Selling Madness: Psychopharmaceutical Companies in Lithuania, 1990-2000

The breakup of the Soviet Union has created enormous tensions, both economic and cultural, for its former member states. Once under the watchful and guiding eye of the Soviet Union, the former republics suddenly had to determine how to react to an increasingly integrated global economy. Lithuania, since its reestablishment of independence in 1991, has been torn between the legacy of Communist influence from the East, and cultural and economic pressures from the West. As I will show, Western influences have led to major changes in Lithuanian mental health. Lithuania has experienced a sharp increase in certain types of mental illness between 1997 and 1998, as indicated in Table 1.*

Disorder	ICD-10 Code	1997	1998	% Change
Organic, including symptomatic mental disorders.	F00-F09	23.8	45.5	+91.2%
Schizophrenia.	F20-F29	23.8	27.5	+15.6%
Mood (Affective) disorders.	F30-F39	25.1	101.6	+305.0%
Neurotic and Stress-related disorders.	F40-F49	16.1	24.3	+50.9%
Behavioural syndromes associated with physiological disturbances and physical factors.	F50-F59	0.6	1.8	+200.0%
Disorders of adult personality and behaviour.	F60-F69	8.2	9.3	+13.4%

The question driving this research is why rates of mental illness in Lithuania have increased so rapidly in the 1990s in light of the rising influence of Western pharmaceutical companies. These firms expanded their marketing strategies in Lithuania, since it became an untapped market after the fall of the Soviet Union. Using both formal and informal means, the pharmaceutical industry influences the diagnosis of various types of mental illness treated by medications sold by these same pharmaceutical companies.

While other scholars have stressed the role of the interaction process between individuals, this research contributes to the debate of the social construction of mental illness by emphasizing the macroeconomic sources of the diagnosis of mental illness.

This section provides a brief overview of three general perspectives on mental illness, and indicates ways in which this paper fits within and contributes to these established paradigms. My argument for a relationship between increasing rates of mental illness and the expanding market of foreign pharmaceutical companies draws upon labeling theory and the antipsychiatric school of thought.
Labeling theory is based on one fundamental idea: those who are labeled deviant and treated as such will become deviant (Scheff 1974, Lemert 1951, Lemert 1972, Becker 1973). By extension, those who are treated as mentally ill will come to act mentally ill, thereby beginning a self-perpetuating cycle. For labeling theorists, mental illness does not exist in the sense proposed by those who embrace a medical (or "biological") model, which sees mental illness as a physiological phenomenon that should be treated like any other disease. Mental illness is fundamentally a social phenomenon for labeling theorists and for those who refer to the "medi-calization" of mental illness. Both see mental "health" as being an arbitrary condition (Conrad 1975, Szasz 1963, Scull 1975, Laing 1967, Goffman 1959). Behavior becomes socially constructed, as proposed in the "radical" perspective of the antipsychiatrists (so-called due to their opposition to the medical model), using the legitimacy of the medical institution as an agent of social control (Conrad 1980, Szasz 1963). Psychiatrists such as Laing (1967,1969) and Szasz (1974), who argue that mental illness does not exist at all, represent the extreme fringe of the antipsychiatric model. While Laing sees schizophrenia as a "sane reaction to an insane world," Szasz sees mental illness as a medical "myth," because there are no signs of physical lesions. What is missing from this perspective is a macro-level analysis that emphasizes economic factors.

The above-mentioned researchers focus on a micro context. My research contributes to their paradigms by proposing that mental illness is intimately tied to large economic processes. I examine how the social construction of mental health at the micro level is shaped by macroeconomic conditions, specifically, the rise of capitalist drug companies in Lithuania in the context of an increasingly integrated capitalist world economy.

