Schizophrenia, drug companies and the internet

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Social Science & Medicine 66 (2008) 99–109

www.elsevier.com/locate/socscimed

Schizophrenia, drug companies and the internet

John Read�

The University of Auckland, Auckland, New Zealand

Available online 10 September 2007

Abstract

To investigate differences in the content of websites funded, and not funded, by drug companies, the top 50 websites

about ‘schizophrenia’ in Google and Yahoo were analysed in relation to five variables: three scales relating to causes,

treatments and violence, and two categorical variables about the condition being extremely severe and about linking

coming off medication to violence. Fifty eight percent of the websites analysed received funding from drug companies.

Drug company funded websites were significantly more likely to espouse bio-genetic rather than psycho-social causal

explanations, to emphasise medication rather than psycho-social treatments, to portray ‘schizophrenia’ as a debilitating,

devastating and long-term illness, and to link violence to coming off medication. They were neither more nor less likely to

describe ‘schizophrenics’ as violent. These results suggest that the documented influence of the pharmaceutical industry

over research, professional organisations, teaching institutions, clinical practice and regulatory bodies may now extend to

public promotion, via the internet, of perspectives conducive to maximisation of sales.

r 2007 Elsevier Ltd. All rights reserved.

Keywords: Schizophrenia; Pharmaceutical companies; Internet; Websites; Marketing

Introduction

It has been argued that ‘Pharmaceutical compa-nies are actively involved in sponsoring the defini-tion of diseases and promoting them to bothprescribers and consumers. The social constructionof illness is being replaced by the corporateconstruction of disease’ (Moynihan, Heath, &Henry, 2002). Psychiatrists Moncrieff and Thomas(2002) replied:

The influence of the pharmaceutical industry isparticularly pernicious in psychiatry where thepossibilities for colonizing ever more aspects ofhuman life are potentially limitless.y The financial

e front matter r 2007 Elsevier Ltd. All rights reserved

cscimed.2007.07.027

373 7999.

ess: [email protected]

muscle of the pharmaceutical industry has helpedto tip the scales in favour of a predominantlybiological view of psychiatric disorder. This hassubmerged alternative therapeutic approaches.

A recent study found that 31.5% of adults withinternet access in England who had experiencedmental health problems had used the internet toaccess mental health information (Powell & Clarke,2006). In April 2007 entering ‘schizophrenia’ intoGoogle produced over 15 million results. Studies ofthe quality of health-related websites have focussedon disclosure of authorship and ownership, pre-sentation, readability, concordance with publishedguidelines and the degree of evidence cited tosupport statements (Griffiths & Christensen, 2000;Kisely, Ong, & Takyar, 2003; Schrank, Seyringer,Berger, Katsching, & Amering, 2006; Silberg,

.

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mailto:[email protected]

ARTICLE IN PRESSJ. Read / Social Science & Medicine 66 (2008) 99–109100

Lundberg, & Musacchio, 1993). The influence of thepharmaceutical industry in research, clinical prac-tice and regulatory bodies has been under increasingscrutiny (Doran, Kerridge, McNeill, & Henry, 2006;Healy & Thase, 2003; Moncrieff, 2003; Newcombe& Kerridge, 2007; Sharfstein, 2005; Shooter, 2005).There has, however, been little research intowhether this influence now extends to internetwebsites.

Methods

Website selection

In May 2006 Google and Yahoo were searchedby entering ‘schizophrenia’. The 66 websites appear-ing in the first 50 of either search engine wereidentified (Table 1).

Funding categorisation

Websites were classified as drug company funded(DCF) if they were Drug Company sites, displayeddrug company advertisements, or acknowledgedfinancial support from one or more drug companies.Where the website provided links to drug companysites without clarifying whether payment wasinvolved, clarification was sought by email.

One website, chovil.com, received drug companyfunding from 1997 to 2005. Another website,psyhchlaws.org, was also difficult to classify. ThisUSA site, which belongs to the Treatment Advo-cacy Centre (TAC), is dedicated to strengtheninglegislation for detention and forcible medicationas TAC’s view is that this reduces violence.It is funded by the Stanley Medical ResearchInstitute, which gives financial grants to, ratherthan receiving money from, drug companies. Thesetwo sites were excluded from analyses of theinfluence of drug company funding, leaving 64 sitesfor analysis.

