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Treat Her with Prozac: Four Decades of Direct-to-Physician Antidepressant Advertising

Treat her with Prozac: Four Decades of Direct-to-Physician Antidepressant Advertising
Cristina Hanganu-Bresch
The soaring popularity of antidepressants by the 1990s came after decades of lockstep efforts by
manufacturers, marketers, and clinicians to present a pharmaceutical solution to the problem of
depression, which skirted the margins of both philosophy and medicine and often defied
psychoanalytical treatment. Discovered almost by accident in the late 1940s (imipramine, the
“gold standard” for antidepressants, was initially used as treatment for tuberculosis),
antidepressants were relatively ignored for a while as psychopharmaceutical researchers pursued
drugs perceived to be both more effective and in greater demand, such as antipsychotics. After
their early dissemination in the 1950s, antidepressants grew in popularity due to a conflation of
factors such as the explosive growth the pharmaceutical industry (partly prompted by research
advances spurred by World War II), the decline of the Freudian psychiatric model, and a
formidable marketing machinery. Callahan and Berrios (2005), writing about the history of the
treatment of depression in primary care in England and the United States, noted that the
popularity of psychopharmaceuticals was indeed due to three factors: safety, efficacy, and
marketing (p. 109). Pharmaceutical companies spent enormous amounts of money on marketing
in the 1970s and 1980s, primarily for advertising and direct mailing to physicians. Studies show
that “there was one pharmaceutical sales representative for every 8 physicians in the United
States and for every 18 physicians in the United Kingdom” (Prather, quoted in Callahan and
Berrios, 2005, p. 110); these numbers are directly reflected in the number of prescriptions written
for these drugs. Coincidentally, the number of depression diagnoses surged during this period,
from less than one hundred cases of depression per million in the early 1950s to one in ten, or
more than one hundred thousand per million in 2000 (Callahan and Berrios, p. 2).
Cultural critics as well as the scientific community have taken a serious interest in the
phenomenon of widespread marketing of minor tranquilizers, especially given the fact that these
drugs are mostly the product of for-profit pharmaceutical companies, rather than academic
research. In fact, historian of psychiatry Edward Shorter claimed that “one could call
psychopharmacology the creation of the drug industry, rather than of the academy or clinicians”
(1997, p. 265). Concerns with the “overmedicated” state of modern society as well as with the
“Machiavellian” marketing techniques of Big Pharma date back at least to the early 1970s, and
they are well publicized on both sides of the Atlantic. For example, writing for Science in 1970,
Lennard et al. voiced an early expression of such fears: “Changing the human condition is a
monumental undertaking. While seeking to change cognitive shapes through chemical means is
more convenient and economical, the drug solution has already become another technological
Trojan horse.” Today, these issues remain as relevant as ever.
Societal anxiety surrounding psychopharmaceuticals is at least partly due to our current
perception of drugs as sites of cultural tension. As chemical “crutches,” drugs prompt debate on
what constitutes illness and health, and ultimately, our humanity; as consumer products, they are
economic units enmeshed in capitalist ideology. Thus, the function of antidepressant
advertisements is to bridge a gulf, however precarious, between values found on opposite ends of
the axiological spectrum: personal fulfillment or individual happiness, and industrial capitalism
or economic success. To explore this chasm, this chapter focuses on four antidepressant ad
campaigns that illustrate how depression has been marketed to physicians over a period of time
during which societal response to psychotropic medication changed and the principles of
psychiatric practice evolved. This analysis is both diachronic (spanning four decades of
antidepressant advertising, from the 1960s to 2001) and cross-cultural, since
psychopharmaceuticals found a particularly responsive market in both the US and Great Britain.
The journals selected for this sample, the American and respectively British Journal of
Psychiatry (AJP and BJP) are first tier publications in the field, distributed to all members of the
American Psychiatric Association, and the Royal College of Psychiatrists. Two representative
antidepressant drugs were selected: amitriptyline, marketed as Elavil in the US and Tryptizol in
the UK throughout the 60s and 70s; and fluoxetine, marketed as Prozac in both the US and the
UK between 1987 and 2001. Ads will be described in terms of content (topic, participants,
scientific illustrations) as well as semiotic structure. To avoid the labyrinthine trappings of a
catchall semiotic vocabulary, Kress and van Leeuwen’s “visual grammar” categories (2001) are
used here since they constitute one of the most coherent visual semiotic taxonomies to date. Such
descriptors will reveal how psychiatrists were prompted to re-frame mood disorders such as
depression in reducible, positivistic terms, and persuaded, eventually, to give up a mindset of
“talk therapy” in favor of solely drug-therapy. The following sections will examine,
chronologically, these four ad campaigns (Elavil in AJP, Tryptizol in BJP, Prozac in AJP and
Prozac in BJP).
Elavil, American Journal of Psychiatry, 1961-1979
Elavil’s marketing campaign in the American Journal of Psychiatry (AJP) can roughly be
divided into three distinct periods. The first, 1961 to 1964, employs mainly a combination of
logos and ethos-based appeals (to science and to the authority of important psychiatrists,
respectively). The second period, roughly 1964 to 1972, is characterized by pathos and focused
on the personal and social aspects of depression. Finally, the third period, up to 1979, is focused
on the idea of treatment and professional ethos.