I hypothesize that Western pharmaceutical companies seeking new markets for their medications are in effect creating a demand for their products, which, in turn, leads to increasing rates of diagnosed mental illness. Theoretically, my project contributes to the field of social psychiatry by linking psychiatric diagnoses to economic changes. Also, the issue of what underlies mental health sociologically has practical implications, both in Lithuania and the United States, for at least two reasons. First, how mental health is defined sets the stage for research agendas and policy issues. For example, if mental illness is deemed a mainly physiological phenomenon, as was the case in the Soviet Union, then biological treatment makes sense. Yet if mental illness is seen as having both social and biological causes, then a blend of treatments, both social and physiological may be useful. Second, how mental illness is defined also impacts the way mental patients view themselves, which, in turn, influences their coping strategies (Townsend 1975, Karp 1996). Third, how psychiatrists view and treat mental patients is related to determining the cause of their afflictions.

This study not only contributes to sociological literature on Lithuania and Eastern Europe, but is relevant to psychiatric processes in the United States and other capitalist countries as well. As the markets that psychiatry comes to dominate expand, consumers and society as a whole must become increasingly aware of the possible dangers in this domination. Sociologists must be aware of and investigate the social nature of mental illness and the relationship between the legitimacy of the medical model and economic and cultural factors supporting that legitimacy.

Figure 1 models the hypothesized relationship between capitalist development and increasing rates of mental illness. Drawing on world-systemic explanations of a global capitalist economy (Chase-Dunn 1982; Chase-Dunn and Boswell 1998), I argue that Western capital influences the operation of pharmaceutical companies. These firms, which must operate profitably, do so by marketing their products aggressively. Western pharmaceutical companies entice Lithuanian psychiatrists to prescribe more pharmaceuticals, which increases both the profits of the pharmaceutical companies and the official rate of mental illness.

Figure 2 diagrams a more elaborate model that illustrates the relationship between the discussed variables. It indicates that there is a complex interrelationship between several important factors. The state is interested in saving money in its health care system, and, therefore, minimizes the use of expensive treatments, such as traditional "talking" psychotherapy. Drug companies seek to maximize their profits. Both the state and the drug companies influence the psychiatrists who deal with clients/patients. Though psychiatrists determine the diagnosis, patients may come to them already seeking medication.

Lithuania is a fruitful choice for studying the effects of capitalist development on rates of mental illness, because it has experienced a sharp rise in the influence of capitalism during the past ten years. One would expect the reforms in psychiatry enacted in Lithuania to increasingly resemble those observed in a capitalist system. This study is a timely one. The breakdown of the Soviet Union in 1990 has led to a major transformation in formerly socialist societies. The breakup of the Soviet Union has created new markets for foreign investors eager to sell products and services to people used to living under communism.

Lithuania's Post-Socialist Economy and Capitalist Influences on Mental Illness

Following the collapse of the Soviet Union, Lithuania's economy converted from the socialist command economy to a capitalist-oriented market economy. There is much discussion within social and economic theory describing the Eastern European economic transition. Szelenyi (1998) built upon the work of Polanyi (1951) in seeing distinct stages in the transition from state socialism to the development of a market economy with capitalist institutions. The key factor, Szelenyi argues, is the role of business in consciously creating and expanding capitalist markets in Eastern Europe. My research draws from Szelenyi's argument by indicating the role of drug companies with the help of psychiatrists in consciously expanding their markets.

Health is related to the economic transition. Brainerd (1999) indicates that there is a relationship between the market reform of Eastern and Central European nations and mortality rates in those countries. Although the money that the Baltic Republics can spend on health and social services is mediated by many social and economic factors, the amount spent is related to the government's annual revenue.

My research suggests that, when faced with difficult economic choices, the Lithuanian government seeks to address the health care needs of the population (e.g., a very high suicide rate) with the most cost-effective means possible (medication, as opposed to psychotherapy).
In this section, I will review different perspectives on the relationship between psychiatry and capitalism. Unlike a capitalist economic system, the Soviet-style command economy fostered no profit motivation for markets to expand.

Under capitalism, psychiatry operates on a for-profit basis. One implication of this is unequal access to quality treatment. For example, Garfield (1994) indicates that the upper classes receive far better psychiatric care than the lower classes in the United States. He suggests that the treatment given to the upper classes is based on insight and inner understanding, while that given to lower socioeconomic groups is based on chemical pacification and containment. This type of care is by far much more expensive than simply medicating a patient, which appears to be the more common practice in Lithuania.

