Healthy Skepticism AdWatch

AdWatch illuminates the logical, psychological and pharmacological techniques used in drug advertisements.

September 2006, Australia

Efexor Tetrapack (venlafaxine) from Wyeth

Antidepressants are not sweets.

Efexor"-XR (venlafaxine) is marketed by Wyeth as a serotonin and noradrenalin reuptake inhibitor (SNRI) and a 'dual-action' antidepressant. In some other countries it is marketed as Effexor™. It is approved by the Therapeutic Goods Administration in Australia for the treatment of major depressive disorders, but not for children or adolescents.[1] These promotional tetrahedron packs were distributed in doctors' surgeries and at conferences in Australia. Each pack contains 15 grams of yellow and blue/black jelly sweets (candies). The main text on the packaging reads: EFEXOR#-XR VENLAFAXINE EXTENDED RELEASE. These sweet packs are inappropriate gifts to doctors, for a number of reasons. Firstly, the Royal Australian College of General Practitioners guidelines state that 'The patient should be the primary beneficiary of any gift accepted by the general practitioner and the gift should be related to the general practitioner's work'.[2] Promotional sweets are of no benefit to patients, and in fact are potentially detrimental to their health. Nor are such sweets related to GPs' work. Similarly, the Association of the British Pharmaceutical Industry code specifies that gifts should be 'relevant to the recipient's work' such as pens and diaries.[3] Sweet packs clearly are not relevant to doctors' work, so they would be banned by the ABPI code. The packaging of these sweets is rich in symbolism. The X in EFEXOR is enhanced with spectrum shades of red, yellow, and blue. The letter X is commonly used in drug names because it implies speed of action;[4] the changing colours add a further sense of movement. Like many antidepressant promotional materials, Efexor advertisements and promotional items, including these sweet packs, use a cheerful yellow, with a contrasting blue (in this case dark blue). Above the main text is a white human head in profile. Within the skull is a yin/yang symbol, in yellow and dark blue. Visual metaphors and symbols are common in antidepressant advertisements.[5] They can powerfully promote therapeutic claims while circumventing the requirement to support written claims with evidence. The yin/yang symbol is particularly significant because it taps into and reinforces the claim that SSRIs and similar antidepressants restore the 'chemical balance' in the brain, a claim for which there is little evidence.[6] The yin/yang symbol also emphasises the 'dual action' of venlafaxine, which purportedly make it more effective than SSRIs. Several studies have reported that venlafaxine has better efficacy than selective serotonin reuptake inhibitors (SSRIs),[7,8] but these studies have been criticised in relation to methodology [9] and conflict of interest.[10] Furthermore, although the adverse drug reaction (ADR) profile of venlafaxine is similar to those of SSRIs, venlafaxine has a stronger association with some ADRs, particularly nausea/vomiting/ anorexia, hypertension, and syncope.xi From mid-1996 to December 1997 alone, the Adverse Drug Reactions Advisory Committee (ADRAC) received 190 reports of suspected ADRs in linked to venlafaxine.[12] Of particular concern is the increased risk of suicidality (suicide-related behaviour and suicidal ideation) associated with SSRIs and similar antidepressants, particularly when used by children.[13-15] There are not enough data to determine whether any are more or less dangerous than the others, but the point estimate* odds ratios† and relative risks‡ were higher for venlafaxine than for most SSRIs. Furthermore, Wyeth is associating Efexor with sweets. The bright colours of the packs would be appealing to children, as would the sweets inside, and it is likely that many of the sweets would be eaten by child patients and children of doctors and their staff. This is somewhat similar to the use of candy cigarettes, an effective promotional technique for increasing smoking by children that has been banned in many jurisdictions. The use of sweets to promote drugs should also be banned, particularly drugs that are contraindicated for children. In 2005, Wyeth was approved as a provider of Level One Mental Health Skills Training for general practitioners, under the Australian Government funded Better Outcomes in Mental Health Care.[16] The inappropriateness of Wyeth's use of these promotional sweet packs calls into question the appropriateness of their approval as educational providers. * Sample estimate. When the confidence intervals are wide, the situation in the population may be very different from the point estimate. † The rate in the treatment group divided by the rate in the control group. ‡ The probability in the treatment group divided by the probability in the control group.

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