Utsu: drugging the ordinary sadness of Japanese and children

[imomus]

"Utsu is the Japanese word for depression," proclaims a Helvetica caption in the elegant trailer for Mike Mills' 2007 documentary Does Your Soul Have A Cold? "Before 2000 utsu was seldom heard outside psychiatric circles. The concept of depression as a mental illness was virtually unknown in Japan... In 2000 the first Western pharmaceutical company began selling antidepressants in Japan. Utsu is now common knowledge."



I ran this "fact" past some Japanese friends. They all told me it wasn't true; that utsu was in fact a fairly commonly-used word long before 2000, and that anti-depressants had been advertised and sold in Japan since the 1960s.

Mike Mills repeats his thesis in this interview given when his film showed at SXSW in Austin, Texas: "Before 2000 they didn't really have a commonly-used word for depression, they didn't really know about depression, and they definitely didn't really know about it as, like, a mental illness that could be dealt with or cured or treated," Mills said. "And so companies like GlaxoSmithKline came in with these very large ad campaigns and website presence and symposiums and taught people about depression and their version of how to fix it."

But Mills adds a sort of disclaimer: "My film is more a portrait of five people who are taking anti-depressants than a heavy-duty reporting on GlaxoSmithKline or something like that." The story of a golden age before anti-depressants forms a kind of mythical backdrop to these five portraits. There are shades of the Garden of Eden and the Tree of Knowledge in his tale, but transposed to Japan; in Mills' telling, malaise is seen as a positive quality in Japanese folk stories, and Buddhism sees pain as an integral part of life. GlaxoSmithKline is the foreign snake suggesting the Japanese innocents bite into the apple.



Even if I'm a bit skeptical of the mythical backdrop to Mills' documentary, I think he's probably right about the lengths to which big drug companies are prepared to go to extend not just the definitions of mental illness into ever-more-normal areas of pain and anxiety, but also the categories of people they're prepared to prey upon. In a shocking article in the current New York Review of Books entitled Drug Companies and Doctors: A Story of Corruption, Marcia Angell exposes the kickbacks authoritative figures in US medical circles are receiving to whitewash new medications from major drug companies. She also shows how drug companies and professors of psychiatry like Dr. Joseph L. Biederman are encouraging doctors to diagnose children as young as two years old as "bipolar" and prescribe cocktails of powerful drugs.

"We are now in the midst of an apparent epidemic of bipolar disease in children (which seems to be replacing attention-deficit hyperactivity disorder as the most publicized condition in childhood)," Angell writes, "with a forty-fold increase in the diagnosis between 1994 and 2003. These children are often treated with multiple drugs off-label, many of which, whatever their other properties, are sedating, and nearly all of which have potentially serious side effects." Many of these drugs have never been approved by the FDA, and none of them have been approved for children below the age of ten.



There are parallels between the penetration of psychoactive drugs into new markets (Japan, children) and the mortgage crisis which triggered the great financial meltdown of 2008; in both cases sheer greed, aggressive marketing and spurious redefinitions have expanded markets in ways which delivered immediate new sources of profit, but also exposed everybody involved to new risks. Just as American banks were developing their ingeniously stupid No Income No Asset (NINA) mortgages, the mental health industry was developing criminally irresponsible No Illness No Effect (NINE, I guess) medications: drugs prescribed for perfectly normal types of sadness, and often no more effective than placebos. Angell describes how FDA reviews of the six most widely used antidepressant drugs approved between 1987 and 1999 -- Prozac, Paxil, Zoloft, Celexa, Serzone, and Effexor -- found that, on average, placebos were 80 percent as effective as the drugs.

This didn't stop GlaxoSmithKline from making $2.7 billion annually in sales of Paxil alone in 2004. Capitalism -- doesn't it make you sick?

The process by which drug companies expanded definitions of mental illness even to ordinary conditions of the human soul is covered well in Adam Curtis' BBC documentary series The Trap. Here are two excerpts from the series covering the invention of conditions like OCD, ADHD and PDSD:

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Dr Robert Spitzer, the creator of a simple new diagnostic system based on yes / no responses to questions about surface symptoms, admits to Curtis that he may have over-diagnosed mental illness by between 20% and 30%. The computerised system, launched in 1979, came back with the startling "finding" that more than 50% of Americans suffered from some type of mental disorder: a "hidden epidemic".