Types of website

The classification of websites into nine categorieswas, for the most part, an obvious process (seeTable 1). For example, the definition for the‘Business’ category was any website (excludingDrug Company sites) whose primary functionseemed to be the sale of products. The ‘Family’category included websites where the organisationinvolved identified itself as serving or representing

families or carers. Some of these websites claimedthat they also represented users of mental healthservices. The term ‘Family’ was employed todifferentiate between ‘Family’ and ‘User’ organisa-tions. There were no websites in the sample run byorganisations of actual service users, patients orclients.

Scale development

The Causes, Treatment and Violence scales wereLikert scales and grounded in the data, i.e. theywere developed after reading all the website state-ments on each of the three issues. The scale-pointdefinitions, including the anchor points, weredependent on the ranges covered by the websiteson each of the issues. For example, none of thewebsites identified psycho-social causal factors asbeing more important than bio-genetic factors;therefore the low anchor point (‘1’) representedstatements in which psycho-social and bio-geneticfactors were given equal emphasis. However, somewebsites placed more emphasis on psychologicaltreatments than on medication and, therefore, it wasnecessary that a ‘1’ on the Treatment scale reflectedthat.

The Causes and Treatment scales included addi-tions of 0.33 of a scale-point to take account ofimportant current areas of contention (see below)which, while clearly relevant to the scale in question,did not readily fit into the dimension beingmeasured in terms of the scoring process. So asnot to overly influence scale scores a conservativeaddition (0.33) was utilised, and for the Treatmentsscale 0.33 was added for either or both of the twostatements.

Causes scale

The scale points in the Causes scale were:

1.
Equal emphasis on bio-genetic and psycho-socialcausal factors.
2.
Named psycho-social factors cited as causal, butsecondary to bio-genetic causes.
3.
Social stressors cited only as events which cantrigger a genetic predisposition or exacerbate theexisting ‘illness’ within a ‘stress- vulnerability’model.
4.
‘Stress-vulnerability’ model with the only stres-sors cited being biological events (e.g. birthcomplications, flu).

