Deep pharma: psychiatry, anthropology, and pharmaceutical detox.

Cult Med Psychiatry (2014) 38:255-278 DOI 10.1007/s11013-014-9369-8 ORIGINAL PAPER

Deep Pharma: Psychiatry, Anthropology, and Pharmaceutical Detox Michael Oldani

Published online: 4 April 2014 Springer Science+Business Media New York 2014

Abstract Psychiatric medication, or psychotropics, are increasingly prescribed for people of all ages by both psychiatry and primary care doctors for a multitude of mental health and/or behavioral disorders, creating a sharp rise in polypharmacy (i.e., multiple medications). This paper explores the clinical reality of modern psychotropy at the level of the prescribing doctor and clinical exchanges with patients. Part I, Geographies of High Prescribing, documents the types of factors (pharmaceutical-promotional, historical, cultural, etc.) that can shape specific psychotropic landscapes. Ethnographic attention is focused on high prescribing in Japan in the 1990s and more recently in the Upper Peninsula of Michigan, in the US. These examples help to identify factors that have converged over time to produce specific kinds of branded psychotropic profiles in specific locales. Part II, Pharmaceutical Detox, explores a new kind of clinical work being carried out by pharmaceutically conscious doctors, which reduces the number of medications being prescribed to patients while re-diagnosing their mental illnesses. A highprescribing psychiatrist in southeast Wisconsin is highlighted to illustrate a kind of med-checking taking place at the level of individual patients. These various examples and cases call for a renewed emphasis by anthropology to critically examine the ‘‘total efficacies’’ of modern pharmaceuticals and to continue to disaggregate mental illness categories in the Boasian tradition. This type of detox will require a holistic approach, incorporating emergent fields such as neuroanthropology and other kinds of creative collaborations.

The content and analysis were derived from my own original research and writing (with some ethnographic work completed in conjunction with Kalman Applbuam/UW-Milwaukee, see footnote 23). This publication has not been previously submitted for peer review. M. Oldani (&) Department of Sociology, Anthropology and Criminal Justice, University of Wisconsin-Whitewater, Whitewater, WI, USA e-mail: [email protected]

123

256

Keywords Psychiatry

Cult Med Psychiatry (2014) 38:255–278

Psychotropy Pharmaceutical detox Sales and marketing

Introduction In many ways, modern pharmaceuticals have become the ‘‘quintessential commodities of our time’’ (Appadurai 1986). In particular, psychotropics (i.e., psycho- or neuro-active medications) operate at the highly profitable nexus of science, marketing, and human desire (see Petryna et al. 2006). The sheer number of psychotropics being prescribed in the United States alone is astonishing— unprecedented in human history. In 2009, there were over three hundred million prescriptions written for psychiatric medication, from generic Xanax (alprazolam) at forty-four million scripts to patented Lexapro (escitalopram) at twenty-seven million scripts.1 Interestingly, in 2014, there is not a single psychotropic that is dominant in both its public and medical popularity like Prozac was in the recent past. During the 1990s, the United States was indeed a ‘‘Prozac Nation,’’ which reflected its blockbuster status, infiltration into various channels of popular culture, and scholarly interest (Wurzel 1994; see also Kramer 1993 and Elliott and Chambers 2004), and prior to this, the US could have been described as Xanax nation in the 1980s, which would have been preceded by Valium nation in the 1960s and early 1970s (see Tone 2009, pp. 175–202). Today, many types of psychotropics are in prescription circulation in the United States. The branded SSRI antidepressants of the 1990s and early 2000s are all generic (i.e., off patent), including the ingenious re-branded compound Lexapro (i.e., previously Celexa),2 and all are still highly prescribed, ‘‘the workhorse psychotropics,’’ as several of my psychiatrist informants have opined over the last several decades. The atypical antipsychotics currently are the dominant branded class of psychotropics (e.g., Zyprexa, Abilify, Geodon, etc.), but they are systematically losing their patent lives as well, and older, generic psychotropics remain highly prescribed, such as the stimulant methylamphetamine, previously the branded ‘‘Ritalin.’’ Makers of stimulants, in particular, have continued to rebrand their products as patents expire. For example, Shire Pharmaceuticals in 2007 introduced Vyvanse, a long acting dextroamphetamine, as its top selling Adderall, which is a combination of amphetamine and dextroamphetamine, was close to patent expiration. The generic benzodiazepines, or ‘‘benzos’’—Valium, Ativan, and Xanax—have maintained an incredible prescriptive staying power over the last five

1

As reported by the New York Times through data provided by IMS Health (International Marketing Systems) and compiled by PsychCentral, http://psychcentral.com/lib/2010/top-25-psychiatricprescriptions-for-2009/, accessed July 2, 2013.

2

Lexapro, or escitalopram, is the patented racemic isomer, of Celexa, which is a mixture of both R and S citalopram isomers (McConathy and Owens 2003, p. 72). Celexa was introduced and marketed first in the US and then Forest Pharmaceuticals, the manufacturer, transitioned to Lexapro, which has had a longer patent life on the US market.

123


257

decades. Collectively, the benzos remain the number one prescribed class of psychotropic medications in the US (Miller 2012).3 This endless expansion of the psychotropic marketplace today has been described as the ‘‘psycho-pharmaceutical industrial complex’’ (see Levine 2008, for commentary on women and children; see also Oldani 2012a). One concrete outcome for patients today is that polypharmacy, the ingesting two or more psychiatric medications on a daily basis, has become a social and medical fact for millions of patients. The concept of polypharmacy itself continues to medically and culturally evolve with multiple definitions and meanings for doctors and patients. The Free Dictionary, which is an online clearinghouse of sorts, defines several types of polypharmacy using multiple medical references. Polypharmacy can indicate the ‘‘administration of many drugs together’’; ‘‘the administration of excessive medication’’; ‘‘the mixing of drugs in one prescription’’; ‘‘the use of… different drugs, possibly prescribed by different doctors…’’; ‘‘the practice of prescribing multiple drugs to patients suffering from more than one malady’’; and ‘‘the prescription or dispensation of unnecessarily numerous or complex medicines.’’4 The current medical literature concerning psychiatric polypharmacy describes it as the prescribing of multiple drugs that most often have no observable clinical benefit (Mojtabai and Olfson 2010; see also Hunt et al. 2012 on the growth of polypharmacy in Type II diabetes management). My psychiatric informants have described this as the ‘‘shot gun’’ approach to mental health treatment, with the medications themselves acting, through their multiple efficacies, as ‘‘diagnostic tests,’’ allowing clinicians to use psychotropic(s) to relieve symptoms and then catalog those symptoms postprescription via the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Statistical Classification of Diseases, (Oldani 2009). Historically, the practice of polypharmacy was most common in elderly populations (e.g., the stereotypical image of nursing home patients ‘‘drugged out’’ on multiple psych meds) and in subpopulations of patients with metabolic disorders (e.g., Type II diabetes patients), but psychotropic polypharmacy is common and on the rise in all age groups, especially in children and young persons (Zonfrillo and Penn 2005). In this current era of ‘‘modern psychotropy’’ (Smail 2008; see also the Introduction to this Special volume), the US continues trending toward the polypharmaceutical. Individuals ingesting what is commonly called ‘‘drug cocktails,’’ or ‘‘drug sets’’ (see Biehl 2010, p. 71 in the Brazilian context) have become a new normal for the mentally ill, for individuals dealing with addiction (Garcia 2010, Chapter One, Meyers 2013; Saris 2010, p. 215; see also Raikhel and Garriott 2013) and for those seeking less mental illness treatment and more ‘‘neuroenhancement’’ (Talbot 2009). For scholars, who have critically interrogated the sales activities and the marketing networks of Big Pharma as well as the third-party companies that provide strategic information, polypharmacy is the logical and desired outcome of sound business practices by the global drug industry (e.g., Applbaum 2009, 2006b; Dumit 2012). In fact, a real and 3

IMS Health data form 2011 also supports this claim and was compiled by the Web Site, Psych Central, which began in 1995 as a way to index online support groups (psychcentral.com/lib/top-25-psychiatricmedication-prescriptions-for-2011/oo12586, accessed February 6, 2014).

4

http://medical-dictionary.thefreedictionary.com/polypharmacy, accessed February 6, 2014.