The ads in the first period are structured primarily around major figures in the history of
psychiatry (such as Pinel, Kraeplin, Bleuler, Meyer, Jung, and Freud) and their writings on
depression, with the counterbalance of chemotherapy (drug) as the proposed modern treatment;
they also employ scientific illustrations—specifically tables and line and bar charts that compare
Elavil’s efficacy to other similar drugs. The first step in the Elavil advertising campaign,
therefore, is to market the drug as different: first as a modern answer to age-old psychiatric
conundrums, and second as a marked improvement over available contemporary remedies. The
composition of these ads is “polarized” according to Kress and van Leeuwen (2001), which
means there is no central element. A drawing of a famous psychiatrist on the left is balanced with
an informational page about Elavil on the right (Fig. 1). This conforms to Kress and van
Leeuwen’s hypothesis of the placement of information in a Western-based coding system: the
‘old’ or ‘given’ is on the left, and the ‘new’ is on the right. The “historical” reading from old to
new is thus seamless and underlies the theme of continued psychiatric progress.
Figure 1. Elavil, AJP 1963. “Bleuler…on depression.”
The ads so far appear to have an “analytical temporal structure” (Kress and van Leeuwen:
following a relatively linear narrative), relying on ethos and the contrast between old and new
psychiatry to lend credibility to the new drug. The salience of the portraits (revealed by their size
and placement) turns these fathers of modern psychiatry into virtual endorsers of the drug. Thus,
the early Elavil ads try to establish a tradition of psychiatric treatments at the same time that they
announce a chemical breakthrough in the treatment of depression.
In 1964, Elavil ads start employing pathos as their main rhetorical appeal. They still use
spreads and multiple panels, and their semiotic make-up consists, by and large, of covert
taxonomies; in classificational structures of this type, according to Kress and van Leeuwen, “a
set of participants ('subordinates') is distributed symmetrically across the picture space, at equal
distance from each other, equal in size, and orientated towards the vertical and horizontal axes in
the same way” (p. 88).
Figure 2. Elavil, AJP 1964: “Depression may lead to social suicide.”
In the “social suicide” Elavil ad above, the structure could be interpreted as a temporal process,
but “taxonomy” is a better descriptor, given that there is no clear indicator of a timeline. Each of
these four panels is a member of an overarching superordinating element, “social suicide”; all of
them are hierarchically equal (same size and symmetric arrangement). A brief narrative of the
toll of depression is provided in the first paragraph, below the image, offering the “clef” for the
images: it is the story of a depressed woman and her subsequent social “decline” captioned by
the four panels (“marital discord,” “occupational problems,” “social estrangement,” “pathologic
tension outlets”). The woman who is the common denominator in all images is never once shown
in a position of what Kress and van Leeuwen call “demand” (i.e., looking at the viewer). Her
tentative body posture, photographed at an oblique angle, the fact that she never faces the
camera, and the impersonality of the long shot allow the audience (i.e., psychiatrists) to distance
themselves from the subject of the dramatic tableaux. The staged quality of the pictures, each
structured around a narrative semiotic kernel (transactional actions in the first two panels, and
reactions for the last two) invites the psychiatrist to position himself as an omniscient spectator
who can grasp many instances of this woman’s life at once and aptly diagnose her. By and large,
the pictures are decontextualized—only the bare minimum of background is provided, further
contributing to the stagey feel of the ad and to the artificial “timeless” quality of the picture
(“this is social suicide”). The lack of a “real” background also gives a strange diorama quality to
the pictures; thus, the psychiatrist is ultimately presented with an educational laboratory display,
rather than with an emotive story.
The anachronistic chauvinist slant of the pictures plays second fiddle to the code that
allows us to interpret these images as manifestations of depression. The forty-plus years that
separate modern audiences from this ad render the ad’s sexism woefully apparent. It is hard to
read the threatening postures of the men in the first two pictures as signs of her illness: they seem
to be the active initiators of an unpleasant argument by leaning forward towards the woman and
directing their hands (or fists) at her, while she stands or sits in a submissive, almost cowering
position. The two women shunning her appear to be gossiping, and the alcoholism angle in the
last panel has moralistic undertones, as it plays on the stereotype of the outcast woman in need of
rescue. If depression is a social anomaly, the “norm” represented by the players in the
protagonist’s life seems depressingly undesirable.
Like many women depicted in antidepressant ads, the “social suicide” victim in the Elavil
ad is married, typecast in a lower hierarchical position in the workplace and in a precarious or
endangered social or family role, and in need of rescue (a portrait that confirms Metzl’s 2004
discussion of the Freudian undertones of women in psychotropic drug ads). To restore her mental
health is to mend the social fabric. The ad does not hint at an etiology of depression, but focuses
on consequences; is not concerned with the person as much as it is with commenting amply on
her failure to fulfill her social obligations. Medication is thus a tool for restoring the status quo.