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Table 1

Websites and total scores

Website Google rank Yahoo rank Country Type Total score

schizophrenia.com 1 1 USA Family 10

wikipedia.org 3 2 USA Educational 6.7

nlm.nih.gov 6 4 USA Government 11

docguide.com 10 6 Canada Business 8.3

nimh.nih.gov 16 3 USA Government 9

mentalhealth.com 2 18 Canada Private Individual 10.7

nami.org 17 13 USA Family 14.3

rcpsych.ac.uk 22 10 UK Professional Org. 8.7

chovil.coma 5 28 Canada Private Individual 13.3

schizophreniadigest.com 13 22 Canada Business 11

staff.washington.edu 26 9 USA Educational 7

mentalhelp.net 15 21 USA Business 10.3

mind.org.uk 25 12 UK NGO 4

sirl.ie 31 7 Ireland Family 8.7

schizophrenia.help.com 19 20 USA Private Individual 4

mhsource.com 30 11 USA Business 12

medicinenet.com 35 8 USA Business 9

narsad.org 11 37 USA NGO 9.7

mentalhealthchannel.net 37 14 USA Business 12.3

schizophrenia.on.ca 21 30 Canada Family 15.3

emedicinehealth.com 27 25 USA Business 11.3

priory.com 36 16 UK Business 10.7

emedicine.com 29 24 USA Business 13

aacap.org 24 35 USA Professional Org. 9

schizophrenia.ca 8 51 Canada Family 8.7

mentalhealth.samhsa.gov 34 29 USA Government 12

esquizo.com 60 5 USA Private Individual 12.3

reutershealth.com 28 40 USA Media 6.3

nmha.org 32 38 USA NGO 10.3

sfnat.org.nz 4 67 New Zealand Family 10

sciencedirect.com 7 64 Netherlands Educational b

schizophreniabulletin. oxford.journals.com 9 62 USA Educational b

nice.org.uk 45 27 UK Government 10

psychlaws.orga 47 33 USA NGO 16.3

schizophrenia.org.au 49 31 Australia Family 9.3

mentalwellness.com 12 70 USA Drug Co. Janssen 13.7

mental-health-matters.com 59 23 USA Business 12

behavenet.com 65 19 USA Business b

surgeongerneral.gov 41 44 USA Government 9.7

psychologynet.org 72 15 USA Private Individual 10

patienthealthinternational.com 40 49 UK Drug Co. AstraZeneca 9.7

rethink.org 20 71 UK Family 6.3

webmd.com 53 41 USA Business 11.3

mercksource.com 55 39 USA Drug Co. Merck 11.3

npr.org 52 42 USA Media b

psyweb.com 46 50 USA Business 7

healthsurvey.com 43 46 USA Business 5

sciencedaily.com 51 45 USA Business 10

hcpc.uth.tmc.edu 74 26 USA Educational 8

successfulschizophrenia.com 71 43 USA Private Individual 3

mayoclinic.com 38 79 USA NGO 13.3

news.bbc.co.uk 42 UK Media 9.3

bcss.org 14 Canada Family 9.7

athealth.com 17 USA Business 11.7

world-schizophrenia.org 18 Canada Family 12

everybody.com 23 New Zealand Business 11.7

geodon.com 32 USA Drug Co. Pfizer 10.3

J. Read / Social Science & Medicine 66 (2008) 99–109 101

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Table 1 (continued )

Website Google rank Yahoo rank Country Type Total score

nhs.uk 33 UK Government 7.7

helpguide.org 34 USA Family 11

medicalnewstoday.com 36 Canada Business 8

psychiatry24� 7.com 39 Belgium Drug Co. Janssen 11.7

answers.com 44 USA Business 11.3

icspp.org 47 USA Professional Org. 4

abilify.com 48 USA Drug Co. Bristol-Meyers 11.7

nzetc.org 48 New Zealand Private Individual 6

jungcircle.com 50 Australia NGO 4

aExcluded from comparisons of DCF and NONDCF sites.bNo Total score due to missing data on either Causes or Treatments scales.

J. Read / Social Science & Medicine 66 (2008) 99–109102

5.
Purely bio-genetic (‘brain disease’, ‘chemicalimbalance’ ‘genetically inherited disease’, etc.);no mention of social factors or stress-vulner-ability model.
In addition, 0.33 was added to the score for adefinitive statement that ‘schizophrenia’ is not

caused by social factors (e.g. dysfunctional families,child abuse, poverty, etc.).

Higher scores on the scale (1–5.33) thereforerepresented emphasis on bio-genetic causationrelative to psycho-social causation.

Treatments scale

The scale points in the Treatments scale were:

1.
Psychological treatments given greater emphasisthan biological treatments.
2.
Psychological and biological treatments equallyemphasised.
3.
Biological treatments received greater emphasis;but psychological treatments seen as genuinetreatments of symptoms on a par with medica-tion.
4.
Biological treatments received greater emphasis;psychological treatments described only in termsof management, education, support, skills train-ing or rehabilitation.
5.
Medication only (with or without reference toECT).
In addition 0.33 was added to the score for either(or both) of:

(a)
Statement about dangers of not staying onmedication.
(b)
Statement against use of insight-oriented, in-depth or psychodynamic approaches.
Higher scores on the scale (1–5.33) thereforerepresented emphasis on drug treatment relative topsychological treatments.

Severity statement

Websites were categorised as having a Severitystatement if they used two or more of the followingadjectives in their general/opening comments: devas-tating, disabling, severe, serious, debilitating, chronic,degenerative, long-term. Websites describing ‘schizo-phrenia’ as a serious or severe disorder or illness (withnone of the other adjectives) did not meet the criteria.

Violence scale

The scale points here were:

1.
Obvious attempt to dispel stereotype aboutdangerousness, such as ‘people with schizophre-nia are no more likely to be violent than anyoneelse’ or ‘yare rarely dangerous’ or ‘yare lessviolent’.
2.
No statement about violence. 3. Statement that one or more subgroups of
‘schizophrenics’ (e.g. drug users) are more likelyto be violent.