123

258


transparent goal by the leaders of pharmaceutical corporations, beginning in the late 1950s, has been to produce medications to treat emergent, chronic conditions, like mental disorders (and cardiovascular disorders/diseases), and to ensure indefinite ‘‘maintenance therapy’’ through pharmaceutical management (see Greene 2007, pp. 1–3). Thus, today we have a situation where the pharmaceutical industry has worked extremely hard over many decades to normalize (for both doctors and patients) lifetime, polypharmaceutical prescriptive treatments of mental health disorders. Recent assessments and critiques of our current state of modern psychotropy have described these outcomes in apocalyptic terms: We have entered a state of ‘‘pharmageddon’’ (Healy 2012) or an ‘‘epidemic’’ of both over prescribing and over diagnosing of mental health disorders (Whitaker 2005). In this paper, I want to offer an ethnographic intervention of sorts which is less apocalyptic and more hopeful for a new era of what might simply be called appropriate psychotropic prescribing, an era that might become less branded Prozac and more generic fluoxetine—both symbolically and in reality. My interventional work documents the intervention by psychiatrists who are working on a daily basis to reduce the psychotropic load of their patients by convincing them that they are less mentally ill than they previously believed (or that they actually may be more addicted to psychotropics and less ill).5 In Part I, I present ethnographic research that describes a local psychotropic landscapes in the upper Midwest of the United States, what I describe as ‘‘geography of high prescribing.’’ Within these geographies, I have focused my ethnographic attention on a key figure or ‘‘figuration’’ (Tsing 2009, p. 151) that is also the primary focus of billions of dollars of pharmaceutical industry sales and marketing efforts: ‘‘the high prescriber.’’ Profits for the pharmaceutical industry in the US remain directly linked to ‘‘the power of the pen’’ and generating the writing of prescriptions, or ‘‘scripts,’’ via ink and paper or electronically, remains the strategic goal of Big Pharma and their legions of drug reps.6 5

The informants discussed and quoted in this paper have given written and/or verbal consent to participate in this study, which was approved by the Internal Review Board of the University of Wisconsin-Whitewater (#O11203096Q). All the names of individuals and recognizable sites/places have been altered to preserve the anonymity of participants; quotations are used for pseudonyms, native terms, direct quotes, and remembered phrases. I have engaged in direct observations and interviews, off and on, with key informants over the longterm (i.e., Dr. Wilby—20 years; Dr. Vindrik and Straminski 9 years). I have observed Dr. Wilby’s clinical practice in two different settings—private practice and public practice. I have recorded fieldnotes in written form, audio file, and scratch notes; and include 100? h of clinical observations and detailed interview transcripts. Part of this research was also supported through a Research Growth and Initiative Grant (Project: A Clinical Ethnography of Mental Health Services in Wisconsin, 2009/10) through the University of Wisconsin System; co-recipients of this RGI grant were Kalman Applbaum (see Note 23), and Paul Brodwin, Anthropologists, UW-Milwaukee.

6

Some countries, such as India and Mexico do not require a doctor’s prescription for patients to obtain medication from a pharmacy or clinic. Many medications can be obtained ‘‘over-the-counter.’’ In the United States, Canada, many countries in Western Europe and Japan a prescription is required, and thus the marketing efforts of Big Pharma are focused intensely on the prescriber. For an interesting discussion and mapping of countries and prescriptions in the context of oral contraceptives see www.motherjones. com/kevin-drum/2012/03/lots-contries-doknt-require-prescriptions-oral-contraceptives, accessed February 6, 2014.

123


259

In Part Two, I present the case of a high-prescribing psychiatrist in Wisconsin, who is engaged in prescription battles with her own patients and another highprescribing primary care doctor. Her type of script-writing and the logic she employs when critically ‘‘checking’’ her patients medication illustrates an indigenized process she has labeled ‘‘pharmaceutical detox’’ and ‘‘undiagnosing.’’ I argue through these ethnographic vignettes that these new psychiatric practices represent a daily struggle by doctors to counter the ‘‘total efficacy’’ of psychotropics, a somewhat daunting task that can only occur script-by-script, patient-by-patient. I conclude by highlighting how tracking the local nuances of high prescribing/ prescribers, with a conscious awareness of the deep networks of Big Pharma, offers an important opportunity for medical anthropologists and scholars of science and medicine to reinvigorate their efforts in the Boasian tradition. Pharmaceutical detox(ing), in anthropological terms, requires the power of the pen of a different sort—an ethnographic kind. Working (and writing) vigorously to ‘‘disaggregate’’ the nature/culture effects of modern psychotropy will continue be a struggle and ultimately represents a high stakes enterprise for all players.7 Ethnography can and should intervene as a counter-force to overmedicating, polypharmacy, and pharmaceuticalization by bringing more doubt than certainty to the very cultural and psychiatric categories of being that have been inscribed in and through us by the simple act of writing a prescription.

Part I: Geographies of High Prescribing The battle over the psychotropic marketplace in any locale remains a battle over the prescriber—the doctors, physician assistants, and nurse practitioners who are licensed to write prescriptions—‘‘scripts.’’ The current level of prescribing and/or the prescribing legacy operating within a geographical locale (i.e., a zip code, a rural county, an urban neighborhood, an entire country, etc.) can result from a variety of factors, ranging from sound medical practice to idiosyncratic prescribing preferences (see below) to successful sales campaigns by drug companies. Based on my own long-term fieldwork and experiences working within the pharmaceutical industry as a salesperson, I have come to describe these locales as ‘‘geographies of 7

The recent work of Carl Elliot regarding psychiatric clinical trials and corruption is a case in point. As an investigational bioethicist, he has not been afraid to call out by name in print the very doctors who have been involved in psychiatric clinical trials at teaching centers. He has highlighted how the structure(s) of the trials, incentivization of clinicians, and the involvement of third-party, for-profit companies have corrupted the very nature of humane care of the mentally ill. This nexus of for-profit interests has led to severe patient side effects and subsequent death (see http://www.motherjones.com/ environment/2010/09/dan-markingson-drug-trial-astrazeneca, accessed February 14, 2014.). The level of transparency his work has created has come at personal and professional cost (see http://www. reportingonhealth.org/blogs/qa-dr-carl-elliott-part-2-finding-fault-his-own-university-after-patientsdeath, accessed February 14, 2014). Ethnographic work requires anonymity of all informants and ‘‘outing’’ specific unethical or criminal activity by informants would present unique challenges. However, my recent expert legal work and the ethnographic work of other anthropologists (e.g. Applbaum 2010) have shown one way to get at naming ‘‘the truth’’ of pharmaceutical practices (and involved clinicians) is to access the public record of court transcripts and/or detailed, depositions of stake holders while under oath.

123

260


high prescribing.’’8 The prescription landscape of these geographies can be variable and dominated by one branded drug or by generic(s) and can evolve into a polypharmaceutical milieu. These spaces will most often be inhabited by one or more high volume script-writer. Since high prescribers are the key figures of interest for Big Pharma and their field forces of drug reps (i.e., ‘‘sales targets’’ in pharmaspeak), these individuals must be intensely studied and tracked by medical anthropologists and other scholars. Locate and assess the logic and practices of high prescribers and one can begin to unravel the specific historical, cultural, and psychiatric aspects of the everyday psychotropic landscapes. Japan, and its relationship to the SSRI-class of antidepressants, remains a paradigmatic case in point for scholars (and the drug industry) to think with. Japan has long been a target of US drug makers, and its psychotropic profile today is saturated with antidepressants. Scholars have documented how was not always the case, where ‘‘depression,’’ in particular, the milder forms, were cast more into categories of everyday suffering, in the Buddhist and/or Shinto sense of the experience (see Kirmayer 2004; Schulz 2004; Kitanaka 2012; see also Caudill 1959). During the early 1990s, everyday suffering was moved into the more profitable and pathological category of ‘‘mild depression.’’ One institution that helped make this possible was the Ministry of Health of Japan, which had very valid concerns about Japanese society and mental health. Suicide rates were alarmingly high compared to the US (i.e., 10:1) and the average length of stay in a mental institution for severe depression in Japan was longer than a year’s duration. GlaxoSmithKline (GSK), the makers of Paxil (paroxetine), saw the depression ‘‘awareness campaign’’ by the government as a new opportunity for an SSRI to reenter the Japanese marketplace. (Lilly, Inc. had actually decided not to market Prozac (fluoxetine) in Japan during the late 1980s, because at that time there was ‘‘virtually no demand for antidepressants’’ Schulz (2004)). GSK needed to pathologize a state of being, or mood, at the clinical level, at the level of the prescriber. The company created its own kind of awareness campaign by co-opting a sales pitch from a Japanese drug company, Meiji Seika Kaisha (MSK). MSK had cleverly come up with an indigenous sales pitch for their own antidepressant, the SSRI, Depromel (fluvoxamine): ‘‘Kokoro no kaze.’’ This translates into ‘‘your soul is sick’’ or your ‘‘soul has a cold.’’ Three thousand GSK sales reps, combined with government ad campaigns, began to shift the public understanding, both individually and collectively, of what ‘‘sorrow’’ and ‘‘suffering’’ might now mean for individuals. The result for the GSK was robust sales of Paxil, into the hundreds of millions of dollars (Schulz 2004)—a number one seller. The transformation of Japan’s psychotropic profile was part of what could be described as the ‘‘global assemblage’’ (Ong and Collier 2005) of pharmaceutical marketing. This involved the co-importing of new kinds of bio-psychiatry (see Applbaum 2004, 2006a; Kitanaka 2012, Chapter 5) as well as a steep rise in selfhelp books on the topic of depression and Internet message boards concerning 8

I worked for a multi-national pharmaceutical company as a drug rep from 1989 to 1998 and promoted a blockbuster SSRI antidepressant from 1992 to 1998, see Oldani 2004 for auto-ethnographic assessments of this time period; see also ex-reps who reflected on their work in Fugh-Berman and Ahari (2007) and Reidy (2005), pp. 8–57.

