A Disease for Every Pill
Professor Endicott bluntly rejects the concern that PMDD is an example of ordinary life being medicalized. "It's an insult to suggest that women with less severe symptoms would even be seeking treatment. Women are not running around saying, Give me a pill for everything."
Finding hard scientific evidence to help settle this difference of opinion is difficult. Mintzes's research has added to a body of studies suggesting that these ads do drive many people into doctors' offices, and that some doctors will prescribe the advertised drugs even when they may doubt their appropriateness for the problem at hand. But there have been few, if any, large studies that rigorously investigated whether direct-to-consumer advertising causes unnecessary medical labeling or leads to inappropriate or harmful prescription of drugs. What is crystal clear, however, is that the ads boost drug sales.
Industry executives argue that the most powerful case for direct-to-consumer advertising is evidence of underdiagnosis and undertreatment among people with serious health problems, including high cholesterol, high blood pressure, depression and, presumably, PMDD. In a special issue of the British Medical Journal devoted to the topic of medicalization titled "Too Much Medicine?" two senior officials from the drug company Merck wrote that the rules governing drug advertising should be loosened in Europe to help fix the urgent problem of undertreatment. They claimed there was little good evidence to support the view of Mintzes and others that advertising leads to inappropriate prescribing or harm: "Unfounded fears" about advertising, they wrote, were restricting people's rights "to have all the information they need to make informed choices about their health."
One of the weaknesses in this argument is the failure to acknowledge the controversy and uncertainty surrounding the definitions of the common conditions said to be massively underdiagnosed. If estimates of the numbers of people suffering from these conditions and requiring treatment are inflated to start with, as some observers consider to be the case with high cholesterol and depression, for example, then claims of widespread undertreatment deserve to be taken with extra-large doses of scrutiny and skepticism. With PMDD, claims of underdiagnosis and undertreatment make little sense if the condition itself doesn't even exist.
There is little doubt that many people in genuine need are not getting the medical attention or medication they require, particularly among the poor of wealthy nations and the wider developing world. Whether spending billions advertising disorders like PMDD on television and in women's magazines is the best way to correct that problem is highly questionable. Undertreatment may often have more to do with lack of money or access than lack of information. And as to the claim that advertising is the best way to inform, educate and encourage more choice, the deputy editor at the Journal of the American Medical Association, Dr. Drummond Rennie, disagrees. "Direct-to-consumer advertising," he says, "has got nothing to do with the public's education and it has got absolutely everything to do with...boosting product sales."
Postscript. In Europe Lilly's marketing of Sarafem/Prozac came to an abrupt stop. In mid-2003 a panel from the European Agency for the Evaluation of Medicinal Products noted that "PMDD is not a well-established disease entity across Europe.... There was considerable concern that women with less severe premenstrual symptoms might erroneously receive a diagnosis of PMDD resulting in widespread inappropriate short- and long-term use of fluoxetine."