ucraag.

Lile Ue is a blisterfuig and truly origiilal ¡vork of reporting

and analyeie, Éaeovering Ameriea's lole in homogenizing
how the x¡orld defince wellnees and healing."
-Po Branoon, author of Nxrtura§keclr

THE
GTOBALIZATION
OF THE
AMERICAN PSYCHE

Crazyr Like tIs

Eá
h
Érá

LG
tr
Ét*
L*
ETrIAN WATTERS
Et
§tt
 4

The Mega-Marlcting of 'Deprersion

in |apan

One of the chilling things about these evenrs, wherher

a puzzle
or a scandal, is how a very few people in key. positions
can
determine the course of evenrs .rrá ,h"p. the consciousness
of
a generation
DAVID HEALY

wenr ro visit Dr. Laurence Kirmayer in his book-lined

office ar
-E McGill universiry in Montreal because he had a particurarry
good story to tell. IU heard that a few years ago, Kirmayer
had a
-personal brush with the pharmaceutical giant GlaxosmirhKrine
lr and the remarkable resources that the company
employed ro,creare
a marker for their antidepressant pill paxil
in Japan.
.l- In person Kirmayer is the picture of a tweedy academic.
I-Ie
--il
speaks in complete paragraphs in a deep authoritative
voice. He
has a large head and a broad face thar is covered
nearly ro the cheek-
bones in a thick light-gray beard. His slightly
wandering left eye
sr-rits his demeanor. If you look at the left
side of his fa." his expres-
sion is attentive and focused on the conversarion.
If you look at
. the.r'ight side of his face h.e appears ro be rooking pasr you inro rhe
middle distance, as if searching for a word o,
po.rd.ri.rg, rho,-rght.

187
 188 CRAZY I-IKE

In te',ing his story of being feted

Iikes to poinr out that h.
US

by Glaxosmi rhKrine, Kirmayer

#
*F
i, .rlr"..rro
wealth. Not that he,s doing
oro,r. o.9ril Í,::*::?:,r31::r#T *
Social and Ti.anscultural psychi
able living a,d adds ro hi' i.r.om. ^rr, ^rMcGill, he makes a respect_
*rrl, a pr-ivate psychiatric prac-
*$
' tice' As editor in chief of
trre journar Transcurturar psycbiatry, *+
well known in ce.ain circles
and can draw a ..o*i
he is
;+
+
grad students and colleagues of
,, ,., *rr,lrropology or "d*i.rrrg
conference. But ro get mental healdr
to those conferences he
flies coach.
Itwas in thefall of 2000,.,
h. ,.11, ¡,, rhar he came ro understand
just how anspectacolarly
an invitadon from something
rich he was. That was *h.,
h.l.cepted
*e"
cared the Internationar
consensus
Group on Depression and

.T:f:.:::; f;l
arli.ry -
-. i n Kyo to
",i,h.
"rr.rrd
rwo all-expenses_paid
second, G* ..,o,,,hs rater
"&
Accepting the invitation
didn't at firsr seem Iike a
on
",&
*.r"
sion. Although he knew difficurt deci-
thar rrr.."J..;:":":"
":^:* *
educationat
ir"r,, from the drrs ;;'i.:üililililfi:i"tí:;
t*
industry funding wasn,r
.r.r,rrr.ifo, academic conferences
field of psychiatry' §,hen
he checked out the rist
of other
in the =r4
tees, he recognized all invi-
the .r.*.r. L .
gro up o f higlily infl uen
the United Stares, and
r#XrH::HyJ;H:::
ti al .l i, i.i rrr

Japan, ,r."",
*e
"Transcultural Issues
alley. Even bemer, he
in Depressior, .]r¿"arrer
countrier. lh. topic,
Anxiet¡,, was right up his
*f*
Junko Kitanaka who was ,"
had .; ."*..;;;;g
"6lirhirg
graduate srudent named u*r*
the hisrory of depression ¡ip." her disserrarion on
in rhe cour. *-f*
Iuminaries *o,rrJi.
a boo¡r to her r.r"llT,l.
,*;,::ffn:t *k
-üL:rl",.".,,,r,.:.Tl',T,Í,'il::Y,l:g,T:'Jl:1ry'". has mucr, ori,s opera- ata
uni ted J"rr.i*r;:ilT:ffJffi fl :ft::' division is based. rhe
*r"
"J*
*q
*[-=
 The Mega-Marheting of Depression in
Japan rB9

incentives, arrendees would be given the chance

to pubrish their
presentations in a supplement of the prestigiousrla
urnal of Clinical
Psychiatry. "I wouldn't say it was a no-brainer,
but it wasnt very
hard for me ro sayyes,,, Kirmayer remembers. ..How
much rrouble
could I ger in?"
His first inkling that this wasnt a run-of-the-mi,
academic con-
ference came when the airline ticket arrived
in the mair. This ticket
was. for a sear in rhe front of rhe plane
and cost nearly $10,000.
The next hinr came when one éf rhe conference
organizers rold hiÁ
in no uncertain rerms that rhese would be closed_door
meetings.
His grad srudenr, Kitanaka, would not be allowed
to attend. There
would be no uninvired colleagues and no press.
On arrival in Kyoto in early October 2000 he found
the luxury
of rhe accommodations to be beyond anything he
had personally
experienced. He was ushered into an exclusive
pr.t of .h. hotel,
where he was given a drinkwhile an atractive
woman filled out rhe
hotel fo'ms. FIis room was a palariar suite. The
bath was drawn and,
strewn with rose petals and dosed with frangipani
oil. There was
a platter on the credenza filred wirh fr*its
so exotic rhat he courd
identify only the mangosreens.
"This was Gordon Gekko rrearmenr-rhe
mosr deruxe circum-
stances I have ever experienced in my life,,,
Kirmayer says, smiling
at the memory. This was how the other half lived,
he realized_
og rather, how the other .01 percenr lived. ..The
h-rxury was so far
beyond anything that I courd persona,y afford,
it was a rittle scary.
It didnt take me long to think that something srrange
was going on
here. I wondered: §That did I do to d..e.r.
thir?,,
Kirmayer was well aware that drug companies
routinely spon_
sor professional conferences and educationar
seminars and that
these events do double dury as marketing
seminars. Ir was also com_
m:on krrowledge rhat drug makers use.enricernenrs.ro
encourage
 *
190 I cRazy LrKE us
both researchers and practitioners
might be treatecl ro a ¡ound
for a*ending an hour-ro.rg
to attend. A prescribing
of golf or a fancydirr.r.,
i,
doctor

r.-ii"r.to,r. rhe effectiveness"*.hrrg.

t
*

*
new drug' These practices ofsome
are the medicar equivalenr

&
*
estate agents do to sell vacation of what rear
rimeshares.
Bur it was crear from the

&
srart that the gatherings
tional consensus Group oFthe rnrerna-
on Depression andAnxierywere
f¡om rhe normal d*g.orop""i different
aof .ra pony show, and not
sim-

t&
ply because the er
o.,.,d.*ili':ffi; *
sroup
ffirffi
ussio nr,"Kir*"r"r
m':"H:::::*
á*f,il:,T.disc reatized quickty tllat-;.
touting.h.,,p,"dJ::,:'j;l;:;:::n:3:ffi
of ttre company,s
months away "r,tid.pr..á".
much more inrererr_:! r"
lr;o*;;il;r,il
:TT,Ji;
, r._
from hitting the m"rk.ti'r,¡"pan.
Instead theyseemed
hearing fror., .h. assembled
t
*
were there to learn. ..The group. They

t
focus á. ,o. on medicatiori,,
remembers' "They were Kir*.y.. *
nor rying to se, their drugs
were interested in whar a.-*. *.,
we k.r"* Jo,rr how..rt.,rr.r.ri".p]lr.
ness experience.,, ,U_

As Kirmayer gor to know

ized that the drug company
them during the conference,
he real_
&
*

&
representatives werent
of the advertising from the ranks
or marketing d.pr.r_.nts
people. As best he could or the peppy sales_
t.ll, tlrJ. *.r. irr*rrt, paid private
who courd hord their own scholars
postcolonial theory
in the mosr sophisticated
.h:-*p..t oF glob" lizationon the
discussion of é4
mind' "These guys alrll had phór human
r"d;.; ve¡sed in the lirerarure,,, é¿
Kirmayer said' "They were
each other on these ropics.,,
crearly.ont irg up what
we had ro say ro
ra
The intense inreresr the

&
GraxosmirhKrine brain {¿
in the topic of how culture rust showed
shapes .i. ,rrrr.., experience
sense given the timing made
of the m..ti.rg. The class .
"r;;;.;;;r"nr
,

#
*

*
 T/te Mega-MarÉeting
af Depression in
Japan 191
drugs known as serective seroronin reuptake
become the wonder inhibitors (ssRls) had
irs theyd garnered
drug of the i;;r, ar Ieast in terms of .h. p.of_
. Ieading regions
p^:r} d.ug .o*p"nies. Thar year
alone, in the
rN., ,",.."gr.*iy l percenr and totaled ove¡
?..f B
Most
;:::::*:,,;1.0",,*,. ";;;,. sares were stlr in Je united
that Iuc¡ative inrernational
markers had yet r#:üff:reement
Indeed it was somewhat
¡emarkable rhat none
of
selling SSRIs had been
l",rrr.h; ;; Japan. This was the besr_
twelve
years after prozac became more rhan
avairable for prescriprion
United States. §flhat caused in the
,fri" *"]i
p a rt o f th es e p ha
rmace u d car gi an tr,
r. :::Xff ::XTr,Í:iffl:
anese eschewed §Testern
drugs. To rhe conrrary,
panies at the time U.S._t¡ased com_
inmedica,ions,o:[ji,i=:iT.::'iJ;:iyrT:;r"""::
patients ferr underserved
if they ¿i¿nt come away from a doctor,s
visit with ar least a
,h:;':l.J;:::o,jl,ff',."0..," ,n..ro
Bur Eri L,ry,
n"*.
ffil:.:j;:;::,1,0
decided in the
"-r, ,rr0,,",," 0,.i..n.
,r,"¡"p",,o.;;;:Tffi ,';;::H::;J::"::Tffi ,r:::üi.ff
wouldnt wanr ro accepr
the disease. ..The people,s
depression was very
negarive,,, explained
artitude io*nrd { ¡
,

Lilly to the wail streetJournar.sh.L. . ,fok.r_o*;; ;, At l

r.r.rri.rg to the fact that the
!, Japanese had.a fundament.rr,
i' than in rhe §.est, one
or*.."; ;":::::::i..-.1, .
!.
!:
L1
that -"d. ¡. r,"*",iH::ff;Í::j::
¿. in Japan wourd *"", ;;-;;e
t!
,f.;i:_::le a drug associated with
¡

i
Most orher SSRI manufacrurers
followecl Eli Lilly,s l..a ,.,a
held offas well. Getring drugs
ble' The rules ar the-dme "OO.or"Jrn Japan was a costly gam_
requir¿i.h"r drug.
in \Testern countries "rr."dy
h"d to lr. ..r.;;.d ;; Iarge_scale
óothe m..k.i
human trials
 192

using an exclusively.Japanese
CF.A7., Y LI KI] US
H
population. ,,at meanr years oFeffort

tr
and millions of dollars rp.r.r*i,hthe distinct p"rriúifiry rhat
drug might fail the trial. No the
company wanted to make
invesrmenr if no market existed such an
fo, ,h" dr,rg.

fr
pharmaceuricar company
.The-Japanese Meiji seika was the first
ro break from thepack, working
throügh the decade to runJapanese
rriars on rhe ssRI Luvox,
whi.t rr hi licensed from the swedish
company sorvay' After reading perer
Kramer,s 1gg3 book Liste*irug
to Prozac, Meijit president,
lái. Kitasato, sensed an unexplored

fr
t#
ese marke tplace. "peopre
,1ffi::::L'|$:1'o "i in the company
..
t r r o oke
Bu d,.*:T l:'ff ;:fi fi
:?; i: :h ::fl :lft:,::i
a big market.,' ;
GlaxoSmithKline w," th- --... -^
prior to the 2ooo ;F:,1:1',:?r::"::;::jTr:T*
,immense amount
of money *rd ,"ro. i:f:::
regutatory ancl bureaucratic
hoops ." *.::'f:JHjü?J:;:: **;
on the marker in th
Havingwatched prozac domin"t.
&
t&
American market r,..or.rrr. tlr.
the adyan ra*.,,. .:,; f;u:: :f,::ff "áffii;;*:,fr:;
wanr Luvox to be tI
But botrr ."*o:';lt,j:5j|JT#.
guaranree that
Japanese doctors would
the poputatr"" *lrr¿ be
that the profession of psychiat.,
probrem: rhere was no

interesteo,"-rff,;;i:t#ffi;
," j.o.., unlike in the §zest,
1':
&
&
dom minisrered to rhe walking;"r;;;rther sel-
exclusively o, rhe severely
was all but nonexistent
they focused
m.-rrt.lly ill. éorrr.q*.;;;;;
in ah..o,r.rr.y. For the small
almost
orrO,
*+
the population diagnosed percentage
wit' d.úilit"ti.rg mental illness, of @r,*
hospiral srays were the "
norm. The average sray in
Iong
a mental hospital *
was over ayear,versus just
:'Jio-r" ten days in the united states.
§o although there was a,psychiatric
term for.depression ih
*
Japan,
*
*
*
.Il
 Tbe A[ega-Marketittg of Depression in Japan 193

utsubyó, what it describecl was a mental i[ness that was as chronic

and devastating as schizophrenia. Utsubló was the sort of illness
that would make it impossible to hold down a job or have a sem-
'W'orse
blance of a normal life. yet, ar least for the sales prospects of
Paxil in Japan, utsub)ló was considered a rare disorder.
At the Kyoto meering Kirmayer began to understand the com-
panyk intense interest in the quesrion of how cukures shape the
illness experience. To make Paxil a hir in Japan, it would not be
enough to corner the small market of those diagnosed with utsubyó.
The objecrive was to influence, ar rhe most fundamental level, rhe
Japanese understanding ofsadness and depression. In short, rhey
were learning how to market a disease.
To have the best chance of shifting the Japanese publict percep-
tion about the meaning of depression, GlaxoSmithKline needed
a deep and sophisticated understanding of how those beliefs had
taken shape. This was why Kirmayer came to realize, dre company
had invited him and his colleagues and treated them like royaky.
GlaxoSmithl(Iine needed help solving a cultural puzzle that might
be worth l:illions of dollars.
Judging from the records of the conference, it's clear that the
company got its money's worth. During the meetings eminent
scholars and researchers gave insightful presentations on subjects
ranging from the history of psychiatry in Japan to the Japanese
publict changing attitudes about mental illness. The prominent
Japanese psychiatrists in attendance were particularly helpful in
framing the state of the publict clrrrent beliefs about depression
and anxiety disorders.
OsamuThjima, a 1¿rofessor at the Department of Mental Health
at Kyorin lJniversiry and a leading Tokyo psychiarist, told the
assembled group of a rising public concern about the high suicide
rates in Japan. FrIe described.how dozens of middie aged rnen,each
year hike deep into the so-called suicide forests in the foothills of
 Mt' Fuji with
194 CRAZY LIKE

lengths of rope to
IJ.S
H
how service arong thr c.rrt.i
hang themserves. He described *
tine R.ir*ay in Tokyo *.. ,o.rrir.ty
disrupted by office workers
reaping in fronr of coámuter
Tajima also gave a detaired üains.