123


261

mental illness (Schulz:Ibid).9 Yet, the tipping point occurred at the everyday level of the pharmaceutical prescriber—the doctor—and was fueled by the on-the-ground efforts of drug reps. At this level of doctor–drug rep and subsequently, doctor– patient exchange(s), a new kind of person emerged as a possibility, a biologically depressed individual, and potentially, a very sick person. For the moderate to severely depressed Japanese individual, this psychotropic intervention may have been highly therapeutic and even life saving. However, GSK was much more interested in the more expansive category of mild depression: the soul with a cold, not a raging infection. In Japan, GSK was able to mobilize a field force of reps and greatly impact a nation’s psychotropic profile at the population level. Nonetheless, its important to note that a geography of high prescribing, regardless of size, is made up of a network of individual prescribers, and the branded psychotropic profile of a local community can be dramatically altered through the prescribing of a single scriptwriter. The industry spends millions of dollars on ‘‘prescribing data’’ from thirdparty data mining companies, such as the globally based IMS, and uploads information on to mobile devises of drug reps on a daily basis. What is essential to understand is that a single prescriber can literally become a profitable market, can make or break the ‘‘sales quota’’ for a local drug rep, whose livelihood is directly attached to that doctor. In the United States, a psychiatrist at a ‘‘prescription mill’’ (i.e., a term used by the industry to describe a medication checking clinic where patients are seen for ten to 15 min by psychiatrists) can actually generate 4,000–8,000 scripts of an SSRI over a 1-year period, through daily script-writing and automatic pharmacy refills (approximately 11–22 prescriptions per day of thirty-day patient supplies).10 In the recent past, when the price of a branded SSRI was on average eighty dollars for thirty tablets/pills, that single prescriber would generate between $320,000 and $640,000 on a yearly basis. Based on these numbers, a company could cultivate a billion-dollar-plus, branded psychotropic market, the benchmark for blockbuster status, by convincing approximately 2,500 doctors nationwide to write on average fifteen scripts per day. The intense focus by drug reps, and the entire industry, on prescribing data explains in large part why sales reps refer to their job as a ‘‘numbers game.’’ Locate and persuade current and future high prescribers in a geographical area to write scripts for their products, and a rep creates and sustains a market for the long-term. All pharmaceutical companies engage in this kind of prescriber targeting, and it helps explaining why newly branded psychotropics can quickly come to dominate a geographic locale, one after the other, until they lose their patent life. Pharmaceutical sales and marketing tactics however are not the sole factors creating geographies of high prescribing. Previous clinical ethnographic work I 9

Groopman has reported on this in the New Yorker (‘‘What’s Normal?’’), specifically as it relates to the growth of Bipolar II diagnoses in children. He shows how one book in particular, the Palolos’s ‘‘The Bipolar Child: The Definitive and Reassuring Guide to Childhood’s Most Misunderstood Disorder,’’ gave parents the right verbiage to speak to clinicians in a way that fuels the diagnostic process for their children (http://www.newyorker.com/reporting/2007/04/09/070409fa_fact_groopman, accessed July 3, 2013.

10 I have seen numbers in this range both as a drug rep and as an expert consultant on court cases related to pharmaceutical promotion of products off label.

123

262


completed in Manitoba, Canada, in the early 2000s among Aboriginal families and their doctors demonstrated that high prescribers of generic stimulants, like Ritalin (methylphenidate), were impacted through deeper cultural and societal factors.11 These practices often led to psychotropic polypharmacy for individual children and could create ‘‘pharmaceutical families,’’ with several members prescribed one or more psychotropic (Oldani 2009; see also Ecks 2010 for psychotropic contestations of pharmaceuticals and family life in a South Asian Context). Two high prescribing doctors, isolated in rural outposts in Manitoba, described how they ‘‘never saw drug reps’’ but nonetheless wrote hundreds if not thousands of scripts per month for psychiatric medication for their younger patients. One doctor described his prescribing in both racialized and geographical terms when discussing his treatment approach to Aboriginal children diagnosed with ADHD and/or fetal alcohol spectrum disorder. He would create his own micro-geographies of stimulant prescriptions based on whether or not children lived on aboriginal reserves. He was more apt to psychiatrically assess and treat children with psychotropics if they lived ‘‘off reserve’’ in foster homes with native or non-native families. He felt they might have ‘‘a future’’ with these families and used psychiatric meds to potentially improve their lives. Likewise, the other doctor I interviewed, employed psychotropics to ‘‘keep foster [aboriginal] children with their siblings’’ to control for mood and behavioral abnormalities with familial and social conformity in mind (Oldani Ibid). More recently, I have studied the psychotropic landscape in the Upper Peninsula of Michigan (i.e., known colloquially as ‘‘the UP’’). I have engaged in interviews and clinical observations with two doctors—‘‘Dr. Vindrik,’’ a psychiatrist, and ‘‘Dr. Straminski,’’ a family practice doctor—both of whom trained in Wisconsin and recently moved to the central UP. What I find interesting about their practices and clinical stories is how they have developed a pharmaceutical consciousness over the last decade regarding the over prescribing of psychotropics and have become staunch critics of polypharmacy and, in general, the ‘‘pharmaceuticalization’’ of psychiatric care.12 This has occurred as they both observed primary care doctors begin to prescribe, especially to young women, atypical antipsychotics as mood stabilizers when diagnosing Bipolar I and II disorder starting in the late 1990s and early 2000s (see Sharpe 2012; Lidz 2007; Martin 2007, Chapter 6 for similar observations). When they moved to the UP in 2011, I was eager to get their impressions on psychotropic prescribing. I assumed the same national trends would be present: a 11 There is an infamous case covered by the Canadian Broadcast Company of a single doctor on Prince Edward Island that prescribed SSRIs to over 5,000 of his patients and eventually had his license suspended. The doctor felt he was doing good clinical work considering the shortage of primary care doctors on the Island (see ‘‘Little Helpers, CBC Broadcasting, Fifth Estate) 12

For work examining pharmaceuticalization (or drugs first treatment practices) in the area of asthma see Whitmarsh (2008); for HIV/AIDS see Biehl (2007); see also van der Geest et al. (1996) and Oldani (2004), Note 9. Similar to the ways medicalization has been studied and articulated by social scientists, pharmaceuticalization has become an extension of ‘‘medicalization,’’ or medicalized practices, that tend to recast social, familial, and cultural-based problems as pathological, in need of control, and treated through the biological efficacy of prescription drugs (see Suissa 2009, pp. 45–46 for a review of literature).

123


263

polypharmaceutical geography of generic SSRI prescribing coupled with shift toward high prescribing of branded atypical antipsychotics. They did indeed encounter and describe a fair amount of SSRI prescribing among their family practice and psychiatric colleagues and what they called an ‘‘appropriate’’ level of atypical antipsychotic use. However, the number one prescribed psychotropic in their locale was generic Xanax—alprazolam. Dr. Vindrik, the psychiatrist, told me he spent the first 6 months of his practice meeting with psychiatric patients and their ‘‘patient advocates’’ trying to explain to them why he ‘‘was discontinuing the alprazolam’’ and why he was ‘‘offering another, non-addicting (non-Scheduled IV) drug.’’ Dr. Straminski told me just about ‘‘everyone up here given any kind of mental health assessment or diagnosis is written a script or has a refill of Xanax waiting at the pharmacy.’’ What can we make of a geography of high prescribing where generic alprazolam dominates? Nationally, alprazolam still is the number one prescribed psychiatric medication in the US (see Note 1). The entire class of benzodiazepines, previously branded Xanax, Valium (diazepam), and Ativan (lorazepam), accounts for eight– four million prescriptions in 2009. The Benzos generate the most scripts, but not the most sales—branded atypical antipsychotics rank number one.13 One could argue that the UP reflects national trends. However, both doctors told me that in their urban-based practice previously in Wisconsin, they simply did not see this kind of ‘‘misuse’’ of alprazolam, nor did they see the patient demand and dependency in ‘‘the average population’’ (Prison, jail, and addiction treatment center populations would be an exception, where a micro-geographies of high prescribing are at work, due to a higher demand for anti-anxiety drugs and surprisingly, stimulants—see below). These doctors had their own local hypotheses about ‘‘Yoopers and Xanax’’: First, the economy of the UP remains in a post-forestry and post-mining liminal state. There is some work, but there are thousands of unemployed workers with little or no prospects for the future, who do not know if traditional jobs will return.14 These doctors describe this collective malaise as omnipresent in their patients and families, which most often presents clinically either as ‘‘depression with anxiety features,’’ or, as they joked, ‘‘anxiety with depression features.’’ They described this as a ‘‘symptomology of the unemployed (or underemployed) workers’’ that extends to their partners/spouses, and even their children. It was not uncommon for these doctors to describe a concrete outcome of this depressed geography and high prescribing as the aforementioned pharmaceutical family, where multiple members were being prescribed generic Xanax. Their second hypothesis, dovetails with their first, and stems from the legacy of Finnish immigration to the area, which created specific cultural personality traits. These doctors describe the typical mentally distressed patient that presents as 13 In 2009 and 2010, Abilify and Seroquel (quetiapine fumarate) accounted for roughly $10 billion dollars in sales in the US (see Note 1). 14 In 2009 for example, National Public Radio reported on Baraga County having the highest unemployment rate in the US, http://www.npr.org/2009/09/27/113251646/u-p-county-tops-stateunemployment-rate, accessed July 2, 2013. The UP’s unemployment rate remains above the national average, in December of 2012 the rate was 9.4 %, with a county-range of 7.3–18.3 % (Baraga), http:// michigan.gov/budget, Accessed July 2, 2013—Civilian Labor Force Estimates, December 2012.

