clear of “Leroy Ambrosia Frazier, an extremely dangerous and mentally unbalanced schizophrenic escapee from a mental institution, who has a lengthy criminal record and history of violent assaults” [21]. Hollywood films such as Samuel Fuller’s 1963 B-movie classic, Shock Corridor, similarly cast the illness as arising in black men, particularly men who participated in civil-rights protests [22].

This all-too-brief history helps tell a story about the Haldol advertisement that complicates a narrative in which the inventions of a particular advertiser led to a specific doctor’s prescription response. Reading historically, we begin to see that the problematic Haldol ad also emerged from a cultural moment in which concerns about race, insanity, and black political protest lodged into mainstream anxieties, social networks, and notions of common sense.

In no way is this telling meant to suggest that doctors in the 1960s and 1970s should have refrained from prescribing psychotropic medications. Indeed, many patients benefitted from Haldol in vital ways. Yet the 1974 ad also suggests that, in its worst moments, the discourse about this medication and the illness it treated reflected a larger set of cultural anxieties that doctors should have been aware of. Such awareness might have helped psychiatrists address a much larger problem that emerged at the same time: the link between the themes of the ad and the emerging overdiagnosis of schizophrenia in African American men. Indeed, at precisely the same historical moment, a series of studies “shockingly” discovered that African American men were “significantly more likely” than other, white patients to receive schizophrenia diagnoses and were also more likely to receive higher doses of antipsychotic medications [23-27].

Ultimately, the Haldol ad presents a cautionary tale about the relationships between pharmaceuticals and society in the present day. Thankfully, we live in an era in which the racial profiling of the 1974 ad seems a relic of the past.

We also live in an era of dramatically expanded pharmaceutical advertising. Information about prescription medications permeates magazines, journals, television programs, the Internet, and seemingly everyplace else. Many times, the advertised medications help people recover from illnesses or lead more meaningful lives. But at the same time, expanded advertising presents ever-more opportunities to link expectations about these medications to cultural desires, anxieties, and stereotypes.

In other words, there has never been a greater need for physicians to become fluent in the social and cultural tensions that underlie many pharmaceutical advertisements. At the least, awareness of these tensions allows clinicians to recognize the social manipulations on which many ads depend. And, at the best, this type of cultural competency enables clinicians to get ahead of the conversation by understanding, and then talking about, the many complex gendered, racialized, and politicized meanings that Americans, patients and doctors both, ascribe invisibly to mental illnesses and prescription drugs.