Ethan Watters
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The Japanese public’s impression that the country was behind the times in addressing mental health got a boost after the devastating earthquake in the city of Kobe in January 1995. The government response to the disaster was criticized by Western mental health experts for being lackluster on many fronts. Researchers from the United States were soon on the scene and garnered much press attention by suggesting that the population needed not just food and shelter but more attention paid to their emotional and mental health.
Several prominent Japanese psychiatrists and mental health advocates used the authority of the visiting mental health experts to make a broad argument that Japanese culture discouraged talking about emotionally loaded issues. “The comparison, quite unfavorable to Japan, was often made to the United States, where the emphasis on psychological issues is generally believed to be culturally strong and given proper priority,” the anthropologist Joshua Breslau reported. “One well‐known newspaper critic noted that his friend told him how nearly everyone in US cities has a psychological counselor.”
A critical turning point came just three months after the Kobe quake. A TV producer named Kenichiro Takiguchi was browsing through the English‐language section of a Tokyo bookstore and started to flip through a paperback copy of Peter Kramer’s American best seller Listening to Prozac. Always on the lookout for good ideas for programs, he took the book to his bosses at Japan’s largest television network and persuaded them to let him produce a fifty‐minute special. The message of the special was similar to the beliefs made popular after the Kobe earthquake, namely, that Americans were far advanced in their recognition and treatment of emotional disorders such as depression and anxiety. The show hit a nerve. Millions watched and more than two thousand viewers called in afterward to praise the network for running the program.
Japanese psychiatrists were largely taken by surprise at this turn in public interest. Up to that point the public had eschewed the intrusion of psychiatry into daily life. As the small population of psychiatrists had mostly limited their practice to the severely mentally ill, the call to address common unhappiness and anxiety that came with bad economic times caught them off‐guard. Like many people in the country up to that point, they had not considered unhappiness (or divorce or suicide) a mental health issue. They were in need of a new and compelling explanation for what was going on. Fortunately for them, GlaxoSmithKline and several other major psychopharmaceutical companies were just then preparing to throw them a lifeline.
Kalman Applbaum, a professor at the University of Wisconsin in Milwaukee, is an anthropologist, but he doesn’t study little‐known tribes in far‐off lands. His interest is closer at hand: the rituals and practices of international corporations. His specialty, the anthropology of the boardroom, has led to teaching posts both in anthropology departments and at business schools, including Harvard and Kellogg. He is also fluent in Japanese and often consults with companies interested in the Asian markets. When he heard in the late 1990s that major players in the pharmaceutical industry were attempting to introduce SSRIs to Japan, he knew he had the topic for his next set of research papers.
At the beginning of the new millennium, Applbaum went out of his way to visit the headquarters of GlaxoSmithKline, Lilly, and Pfizer, the major international players who were at various stages of trying to get their drugs into Japan. At the time both Pfizer and Lilly were playing catch‐up to GlaxoSmithKline, which was just then launching Paxil in the country. Although he had to sign non‐disclosure agreements promising that he wouldn’t identify the executives by name or company affiliation, Applbaum managed to get remarkable access to the inner workings of these companies. Several of his former MBA students who were then working in these firms helped make key introductions, but in the end these executives proved more than willing to talk. When I asked Applbaum why they were so forthcoming, he told me it was simple: because of his business school credentials and his extensive experience in the Japanese market, they thought he might be able to give them some free advice.
Applbaum discovered that the companies intent on entering the SSRI market in Japan were not battling each other like Coke and Pepsi for market share – or at least not at the beginning. Instead he found wide acknowledgment within the ranks of drug company executives that the best way for companies to create a market was for competing companies to join forces.
A critical player in this joint effort was the trade organization Pharmaceutical Manufacturers of America, or PhRMA, which functions as the national and international lobby and public relations organization for a coalition of major drug companies. In the late 1990s Applbaum found PhRMA working on a number of levels in Japan to influence what they considered to be a backward and bureaucratic drug approval process. As one PhRMA executive based in Chiyoda‐Ku, Tokyo, told Applbaum, their job was to create “a market based upon competitive, customer choice and a transparent pricing structure that supports innovation.” The lobby wanted drugs such as Paxil to be able to enter new markets based on “global, objective, scientific standards.”
