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A Rare But Potentially Life-Threatening Condition

It's an odd thing that legislation would result in the input to one sensory organ directly contradicting that of another. But it's a funny world we live in, and this is the situation we get with direct-to-consumer broadcast advertising of prescription drugs. If you live in the United States, you've been there: while a scene unfolds before your eyes in which people are doing all the things that you normally think of as constituting a happy and fulfilled life, a narrator is reminding you that the product advertised "can cause serious and sometimes fatal bleeding" or "may lead to increased depression and thoughts of suicide." When the input to your visual cortex is contradicted by the input to your auditory cortex and Wernicke's area, who wins?

Readers outside the US who have not experienced this form of sensory stimulation may want to try an experiment. First, watch this commercial without the sound and try to figure out what its message is:

For the first twenty seconds of the commercial, solitary and morose people fret, flop about, or snooze in a dark interior world of subdued colors. After this we learn the name of the product, Cymbalta, and at 27 seconds we see a graphic of an amorphous blue-green substance oozing out from the spinal column of a stylized figure. Thereafter, the curtains open, the sunshine comes in, and everyone gets happy, active, lighter, and extremely social — even the dog in the commercial, who was all alone to begin with. Without the audio portion of the commercial, you would conclude that Cymbalta is definitely a happy pill, and you might want to take it.

The soundtrack of the commercial confirms most of the points you get in the video part with one important difference: when the people get all happy, the narrator gets all serious about the possible side effects of the drug. This is the point where the sensory integration function of our brains seems to be needlessly taxed: it's a challenge to process information about liver disease when the deadpan description of it that you hear is accompanied by smiling kids with ice cream cones. Or to put it another way, when a soundtrack is talking about "risk of coma or death," it would be a lot less startling to see a patient on a drip being rushed down a hospital corridor on a gurney than to see a happy and attractive young couple strolling quietly under colorful party lanterns, as you see in this commercial:

The legislation that results in this peculiar experience being available to US television viewers is broadly the Federal Food, Drug and Cosmetic Act, and more narrowly, Title 21 of Federal Regulations and a Guidance for Industry issued by the FDA and the Department of Health and Human Services in 1999. All of these documents spell out in great detail the prohibitions on various practices that a profit-seeking corporation might be tempted to engage in, but guidance about the exposition of major risks posed by these drugs is not very specific: it must be presented "either the audio or audio and visual parts of the presentation." Folks were aware that a picture is worth a thousand words long before these regulations were formulated, and drug manufacturers seem to have chosen the course that will showcase the benefits of their products visually, while a simultaneous audible portion presents the cautions. Some commercials present some of the risks with text visible on the screen, like this commercial — also highly recommended for a first viewing without the sound — for Lunesta, a prescription sleeping pill:

The most startling possible side-effects of this drug — somnambulism, aggressiveness, agitation, hallucinations or confusion — are confined to the narration between seconds 20 and 50 of the commercial, while a luminescent lepidopteran pays calls on various troubled sleepers and attaches itself briefly to their backsides. It's a very artful commercial that takes an expressionist approach combined with elements of vampirism to explain the effect of the drug. But it would surely be more entertaining, and probably much closer to the idea of truth in advertising, to see some of the side-effects re-enacted in these commercials, rather than being confined to the narration; in other words, to see the "show" and "tell" portions of the commercial switched.

Does this sort of advertising work? A report by the Kaiser Family Foundation found that consumers are very responsive to the intent of this kind of advertising, and that a significant number do in fact act as prompted by the concluding suggestion in many of the commercials: "Ask your doctor if ______________ is right for you." The report says that "nearly a third of adults say they have talked to their doctor about a drug they saw advertised, and 44% of those who talked to their doctor received a prescription for the medication they asked about. This means that 13% of Americans have received a specific prescription in response to seeing a drug ad." The study concluded that for the period examined, each additional dollar that the pharmaceutical industry spent on direct-to-consumer advertising yielded $4.20 in additional pharmaceutical sales in that year.

The US is the only country besides New Zealand that allows this sort of advertising of prescription drugs; it would be interesting to hear from readers there whether the commercials are in a similar vein. It's an interesting feature of the use and subordination of language in a consumer economy, and it is in some ways the other side of the coin to a different kind of drug-related advertising that is very common in the United States but widely prohibited elsewhere: what we might call the ambulance chaser commercial, in which law firms try to attract the business of people who think they may have suffered ill side-effects from prescription drugs. These are a completely different genre of commercial, with rather low-budget production values, no live action, no hired talent, little or no music, and large, comic-book style graphics:

The virtue of this sort of commercial, if it has one, may be that the video and audio portions of it present a completely unified message.