4.
Generalised, unqualified, statement about in-creased probability of violence.
Medication-violence statement

Websites were categorised as having included aMedication-Violence statement if they stated the

ARTICLE IN PRESSJ. Read / Social Science & Medicine 66 (2008) 99–109 103

belief that violence is related to non-compliancewith medication, or that medication preventsviolence.

Total score

A composite score was generated for each websiteby adding the scores of the three scales plus onepoint for each of the Severity and Medication-Violence statements. The possible range for the totalscore was 3.0–16.67.

Data analysis

All ratings were conducted by the researcher. TheMann–Whitney U test (U) was used to analysedifferences between groups on the three ordinalscales. Spearman Rank coefficients (r) were used tomeasure the degree of correlation between variables,except that Chi-squares (X2) were used to analysethe relationships between categorical variables.Four websites had no statement about Causationor Treatment (see Table 1) producing minorvariations in the N’s for analyses for those twoscales.

Ethics

Ethics approval was not required.

Results

Location and type of websites

Forty-one of the websites (62%) were based in theUSA, 11 in Europe, nine in Canada, three in NewZealand and two in Australia. The most commontypes were Business (19; 29%), Family (11), PrivateIndividual (seven), Drug Company, Governmentand NGO (all six). (A Private Individual and anNGO website were excluded from analyses aboutdrug company funding, leaving N’s of six and five,respectively).

Relationships between the five measures

The Treatments scale was positively correlatedwith the Causes (r ¼ .46, po.001) and Violencescales (r ¼ .32, p ¼ .012). The Causes and Violencescales were not significantly correlated with eachother. All three scales were positively related to the

Total score at the po.001 level: Causes, r ¼ .70;Treatments, r ¼ .74; Violence, r ¼ .55.

Websites with the Severity statement scoredsignificantly higher than those without the state-ment on the Total score (U ¼ 140.5, po.001), andon the Causes (U ¼ 289.5, p ¼ .008), Treatments(U ¼ 290.5, p ¼ .008) and Violence (U ¼ 391.5,p ¼ .039) scales.

Websites with the Medication-Violence statementscored higher on the Total score (U ¼ 196,p ¼ .034), but not on the Causes, Treatments orViolence scales. The Severity and Medication-Violence statements were not significantly related(X2 (1) ¼ 3.71, p ¼ .054).

Drug company funding

Thirty-seven of the 64 websites (58%) receiveddrug company funding. Most of this fundingwas, besides the Drug Company sites, for Family(91%), Business (89%) and NGO (60%) websites.One of the Private Individual sites and none ofthe Professional Organisation, Educational, Gov-ernment or Media sites received drug companyfunding.

The Family and Business websites were bothsignificantly more likely to receive drug companyfunding than the Private Individual, Government,Educational, Professional Organisation and Mediawebsites at the po.005 level or beyond. Forexample, the analysis comparing Family andGovernment websites was: X2(1) ¼ 13.25, po.001;and comparison of Business and Education websitesproduced: X2(1) ¼ 15.34, po.001.

Geographical location of the websites was notsignificantly related to receipt of drug companyfunding (Canada—87%; Australasia—60%; USA—55%; Europe—45%), or to any of the five specificmeasures analysed in this study.

Causes

Table 2 shows that on the Causes scale DCFwebsites (M ¼ 3.74, SD ¼ 1.09) were significantlymore bio-genetic than the NONDCF websites(M ¼ 2.21, SD ¼ 1.06), U ¼ 146, po.001. Thedifference remained significant when the DrugCompany sites were removed from the analysis:U ¼ 124, po.001.