The more Applbaum talked to drug company insiders, the more righteous frustration he found. When he visited the offices of a leading SSRI manufacturer in November 2001, he discovered a wellspring of anger directed at what they perceived as Japanese resistance to pharmaceutical progress. These executives criticized scientific standards for clinical testing in Japan as “quite poor” and asserted that there was no “good clinical practice” in the country. Why, they asked Applbaum rhetorically, should their company be forced to retest these drugs in exclusively Japanese populations? The assumption was that the science behind the American human trials was unassailable – certainly better than anything the Japanese would attempt.
No doubt that annoyance at having to retest drugs was so intense because a couple of recent large‐scale human trials of SSRIs in Japan had failed to show any positive effects. Drugs such as Pfizer’s Zoloft, which were widely prescribed in the United States, had at least one large‐scale human trial failure in Japan in the 1990s. Instead of considering the meaning of such results, the drug company executives railed at Japanese testing practices, calling them second rate. “There is no sense of urgency about patient need in Japan,” one executive complained to Applbaum.
Although drug company executives clearly would have preferred to avoid the expensive and time‐consuming process of retesting their SSRIs in Japan, they ultimately found a way to put those trials to good use as the first step in their marketing campaign. The drug makers often bought full‐page ads in newspapers in the guise of recruiting test subjects. Applbaum believes that this was one of several savvy methods the drug companies employed to sidestep the prohibitions in Japan on marketing prescription drugs directly to the consumer. These advertisements, supposedly designed only to recruit people for the trials, were well worth the cost, as they both featured the brand name of the drug and promoted the idea of depression as a common ailment. One company scored even more public attention when it recruited a well‐known actress to take part in the trials.
But getting the drug approved for market was only the first step. Talking with these executives, it became clear to Applbaum that they were intent on implementing a complex and multifaceted plan to, as he put it, “alter the total environment in which these drugs are or may be used.” Applbaum took to calling this a “mega‐marketing” campaign – an effort to shape the very consciousness of the Japanese consumer.
The major problem GlaxoSmithKline faced was that Japanese psychiatrists and mental health professionals still translated the diagnosis of “depression” as utsubyô, and in the mind of many Japanese that word retained its association with an incurable and inborn depression of psychotic proportions. In hopes of softening the connotations of the word, the marketers hit upon a metaphor that proved remarkably effective. Depression, they repeated in advertising and promotional material, was kokoro no kaze, like “a cold of the soul.” It is not clear who first came up with the phrase. It is possible that it originated from Kenichiro Takiguchi’s prime‐time special on depression. In that show, it was said that Americans took anti‐depressants the way other cultures took cold medicine.
Whatever its origin, the line kokoro no kaze appealed to the drug marketers, as it effectively shouldered three messages at the same time. First, it implied that utsubyô was not the severe condition it was once thought to be and therefore should carry no social stigma. Who would think less of someone for having a cold? Second, it suggested that the choice of taking a medication for depression should be as simple and worry‐free as buying a cough syrup or an antihistamine. Third, the phrase communicated that, like common colds, depression was ubiquitous. Everyone, after all, from time to time suffers from a cold.
Although advertising couldn’t mention particular drugs, companies could run spots in the guise of public service announcements encouraging people to seek professional help for depression. In these ads SSRI makers attempted to distance depression further from the endogenous depression as it was understood by Japanese psychiatrists for most of the century. One GlaxoSmithKline television advertisement showed an attractive young woman standing in a green field, asking, “How long has it been? How long has it been since you began to worry that it might be depression?” The scene then shows a woman on an escalator and then a middle‐aged office worker staring out a bus window. The voiceover then recommends that if you’ve been feeling down for a month, “do not endure it. Go see a doctor.”
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Depression was so broadly defined by the marketers that it clearly encompassed classic emotions and behaviors formerly attributed to the melancholic personality type. The label of depression then took on some laudable characteristics, such as being highly sensitive to the welfare of others and to discord within the family or group. Being depressed in this way became a testament to one’s deeply empathic nature.