Bryan Turner (1995) points to the increasing globalization of Western medical knowledge. He discusses medical knowledge in theory, but does not address the complex interplay between professional psychiatric organizations and capitalism. According to U'ren (1997) both capitalism and psychiatry are interested in expanding their markets. U'ren draws upon Marxist conceptions of economics in capitalism, using Marx and Engels' (1848/1948) notions of capitalist competition, where capitalists create a "market" for the psychopharmaceutical industry. Using the Marxist M₁-C-M₂ formula, an initial investment (M₁) leads to a commodification (C), which is then sold for profit (M₂). This profit is then reinvested for more profit as the cycle continues. In short, in order to create a profit, goods must be marketed.

Foucault (1965) also saw socioeconomic factors as influencing the conception of, and creation of, mental illness. He argues that as the industrial revolution brought new era thought about the mentally ill, the rhetoric used to discuss the mentally ill changed: the "village idiot" began to be identified as a patient. Foucault finds no surprise that the industrial revolution brought with it the first asylums for the mentally handicapped, as the need for increasingly reliable labor became important. Although Foucault focuses on the relationship between discourse and economic factors, he sees the economy as a unit, rather than a set of competing interests that seek profit through labeling some as mentally ill. While U'ren sees psychiatry as operating along with the capitalist economic system, Foucault sees demeaning language as being an indirect cause of the changing economic systems. In contrast to Foucault, who emphasizes the capitalists' interest in maintaining a steady supply of reliable labor, I focus on the need to expand drug markets, which encourages the labeling of people as mentally ill.

Though my research draws upon aspects of all the mentioned theorists, it most closely resembles the claims made by U'ren. However, while U'ren focuses on diagnostic criteria, I see psychiatrists as the middlemen between larger capitalist economic forces and the official rates of psychiatric disorder they create. What is missing from U'ren's discussion is the way that psychiatry expands its markets and the role drug companies play in this expansion.

My research further indicates that mental illness is created through economic processes. Various researchers see the major diagnostic tool used by American psychiatrists, the Diagnostic and Statistical Manual, as creating mental illness through its use of categories, labeling the afflicted, and treating behavior as signs of mental illness (Sands, 1983; Mi-rowsky, 1989).

Three primary sources of data will be utilized to support my argument: interviews with various individuals associated with the mental health care system, government statistics, and archival data. Most of the archival materials consist of Lithuanian news articles from the Mazvydas Library and the Vilnius Medical Library.

This extended case study focuses on developments in Lithuanian psychiatry in the period from 1990 to 2000. 1990 is the year Lithuania first began to take clear steps towards independence on the world stage. Through interviews, I was able to see the world thorough the eyes of Lithuanian psychiatrists. Those interviewed were found by using the "snowball" approach. From a personal contact in Los Angeles, who had finished medical school in Vilnius, I was able to interview her former professor, who is now the current dean of the University of Vilnius medical school. This contact, in turn, led me to other psychiatrists in Lithuania, and so on.

Some of those interviewed, such as the dean of the Vilnius medical school, offered perspectives from a position of power within the health care system. Another psychiatrist interviewed was the director of a state-run clinic, while others were former presidents of the Lithuanian Psychiatric Association. Lastly, some psychiatrists were physicians employed by various state-operated clinics, which constitute the bulk of psychiatric clinics in Lithuania.

Interviews were conducted in an unstructured format, and all conversations took place in the Lithuanian language. Five individuals were interviewed during the summer of 2000: four psychiatrists and a Baltic representative for the pharmaceutical company Eli Lilly. Open-ended questions were asked; interviews typically lasted from one hour to an hour and a half. Three general topics were discussed in interviews: the respondents' accounts of the economic transition to capitalism, the role of medication versus psychotherapy, and Western pharmaceutical companies' influence on psychiatry in Lithuania.

The government statistics used to support my conclusions were obtained from the Lithuanian Ministry of Statistics and, in the case of diagnoses of specific types of mental illnesses, from the Vilnius Psychiatric Clinic. Archival data were used for general background information on changes in government policy on mental health and public perceptions of mental illness.