123

264


‘‘really unable to talk… as alexithymic.’’ Alexithymia is defined clinically as the inability to identify and describe the emotions of the self and also lacking, at times, the inability to interpret the emotions of other people. These doctors are likely observing a linguistic expressive phenomena in the UP that is less clinical and more cultural. The social psychological literature describes a core aspect of Finnish personality as one of ‘‘quietude’’ requiring periods of ‘‘positive silence,’’ which for Finlanders is a ‘‘natural way of being’’ (Carbaugh et al. 2006). Whether quietude or alexithymia, patients have presented to doctors overtime in the UP in such a way that fosters a particular kind of psychiatric approach. These two doctors claim that you really cannot get patients to talk about a lot of ‘‘issues’’ or ‘‘personal problems.’’ Their experiences has been that patients may nod to questions related to ‘‘worrying’’ or ‘‘distress about the future’’ or ‘‘anxiety about work,’’ but it takes weeks or months (‘‘or never’’) for them to truly open up, and by then they are already on an established psychotropic regimen of an anxiolytic, like generic Xanax. A third hypothesis is biological: all benzodiazepines are addictive. Once a patient is prescribed the medication they are very susceptible to biological dependency, which increases in its intensity the longer a patient is on the medication (Schatzberg et al. 2010, p. 391). Withdrawal symptoms can include severe sleep disturbances, severe anxiety, and panic attacks (Ibid.), all which are actual indications for treatment with benzodiazepines in the first place (and other types of psychotropics)—a vicious cycle of psychotropic dependency takes root, persists over time, and produces consumer demand. During the recent past, ‘‘worry’’ as a psychiatric symptom appears to have placed many UP patients on a path to a prescription for an anxiolytic like alprazolam. The cheapness of the drug helps to also explain its widespread use in an economically depressed region (similar to generic fluoxetine in rural India, see Ecks and Basu 2009). Another, not-so-obvious hypothesis has to do with Upjohn drug reps in the 1980s and 1990s in the UP. As a former working drug rep in Wisconsin, I recall entering the psychotropic marketplace in 1992 with a new SSRI for depression. An older rep I worked with—‘‘Phil Ganey’’—coverer the UP sales territory. He was quite concerned because he resided in Green Bay and was not ‘‘a local,’’ or a Yooper, and realized his social capital with doctors would be less than a UP-residing drug rep. In particular, he knew that Xanax was the drug of choice for anxiety, in large part because the Upjohn rep lived in the state (Ganey had also sold two older ‘‘neuroleptics’’ in the late 1970s and new the social geography of drug reps living in the UP). In pharmaceutical sales parlance, this Upjohn rep ‘‘owned his doctors’’— lived with them, hunted, fished, and golfed with them. Phil, never to be completely outsold, eventually did very well in the UP as the growth in prescribing of SSRIs as a class grew almost exponentially in the 1990s, and Upjohn’s patent for Xanax’s expired in 1993. Nevertheless, the socially entrenched Upjohn sales rep spent almost a decade working the UP effectively, maximizing social capital and creating a ‘‘feel good economy’’ through gift exchanges with high prescribing doctors (Oldani 2004; see also Fugh-Berman and Ahari 2007). In particular, Xanax promoting drug reps, before the full thrust of direct-to-consumer marketing was felt in the marketplace (i.e., prior to 1998), were able to effectively create a paradigmatic example of

123


265

‘‘disease mongering’’15 for the little known category of ‘‘panic disorder’’ (see Tone 2009, pp. 213–14 on Upjohn-sponsored clinical trials; Orr 2006, Chapter 5). In effect, rebranding the Benzos, post-Valium, and pharmaceutically maximizing an emerging category of the DSM IV. In the late 1990s, drug reps promoting SSRIs began to battle for the anxiety market. Xanax was promoted for anxiety with or without depressive features and similarly the SSRIs for depression with possible anxiety features (see Healy 2006, p. 62–6 and Healy 2004, ‘‘Introduction,’’ for the Rx genealogy of this diagnostic flip flopping). Phil Emery always made his yearly sales quota for his brand name SSRI, but often lamented at sales meetings, that ‘‘Xanax was still number one in the UP.’’ The legacy of promotional campaigns helps to explain, along with other factors, how generic alprazolam remains a highly prescribed psychotropic. The geography of high prescribing in the UP has retained a particular psychotropic profile through the convergence of multiple factors: historical, cultural, biological, and pharmaceutical-promotional. Part II: Pharmaceutical Detox Dr. Vindrik and Straminsky are now committed to altering the local psychotropic profile by vigorously ‘‘discontinuing’’ alprazolam in their patients. Dr. Vindrik may actually have more success than Dr. Straminsky, because he works within the model of American bio-psychiatry that has become structured through reimbursement schemes and productivity models into clinical med-checking. In short, he spends 10–15 min with patients discussing the efficacy and side effects of medication. He also works at a tertiary care center, where he receives referral cases from the entire UP, and during these exchanges, he can initiate a strategy to taper patients off of alprazolam and other drug sets. My clinical ethnographic work over the last 5 years has documented how a growing cohort of doctors, like Vindrik and Staminsky, are engaged in a different types of med-checking. One that does not lead to overprescribing or polypharmacy, but a type of med-checking that critically assesses the psychotropic profile of each patient. These doctors run up against many of the factors, described above, that lead to geographies of high prescribing and yet are still attempting to create new cultures of prescribing at their respective clinics, patient-by-patient and script-by-script. I had previously met Vindrik and Staminsky through another psychiatrist, ‘‘Dr. Wilby,’’ and all three had trained together a residency programs in southeastern Wisconsin in the late 1990s. Vindrik and Wilby in a psychiatry program, with Wilby crossing over into Staminsky’s family practice training, because she was training to be board certified in both psychiatry and family practice. The psychiatric program was somewhat unique at that time, bucking the trend of moving programs solely toward a neuro-biological approach to care (Lurhmann 2000). Instead, as they have described to me, their program stressed the need for an ‘‘integrative approach’’ to treatment, with psychopharmacology and psychodynamic methods being taught, 15 See the entire issue of PLoS Medicine, April 11, 2006, ‘‘Disease Mongering Collection,’’ http://www. ploscollections.org/article/browse/issue/info%3Adoi%2F10.1371%2Fissue.pcol.v07.i02, accessed July 12, 2013.

123

266


and where residents willingly entered psychotherapy (or psychoanalysis), which was covered by medical insurance.16 Dr. Wilby too has been engaged over the last 3 years in a similar process of tapering patients off excess psychotropic medication. Her situation is someone unique because she has managed to institutionalize the process of lowering the psychotropic load of her patients within a public mental health setting. However, Wilby had previously been employed at a private medical clinic where med-checking led to high-volume prescribing and patient polypharmacy. In the early to mid-2000s, she performed a kind of med-checking she described to me as almost driving her ‘‘mad.’’ ‘‘I hat[ed] my work… it [was] all about productivity,’’ she had said to me on more than one occasion before moving into public health. ‘‘[Its] all for the [clinic]… the more patients you can squeeze in, the more money the clinic makes through third-party payers, the more raises you received and the more bonuses you are given at the end of the year’’ (see Magrath and Nichter 2012 on pay-for-performance models; see also Oldani 2010). Dr. Wilby joked to me back then that she ‘‘writes for a living’’—writes prescriptions that is, constantly. She would go to work and receive a stack of patient charts from the clinic staff. I observed how these charts would sit on her desk as the patients came in one-by-one, and her day involved going through each chart with the patient. When she was done with the med-check, she would put their chart on the ‘‘finished pile.’’ If you like what we began to call ‘‘drug talk,’’ her exchanges with patients were fascinating. I observed her talking back and forth during the 10 or 15 min sessions about efficacy and side effects: ‘‘How do you feel since we put you on ‘‘Seroquel’’? ‘‘Are the voices diminishing—are you hearing the voices less?’’ ‘‘Would you say you feel better on medication?’’ ‘‘Are you sleeping better?’’ ‘‘Are you having any particular side effects that stand out?’’ ‘‘Are you gaining weight?’’ ‘‘Are you hungry?’’ ‘‘How did you feel after we changed the dose?’’ The majority of patients engaged in this kind of productive drug talk, but the conversations invariably needed to be ‘‘wrapped up.’’ ‘‘When I see you next time, lets talk about how this new dosage is working… ‘‘Or, ‘‘try and keep track of how you feel after we add Celexa to the mix.’’ Sometimes patients would try and squeeze in some personal narrative: ‘‘I’m getting married soon…not sure if I love [this person]…’’ ‘‘I can’t live with my mom anymore….’’ ‘‘That’s the summer my brother abused me in the family car…’’ Or, patients might integrate compliance issues within their personal narrative: ‘‘…I know the medication might work… but my [friends] told me not to take it because of side effects… I won’t be the same…’’ These talking points, what some in the psychiatric literature have described as productive opportunities for ‘‘pills and play’’ 16 According to my doctor informants, the chair of the psychiatry department had created an integrative psychiatric culture by stressing both psychopharmacology (i.e., hiring psychopharmacologists, who brought their funding with them and could teach the state of the art of modern psychotropy) and setting up an insurance reimbursement scheme that paid for 100 % of psychotherapy and psychoanalysis for all medical staff, residents, and medical students. The result was several generations of psychiatrists and other specialties that understood, both through practice and personal experience, the benefits of integrating both approaches. I also verified through personal conversations with the former chair of the department of psychiatry, that this indeed was his overall goal.

