Readings. Crazy Like Us. Part Four: Marketing Depression to Japan

This is the last of four posts about issues raised in Ethan Watters' new book Crazy Like Us: The Globalization of the American Psyche (2010, Free Press). (Previously we looked at Anorexia in Hong Kong, PTSD in Sri Lanka, and Schizophrenia in Zanzibar.)

The final focus of Watters’ book is depression – specifically the efforts undertaken to export western-developed conceptions of the disorder and its treatment to Japan.

One might think that this would be an easy sell to a country with a legendary suicide rate. Not so.

Clinical depression in Japan, into the 1990s, was conceived as an extremely severe psychotic-spectrum disorder afflicting relatively few people in the population. Garden variety sadness and anxiety were regarded as normal phenomena, and to a degree were even valued as signs of a sensitive, thoughtful nature.


And suicide? Suicide was not regarded as predominantly linked to a disorder called depression.

Convincing people to seek treatment for depression would mean getting them to equate their own unhappiness to a severe and frightening condition.

So why bother? If the people did not see everyday sadness or anxiety as a major problem, why tell them that it is?

Partly the answer is western benevolence. Some seem to have felt that the Japanese had accepted a problem as normal because there was no recourse, just us families in some countries appear to expect – and accept – high rates of malaria or credit card debt. But if the problem can be resolved, then there is no need for such forbearance.

Another motive is profit. If people can be induced to see depression as a problem, we create a need. Needs drive purchases. And if we have a proprietary product that we can sell to meet that need, we stand to make a great deal of money. Who had such a product? The pharmaceutical companies.

I’ll leave it to you to guess which motive Watters seems to feel was more significant in this instance.

Although SSRI antidepressants began to be introduced in the west in the early 1980s, there was a delay in introducing them to Japan. Part of the reason was a set of Japanese regulations requiring drug testing to be carried out on Japanese subjects (whereas many countries simply accept the outcomes from studies carried out in the US and elsewhere). But part of the reason was the Japanese “failure” to appreciate mild to moderate depression as a significant mental health problem.

Watters recounts the story of how the pharmaceutical companies went about changing Japanese attitudes toward depression in order to create a market for their products. This involved public education campaigns, seeded media coverage, direct-to-consumer advertising, and funded professional continuing education for mental health professionals.

Each of the four case examples in Watters’ book can be summarized with the same formula: Poor product, great success. To a great extent, Japan adopted westernized views of depression, and antidepressant sales went up.

As Watters points out, this would be a happy story if the rationale was true: Mild to moderate depression is a distinct and disabling problem independent of culture, and antidepressant medications are remarkably effective antidotes that can eradicate the problem and get a depressed society on its feet again.

It's a shame that reality is often more complex.

Watters reviews data on the antidepressants that is now widely known, and that I may touch on in posts later this fall, so I'll summarize it quite briefly here:

• Most studies of antidepressants are funded and carried out by the very companies standing to gain or lose millions by the outcome.
• Despite this fact, many such studies indicate that SSRIs are not markedly more effective than placebos.
• There's a difference between statistical significance and actually meaningful response to medications, so even when differences between SSRI and placebo are found they are often not particularly powerful.
• Studies that support SSRI effectiveness appear to be much more likely to find their way into print than studies which do not, resulting in a perception that the pharmacological effect may be more powerful than it is.
• Side effects of these medications are often under-reported or minimized more than may be wise.
• Studies of these and other medications are often not, in fact, written by the people conducting the study nor by the authors whose names are on the papers, but by ghostwriters provided by the companies holding the patent for the drug.

Each of these suggestions deserves more consideration than can be given in this post, so let's save that for another day. Suffice to say that many people really do seem to benefit from these medications (for whatever reason), there may be some subtypes of depression that respond better than others, and the way they are used in everyday practice may produce different (possibly better, possibly not so good) effects than are observed in clinical trials.  

The conclusion Watters reaches is difficult to escape: Given that we have such unreliable treatments for depression developed in the west and tested on western subjects, exporting them to other cultures and attempting to convince those cultures to adopt our own ideas about depression (and other illnesses) may not be the altruistic enterprise it is alleged to be.  

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To sum up, Watters has produced an interesting and wide-ranging book that challenges many of our culture's pet ideas about mental illness and its treatment. He documents a potent mix of naive altruism, cultural narcissism, and profit motive that combine to make the West's contribution to global mental health questionable at best. It is difficult to come away from the book convinced that the overall impact is a positive one.

I'm tempted to say that the book should be required reading for any mental health professional - certainly any holding a passport. 255 pages.

A BONUS: Want to know more about clinical depression? Maybe my online course "What is Depression?" can help. Click here to access this $20 course for 75% off, or just $5.

(Previous posts looked at Anorexia in Hong Kong, PTSD in Sri Lanka, and Schizophrenia in Zanzibar.)