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Orin Hargraves is an independent lexicographer and contributor to numerous dictionaries published in the US, the UK, and Europe. He is also the author of Mighty Fine Words and Smashing Expressions (Oxford), the definitive guide to British and American differences, and Slang Rules! (Merriam-Webster), a practical guide for English learners. In addition to writing the Language Lounge column, Orin also writes for the Macmillan Dictionary Blog. Click here to visit his website. Click here to read more articles by Orin Hargraves.

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Comments from our users:

Wednesday February 1st 2012, 1:45 AM
Comment by: Marilyn B.
Well done. I'd add to this list political advertising. The toxic side effects are well known...and lasting.
Marilyn Blundin
Bracciano (RM) Italy
Wednesday February 1st 2012, 3:34 AM
Comment by: Roger Dee (Haslett, MI)Top 10 Commenter
I find scintillating fodder for my personal sense of humor in the many ads that contain the words, "When the time is right." Suggesting that a certain drug will protect you from the embarrassment of sexual malfunction, one has only to mention the phrase in "polite society" to obtain immediate recognition of the humor in our anxiety-based fears of "not being ready".
Wednesday February 1st 2012, 6:46 AM
Comment by: Dick. (Salisbury, MD)
The death-defying context of the cited TV commecials, presented so blithely, would be downright amusing if they were not so sinister. I seethe when I see and hear them and if I were still practicing medicine I believe I would categorically refuse to prescribe the thus advertised remedies.
Wednesday February 1st 2012, 7:45 AM
Comment by: Karen D. (Laurel, MD)
I believe this effect is well-known. A picture is worth a thousand words, after all. You say "the sensory integration function of our brains seems to be needlessly taxed: it's a challenge to process information about liver disease when the deadpan description of it that you hear is accompanied by smiling kids with ice cream cones", but that is the whole point. The people selling this stuff - whether it's a drug, a political idea or politician, or a new car - know that when there is a conflict, you will remember the images rather than the words.
Wednesday February 1st 2012, 8:29 AM
Comment by: Rees M. (Ann Arbor, MI)
This example of corporate greed further documents much of what is wrong today in the United States. Patients should go to physicians to obtain the results of years of study, practice and reasoning. Pharmaceutical firms have an obligation to conduct comparative trials and provide evidence that can be used by physicians. For the patient to be encouraged to circumvent this process and badger their physician to use a particular drug independently of the evidence-based reasoning process is abhorrent and dangerous. It is sad that our political process and interpretation of free speech leads to this outcome.
Wednesday February 1st 2012, 8:45 AM
Comment by: Karen G. (Washington DC, DC)
You'd rather the doctor just prescribe drugs for which the patient has no knowledge? Please. Doctors do not know everything. While I find these commercials tedious, I wholeheartedly support the right of individuals to make up their own minds whether they want to talk to their physicians about medication. Otherwise, they're just dupes being played by the medical association.
Wednesday February 1st 2012, 9:19 AM
Comment by: Joann Z. (Rockford, IL)
and sometimes it backfires. My friend , a dermatologist, states when patients come to dermatologists asking about DrugX for their toenail problem, they are routinely prescribed DrugY, which is superior and cheaper.
Wednesday February 1st 2012, 9:41 AM
Comment by: Wood F.
Totally agree with @Dick and @Rees M. Ordinary consumers are not qualified to make decisions about what drugs are right for them, @Karen G's objections notwithstanding. That said, the required disclaimers are ludicrous in the context of advertising of any sort, and should be relayed by the doctors, not by the ads. I don't think this type of advertising should be allowed, but if you're going to allow it, don't insult our intelligence on top of it.

Imagine if the deleterious effects of high-fat foods were required listening as we watched them being happily consumed by thin, good-looking models. "May cause diabetes, high blood pressure, heart disease, and early death. Ask your doctor if [insert favorite guilty pleasure here] is right for you."

Actually, maybe that's not such a bad idea. A lot more people would be saved by that kind of message than by warning about the .01% percent of drug consumers who experience a deadly side-effect.
Wednesday February 1st 2012, 9:50 AM
Comment by: Katy P. (Bloomington, MN)
I recall "Saturday Night Live" did a sketch mocking one of these commercials. It was hilarious. The people in the "commercial" could hear the announcer's dire warnings - which of course were much worse than those on 'real' commercials. Consumerism in the U.S. has become a strange thing indeed. Just look at all the hype being given to the commercials that will air during the Super Bowl! I'm sure advertisers are smiling, all the way to the bank.
Wednesday February 1st 2012, 9:54 AM
Comment by: Licia C. (Milano Italy)
In Italy, advertising of OTC medication is allowed but there are specific rules that must be followed, e.g. the message should not suggest that one self-diagnoses, it should not contain any misleading information, it should not make any comparison with similar products nor get any endorsement from celebrities or physicians etc. The ad must also contain all necessary information for correct usage and mention potential side effects, and it must state that users should carefully read the warnings in the information leaflet (“leggere attentamente le avvertenze”); from a linguistic point of view, this is the most interesting part because usually it is said much faster than the rest of the message, especially on the radio, and although the words are enunciated clearly, their speed makes it difficult to process the message, so I wonder if anyone really pays any attention to it.