t-+
d.J.ription of how psychiatric ser-
vices were srru*ured within *
rh. oá., healrh ."l;;;rtus of
Japan. Services were in the midst of
a critical change, he reported.
was a burgeoning concern
T...- in the population abour mood
disorders and the need for
sociar arrenrion to suicide
rates and
dF
t
depression' He arso docume,red
how the §Testern definition
symptom checklist for depression-th".,ks and
the D'SM in the professiq¡_y¡as
to the influence of
steadily gaining ground among
younger psychiatrists and
doctors in Japan. ..Japanese
undergoing a period of importan, psychiatry is *
.i"rrg.,,, he concluded, which
was cerrainly good .r.*,
á, GlaxoSmithKline. He was upbeat *
about the changes heralded
by the ,r*rrdrrdirrtion of psychiatry
around the world- .Adoption
of inrernationally rrr.r¿"rár"i
*
nostic criteria and terminology Orrr_
in psychiatrywi, provide *
advances in assessing prevalerrce additionar
and faciritating accurate diagno-
sis"' He was also crearly impressed *
with the scientific advances in
drug treatments that were soon
ro come to his country. ..New
effective riearment options,,,
he said, ..most notably rhe
and *
SSRls, will
b urden or clep ression *
;::Tff;::*;.*e and anxiery disor-

Afterlunch on rhe second dayofthe

conference, irwas l(irmayer,s
*
turn ro speak' He had written
ing the differing expressions
many papers in his career
documenr- G&
the meaning hidden in those
of d.pi"..ion around the world
diff.r.n.es. He had found ,h*..r.ry
has a rype of experience
that is in
and
&.
_c_uftur-e
\'esre¡n .o.,..p,iorr of depressior,
*.;:"1::,:T"t
r:1'r*:l: *
iors that relate to a ross "
of connectedness
social starus
to others or a decrine in *
"..0.1r"":l mouvatio" 11. rr. i.r¡i"ffiin., *

*
* -r
 The Mega-Marketing of Depression inJapan
t95

culrures have unique expressions, descriprions,

and understandings
for these stares of being. -__
He told the assembled scholars and drug company
represenra_
tives of how a Nigerian man might experience
a culrurally distinct ,

form of depression Lry describing a pepp€ry feeling

in his fr.ra. a¡ l'-i
rural Chinese farmer might speak only of shoulder il
o, ,.orrr..h_l
aches' A man in india might ,*lk of semen
ross or a sinking t ."r. o.l
feeling hot. A Korean might tell you of ..fire .-L
illnes.,,, whiJ i, ;p.-] I
rienced as a burning in the gut. Someone
from Iran might ."U ofi
tightness in rhe chesr, and an American Indian
might a**iu. ,n"
experience of depression as somerhing I

akin to loneliness. i
Kirmayer had observed rhat curtures often
differ in what he
called "explanarory moders" for depression-rike
srares. These cur-
tural belieG and srories have the efFect of directing
the attention of
individuals to certain feerings and symptoms
and away from oth-
ers. In one culrure someone feeling an inchoate
distress might be
prompted to search for feelings of unease in his
gur or in muscle
pain; in anorher place or rime, a differenr rype
of symptom would
be accepted as legitimate. This inrerpray
berween the expe.t.tion,
of the culture and the experience of the individual
reads to a cycre
of symptom amplification. In short, beliefs about ,
rhe cause, ,r;;_
tomatology, and course of an iflness such as
depression rended to be
self-fulfilling. Explanarory moders created th.
.,rltu.aily expecred ,
experience of the disease in the mind of the
sufferer. such irff.r-
ences, Kirmayer warned the group, tended
ro be overlooked when
clinicians or researchers employed rhe symptom
checklists reraring
to the DSM diagnosis of depression.
[fnderstanding these differences is criticar, however,
because cur- i
turally distincr symproms often hold precious
clues about the causes
of rhe disrress. The American Indian symprom oFfeeling
lonel¡ for
instance; likely reflects ásense of sóciar marginalfuation.
A K-oiean
 196 I CRAZY LIKI] US

who feers dre epigastric

pain of 6re irness is
an interpersonal conflict expressing distress
over
o, *.oll..t.
rhe wi de vari e ry r,r**" *. ;:::;il. J;..:[H,jI
ca'¡ not everyone in" the t,i,i _
-o.rd "g...d
that thinking ofsuch experi-
;il #:ffi:::t;l',:.f Í:*' rnight categorize
do.,,
-., ád h o* ree,i n gs
sion are often viewed
in other .rrauaor as something * d.p*_
compass,,, prompting of a ..rnoral
both the ,.rdr.,jrcr
fo r .h. r" ;..
;;,¡,."r".,"i, :ffi ;:i:i".:, :,.,ffi:d *f,r
norion j.O..*r"n
i mayer
::-,1:"e_size_fits_all around the world,
i responseargued' we run the risk of ol*..rri.rg the social meaning Kir-
"O
\ the experience might
b. i.,dl.".irg.
and
Indeed, around afr.
_"'rl¿, ,, ,r' t::.
d.p r.", i or¡ r,
the most curura'y
ol r rr. r, th e Am e ri
"r
d.isrinctive. K;;;,
;
. f;ffi ;:::: :ff ::
,
tord the group tharAmer_
, .-:,.*:1TT.?:: ;iiü in being to openry express distressrur
;;;; ü,::;l:-¿Ii"_ :1ñ:; ;d
,' in other .,rlrI..,
in ou r 0..."",,?,,,i.*

find social ,r, p*pl:

_"r;Xtr:,tJ:,:.":.1lrl
'
distress, rhey orten
communiry erders or
;;-.;iliffi:,;TH,HI; [:#::Tj
Iocar spirituar leaders-
from The idea
' a doctor or menrar
l,.rtt o;¿rr;;".r outside one,s"rr..r.rr* rr.rp
cle has traditionally sociar ci¡-
made Iirtle sense.
reP fesen tati ves
,-3:i;:: ::Tfi "' lis
him heartily afterwatd.
tened cl oserv to Kirmayer,s
not endrely rr.. *nt'fed
took away From n*
á
.ir, 0", n.o
end Kirmayert .o**'they 0",..rr"*.r-.i" .n.
*.,ffi,J.':::tTl,l":jt." in two *,^ o"
1n"o,..,,,oJ,
the rurai ¡,..rr ry f uma
cut d ;

p."r.ntirg.lecrure ro
n, ; ¿;;;;] r:-fi s:;1*:1il: j
o h írr"
lolanisr Iumber a
ecology of the for.r.. on the
o,t i-"r,alilr.ffl*::n*:
Gláxósm thKline
i
rés.,r."r,r., ".
rep
;f, á;;;.. th.y *.., t.d to hear:
EE
;i:
&r*
 The Mega-Marheting of Depression inJapan r97

that cultural conceprions surrounding illnesses such as depression

could be influenced and'shifted over time. He mad.e that poinr
clearly in the conclusion of the paper he wrote basecl on his
presen-
tation:

The clinical presentarion of depression and anxiery is a func_

rion nor only of patients' ethnocultural backgrounds, but of
the st¡ucrure of the health care sysrem they find themselves
in and the diagnostic categories and concepts they encounrer
in mass media and in dialogue with famir¡ friends and clini-
cians.

In the globalizing world, he reported, these conceprions are

in constant transaction and transformation across bound.ar-

iesof race, culture, class, and nation. In this context, it is
important to recognize rhat psychiatry itself is part of an
international suhculrure that imposes certain categories on
rhe world rhat may not fit equally well everywhere and that
never completely caprures rhe illness experience and con_
cerns of patienrs.

In other words, cultural beliefs about depression and the self are \\
malleable and responsive ro messages that can be exported from
il
one cuhure to another. One culture can reshape how a popula- t,;
tion in another culture categorizes a given set of symptoms, replace
their explanatory model, and redraw the rine demarcating normar
behaviors and internal states from those considered pathorogicar.
Kirmayer's appreciation of the irony of his brief encou'rer with
GlaxosmithKline has only grown over rhe years since he gave that
presenration. like' me got into,cultural psychiatry, §66.*r"
"ÍPeople
we were interested in differences between ¿ul¡u¡s5-6ven treasured

f-iÉ
-l
 198 I cna zy LIKE us
#
*
rhose differenc«
*
l;i:lirh:# :h il: ::,,i p::iü ffi,ffi.:r,TÍ
-,,i...
*
m arke tin g
","J::ffi::,L",:, H:: 1."ai",1.,, .o gr o bar

rerences I . i,, ord..

.
to .apit.riz. ;; ;::il"t"[::-
cutturar dir- *
I asked Kirmayer ho*.1..,
I was interested in changing it *r, ro him rhat GlaxosmithKline *
r ' very
,"rr"r, in ..ft
expricit' \xzhit I was "rrepression Japan.
wirnessing was a murtinarionar
was *
; ceutical corporation. pharma_
working il;;." rede'ne
" nrental
health,,, he said. .,These na¡rarives about *
chanr
ing,h. rr.rr*
"8.* ,Íf
in fo rm .u r
i ;T
::H:r^ff *
".., "
ple conduct their everydayrives.
A¡d
:::
scale' These companies this is happening on a grobal G+*
,
afe upending long-herd
about the meaning ofiflness
The consensus
ñ;;d*.,, 'ó'
.urru."r berie*
#
fl H':** i.' H1 ;,f-
ilTiffi :i,' *f
.
Depression *o oi:l-ller
qhe üriilT
rnternation"lcot']t",,, áro.ro ot
estimatedi,¡"p..,illi7nlT.:1.**.ffi:ff,;:.§:1,::Í:.
..CIin,*,.",r.r.]'.
l. "l hand to help.
3:,.ffi:,1.,"orfo.depression;J;;:i#T,:,}lI;,:;ttil;::
Looking back, Kirmayer
. can now
th. .o, f.á.; ;;' ;. s(
b egi n nin
*., ñ.r,0.-. "
g r,., i rl.lll;:il:,H :f#i
.h,rr., g., j_o".,il¿
;:.:ffi;:.:,;:,:: "1."."1 ", *,
;: il:l.#,:'J'l:ffi,,lff;:'.:1;:;l;*:Xi* "

I f.::
*::,y.iljiltril:.ffi f"fl il*t:i{f*::ffi
surveys to help diagnose
rnental illness; th"r
the criteria,for depression p"ti..rt, ,r, ...ar"*
should ,rilt i""orrside¡ed
sick; and thar
 The.fulega_Marheting
of Depression inJapan I 09
the Japanese shorrrd be
rrerped ro reconceive
sociar stress rerated ro
work and indusmializ"tio.,
*, ,rg"r-;;;.pression that should
treated with SSRIs. These corrfid".rr be
foundation on which GlaxoSmithKlir.,
.o.r.lrrrio* would prove the
culture ofJapan. '''ould begin to change'the

Psychiatry in the.Time
of Cholera
The rapid rise of the depression
narrative in Japan, whic;
place over the next f.* rook
y..rr, i, ..*".f."Ule in many
marketing campaign of respects. The
Glaxosmrtht<Iirr. and other
set offa seismic shift ssRI makers
in rhe curture, th.
of which are sti,
' being felt' And just as earthquakes are"ft..rhoc&s the expression of tecronic
pressures that buird slowry
ove¡ decades, rhere were
in the curturar history ofJapan ufrseen forces
thar raid rhe groundwork
SmithKline,s rema¡kabl. for Glaxo-
r.r...rr.
To understand how GlaxosmitrrKrine
was so successfur in ser-
Iing depression in
Japan ar the b;;;;"* of this
imporrant to spend. some millennium, irt
rirne *rif,
rorical lay of rhe rand'^Ironica,y.h. " *rrae who knows the his_
p"rron who best undersrands
the cultural hisrory of
d.pr.rrio" ;;"" rurns our ro be none
other than Ju'ko
,lr. gr.J r.raent who was ba*ed
the conference in !1anaka,
2000. In the from
winning disserrarion, ..Sociery rl"r, ,rrr.", she finished her award_
i" D;;;.rr, The psychiarric prod-
uction of Depressi"" ,:-
Cont.*po, ary Japan,,, h", ,"t
an associate professorship uO
ar Keio universiry, an "rri "r,
compared withAmerican insdrution ofren
Ivy League schools.
A visitor to the unirrersin,.,,,t,"^.,,_,-,.--'"' .

recrswereintent"";,'J,'":'l;[::fáfi
At the Mita campus where,Kitrrrrt [:rf ifi:jff::
, *o.t*, i:ampus gares are ser,in .
arches in red brick buildings

ry
ffi
a.d p.rf,r-rr' into open courryards

I
 200 q
6lled with hu
I CRAZY LIKE
US
,+
¿;ü;.,rT lliru;::.l}:::1" ruminescen, yerrow in ,he f*F
Japanese acade
§/hen . ,,*,iií;ff
rt:;h:*Í #'i,T: ifl :ü: j c*f,
,-"' ;of':ilu' ""r" "
*"' il r,,..,.. ; ;,fr
rT
.d ..ff :
f'+
that . ""
s"",1_,orr,"s
.h. ;i;;t"9*tsted ;;';, roward *
".rd

ffi '.:rfi iT::";"H1::[TJ:#!.:fi il'::ln,:i:*;

began to 6lter
*
ú;;.;;'s-first ir.o ¡"p.r.;;;;:,"nal É+ -J

ct
and
Cultures áfe rnoct
* ;;;;;#.i'jJi;:: o,,^__

:f
ideas aboü,,he
na,ure
change and upheaval,
of the ":.:T"io. and *
Japan. The Edo "r;;;;ucial
end. For .r,.
250 yeats"i*.i";Ji:,l:,:;:*":T
o,",.111- 1n' "' Japrn hrir,"y;il;il;
j; *
frorn man)r .;;,".""." isorated *
l"i"l*'n*"
;fi*r,il#;:Iiill"l:;:'''"'n''i^"' *
"?
co n cep,s,
- o",,.li'|.'"* [r f $;]
and tenth cenruries.
::T;;{k; ffi *
nÁ'.1"'"')i_-t:Tt':T. berween the seyenth
*
ffi
*":rro #i:'#*lT:::1T:1":#:i.*:*n
culrure, and
educarion.
s of social
health, including FI€
During this tirn
n<¡tions ofd.pr...iJe
the concept that
:n would n*t ott'
m closely tracked
rnodern
Bk
sragnation of ,ost which dt"'lbtd J'
vital o'^q¡' th¡r'i;xustta' *
corne from ..".ro,ltl.*
*
{,JTT.:::::;,,":i*::ilil:#i:;:';.ffi
.r a¡,",,. "": ;:,::;.ffi
:""':,'f
.",.go ry
i; *
;H: :l ;T:,.:"* "r,- ,-,.,,
_
'Gok,
K:l;';;i:,:#*,:::i:::."rr,":il:::i::l;;::i::fl: Fk
16y utsush6*r,
no, .or_
#
#
*
 The Mega_Marheting of
Depression inJapan I ZOI

sidered sick and did not necessariry

seek a cure for his symptoms;
rather it was son
rookror.h.,".,l;:'ff';:]['i::,:T,'"'Hffi:::wourdhaveto
As the rule ofthe shogüns
*". r"!l"..d with that ofrhe emperor,
began to open up ro ideas
I11"" from Europe and the united
The Japanese pubric's.acceprance stares.
of psychiatry as a legitimate
of science and mental h."ith field
I..g.ly p"."lleled the growing influ-
. ence of§festern medicine.
It was rhe cholera .pid.*i.r,
which began in l B59 and plagued
the nation for the restof the
cenrury, rhat were criticar
rhe hold of the yojo beliefs irrir."kirrg
,.gurding health. These d,eadlyepidem=
ics ter¡ified the popuration.
Thouslnds died. The sick and
I'
thought to be infected were those
haured away tohospitals under
t.

