How The Pharmaceutical Industry Profits From Unprocessed Civilizational Shame

In 1990, Prozac was six months old and had already appeared on the cover of Newsweek. The drug was not a breakthrough in the scientific understanding of depression — it was a relatively modest improvement in the side effect profile of existing antidepressants. But it was marketed as something else: proof that depression was a chemical imbalance, specifically a serotonin deficiency, and that correcting the imbalance with medication was the appropriate medical response.

The "chemical imbalance" theory was attractive to everyone involved. Patients felt their suffering was legitimate and biological — not weakness or failure. Physicians had something concrete to offer. Insurance companies had a billable, bounded condition. And pharmaceutical companies had a massively expanded market.

The problem was that the theory was not well-supported by the science, even at the time. Serotonin's role in depression is real but not simple. Antidepressants work for some people in some conditions — the evidence is clear on that — but "chemical imbalance corrected by medication" was always a marketing simplification, not a scientific consensus.

In 2022, a landmark umbrella review of evidence published in Molecular Psychiatry by Joanna Moncrieff and colleagues at University College London concluded that there was no convincing evidence that depression is associated with lower serotonin activity or levels. The review was widely covered and disputed — particularly by those with financial interests in SSRI markets — but it reflected a genuine scientific conversation that had been underway for years.

The significance is not that antidepressants don't work — for many people they do — but that the story sold to justify their use was inaccurate, and that inaccurate story had consequences. People were told their suffering was chemistry when it was often also circumstance. They were given medication to manage symptoms while the circumstances were left unaddressed.

No story illustrates the mechanism more clearly than the opioid epidemic.

OxyContin launched in 1996. Purdue Pharma's marketing was aggressive, targeted, and built on claims the company's own research did not support. They told physicians and patients that extended-release opioids were significantly less addictive than immediate-release versions. They funded ostensibly independent medical education programs that promoted opioids for a wider range of conditions, including chronic non-cancer pain — a category that had previously been treated more conservatively. They deployed a sales force specifically to high-prescribing physicians and tracked prescription data to target their promotions.

The patient populations being targeted included many people whose pain had significant psychological components: chronic back pain exacerbated by workplace conditions, fibromyalgia, anxiety-related somatic symptoms. These were not always people suffering from conditions that would respond primarily to medication — they were often people whose suffering included elements that would respond to therapy, to changes in working conditions, to social support. They were given opioids.

By the time the addiction crisis became undeniable, hundreds of thousands of people had developed severe opioid use disorders. Many had started with legitimate prescriptions and found themselves addicted through no moral failing — they had taken medication as prescribed by trusted physicians, and the medication had done what opioids do.

The societal response was initially to double down on shame. Addiction was framed as moral weakness. People who were addicted to opioids derived from prescriptions were treated the same as people who used street drugs — as though their circumstances were equivalent. The legal system imposed criminal penalties. The medical system was often unhelpful. The shame prevented help-seeking.

The Purdue Pharma bankruptcy proceedings and the subsequent litigation revealed the extent to which the Sackler family (owners of Purdue) knew what their drug was doing and continued selling. The company's internal documents showed awareness of addiction rates, awareness of diversion to illicit markets, and deliberate strategies to manage the public relations problem while continuing to profit. The total death toll attributable to the opioid epidemic exceeds 500,000 Americans.

Shame was functional throughout this story. The shame attached to addiction prevented individual help-seeking. The shame attached to opioid prescribing (for physicians who recognized the problem) prevented early collective action. The stigma of addiction in public discourse prevented policy response. The Sacklers relied on all of these silences.

Attention Deficit Hyperactivity Disorder is a real neurodevelopmental condition. Stimulant medications — Ritalin, Adderall, and their successors — are genuinely helpful for many people who have it.

But ADHD diagnosis rates in the United States have increased dramatically over the past three decades — from approximately 3-5% of children in the 1980s to approximately 10-12% today. Some of this reflects better identification. Some reflects genuine environmental factors — increased stress, sleep deprivation, screen exposure. And some reflects the expansion of the diagnostic category under commercial pressure.

The production of ADHD medication is a multi-billion dollar market. The diagnostic category expanded as the market expanded. Direct-to-consumer advertising for ADHD medications — permitted in the United States — contributed to increased parental requests for diagnosis. Pharmaceutical companies funded ADHD advocacy organizations and medical education programs.

