"Will I be pretty, will I be rich?" The Missing Self in Antidepressant Commercials "... this undoubted faith in the integrity of the photograph is often rudely shaken; for while photographs may not lie, liars may photograph." Lewis Hine, 1909. In "Ban the sunset? Non-propositional content and the regulation of pharmaceutical advertising" Paul Biegler and Patrick Vargas (B&V) raise concerns about the influence of the Direct to Consumer Advertising (DTCA) of prescription pharmaceuticals on viewers' decisions to use the advertised medicines. B&V point out that the U.S. Food and Drug Administration (FDA) enforces a strict regulatory regime on the propositional content of the commercials by requiring risks and benefits to be outlined, and mandating that messages about effectiveness and side effects be presented. Yet no regulations control the non-propositional content, including imagery, music, and sound effects, causing B&V to ask how such content may foster unjustified beliefs about drug safety and efficacy, and therefore jeopardize the autonomy of viewers' choices by means of evaluative conditioning. Extending B&V's concerns, I argue that, just like the non-propositional content, the propositional content of the antidepressant commercials can also trigger some cognitive biases in the viewer, such as the Barnum effect and guide individuals to develop unjustified beliefs about drug efficacy and safety – albeit implicitly. Consider the commercial for the antidepressant drug Pristiq R©. A woman with depression appears on screen. She says, "Depression can take so much out of you. I feel like I have to wind myself up just to get out of bed." As she says this, we see a wind-up doll, ostensibly illustrating how she feels. She lists her symptoms: "the sadness, the loss of interest, trouble concentrating, lack of energy." As she does so, we see the doll walking in a robotic fashion, 2 after being wound up. The doll stops intermittently, as its wound up energy expires; it needs to be wound up repeatedly. The patient pauses between symptoms, creating the same stop-start effect. Her eyes are red, as if she is about to cry. A voice-over now describes the chemistry of Pristiq R©: "Pristiq is thought to work by affecting the levels of two chemicals in the brain, ceratonin and neuorophreprin." A fast-paced script listing the side effects follows: "Tell your doctor right away if your depression worsens, or if you have unusual changes in behaviour and thoughts of suicide. Antidepressants can increase suicidal thoughts and behaviours in children, teens and young adults. Pristiq is not approved for children under 18. Do not take Pristiq R© with MOAIs." Of course, while all potential positive effects are enacted on the screen, there is no visual representation of the side effects. We do not, for instance, see anyone on the verge of suicide. Instead, we witness the woman's transition from depression to health: she smiles, her eyes are clear. She is sitting by a picnic table, watching her young family playing a game in a beautiful park. She sets the wind-up doll aside and directs her attention to engaging with her family: she hugs her kids and smiles happily. The commercial ends as she says: "For me Pristiq R© is a key to help treating my depression." Such commercials are widespread. Each antidepressant commercial has a similar narrative of a depressed person, who is isolated, sad and disengaged; with the introduction of the medication, she/he transitions into an engaged and happy life, despite a frightening litany of side effects. Having set the stage, I shall evaluate how the propositional content affects patients' beliefs about drug safety and efficacy. In the Pristiq R© commercial, depression is individuated as a list of symptoms: sadness, loss of interest, trouble concentrating, lack of energy. This is consistent with how depression is operationally defined in the Diagnostic Statistical Manual of Mental Disorders (DSM), the psychiatric manual used 3 for research, treatment, and administrative purposes. The symptom-based description of depression is a useful clinical feature of the DSM because it picks out the observable features of the patient's experiences and ascertains the reliability of a particular diagnosis across clinical contexts (Tekin 2010, 2011, forthcoming). The diagnostic criteria for depression in the DSM include such observable behaviours as sleep disturbance, depressed mood, and so on. If the patient's complaints match these observables, and if the psychiatrist sees fit, the patient is given a diagnosis and an appropriate treatment plan. In addition, the symptom-based descriptions facilitate the development of antidepressants that target specific complaints, such as insomnia, lack of energy, inability to concentrate etc. Under the symptom-based approach, phenomena that describe a particular patient's encounter with depression, individual circumstances that play a role in the emergence or aggravation of her condition and her unique life story