Furthermore, in this ad, she is portrayed as the goal (in Kress and van Leeuwen parlance) of
somebody else’s action or reaction; by contrast, her gaze is “object-less,” directed downwards or
mid-distance; she is objectified, both for the other participants in the pictures, and for the viewer
(i.e., psychiatrist) himself. The sequence of pictures implies that the woman’s depression is the
reason for marital strain, work-related problems, and social isolation. Whereas the ad does not
make the visual argument that it is all a matter of chemistry, the counterposition with the
promise-laden copy and the simplified table that accompanies all early Elavil ads allows the
audience to draw the inference. There is nothing wrong with the social status-quo, except for her;
and the magic pill promises to correct that imbalance.
During this stage of the marketing campaign, patients are, as a rule of thumb, shown as
part of a covert taxonomy (they are instantiations of the concept “depression”). In a 1969 ad, a
woman is shown in the typical posture of the melancholic (head bent, hand supporting head,
visible frown on her face) leaning on a window frame. The second page shows an identical
window, but with the blinds drawn. The caption implies that there is a patient behind the blinds
that is completely “shut down” from the outside world; the woman in the first frame doesn’t fare
much better, as she has to “face each day with dread.”
Figure 3. Elavil, AJP 1969. “Whatever the degree of depression”
Windows are consistently found in drug ads as places that mediate the passage between
two worlds—in this case, between an inner world of depression and an outer world of normality.
In this ad, the window also acts as a framing device, effectively symbolizing the patient’s utter
isolation and inability to communicate with the outside world. The use of the window (and door)
in antidepressant ad imagery leads to a cascade of inferences about depression as that which
separates the inner from the outer, the personal from the social, the domestic from the public, the
static from the dynamic, the darkness from the light. As in the ‘social suicide’ ad above, the
psychiatrist is invited to recognize symptoms and degrees of depression, and file them under
“Elavil,” as the drug holds the key to this opening toward the world.
The third period of Elavil ads brings in the doctor even closer. The patient may be
present, but she or he is undergoing “productive” psychotherapy, for which the drug is a mere
facilitator. The mastery of the doctor, trained to recognize symptoms, is what ensures success,
and the drug paves the way for it; a different kind of pathos infuses these ads, this time directed
at the target audience’s ego. Women are again stereotypically typecast as depressed, helpless,
and in symbolically lower positions than men. The woman undergoing therapy in the 1977 ad
(second panel) is featured on the left of the image, looking up at a doctor casually sitting on a
table and looking down at her (fig. 5). By contrast, in the 1978 ad, the man talks to the doctor as
his equal, and in a second shot, where they are shown walking together toward the door (where
the door carries the same underlying symbolism as mentioned above), we notice that the patient
in fact is taller than the doctor, and also placed in a “new” position (fig. 6). This kind of superior-
inferior placement and relative infantilization of women relative to men confirms Erving
Goffmann’s groundbreaking study of gender bias in advertising (1979). Goffmann commented
extensively on the “ritualization of subordination” emerging from consumer ads: classic rituals
such as lowering oneself physically in some form are deployed in ads universally.
Figure 4. Elavil, AJP 1977. “…penetrating the symptom barrier to productive psychotherapy”
Figure 5. Elavil, AJP 1978. “He’s getting better…and Elavil is helping.”
The 1978 ad further reaches out to its intended audience by placing the doctor with the
back to the viewer, having approximately the same vantage point as the viewer of the ad
observing the patient who “is getting better”; it is as if the shot was taken behind the viewer’s
shoulder. This conversational posture of the doctor is a frequent topos in the American
psychotropic ads of this period. The room is full of accoutrements and furnishings typically
associated with male sensibility (leather chairs, dark-wood shelves filled to the brim with books,
a globe, a ship painting, and a Persian rug). All of these higher-end furnishings are also marks of
the prosperity of the doctor. The not-so-subtle inference is that his success is owed in fact to
Elavil. Still, the long shadow of Freud reaches out to the viewer from this picture. Depression is
presented in these ads in purely psychotherapeutic terms, as something that the patient must
work through together with his psychoanalyst in order to get better. The discrete image of the
drug (colorful pills against a green background) visually distills and punctuates the ad, looking
subordinate to “talk therapy.”
Towards the end of the 70s, Elavil’s patent on amitriptyline expires and the drug starts to
be produced under different name brands. The last two ads in Elavil’s campaign, run in 1979,
address that competition by claiming that “there is no substitute for experience—yours….or
ours.” The appeal is again to the psychiatrist’s authority, but that authority is now equaled by the
drug’s prestige as well.
Figure 6. Elavil, AJP 1979. “There is no substitute for experience”
The two panels are also part of a covert taxonomy: they both stand for the same thing,
“experience.” The two protagonists (experienced psychiatrist on the left, tried and true bottle of
the proven drug on the right) share the same hierarchical placement, except the drug is in the
“new” position, concluding the visual argument. Although they are visually equal, the drug has,
in fact, the last symbolic “word” in this statement through the meaning of composition. The
appeal of the ad has shifted from the previous arguments from authority or pathos to a bold
assertion of the drug’s own ethos. Fictional endorsers or patients eliciting recognition and
sympathy are no longer necessary. The ad enrolls its audience as its ultimate endorser through
the narrativized subjective perspective (Kress and van Leeuwen, 2001): only the psychiatrist’s
hands are visible—male, mature, white, inviting the viewer to identify with the prescription
writer and with the attributes touted for Elavil. The doctor’s replacement with a bottle of pills in
the second frame, however, unwittingly speaks volumes about the direction psychiatry is headed.