This section is organized around several dominant themes appearing in the data. First, recent trends in Lithuanian mental health care will be discussed, in addition to current rates of mental illness. As will be indicated, the government's need to save money, the prior dominance of the medical model under Soviet rule, and the perception of suicide as a public health problem have all had an impact on rates of mental illness. Next, an argument is presented about the means by which pharmaceutical companies influence rates of diagnosis of mental illness.

Since re-independence, Lithuania's Ministry of Health began to gather its own health statistics. Table 1 indicates the total number of reported cases of mental disorders in the records of the Ministry of Health for the years 1997 and 1998 for all types of mental illness. As is evident, the rates of increase are high—up to 305% for affective mood disorders— from 1997 to 1998. How can such rapid increase be explained?

Drug companies in Lithuania use aggressive marketing techniques. The conference Depresija 1995 (Depression 1995) was sponsored exclusively by Eli Lilly, and the 2000 National Suicide Conference was cosponsored by Eli Lilly. These conferences served several purposes. According to an Eli Lilly representative, "Doctors came and learned about depression and its treatment." Psychiatrists indicated that drug companies actively encourage doctors to attend conferences through informal enticements. The dean of the medical school told me:

When asked about the Depresija 95 conference, a psychiatrist came to a similar conclusion:

Though such perks are common to medical conferences in the Unites States, one must remember the cultural and temporal context in which this "courting" is taking place. During the Soviet era, Lithuanian medical doctors were (and continue to be) paid very little relative to their Western counterparts. According to government statistics, in 1997, the average worker in Lithuania earned 785 litas (approximately 196 USD) per month, whereas those engaged in human health activities earned only 640 litas (approximately 160 USD) per month. In 1997, doctors and other medical personnel earned, on average, the same amount per month as those engaged in sewage and refuse disposal (Statistical Yearbook of Lithuania, 1999).

Psychiatrists in Lithuania enjoy going to corporate-sponsored conferences very much. For them it is a taste, perhaps the only taste, of the "good life." As Western culture becomes increasingly visible in Lithuania, doctors would be expected to desire the cultural and material rewards associated with the medical profession in the West. The amount drug companies spend on conferences is only a fraction of the amount earned from the potential sales of pharmaceuticals.

When asked if drug companies can find out if particular doctors use certain products, a psychiatrist responded, "Yes. It's all in the books." Thus, informally, drug companies are able to "reward" doctors that prescribe their drugs through conference invitations. It seems that drug companies are "enticing" psychiatrists to prescribe medications, which is, in turn, reflected in the increasing diagnoses of mental illness.

A second explanation of why drug companies have been able to market their products so easily in Lithuania revolves around the high incidence of suicide in the country. Before the Soviet occupation, Lithuania's suicide rate was among the lowest in the world. However, as Table 2 shows, the rate steadily increased during the Soviet era and is now among the world's highest. Table 3 shows Lithuania's suicide rate compared to several other nations.

Year	Total	Rate per 100,000
1990	969	26.0
1991	1142	30.5
1992	1294	34.6
1993	1572	42.1
1994	1703	45.8
1995	1694	45.6
1996	1723	46.4
1997	1632	44.0
1998	1554	42.0

Various explanations have been offered for this high rate. One supposes that the rapid pace of social and economic change in Lithuania, following its independence has caused an increase in anomie. Another reasons that it is related to Lithuania's high rate of per capita alcohol consumption, which historically has been roughly proportional to rates of suicide. As shown, compared to other nations, even those close by, such as Estonia, Lithuania's suicide rate is very high.

Country	1990	1995	1998
Lithuania	26.1	45.6	42.0
Estonia	27.1	40.1	33.2
Hungary	39.9	32.9	32.1
USA	12.4	11.9	11.4	(1997)
Spain	7.5	8.1	8.5	(1996)

The growing perception of suicide as a major public health problem in Lithuania is important for this research because suicide is linked to various diagnoses of mental illness, such as depression. Partly in reaction to the high rate of suicide, a conference on depression was sponsored in 1995 in the city of Kaunas. Furthermore, a national conference on suicide prevention took place in Lithuania in 2000. From the Lithuanian government's point of view, such a high suicide rate provides a mandate to seek cost-effective strategies such as drug-based therapies, aimed at reducing suicide.