I guard' §rhore neighborhoods porice

we¡e seared off and quarantined.
i According to Kitanaka, rhe
t' srare used the outbreaks to justi$,
c¡eation of an imposing nerwork the
i
of local government conrrols
t claimed aurhoriry from \Testern thar
advances in medicine. rmprove-
menrs in sanirary conditions
and public hygiene aia rpp.*
the cholera epidemics, and ," f i_i,
the success was raken as proof
pean and §Testern knowledge that Euro-
about hearth and irness hart varidiry.
tadirional beliefs surroundin g yojo*.r"
newer ideas of eisei, wfrich
;;.;r;;;;;;r;..0 O,
encouraged the population
to rhink of
as something that must
lealrh be and carefury cultivated
by following scientifically "rrir.ly
approved hygi"ri. pracrices.
In choosing which §Testern p"bñ
hearth moders to forow,
.n. ¡"p.,,.,. ro,...,-.,,r were particutarry
lfjj#rT::.T
i nd ivi d uar::H "jj: ;:.::r::r, : :.¿:T,,H..H*:
a n d th e
ism' each dependent on the hearth of the orher. As
more and more
Japanese docrors and public healrh officials srudied
t,
advances in
!'
!.
German medical pra*ices,
chiatry was bound to follow.
the burgeo;;;",il.;lliIil.;l
L *rrrr"i long before many ofJapan,s

ñ€
i
 202 I CRAZ}. LIKE
L,S
mo§tpromisir
::T :ffff il: T"[:.#t :f:T:::: j" r.._ ,,'
:: r: 1# the farnous TJff 3
neuropsychirt.¡ri
Those Germr., A^^_^--
severery ***ilri,,l:il:JffTocusins rheir aftention
on rhe
relared to schizonh Patlents wirh psychotic
.-^-,i'j'*',
o' r
they berieveo
J"onttl" -'nit a.p..rr,orf;; ;:svrnPtoms
;#,tH,',*#xTi';';":?-:lxxL;:::fi;
ú. o*, ffi H:.,1 iliff:
1,,,,,
on those
wirh
o.,j;;i
il:*T:Hüffffi
t"ho :::j*
seyere
rocused rheir
ministrations
dc svmp toms'
Kitanaka rrr"*llt-f
*
thar, as
¡rp"n.r. f,lor,. §Testernthe chort epidemic' inroduced
chiatry ** .".rr.t? .
;;;;;rtttof medicine,
the
§feste
crisis was .r* r"i,,..l,I,:,
*'á' " i
.o.1,"r" ;;li :üI X[::i
3.,,i.,....,, ,,, .1lo' ;::]#
ff ",.15",:.il:ti!*,#,ilj:Í,:.u"",,,,i""",á.i,"r**,,
ing rhis ri-. or..
rTIl" "'::' d;:3 #:;ft"::::'# ;ff-
j":."?'**ff
i"'j:Hf *,#Td,J H#,T.H]:*",*
practices ,rd ,^r-
rhe discontent o-gr..o *f".*"ditional
rising suicide
of ,ri_, rates and
rnedicar docrors.ontt Io1*"* /r* as sflesrern_orienred
'"J' ^,?n
outbreaks or.hor..*rrr*o *,r-n *"".^*
ti me. *.'"l,ll1] ""' "1",., ;T:Jfl':il: ::.::ffi:jj::
ten r or th e

f**",,. ;;;:r.;",:,lr,T;.t"f*'i',":","
th.. p,,btill;;;i.:'""' suddenlv rou,d ,nr, ,ffi"i 1"",::
r,oü".;:;'j
In popular lecrur
,';
psychiatrisrs newspapef
began "no and.magazine
articles, these
,,tt
'o introduce new
The peopre ideas ir¡to the
,*.i.1 oout hysteria in popurar.rr.,r...
antisocial p..ro.rrr,a, won
,,*
"r,*,'*rffi ;; "*:;:1.;***f.:::#
 The Mega-Marketing of Depression ínJapan 203

and debate on these topics. Kitanaka cites one prominent intel-

lectual who wrote in the early part of the twentieth century that
the new medical knowledge had brought to light many ailments
that the people had never heard of and that had previously gone
unnoticed. The people, he said, were now "constantly w.orried over
the slightest changes in their health" and had consequently become
"more vulnerable to illness."

|apan's First Mental Health Epidemic

Of the many ideas being imported from those \festern advances

in psychiatric thinking, one in particular struck a chord with the
Japanese population. Riding on its recent populariry in the United
States and Europe, neura§rhenia was introduced to the Japanese
public as an illness of modernitY.
\Mriting in professional and popular forums, Japanese psychia-
trists and orhers knowledgeable about §Testern illness categories
carefully explained to the public that neurasthenia (translated as
shinkeisui¡aku) was a disease of the nerves. The idea that the body
had nerve pathways, often described as tiny electrical cables' was
a new one for the Japanese, but the notion quickly became con-
venrional wisdom. The metaphor often employed to describe this
new condition was that of electric streetcars. Just as a trolley would
fail to function if its electric cables became worn or broken, so too
could human wiring fray and malfuuction from overuse'
\fhat made neurasthenia different from other psychiatric illne-
sses studied byJapanese psychiatrists at the time was that it was
not
a disorder of the severely mentally ill but of the á^.rron rnan. "The
rise of neurasthenia," Kitanaka says, "was th€ 6rst instance of the
broad-scale medicalization of everyday distress inJapan.ll She found
remarkable parallels berween the rise of neurasthenia at the begin-
 '204 #
CRAZY LIKE US
#
#
|

ning of the twentieth cenrury and the

#
introduction of rhe .üfes_
tefn conception of depression ar the
beginning of the rwe,ty-first.
Neurasthenia, she believes, became
a cornpelling social narrative
inJapan because it disti,ed and gave
a name to the inchoate anxiety
of the times' commentarors connected *
the crisease wirh a, manner
of troubling rrends, incruding increased *
markerprac" .o*f.,irio.r,
excessive studying, smoking,
drug abuse, l*bo. inequities, rising
crime rares, and juvenile delinquency. *

*i'l,:i:f ::li:;:.*y::;X *Fl*

The excitement
notonryrromthe;."'.ffi
popular culture as well. Articles,
pamphlets, and books
f.orrd.a
guides to self-diagnosis, symptom
specific gtoups shourd be considered
li.tr, and suggestions for which
particularly vurnerabre. peo-
#l*
plewere told to be on the lookout *
fo.ryrnp,o_s: insomnia, ringing
in the ears, lack of concentration,
stomach pains, .y. f.tigr",
the feeling that a heavy pot covered
pills and potions ro cure the illnesses
untike orher menrar ilrnesses being
at the time' this one carried littr.
one's head. A brisk market"rd
soc
a[.'fi::T!"0,r,r. currure
in
#
*

#
social stigma. Ind.eed, because
neurasrhenia was at first considered
an irness of th. the diag_ ¿*
nosis became somewrrat trendy- "rit.s,
An article in an interectual maga-
zine circa l9O2 was headlined ..Neurasthenia: ¿*
Operators, §frirers,
Governmenr Officials, and Srudenrs,
wa1_that those employed in
Read This.J The assumption
positio's requiri,g.r..;;; ,"r.rr.._ vla
tual lal¡or were dangerou.ly
ái.rg,reir nerves. ..The media initially ¡¿f a
depicred it as an inevirable
or,á*. for peopre on rhe forefronr
of the process of moderni zation,
fo. *hoá .j;;;;0";:;;.; ."""
*Ie
became a mark of disrincrion,,,
edented ,umber of cases
Kiranal
of neurasth."J:ffj}lilr.3:ffJ.,,.*
¿!a
gbvernment oflQcials, company
and a¡tisrs began to be reportecl.,,
execurives, universiry professors s*la
*^
.+*
.#
#
?n*ry
-h
{4a Tbe Mega-Marketing of Depression ín Japan 205

"h
The belief that neurasrhenia was a disease of the elites and intel-

#
#
lectuals no doubr helped with the wide acceprance of the illness
in Japan. By the early years of the rwentieth cenrury, however, it
was nor only the elires on the fronr lines of cultural change who
were claiming this disease of moderniqy. In.1902 an arricle reported
FF. that fully o-ne-third of patients visiting hospitals for consultations

+.
d*
were suffering from this new disease. Large and diverse segmenrs
of the population were also reporting or being diagnosed as hav,
ing frayed nerves. Neurasrhenia was suddenly being referred to as

d* Japant "national disease."

But although rhe Japanese people seemed willing to accept,
,4* even idolize, rhis disease when it was only in an elite population,

d* they were less sanguine when large numbers of regular citizens also

#
invoked the diagnosis. \7ith tens of thousands claiming the illness,
the country was poised for a bacldash.

#
A€-
Kitanaka identified one early sign of change in the debare sur-
rounding a single suicide that caught rhe public's artention. In 1903
a young student named Misao Fujimura carved a poem in a tree
near Nikko, a popular scenic area norrh of Tokyo. The message in

h the brief verse was that life was "incomprehensible." §7hen he fin-

# ished, he walked to a local waterfall renowned for its beauqy and

leaped to his death.

# Those who wrore about his suicide in the years afterward fell
into two broad categories. There were many artists and intellecru-
h als who saw such suicides as having great social and philosophi-

h cal meaning. Fueling rhe rise of the neurasthenia diagnosis was a

popular idea thar someJapanese were roo pure of hearr to live with

# the conflicts, cqmpromises, and demands of modern life. Misaok

#--1.
suicide was a brave act, some prominent thinkers suggested, com-
mitted by a young man freeing himself from the mental rorrure
of rnodeririry. -In-is understanding of his actions'was in'line wirh
Éa,€-

F¿e
&
 üfl.eá*
206 CRAZY LIIiE US #
#
#
a long Japanese tradition of viewing suicide as an acr of personal
resolve . Just as neurasthenia was considered a mark of distinction
arnong cerrain elite groups, suicides among similar groups were
often excused or even admired as expressions of the puriry of the
Japanese character.
'
#
But as the diagnosis of neurasthenia began to rise exponentiall¡ *
some prominenr doctors and officials stepped forward to challenge
the social starus given individuals like poor Misao. Kitanaka cites
*
a speech to psychiatrists reprinted in a 1906 issue of
theJournar of *
Neurologlt, in which rhe statesman shigenobu okuma took a harder
line: *
*
These days, young students talk about such stuffas the ..phi_
losophy of life" [applause from the floor]. They confront *
important and profound problems of life, are dgfeated, and
*
develop neurasrhenia. Those who jump offof a waterFall
or
throw themselves in front of a train are weak_minded. They Ft=
do not have a srrong mental constitution and develop mental
*-b
illness, dying in the end. FIow useless they are! Such weak_
minded people would only cause harm even if they remained
alive [applause].
#
*
Prominent psychiatrists also began to question the diagnosis. In
a book on menral illness published
*
in rgLTa professor at Kyushu
universiry wrote that those who suffered from neurasthenia were
"born with an inherent weakness in the brain" and
*-b
had only .,harf
the mental capaciq, of a normal person.,' Not everyone *
who had a
mentally taxi'g job, other psychiatrists pointed. our, developed
the *
disease; thus there must be someching fundamentaily
the affected individuals to make them vulnerable.
wrong with
wl*
Psychiatrists began to offer up new categories and formulations.
They- began,.ro talk of the difference between the.few
who had ..true- '
É#
FL,n
#
eJ* !
 Ll
f
F' Tlte llega-Marketirtg o1f Depressiott in Japan
r, 207
:r,.
ir.
,
t' neuiasrhenia" and a larger number of
i. peopre who were burdened
L
t with a rype of nervous disposition. This sort of
dispositioir was nor
§l
caused by the overwork and menrar stress
thar came with high-
profile elite.jobs bur came from an inherited
abnormal personariry
that made the sufferer incapable ofwithstanding
the eve.yday chal_
Ienges of a normal liG.
Looking back on the debate, ir seems as
if acceptance of neur_
asthenia had been so successful that psychiatrisrs
Árr obrigated to
restigmatize rhis mentar disorder in hopes
of rimiring its aáption.
By the end of §7orld \tr/ar II rhe diagnosis
h.d dmJ.t .o_pl...ly
gone our of sqyle among both psychiatrisrs
and the popr.l..io., ,.
large. A new generation of psychiatrists
wrore papers and gave pre_
sentarions dismissing neurasrhenia by
suggesting that the thou_
sands of parients who had craimed
to suffer from the irness had
either been misdiagnosed by uninformed.
d.octors orwere malinger_
ers rrying ro ger pime offwork.

The Culture of Sadness

During the earlypart of the twentieth cenrury
rhe concept ofdepres_
sion remained attached to the diagnosis
of severe *".ri. depression
imported from those German neuropsychiatrists.
It wasir't untir
after §,orld §'ar II that depression b.came
a disease category of
its own. There was nothing mild about
this conceprion of á.pr.._
sion. This so-called endogenous depression
was a crippling qype of
psychosis believed to tre caused by
a genetic abnormaliry. ploár.o*
of psychiatry at rhe time often .*piain.d
endogenou, d.p..r.io,
using rhe metaphor of an inrernal alarm
clock. "a..o.dirrg to this
r-4 model, the depressed person is like someone
carrying a psychotic

rF time bomb' for'whom' depression-tregins

goes offand ends afrer it runs its course,"
when the internar crock
Kitanaka explains. Endog-
f€
f 'bÉ
I

1
 E *-F
208 CRAZY LIKE US
F**
enous depression expressed
itserIonry
ing alarm clock and wasnt.o.r.r..a"d
in individuars witrr that tick-
to external causes.
E6+
At the same time Kitanaka shows
that another idea was É**
, irg ground in Japan,s menral gain_
typus ruelzncltoli
t .rirt
F g,P
;:*ff H','#;ffi'"',H ffi?ffi:.;jT Ttiffi Hi §**

":T;*t: F+
quickryo..,-.'á.llJ'i.,'tT;l*.,yilfl
rhinking in Japan' As
Terenba.r,
a melanchoric personaliry
á^, described it,.sorieoneiG#
with
possessed
orderliness as well
"
own achier¡ements."
..^..ptio""rr, a highry deveroped sense
frr*f. demands regarding
7rp"t *"knrhot¡rus mirroreda one,s
of
;,F
respected particularly *:*
nersonaly sryle in Japan: those
gent, and thoughrfur who *.r. ,iriors, dili_
*d op..rr.d great *;..;;;;'.il'il,.ra.. G,á
or
orher individuars and
we-nt' were prone to
upheaval disordered
.t . ,o.i..y r.
"t-rrol.
feeling overwhelming
such people, the theory
sadness when cultural
A*
*I
their li.]es r"; ;r;."*ned rhe welfare of orhers. 6t:a
Neither
. rvpe endogenous depression no
irv *.,. or-*..at concern
Because endogenous
depression
akin to schizophrenia in
." .,,. iJll;'in:r::I,'jTri.
*.r-i"r*nr ofas a psycrrotic state, g;:
severiry it.rrr¡.¿
considered rare. As for
the _.1'r.r.holi
ciation with such prized,Japanese
a sevefe stigma and

,.jrT:t:ff::IJr:.;:
was
;T:
.
achievement mearlt
was somerhing
tlr"t lrrri.rg ,".;;
not to lr. f".¡"dÁur aspired
il;
sadness_prone personality oi*.
This absence of
to.
ho
sryredepresr,;;;.r:,,'r:oili:::;:';:^l:'#:i:o#rlffi:;
first translared into
Japanese ," ,íuL,
with its two-week threshord
a-Ll."od,
ie diagnosis of depression, Y
Y
ry
was widery criticized
:-"lg Japanese psychiarrist. ,, A. ,".
be ofany prom.
use. t psychiat"'*
en
o""uLtTti::r,".iT.J:
'des*ip ti I
on di d .ro, rmotint to
í méaningful m.nt.i rrJ;-t',t %-?
*iY
é4
r^
*,"
r^
s4E
 Tlte Mega-lVlarherirtg of Depr.essiorz in 209
Japan