Tryptizol, British Journal of Psychiatry, 1960-1979
Like their American counterparts, the Tryptizol ads published in the British Journal of
Psychiatry can also be divided into three “ad periods,” although the results of this division are
rather different. The first period (1960-1964) is characterized by the abstract and symbolic
suggestive representations; according to Kress and van Leeuwen, “[s]uggestive processes
represent meaning and identity as coming from within, as deriving from qualities of the Carrier
themselves, whereas Symbolic Attributive processes represent meaning and identity as being
conferred to the Carrier" (2001, p. 112). The first Tryptizol ads lack patients as “Carriers”;
instead, they suggest the theme of depression through moods and symbolic objects. From 1965 to
approximately 1971, Tryptizol ads consistently depict human subjects—patients—in their ads.
Finally, the last eight years of Tryptizol ads employ, as a rule, symbolic semiotic structures, and
make a more sustained appeal to ethos by contrasting new and old psychiatry.
As was the case with Elavil, the first period of Tryptizol’s campaign is marked by
attempts to emphasize the “uniqueness” of the drug, specifically its dual action as tranquilizer
and antidepressant—an angle which, as in the Elavil ad campaign, is dropped later on. Ads
feature low modality suggestive drawings, employing visual metaphors to suggest the
comorbidity of anxiety and depression.
Figure 7. Tryptizol, BJP 1962. “Often two sides of the same coin”
The bottom half of the first Tryptizol ads is occupied by text, whereas the top half is reserved to
a symbolic suggestive illustration—rather generic and timeless, that is, not anchored in an
individual reality). In symbolic suggestive structures, according to Kress and van Leeuwen, there
is only a carrier, and emphasis is on mood/atmosphere. Depression as the main topic in these first
ads is illustrated by a timeless, symbolic, generic image. Symptoms are described as matter of
fact (“sleep disturbance,” “depressed mood” etc.), completely disembodied from a carrier. The
drug treats symptoms, but not patients; in that sense, it also is a generic entity. The drug is
presented as a fortunate solution to a medical puzzle (the comorbidity of anxiety and depression).
By contrast, the Tryptizol ads of the second phase show a realistic-looking potential
patient whose symptoms are ripe for chemical manipulation. When patients are shown, they are
overwhelmingly female; the major difference from the Elavil campaign resides in the preference
for the medium and close shot, betraying a smaller social distance from the depressed patient
than in the American ads (which favored the more “impersonal” long shots).
Figure 8. Tryptizol, BJP 1965. “Waiting for the dawn”
The woman lying in bed is a topos of antidepressant ads, used in both psychiatric journals
quite frequently. Whether she is “depressed” (hence, lying awake, wishing for sleep) or “happy”
because the drug is working (hence, sleeping peacefully and unaware of the viewer’s gaze), she
is, still, usually married—wedding ring is carefully displayed whenever possible, or sometimes
there is a hint of a partner, sound asleep on the other side of the bed. By placing a woman in
certain semiotically relevant positions (bent, looking to the left, often decontextualized, and in an
intimate or medium shot), the ad allows the psychiatrist to use the patriarchal cultural baggage
described by Goffmann (1976) to work in his favor. Decontextualization works to render the
portrait “timeless” while hinting at the loneliness and isolation engendered by depression.
The last period of the Tryptizol ads is markedly symbolic and more abstract than before.
The marketing angle emphasizes the improvements in the patient’s sleep patterns. When patients
are present, they are, this time, shown in long shots and utterly generic poses.
Figure 9. Tryptizol, BJP 1975. “1875 – 1975”
The “1875-1975” Tryptizol ad (Figure 9) is a fascinating contrast between “old” and “new”
psychiatry which pits a psychiatric diorama against a close-up of a Tryptizol capsule. The
“1875” picture shows three psychiatrists surrounding a seated old man posed in a typical
“depressed” posture (hanging head, downward glance, idle hands, black clothes). The caption is
an excerpt from a resolution adopted by the Royal College of Physicians of London in 1875,
describing the educational equivalency between instruction in “a lunatic asylum” and in “a
general hospital.”
The meaning of the picture and its caption comes in full play when contrasted with the
1975 one, showing a close-up of a Tryptizol capsule, held between a thumb and index finger.
“Tryptizol 75 once a day dosage for many depressed patients,” the caption tells us, “means more
convenient and easily remembered treatment for patients—more certainty of patient compliance
for physicians.” The pictures are identical in size, but not in perspective: the tips of the fingers
holding a pill in “1975” fill the same space as the four participants in “1875.” The protagonists of
the historical tableau are shown in “offer” (passive) stances, which reinforce their helplessness.
