The Fear Is Sold First

What they were, and who they were for

These are real advertisements for psychiatric medicines, published in medical journals between roughly the mid-1960s and the mid-1980s. They were not aimed at patients. They were aimed at doctors, in the pages of the journals doctors read at work. Hold on to that while you look at them, because the usual defence of frightening advertising is that ordinary consumers need protecting from it. These were made for professionals.

The first asks a clinical question, “Hallucinating and delusional?”, above a painting of two faces dissolving into each other in reds and greens. Nothing in that image is information. It is a rendering of what the advertiser wants psychosis to feel like to the person reading: lurid, unbounded, closing in.

The second is quieter and, to my eye, stranger. A woman in a kitchen dress stands smiling while her small daughter winds string around her legs, tying her in place. “now she can cope… thanks to Butisol Sodium”, a barbiturate sold as a “daytime sedative for everyday situational stress.” The copy names its market plainly: when stress is situational, environmental pressure, worry over illness, the treatment often calls for an anxiety-allaying agent. Lower in the same column, in small type: Warning: May be habit forming.

That single page contains the whole argument of this article. The headline sells an ordinary difficult afternoon as a condition. The fine print tells the truth about the risk. Both are on the page. Only one of them is designed to be read.

The third, “In manic-depression control the fire in the mind”, shows a man’s head opened at the crown with flames pouring out of it, advertising slow-release lithium carbonate. Here too the fine print is scrupulous: lithium toxicity is closely related to serum lithium levels and can occur at doses close to therapeutic ones, so facilities for prompt and accurate serum lithium measurement should be available before treatment begins. That is correct and clinically important. It sits underneath a picture of a burning head.

The fourth is the one I would put on a teaching slide. Under the words “Change upsets me” is a photograph of an anxious young man. The body copy reads: Most patients with psychotic symptoms need a quiet, undemanding life that provides refuge from a confusing and overwhelming world. You can help avoid one potentially stressful change by making sure your patients receive the unique HALDOL Tablet they can recognize.

Read it twice. The fear being sold is not psychosis. It is the fear that a patient might be handed a differently shaped tablet. The advertisement takes a real clinical observation, that people with psychosis can be destabilised by disruption, and aims it at a commercial problem, which is generic competition. The concern is genuine. The use made of it is not.

The fifth is the most modern-looking of the five: a painted portrait with the face left blank, and the line “The portrait of anxiety is often complicated.” By the 1980s the visual grammar had changed. No flames, no melting flesh. Just an absence where a person should be. The fear had become quieter and more literary. It was still the first thing on the page.

Amplify, include, then resolve

Strip away the pictures and the same three beats appear in all five.

One: make the problem vivid. Not described, not quantified. Rendered. Anxiety becomes a face erased. Mania becomes a burning skull. Psychosis becomes a world that will not hold still. The emotional temperature is set before a single claim is made.

Two: make it yours. The Butisol page is not about severe illness. It is about a woman having a difficult afternoon, and it says so: everyday situational stress. The frame widens until the reader is standing inside it.

Three: arrive with relief. The product enters clean, plainly named and calm, its typography orderly where the image was chaotic. It is not so much argued for as offered, as the exit from a state the advertisement itself produced.

Notice what is not required for this to work. Nothing here has to be false. Lithium does treat mania. Haloperidol does treat psychosis. Every individual claim can be accurate while the page as a whole is doing something other than informing you.

The evidence is less flattering than we would like

There is a large body of research on what are called fear appeals. The most comprehensive analysis, published in Psychological Bulletin in 2015, pooled 248 independent samples and more than 27,000 participants. Fear appeals had a positive effect on attitudes, intentions and behaviour, of small to moderate size, and the authors found very few conditions under which they simply failed.

The detail that matters most is which features made them stronger. Effects grew when the message depicted higher levels of fear, when it made the threat feel likely and severe, and, critically, when it included an efficacy statement: something the reader could actually do about it.

Fear on its own tends to produce avoidance. Fear paired with an easy, specific action produces the action.

That is the shape of an advertisement, exactly. Here is the danger; here is the tablet. The structure is not incidental to persuasion. It is the engine of it.

Three further findings from decision research explain why the sequence cannot simply be reasoned away. Losses and threats carry more psychological weight than equivalent gains, a pattern documented since Kahneman and Tversky’s work on prospect theory and studied since as negativity bias. Threat compresses the time horizon, so a frightened reader evaluates less and acts sooner. And under what Paul Slovic named the affect heuristic, once we feel strongly about something we judge its risks and benefits by the feeling rather than by the evidence.

None of this requires the reader to be foolish. The psychiatrists reading those journals in 1974 were not foolish. Persuasion of this kind does not work by defeating your reasoning. It works upstream of it, by setting what the question feels like before you begin to reason about it.