Indeed, as Kirmayer has pointed our, in the late rwentieth cen_

tury r1o word in Japanáse had the same connorarions as the word
"depression" in English. consider the various words
and phrases
that have often been translated into English as .,depr.r.iorr.',
utsubyó describes a severe, rare, and debiritating condirion rhat usu-
ally required inpatient care and thus was not much of a match for
the common English word "depression.,, yuutsu, which describes
grief as well as a general gloominess of the body and spirit, was in
common use. There was also hi ga
fusaga, which refers ro block_
ages in vital energy. similarl¡ ki ga meiru is the leakage or
loss of
such energy. Although each of these words and phrases had overlaps
wirh the English word "depression," rhere were also critical differ-
ences. The experiences these words describe do not exist onry
in the
thoughts and emorions but encompass full-body sadness. As such,
the Japanese person who felt
luutsu or ki ga fusagr was likely to
describe it in terms of bodily sensarions, such as having headaches
or chesr pains or Feeling heavy in the head.
Not only did Japanese ideas of sadness incl¡-rde both the body
and the mind but, metaphoric ally at least, they somerimes existed
beyond the self. The experie nce of
ltuutszz in particurar contained
connorarions of the physical world and the wearher. A young
Japanese researcher named Junko Tanaka-Marsumi, studying at
the ljniversiqy of Hawaii in the mid-1970s, conducted a simple
word-associarion resr on a group of Japanese colrege students and
compared the results to caucasian American college students. The
American students were asked to respond with three words that
they connected wirh "depression." The Japanese students were
asked to do the same withyuutsa.
The top ten word associations for the native
Japanese were

1. Rqin
2. Dark
 n+
3.
4.
§7o¡ries
210 CRAZY LI i(E US
t#
Gray

t
5. Suicide
*
6. Solitude
7. Exams
B. Depressing
9. Disease
10. Tiredness #
*

For the caucasian Americans,

the top ten fvord associations
*
were
*
l. Sad or sadness
2. Lonely or Ionelines.s *
3. Down
4. Unhappy BK
5. Moody GJ€
6. Low
7. Gloom *I€
. B. Failure
9. Upset
*I"
10. Anxious FTá
Comparing rhese answers, c+n
ference. In the responses
Tanaka_Matsumi saw a
given by the Japanese narives,
oft'e words (such as ..worries,, ,.ri .toli*ae,,)
notable dif_
only a few
BK
nal emorio,al srate.s. on u.ere related to inrer_
the other lra¡rd, ,h.;;;;r;*
*Ja
associarions suppried by
rhe American students
rerated
"i",i" *rro *.f-*
moods' The Japanese, in sho*, to internal
yaa*u, and theAme
,.*;;;il;;H
lvere rooking ourward
to
to describe
*J*
sion. ranaka
tic differences but cultural .
f:ff:,:"*,rd
rrrirtio.r,
describe depres_

; .I:T;XT Tl}:il;
*F,
and .exp e ri e n ce.of depr
essio n,,r *J*
-#.
de
*F.
 The A4ega-Marle eting of
Depression in Jttpan
211

The Japanese and Americans

werent just talking abour depres_
sion and sadness differentl¡
she berieved; they were
staresdifferently feering these
as wer- §'hat she saw refleired in
rhe ranguage
was
adifference between howJapanese
and Americans conceived
narure of rhe sel' The word of the
associ.iior. ..rgg.rr.d rhat Americans
experience rhe serfas isorared wirhin
the individuar mind. ,oe
nese' on the other hand, Japa_
conceive of a serf that is ress
I and more inrerconnected and individuated
I dependent on sociar and environ-
I m en tal contexrs. Feelings
have, in Japan, b..., *.rpoed
th at Ame ric"... r."*^.,-o1.,,,
"* l ^ _
up ,"
rhat arrered their meaning and ";::,:;":f::il::,itfl:';;::
rhe subjective experience for
individual. the
Even as the DSM diagnosis
of depression became more
employed around the world widely
during th. l9g0s, the experience.of
deep sadness ancr distress in
Japan retained rhe characterisrics of
the premodern conceprion
ofboth ubushóand the mid-rwenderh-
cenrury idealization typus
melancholicus, the idea thar
ing sadness was narural, quintessentially overwhelm-
Japanese, and, in some
ways, an enlightened state.
As Kirmayer has documented,
this was a culrure that often
alized and prized states of ide_
meranchory.'Feerings of overwherming
sadness were often venerated
in television shows, movies,
ular songs- Kirmayer noted and pop-
that yuutsu.rd
choly and sadnes. Il.r: been ";.;'r;;;:ilrr"_
thigh t of as jibyo, that is, personal
rhar build characrer. r..i.rg,
'ardships .rr"t we might pathologize
as depressive were ofren thought
of iI ¡.p"r, as a source of moral
meaning and serf-understanding.
He othe¡s have connected
this reverence to the Buddhisr "rrd
blli.f ,h.. suffering is more endur-
ing and more definitive of the
human experience than transienr
happiness.
Other cross-eultural scholars.have
also noticed this
neseaffinity for states of sadness. J^pa-
Studying menopause in Japan,
 *
212 CRAZY LIKE US
t+
McGill Social Studies oF Medicine professor *
Margaret Lock
wfote:

Feeling sad and reacring sensidvely

*+
ro losses, parricularly of *
is an idea that has a singul". ,pp.i
fved¡nes, ;;;;;.r..
lhe rhearer, a range of literature and indigeno,r, pop.rl*, *
sorrgs, rraditional and modern,
positivelywallow in
sensadon of grief and loss, and ";á;;r, *
a sense of the irnpermanence
of.things. People cry {reely (by
NorthAmericanand northern *
Eu"ropean standards) about ,.p"..tio.,
and lost loved ones,
but at the same tirne they seem ro
draw strength from these
*
experiences, to tighten their bonds
wirh those who remain *
amonÉi the living, and to reafErm
group solidariry.

This cultural embrace of sadness,

mo tivated by socie ry's disco
Lock believes, might have been
uragement of o ther .*o ar-orrd r r"r"r.
&
*

ir*
Unlike anger and irrirabiliry which
and threaten the social orde¡ sadrress,
both disrupr harmony
grief, and melancholy
Gk
are accepted as an inevirable
part ofhuman life and even wel_ *
comed at times for their symbolic
ephemeral narure of this world.
value, as a reminder of the
An associarion berween mel_
ancholy and the weather reinforces
*1,
unavoidable and hence as srares
sad feelings as natural and
not ind.,.eJ solely
col*
human exchange.
through
ol*
Given these cultural currenrs, it
makes ...rr. ahr, the first pop_ ¿1"
ular psychopharmacorogical medicarions
and 1970s were sedatives, whereas
adopted in the 1960s
ampheramines and early mood
ul¿
enhancers yere viewed wirh
suspi.ion. As Lock implies, cultur_ Glá
ally designared pathorogi.rl ,tat.,
are often t'e flipside of srates
*ra
ér1é
&
*
 The Mega-Marketing of Depression in Japan 213

a culture values. Along with rhe sedating drugs, Japanese quickly

adopted disease categories describing social anxiery or aggiession
but resisted viewing deep and extended periods of sadness as a men-
ral illness.
' §7hen the first SSRIs came online in the \7esr, consequeñtly,
Japanese considered them harsh medications rhar exaggerated
rypes of personality valued in the United States. A leadingJapanese
psychopharmacologist described how classes of drugs marched
or ran afoul of di&renr'cultural narratives: "The Japanese sysrem
is much more modest and co-operative-people work together
more. Against this background, amphetamines are much more of
a problem than are the benzodiazepines; we are much more sensi-
tive to the changes, the exaggerarion of behavior, produced Lry rhe
amphetamines. Sedative agenrs are seen as much less of a problem
in Japan. . . . There is something of a preference for an agent that
will be sedative rarher rhan arousing, like, perhaps, Prozac."
"One socieryt enhancemenr of personal iry can be anothert
pathology or provocarion," remarks Kirmayer. "somerhing like this
may occur with Prozac, where the extraversion, gregariousness and
pushiness that rypi§r the life of a salesman in the USA may be asso-
ciated with inappropriarely brash and insensitive social behavior in
Japar-r."
Given all these cultural forces, it is not surprising that major
drug companies ar first saw no marker for SSRIs in Japan at the
beginning of the 1990s. The psychiatric category of depression was
not a widespread public concern, and the capacity ro experience
great sadness was considered not a burden but a mark of strength
and distincrion. That belie[, combined with a suspicion of drugs
that heightened moods or exrraverted personaliry rraits, made the
market for SSRIs unpromising. Those public percepdons, howeveq
.we{e soon ro.change.
 214 i cn AZy LrKE u.s
q+
In the Lost Decade a young *
Man Joins an Ad Firm
In the sprin gof lggo'
24-yea*ord,oshima
r+
tt
adverrising agency, Ichiro joined rhe
\ü7hen
th. I*rg..r .;;;;, of its kind in the
Dentsu *
he first showed ,p
*l o.n.rrlO"n,_, was world.
Ietic. His fellow ._ploy.., healthy and atlr_
d.r.r;;.d n': honesr,
ra,her, ;il;J:ir
commimed. Like ;;::::':::::'jo'o

get mar¡ied; establishing

i'
ff*ftl:*,:*:I*:;*::l
rrapp¡ and

*
his Iareer *o,rld corne
he was assigned the firsr. A, jl..r.ru
dau,ting o"r. ;ri"ndring
more than forty corpor-ate 4rrurtrrg pubric relatit
PuLtIic rerarions for
*
clients.
_ Because Kitanaka
believes ,lr"a alr.
began a new ñ;.;;:J::li'
th; odrsser
odw""o,, orvoung
^r ___ oshima
*1*
of depressiot
recounrs the story ll'i1"* t",.,á. * ip"*.,, .h. *
:"d
:iT'iJil::*x","#,g ;r*
ilt*Hflffifp:::
ofhis hiri,g in G+
&
ro nore the
r.rrtio.t;;;. .:":^::^11pausing dming

-*',ffi il:i""'iü:;*:H"#;[T,i:::"i:i":í',ix;.
all-time h¡gh. That
,ltl
iiu' that the Japanese
had nearly quadrupled
Nitr<kei index h,.
*., F*
previous five years.
,tot* ," *irJJ".. ,r"
those go-go days, *
menrs in the Ginza
oll l"t :*:t were
choice aparr-
per square foot. The
Ir was a rirne
*h.,
;t:::"""T--vo
l^n,n..^
P
i,J "tt"
-^^.-
' -^" going

:';"";;;;f. .", "IJl'-"rr.

6v,r6 for
rornearly$100,00C
ne".r, siirlooo ula
;;Í,üi,fi:
;;.f,* *il:-,1liJ.:::ff ff:
ffi* ;T.T#*
uIa
But when stock traders
gor back
C*
ning ofJanuary t99o,ro*..iirrgi"i ro their posrs at the begin_
riro.r. In the next days uf¿
weeks stocks began
starred his
to slide, ."a ifr-."a.r*_fall.
;ob in Anril ,rr.* *rr.";;;
and
By the time Orrrr*" C*
the financial
-"rk.*.
ing approaching
panic irr
Cd
*t;
#
 Tbe Mega-Marketing of Depression in Japan 2t,

As was true of many new hires, the sudden economic downturn

steeled Oshima's resolve ro prove his worth. He showed right away
that he was willing to roll up his sleeves and dig into his consider-
able workload. He ofren spent the first eight hours of his workday
just trying to juggle meerings and field phone calls. Staying at work
after hours was rhe only way he could write the press releases and
proposals his clienrs requiied. Jusr a few monrhs into his job, he was
coming home past midnight on most nights. On some mornings,
when his colleagues ihowed up for work, it was clear thar rhe hard-
driving Oshima had been at his desk the entire nighr. He rook no
days off.
In November 1990 his mother and father began to wo.iy about
his health. Oshimat eyes looked unfocused and he sometimes fell
asleep while sitting with them at the kitchen table. In his contract,
Oshima was promised ten days of vacation each year, and his par-
ents suggested that he schedule some days to resr. But he refused.
He felt that any days offwould only increase the burden he would
face when he got back to work. Anyway, he told them, he didnt
think his boss would allow him the time off. Not knowing what else
to do, his mother made him nurritious breakfasts in rhe morning
and drove him to the train starion ro ease the burden of his hour-
long commute.
After months at this sprinter's pace, cracks began to show in his
behavior At work small setbacks and rnistakes brought on waves
ofself-loathing. "I'm no good as a human being," coworkers some-
times heard him saying out loud to himself. "f'm of no use."
The New Year brought no relief from the economic bad news
or from Oshima's burdens. From its high in 1989, the Nikkei had
lost nearly half of its value. Home prices were plurnmering just as
precipitously. The normally hardworking life in corporare Japan
l¡ecame even more intense. The frustration of.Dentslr executives.at
their declining profits rolled down the chain of command, putting
 216 CRAZY LIKE US

ever more pressure on rhe rank and file. At one

late-night dri,king
binge at the ofHce, oshima's boss poured tieer
into his own shoe
and demanded that oshima drink it down. §fhen
he momentariry
refused the requesr, his boss bear him.
By the summer of that year oshimat workload
had onry gorren
wof§e' on top of his regular duties, he was
put in charge of a four-
day conference for a crient to be herd in
August. If h. got home at
all that summer, his parents remembeE it was
often .imply to clean
himself up before getting back on rhe train
to the office. on the
night before the beginning of rhe conference
he *.rr.g.at; ;..
home at 6 a'm'.He was back at work ress
than four horr. rater ro
drive his boss to rhe site of the conference.
As théy drove, his boss coulcln't help but notice
thar oshirna
seemed troubled. He drifted and swerved
erratica,y from lane to
lane' He mumbled incoherentr¡ something
about u.i.rg possessed
by spirits.
After a grueli,g four days at the conference,
Oshima made
his way back horne at 6 a.m. on August
26.Helooked so'nallydrawn and
haggard that he promised his brother rhat
he would go to the hos-
pital drat day. He called trre office at 9 a.m. to
tell thern that he was
sick and would nor be in that day. Less
than an later, his famiry
Found him dead. He had hanged himself
in rhe'our
bathroom.
\,he' oshimak parents' rawsuit against Dentsu came to court a
few years after his death, newspaper .diro.,
and relevision produc_
ers featured the story prominently.
It was an easy pick, given that
the story'ad a clear anrecedent. In the
boom years of lrre 1980s
hardworking Japanese businessmen somerimes
coflapsed and died
at their desks after putting in weeks or
months of overtime. In rhe
opress this was called karoshi, death from overwork, and reports o'
the trend had become popular. In the early
1990s suicides ropped
thirry thousand a year' This was between three
and four times
'the number qFJapanese kilred in car.accidenrsi-The
suicide trend
 Tbe Mega-Marketirug of Depression in Japan )17