The angle of the shot is oblique—facing the corner, as opposed to the frontal shot of the pill-
holding hand. Both the angle of the shot and the size of the shot (the long shot is “impersonal”
according to Kress and van Leeuwen) suggest detachment from psychiatry’s antiquated methods,
by contrast with the sense of immediacy and here-ness of the frontal angle and the close up for
the pill. The audience is constructed as a detached observer of the first tableau, and as an
engaged viewer—or perhaps consumer—in the second. The play of perspective emphasizes the
pill’s “magic” and is reminiscent of the ads for domestic technologies, whose overarching trope
is also the “before/after” structure. The new psychiatric technology eliminates the doctor; it
eliminates even the patient. The narrative told by the two panels is one of optimism in science’s
progress, a positivist faith that technology can provide the solution society’s medical and
spiritual ailments. The first picture illustrates an exercise in futility; the second—a paragon of
The implication is not that we need to effect social change to create a better world, but
rather that we need to create better drugs so we can be better adjusted to the world we are born
into. Maladjustment is really an internal function and rests with the individual; any social
implications of depression simply do not enter the equation. The brain, however, enters into that
malleable meaning of “setting” as something that can be adjusted, tweaked, mended, so it
performs its given social function—enabling the person to operate according to its set
predisposition—mother, housewife, or middle management clerk (on an aside: the jobs of these
people are almost always “ordinary,” involving little or no leadership or high achievement
positions). This intimation of the “magical” change of one’s outlook to effectively facilitate
integration is fairly obvious in one of the last ads run for Tryptizol:
Figure 10. Tryptizol, BJP 1979. “Tryptizol helps make living worthwhile”
While there is no indication about the quality of life that is made “worthwhile” through the pill,
removal from society seems to be the major pernicious effect of depression. The “life” he is cut
from is all but synonymous with “culture and society,” whereas solitude and nature come across
as markers of depression. In this ad, a slouched silhouette is headed off into a gold-sepia sunset
in the middle of a field taken over by weeds. The barren, un-civilized nature is a symbol for
social isolation; it’s also contrasted with the promise of the drug (presented as a schematic
drawing in the upper right corner –the “ideal” position according to Kress and van Leeuwen).
The figure of the depressed man as a traveler is also a topos in British advertising, though much
less so in the American ads. This may be because the British ads pick up, in general, on more
past cultural references than their American counterparts; in particular, the figure of the “mad
traveler” is persistently employed both as an echo of early representations of “madness” and as
an allusion to the shortly lived 19th century psychiatric diagnosis of “fugue” (cf. Gilman, 1982;
Hacking, 1998). The “mad” (or melancholic) traveler is always caught in between two
destinations/two worlds, always in transit, but never finding peace because “he” is essentially
homeless, quite literally “out” of his mind. The freedom of movement is illusory, as the
wandering is aimless.
The new antidepressants: Prozac
The first Prozac ad was published in 1987, 26 years after the first Elavil ad. By then, psychiatry
had changed considerably. It is the year of the publication of the DSM-IIIR, and the golden age
of selective serotonin uptake inhibitors (SSRIs) is poised to begin. The most powerful
explanatory hypothesis available regarding the mechanism of depression is neurotransmitter-
centered, and Prozac’s amazing clinical success and consequent popularity only confirms that
hypothesis. Prozac, the most famous brand in psychopharmacology, soon became a phenomenon
and the new gold standard for antidepressants.
Prozac in the American Journal of Psychiatry, 1987-2001
The Prozac campaign one can be divided into three fairly distinct periods: the first (1987-1990)
is focused on scientific imagery and text (based on logos); the second (1991-1998) focuses on
patients and appeals primarily to pathos; and the third, 1999-2001 (when Prozac’s patent expires)
is focused more on the drug itself and its status, appealing mainly to ethos. This division seems
to follow pretty closely the one for Elavil, suggesting that perhaps there is a pattern in the way
antidepressants are marketed in the US: making bold scientific claims in the beginning, powerful
emotional appeals in the middle-period, and tapering off into ‘prestige’ and brand-driven appeals
as they approach the expiration date of their patent.
The first period is particularly fascinating in the Prozac ads because of the efforts made to
explain the antidepressant chemical mechanism. One of the early Prozac ads from the 1990s
employs a computer-generated 3-D grid to depict a “battle” engaging receptors,
neurotransmitters, and Prozac. The image is reminiscent of a videogame still frame; the grid is
the brain (and, by extension, the battlefield), the synaptic cleft is the localized battle, the Prozac
“molecules” are foot soldiers, and so on. No labels are needed to identify the agents in this
confrontation—the preliminary work had been done by other antidepressant ads.
Figure 11: Prozac, AJP 1990. “Unique…Specific”
What the composition may lack in scientific accuracy, it more than makes up for in dramatic
effect. An orange glow permeates the underside of the axion, where little red molecules of
serotonin seem to escape towards another neuronal connection. Here’s where the picture
abandons the pretense of ‘scientific’ illustration and introduces, in a mixed-code, comic-book
manner, the real “heroes” of the story: two Prozac logos (gold-orange spheres with undulating
striations underneath that “calm down” or “straighten up” toward the top).