Six of the 36 DCF sites (17%), but none of theNONDCF sites, received the maximum score of5.33, a purely bio-genetic causal explanation plus an

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Table 2

Analysis of websites in relation to drug company funding and website category

n Drug

company

funding (%)

Severity

statement (%)

Mean on

causes scale

(1–5.33)

Mean on

treatment

scale (1–5.33)

Mean on

violence scale

(1–4.0)

Medicine-

violence

statement (%)

Mean total

score

(3–16.67)

Drug company funded

Yes 37 70.3�� 3.74�� 3.82�� 2.35 27.0� 10.90��

No 27 25.9 2.21 2.93 2.11 7.4 7.64

Drug

company

6 83.3c 4.05d 4.00 2.50 0 11.38f

Family 11 90.9a 63.6 3.48d 3.54 2.27 54.5e 10.48d

Business 19 89.5a 63.2 3.28d 3.70 2.42 26.3 10.34d

NGO 6 60b 50 3.33 3.41 2.17 16.7 9.61

Priv. Indiv. 7 16.7 28.6 2.95 3.09 2.14 0 8.47

Government 6 0 50 3.06 3.97 2.33 0 9.89d

Educational 5 0 20 1.67 2.83 2.00 20 7.22

Prof.Org. 3 0 33.3 2.22 2.44 2.33 0 7.33

Media 3 0 33.3 2.75 3.16 1.67 0 7.83

apo.005 vs. Educational, Government, Media, Private Individual, Professional Organization.bpo.05 vs. Government.cpo.05 vs. Educational, Private Individual.dpo.05 vs. Educational.epo.05 vs. Drug Company, Government, Private Individual.fpo.05 vs Educational, Media, Professional Organisation.�po.05.��po.005.��po.001.

J. Read / Social Science & Medicine 66 (2008) 99–109104

additional statement about ‘schizophrenia’ notbeing caused by poor parenting, abuse, etc. Sevenof the 24 NONDCF sites (29%), but none of theDCF sites, received the minimum score of 1.0, equalemphasis on bio-genetic and psycho-social factors.

Treatments

On the Treatments scale DCF websites(M ¼ 3.82, SD ¼ 0.61) were significantly moremedication-focussed than NONDCF sites(M ¼ 2.93, SD ¼ 1.24), U ¼ 240, p ¼ .003. Thedifference remained significant when Drug Com-pany sites were removed from the analysis: U ¼ 210,p ¼ .008.

Severity

Thirty-five of the 66 websites (53%) included astatement about ‘schizophrenia’ being a debilitatingor devastating, chronic illness. Twenty six of theDCF sites (70%), but only seven of the NONDCFsites (26%), made such a statement: X2(1) ¼ 12.29,po.001. The finding remained significant withoutthe Drug Company sites: X2(1) ¼ 10.11, p ¼ .001.

Five of the Drug Company sites (83%) includedthe Severity statement. Drug Company sites did sosignificantly more frequently than Private Indivi-dual sites (29%), (X2(1) ¼ 3.90, p ¼ .048) andEducational sites (20%), (X2(1) ¼ 4.41, p ¼ .036).

Violence

Thirty of the 66 websites (45%) made nostatement about violence, and therefore scored ‘2’on the violence scale. Ten (15%) received a ‘4’ onthe scale (unqualified statement about increasedlevel of violence), 12 (18%) received a ‘3’ (statementthat some sub-groups of ‘schizophrenics’ are vio-lent), and 14 (21%) received a ‘1’ (statement that‘schizophrenics’ in general are rarely violent or nomore violent than anyone else).

There was no significant difference between theDCF (M ¼ 2.35) and NONDCF (M ¼ 2.11) sites orbetween any of the nine website categories.

Violence and medication

Only 13 of the sites (20%) made a statementlinking violence to coming off medication, or


medication to the prevention of violence. Thestatements occurred in only four categories: Family(54%), Business (26%), Educational (20%) andNGO (17%).

The difference between DCF (27%) andNONDCF (7%) sites was significant: X2(1) ¼ 3.94,p ¼ .047. When the Drug Company sites (none ofwhich included the statement) were removed thefinding remained significant (X2(1) ¼ 5.43, p ¼ .02).

Total scale

On the Total scale the DCF websites producedsignificantly higher scores (M ¼ 10.90, SD ¼ 1.86)than the NONDCF websites (M ¼ 7.64, SD ¼ 2.66),U ¼ 140, po.001. The difference remained significantwithout the Drug Company sites: U ¼ 126, po.001.