became a concern ro rhe general public and there was much debate
over who or what was responsible. §7hen Oshimat suicide came
to light, journalists and editors immediately saw rhe story's poten-
tial. Headlines announced rhe new trend: karojisatsu, suicide from
overwork. Because the Oshima familyt lawsuit sought ro assign
blame for his dearh, it was tailor-made to become the focus of rhis
public debate.
The lawyers for oshimat parenrs argued that the stress of his job
and his long hours brought on a depression that caused his death.
As Kitanaka demonsrrates, this form of depression was different
from rhe endogenous depression in the Japanese psychiamic ritera-
ture because it hadn't resulred from an inherited defect in oshimat
brain; rarher itwas broughr on by the circumsrances of his life. This
was a qype of depression that could strike anyone.
The newspapers followed each revelation of the case. There was,
for instance, the mystery of just how many overtime hours young
oshima worked during his time at Dentsu. According to the time
sheets he submitted to rhe company, his overtime ranged berween
twelve and rwenry hours each week. Lawyers for the company
pointed out that rhar level oFcommitmenr was hardly unusual in
hardworkingJapan, and it was cerrainly nor the sort of workload
that youd expecr would drive a healthy ancl ambitious young man
to hang himself in the bathroom. To prove that he had worked
much longer rhan he claimed, rhe lawyers for his parenm relied on
the records of the office night guards, who were required to make
frequenr checks of each foor of the building, noting the names of
the employees at their desks. Based on that evidence, it was crear
that oshima was clocking a much more problemaric auerage of
forry-sevel overrime hours per week.
Oshimat parenrs won their case. As the Denrsu lawyers appealed
the vqrdict ¡hqough thq gour¡s they cor-r1i¡rq-d.¡q algue
sh+t lhe
company should not be held liabte because oshimat depression

q€'

f-re
 *--lá
1ül
2)8 I

was a result of a preexisting

CRAZY LIi(E

mental weakness. They

US
.+
arguing for
a pre_D SM_ilI version were,
in effect, *
of .rdog.á,r, d.pr.rrio.r,
.?.',lilil,"#ff*:;:l"o,"' 'i'k t'"a n"'o't',"a ]rL ¡*.- .ro.r. *
The diflGrent rulings o[ *
rhe higher courrs,
. rather neatly *:.j.: Kitanak
,., ,n.'Oro..ss
mind' The Tokyo High:JI"* of cnangi,r* ,;::.J*,.T;r;
court firsrreduced the
*
pensation, concluding *orrr-, of the com_
Ieasc
drar oshirna,s inborn
was ar
*
pam of rhe cause in
his dearh. ..Nor everyor. "r.;;;:;;;ina
,.."_., depressed
from being ovelwolked o,
U.irrfirl *
read. "Jt cannor be
rrrorfrl siruarion,,, the verdict
denied ,¡r* rri. . . .
in increasing the amount ¿,
earlier nodons ptominenr
orhis o*., *llll;:: ff:,."#:Ti::::i
inJapanese
psychiatry: .lr"a irrbo.., *
were patho_
::ii*:Hisrics '¡" o'r'¡*"ic equivalen, orar-* rn. s,,p- *
§ecred rhat lower. court,s ruling
thatindividrr.rr.r." and argued
-*i., ",,o.-i"f .*f um-- *
sho urdnot be .;::il:::;,T lffi
anyong, put under
T :j' The ruling
enough srress, .orr,1tt'
suggested thar Hk
, Tr*L partry to rhe d.brre
the shifr in pubric
o":.;;,Ir',r'r'.Io* i!Hil;.*".r.
opinion durirrg.hi.;oiod
áro
courdnt have been
#;Hy::
people n.,t há,¿ more
the ririgation, they
Frta
a'ecausedby,he.T#::::,]ff
"to,,,
*II,J:;L,.#1:i*ix:
woutd
J¿
;IiilHff'
cotnmenting "\f{henJapanese
many came ro hear,
hea¡d in the rnedia
probably for the n.r.
oF
J;:
thar suicide .orld [S .i.rr.,
;;,:',',':r#il.Í,:H: .#j l.ffi,,ffi %1
rha r osh i m,.

;:ffi:t::: H: :Y::::i' : : * i "a ro. . v",..,.,'..'.1 .",.,-

:
ac,s re earrv,
a n

ing the Japang¡e

{i:::::
depression' Indeecr
fi,, i'.'J,T liffi:,"x
thr'v.rt..., éto;;r"facturers :,
m*keq in -,n*
:#
,rro.'r"urinely invoked
**:
who were eye-
*z
the high. .

#
*

+
 T/te fuIega-klarkering o1f Depression in Japan )ro
suicide rare as proof posirive of an
epidemic of depression in
Yer the Japanese pubric ,..rr"i.r.d Japan.
sprit as ,;-J;.; suicide
was an intentional act wirh
moral or philosophical meaning
a desperate acr of a menrally or
ill person. In many ways the public
debare regarding why oshima
tr".rg.a tri-serf picked up rhe
dialogue that took prace armost, pubric
hrnd..d years before, when Misao
Fujimura jumped offthe waterfar.
Although manyJapanese agreed
that the high rate of suicide
was a legidmare public hearth
there was nor yer a consensus concern,
that the epidemic, or t'e act
itselfi' was the result of mentar ofsuicide
irness. I., ¡"p"rr.r. history,
and movies there were many rirerarure,
srories of the noble suicide,
when Samu¡ai war . such as
die¡skirred*.*J:i,:ffi;:::i:::_:?,;;i,y,:Jli"yil;::
moro was not arone when he
remarked in lgg' rhat he
much of a connecrion berween didnt see
the rise
Most of the reasons "r.",.á.'"loiffirr.r.
Jrp*.re people kill themselves have nothing
t3 do.with depression,
¡. "rS,r.a.'.A peculiar iry ofrheJapanese is
thar they often die for the r"k. of th. g.o,rp,,, he said. .,They
shame." \Wararu Tsururni,s die for
Cr*plrrc ñonual ofSuicicle,published
I 993, was the modern in
embodiment of the
Japanese public,s intense
interest in suicide. The book,
written in flat, unemorional rones,
is a guide to the ten mosr
popular merhods of suicide, including
hanging, drowning, .1..*oi.r.ion,
and irr..,pirrg flom heights.
author awards a number of skurs The
.o ."rá each method in categories
such as painfulness, how much
a nuisance you,ll cause others,
much efforr is required, and how
rhe rikelihood of success.*
The remark-
*Tlre insrructions
are piven in grear crerail.
For potenriar jumpers, for
rhe book r..o*,...,dr"rrr"r"*íii*Iffi; exampre,
to help rhe reader 6nd the il"li;", projecr and provides a map
train recommends preciselj
ofr... ft.Ii"fr.il, .n."*rng oneself in front of a
where ro
";;?;;;. plif"; ,"r;;,;:;or.",
ivc¡tk.'To'¿oinu*:.r,¿"e,-or.,,i..ioii¡,
ffi;-#,tr':.:;T,,..f"
-,,,I,
.i. ., *l;;-
o,,.t ..n..,á., ;.:::::::t:T j:Tft6,,"*, ",
th e rheory .h..,..r., g
 22A CRAZY LIK-E US

able sales of the O:"U:0.*_ro a uniquelyJapanese

ing the I990s the book rold fascination. Dur_
_o.. tÉ
berieie trre author, the book
from a deeplyphilosophical
*", *rT.l"';:?:.Tffi'"ff..;il
b.lieFth^;..,,.,.^,,,i. :": ;:::."
p"rG.try...r..ir., of personal *ir. t suicide is a legitimate-and
The story ofyoung oshima
and several other prominent
from overwork put faces suicides
and O.rrorr., srories
concern thatJapan had on the growing public
ignored the rr hearth
overrn ork. As was conseque.ces of
true at the turn oraor.ra.t
the ninetee¡th cenrury,
of the *.rrri.rr, .";:^:.:^'"":1:t the end
o r rap an., h
"* ;;TIffiX.:T:,:.:: ff jffi ?:,*:j*
unemproymenr were on the rise.
Jusr as at the end of the
a hundred years before, Edo era
th. publil;;, t'e hunr
disrress being felr during to explain the
.t
"r. *rr..rrlir,"r,
.i.rr...
*.HJ:i;'lTLi:?I'j:o'::" "¡ ir,". .r,. co un rrv was beh i n d
.

,a,ingearihquakelTif
ernmenr respon§e to the
.T**T:i':,:r:::#i#JH".rH-
disaster was criticized
health experrs for being by \Tesrern menral
l*f.lrr,., rnarly fronts. Researchers
from the United Srates
rvere soon on "1,
th

ff Ifl ::r.?bysuggesti'gthat,h.;'";';r::;:t"-.H:,H:.:
ur more attenriorr paid
mencal
to their emotional and
'ealth.
severar promi,en't.Jrpan.s. psychiauists and mentar
adyocates used the *.rthoriry heardr
of .ir.'rriri
.

to make a broad aT:rnenr

ing about emotionally
t'atJapane.:'f,.TJ;ll:Il"f:;
loaded *r"J..::n
vorabte ro Japan, was
orten made ."
emphasis on psychorogical
.ni'#[Tl,lrl,,tJi]l;if.
issues r,
o".lrr, berier¡ed to be currur_
"As discussed in chaoter
uo*'¡."iri. n;;;ffiSillldisastelalso plaved a kev rote in the internationa.r

-
 The Mega-Marketing of Depression in
Japan 221

ally strong and given proper prioriry,, the anthropologist Joshua

' Breslau reporred.'"one
well-known newspaper critic noted that his
friend told him how nearly everyone in U.S. cities
has a psychologi_
cal counselor."
A critical turning point came just three monrhs afte. the Kobe
quake' A Tv producer named Kenichiro Tákiguchi
was browsing
through the English-language secrion of a Tokyo
bookstore and
lla1ted to flip through a paperback copy of peter Kramert Ame¡i_
can best seller Listening to prozar. AJways on
rhe lookout for good
ideas for programs, he took the book to his
bosse. ., ¡rp..rt-iargesr
television network and persuaded them to let
him prod,r.. a frft¡-
minure special. The message of the special was
simiLar to the beliefs
made popular after the Kobe earrhquake,
namel¡ thar. Americans
were far advanced in their recognition and
rrearment of emotionar
disorders such as depression and anxiery. The
show hit a nerve. Mil-
lions watched and more tha, rwo thousand
viewers calred in after-
ward to praise the nerwork for running the prograrn.
Japanese psychiatrists were rargery taken by surprise at this
turn
in public inrerest. Up to that point the public had.
eschewed the
intrusion of psychiatry into dairy life. As the
srna, population of
psychiatrists had mostly limited their practice
to the severery men-
tally ill, the call to address common ,r.rh.ppin.rs
and anxieq, thar
came with bad economic times caught
them off_guard. Like rnany
people in the counrry up ro that point, they
had nor considered
unhappiness (or divorce or suicid"e) a mentar
hearth issue. Theywere
in need of a new and compelling explanation for
wh.r war.goi.rg
on. Forrunately for them, GlaxoSmithKline
and several other major
psychopharmaceutical companies were jusr
then preparing to throw
them a lifeline.

i
 'r)1
CRAZY LIKE
ryrt
US
*
,,,, . Iunk scie¡rce and First World ,*
,. Medicine
i *
{lffjffi#::o^T*, a proressor ar rhe
universiry of \üzisconsin
in *
;::I;nf:::: ft :x*: **
;** x # ::,,,ffi
tr :# ::ff H1;1#
;:,:m::' u*H
l
f"',;:*;i' **: *
+
*

;1I,i[,;1.1':']':i":;H;"i.,:;i:;:T:]i"Tili:i
ttttt' in the Asian ma,rkets. *
Iate I990s .nrr *n. iJi.r.a i., .¡r.
*
il:tri:T:;1i1iT$:i"'*j,x**i[f .ff;i:
the o.*,*",*'jl,lj:H ;,r, *
of-.At
h is
*ro,.r.*rTHl*#.fl
way to ri. i. .h.,,
lff *
Pfizer, the rnaiol
inr"rn*ionrio-";, who
of trying ro ger rheir
;ñ,,
were ar varior
;:.
drugs *
' Littv were praving carcrr-up rhe rime o".n oii.rr'ilT
'"r"ffi.^ot
." til:TithKlir,., .J*
in ;ffi *. ;,.,r,
;1'Ji:il.#iaxil 'r" '",,I¡llrthough he had ro sign non-
*
;*:{:,,r:i:l:._Hil::.j.#11::** j::*; c/*
erar orhis a,*Jrul.,ffi::,§fls,were"E**. ."*o.",1.,. s.,,_
firms helped make
L",, ,-.]]--_':".*'o then working in
these
ul^
ri*, p.o*d ;;;; á*;ffil*'::;;tolTj i i1. ;T1';: i'....,. ero
wley they were so
forrhcoming, he
his business schoor
.*r._.,1r"^'
,
:rH
told me it was simple:
::': -L3
-* his
credentials and
Apprbr.r-
because of *fa
Japanese market, ,n
rree advice.
,eythousht,,Jil;rT:.ilffi;:,il;,:*:
<

sf*
u[a
*k
Applbaum
disco,
,rn*.,üü;",.:"::T j5::,ffi
:::,1::ilil_:tH_. j;
*&
d¡
d-e
I
Tbe Mega-Marketing of Depr€ttion in 223
:
Japan

Pepsi for marker share-or ar leasr nor ar the beginning. Instead he

found wide acknowledgment within the ranks of drug company
executives that the best way for companies to create a market was
for competing companies to join forces.
A critical player in this joini effiorr was dre trade organization
Pharmaceutical Manufacrurers of America, or phRMA, which
functions as the national and internarionar robby and public rela-
tions organizarion for a goalition of major drug companies. In the
late 1990s Applbaum found phRMAworking on a'number of lev-
els in Japan to influence what they considered to be a bacl¡vard
and bureaucraric drug approval process. As one phRMA execll_
tive based in Chiyoda-Ku, Tokyo, told Applbaum, rheir job was to
create "a market based upon competitive, customer choice and a
transparenr pricing srructure that supports innovation.,, The lobby
wanted drugs such as Paxil to be able ro enrer new markers based on
"global, objective, scientific srandards."
The more Applbaum talked ro drug company insiders, the
more righteous frustration he found. §7hen he visited the ofñces
of a leading ssRI manufacturer in November 200 I, he discovered
a wellspring of anger direcred at what they perceived as
Japanese
resistance to pharmaceutical progress. These executives criticized
scientific standards for clinical testing in Japan as ..quire poor,, and
asserted that there was no "good clinical practice" in the counrry.
\XZhy, they asked Applbaum rhetoricall¡ should their company be
forced to reresr these drugs in exclusivelyJapanese popurations? The
assumption was that the science behind the American human tri-
als was unassailable-certainly better than anything the
Japanese
would arrempr.
No doubt that annoyance ar having to rerest drugs was so
intense because a couple of recent l¿rge-scale human trials of ssRls
in,Japan hadfaited to show any positive effecrs. Dr-ugs,such as pfiz-
er's Zoloft, which were widely prescribed in the unired states, had
 224 I cRazy LrKE us r#
r+
il,I;Tj:i:;,il.,.:ale
pany execu.i,.,,.¡rl5
human triar fairure in

ffi;il1:-,:,*:t
Japan in the 1eeos.
.;"i":;; ;;; .,*-
+
second rare. ..There . *
sense of
e complained to"".".|tJílr;;.#i-.:::T
Jrpan,,, on execu ri* :"'o *
Applbaum.
-L
The Mega_Marketing *
of Depression
Although drug company *
*+
execurives cl,
ro avoid,h. ."*p.n.L.
their ssRls in
il ;;;ff;i_ ;:j:.lT[:*.;
Japan' they urtirna*ir'Ár", a way ro pur those tri-
als ro good use as
th. fi.rt
drug makers orten
bo ugh.
of recruidng test subjei,
severar sav'y merhods
ür;.;
.",,;; ;,
ü:*ffi .:ff lfJ_*:
oooi'"""*i.rr.r.., that
this was one of
*k
"J"
*
&
rhe ar"* ."*üies
employea ." na*r.p
:iJ".:fjl fl:' H:r" ;il;i!'i,.".,,o,i
&
.': " o n dr uss d i rec dy