123


267

(Wilsons 2005), had to be pushed to the side to save time and refocus the conversation on medical management. Dr. Wilby, who shows empathy with her patients, was forced to say things like ‘‘save that for therapy,’’ or counseling, or the social worker. The patient then was redirected to discussing the medication: efficacy, side effects, drug interactions (between prescription medications or illegally obtained drugs and alcohol), and the economics of getting actual prescription(s) filled– whether or not a patient could pay for the drugs, needed samples obtained from the clinic sample closet via local drug reps, or if they qualified for drug company ‘‘vouchers’’ for free, monthly supplies of medication. Around the spring of 2009, Dr. Wilby shared with me that she could no longer work in this clinical setting any longer. She searched for something different and found what she later described as the ‘‘ideal situation.’’ I envisioned a clinic where she could take an integrative approach to patient treatment, but I soon learned she meant she found an ideal med-check clinic. Ideal because now, in a public mental health setting, Dr. Wilby could spend up to 45 min with each patient during their med-check appointment, where, according to her, ‘‘more productive drug talk’’ takes place. This in part occurs because she now is a salaried employee—her productivity (i.e., the number of patients seen per day) is not central to billing nor is it part of the formula for overall compensation and year-end bonus (i.e., She now receives no bonus pay.). This extra time allowed with each patient has created the possibility for Dr. Wilby to critically assess the pharmaceutical management of each patient. Moreover, the clinic also has a fairly easy-to-use electronic medical records system and Dr. Wilby can type. This basic skill allows here to sit behind a desk with a computer screen visible on her right and to type in patient information (i.e., take notes) during interviews and clinical exchanges. The computer also allows here to scroll up and down and to quickly move back and forth in time (i.e., through the patient’s historical file self) to check on which meds have been prescribed (or not) by her or other doctors. Drug histories are literally at her finger tips and gives her a decided advantage when dealing with her patients. In particular, Dr. Wilby has encountered a lot of resistance with a large group of patients, who are reluctant to engage in two overlapping med-check processes she has labeled as ‘‘undiagnosing’’ and ‘‘pharmaceutical detox.’’ Her clinical work is still structured in and around medication—everything centers on acquiring and delivering psychotropic medication to patients, either through a generic or branded prescription or the aforementioned free formulations of branded drugs. And, the number of drug reps in circulation at the clinic indicates she is still considered a (potential) high prescriber.17 Nonetheless, she has stressed to me, that she has had to psychotropically ‘‘clean up the joint’’ since arriving. In large part because the previous psychiatrists were, in her words, ‘‘drug rep friendly,’’ meaning they wrote 17 Potential high prescribers are always targeted by pharmaceutical sales persons. They have the data to see how many branded and generic psychotropics a prescriber writes over a given time period. The overall ‘‘universe’’ of prescribing is a key assessment a rep makes through this data. A physician, like Dr. Wilby, may currently have a very low ‘‘quintile’’ rating of say 3 out of 10 for their product, but the data shows she can be potentially be moved into a quintile of 10 over time. That is the goal today of Pharma sales reps, to move those potential high prescribers into high branded product quintiles of 8 and above.

123

268


scripts for patients based more on helping the local rep than good psychiatric practice (see Elliot 2006 for examples of this shift in obligation). For instance, many patients ‘‘for no particular reason’’ (i.e., did not have a psychiatric diagnosis) were on Intuniv (quanfacine), because the Shire company drug rep was ‘‘in the clinic all the time sampling meds and detailing the staff…’’ This medication is basically a second-line, ADHD medication (and antihypertensive) that Dr. Wilby described as ‘‘not really working.’’ She quickly began ‘‘DC-ing’’ (discontinuing) Intuniv, and, because the medication is not an addictive compound, there was little resistance by patients.18 Detoxing patients off of other kinds of drugs was more challenging. Referral patients from the county jail population were ‘‘overloaded with stimulants,’’ specifically, generic Ritalin, methylphenidate and generic Adderall, amphetamine and dextroamphetamine mixed salts, as well as tranquilizers (e.g., generic Valium and Xanax). As Dr. Wilby described the situation: ‘‘The culture needed to be changed because obviously these drugs are addictive and dangerous and most of the patients coming in and out of the jail population are having problems with other kinds of [addictive] drugs [like] pot, cocaine, and other [prescription] drugs [like] Seroquel.’’19 Her efforts at pharmaceutical detox caused friction with caregivers and human service personnel. Older staff at the prison as well as employees at her own psychiatric clinic did not want to engage in detox, in her words it was easier to keep the ‘‘status quo going.’’ Parents of her patients who were in jail and patient advocates also did not want to alter the psychotropic profile of those under their care, resisting her efforts through verbal and/or written exchanges.20 Older doctors within her community were somewhat bitter toward during in-person meetings or on the phone because she had called their psychotropic judgment(s) into question. Yet, with administration backing her actions, she began to win these detoxing battles.21 Dr. Wilby was very careful to point out to me that there are essentially two kinds of patients she negotiates with during these med-check clinic exchanges where pharmaceutical detox is at stake: ‘‘the worried well and schizophrenics.’’22 At this public mental health clinic, ‘‘schizophrenia’’ is a stand in category for all psychotic patients as well as those clients that are ‘‘truly bipolar’’ (i.e., Bipolar I)—with mania 18 The non-addictive chemical properties of quanfacine also help to explain why a second-line ADHD medication could so easily become a first-line agent through the activities of a local drug rep (i.e., low risk to prescribing the medication for a ‘‘sales friend’’ (Oldani 2012b)). 19 During October of 2011, I was told by multiple staff members at the clinic, including the director that Seroquel was the ‘‘new favorite’’ of middle-class, white suburban children and young adults. Its mildly sedating, but according to their experience, users were ‘‘hitting’’ multiple dosages (by crushing and sniffing or by injecting) to get a real ‘‘downer effect’’ (see Sansone and Sansone 2010 on Seroquel’s emerging illicit reputation.) 20 Interestingly, Dr. Wilby described these parents as ‘‘the same parents who would actually call the authorities to have their child arrested for abnormal behavior usually related to drug addiction and criminal activity.’’ 21

There are no official public records, but supportive staff at the county jail that dispense medications and administer the budget have told Dr. Wilby she saved them around $75,000 in 2012. 22 The worried well in this clinical context are not part of the classic definition of patients having only ‘‘emotional problems,’’ that do not require medical management. Rather, I believe Dr. Wilby sees the worried well as mentally ill and needing less medication.

123


269

bordering on psychosis requiring immediate intervention with medication and usually hospitalization. ‘‘There is no messing around with these patients at clinic,’’ she told me, and ‘‘there are protocols to follow with medication.’’23 The worried well were a different story and were the focus of her detoxing and undiagnosing efforts. This mix of patients involves addicts with a previously diagnosed mental illness, patients with a self-diagnosed mood and/or behavioral disorder (e.g., Bipolar II or ADHD), and patients referred to Dr. Wilby from primary care, usually on multiple medications and an established diagnosis. Dr. Wilby looks forward to dealing with these patients on a daily basis, and I observed intense power struggles over prescriptions. I observed how the worried well were attached to their medication and usually wanted to maintain the status quo concerning their drug sets or pharmaceutical cocktails. Dr. Wilby occasionally would admonish patients for ‘‘self-medicating,’’ either through low-level substance abuse, or what she called ‘‘prescription addiction,’’ meaning self-prescribing, or tinkering with non-prescribed psychotropics, which is part of a larger process of self-diagnosing one’s own psychiatric disorder (see Fainzang 2013; McKinney and Greenfield 2010). The biggest challenge, according to her, were patients that presented on established drug sets with a diagnosed mental health disorder that had become paramount to their identity (e.g., ‘‘I am bipolar, have been since I was fourteen… so is my mother’’; ‘‘My son has always been ADHD… how can you take him off Ritalin?!’’). Dr. Wilby would use the electronic medical records system (i.e., scrolling back and forth in real time on her computer during clinical exchanges) to discover for herself, her patients and the ethnographer that many of these psychotropic prescriptions were written by primary care doctors. These patients had also received their initial diagnosis of a mental health disorder from these same primary care physicians. Big Pharma has long targeted primary care for increasing the market share of their psychiatric products (see Vallerstein 1998, Chapter 6), and the prescribing numbers clearly show their efforts have worked. Outside of lithium and Depakote (divalproex sodium)—true anti-mania drugs, primary care writes more anxiolytics, antidepressants, stimulants and virtually the same amount of atypical 23

There is not enough space here to fully discuss the pharmaceutical management of these patients. However, clinical ethnographic work I have conducted with Kal Applbaum (2009 to present) has initially indicated that the future of branded psychotropy may center around IV and intra-muscular (IM) forms of psychiatric medication. Schizophrenics at Wilby’s clinic will be prescribed one of three intramuscular formulations on the market: either CONSTA (IM risperidone), IM Abilify, or Invega Sustaina. In particular, Invega Sustaina seems to be a very promising form of antipsychotic medication—100 % compliance, if you get the patient to clinic. One IM injection is good for one month. At Dr. Wilby’s clinic, there is one nurse practitioner dedicated to administering Invega Sustaina—she says it’s ‘‘a miracle drug,’’ because, there is ‘‘no negotiation.’’ If the patients have family support and are compliant (they want to get better, they want to decrease the voices or visual hallucinations) they are prescribed oral, atypical antipsychotics and return to see her on a routine basis, often with parents if they are young adults, and they receive a tremendous amount of social support. The drug talk revolves around whether or not the atypical antipsychotics, are even working at reducing hallucinations. There is quite a bit of polypharmacy with other psychotropics: dosage titration (up and down) adding and discontinuing meds. All of this drug talk and polypharmacy is an effort to try and restore daily functioning, allowing the patient to resume a kind of normality. Dr. Wilby: ‘‘so they might be able to live on their own some day, to understand money, to perhaps cook a meal.’’ These cases are heartbreaking because a large percentage of the patients are never fully restored, many patients remain noncompliant, and their life revolves around polypharmacy.