Seven of the NONDCF sites, but none of theDCF sites, produced particularly low Total scores(six or below). The five lowest scoring sites includedtwo Private Individual sites in the USA, success-

fulschizophrenia.com (3.0—the lowest possiblescore) and schizophrenia.help.com (4.0), a BritishNGO mind.org.uk (4.0), an Australian NGO jung-

circle.com (4.0), and a USA Professional Organisa-tion icspp.org (4.0).

Seven of the DCF sites, but none of theNONDCF sites, produced particularly high Totalscores (12.3 or above). The second to fourth highestwere two Family websites, schizophrenia.on.ca (15.3)and nami.org (14.3), and the Drug Company site(Janssen) mentalwellness.com (13.7). The highestwas psychlaws.org (16.3).

Business (M ¼ 10.34), Drug Company (M ¼ 11.38),Family (M ¼ 10.48) and Government (M ¼ 9.89) sitesall produced significantly higher Total scores (po.05)than the Educational sites (M ¼ 7.22).

The North American sites (USA—10.02, Cana-da—10.78) produced significantly higher Totalscores (M ¼ 10.16) than the other sites (Europe—8.67, Australasia—8.20) (M ¼ 8.51): U ¼ 217.5,p ¼ .026.

Discussion

Limitations of the study

The differentiation of DCF from NONDCFwebsites was imprecise. Some organisations whosewebsites were not funded by drug companies mayhave received such funding for other activities.

The scoring process was not blind to the type ofwebsite. An improved design for future studiesmight involve inter-rater reliability checks of tran-scripts of the websites with identifiers removed.Nevertheless, the public nature of the data allowsreaders to make their own assessments of thecoding.

The study does not allow any firm conclusionsabout whether the correlations and differencesfound are causal in nature, or about the directionof possible causal relationships. It is possiblethat drug company funding does not directlyinfluence the content of websites but that, instead,drug companies tend to fund organisations whosewebsites are already espousing a bio-geneticperspective.

The number of analyses conducted introduces thepossibility of Type 1 errors (false positives) atsmaller levels of significance.

Causes

DCF websites are more likely than NONDCFwebsites to espouse a bio-genetic rather than apsycho-social perspective on causes. The differencebetween the DCF and NONDCF sites was sig-nificant at the po.001 level, with or withoutinclusion of the six Drug Company sites in theDCF group. This suggests that the pharmaceuticalindustry may be promoting, via its own websitesand those it funds, a perspective on etiologyconducive to increasing sales and profits. None ofthe 36 DCF sites placed equal emphasis on psycho-social and bio-genetic causal factors.

Leaving aside the poor reliability and validityof the construct (Bentall, 2003; Read, 2004), theactual causes of, and risk factors for, ‘schizophrenia’are many and complex (Larkin & Morrison,2006; Murray, Jones, Susser, van Os, & Cannon,2003; Read, Mosher & Bentall, 2004; Read, Perry,Moslowitz, & Connolly, 2001). To minimise, or—assome DCF sites did—ignore altogether, the psycho-social factors in this complex interaction of variablesmight be interpreted as doing a disservice to thepublic.

The limited and one-sided information aboutcausation provided by many DCF sites couldreinforce the lack of emphasis, during mental healthassessments, on the psycho-social causes of indivi-duals’ difficulties. Clients who have read andbelieved some of the websites in this study may beless likely to report adverse live events whether


asked or not. This might lead to inadequateproblem formulation and limited treatment plans.A case in point is the recent research documentingthe failure of many clinicians to take comprehensivepsycho-social histories including childhood trauma,a failure particularly marked for people diagnosed‘schizophrenic’ (Read, van Os, Morrison, & Ross,2005) and linked to strong bio-genetic beliefs on thepart of clinicians (Read, Hammersley, & Rudegeair,2007).

Treatments

DCF websites are more likely than NONDCFwebsites to emphasise medication rather thanpsycho-social treatments. The difference betweenthe two groups was at the p ¼ .003 level, andat the p ¼ .008 level after the Drug Companysites were removed. While there is little doubtthat anti-psychotic medications help some peoplethere is evidence that the benefits have beenexaggerated over recent years, that many do notbenefit and that the newer atypical drugs can haveserious adverse effects (Ross & Read, 2004). Thereis also evidence that a range of psychologicaltreatments are effective for the ‘symptoms’ of‘schizophrenia’ (Johannessen, Martindale, & Cull-berg, 2006; Larkin & Morrison, 2006; Read et al.,2004), including CBT (Kingdon & Turkington,2005).