;: ffi il :iY:
;T :*;: il :J ;irfl::;irtiT*' XÍ
ofthe drug and p,o*o*a.i.I."
depression ,, . .o*Io,name or *
public atrenrion
in the rials.
*n.llljl'*1":
one-¡ompanv scored
-_n rr recruited a well_known
even more
acrress to rake part *k
3,::*.r:,,"*the
Thlking
king
,,' rhey wirh
with
drug approved for market,
,h.r".*J.rriwe.
these executives,
-*l^'""' ,, r-^^- clear
io t'ecárrle
rt ,
wasonlyrhefirsrstep.
was only the first step. *k.
they were intent .. ;-^r^*
inrent on
rr..rrtt*et
complex
to
ro Applbaum thar
."1
that *l
I

!
i
i, ptan
pur ,. .rii..
plan ro, as he put,r, #*:::".""*,'
,r. .".i:"T:1,-:
drugs are or mav he ,r"o; ,, A-__ tt
-., **r;+0,il1" ,:"ii::r"-
o.
and murtifaceted
tfonrnent in which
these
*fo
*::n:._",,.
il: ;:::::,.'::
the :':1--
Japa,es. .o*rri.r.
;ffi
;#,1# :::lX-:=
consciousness of
*Ju
The major problem
GlaxoSmithKline
*J-u
far was rhat Japanese
*]-u
F*t

+
*ñ
 The Mega-Marheting of De?retsion inJapan )') <

psychiatrists and menral health professionals still rranslated the

diagnosis of "depression'as utsublró, and in the mind of manyJapa-
nese thar word re tained its association with an incurable and inborn
depression. of psychotic proporrions. In hopes of softening the
connorations of the word, the marketers hit upon a metaphor that
proved remarkably effective. Depression, they repeated in adverris-
ing and promorional material, was hokoro no kaze,rike "a cold of the
soul." Ir is nor clear who first came up with the phrase. It is possible
that it originaied from Kenichiro Takiguchit prime-time special
on depression- In that show, it was said thar Americans took anti-
depressanrs the way orher cultures took cold medicine.
§Tharever its origin, the line kokoro no hazeappealed ro the drug
marketers, as ir effectively shouldered three messages at the same
time- First, it implied that utsubyó was ncr rhe severe condition it
was once thought to be and therefore should carry no social srigma.
§Zho would rhink less of someone for having a cord? second, it sug-
gested thar the choice of taking a medication for depression should
be as simple and worry-free as buying a cough syrup or an antihis-
tamine. Third, the phrase communicated that, like common colds,
depression was ubiquitous. Everyone, afrer all, from time ro time
suffers from a cold.
Although advertising couldnt menrion particular d,rugs, com-
panies could run spors in the guise of public service announce_
ments encouraging people to seek professional help.for depression.
In these ads ssRI makers attempred to distance depression further
from the endogenous depression as it was understood by
Japanese
psychiatrists for most of rhe cenrury. one GlaxosmithKline relevi-
sion advertisemenr showed an arrracrive young woman standing in
a green field, asking, "How long has it been? How long has ir been
since you began ro worry rhar ir might be depression?,, The scene
then shows a úoma,'on an escalaro¡ and then a middre-aged office
 ü"+
-l
226

worker staring out a bus winrow.

CRAZY LiKE US
#
The voiceover the¡r recommends *
that ifyouve been feeling down
see a doctor.,'
for a month, ..do noi endure
it. Go
*+
The subtext of the ad is clear
-lt
+
to Kitanaka. It presents depression
as "intenrio'ally ambiguous
and ir-defined, appricabre
est possible popuration to the wid_
and to thewidest possibre
range of discom-
forts' ' ' ' The onry feature rhat
from an ordinary depressed
(one month) thrt th.
distinguishes depression
*ooa ,-""
as a
.disease,
*l*
p.rson has .;;.-rT.::
Depression was so broadly
T.::ifi::;:i::" er-,
d.fi.r.d by the rnarkerers that it
clearly encompassed crassic *
emorions and behaviors formerry
attributed to the meranchoric
personariry rype. The laber
sion then took on ,o_. l"rdrbl. of depres- é*
.hr."á:il:r,.ffi ;, being
eh
twh
highly sensitive to the werfare
and to discord within the
family or group' Being depressed "r".rr.r,
in this way became a testamenr
one's deeply ernpathic nature. ro
To get these m
*,k.,, .*proyed ;'""'*:11::r:[ J::lffi:i::::,
marketers quickry reproduced
j;;:il &
*nd *id.ry disseminated arricres
in newspapers and magazines
mentioning the rise of depression,
particularly if trrose pieces toured
panies also sponsored the
the benefirs of ssRls. The
transladon of
com_ "J*
*t"
first pubris¡,.a r, the united
antidepressanrs.
stares
", ffi,|;XÍlg3:I; *f*
Given all the ways that GlaxoSmithKline
makers managed to make
rhe
and the other SSRI
average¡"frr.r. awar-e of rheir
*r*
the of,cial b., on di¡ect_to_corrr,r"r.r"rt_rrketing
meaningless. If there was
drugs,
became almosr
.*f*
any doubt about this, one
only had to
look at how these companiqs
reach patienrs today is
based marketing manager
used rhe Inrerner. ..The
nor via ,d,r.rti.ing but the
besr way ro
§feb,, orr. f6,r.ro_
told Applb"aum. ..The §7eb basically
circumvents [direcr-to-coüsumer
J*
"Jo
J*
advertisingJ,rules,.so therb
is no
.,.
ela-
#
4=
 T/te lfega-Marhetirtg of Depression in
Jdltan ) )-/

need ro be concernecl over these- people

go ro rhe company website
and take a quiz ro see whether they might
h.r" d.p...rio.r. If y.r,
then they go to the docror and ask for
medication.,,
The mega-marketing campaign often came
in disguised forms,
such as patienr advocacy groups that
were actually.l..r.d by rhe
drug companies themselyes. The website uru_ner.com,
which
appeared to be a coalirion of depressed
patients and. rheir advo-
cares' was funded by GraxosmirhK.line,
although visirors ro the site
would have had no clue of the connecrion. §'har
drey would have
found was a series of articles on depression
driving home the key
points of the campaign, including the idea
that ir *", common
illness and that antidepressants bring the
braint naturar"chemistry
back into balance.
The public interest in the new diagnosis
brought a remarkabre
amounr of media arrention. Often in back_to_back
months, the
major magazines Toyo Keizai and Dacapa
ran pieces on d.epression
and rlre new drugs. ln 2OO2 a leadingJ"p"r,...
busíness *rgrri.r.
ran a ñ,venry-six-page cover srory encouraging
businessp.opl. ao
seek professional help for depression.
The articre rarher perfectry
mirrored the key points of the SSRI makers,
mega_mark .irrg."__
paign and in many ways reflected the .r.ry.or."ptions
of ,r".,.."r-
ihenia a cenrury before. The article suggestecr
that it was rhe more
talented and hard-charging workers who
were the most susceptible
to depression. Estimates of how many
Japanese secretly suffered
from depression, which ranged from
3 to 1i p....rt of ,ú
tion, seemed to increase every month. O"O"r"_
The distress caused by the long_ailing economy
also proved to
be a useful selling point. GlaxoSmithKlinepromored.
the idea thar
there was an enormous economic cosr
for untreated. d.epression,
which could be counted in lost man-hours
and decreas.ip.odr.-
tiviry. In'rhis way, the lure oF the d.ug, espe.ially
to .h. jlo,rrg..
generation, was tied to ideas about competition
in dre global mar_
 228 | CRAZY LrKE US
#
,
ketplace' one Japanese psychiatrist
per describing ssRls as 'urugs
was quoted in a rocar newspa-
that can r¡ansform minus thinking
into plus thinking,, and thar .tan
&
*

nrrrrr.i.tt¡r,r.**r"ro-.ricans.
hel p a per§on live tough," like
='k
The ssRI makers made much
'particular' Ir was rumored
of one pubric reladons windfa, in
"&
Fh
Imperial HousehordAgency) that
for years (and finary con,rmed

from depression' soon ir was reveared

pressanrs as parr of her rreatmenr.
by the
crown princess Masako suffered
that she was a"t irrg.rr,ia.-
&t"l"B
profile of depression and SSRIs
personal psychiarrist was none
This was a huge boorl fo. .h.
in the country. princess Masako,s
other than yutaka ono, one of
firl4: lelders t'at GraxosmithKline had rhe
feted at the r<y"," .""r..-
&
F-k
ence in 2OOl.
As a marketing line, there was
kokoro no haze: the metaphor
condition' After a,, one rarely
one problem with the phrase
lacked . ,";;;;r*.'"r'"i"*,
.n" "I*
#-e
§7o¡se ler, medicating a cold
away rather quickly on its own.
'Io counter rhis
rushes ro the doctor with a
was always optional, as the illness
cord.
goes *f*
aspect of the metapho¡ the
drug companies lev-
¿-
eraged the population'sgrowing.orr..r.,

J.
.{-
over the high suicide rates.
The medical anthroporogist Eliko
Namihira repo.ed that ssRI
makers were funding srudies
ro p'ove the Iink b**..,
and suicide. Those studies th"t.ho*.d e
depression
J-.
in pamphler form and reporte¿
ing news. Studies that failed
isnored. The founder of the
claimed in theJapan
r" r,",,",i1i1.#:J,::TrT:[1
ro show a cc
Mood o,r"I].r'Xll:,"":,jjff#;
d,
J*
thar ..90 percent of those who
suicide are consideredlimes
to suffer From one kind oFmentar
commir
d-*
#-
anorher' and70 percent of suicides irness or
are att¡ibutabre to depression.,,
\Tithout medical amention, the
message wenr, this ..cold. of
soul" could kill you. the
dl-
'rürhen taken togethe¡
the messáges'adváncecl by GlaxoSmith-
#
#
 T lt e fuI ega - A,Lt r L e t i ng of D
ep re s s i o n in ./ap a n )') q

Kline during their ro,out of paxir

don't arways make sense. previous
notions of endogenous depression
were employed only sparingly
order to evoke rhe se¡iousness in
of the disorder. on the oth.r
rhey were hrppy to associare hand,
this new concepdon.ofdepression
the Japanese'venerarion of with
the meranchori.
thar didn t particurarry.jibe f.rror"liqy, .rr.., tho,.gh
with the pararel message that this
illness caused by an imbarr.r.. was arl
ofr..itonin. Neither drd the message
that overwork courd spark
depression mesh with rhe idea
duals s^ould counter such social
that indivi-
disuess by taking a medication
changed their brain chemistry. rhat
If it was unrealistic social demands
thar were the cause of dist¡ess
in the popr-rlation, why shourd the
individual be raking the pills?
In the..ud, ho*.rr.r, the coherence
these various messages took of
second place to their effecdveness.

Speeding the Evolution

Afrer the Kobe earthquake in

Japan there was growing consensus in
the counrry that the §'est,
ih. united states in parricurar, had
"rrd
a deeper scienrific understanding
of parhorogicar emotionar srates
such as PTSD and depressiorr.
R.rpo.rding to rhis insecurity the
adverrisemen ts, websites,
waiting r""* Ur"]r.r*., ffi;.;
rials produced by rhe drrg.o-plnies **r._
played up the idea that SSRIs
represenred rhe cutting edge
of mecli."l ,.i.n.e. These drugs,
were said ro rebalance rhe natural which
chemicals in the brain, would
bringJapan up to date.
GlaxoSmithl(Iine worke d very
hard to win over rhe mosr promi_
nent rnedical researchers and
psychiatrists in the country and
them on message' Their inclusion keep
ar lavish conferences such
as the
one Kirmayer attended. was j
ust a taste of the incentives
o6?red. Drug
compahies offered granrs ro
sponsor research.óñ rheir diuss;
researchers wrro produced those
resurts favorabre to the drugs
founcr them_
 #
serves
230 CRAZY LII{E

with new offers ofresearcrr

U.S
#
tt
funding. Resea¡ch that
drug in question ro be both
safe
showed the *
an
companvandtheresearchers"n;i;,T*.:'":ffiT]ff
researchers were given
honoraria for speaking
Tj.T:::
drug company-sponsored about rheir at
p rofessio nar co
the prominent 'ndings
nferences. rnfr uence
over
scientist' researchers in
thatApprbaum co,cruded""d Japan was so pervasive *
: that these scientists
basica'v'tomrnandeered and docrors had been
into r.aa oFmarker..;;;;;rpharma_ *
ceuticar companies' "
, The research simurraneo.,rtr
r.*.r as pubri.iry
, for the essentially pr.a",.r_¡r.-JJo.rrlr*., *
need.,,
It importanr ro note rhat
is
rhe d ug comPany executives
te ar *
Appl baum ir...u
"*,.i ;";:l :r who m

i[Í i::. i:TTiTil*.:# *JÉ

o nry by
o," o,,'l'
acting with rhe best
drugs represenred the
wo rt d. rh er s
of intendons, morivated
proud ;;;;,
by rhe
ff :#:,1:i*
belief thar their t
*_
ryr d
; :1.*,.i;;;
ety, and social phobia_diseases ;:::,HT,Ífi
;;
.1r". ."_i,l:":Trt
.ffi: :::,"1 :
&
in Japan *nd erse-*'ere.
morar certainty and th.
was a potent force.
Appr b a",-il;r:::
lure orutrro.,. ofdorars
:1J H:'#::::':1
in potentiar prófits &
"These execurives
seemed ro berieve that *
wardly trying they are srfaighrfor-
to heal the world,, ,"ia
meeting them in 2000 appmaum. §7hen he was *á
i'
self-asse§smenrs' "They
tive and they *...
and 2001 he had no
seem.a a" u.rr.". rheir
reason to doubr these
producb were effec_
gim¡a .h.r.;;;;. should question
Fk
I fht pharmaceutical indusrr, their value. *
;;'r";;an
i its marketing activiries
ro *rrr-.i
other

sch.*. ir,"i"crives.
industries,
The resurr is
can link
a mar_
éa
*t*
riage of the profit-seeking
-nrri.h disease is
, opportuniry, ro th. .thiál regarded as .an
u"1,,..: ní,.
they are perForming
i.ri.
oi.* .t *
"".1 ll.
",
_o,r"*rlltl;r:::*tlmrul:
public service.,,
a
Borstering'their certainty
J*
was their'faith in dre,sciente tiehind. . ,

&
*

+
*
 The Mega-Marbeting of Depres;lon in Japan 23r

these drugs. The fact thar these SSRIs had proven clinically effec-
tive made it morally imperative that they be introdüced inro other
cultures. The drug companies were replacing what one executive
referred to as "junk science" in Japan wirh "first world medicine."
During his talLs wirh the execurives, consultants, and market-
ers for the drug companies, Applbaum heard a repeated theme. I l
These ¡nen and women kepr talking about differenr cultures as',
if they were at different srages of a-predetermined evolution. The ',
American market, with its the brand recognition, high rares of pre-
scriptions (by specialism and nonspecialists alike), and free market
pricing, was seen as the most modern and advanced of markets.
Japan was fifteen years behind the United Smtes, executives would
say. Or China was five years behindJapan. The lucrative IJ.S. mar-
ket, Applbaum could see, was the standard against which all others,
were measured. §7e were the most "evolved," culture *.rd, as one,
executive said to Applbaum, their job was [o "speed the evoludon
along," that is, to.move other countries along the path to be like us.
This talk of evolutionary process wasnt idle chatter, for it was ,

often the same executives and marketing specialists who went from
country to country wairing for the right momenr ro make their
push. "Pharmaceutical manufacturers . . . circulate internal instruc-
tional materials regarding experiences with the same producr in
what they consider similar markets," Applbaum said. "Managers fly
about the world to training conferences where such archerypes are
hardened. And old adverrisements and communications srracegies
from the earlier stage of more 'advanced' markets are imporr.ed."
§7ith each new implementation of the mega-marketing campaign,
these drug companies learned new maneuvers and strategies. They
got better at helping along rhe evolution.
The reasons these executives were so open about this endeavor
goes back.to,their shared l¡elief that the. evolution. in quesrion v¿as
toward higher qualiry science. §(/esterners may have lost their sense
 #
)7) CRA7,Y LIKE T]S #
" of_moral authority in many
areas of human endeavor, l¡ut
still ger our brood up defencring
our icien;.. ilIJriJ*"ro
we carl
da
scienti'c discovery and medical ," *
the citizens of Japan and other
b¡eakthroughs, so *t rt o,larrt
r
counr¡ies around the worrd &
access to the newest brand-name
wefe cfeated using trre latest
andd.epressantsl
advances in science and
have
rhese morecules
&
They had been reviewed by technorogy.
the reacring researchers at trre
worrd,s +a
mosr famous universities and
found effective ih studies
in the mosr prestigious scientific journals. frurrrrr.o
&
&
The lat.st antidepres-
t...ar, in this moral logic, were
I akin to antiretrovirals, polio vaccine,
j ':o penicillin' Everyo,e in the worrd deserved access
to the fruits
/ of our scientific discoveries as a human right. F*,
éa
is not an argument without