123

270


antipsychotics as psychiatry.24 In 2011, Dr. Wilby shared a ‘‘typical case’’ of detoxing where multiple factors converge: ‘‘Diane,’’ a women in her thirties, comes to see me on three meds—lithium, Depakote and Risperdal (risperidone). I literally spend months negotiating her off this cocktail. We meet every week or two to talk about how she is doing, while I taper her down off these meds. I detox and undiagnose her from bipolar [disorder]. And she doesn’t have [Bipolar] ‘‘one’’ (You know the difference?) She thinks she has [Bipolar] ‘‘two,’’ which all my patients just call ‘‘bipolar,’’ when you and I know true bipolar disorder usually puts people in the hospital. By the end of it all, I re-diagnose her as ‘‘depressed with anxiety features,’’ and I write her a script for one drug, Lexapro (citalopram). She also has sort of a sad reaction, at first, to this whole turn of events. I don’t know… I tell her its better to be a little depressed than bipolar! I am not sure if she gets the difference. I finally can send [the patient] to a social worker to deal with her main problems, like her anxiety, which you know is like the classic way to approach these kinds of patients—use anxiety as the window into deeper issues… How does a patient like Diane become bipolar when Dr. Wilby clearly does not see her exhibiting that kind of symptomatology? Her resistance to altering her pharmacotherapy and ultimately her type of mental illness stems in larger part by the fact that her everyday life and identity had become invested in this category over a number of years (see Floersch et al. 2009 on how adolescents can become bipolar). This patient had been referred to Dr. Wilby by ‘‘Dr. Crenna,’’ a high prescribing family practice doctor in the same county, who promotes himself as ‘‘a primary care specialist in Bipolar Disorder.’’ He originally made the diagnosis and prescribed the drug sets to Diane several year earlier. Dr. Wilby claimed that just about every patient referred to her by Dr. Crenna were diagnosed as ‘‘bipolar and on tons of meds.’’ I Googled his name and was able to identify Dr. Crenna and confirm my own suspicions that he was the same primary care doctor I encountered while working in the pharmaceutical industry in the 1990s. During that time high prescribing primary care doctors were considered ‘‘the front line’’ and the ‘‘gate keepers’’ that saw the mentally ill first and could start writing psychotropics for their patients before sending them on to psychiatry. Drug reps relentlessly targeted, called on, and gifted doctors such as Crenna. Dr. Wilby’s specific case reminded me of a company meeting I attended in 1994 where two other family practice doctors came to speak to a group of drug reps—to teach us the nuances of primary care medicine and mental illness management. One of the doctors, in particular, was adamant: ‘‘I know that seventy percent of the patients I see when I walk in the clinic need a mental health work up that day.’’ Pharmaceutical salespersons began to target and recruit these kinds of primary care doctors to give small round table presentations to other primary care doctors and residents in training. 24 See American College of Physicians’ ACPINTERNIST newsletter compiling IMS National Audit Plus database, http://www.acpinternist.org/archives/2009/11/national-trends.htm, accessed July 9, 2013.

123


271

Dr. Crenna, who treated Diane first, was part of this mid-1990s push to get primary care doctors ‘‘on board’’ with writing the SSRIs. I remembered his name from reps I worked with—he was a ‘‘key player,’’ and then evolved into what is known today in the industry as a ‘‘product champion.’’ 15 years later his practice had also evolved into one that specialized in the diagnosis and treatment of mood disorders, especially bipolar disorder in his local community. A ‘‘fuzzy category,’’ according to Dr. Wilby, that leads to polypharmacy for many patients: ‘‘[he writes] atypicals, SSRIs, anxiolytics… stimulants…’’ Dr. Wilby works in the same county and continues to battle with Dr. Crenna over the mental health destinies and pharmaceutical treatment plans of individual patients, like Diane. She has told me on more than one occasion, during my clinical observations, that she would love to ‘‘put [Crenna] out of [the mental illness] business.’’ Dr. Wilby also knows this will not happen any time soon—‘‘maybe when he retires.’’ In the mean time, Dr. Crenna, whose daily practice in mental health care has been fueled in part by the deep networks (and pockets) of the pharmaceutical industry, continues to prescribe psychotropics for his patients on a daily basis. In this one county in southeastern Wisconsin, the psychotropic profile for hundreds of patients, in particular young persons, continues to be impacted through the high prescribing practices of one primary care doctor,25 while another high prescriber works to detox many of these same patients and re-diagnose their conditions.

Conclusion Dr. Wilby, similar to Dr. Vindrik, seems much more satisfied engaging in pharmaceutical detox with patients during med-check clinic appointments.. Their work has become a more enjoyable daily struggle to ‘‘un,’’ and to essentially, ‘‘re’’ diagnose their patients. To titrate addicts and inmates off of addictive compounds, to unscript decades of high prescribing, polypharmacy, and pharmaceutical industry influence on primary care. Their most daunting task appears to be convincing people they are less mentally ill than previously believed or medically diagnosed. This phenomena has been confirmed by recent autobiographies that describe in detail how personally challenging and how long a process it can be for patients to reestablish a new normal or to re-identify as less mentally ill after years, and sometimes a decade or more, of psychotropic polypharmacy (Lidz 2007; Sharpe 2012; Bell-Barnett 2012). Patients and their concerned prescribers are confronting what medical anthropologists have described as ‘‘the total drug effect’’ of modern psychotropics (van der Geest et al. 1996, pp. 167–169) The multiple efficacies of drugs—the social, cultural, psychological, metaphysical and neuro-biological effects (Ibid.), which can have dramatic impacts on individuals and human relationships. Elizabeth Sharpe (2012) in her autobiography Coming of Age on Zoloft describes how a sexuality 25

I did not have direct access to patient numbers or medical records. Based on interviews with clinic staff and Dr. Wilby as well as taking into account Dr. Crenna’s two plus decade involvement in treating mental illness at the primary care level, the numbers are probably much higher—mostly likely, into the thousands of patients.

123

272


effect, a combination of neuro-biological and psychological efficacies, has been experiences by young persons, who come off their psychopharmaceutical cocktails after a decade more of use and/or abuse that began in early adolescence. Many individuals come to realize during their own versions of pharmaceutical detox that they are not indeed asexual, or lacking in sexual desire, rather they were experiencing a life void of sexual desire(s) thanks to the psychotropic and biological side effects of their medication (129–132; see also Bell-Barnett 2012, pp. 153–6). Sharpe very effectively describes the struggle young people have simply understanding and re-establishing an unmedicated sexual identity—a new normal state. The pharmaceutical industry has interpreted this collective lack of sexual desire, even if caused by the overprescribing of drugs they produce and sell as a new abnormal state; as another opportunity for creating a sexual-psychotropic marketplace. Lybrido and Lybridos, psychotropics developed for women by a Dutch inventor, Adriaan Tuiten and eventually marketed by a company called ‘‘Emotional Brain,’’ are in the end stages of clinical trials and could gain FDA approval in the US by 2016 (Bergner 2013). Future ethnographic work should more fully address the patient-side of pharmaceutical detox and these new normal states of existence post-psychotropy (see Frances 2013, pp. 3–116 for a psychiatric perspective on ‘‘saving normal’’),26 as well as the nature/culture effects of pharmaceuticals in general, which demands a more integrated anthropological approach. Pharmaceutical detox should remain quintessentially of interest to anthropologists because as a discipline we remain uniquely suited to interrogating these multiple drug efficacies at multiple sites. ‘‘Detoxing,’’ to borrow Dr. Wilby’s term, as a strategic intervention, or ‘‘strategy of interference,’’ for anthropology does not mean one is ‘‘anti-prescription drug.’’27 In fact, there is important work being done by anthropologists that critically exams how groups of patients have been forced to fight for their ‘‘right to pharmaceuticals’’ through judicial and legal channels (e.g., Biehl 2013 in Brazil). However, detoxing outcomes within the context I have provided here, should equate to less drugs, more appropriate diagnoses, and a more complete anthropological understanding of these total efficacies. This paper has 26 Allen Frances was Chair of the DSM-IV Task Force and offers a trenchant critique of DSM V throughout this volume. I have pending IRB approval to begin tracking patients outside Dr. Wilby’s clinic, including working with the aforementioned Diane, and also with a group of patients that are being sent to Wilby’s clinic (from other counties) through clever bureaucratic maneuvering for detox—especially patients in the in the criminal justice system on addictive psychotropics. Additionally, I am part of a case study project in southeastern Wisconsin, where I will specifically work with a mentally ill client, who is also on probation and being monitored through a public defender office pilot program. This client-patient, a forty-six year old white male, is currently being prescribed Ambian (Zolpidem) for sleep, generic Xanax (alprazolam) for anxiety, Luvox (fluvoxamine) for OCD, Lamictal (Lamotrigine) for bi-polar disorder, lithium, intermittently for manic episodes, and oxycodone for pain management. His primary care doctor and psychiatrists have been described as ‘‘defensive’’ when the issue of his polypharmacy and drug side effects have been raised. 27 These processes were elaborated on by Arthur Kleinman, within the context of using medical anthropology and medical humanities to confront the inadequacies of modern healthcare systems, during a symposia at the University of Wisconsin-Milwaukee on December 10, 2005 (see http://somatosphere. net/2010/12/arthur-kleinman-on-caregiving.html, for a full review, access February 1, 2014. See also Kleinman 2009 and 2008).