The other important thing that happens in this visual is the placement of this epic
depression ‘battle’ somewhere ‘outside’ the human being affected. While this is a commonplace
of medical imagery in the Western world, mental illness had, so far, been less amenable to such
objectification. The age-old duality mind-body, so enduring in our culture, is now stretched to its
ultimate conclusion—the “person” is separate both from the mind (loosely construed as located
in the brain) and the body. Brain cells are “floating” in a vast, generic, three-dimensional grid;
the Prozac logo-soldiers are deployed to fix a ‘chemical’ process that simulates a serotonin spill
which needs to be contained; the ‘battlefield’ looks like a space age simulation. None of the
players seems to be either the patient or the doctor. A disembodied part of the brain is defended
by a chemical shield (the heroic Prozac pill) against another part of the brain. It is not clear how
this benefits the human being presumably in possession of said axion; in fact there is no “whole
person” to speak of here. Depression is depersonalized; the psychiatrist becomes a spectator; and
the drug is medicine in action—a shiny chemical gadget that the clinician can deploy into the
virtual-reality grid of the patient’s brain. The ad captures in a nutshell Prozac’s phenomenal
medical and cultural success as the “real” protagonist in our generic battle against mental illness.
Such representations, which start back in the 1980s, turn depression from a human
experience with identifiable causes, socially alienating consequences, and treatments that often
involve human relationships (with doctors, among others), into a transparent chemical and
biological mechanism underpinned by the “serotonin uptake” theory. The ads for the new brand
of antidepressants objectify the patient, flatten the multidimensional aspects of depression into a
chemical cartoon, and eliminate the doctor. The disembodied brain and the drug are the only
ones actually entering a relationship. This is also an effective way to restore ethos to the field of
psychiatry, which is transitioning from a Freudian model into a biological model. Representing
mental illness as a molecular process and the drug as acting at molecular level is, in effect, a
transubstantiation: if happiness is caused by chemistry and the drug can influence that chemistry,
the discourse surrounding mental illness is flattened, simplified, and tamed. For a biological
psychiatrist that may still face credibility issues from other branches of medicine, this is a very
seductive argument.
Once the status and mechanism of the drug are established, the second phase in the
Prozac marketing campaign moves to show a pronounced preference toward human
representations. The logos-oriented, scientific illustration era (laden as it is with charged
assumptions about the nature of mental illness) is replaced by a sweeping appeal to pathos: the
audience is invited to respond emotionally to the ad. Unsurprisingly, the overwhelming majority
of the subjects are white females, generally decontextualized, shown usually in close or medium
shots; toward the end of the 90s, the ads feature more occurrences of couples and family life.
Most of the “Prozac” faces are white, relatively young, middle-class women; rarely,
couples as involved as well (Figure 12).
Figure 12. Prozac, AJP 1997. “PROZAC for both restful nights and productive days”
The young couple in the 1997 ad are painting their house and stopping for a moment to
“pose” for the camera. They are both wearing jeans, clean clothes, and display shining smiles.
She leans on her husband and tilts her head a little. This is just one of several instances of
painting as a metonymy for happiness, a topos frequently employed across antidepressant ads in
the 1990s and early 2000s (Hanganu-Bresch, 2008). Painting is an ocularcentric occupation, and
painting is symbolic of illusion, façade, surface, appearances, as well as of covering, mending,
and mirroring. The couple is positioned on the right, in the “goal” position (Kress and van
Leeuwen, 2001), above the “Prozac” logo (again, in the lower right corner), as if they are
supported by it. The requisite “reclining woman” juxtaposed with “woman working” is used
again in another 1997 ad:
Figure 13. Prozac, AJP 1997
This ad uses the diagonal ‘dynamic strip’ effect—in fact, very similar to a paintbrush whose
“color” is ‘Prozac’—and the various ‘normality’ representations it engenders (rest/work). The
doctor is now, in fact, the painter recreating reality with a Prozac brush.
Starting with 1999, Prozac ads assume a cartoonish quality. They rely mostly on
decontextualized objects set against a bright, cartoonish orange background. The human face all
but disappears, and is replaced by metonymic allusions, such as in these 1999 ads:
Figure 14. Prozac, AJP 1999. “Just like normal.”
In this series of late Prozac ads, women are invoked as having regained their sense of
normalcy (“Sue’s playing with her kids again…just like normal,” “Barb’s golfing again…just
like normal”). The human representations are replaced with metonymical hints of ‘normal’
activities which have three things in common: they are performed by women, they are middle or
upper middle class leisure activities involving the outdoors, and they are acceptable “failures”
(the basketball shot catches “nothing but the rim,” the golfing ends up “in a slice,” the kite is
stuck in a tree). This ethos seems in contrast with the accusatory tone of the 1964 Elavil ad
(where the hapless protagonist was a social failure)—but at a close look, it is apparent that these
minor failures are really disguised markers of success (golfing is, after all, perceived as an upper-
crust sport). The “just like normal” slogan “anchors” (Barthes, 2002[1960]) the image as
representative of normality. The bright orange background and the cartoon quality of the
drawings are symbolic indicators of the simplicity of the course of treatment for depression; at a
meta-level, they signify the cartoonish quality of life on Prozac. The drug here is an enhancer of
a simple, angst-free middle-class life, allowing people to enjoy quotidian leisure activities (the
copy elaborates: “Depression can keep your patients from enjoying the simple pleasures of life…
etc.”); or, perhaps more accurately, a leveler, the dial the psychiatrist adjusts to achieve
acceptable levels of social conformity. The parallels with Huxley’s feel-good soma in Brave
New World are hard to ignore; the ads are reminiscent of "the warm, the richly coloured, the
infinitely friendly world of soma-holiday. How kind, how good-looking, how delightfully
amusing every one was!"