Since effective psychotherapy is potentially longer and more expensive than drug therapy, the latter is favored by the government. As one psychiatrist said,

Changes in health care reform favorably influenced pharmaceutical companies' ability to sell their products. Prior to 1994, there was no national health insurance in Lithuania. According to the first president of the Lithuanian Psychiatric Association, since the passage of a 1995 law, which promises all employed Lithuanians health coverage, there has been a movement toward greater biological-medical treatment of mental health. As Polubinskaya (2000) points out, there was a movement among psychiatrists in Lithuania to make a conscious break with the past. The dean of the Vilnius medical school explains,

The "Sajudis" political movement, which sought independence during Soviet rule and whose proponents ultimately came to power in the newly democratic Lithuania, wanted progressive psychiatrists, such as the current dean of the medical school, to steer Lithuania's practitioners away from Soviet-style therapy. To illustrate his reformed practice, the dean placed a renewed emphasis on psychotherapy and other forms of social and nonbiological therapy in Lithuania.

The shift from psychotherapy to drugs is related to a shift in government agencies, such as the Ministry of Health, toward private, rather than governmental sources of funding. Also, embarking toward deinstitutionalization of the mentally ill, the government is shifting to medicines that deal with the most severe cases ("ambulatory" medicine), as indicated by the reduction in the number of psychiatric hospital beds. Through medication, physical restraints have been replaced by chemical ones. Drugs used by Lithuanian doctors to treat affective mood disorders are now prescribed more often, reflecting the increase in diagnosed disorders.

The biological model that dominated Soviet medicine viewed psychiatric disorders as resulting from a breakdown in the organism itself (Krethschmer, 1978). According to Marxist dialectical materialism, which was the philosophical basis of Soviet ideology, in the Utopian workers' society (which the Soviet Union claimed to be), there could be no social cause for mental illness, hence the ideological search for biological causes of illness. A biological breakdown in psychological functioning was treated with biological means, as Miller (1985) clarifies:

The Soviets rejected Western models of psychology, such as the Freudian, because they did not deny the influence of external factors on mental health (Miller, 1985). As a result, Soviet psychiatry stressed the role of biological and chemical forms of treatment (Wortis, 1950). This biomedical approach has established societies that see the role of medication differently than do Western societies.

Professional associations in Lithuania and other post-Soviet countries are seeking new approaches to treatment. For example, Polubinskaya (2000) affirms the intention of the Lithuanian Psychiatric Association to "develop diagnostic and therapeutical [sic] approaches other than biological psychiatry." Polubinskaya's work relates to my research by indicating the legacy of the biomedical model in Lithuania and the LPA's attempt to move away from biological psychiatry.

This Soviet predisposition to see mental illness as something to be treated biologically, further enabled the drug companies to market their products to the medical community. In elaboration of this view, a Lithuanian psychiatrist told me:

The psychiatrist's reference to the "government" includes agencies responsible for health care, but especially the Mi-nistry of Health.

It seems clear that the stage was set for drug companies to enter Lithuania around the middle of the 1990s. According to a Baltic representative for a Western pharmaceutical company, following the disintegration of the Soviet Union, many corporations began conducting business in the newly independent Baltic States to meet a need for insulin. In 1994, Eli Lilly opened an office in Vilnius and began to market its products. The expansion of drug companies into Lithuania had an impact on psychiatry as well.

The number of psychiatrists in Lithuania has been relatively stable, perhaps due to informal benefits, while the numbers of other specialists are in decline, as Table 4 indicates, following the strategy employed by the Lithuanian health Program (http://www.sam.lt), a long-term goal of the Lithuanian Ministry of Health is to increase the number of psychiatrists from 230 to 250 by 2005. Table 4 indicates the changes in the number of various types of health care professionals in Lithuania.