To get these messages out to the Japanese public, the SSRI makers employed a variety of techniques and avenues. Company marketers quickly reproduced and widely disseminated articles in newspapers and magazines mentioning the rise of depression, particularly if those pieces touted the benefits of SSRIs. The companies also sponsored the translation of several best‐selling books first published in the United States on depression and the use of antidepressants.
Given all the ways that GlaxoSmithKline and the other SSRI makers managed to make the average Japanese aware of their drugs, the official ban on direct‐to‐consumer marketing became almost meaningless. If there was any doubt about this, one only had to look at how these companies used the Internet. “The best way to reach patients today is not via advertising but the Web,” one Tokyo‐based marketing manager told Applbaum. “The Web basically circumvents [direct‐to‐consumer advertising] rules, so there is no need to be concerned over these. People go to the company website and take a quiz to see whether they might have depression. If yes, then they go to the doctor and ask for medication.”
The mega‐marketing campaign often came in disguised forms, such as patient advocacy groups that were actually created by the drug companies themselves. The website utu‐net.com, which appeared to be a coalition of depressed patients and their advocates, was funded by GlaxoSmithKline, although visitors to the site would have had no clue of the connection. What they would have found was a series of articles on depression driving home the key points of the campaign, including the idea that it was a common illness and that antidepressants bring the brain’s natural chemistry back into balance.
The public interest in the new diagnosis brought a remarkable amount of media attention. Often in back‐to‐back months, the major magazines Toyo Keizai and DaCapo ran pieces on depression and the new drugs. In 2002 a leading Japanese business magazine ran a twenty‐six‐page cover story encouraging businesspeople to seek professional help for depression. The article rather perfectly mirrored the key points of the SSRI makers’ mega‐marketing campaign and in many ways reflected the early conceptions of neurasthenia a century before. The article suggested that it was the more talented and hard‐charging workers who were the most susceptible to depression. Estimates of how many Japanese secretly suffered from depression, which ranged from 3 to 17 percent of the population, seemed to increase every month.
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The SSRI makers made much of one public relations windfall in particular. It was rumored for years (and finally confirmed by the Imperial Household Agency) that Crown Princess Masako suffered from depression. Soon it was revealed that she was taking antidepressants as part of her treatment. This was a huge boost for the profile of depression and SSRIs in the country. Princess Masako’s personal psychiatrist was none other than Yutaka Ono, one of the field’s leaders that GlaxoSmithKline had feted at the Kyoto conference in 2001.
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There is no doubt that the efforts of GlaxoSmithKline in Japan proved profitable. In just the first year on the market Paxil sales brought in over 100 million dollars. At the end of 2002 the company reported, “Sales of Seroxat/Paxil, GSK’s leading product for depression and anxiety disorders, was the driver of growth in the CNS (Central Nervous System) therapy area, with sales of 3.1 billion, up 15% globally and 18% in the USA. International Sales of Paxil Grew 27% to $401 million led by continued strong growth in Japan, where the product was launched only two years ago.” By 2008 sales of Paxil were over one billion dollars per year in Japan.
Kitanaka has been stunned to see how fast things have changed in Japan since SSRIs were introduced. “The whole culture surrounding psychiatry has changed drastically,” she told me. “From a stigmatizing notion that no one talked about, depression has become one of the top concerns of people. It has become a legitimate disease at so many different levels and at the same time these changes have transformed the nature of depression as an experience itself.”
Some Japanese psychiatrists, even Ono and Tajima, whom the company feted in 2000, felt they were not leading this new trend but reacting to it. Ono reports that starting in 2001 he suddenly had a rush of patients showing up at his office with either a magazine article or an advertisement in hand and wanting to talk about their depression. It was clear to him that the mild symptoms these patients described would not previously have been considered an illness. As more and more Japanese began to identify themselves as depressed and as the risks of SSRIs came to his attention, he has wondered if there were ways to reverse the trend.
“The marketing campaign has been in many ways too successful. The slogan, depression is like a ‘cold of the soul,’ has convinced far too many people to seek medical treatment for something that is often not an illness,” Ono told me. “Perhaps we could start saying that depression is like a ‘cancer of the soul.’ That would be more accurate and perhaps not so many people would be willing to adopt that belief.”
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