Context was ignored; "we don't know the causes, but this is what these new conditions look like". The new conditions -- OCD, ADHD, PDSD, SAD -- were met, conveniently, by new drugs from the major drug companies, SSRIs like Prozac, which modified behaviour chemically. Spitzer's checklist became a powerful guide to what was considered normal and abnormal, and people came to doctors expecting prescriptions for chemicals which would take away perfectly normal, realistic and, in many cases, appropriate mental states like fear, grief, anxiety, disappointment and loneliness. Social problems were medicalised, political solutions tranquilised.

When the American adult market became saturated with these abnormality-defining conditions and the normalcy-bringing drugs associated with them, it was time to move on to new markets: children and -- apparently -- Japanese people.

Comments

[krskrft.livejournal.com]

What's sad about this is that there are people who can obviously use and benefit from these types of medication. But the medical community, which is firmly in the pockets of the pharmaceutical companies, sets the bar extremely low for positive diagnosis of very real psychiatric problems. Like, I don't deny that ADHD, for example, is a real, distinguishable issue that prevents many people from functioning as they would like to in their every day lives, but when little children are diagnosed attention-deficit just because they won't sit completely still all day in school (what normal kid does sit still all day in school?), that's fucked up. Because not only are these kids being unduly medicated. That's, oddly enough, the less important issue. The bigger problem is that these kids are told that they have a mental problem, and so they grow up feeling dysfunctional and broken, and the illness becomes an excuse for anything that goes wrong (leading to self-hatred and depression, in many cases). The most damaging aspect of it is the social labeling, not the unnecessary medication.

[wolodymyr.livejournal.com]

I tutor, and I see a lot of kids diagnosed with things that require drugs whose necessity I question. But just about every time, the situation in the home is emotionally/ psychologically extreme.

In order for the kids to be medicated, there are two things that need to happen, and the complicity of the medical community is only one of them. The other thing that has to happen is that a parent has to pay to have the prescription filled, and likely often make sure the drug is taken.

In order for the parent link of the chain to be broken, we'd have to be more okay with talking far more openly about parent-child relations.

Chicken-egg question of the day - what's going to happen first? Big Pharm stops directing medicine, or parents say "I have a problem" before they say "my child is a problem"?

[imomus.livejournal.com]

Talking about it with Hisae, we kind of agree with the milder formulation of Mike Mills' argument -- in the SXSW interview he says utsu wasn't openly talked about until the mid-90s on. And Hisae thinks this might be true -- Japanese society has been very secretive about mental disorder. It was the arrival of the internet that started the conversation. On the internet you could talk anonymously about depression (even plan group suicides), circumventing the usual taboos. You could also order drugs from overseas online.

[saikoutron.livejournal.com]

Having someone in the family who has been diagnosed with mental illness could potentially interfere with any other immediate member's chances of marriage in the future - and the term "mental illness" is used very broadly here. A friend of mine found her marriage to have met some opposition from the other family, simply because her sister was colour blind. I wonder if "not openly talked about" meant that you ahd to keep it from your own family as well?

Otherwise, I'm pretty sure you've read Dr Rosenhan's "On Being Sane in Insane Places (www.scottsdalecc.edu/ricker/pests/online_articles/Rosenhan1975.pdf)," (pdf), but seeing those first few minutes of the YouTube videos brought all that back to me. Having done a rotation in a psychiatric unit, it's all a bit too easy to imagine.

[dabroots.livejournal.com]

The FDA's relaxation of direct-to-consumer advertising by pharmaceutical companies in the US, and the billions in profits reaped through it, no doubt emboldened those same companies to take on the most Westernized of all Asian countries.

[cheapsurrealist.livejournal.com]

Somewhere between big pharma and tom cruise there is a wonderful place where people in mental anguish can find relief. The secret is - find the right Doctor. It could take years.

And scientific research needs to continue. Just think if SSRIs where available in 1974. Nick Drake might still be alive and working on his 8th mediocre come-back album. It would be nice to have the old boy around.

As far as young children go - bit of a stcky wicket. No easy answer there.

But as a 53 year old man all I can say is - Don't be fuckin' with my zoloft!

[lord-whimsy.livejournal.com]

I'm currently enduring two herniated discs, sciatica in my right hip, bursitis in my right shoulder and burns on my face from removing precancerous lesions. But I'm hesitant to even take an aspirin.