123


273

focused on the level of the high prescriber, and the literature is conclusive in one regard: We know that pharmaceutical sales and marketing tactics lead to more prescription writing of branded medications (e.g., Wazana 2000; Elliot 2010; Brody 2007; Oldani 2004). However, we also know that psychotropic drugs and disorders continue to emerge and proliferate hand-in-hand (Hacking 1999, 1998, Chapter 4), through complex biocultural processes not yet fully articulated. Through pharmaceutical prescribing cultural norms can become inscribed in one’s ‘‘biology’’ (e.g., stimulants produce potential new identities and lifetime treatment for ‘‘ADHD’’) and new biologies and affective states can become normalized into culture (e.g., prescribing ‘‘36 h Cialis’’ for everyday maintenance treatment of erectile dysfunction.); (see Loe 2004 on Viagra’s cultural impact). Psychotropics create new forms of pharmaceutical personhood (Martin 2006; Jenkins 2010), while putting into play the nature/culture plasticity of humans (see Smail 2008, p. 154 on plasticity from a neurohistorical perspective). These drugs can reorganize and crystalize the very categories of ab/normality within societies that anthropologists have long sought to interrogate through robust ethnographic critique, beginning with the Boasians (e.g., Benedict 1966[1934]). The interest in ‘‘disaggregating’’ categories continues (Boon 2010) and it is important to stress that Franz Boas himself (1921: Chapter 13) took on the most ab/normalizing, biocultural category of his era: Race. Likewise, the nature/culture effects of modern psychotropics demand all the disciplinary tools at our disposal precisely because these chemical entities have become the ab/normalizing agents of our time. Ethnography, while working to capture the disaggregating and detox efforts of prescribers and patients, must begin to incorporate the methodologies and empirical work of emergent, interdisciplinary fields such as neuroanthropology to more holistically examine modern psychotropy (Campbell, this Volume; Lende and Downey 2012, p. 2). Psychotropics flow in and through people and effect humans and non-human species alike and impact both social and natural environments, which requires a disciplinary effort that can document and theorize at the intersection of the biological, the evolutionary, and the cultural.28 Modern Psychotropy has forced our hand: we must react to the multiple efficacies of these agents by engaging with, and tracking, these ‘‘things’’ from multiple perspectives and fields, which may require the intensive collaboration, in method, theory and writing, of research teams (Lende and Downey Ibid; e.g., Tsing and the Matsutake Worlds Research Group 2009). Smail (2008), in his ‘‘neurohistory’’ of humanity, describes how all postlithic societies have developed a ‘‘characteristic psychotropic profile,’’ where ‘‘economies’’ throughout time and space become devoted to specific psychotropics (e.g., Europeans and coffee after the 1660s). The current global assemblage of psychotropy today is increasingly dominated by the pharmaceutical, a kind of 28 Increasingly, we will not need to be prescribed pharmaceuticals to feel their nature/culture effects. We now swallow small amounts of psycho-pharmaceuticals through our urban water supplies. And recent research has shown if you adjust the concentration of fluoxetine (i.e., Prozac) in the water you can ‘‘turn on and off’’ the mating signals (i.e., the sexuality effect) of other species, such as freshwater fish (Crago et al. 2011)—a researcher in this field described to me that we need to understand ‘‘serotonin pathways as evolutionarily deep’’ and occurring across species.

123

274


New World Order, Inc. (Haraway 1997, pp. 6–7), that simultaneously blurs and reifies nature, culture, and the market. I am hopeful that anthropology will continue to work as a counterforce to the pharmaceutical, providing the counter-narratives, insights and alternative scripts to overprescribing; to expose the limits, the stakes, and the nature/culture consequences of modern psychotropy. A radical detoxing of the world requires a kind of pharmaceutical consciousness that signals the breaking free of this new normal, one that alters our collective perspectives. Similar to the chemical agents of the 50s, 60s, and 70s (see Carson 1962), pharmaceutical efficacies continue to run deep, altering affects, biologies, lives, and environments, driven by devastatingly effective corporate devotion to profit. Acknowledgments I owe a debt of gratitude to all the ethnographic participants who made this work possible. I would like to thank the Center for 21st Century Studies at the University of WisconsinMilwaukee for an intellectual home to complete this project during 2013–2014 year; in particular, I would like to thank Richard Grusin, Director of C21 and Emily Cark, as well as my fellow Fellows for robust exchanges and critique. I want to thank Kal Applbaum and Paul Brodwin at UW-Milwaukee for their ongoing collaborations and intellectual exchanges. Versions of this paper were presented at the American Anthropological Association Meeting (2012); the UW-Whitewater Brown Bag Sociology Series (spring 2013) and UW-Milwaukee, Anthropology Colloquium series (fall, 2013), and I would like to thank Tazin Karim, Akiko Yoshida, and Ben Campbell and Kal Applbaum, respectively, for their invitations and assistance. I want to also thank the two anonymous CMP reviewers for extensive input and critique as well as Brandy Schillace at CMP for her editorial guidance.

References Appadurai, A 1986 The Social Life of Things. Cambridge: Cambridge University Press. Applbaum, K 2004 How to Organize a Psychiatric Congress. Anthropology Quarterly 77(2): 303–310. 2006a Educating for Global Mental Health. The Adoption of SSRIs in Japan. In Global Pharmaceuticals: Ethics, Markets, Practices. A. Petryna, A. Lakoff and A. Kleinman, eds., pp. 85–110. Durham: Duke University Press. 2006b Pharmaceutical Marketing and the Invention of the Medical Consumer. PLoS Medicine 3(4): e189. doi:10.1371/journal.pmed.0030189. 2009 Getting to Yes: Corporate Power and the Creation of a Psychopharmaceutical Blockbuster. Culture, Medicine and Psychiatry . doi:10.1007/s11013-009-9129-3. 2010 Shadow Science: Zyprexa Eli Lilly and the Globalization of Pharmaceutical Damage Control. Biosocieties 5: 236–255. Bell-Barnett, K 2012 Dosed: The Medication Generation Grows Up. Boston: Beacon Press. Benedict, R. 1966 [1934] Anthropology and the Abnormal. In An Anthropologist at Work: The Writings of Ruth Benedict. M. Mead, ed. Boston: Houghton Mifflin Company. Bergner, D. 2013 There May be a Pill for That. New York Times Magazine, May 26: 22–27, 47. Biehl, J 2007 Pharmaceuticalization: AIDS Treatment and Global Health Politics. Anthropology Quarterly 80(4): 1083–1126. 2010 ‘‘CATKINE…Asylum, Laboratory, Pharmacy, Pharmacist, I and the Cure’’: Pharmaceutical Subjectivity in the Global South. In Pharmaceutical Self: The global Shaping of Experience in an Age of Psychopharmacology. J Jenkins, ed., pp. 67–96. Santa Fe: School for Advanced Research Press. 2013 The Judicalization of Biopolitics: Claiming the Right to Pharmaceuticals in Brazilian Courts. American Ethnologist 40(3): 419–436.

123


275

Boas, F 1921 The Mind of Primitive Man. New York: The Macmillan Company. Boon, J 2010 On Alternating Boasians: Generational Connections. Proceedings of the American Philosophical Society. 154(1): 19–30. Brody, H 2007 Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry. New York: Rowman & Littlefield Publishers Inc. Carbaugh, D, M Berry, and M Nurmikari-Berry 2006 Coding Personhood Through Cultural Terms and Practices: Silence and Quietude as a Finnish ‘‘Natural Way of Being’’. Journal of Language and Social Psychology 25(3): 1–18. Carson, R. 1962 [1990] Silent Spring. New York: Houghton-Mifflin Group. Caudill, W 1959 Observations on the Cultural Context of Japanese Psychiatry. In Culture and Mental Health. M Opler, ed., pp. 213–242. New York: Macmillan. Crago, J, S Corsi, D Weber, R Bannerman, and R Klaper 2011 Linking biomarkers to reproductive success of fathead minnows in streams with increasing urbanization. Chemosphere 82(11): 1669–1674. Dumit, J. 2012 Drugs for Life: How Pharmaceutical Companies Define Our Health. Durham: Duke University Press. Ecks, S 2010 Polyspherical Pharmaceuticals: Global Psychiatry, Capitalism, and Space. In Pharmaceutical Self: The Global Shaping of Experience in an Age of Psychopharmacology. J Jenkins, ed. Santa Fe: School for Advanced Research Press. Ecks, S, and S Basu 2009 The Unlicensed Lives of Antidepressants in India: Generic Drugs, Unqualified Practitioners, and Floating Prescriptions. Transcultural Psychiatry 46(1): 86–106. Elliot, C. 2006 The Real Drug Pushers. Atlantic Monthly April, http://www.theatlantic.com/magazine/archive/ 2006/04/the-drug-pushers/304714/, accessed July 9, 2013. 2010 White Coat Black Hat: Adventures on the Dark Side of Medicine. Boston: Beacon Press. Elliott, C, and T Chambers, eds. 2004 Prozac as a Way of Life. Chapel Hill: North Carolina Press. Fainzang, S 2013 The Other Side of Medicalization: Self-Medicalization and Self-Medication. Culture, Medicine and Psychiatry 37: 488–504. Floersch, J, et al. 2009 Adolescent Experience of Psychotropic Treatment. Transcultural Psychiatry 46(1): 157–179. Fugh-Berman, A, and S Ahari 2007 Following the Script: How Drug Reps Make Friends and Influence Doctors. PLoS Medicine 4(4): 0621–0625. Frances, A 2013 Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma and Medicalization. New York: HarperCollins Publishers Inc. Garcia, A 2010 The Pastoral Clinic: Addiction and Dispossession Along the Rio Grande. Berkeley: University of California Press. Greene, J 2007 Prescribing by Numbers: Drugs and the Definition of Disease. Baltimore: Johns Hopkins Press. Hacking, I 1998 Mad Travelers: Reflections on the Reality of Transient Mental Illness. Charlottesville, VA: University of Virginia Press. 1999 Making Up People. In The Science Studies Reader. M Biagioli, ed. New York: Routledge.