1985	1990	1995	1996	1997	1998	Specialty (Area and % Change) 1985-1998
418	552	543	531	530	503	Neurology (+16.9%)
445	497	512	505	527	519	Psychiatry (+14.3%)
1716	1960	1699	1666	1646	1583	Pediatrics (-8.4%)
1693	1521	1371	1352	1340	1229	Surgery (-27.4%)
364	287	255	253	243	229	Pulmonary disease (-59.0%)

As a whole, after reaching a high point in 1990—the year prior to Lithuania's Independence—the number of physicians in Lithuania has steadily decreased. This can be explained by a number of factors, including a changing demographic structure in Lithuania. Table 5 shows the decreasing number of 20 to 24 year-olds, roughly the age group that would be entering college or medical school.

Due to this demographic shift, fewer students will finish medical school and go to work as doctors, or enter medical school at all. The relevant conclusion of Table 4 is that, while the number of specialists in various fields are decreasing, psychiatry is one of the few specialties that seems to be maintaining its numbers. One explanation for this is the desire for doctors to enter a field fostered by the government. Despite a decrease in 20 to 24 year-olds, there has been no decrease in the number of psychiatrists. Yet another explanation is the role of well-paying foreign drug companies vying for medical school graduates. As the medical school dean indicates, there are competing interests for those that potentially may be entering psychiatry, "Doctors that graduate here [from Vilnius Medical School] and work for drug companies earn five times as much as [those] working at a hospital—it is a dream for them."

Another interesting conclusion relates to the surprisingly small number of physicians entering cardiovascular medicine. According to the Ministry of Health, heart disease accounts for approximately one half of total mortality. Given this high rate, one would imagine the number of physicians entering the field to dramatically increase, not decrease.

The expected rise in Lithuanian psychiatric specialists would lead one to predict a further rise in affective mood disorders in the near future. With more psychiatrists entering the health care system, one would predict that there will be an overall increase in diagnoses. In the coming years, with predicted increases in the number of psychiatrists, a continued increase in the diagnosis of mental illness would not be surprising.

In summary, my research reveals the connection between economic factors and the increasing diagnosis of depression in Lithuania. The primary reason for the increase in diagnoses of depression is the influence of Western drug companies, which have managed to sell their products in Lithuania for three reasons: the government's need to save money, the prior dominance of the medical model, and the perception of suicide as a major public health problem.

Three general conclusions can be drawn from this research. First, the relationship between drug companies and the Ministry of Health is called into question. In young democracies, such as those in the former Soviet republics, business and social welfare must remain distinct. Second, increasing medicalization allows more power to fall into the hands of the medical professionals, who, as was indicated, are closely tied to market forces. As this research indicates, mental illness is a label which is all too easily applied. When individuals are led to believe that they are sick, their entire lives are affected. A third implication of this research relates to the consequences of medicating a population for the sake of profit. Anyone who has noted the side effects listed for common psychoactive drugs sees that often the physiological effects, such as sexual problems, tremor and in the case of Zoloft, feeling unusually sleepy, may be just as serious as the symptoms the drug was taken to relieve.

Lithuania is an ideal market for pharmaceutical companies. Of course, there may be a positive aspect to the presence of drug companies in Lithuania: Sick people are treated with quality medicine. Nonetheless, medicalization can be abused, and patients who could be treated through talking forms of psychotherapy may be overmedicated to their detriment.

My research contributes to the field of social psychiatry by linking capitalist economic influences to the rates of mental health diagnosis. Under capitalism, psychopharmaceutical companies operate for a profit. In order for drug companies to realize a profit, they must make sure that patients are diagnosed with mental illnesses treatable by psychotropic drugs. Mental health, therefore, is an arbitrary condition closely tied to economic factors: under capitalism, where profit is paramount, diseases, such as anxiety disorders, are marketed to their fullest extent by drug companies and psychiatrists.

My research indicates a connection between capitalism and the increasing diagnosis of mental illness in Lithuania. We are forced to consider the role of the economy in creating disorders and illnesses from thin air. Medicine, as a profession, rose to prominence only in the later half of the last century, yet today it holds a legitimacy that rivals hard science. We must remain skeptical of the objectivity of medicine, since, as this research indicates, those who practice medicine—the physicians themselves—are greatly influenced by market forces.

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Year	1985	1990	1995	1999
Number	297	276.9	283.7	259.8