+
.ft merit, but it depends rather criti_
cally on rhe accuracy and varidity
of the science behind the medi-
cal adyance being touted. IF
the science is overblown, skewed,

#
downrighr wrong, then the or
moral ...,rirrry that fuels the charge
into other cultures becomes suspect.

Blinding Them with Science

#
*#
of all the luxuries providecr him during
Kyoto conference in 2001, Kirmayer
particular rerish' on the second
that Glaxo-spo'sorerl
remembers one evening with
#
*fl l

night of the conference he was

insrrucred ro dress in a .tmart
,uir,, lnd was raken to the
Tsuruya
restaurant' one of the most
exclusive and expensive restaurants
Japan.At the restaurant he was shown
the guest book, where Henry
in "+1
-H-*
Kissinger and orher worrd leaders
ing dinner a per-sonal geisha
had reft their compriments.
Dur- u4
his tea,,d,,k..
sat at his ¿
d; :;ü ; ;"il'.il; xlT?;".i,§:il;
woman in his limired
w4
Japanese, he turned to
bring up a.question that had.been James B"ll.-ng.. to
on his mirid-
, *
g#

ff
 The Mega-Marketing of Depressiott in ?11
Japart

Ballenger was rhe head of the International

Consensus Group
on Depression. For three years he and a group of
other academic
researchers hosted seven meetings at various
luxury resorts and.
hotels around the world. Ar these conferences,
funded by Glaxo_
SmidrKline, Balle^ger gathered prominent scholars
..r..r.h_
ers to consider the best rreatments for ".rd
panic disorder, and
generalized anxiery disorder. In the end'TSD,
these supporedly indepen_
dent scholars, with their affiliations to some of
the world,s finest
universities, recommended that SSRIs be prescribed
for alr of these
conditions. Tellingly, the only SSRI mentioned
by name in the ,,

Consensus Groupt summation pap€rwas

paroxetine, aka paxil.
Kirmayer was curious about the relationship berween
the drug
companies and academics rike Baflenger who
published rhe papers
recommending these drugs. §Tanting to be polite,
he thanked Bal_
lenger for the remarkable
and trearment he was
receiving. Kirmayer was, of"..o**oá-arions
course, in no posirion to take the moral
high road, as he was at that very momenr enjoying
the splendor and
luxury for which GlaxoSmirhKline was piicking
up th. rab. Never_
theless he felt compelled to ask Brl.ngel
as nicery as he courd: Isn,t
this something of a conflict of interesJ
Although he can't remember whar Ballenger
said word for word,
he remembers the gisr.* ..He told ¡ne, .Look,
IVe made my peace
with this a long time ago. The drug cornpanies
are going to do this
anyway-rhey are going to market drugs and
produce guidelines, i

so they can either do ir wirh input of

good people *ho knowl_
.

edgeable and scientifically sophisri.rt"d "r.

and evenhanded or nor,,,,
Kirmayer remembers. !

"In their heart of hearts," Kirmayer said, "I

think academics who
have consulted with drug companies
think that they are doing good
and that they deserve rhe consulting fees
and perks.,, I^ .ho=r-t, .ro
r-É -ar-"* * nor rerurn phone calls requesring r., ,.ra.r.,rr.*
fo..frr, UooL
-4e
r.-
r-E@
 ePi
#
e+"t
The Mega-Marheting of Depression
in Japau 235

r*h
#
enough; as in a conversarion, one
person might do all the talking
and rhe other person does not
ger ro commenr? leading to a com-
municarion imbalance.,,

r+"n
--t
Here's how GlaxosmirhKrine
sire adverrising paxil CR: ,.ñorm
describes the same idea on irc web-
ally, achemical
€*F in your brain' ca'ed seroronin, ^.*r"rrrrr_r.r.,
helps send messages from one brain
-t
fF cell ro anorher' This is how the ..11,

#
i.r your brain communicate.
Serotonin works to keep rhe messages
moving smoothly. How_
ever, if serotonin lev.els become
.rrb"]".r..d, á.rr,r.rr.;.1;, _r,

#
eh
become disrupred and lead to
depression. . . . paxil CR helps main_
tain a balance ofseroronin levels.,,
As ofren repeated as this story is,
ir turns our thar there is cur-

rh
--l
rendy no scientific consensu§ that
deficiency or that sSRIs resrore the
depression is rinked ro serotonin
brain's normar .,balance,, of this
neurorransmitter- The idea thar depression
is due ro deficits ofsero_
Éá
_i tonin was first proposed by George
Ashcroft in rhe r950s, when
EF he thought he derected ro* level.
in the brains of suicide victims

ryl and in the spinal fluid of depressed

parients. I.ater studies, however,
performed wirh more sensirive .quiprrr..,,

rc no lower levels of serotonin in these ""d

*J;;;r, ,i"*"0
fopuradons. By 1970 Ashcroftl
had publicly given up on the serotonin-depression

Cá 'ro date, no lower

revels of seroronin or "inbalance,,
connecrions.
of the neu-
qti rotransmirter have been demonsrrated
American Psychiatric prcss Textbooh
of
in depressed patients. The
Ct¡n¡rnl t ryrlrr*ry srares ,
simpl¡ 'Addirional experience ¡as not ".or,fi.n..d
er4 [of which seroronin is a sulrgroupl deplerion
,ú *oir*;r,.
t,rp"rf,.r,..;""4
er4 .b ut
SSRIs dont bring a patie.t,s brain
chemistry back into balance,
i

{F rather broadly alter brain chem istry.

somerimes help a depressed parienr,
Al rh";;;;;; ;;;;
the iclea rlar ssR,s ,.Lr. .
*",
f_- narural balance of serotonin is
a theory wirhout evidence. put
another wa;4 this idea is.more of
ffi a culturally shared.srory than a

fÉ
ffi
 236
,n. exac
I CRAZY LIKI]

same way neurasthenia,s

US

inyocarion
tffi
tt
ffi:T.*:,,,: of

.;Y,T'#:iIT#l: popurar was rhat it turned our to be an *

Europe..,a,n..,il,so,j;,f
public scandal ,b:_": the
1:TÍrr.*::*:yJ,.[.rr.::ffi i *
overprer..iUlrrg of U enzodiazepiHes. *
including Valium These-
1r**., I-rOrr,rrr:
the medical .,rlumn*.r."rra
addicdve. As SSRIs
;;i ;;;,;::: #:,ilí r:ffi'il *
carne ro
v{ary of psychopharmacological
*.i."ri.public*", ,rd.*tandably *
agents. The story rLr.
helped balance natural
.h.Iri."kl,, .i..Ur.r.r, therefore, iinr, *
what the pubric needed
"rf,
was just
to hear. nt, *"rn.ting
simila¡ way in
J.p*1, where many.o*ia.r.d
line was usefur in a *
medicines to be harsh §Testern psychiatric
,rrrr*,,rrd. *
In the end, to judge".rd
- ,fr. .,r"t,r. lf a drug, its benefim
considercd in light
of its risks. Ur¿r,; must be *
.ffiil*,'?"o'"""*,"'"0''.ll,l":Y;:lif ::i:l"i::; FK
;: #-:* ñTHT, I:5'ü:
r Iffi ;;*Ti'l'F,,,il'
#
#
pharmace".,*0,,[l':".rT:::fifi
:t?;.f I*:J;,:.:: jj
t¡ol":ff
over rhe creation and
ek
#
presentation of the
purport to show that sciendfic data rhar
these drugs are safe
and effecdye.
.
#
harder .lr0",.,ne
_.):il:i }1f;-n, process by which phar_

drugs than ñ;ffi::i,'fi:;Xledge piperin. b.hind th"ir

o.f n r. gi.a r il ;; ;.' ; *4
1.1,
of cardiff' Healy's
h o ro
il : ;,#,::.::,Y: i'"?#l;

+
particular crusade r,
,i". against ssRls or rhe use k4
:l##-"T:;T:Hi:,:..,*:iñiounbiasedaccourft ing
to"--
Because G raxosmi
th *,;J;:;:::::: ::;rlT:
"l:,r,l]" debare over rlre
middrc grou,d ,,,.r
risks and benefits oF.s.SR
, *.rr,h are,rcw peopre irr rrre
Ge
"r.r.i, 'ornrat io¡r designcd

"+
tr
"......1i,;llll:-,]1"11 to apl)eár

efl4€t
-.-
 The ktega-fuIarketing of De¡tression in
Japan 237

have control over the crearion of rhe science,

Healy argues, .,rhere
is almost no.possibiliry of discrepant data
emerging to trigger a
thought that might be unwelcome ro the marketi.rg
d1p.r.*-.r* of
a pharmaceurical compan¡,,
This skewing and shaping of rhe data becomes
more confound_
ing as the information gers rransmitted across
cultures and ran-
guages by rhe marketers intent on selling
the medication.
According ro llealy, drug companies first s-rarted
ghosrwriting
scientific p"p.rr for universiry researchers in
rhe 1950"s. ur.u-rn."
it was seen as a marginally disreputable practice, and
these papers
usually appeared only in obscure journals with
litde pr.rrig. o,
influence' But by rhe r970s the drug companies
had taken contror
of funding the major randomized control studies,
and by the mid_
1990s, Healy esrimares, over half of the
studies in the
gious journals were being drafted not by the -o.t p..rti-
universi.y r.r.ri.h.r,
supposedly heading the studies but by medical
writing companies
paid by the drug companies.
Once this became an accepred pracrice, the
drug companies
found that they nor only had control over what
information made
it into print but they arso had remarkable power
over which univer-
sity researchers rose to become stars in their field. "In
effect,,, writes
Nassir Ghaemi, director of the Mood Disorders
and psychophar_
macology Programs at Tufts Medical Cenrer, .,ghosr
*,.rhor.hip i,
the steroid problem of acad.emia; some ofour
experrs get their fame

evenhanded that is' in fact, secretly produced

by rhe drug companies or rhe
mosr exfrerne crirics. For,insrance, l¡orh the
drug companiel ancl écientologisrs
(who believe psychiatric drugs are
basically poiro',r) ,porr.o, *.bJ;;;;;;;;p...
to the reader to be creáred ñy patient ,dío.",.,
o. impartial experrs in menrar
heahh. Although rhe SSRI malers_have activelytried
.o por,rry H..ty r. . ,rrr.,
gf radical opinions, the facts of Healy's p.or..rion"t
lif. ro. .i..rrr.l,,.r.
Not onlywas he rhe former r....t.ry of tle British "p."ú
Associition
micology and a lrofessor in psychoiogi.rr rr*ar.i". "ip.yJ"pn*-
ar Cardiffunivérsiry, but
in his medical practice he continues to-use antidepressants
r with patients who he
believes can benefit from the drugs.
 240 €G
I CRAZY LIKE US
#
l,'ffiirlJ;; i§T *T.j;:
1ffi Hrffi j::5.::T €-A
effective for major depression in
\Mithin a month adorescenrs.,,
,
,

#*
oi th. OrUir...an of the stud¡
sales reps were al¡rted
.o á. ,ooJ-rr.*r. A
the company
#t
2OOl from paxil product
selling paxil"
memo dated August
tvtr.ri'g;.nt to .hll sales representatives
trumpeted ..this .Iurting
having "demonstrared edge,, f".r¿*.Juudy,,
fr*
treatment of adolescent
n*¡nran*ua, Efficacy and
safety in rhe
as
ÉÍ?^
.
Internal compaxy docurnents
depression.,,
fla
H: :::,f
that have come ro light
investigations repom
i,r"::.:"*ent
through
remarkabty diffe_ €a
a¡r.d,"li";*;:Ti;H::::-r-.il..***y*Í,i* FA
on any of the eight measures
the ,trdy h"d ser our
memo reported that the .o .rr.. o ].rmpany
results'ad
p.or., "ir..rfficientry
I recommended that rhe cornpan/:.ñ..t".ry robust,, and
narion of these da." in manage the dissemi-
/ order ro *rrr_o.ttll:::.*:,*.
potential
o

f impacr." The rnemo ..It ^n' commercial

wenr on: wciuld o"
to incrudesrarernenr that effi cary
a
would undermine the
r.J,jffIffj]:*:x, l1i:
profile paxil).,
:

Needress ro sa). trris "Up".*n"e (aka

in-hous.
staff stands in remarkabl. "rr-.r.*..rr by GlaxosmithKline
.orrr*t
rhat Paxil ..well ," .n. published conclusion
was rolerared;;:;, tu' maj or depression in
", ;;;"';.::.il:^'iTtl"'.
adolesce, ts. "r

:fr*: ,.f:T:il*'#:i:,,1":,li:=Iin."';::l
side effe*s r,".i".,
more trra' five times
ü'n'J,J,1l*:
more Iikery in the teens
;:ffiX._m:*
those taking theptacebo. raking paxil than in
tr, *ddí,io;:.".J^TT:j,Tl,
ing problerir *,,r, ,il"".., ,::,-:::-"' severeand often incapacitat-
. "
a,,no,.",,*.i',i.',iffi iJ::T;:T*::X';.T:::::T
submitted for p*bri..tion theié'wai nó
meniion of any seriorr,- - .
 T/te -üIega-Ltarketing
of Depressiott in
Japan | 241
adverse side effects' In a subsequent version thefe
suggesring rhat .,w_orsening wa§ a senfence
depression, emorional labiliq¡,
ache, and hosrilir¡r
*... p-orriül. rJ.-.n.ts. Even rhat head_
edgment was lefr our acknowl_
ofrhr final pubrished version
reporrs the side effects of rhe paper rhat
as ..h".d".h..,,
only o.r.
So here is an exar
Smi,,r Krine il
that rhe study data thar
:ij'.::::[;:]iX::::ffi :.ff:* ::T
.r,,*.a .¡r. f*rr". showed rhat the effecr

;::::*::;; *,, "i.,,, m.,."ir," 0,,,;^I;

j,".0:.." n i n reens
o

hospitarizat,";;;',Tü*:H::T::f.,*ffi':.*::::::
At rhe other end of the
.";;;. markedng claim that rhe
pipeline
study "demons rrared n¡Man¡rau
aa im.".y and Safery.,l
and the 0,"0,; that it
,,"*.r:1.í;T:;,"0, highrights, is nor
tanctrournat"f M;d:;:;:;,i:.;3:fi ,.1^:;:.::::"*:^*;r¡
rhle,druqs
,;;i?;,,nc
,§::::^tl^:In
issimpr¡rnoi""r..;;,;;;?.ffi
that is published,
::ffi .T:T;.rJ,".:::, j
starus is broken. r.rt ,

"1.." ...1, on the ;udg*..,. of rrusred physicians

or aurhorirative medical
guidelinesj, ,h?*.or. in
Yorh Reuiew of Boohs. 2AA9 in theNew
The p.obl.m; ;;;"r.*riting
to researchers f¡om the and payments
drug comp".ri." f,rrr., she
most florid form in th.6.lJofR"r.frr"r.f said, reached their
The science behind ssRls
.rd rhe srudies ofSSRls.x

has proven to be suspect ',.j."