Widening the boundary of who counts as unwell

The Butisol page did something more ambitious than sell a barbiturate. It proposed that an ordinary bad afternoon belonged in a doctor’s consulting room. In 2002 Ray Moynihan, Iona Heath and David Henry gave this practice a name in the BMJ: disease mongering, which they defined as widening the boundaries of treatable illness in order to expand markets for those who sell and deliver treatments.

The commercial stakes were considerable. Meprobamate arrived in 1955, chlordiazepoxide in 1960, diazepam in 1963. Diazepam was the most prescribed drug in the United States from 1969 to 1982, and at its peak in 1978 the manufacturer sold it by the billion of tablets a year. The Rolling Stones had already named the phenomenon in 1966. It was called Mother’s Little Helper.

The clearest documented example came later. In 1999, ahead of a licence decision for paroxetine in social anxiety disorder, its manufacturer engaged a public relations firm, which produced the slogan Imagine being allergic to people and placed it on bus shelters across the United States. The posters did not name the drug or the company. They carried the badges of a coalition of professional and patient organisations. In the two years before the decision, fewer than fifty articles on social anxiety disorder had appeared in the American press. In the month the decision came through, there were hundreds. The campaign won an industry award for the best public relations work of the year.

The opposite error is the more dangerous one

The most common misreading of this history is also the one that does the most harm. It runs: if the marketing was manipulative, the medicines must be a confidence trick, and the illnesses must be invented.

Consider what those five pages were actually selling. Lithium remains one of the most effective treatments in psychiatry, and among mood stabilisers it has the strongest evidence for reducing suicide risk. Haloperidol and the drugs that followed it allowed people who would once have spent their lives in institutions to live outside them. Alprazolam has genuine uses, alongside genuine problems with dependence that took the profession far too long to take seriously.

A good product can be sold badly. A necessary product can be sold with fear. The quality of an advertisement tells you very little about the quality of the thing advertised, and the two questions are constantly collapsed into one. The reverse holds as well: a calm, restrained, tasteful advertisement is not evidence that anything works.

Nor is fear itself disqualifying. Public health has used it for decades, for tobacco, road safety and helmets, and it has saved lives doing so. The ethical question is not whether fear is used. It is a narrower three-part test.

1. Is the threat real, and is it described at its real size? Exaggeration of magnitude is the most common form of dishonesty here, and the hardest to notice, because the underlying fact is true.
2. Does the recommended action actually reduce the threat? Fear of ageing is real. It does not follow that a particular serum addresses it.
3. Who benefits from your fear? If the person naming the danger also sells the remedy, that is not automatically disqualifying. Doctors do it every working day. It does mean the standard of evidence you ask for should go up, not down.

The grammar survived the ban on the advertisements

India does not permit prescription medicines to be advertised to the public. The Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954 restricts what may be advertised and for which conditions, and prohibits advertisements that are false or misleading. You will not see the Xanax page in an Indian magazine.

What survived was not the product category. It was the structure. Once you can see the three beats, they are difficult to stop seeing.

If you have not started an SIP by thirty, picture your retirement. The threat is dependence in old age. Without this, ageing. The threat is disappearing from other people’s attention. Without this course, your career stalls, or your child’s does. Anything aimed at parents is especially effective, because the fear can be attached to a child rather than to the buyer, and few of us are willing to argue with a fear on a child’s behalf. Full-body check-up packages sell the fear of the undetected. Supplements sell deficiency, immunity and weakness.

And none of that means SIPs are bad, or that a health check is pointless, or that a course has no value. Systematic investment is sensible for most people. Some screening is worth doing. Good things are routinely sold with fear, because fear sells everything.

A practical test for the next time it happens

When an advertisement lands and you feel the sudden pull, the sense that you need this and you need it now, there is a single question that usually settles it.

If I had not been made anxious first, would I still want this?

It is a better question than it sounds, because it separates two things that arrive together and feel like one thing: the desire for the product, and the discomfort that was manufactured to produce the desire. Occasionally the answer is yes. You needed a health check anyway; the advertisement simply reminded you. Often the answer is no, and that is worth knowing before you pay.

Three smaller checks are useful alongside it.

1. Restate the claim in flat language. Write down what is actually being asserted, with every adjective removed. Most fear-based pitches lose most of their force in translation, which tells you where the force was coming from.
2. Ask who set the deadline. Real urgency comes from the world: a symptom that is worsening, a date fixed by something other than the seller. Manufactured urgency comes from the person selling.
3. Ask what happens if you wait a week. If the honest answer is “not much”, then the urgency was decoration, and a week is a small price for making the decision as yourself.

What is worth protecting here is the ability to want something calmly. A decision made from fear feels urgent at the time and often ages badly. The same decision made once the fear has cooled is usually either clearly right or clearly unnecessary, and you can tell which.

The advertisements at the top of this page are fifty years old and look ridiculous, which is what makes them useful. Nothing being sold to you today will look like that. It will look reasonable, well-designed and concerned for your wellbeing, and the fear will still arrive first.