The harder question — what conditions produce the inattention, impulsivity, and dysregulation diagnosed as ADHD — is not always asked. Research consistently shows that trauma, particularly adverse childhood experiences, produces symptoms that overlap substantially with ADHD. Children who experienced abuse, neglect, family instability, or poverty frequently show attentional and regulatory difficulties.

When these children receive stimulant medication, the medication may help them function better in school. That's a real benefit. But it does not address the traumatic experiences or the chaotic home environments that may be contributing to the symptoms. The medication manages the presentation; the root cause remains.

The diagnostic expansion is not a conspiracy. Most of the physicians prescribing medication believe they are helping. But the system in which they operate has financial incentives that point toward medication and time constraints that prevent the thorough assessment that would distinguish ADHD from trauma response from simple sleep deprivation.

The pharmaceutical management model crowds out alternatives — not through malice but through resource allocation and framing.

Insurance reimbursement structures in the United States systematically favor medication over psychotherapy. A psychiatrist can see four to six medication management patients in an hour. A therapist can see one therapy patient. The revenue differential is enormous. Many psychiatrists no longer do therapy — they see patients for 15-minute medication management appointments. Therapy is left to therapists who are often not covered by insurance or whose reimbursement rates make their practices economically marginal.

Evidence-based therapies that address root causes — EMDR for trauma, CBT for depression and anxiety, DBT for emotional regulation disorders, ACT for a range of conditions — are effective. Meta-analyses consistently show therapy is as effective as medication for mild to moderate depression and anxiety, and more effective for preventing relapse. The combination of therapy and medication often outperforms either alone.

But the system makes medication cheaper, more accessible, and more reimbursable. The rational response for a patient without resources or time is medication.

Community mental health, which was supposed to provide the alternative after the deinstitutionalization of the 1960s and 70s, was chronically underfunded from the beginning. The community mental health centers that were meant to replace the asylums were never built at the necessary scale. The gap was partially filled by emergency rooms, jails, and homelessness — more expensive and less effective than the treatment centers that never came.

The pharmaceutical industry did not create this system. But it benefited from it and has consistently lobbied against the structural changes — expanded insurance coverage for mental health, parity requirements, funding for community mental health — that would create genuine alternatives.

What would it look like to design a health system that used medication as one tool rather than the primary one?

It would start from a different question. Not "what symptoms does this person have that I can treat pharmacologically?" but "what is this person's suffering about, and what does that require?"

That question leads in different directions depending on the person. For some, medication is part of the answer — possibly a large part. For others, the primary need is therapy, social connection, economic stability, escape from an abusive relationship, meaningful work, or treatment for a physical condition being expressed as psychological symptoms.

A system built to actually ask and answer that question would require:

Adequate time for assessment. Fifteen-minute medication management appointments cannot produce thorough clinical pictures. The system that produces them is not designed for thoroughness — it is designed for throughput.

Integration of social determinants. The physician who can prescribe medication but cannot address the patient's food insecurity, housing instability, or interpersonal violence is working with one hand tied behind their back. Integrated care models — where primary care, behavioral health, and social services share the same record and the same team — exist. They are not the norm.

Equitable access to psychotherapy. Universal or near-universal coverage for evidence-based therapy, at rates that make therapy sustainable as a practice, would fundamentally change the treatment landscape.

Trauma-informed practice throughout the health system. The patient who presents with depression and has a trauma history is better served by a practitioner who understands that history than by one who sees only the depression. Trauma-informed care is not a specialty — it is a practice framework that should be standard.

Non-shame-based addiction treatment. The evidence is clear that shame-based approaches to addiction treatment are less effective than approaches that preserve dignity and address underlying pain. Harm reduction — meeting people where they are, reducing the immediate risks of addiction without requiring abstinence as a precondition for help — consistently outperforms abstinence-only approaches on most outcome measures.

The pharmaceutical industry is not the villain in this story. It is an industry doing what industries do: finding profitable markets and expanding them. The failure is systemic — the absence of strong public health infrastructure, the underinvestment in therapy and community mental health, the economic structures that reward symptom management over root-cause treatment.

Changing it requires treating emotional wellbeing as a public good rather than a private market. It requires building the non-pharmaceutical alternatives that the current system crowds out. And it requires refusing the story that suffering is always a chemistry problem — because that story, however comforting, leads people away from the harder truth about what they actually need.