Prozac ads in 2000 and 2001 ads simply show the pill (a device rarely used in the
antidepressant ads) as the main persuasive technique:
Figure 15. Prozac, AJP 2000. “There’s only One.”
The Prozac capsule is central to this ad, which focuses on the convenience and on the Number
One status of the drug. The diagonal formed by the pillbox moves upward to the right, a
compositionally ‘optimistic’ message, especially as the “vector” (Kress and van Leeuwen, 2001)
originates in the pill. Human presence or hint thereof is dispensed with. The appeal of the ad is
purely ethos-driven, just as in the last Elavil ads.
Prozac in The British Journal of Psychiatry, 1990-2000
Prozac ads in the British journal fall in two categories: early 90s before-after structures, and late-
90s ethos-based structures. Unlike their American counterparts, no actual face of depression or
happiness is fully featured in the first period (1990-1995); human presence is connoted through
synecdoche—parts for the whole (e.g., feet or eyes for the person)—or metonymy (e.g., kitchen
for the place where the person lives). The second phase of Prozac advertising in BJP, starting
about 1995, focuses solely on Prozac’s domination of the antidepressant market, choosing visual
metaphors signifying “leadership.” The human presence in such ads is merely symbolical.
Figure 16. Prozac, BJP 1990.
The first ads for Prozac in BJP date back to 1989 and show the legs and feet of a group of
people, playing on a visual pun (“Isn’t it time to look at depression from a different point of
view?”). The second ad in the series provides narrative coherence to the first ad, by providing the
“after” shot. Depression’s absolute opposite here is “out and about”—which makes
immobility/passivity is its chief characteristic. Both women and men’s legs and feet are shown,
though the women are central to the first ad (connoting depression), and the men are
foregrounded in the second ad (as “out and about”). The woman in the fancy red shoes in the
second ad carries a shopping bag (shopping is an occupation that women, unlike men, are often
shown as doing in antidepressant ads), while the men are shod in work boots, and are poised for
manual labor. The images are symbolic-attributive processes; they work by invoking general
notions of “active” vs “passive” and implying that getting out of depression is a simple matter
turning from a state of rest to one of motion. The agency, however, does not belong to the
patients, or even to the doctor; Prozac has the power to set things in motion. The
depression/happiness pair are cast as bodily functions—as literally, what one can do with one’s
body—or in one’s environment (as the dirty/clean kitchen metaphor suggests in a 1990 ad):
Figure 17. Two ads for Prozac in BJP, 1990
The binary opposites that play into the depression/happiness duality are mobile/immobile, dirty
and disorganized/ clean and organized, and sedated/alert. They are all represented through
symbolic attributive structures woven into temporal, before-after processes. No doctor and,
significantly, no patients are present, except metonymically.
The latter category of British Prozac ads is focused on the status of the drug itself, much
like the ethos-centered American Prozac ads after 2000; the British ads, however, turn to visual
metaphors of leadership to connote Prozac’s leading status.
Figure 18. Prozac, BJP 1995, 1997, 1998. “True Leadership has to be earned.”
These three ads (from 1995, 1997, and 1998, respectively) turn to sports imagery as an obvious
metaphoric reservoir for competitive “leadership.” Under variations of the slogan “True
leadership has to be earned,” images of a victorious climber on top of a cliff, a running race with
a leader breaking away from the pack, and a driver in a formula one race car are used to signify
Prozac’s “World’s No. 1 prescribed antidepressant” status.” There are no claims made about
depression (at least through images), about happiness, about patients, or even about doctors.
However, the leadership images from highly competitive sports dominated by men are meant to
connect with an audience assumed to be dominated by male psychiatrists (the phallic
connotations of the rock climbing ad, and to a certain extent of the running race one, can hardly
be missed). Fight and competition metaphors underscore the ads’ message. Although outwardly
focused on branding, the ads are about putting the psychiatrist in command. The perspectives
used denote omniscience—the viewer is so positioned to instantly and comfortably grab the
bigger picture, view the whole race dynamics from above, and even be positioned in the driver’s
seat in the last ad, in leading position. “World’s No. 1” status transfers, metonymically, onto the
symbolic status of the Prozac-prescribing psychiatrist as “No. 1.”
This analysis, however cursory, suggests that antidepressant ad campaigns are organized
in cycles that conform to the relative success and prestige of the drug; these cycles are
respectively logos, pathos, and ethos-oriented (i.e., invoking scientific authority, appealing to
emotions, or relying on the authority of the brand). These cycles were more obvious in the
American than in the British ads; still, in all four ad campaigns described, the pathos and the
ethos phases are always present, and always in that order. In the pathos phase, the marketing for
the old antidepressant (Elavil/Tryptizol) relies, generally, on representations of depression; by
contrast, the marketing for the newer antidepressant employs more direct representations of
“happiness” or “normality.” The earlier ads (1960s and 1970s) need to sell the pill in to a
practice community still dominated by the Freudian paradigm, to which the idea of mood
engineering via prescription drugs is relatively new, as is the ubiquity of the diagnosis of
depression; by contrast, newer drug campaigns, from 1980 on, work with a “primed” audience
who is abandoning the psychodynamic paradigm in favor of the biological one and who happens
to diagnose many more cases of depression than 20 years prior. It thus appears that the greater
the need for persuasion (as in the earlier ads), the greater the emphasis on realistic detail and on
the visual representations of depression symptoms; the lesser the need for persuasion (as in the
later ads), the higher the incidence of symbolic structures and the greater the emphasis on images
of happiness and success. In very broad lines, it can be said that the early antidepressant ads sell
depression; the later ones sell happiness.