Slightly off topic but hopefully amusing, the standard Italian name for patient information leaflet is “foglietto illustrativo” but the more common word, recorded in all Italian dictionaries, is “bugiardino”, from “bugiardo” (liar) plus the diminutive suffix –ino.
Wednesday February 1st 2012, 10:06 AM
Comment by: Rees M. (Ann Arbor, MI)
To Karen G.: Clearly doctors do not know everything. This is why I described the obligation of pharmaceutical firms to inform physicians based on controlled studies. The practice of medicine should be based on controlled studies and the resulting evidence used to guide therapy. If I felt my doctor was not keeping up by reading the current journals, I would change doctors. And for patients, the web is filled with excellent, generally unbiased advice (major medical centers, the NIH, WebMD…) to which patients should turn. My objection to these ads is that they are designed solely to sell a product, not to provide unbiased evidence. As a patient, you have no way of knowing if the drug being described works better for someone with your condition (complicated by a myriad of genetic, life-style, and past history risk factors) than other drugs nor know which are safer for you. These considerations require study, visits, examination, and follow-up, not an ad.
Wednesday February 1st 2012, 10:52 AM
Comment by: dr phillip D. (kansas city, MO)
Simply stated, I agree with Dick from Salisbury...don't give in to to these merchants...TV is a huge marketplace and like the Internet is ful of scoundrels peddling substances along with guarantees of eternal life and happiness along the way. Fie on them all!
Wednesday February 1st 2012, 12:02 PM
Comment by: Gordon W. (Jonesboro, GA)
Wow,Orin! You really are the kid in the neighborhood that always thought poking sticks into a hornet's nest was a good idea. It seems that a number of comments have veered away from the incongruity of the audio and the visual of the ads and into opinions about the ethics of the ads. One thing I noted was that you did not mention print ads (like, you know, man, pictures and words on paper) for these same drugs. Do you see any incongruity there between the visual with pictures and bold, stylized print in color, and sometimes as much as a page of warnings in fine, black print on a white background?
Wednesday February 1st 2012, 5:12 PM
Comment by: Tom L. (Apalachicola, FL)
I often pine for the days when drugs, lawyers, doctors, and hospitals were kept from advertising for ethical reasons. The ethics haven't changed but the breach of ethics has become such a minor event in our society that we hardly notice. The ads seem to ask us to diagnose and treat our own ills. We do not have the necessary knowledge for that. That's why we have doctors and lawyers. It's a real shame that the doctors and lawyers are so often complicit in these exercises in greed above ethics. If I have trouble sleeping, I go to my doctor, not my TV. We have lost so much and it is sad.
Wednesday February 1st 2012, 7:19 PM
Comment by: Roger Dee (Haslett, MI)Top 10 Commenter
Very well said, Tom L!
As a retired physician, I believe you have stated the crux of it quite succinctly.
There has been an erosion of ethical principles that cuts a wide swath across across most of modern life.
The fields of expertise that formerly represented a bastion of ethical behavior and principled practice are long gone, I'm afraid. Medicine, research, law, etc. (fill in the blanks!).
It is pervasive and the new god is money, power, and pleasure.
Wednesday February 1st 2012, 7:38 PM
Comment by: Lily T. (Mesilla, NM)
This is a really interesting article, as my brother and I, when we were kids, used to play with our stuffed animals and make fun of these commercials, stating devastating side effects in a calm voice while happy children play in artificial sunlight with perfectly scooped ice cream cone as their mother with perfect hair, designer clothes and a blinding smile watches from the sidelines.
I firmly believe that you have uncovered the nasty truth behind these commercials in this muckraking article. Congratulations, I applaud you, and thanks for showing us the truth.
Roger Dee said it best: There HAS been an erosion of ethical principles that cuts a wide swath across most of modern life. I completely agree. Medicine ads are just one of the many examples.
Wednesday February 1st 2012, 9:57 PM
Comment by: Ferial E R (Woodbridge United Kingdom)
GOOD GRACIOUS!!!!!!!!!!!!
Ferial (England)
Thursday February 2nd 2012, 8:09 AM
Comment by: Orin Hargraves (CO)Visual Thesaurus Contributor
Thanks to all for your interesting and insightful comments. A few responses:

Roger Dee (first comment): Yes, the commercials about drugs for men are particularly insidious; they all aim at our insecurities. The virility drugs suggest that it’s a failure of manliness to be unable to perform on demand, but then they warn at the end: “Ask your doctor if you’re healthy enough to engage in sexual activity.” I wonder how many doctors ever actually hear this question!