Severity

DCF websites are significantly more likely thanNONDCF websites to portray ‘schizophrenia’ as aseverely devastating, disabling or devastating con-dition; at the po.001 level overall, and p ¼ .001without the Drug Company sites. These statementsrun contrary to research showing large variability inactual outcomes for people diagnosed ‘schizophre-nic’ (Ciompi, 1980; Read, 2004). A review of theWHO International Study of Schizophrenia (ISoS)(Harrison et al., 2001, p. 513), which reported anaverage recovery rate after 15 or 25 years of 48%,concludes:

Because expectations can be so powerful a factorin recovery, patients, families and clinicians needto hear this.y The ISoS joins others in relievingpatients, carers and clinicians of the chronicityparadigm which dominated thinking throughoutmuch of the 20th century.

Violence

There is no evidence from the current study thatthe industry is reinforcing the stigmatizing violencestereotype that is central to the prejudice experi-enced by people with this diagnosis (Read, 2007;Read, Haslam, Sayce, & Davies, 2006). There is alsono evidence that they are challenging it, via theirown websites or those they fund.

Violence and medication

DCF websites are more likely than NONDCFwebsites to link violence to coming off (or not beingon) medication. The difference between DCF (27%)and NONDCF (7%) sites was significant, but onlyat the po.05 level.

This issue was identified by Mosher, Gosden, andBeder (2004, pp. 125, 126):

The Treatment Advocacy Center (TAC), whichwas originally established as a branch of NAMI[National Alliance on Mental Illness], has beenfeeding a line to the media and the public about thedangerousness of untreated schizophrenia. y Thepolicy intention is to weaken civil liberties protec-tions in mental health laws in order to increase thenumber of people eligible for involuntary treat-ment. Involuntary treatment is an essential part ofthe market for schizophrenia drugs.

NAMI is heavily subsidised by the industry,listing 18 pharmaceutical and biotech companies as‘Corporate Partners’ (NAMI, 2006, p. 9). Althoughnot classified as a DCF site (see Methods),psychlaws.org (Treatment Advocacy Centre) hasseveral Directors in common with NAMI, and isheavily funded by the Stanley Medical ResearchInstitute which also funds the industry’s researchinto biological causes of ‘schizophrenia’.

The websites of both NAMI and TAC include astatement in line with Mosher’s claims. The TACwebsite publicises stories about violent incidents inthe media of precisely the kind that anti-stigmacampaigners are trying to reduce. It includesaccounts of TAC’s successes in the USA inextending the powers of the courts to order medicaltreatment against the will of patients.

Implications

This rather neglected area presents a range ofresearch opportunities. Future studies might compare


websites targeting different audiences; patients,carers, professionals and the public. Studies of themechanisms by which websites gain prominence insearch engines (e.g. via linking to other sites) could bevaluable. Investigations of the effectiveness of variousapproaches to regulation of the internet will beimportant.

Taken together the findings of the current study,including the highly significant difference in Totalscores between DCF and NONDCF websites,appear to indicate that drug company money mayhave an impact on the content of websites. For thewebsites examined in this study, perspectives andstatements that are likely to increase drug sales aresignificantly more likely to appear on websitesfunded by drug companies.

The effects of the industry’s influence in research,professional training, scientific journals, profes-sional organisations, clinical practice and regulatorybodies have only recently become the focus ofserious analysis, with disturbing conclusions (Doranet al, 2006; Healy & Thase, 2003; Moncrieff, 2003;Mosher et al., 2004).

A recent examination of an internet forum foroverweight people using Xenical, entitled ‘The‘‘expert patient’’: empowerment or medical dom-inance?’ found that the exchanges perpetuated abiomedical model of obesity (Fox, Ward, &O’Rourke, 2005).

Concerns have also been expressed about theindustry’s exploitation of community, advocacy,patient and family groups by making them finan-cially dependent while appearing to provide analtruistic public service (Moncrieff, 2003; Mosheret al., 2004). The current study suggests theseconcerns may be justified.