Images of doctors are a rare, but consistent presence in the early American Elavil ads;
however, they lack altogether in all British ads as well as in American Prozac ads. Also,
causation (a Freudian category that was most important in both diagnosis and treatment) is, in
general, absent. Depression is represented as a decontextualized disease, with no cause other
than, perhaps, rogue synapses, requiring, by and large, no therapeutic process. The ads reduce
depression to symptoms; and this reduction makes the drug a very attractive option.
Representations of patienthood are heavily biased in terms of class, race, and gender.
Typically, all patients are white and overwhelmingly middle-class as shown by dress or
occupation, fitting (anachronistically) the category of the “worried well” patient described by
Peter Kramer (1993), the psychiatrist who discovered that Prozac made his patients “better than
well.” Mini-narratives of these patients are often used to provide the psychiatrist recognizable
scripts for their practice. Such narratives act as case study kernels for the doctor, providing
cognitive models that would facilitate a diagnostic in “real life” (as in the case of the “social
suicide” Elavil ad, for example). All ads tend to cast more females than males in “depressed”
roles; furthermore, women-as-patients are typically cast in a “lower” position or lesser and/or
stereotyped social role. Women are also often decontextualized, disembodied, or placed in
domestic settings (kitchen, bed, bedroom). These gendered representations perpetuate a public
image of depression as a women’s affliction, and discourage recognition of the disease in men by
reinforcing a series of stereotypical inferences that equate the feminine with weakness,
inferiority, and depression.
In terms of cross-cultural differences, American ads seem to prefer more visual
taxonomies as a way of structuring their imagistic evidence, employ more doctor-references and
more scientific illustrations, and are generally visually organized to be “interpreted” left-to-right.
The British ads tend, in exchange, to be much more symbolic, to employ no scientific
illustrations, and are usually organized top-bottom; they also never mention psychotherapy.
American ads also seem to provide a more “framing narratives” (e.g. scenarios) for depression
than the British ones. There are also subtle preferences in the symbolic imagery between the two
journals; while some depression/happiness metaphors transcend culture (e.g., the window),
others some seem to be more culture-specific (e.g., the traveler in the British ads). The British
ads, being generally much more connotative than denotative, tend to use a broader palette of
metaphors to convey their message. By contrast, the American ads tend to be slightly more
“concrete” and rely on some sort of scientific visuals to back up their claims. Also, overt
representations of “happiness” and couples are avoided in the British journal.
An antagonistic model of depression (as something that has to be “fought” or “defeated”)
is promoted in both journals, although it is more evident in the American journal, especially in
the “scientific” illustrations. Depression is gradually reduced to a mechanism; treatment—to a
matter of brand loyalty. Eventually, the patient disappears completely from the later ads, and is
replaced by pure branding. In their imagery, the antidepressant ads have rendered doctor,
treatment, and patient entirely invisible, and replaced the mental care process with one pill, “the
only one.” The ads undoubtedly reflect (perhaps even helped effect) the same symbolic
transformation in the contemporary mentality of health care providers and recipients alike; this is
true especially since the advent of direct-to-consumer psychotropic drug advertising in the 1990s
(which picks up on most of the same devices discussed here for the direct-to-physician ads).
Calls to reform the psychopharmacologic treatment model are already in place (see Healy, 2004;
Callahan and Berrios, 2005; Shorter, 2008); however, it remains to be seen whether, how, and
when we can move beyond the chemical paradigm of happiness. One step towards that vision
should be the acknowledgment that the Prozac-filtered life is a constraining and impoverished
version of reality, something that the history of antidepressant advertising abundantly
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Full-text available
The so-called psychopharmaceutical revolution began in the 1950s, with apparently ever better drugs coming to market. Amitriptyline (Elavil), introduced in 1961, was one of the first ‘antidepressants’. Over the next decades, many other antidepressants came out, including fluoxetine (Prozac). In the 2000s, critiques that antidepressants were no better than placebos could not slow down a massive global rise of prescriptions. In 2018, a large meta-analysis of clinical trials argued that antidepressants were indeed better than placebos, but that none of the new drugs was as effective as the old amitriptyline. 1961 is also the birth year of psychiatry in the Himalayan country of Nepal. Since the 1960s, Nepali psychiatrists have been using amitriptyline as their first-line drug. The inclusion of amitriptyline in the first WHO list of Essential Drugs (1977) cemented its status. All the ‘new’ psychopharmaceuticals came to Nepal, but they never displaced the ‘old’ amitriptyline. No other drug could beat amitriptyline's affordability, availability, and efficacy for the typical Nepali depression patient: a ‘somatizer’ who suffers from multiple bodily aches, insomnia, and anxiety. Fieldwork with Nepali psychiatrists reveals the tenacity of local affordances over global changes in evidence and health policy.
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