are not included because these features are not readily measurable and cannot be generalized across patients. While subjective contingencies, such as personal identity (gender, race, socioeconomic status, etc.), interpersonal relationships, and self-care habits play a crucial role in the onset and the course of depression and are therefore important factors in addressing it (Tekin 2010, forthcoming), the symptom-based account renders these subjective contingencies irrelevant. The DSM's symptom-based schema is widely accepted and disseminated within what I have previously called the DSM culture; the interactive social, cultural and institutional context in which the DSM-based schema of mental disorders is put into use outside the clinical context, thereby standardizing the way mental disorder is understood and engaged (Tekin 2010, 2011, forthcoming). The antidepressant commercial is a part of the DSM culture. It presents the depression as a symptom cluster, which can be alleviated by using the antidepressants alone. To be clear, as B&V highlight, 4 following the FDA regulations, the propositional content of the commercial is not misleading; it provides information about the symptoms of depression and the possible side effects of the antidepressants. But the information is incomplete. Depression is more than a symptom cluster; the listed symptoms are encountered by an embodied self, situated in a network of subjective contingencies central to the onset and the course of depression. Further, as research indicates, a combined antidepressant and talk therapy treatment yields the best results for treatment (Whittington, Kendall and Pilling, 2005). Elyn Saks, a schizophrenia sufferer, emphasizes how helpful medications have been in learning to cope with her illness; nevertheless, she says she would not have "had a life" without psychotherapy, psychoanalysis, and the support of friends and family: Medication has no doubt played a central role in helping me manage my psychosis, but what has allowed me to see the meaning in my strugglesto make sense of everything that happened before and during the course of my illness, and to mobilize what strengths I may possess into a rich and productive life istalk therapy. (Saks 2007, 331) We do not get this kind of information in the antidepressant commercials. Rather, they give incomplete information about depression and promise more than they can deliver. Note also the possible effect of a viewer's cognitive biases. As I argue elsewhere, empirical research in cognitive and social psychology increasingly points to short-sighted reasoning strategies, biases and opportunistic oversimplifications in human reasoning. In other words, humans consistently make errors of judgment. For example, consider the subjective validation effect, or the Barnum effect. This cognitive bias is defined as the tendency of subjects to identify their personal features with broad characterizations of their personality, even when such characterization is not veridical. A paradigmatic example is a subject's response to astrological projections, personality profiles and the like. Personality profiles involve such observations as: "You REFERENCES 5 have a great need for other people to like and admire you" (Jopling 2000, 40). Nothing in this definition is specific to the individual, yet many believe this is a valid and unique characterization of their personality. The symptom list given by the woman in the antidepressant commercial might trigger a similar cognitive bias. Because the description is general, lacks detail, and provides no room for particular contingencies, the viewer/ patient might over-identify her experiences with the suggested symptoms and develop unjustified beliefs about the antidepressant's efficacy. Thus, in addition to evaluative conditioning that might be at work in the antidepressant commercial by way of leading the viewer associate the positive images of happy people with the antidepressant drug, the propositional content may also trigger some cognitive biases to elicit unjustified beliefs about antidepressant efficacy. I conclude that both the implicit reasoning processes and evaluative conditioning must be cautioned against in the FDA regulations. References Jopling, D. (2000). Self-knowledge and the self. Routledge. Saks, E. (2008). The center cannot hold: My journey through madness. Hyperion. Tekin, Ş. (2011a). Mad narratives: Exploring self-constitutions through the diagnostic looking glass. Ph. D. thesis, York University. Tekin, Ş. (2011b). Self-concept through the diagnostic looking glass: Narratives and mental disorder. Philosophical Psychology 24 (3), 357–380. Tekin, Ş. (forthcoming). Self-insight in the time of mood disorders: After the diagnosis, beyond the treatment. Philosophy, Psychiatry and Psychology . REFERENCES 6 Whittington, C., T. Kendall, and S. Pilling (2005). Are the ssris and atypical antidepressants safe and effective for children and adolescents? Current opinion in psychiatry 18 (1), 21–25.