¡r.níi"rr sare in orher curtures
ar besr.

,I,fff]ln!ffi.ilt.,,: against Angetrr charses,

Association,
Dr. Nada stotland, presi-
unnair ro suggesr
,nr.,.,lll'i-'^'ic
*pii.á - *tJi'. *,rilillr, "u *
;ü;:#íJ.:1üff ;:#il:::trriüties
,

rhac w"e..
':r yl_-, "".,"irr',,",,.. i

jF*il.:':J,ltl*f ,*ltri::1*T#iür*:.1,1,';:'ii'T:fl r;1'l I

rhar ensures ,hr, ,hoL-in .;]|:rorron is she rbrying on

the majoriry cannor
* ,t
 242 CI\AZY IKE
T, US

Suicides and SSRIs

The quesdon o.wfrether these

drugs can, in some patienrs,
thoughrs oFsuicide has become increase
, Jorrt..rtious public debate. Given
thar GlaxosmidrKline was leveragi,g
the suicide-depression con-
necrion to sell paxil in
Japan, tlri, ql.rrlon becomes even
salienr' Healy esrimares thar more
ssRI trirlr, *h.r taken togethe¡
that about one in s'ow
these drugs ;;;:ffT":il:n" m::'il;kffi:fl :;
will sparksuicidal thoughrs oÁehavior.
frre likelihood is that trrese
drugs are ineffective irr most
parients, work well for a small
age ofpatients, and spark percenr_
suicidal thoughts or behaviors
small segment' Th'o welr-design.d in another
r.,rái., conducred fift.., y.r..
apart both point to this conclusion.
In 1993 three researchers from
the Departmenr of psychiatry
at Flaivard concluded that antide-
pressanrs' incruding trre ssfu prozac,
rikery
' ofsuicide in some parients while raising it in ressenedl.These trre chances
orhers. obser-
vations suggesr that anticrepressanrs
Lay redi.tribute the risk,
attenuaring risk in some patienrs
who respond wer, whire possibry
enhancing risk in others who
respond more poorly.,,
Fully fifteen years Ir,..
set of researchers, these fro¡n
the college of physicia,s "roÁer
and surgeons of columbia
came ro a sirnirar bur more rJniversit¡
refined concrusion- Thi. ,tudf
closely at rwo years' worrh rooked
of parient data and found that
t'ere was no significant difference in adults
berween the group trrar got
drug and the group that didn,c. the
In teenagers and children, how_
ever, those who took the
drug were significandy more
rhose who didnt ro a*empr likely than
suicide within four month,
started on the drug' Looking ,f... b.i.rg
at trre dara furthe¡ researc'ers
one group in whic' the found
drug had a prorective effect
against suicidal
behavior: adulr men.,The
redistriüution of trre risk;.i¡
this cásé,.
.
#
F'F" The Mega-Marketing of Depression in
Japan 243

=h to be away from adult males and toward teenagers and

t+* appearecl
children.
FF In the end it is possible that borh the critics of ssRls and. their

rF
--l

*+*
promorers mighr have legitimate points on rhe suicide question.
Tire agitation and aggression somerimes noted in association wirh
these drugs are mosr pronounced early in the rreatment, rhe very

#
#
period often focused on in clinical trials. In real-worlcl use such
negative reacrions ro rhe drug may lessen or disappear after this
early period. In addition, attentive doctors may quickly take a

tr
tr
patient off the drug, so rhat only patients who respond well (or at
least dont spiral into suicidal behavior) conrinue taking the drug.
Thus ir is possible that these drugs increase suicidaliry in test sub-
jects in slrort-term clinical trials, as critics have conren ded,, and

#
#
when judged over years, reduce suicide in the overall population.
Even if it proves to be rrue that ssRls reduce suicidaliry in large
populations, the drug companies and the researchers who helped
yet,

ffi them distorr or underreporr negative dara might still be culpa-

#
4
ble. Had those early rrearmenr risks been accurately reported in
the published research on these drugs, doctors would have had a
chance to change the way they monitored dreir patients and been

#
l¡etter prepared to spot a patient having a bad reaction. Because
suicidal behavior has been clemonsrrared even in healthy subjects
(those taking the drug with no symproms of depression), doctors
almost certainly would have second-guessed prescribing this medi-
"+*
ff
-l cation to those with only mild symptoms of depression.
The timing of who knew whar and when regarding the risks
f€
-l associated with Paxil is a crirical issue because
Japan was so late in
adopting the drug. §7as GlaxoSmirhKline hiding or downplaying
ffi
tr
side-effect risl¡s at the same rime itwas rolling out its mega-marketing
campaign in Japan? Internal company documenrs thar surfaced in
a recent lawsuir appear to aoswer that.quesrion.quite clearly.,Data
ffi originally submitted to the u.S- Food and Drug Administrarion

Éffi
fqe
 *
244 CRAZY LIKE TJ.S
*h
back in the late 1980s and early 1990s, but never
published, eppear *
to have been presented to intentionaily hide resurts
that test sub-
jects on the drug had an eightFold increase
in the risk of suicidal_ *
ity. "It looks like GlaxosmithKiine bamboozled the
FDA,,,senator Fl*
charles Grassley said in a speech on rhe flgor of the
he examined the evidence- "§7e cannot live
sena¡e aftei
in a'arion where drug
companies are less than ca'did, hide information
*+
and attempr to
mislead the FDA and rhe public.,, *

t
The extent to which the SSRI makers have manufactured
a¡d *
systematically controlled the crearion, flow,
and inrernarional dis-
tribution of the science is hard ro oversrare. Thke
a srep back and
Iook at the sysrem as a whole, and you can suddenly
see it in a *
different light, as a massive interconnected marketing
sysrem.
Applbaum, the anthropologistwho documented the
ofJapan, puts it this way:
ssRI invasion

Actors traditionally found outside the "distribution

cha'-
tul*
=l-
nel" of dre market are now incorporated into it as
ponents of exchanse. physicians, academic
active pro-
opinion 1."á.rr,
,-to
patient advocacy groups and other grass roots
nongovernrnental organizations, public health
movements, r"rf*
bodies, and
' .even ethics overseers, through
one means or another, have one vrl*
by one been enlisred as vehicles in the distribution
chain. . . .
In our pursuit of the near-utopian promise of perfect oln
health, we have, without realizing ir, given corporate
mar_ olo
*1 ,
keters free rein to take conrror of the true instruments
of our
freedom: objectiviry in science, ethics and fairness
in health
care, and the privilege to endow medicine
omy ro fulfill its oath to work for rhe benefit
with the auton_
of the sick.
oI ,
Even the patient, often now referred to as ...orru*.r,,
k{,
si
the h^
been enlisted in'tlre distri'o-ution chain. Iñ
maiketing directry to

*
ñúD
 The Mega_Marheting
of Depressiarz inJapan | 245

rhe consumer through

the Internet and various other
avenues, drug
companies'can craim ro be trearing parienr§
as informed consum-
ers' Such informed consumers
.".r-u. enlisted ro pedrion rheir
docro-rs and drug review
boards for access to the drugs.
been heralded as a positive This has
change: no longer is the padenr.a
sive recipient of thedocror's pas_
privireged knowl"dg". üfo.r,r.r"..r¡
t'e patienrs, particurarry rhose rivin!
outside ,re unired Srares, are
often the last ro know rhar the
k.roll.dg. rhey are acquiring may
have been'manipulated ro
creare specific beriefs and desires.

Early Adopters Have Second

Thoughts
There is no doubt that the
efforts of GlaxoSmithKline in
proved profirable' In just the Japan
first year on the marker paxil
brought in over r00 mirion sales
do,ars. At the end of 200 2 the
pany reported, "sales of seroxar/paxil, com-
GsKk reading producr for
depression and anxiery clisorclers,
was the driver of growth in
CNS (Cenrral Ner the

Io,,,,o r5 v" gtor,::;: :íffi],'l : mu: il:H::::i 3;Li l;

PaxilGrew 27o/o to $401 mirion led
by continued srrong growth
in Japan, where the produca
*r, l.t,r.hed only rn/o years ago.,,
By 2008 sales of paxil were
over one billion dollars per
year in
Japan.
Kitanaka has been stunned ro
see how Fast things have changed
in Japan since ssRls were introcruced.
"The whore cu*ure sur-
rouldinS p.sychiatry has changed
a stigmatizing nodon thar
drasdcall¡,, she rold me. .,From
"i"p..r.r""
no one ralked
become one of the t "U""., n*
mate disease ar so *:i;ñTT,:::r':::'; IT:lfXJ:f::;
have tranqformed rhe narure
-.f1arg.. of d,-epre-ssion experience
irself.,, 4§ an
 246 CRAZY LiKE
US
G'+
Sorne Japanese
€omPanv feted
but reacring to it.
psychiatrists,
in ;ñ,;;:;f*"
e.

ono reportslni*t
ono and G¡ima, whonr
not Ieading thj,
had a rush of nr"i..,. .].1"I..." cnat starring in 2001 h
showin§ uP at
,r.-
the
tr.rj
suddenlv
+
e
*

zine articre ,r::t:':* his *;.;; 'te

"ffi'.;
J i, r,
o,
.h.i. a.p,.,;; I iT::,:',:ITr
-*' ;H
rrrm T
LV : " *' J ij, ; ::T;
that the nrild
. *
illness. or,r-,
*"''' "t t ilfl *:#t'::ff
patients descrihe.l ,,,^,.,, srmo
*
o.lto ::il L*:;
;,"l:ff : j:l:l$J:ii:ñ:.:tr:,:",,tIg#:,..f: G&
*:tt ways Éo revérse the trend. *
'"The rnark.,',:t
n, m anr wars
"' "*"", ñ:::,TI: ;i:
3' -"", *
to o s uccessrur.
I t"1:': ; soul,'has convinced
p.oit.
l? not an
often
ro seek medical
illness,,,
...ootnt for something
."" *'-ti.t:t-t"t
far
thar is
er€
,h,t d.p,.,;; ;;' ;';;:"";#*;.,no".n,1:
""" ; ;;',.: *
rh", ;;;;;:y:::
",,, o..i'.lli;,::.::,:rthe.sour.,
_r_..laps nor
F&
:
lccu,rare manypeopt. *o,rlJ
so
rhar belief ,, i**ñil ;ffi: .
Dr. Tajima has ..-- '
---^, . . :

É"k
jn Kyoto in "," ,rraee such encouraging
srandards thar
2OOO eh-,,* -;
i?:.:t
encouragins r
th' ;;";'i-, or rnternational remarks
,

trrtc
diagnostic
ete
;

wor "r".;llr"t.l"Luulr '

wercomed rh.,,rr.'11 diagnosis'" At the ;.;;;

tri b ure,o,.du.i n no-ducr
ion ;;;;r,,:e
*h I-
]11-"
cnratrists
*",:al
i, the."-;;;;,L""'
figure 'n' Tr¡im, conference, l É'l€
l--
in Japan. He ",lltt-P,
*"" ^::"'well bv to win over orhe
speeches ,nd
at conGrences'
Gla*osm¡th¿;;.'."t;,Y. @lf,
j-
"oo.rrT::".0"'o il¿lil*'j - #+
:

the Kyoro.""á;;: The paper

mate¡ial :ewaswiderrrr"d;fl::l#:i;*:T*i ;

i I

--- _U,". .in

rhe pasr few years
he has be
r B+'{
-I'h'd
€.f
r
just how rnany;;;; concerned as
* he,s
qn o.o;.-.,iilfiy":j :; "^,:::_:*ome :

;I,l, ffi:;l;: :x *|,ry

ry
et!
fr
#
tErk
# The Mega-Marketing of Depression in Japan

David Healy and others have caused him to become skeptical

) 1)-7

as

"fu to whether GlaxoSmithKline has accurately reporred the scientific

data regarding the drugt effecriveness and risks. He has taken it

#
"{*
upon himself to rranslare one of Healy's bools into Japanese and

#
Fqil
now jokes that he is goihg to becorne "the David Healy of Japan."
In discussing the remarkable changes thar he's seen in Japan over
the past ten years, Tájirna does not corne offas a man who is a\gry
with GlaxoSmithKline. Indeed, in recounring his own participa-

d*
FJt
tion in these changes, he often laughs hearrily, like a man telling
the story of hoú he was thoroughly fooled by a talented magician
or card shark. His laughter comrnunicares "I have only myself to
blame."

"h
#
He maintains that Paxil is helpful for some anxiery disorders and
can be used in serious cases of depression so long as rhe patient is

*b monitored closely through the early days of trearmenr. Flowever, he

#
has come to believe that the drug is massively overprescribed and
that it can somerimes spark suicidal thoughts in patients. 'After the
Ministry of Healrh in Japan issued a warning of a suicide risk with
this drug for patients under rwenry-five, many docrors and patients
á*
are now aware of this risk," says Tájima. \ü/har he cant understand,

"+
-h
however, is why the drug remains so widely prescribed for patients
with depressive symproms thar are rransient and relarively mild.

+.
.+-
The warning about the risk of suicide seemed nor ro have had much
effect against the forces of the mega-marketing campaign spon-
sored by GlaxoSmithKline in the years since 2000.
Thjima has also come ro mistrust the confidenr science presented

*J^ by che pharmaceurical manufracrurers. Akhough he is aware rhar

the drug companies don'r take kindly to criticism, he is commirted

"F
-F
to fighting rhe good fight and geming the best informarion ro the
Japanese people anyway he can.

#
q+*
Did l¡e have 4ny hpp-e,.I askgd hf m, 9f qhallenging qhe imported
ideas that helped popularize depression in Japan? "The force of this

r+*
 248 CRAZY LIKE US
#
_i4
tide is still very srrong,,,
Thjima said. He did poinr
ro some signs #
tr
that might indicate . l.rr..rirrg
of .h. rnomenrurn. The
effecriveness of rhe drug marginal
has Io, g;. unnoriped. ..There
manypatients inJapan who are so
he told me. ..Ma,y
have not improved a^d
ordinary peopl. ,o* h.r.
nor recovefed,,,
fr4
so-called magic drugs."
As journalists often do,
tion for the very end of my
I saved rhe
-^- ' v questions a'our these
YuLrLrurr§ aDoL.
#
#
that I did nor wanr ro
wanted to k,ow how he
GlaxoSmithKline over the
ir...r,i.* *Tffi:Hr,*:?:LT,.;
pry too far into his personal
felt arrout the money he had
years. -y*," h;';;;:ü;il
finances, but J
taken from
#
*+
"This is avery important asain.
question. some peopre say
that

#
tionship berwee' the researchers this rera-
of prosdtution. I agree.
and trre drug companies
is a kind
"1"
#
yT., am nor a puritan. I am
tic man' This is very probrematic. .M. a very realis_
Ir".r.. to change rhe currenr
situation not onry in
Japan bur also i, .¡r. united states
counrries' The srrong force and orher
ens to rurn medicir
of rhe prrarmaceuticar indusrry
rhreat- .JF
[il: ; H]*H:il.:ff:;ffiI jf r *J"
;:;x:}I
laughed again' and added, "§Tewere *,
,r#r}f,paused' verycrreap
gJ*
*T*
*fo
*f*
*f*
Ff^
*r*
#
+
Ft^