Medicine Observations Systems

Representation Matters.

This post comes directly from a Twitter conversation I was in a few days ago:

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… though this topic has actually been on my mind for nearly a year due to some events that have occurred at work.

Many medications that were originally developed for the treatment of schizophrenia, called antipsychotic medications, are now used for other conditions, such as major depression and bipolar disorder. (The reasons for this are beyond the scope of this post. However, I will comment that this is why the “serotonin theory” of depression should really be called the “serotonin hypothesis“.) Several antipsychotic medications come not only in pill form, but are also available in long-acting injectable forms. Instead of swallowing pills everyday, some people receive an injection of medication once every few weeks or once a month. These medications are injected into shoulder or butt muscle.

Some people prefer to receive injections because that means that they don’t to remember to take pills everyday. Many people who accept long-acting injectable medications do well. No one would guess that they have had experiences hearing voices or believing fixed, false ideas. Some of these individuals report that these medications have saved their lives.

Some people, in varying degrees, are coerced into receiving injections (e.g., payee allowances—money—are handed over only after the individual receives the injectable medication; courts “encourage” individuals to receive injectable medication). Long-acting injectable medications are never used in emergencies, regardless of who is defining the word “emergency”.

Most people prefer not to get shots of medication, even if they know they are in their best interests. Many adults look away and wince when they receive vaccines, even though they know that the benefits far outweigh the risks. Most vaccines, though, are available only in injection form, so people don’t have a choice as to how else they can receive the vaccine.

So, with that, let’s look at the advertisements for long-acting injectable antipsychotic medications and any intersections they have with race. The target population is admittedly small: Only around 1% of the population has a diagnosis of schizophrenia at any given time. (However, if you’re part of that 1%, this stuff matters a lot.)

Here’s the landing page for one long-acting injectable antipsychotic medication:


We see what look to be white people with sporting equipment. I’ve drawn in a pink arrow to show the link that leads to the page about the use of this medication for the treatment of SCHIZOPHRENIA. If you click on that link, it brings you here:


Anything different about the people in the photo?

There are journal articles that span decades that show that schizophrenia is overdiagnosed in black people. One wonders: Do the ads come from the overdiagnosis? Or does the overdiagnosis come from the ads?

To be fair, if you scroll through the photos in that image, the other photos are of white people, including women. However, the scrolling does not automatically occur. The photo of the three men of color is what you see when you click on “schizophrenia” from the main page.

So what happens if you click on “schizoaffective disorder” from the page for schizophrenia? (Curious that there isn’t a link to schizoaffective disorder on the main page.) This shows up:


Only women for a psychotic disorder that also features mood symptoms, huh? (Side note: There’s ongoing debate within psychiatry whether schizoaffective disorder is even a valid condition. Meaning, psychiatric researchers are still arguing about whether this condition even exists. This is a topic for another post.)

“Oh, Maria,” you might be thinking. “You’re reading too much into this. It’s just one ad for one medication.”

Okay, let’s look at another long-acting injectable antipsychotic medication. How about this landing page?


Note the comment in the bottom right-hand corner: “Model portrayals.” Meaning, the company chose these specific images for these specific diagnoses.

The “schizophrenia” link takes you to a page that has scrollable photos: Two women with less melanin and a man with more melanin. The “bipolar” link has two scrollable photos: One light-skinned woman and a darker-skinned man. Maybe there’s something there; maybe there’s not.

Here’s another one for essentially the same medication, but with a different manufacturer:


Okay, so this photo assortment seems to strike a more even racial balance. I won’t nitpick further on this one.

Let’s go to the longest-acting injectable antipsychotic medication on the market right now, an injection that is administered once every three months:


Oh goodness.

If you click through the “Go to videos” link, there are three video vignettes. Two of the individuals are black. Again, one wonders: Do the ads come from the clinical diagnosis? Or does the overdiagnosis come from the ads?

The other long-acting injectable antipsychotic medications are now available as generic formulations, so their websites are full of text. My efforts to find past advertisements, commercials, and press kits for them yielded no images. I find that interesting, too.

To be clear, these ads comprise a small sample and are for a specific form of medication. I don’t know what advertisements look like for all other psychiatric medications. Maybe I am reading too much into these websites. However, when (1) local, regional, and national data indicate that people of color, particularly African Americans, are more likely to receive a diagnosis of schizophrenia, (2) medications used to treat schizophrenia often have significant side effects of sedation and lethargy, and (3) these medications are available in long-acting forms, it makes me wonder.