Wood F: I too would like to see junk food commercials accompanied by these dire warnings, or better, acted out by obese people or people with seriously compromised health. But let’s not hold our breath.

Katy P: I looked for that sketch on Hulu but couldn’t find it. Please post if you know where it is, I would love to see it!

Gordon W: Yes, I think the print ads are an analog of the TV ads: a full-color, double-page spread extolling the virtues of the drug, followed by a full page in 3-column, 8-point type, laying out the warnings. Does anyone read this page? Doubtful.

Lily T: your stuffed animal commercials sound like they could be a YouTube hit (and I’m glad to have a reader in Mesilla, one of my favorite corners of the world!).
Thursday February 2nd 2012, 11:00 AM
Comment by: Ben Zimmer (New York, NY)Visual Thesaurus ContributorVisual Thesaurus Moderator
SNL has done the "side effects" bit a couple of times -- there was Happy Fun Ball in 1991 and Annuale in 2008. In the same vein is the classic E*Trade commercial warning that the drug Nozulla may cause "itchy rashes, full body hair loss, projectile vomiting, gigantic eyeball, the condition known as Hot Dog Fingers, children born with the head of a golden retriever, seeing the dead, bone liquification, possession by the Prince of Darkness, tail growth, elderly pregnancy, back pain...."
Saturday February 4th 2012, 1:40 PM
Comment by: begum F.Top 10 Commenter
I am writing this comment because, Mr. Orin's comment regarding the advertised drugs tuned fully with my thoughts. When I watched those advertisement, long time ago,I asked this question to myself that is there any medicine available that won't create any side effect upon consumption, I mean the least riskiest pills? Not at all!
As a chemist I have a pretty good idea about what drug synthesis is.But I do not use any of these advertised drugs to kick away my depression. Because, I know it will hurt myself more than making any good to my feeling.
However, I use Aspirin sometimes in order to sleep well at night(because I have pressure symptom). It means, I am advertising here for Aspirin.
Is there anyone left to read my comment for drug use: Go outside and walk for a while; avoid taking any medicine to remove your depression.
Have a nice weekend!
Sunday February 5th 2012, 12:05 PM
Comment by: Marah (Mount Shasta, CA)
Thanks. Important to take in and understand your statement, "When the input to your visual cortex is contradicted by the input to your auditory cortex and Wernicke's area, who wins?"
Friday February 10th 2012, 10:55 AM
Comment by: Mark R. (Paradise, CA)
This technology is being applied to political advertisements & no side effects are ever mentioned. There is no substitute for consciousness during such moments. (;-))
Wednesday February 22nd 2012, 3:51 PM
Comment by: Jane B. (Winnipeg Canada)Top 10 Commenter
Avoid relying on test results, too. Far too often those reported in medical journals involve doctors who are paid by the pharmaceutical companies!

A friend of mine, a doctor, also related the 'gifts' he got from various companies. The objective, of course, was to guarantee that he would prescribe these.

I have found that with most prescription medications I will have some sort of reaction. Usually, a consult with one of my pharmacists will resolve any problems. Long before Vioxx was labelled as a problem drug, I had problems with it, palpitations. The pharmacist checked and did find a clue in the very, very, fine print they were provided with. Her advice was to stop the drug and THEN consult my doctor.

Another bit of good advice from the pharmacists was to get just a partial fill of any prescription. If nothing happened after a few doses, try more, but still be watchful.

I must mention that my system is highly reactive and full of items I'm sensitive negatively to.
Wednesday February 22nd 2012, 5:22 PM
Comment by: Roger Dee (Haslett, MI)Top 10 Commenter
I've truly enjoyed all this discussion about pharmaceutical advertizing on TV for certain prescription drugs.
But doesn't the underlying issue have mostly to do with the invasion of our personal sense of ethical behavior on the part of the pharmaceutical industry?
We've been betrayed.
Certainly, doctors "don't know everything", but we have been placed in a position of trust to ensure a responsible and ethical behavior in our dealing with our patients.
That trust has been abrogated by industry for profit. We should be outraged!
The "Lawyer Industry" has recently taken a more hideous role with an ad that begs the viewer to search his memory for details that may provide a "possible opportunity" to win a large settlement if it is discovered he was "injured" in any way by the use or exposure to the "offending agent".
Thus, both the firm and the client can greatly benefit.
This last example was particularly offensive to me as it seemed to cross another line of ethical misbehavior.
Thursday February 23rd 2012, 6:01 PM
Comment by: Jane B. (Winnipeg Canada)Top 10 Commenter
I have to laugh at the double edged sword created. In the same break you can see an ad explaining the wonders of a drug, followed by an offer for legal advice regarding another -- or even the same one!

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