When the fifth edition of the Psychiatric Association’s Diagnostic and Statistical Manual (DSM) was issued, there was a newly classified mental disorder tucked away in the voluminous 991 page book. It’s called premenstrual dysphoric disorder (PPMD) and, up until the book’s publication, it was known merely as a condition. Now, however, because of its reclassification as a mental disorder, the potential implications are far reaching.
What is PPMD?
PPMD is a serious form of premenstrual syndrome with profound and debilitating symptoms ranging from irritability and marked depression to social withdrawal, headaches, anxiety, and hypersomnia or insomnia. Often called ‘PMS on steroids’, PPMD affects roughly 3% to 9% of women. It’s a cyclical condition that occurs approximately two weeks before a woman’s period.
Why the Controversy?
Mental disorders in the United States have historically had stigma attached to them. Some believe that if PPMD is labelled as a mental disorder, women will be socially stigmatized in that regard. According to PhD author and psychologist, Paula Caplan “It is really appalling that using PMDD for women who want recognition for discomfort is a very clear message that goes something like: ‘OK, OK, we’ll believe you are feeling bad if we get to call you mentally ill for feeling bad.’ Can you imagine if we did that to men?” In an online article, posted at www.apa.org, Dr. Caplan explains “It’s a label that can be used by a sexist society that wants to believe that many women go crazy once a month.”
But, there could be legal consequences as well. According to Sarah Gehlert, who studies health disparities at Washington University in St. Louis, it could even come down to custody disputes. In an October 21, 2013 online article posted at NPR.org, Sarah said “Say a poor woman is in court, trying to see whether she could keep custody of her child. Her partner’s or spouse’s attorney might say, ‘Yes, your honor, but she has a mental disorder.’ And she might not get her kids.” Considering the fact that the DSM is the psychological disorder authority, Ms. Gehlert’s assessment may not be too far off base.
Is the DSM Just a Conspiracy for Marketing and Profit?
Maybe all of the fiery dialogue is just par for the course. In an online article for The New Yorker, Gary Greenberg writes “Every revision of the DSM causes controversy; that’s what happens when experts argue in public about the nature of human suffering.” If the rhetoric surrounding the classification of PMDD as a mental disorder is just reflective of a natural response to change, maybe the social implications are much ado about nothing, and they will pass just as they usually do when a new DSM is issued.
The problem is, according to Greenberg, that there is something more sinister at work. Namely, the potential connection to pharmaceutical companies, and how they stand to profit greatly from these changes. In the April 9, 2013 article, Greenberg, author of the book The Book of Woe: The DSM and the Unmaking of Psychiatry, argues that the revised DSM is going to lead to an increase in the eligibility for people to receive a psychiatric diagnosis which, in turn, leads to more drugs being prescribed.
His statement carries weight, too. The last major revision of the DSM was in 1994, and, partly as a result, antidepressant prescriptions jumped from 5.84% in 1996 to 10.12% in 2005. In fact, prescription medication use has increased overall, with the CDC reporting that in 2008, $234.1 billion was spent on all prescriptions across the board, which was more than double the figure from 1999.
To take the point further, it is estimated that approximately 70% of Americans are currently taking at least one prescription drug and, of that number, 13% are antidepressants. That is according to findings published in the online medical journal Mayo Clinic Proceedings. The prescription records for Olmstead County, Minnesota were evaluated, and published online June 21, 2013. They showed that a total of 68.1% of the Olmstead County population had been given one prescription, 51.6% were on two prescriptions, and 21.2% of the population had five or more prescriptions.
The male-female gender divide in Olmstead County mirrors that of the United States. In the United States, women represent 50.8% of the population, and in Olmstead County, 51.1% of the population is female (2012).
Overall, the report concludes that “women received more prescriptions than men for several drug groups, in particular for antidepressants.” The Mayo Clinic’s findings stand up to the information contained in the Center for Disease Control’s report, which reflects that between 2005 and 2008, 12.7% of the United States female population had been prescribed an antidepressant within the preceding 30 days. That’s compared to only 5.0% of the male population during the same timeframe. What does all of that mean for women and pharmaceutical companies? And, what does it have to do with PMDD?
Rebranding for Profit
Maybe everything, according to the article at NPR.org. In the article, the prescription drug, Sarafem, is used as an example. Identical to Prozac, Sarafem has been approved to treat PPMD since 2000. It’s marketed as a PPMD-specialty drug, but the only difference between Prozac and Sarafem is the cost. While generic Prozac only costs about 25 cents a pill, Sarafem costs about $10 a pill. Aside from the cost, the only other difference between the two pills is their color. Prozac is green and Sarafem is pink. Other than that, they are chemically identical.
The manufacturer of Serafem, Lilly Pharmaceuticals, lost its patent on Prozac in 2000, and market analysts recognize that Lilly engaged in a marketing ploy when it attempted to repackage Prozac as something more socially acceptable. It took $30 million in advertising to do it, but it worked. With Sarafem, pharmaceutical companies again found a way to take advantage of women and the DMS classifications.
What’s next for pharmaceutical companies now that PPMD is officially a mental disorder, and not just a condition? Based on their history of rebranding (Sarafem was just one example of many), and how women’s antidepressant prescriptions outnumber men’s by more than 2 to 1, as well as the fact that prescriptions surge when a new DMS revision is issued, it’s safe to assume that the pharmaceutical companies will likely seize the opportunity to rebrand other drugs. They’ll paint them pretty colors, inflate the price and market them as ‘new’. The problem? Regardless of how pretty they package it, for women who will now be facing the stigma of being classified with a mental disorder, it will be a hard pill to swallow.