123

276


Haraway, D 1997 Modest_Witness@Second_Millennium. FemaleMan_Meets OncoMouse pp. 1–20. New York: Routledge. Healy, D 2004 Let Them Eat Prozac. pp. 1–39. New York: NYU Press. 2006 The New Medical Oikumene. In Global Pharmaceuticals: Ethics, Markets, Practices. A Petryna, A Lakoff, and A Kleinman, eds. Durham: Duke University Press. 2012 Pharmageddon. Berkeley: University of California Press. Hunt, LM, M Kreiner, and H Brody 2012 The Changing Face of Chronic Illness Management in Primary Care: A Qualitative Study of Underlying Influences and Unintended Outcomes. Annals of Family Medicine 10(5): 452–560. Jenkins, J, ed. 2010 Pharmaceutical Self: The Global Sharping of Experience in an Age of Psychopharmacology. Santa Fe: School for Advanced Research Press. Kirmayer, L 2004 The Sound of One Hand Clapping: Listening to Prozac in Japan. In Prozac as a Way of Life. C Elliot and T Chambers, eds., pp. 164–193. Chapel Hill: University of North Carolina Press. Kitanaka, J 2012 Depression in Japan: Psychiatric Cures for a Society in Distress. Princeton: Princeton University Press. Kleinman, A 2008 Castastrophe and Care Giving: The Failure of Medicine as an Art. The Lancet 371: 22–23. 2009 Caregiving: The Odessey of Becoming More Human. The Lancet 373: 292–293. Kramer, P 1993 Listening to Prozac. New York: Viking. Lende, D, and G Downey 2012 Neuroanthropology and its Applications: An Introduction. Annals of Anthropological Practice 36(1): 1–25. Levine, B. 2008 Psycho-Pharmaceutical Industrial Complex: Profiting from ‘‘Drugging’’ Women and Children. Z Magazine, October: 28–31. Lidz, G. 2007 My Adventures in Psychopharmacology. New York Magazine Oct 24, http://nymag.com/news/ features/260006/, accessed July 3, 2013. Loe, M 2004 The Rise of Viagra: How a Little Blue Pill Changed Sex in America. New York: New York University Press. Lurhmann, T 2000 Of Two Minds: The Growing Disorder in American Psychiatry. New York: Vintage Books/ Random House. Magrath, P, and M Nichter 2012 Paying for Performance and the Social Relations of Health Care Provision: An Anthropological Perspective. Social Science & Medicine 75: 1778–1785. Matsutake Worlds Research Group 2009 A New Form of Collaboration in Anthropology: Matsutake Worlds. American Ethnologist 36(2): 380–403. Martin, E 2006 The Pharmaceutical Person. Biosocieties 1: 273–288. 2007 Bipolar Expeditions. Mania and Depression in American Culture Princeton: Princeton University Press.. McConathy, J, and M Owens 2003 Stereochemistry in Drug Action. Journal of Clinical Psychiatry 5(2): 70–73. McKinney, K, and B Greenfield 2010 Self Compliance at ‘Prozac Campus’. Anthropology and Medicine 17(2): 173–185. Meyers, T 2013 A Few Ways to Become Unreasonable: Pharmacotherapy Inside and Outside the Clinic. In Addiction Trajetories. E Raikhel and W Garriot, eds., pp. 88–107. Durham: Duke University Press.

123


277

Miller, L. 2012 Listening to Xanax: How American Stopped Worrying about Worrying and Pop its Pills Instead. New York Magazine, http://nymag.com/news/features/xanax-2012-3/index1.html, accessed February 6, 2014. Mojtabai, R, and M Olfson 2010 National Trends in Psychotropic Medication Polypharmacy in Office- Based Psychiatry. Archives of General Psychiatry 67(1): 26–36. Oldani, M 2004 Thick Prescriptions: Towards an Interpretation of Pharmaceutical Sales Practices. Medical Anthropology Quarterly 18(3): 325–356. 2009 Uncanny Scripts: Pharmaceutical Emplotment in the Aboriginal Context. Transcultural Psychiatry 46(1): 131–156. 2010 Assessing the ‘Relative Value’ of Diabetic Patients Treated Through an Incentivized. Corporate Compliance Model. Anthropology and Medicine 17(2): 17–28. 2012a The Pharmaceuticalized ‘‘Good Mother.’’ Atrium: The Report of the Northwestern Medical Humanities and Bioethics Program. Spring 10: 29–31. 2012b Drug Reps in Film: Un/Scripting Markets, Medicine, and Mental Health. Journal of Ethics in Mental Health 7: 1–6. Ong, A, and SJ Collier 2005 Global Assemblages, Anthropological Problems. In Global Assemblages: Technology, Politcs and Ethics as Anthropological Problems. A Ong and SJ Collier, eds. Maldan, MA: Blackwell Publishing. Orr, J 2006 Panic Diaries: A Genealogy of Panic Disorder. Durham: Duke University Press. Petryna, A, A Lakoff, and A Kleinman, eds. 2006 Global Pharmaceuticals: Ethics Markets, Practices. Durham: Duke University Press. Raikhel, E, and W Garriott 2013 Introduction: Tracking New Paths in the Anthropology of Addiction. In Addiction Trajectories. E Raikhel and W Garriot, eds., pp. 88–107. Durham: Duke University Press. Reidy, J 2005 Hard Sell: The Evolution of a Viagra Salesman. Kansas City: Andrews McMell Publishing. Sansone, R, and L Sansone 2010 Is Seroquel Developing an Illicit Reputation for Misuse/Abuse? Psychiatry 7(1): 13–16. Saris, J 2010 The Addicted Self and the Pharmaceutical Self: Ecologies of Will, Information, and Power in Junkies, Addicts and Patients. In Pharmaceutical Self: The global Shaping of Experience in an Age of Psychopharmacology. J Jenkins, ed., pp. 209–230. Santa Fe: School for Advanced Research Press. Schatzberg, A, J Cole, and C Debattista 2010 Manual of clinical Psychopharmacology. 7th Edition. Washington D.C.: American Psychiatric Publishing Inc. Schulz, K. 2004 Did Antidepressants Depress Japan? New york Times Magazine, August 22: 38–41. Sharpe, K 2012 Coming of Age on Zoloft. New York: HarperCollins Publishers. Smail, DL 2008 On Deep History and the Brain. Berkeley: University of California Press. Suissa, JA 2009 Addictions and Medicalization: Markers and Psychosocial Issues. Canadian Social Work Review, Revue Canadienne de Service Social 267(1): 43–58. Talbot, M. 2009 Brain Gain: The Underground World of ‘‘Neuroenhancing’’ Drugs. The New Yorker, April 27, http://www.newyorker.com/reporting/2009/04/27/090427fa_fact_talbot, accessed July 2, 2013. Tone, A 2009 The Age of Anxiety: A History of America’s Turbulent Affair with Tranquilizers. New York: Basic Books.

123

278


Tsing, A 2009 Supply Chains and the Human Condition. Rethinking Marxism 21(2): 148–176. Vallerstein, E 1998 Blaming the Brain: The Truth About Drugs and Mental Health. New York: The Free Press. van der Geest, S, S Reynolds-Whyte, and A Harding 1996 The Anthropology of Pharmaceuticals: A Biographical Approach. Annual Review of Anthropology 25: 153–178. Wazana, A 2000 Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift? Journal of the American Medical Association 283(3): 373–380. Whitaker, R 2005 Anatomy of an Epidemic: Psychiatric Drugs and the Astonishing Rise of Mental Illness in America. Ethical Human Psychology and Psychiatry 7(1): 23–35. Whitmarsh, I 2008 Biomedical Ambiguity: Race, Asthma, and the Contested Meaning of Genetic Research in the Caribbean. Ithaca: Cornell University Press. Wilson, S 2005 The Meanings of Medicating: Pills and Play. American Journal of Psychotherapy. 59(1): 19–29. Wurzel, E 1994 Prozac Nation: Young and Depressed in America, A Memoir. New York: The Berkley Publishing Group (Penguin Group USA). Zonfrillo, M, J Penn, and H Leonard 2005 Pediatric Psychotropic Polypharmacy. Psychiatry 2(8): 15–19.

123

Good pharma? Bad pharma? Better pharma.

Stereotype detox.

"Annual pharma statistics" as a health information system application in Iranian pharmaceutical sector.

[Deep brain stimulation in psychiatry: ethical aspects].

"Pharma value".

Academia and big pharma United.

Nanomedicine: a pharma perspective.

The Next Era: Deep Learning in Pharmaceutical Research.

SPER 3(rd) annual conference on "Recent trends in pharma industry: Bridging the gaps in pharmaceutical education".

Anthropology stampede in Calgary.

Bayes in biological anthropology.

Anthropology. Out of Beringia?

An open source pharma roadmap.

Medical anthropology and the depths of human experience: contributions from psychoanalytic anthropology.

Reframing the science and anthropology of autism.

Courses in medical anthropology: Germany.

Big Pharma Profits and the Public Loses.

Drug promotion tactics-yet another pharma deception?

The costs of vilifying pharma.

Skunkworks project for Big Pharma.

Medical anthropology and the physician assistant profession.

Medical anthropology and international health planning.

Big Pharma vs India’s Patent Office.

Forensic anthropology in the 1990s.