Just don't like pills.

a longer history?

[(Anonymous)]

Do have a look at this amazing collection of psychiatric drug packaging from Japan, starting post-war.
http://psychodoc.eek.jp/abare/gallery/index_e.html
wishing you well,
roger

Re: a longer history?

[lilitu93.livejournal.com]

I want to take the happy cat drug:

http://psychodoc.eek.jp/abare/gallery/doral.jpg

Seriously, as someone who's suffered off and on from depression and whose life has been helped by taking one form antidepressants (Cipramil/Celexa) and hurt by taking another (Amitryptaline, taken in low dosages for chronic pain, not depression), I have mixed feelings about the whole issue.

On the one hand, mental illness is probably still underdiagnosed, and it's not surprising that 50% of people or more suffer from it a year - look how many people suffer from physical ailments in a year - but that doesn't mean that everyone from it suffers from chronic mental illness or that acute mental illness always needs to be treated by drugs. And I do worry about little kids being drugged out of their minds, so to speak.

Also, don't forget the flip side of current medical practice is that non-drug treatments of illnesses aren't researched as thoroughly as they should be. So if you have an illness that can't be treated by a drug, it's less likely that research will be done into what can treat it.

[st-ranger.livejournal.com]

Effexor gave me my life back. Even if the makers of this amazing medicine are greedy soul-sucking jerks, I still love them. :)

[simasima.livejournal.com]

Uh . . . doesn't this entry contradict your recent one on Affluenza, at least in terms of Western societies? I mean, either it's a pharmaceutical conspiracy, or we really do have increased mental illness thanks to capitalist policies.

[imomus.livejournal.com]

I don't see why it can't be both a pharmaceutical conspiracy and an increase in mental illness thanks to capitalist policies, since it's the drug companies (via sock puppet doctors) who define what "real mental illness" is.

[(Anonymous)]

A big part of medical marketing is “inventing” lifestyle diseases and creating awareness of the new treatments available.

Many articles in scientific medical journals are written by professional medical writers, paid for by the pharmaceutical companies, and not the actual doctors (key opinion leaders) listed as authors.

[(Anonymous)]

Taking potshots at big pharma is a bit too easy. The drug companies do as much good as they do harm. But it's a business, and like any business it needs regulating, proper oversight and transparency, and it's the government that's been falling down on the job in that respect.

[(Anonymous)]

The name of Thomas S.Szasz springs to mind when you all talk about this "pharmacologization" of society. He's the author of The Myth of Mental Illness", which I'm sure most of you eggheads have heard of, or even read.

Here's "the antipsychiatrist" talking in a strange setting: http://es.youtube.com/watch?v=Qj7GmeSAxXo

[electricwitch.livejournal.com]

You do know this whole anti-psychiatry stance has ceased to be edgy since Scientology, right?

[aienn.livejournal.com]

“depression” is not a medical condition here in Russia
and, thankfully, never was in USSR

I recall a friend from Denmark seeking medical leave here in Moscow complaining that she is depressed. several doctors politely explained to her that depression is not a medical condition and she should get her shit together and come back to her university studies. the public reaction is, thankfully, the same — “depression = sadness, cheer up, make yourself useful and everything would be alright”

yes you could (potentially) buy Western antidepressants, but that changes almost nothing — Russians are still supposed to experience the full sensory palette, which is good

[krskrft.livejournal.com]

This is all fine and well, and I've got a healthy skepticism about mental illness myself. But I do actually know people who've suffered from bipolar disorders (namely my father, my sister, and a very good friend). It would seem to me that a bipolar disorder (manic highs and rock-bottom lows) is something that is fairly observable, and easy to segregate from "normal" or "healthy" feelings and/or behaviors (i.e. those feelings and behaviors which allow a person to maintain at least a baseline functionality in his/her life). This, as opposed to, say, ADHD, where diagnosis is incredibly vague, and for which it is very difficult to segregate behaviors from "normal" or "healthy" responses to certain stimuli (i.e. the fact that kids tend to have more unspent energy, aren't equally socialized for, say, the classroom environment, have been raised under different cultural circumstances than those of the generation doing the diagnosis, etc).