In May 2000 the website of PharmaceuticalMarketing Ltd. reported that ‘‘the ABPI [Associa-tion of the British Pharmaceutical Industry] battleplan is to employ ground troops in the form ofpatient support groups, sympathetic medical opi-nion and healthcare professionals. y This will havethe effect of weakening political, ideological andprofessional defences.’’ (Pharmaceutical Marketing.2000). As reported elsewhere:

The Social Anxiety Disorder Coalition, the PostTraumatic Stress Disorder Alliance and theNational Mental Health Awareness Campaignoperated out of public relations firms hired bydrug companies. y IAPO (International Alli-ance of Patients Organisations) was founded and

is funded by Pharmaceutical Partners for BetterHealthcare, a consortium of about 30 companies,and GAMIAN (Global Alliance for MentalIllness Advocacy) was originally founded byBristol Myers Squibb. Neither discloses itscurrent sources of funding. y In the mentalhealth field it [the industry] gives funding togroups that promote biological views of mentalillness and drug treatments, including the Na-tional Alliance for the Mentally Ill (NAMI) andthe National Mental Health Association in theUnited States and SANE and the DepressionAlliance in the UK. (Moncrieff, 2003).

Solutions will not be easily found. The economicmight of the industry, and its driving imperative ofmaximising returns to shareholders, renders regula-tion difficult and self-regulation improbable.

Assessing the ‘quality’ of mental health websites isa complex process. Comparing content with pub-lished guidelines (Griffiths & Christensen, 2000;Kisely et al., 2003) seems, at face value, a reasonablemethodology. It may, however, be compromised byindustry lobbying of the government departmentsresponsible for the guidelines, especially in the USA(Mosher et al., 2004). Using the criterion of whetherwebsites are owned by an organisation (Kisely et al.,2003) is equally problematic, as can be seen by thefindings of the current study. A study examining thecontent of depression websites in relation to owner-ship, concluded: ‘‘Sites owned by organisations weresignificantly more likely than individually ownedsites to cite scientific evidence in support of anti-depressants, as were sites involving drug companiescompared with others’, and ‘sites owned by organisa-tions and those involving drug companies were lesslikely than their counterparts to indicate the author’sidentity, affiliation, and credentials’ (Griffiths &Christensen, 2000).

There is a body of research which suggests weshould not be too concerned about drug companyinfluence over public opinion. Recent reviews foundthat, despite several decades of attempts, oftensupported by the drug industry, to ‘educate’ everyonethat ‘mental illness is an illness like any other’, thepublic in at least 16 countries continues to espousepsycho-social causes more than bio-genetic ones, andto prefer psycho-social interventions over medica-tions, for both schizophrenia and depression. Theseviews are also held, internationally, by patientsand family members. This brings into questionwhether family organisations which espouse a strong


biological perspective, frequently supported by drugcompanies, are representative of family members ingeneral (Read, 2007; Read et al., 2006).

Nevertheless, research has also consistentlyshown that any increase in ‘mental health literacy’(i.e. the extent to which we see distress, despair anddisorientation as biologically based illnesses requir-ing medication) leads to increased prejudice andfear (Read, 2007; Read et al., 2006). This suggestswe should remain watchful and do what we can toensure that a range of evidence-based information,not just claims convergent with industry needs, ismade available to the public.

Some at the very highest levels of psychiatry havestated the broader issues, of which the currentfindings form a small part, in stark terms. In 2005Professor Mike Shooter, President of the RoyalCollege of Psychiatrists, wrote:

I cannot be the only person to be sickened by thesight of parties of psychiatrists standing at theairport desk with so many perks about them thatthey might as well have the name of the companytattooed across their foreheads.

In the same year, Shooter’s USA counterpart,Dr. Steven Sharfstein (President of the AmericanPsychiatric Association) warned:

As we address these Big Pharma issues, we mustexamine the fact that as a profession, we haveallowed the bio-psycho-social model to becomethe bio-bio-bio model. y If we are seen as merepill pushers and employees of the pharmaceuticalindustry, our credibility as a profession iscompromised.

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Documents

Schizophrenia, drug companies and the internet