I have firsthand accounts, from one of my best friends, of what his life was like when he was manic, and before he was briefly institutionalized. I believe him when he says that he literally had no idea what he was doing at the time, that he was being controlled by an out of whack brain chemistry. And this is what I come back to whenever anybody, in response to the slimy behavior of the pharmaceutical companies, tries to deny that there is absolutely no such thing as a mental illness. That experiencing a mental illness merely means "to experience the full sensory palette." It would seem to me that only a person who's never gone through such an experience could formulate such an assertion.

I had a roommate in college who wanted to study neuropharmacology (and was in graduate school doing just that, last I heard). He wanted to create the "perfect drug," which he argued would probably be like exstasy, only with no side-effects. His (oh so clever) argument was that nobody should have to feel pain or discomfort or depression or any kind of anguish. Such a drug would be better than anything. It would be all we would ever need. And the question I immediately put to him, knowing that he'd just started going out with this girl: would this drug be better than her? Would you not need her? And of course, he sort of giggled and didn't answer me. At the time, I didn't have the vocabulary or academic background to explain it, but I was coming around to what I now understand to be the structuralist/post-structuralist idea, that we can't know a thing without the existence of its opposite, or of those things which allow us to distinguish it by comparison or contrast. We can't know what it means to be happy without knowing what it means to feel sad, or angry, or any number of other emotions that some pharmaceuticals purport to "cure" or otherwise cleanse our lives of. And it seems like that's what you're trying to get at when you talk about "the full sensory palette."

But at the same time, severe depression and severe mania are real, observable things. They may be conditioned, triggered, whatever, to a certain extent, by the things that happen in our lives, or the ways we live, or the things we do. In many cases, it is just a simple matter of "getting our shit together." But when you're wandering around a big city thinking you're a superhero, and the day before you were fine, and after the fact you can't recall what made you feel that way, or when you do pin down the trigger, it seems like it would not have triggered such a severe reaction in most others, that's kind of a red flag.

Misdiagnosis is rampant in psychiatry, but we shouldn't take that to mean that there aren't some "disorders" worth paying attention to. As always, I think the controlling factor should be that the patient desires care due to not being able to engage in normal, everyday functions. Everything should be on the table: life changes, habits, diet, and yes, even medication.

Anyone want any beta-blockers?

[(Anonymous)]

I was given them for a numb finger.

The best doctor I've been to was a herbalist. They simply have more time to ask you about your lifestyle and what factors to remove, rather than add.

I'd say that 3 out of the past 5 visits to my GP were misdiagnoses.

[(Anonymous)]

We are the least satisfied species on the planet. That is why we have evolved to this point, and built so much huge crap (skyscrapers, airplanes, computers, etc).

Formerly, the majority of the population had religion to support them when the daily events of their lives brought on doubt (which was an inevitable occurance for the least satisfied species). Since compulsory education became the norm, we now have lots of half-way eduated people who have moved beyond the the hokey religion stuff, but have not found anything to take its place except pills.

I think in the future, the temptation will be far too great for the majority of the population to avoid being on pills all the time and eventually spending increasing portions of their time in synthetic virtual reality worlds. Societal progress should grind to a halt at exactly that point.

[imomus.livejournal.com]

Well, if people in the future are anything like me they'll be completely un-interested in drugs. I'm not sure why, but I've always been this way. I hate to be controlled by external influences, and I hate the idea of a reward without an objective correlative, happiness without a reason to be happy.

[(Anonymous)]

But it's my understanding that the suicide rate in Japan has traditionally been comparatively high, and that even non-psychiatrists are aware of that. How, until now, have ordinary Japanese explained the suicide problem if speaking of depression was taboo?

[imomus.livejournal.com]

Because suicide in Japan is not essentially a matter of your head, but of your face. It is more about shame, honour, appearances, omote than sadness, depression, hopelessness etc. Though obviously there is a connection.

[xyzedd.livejournal.com]

Depressing. In recent weeks, in the little bit of news I've witnessed, there has been a lot of mainstream media attention in America to doctors no longer accepting swag from drug companies (is there a new AMA rule or something?) and also a lot of focus on people, from comics to psychiatrists, debating whether things like Aspberger's syndrome or even nut allergies are being over- or mis- diagnosed.

[krskrft.livejournal.com]

If you're a tad bit eccentric now, they think you have Asperger's syndrome. Again, probably a real issue (you'd have to believe that autism is a sham in order to believe that a gradation of it--which is what they believe Asperger's to be--doesn't exist), but it seems like it would be very difficult, and possibly quite pointless, to diagnose a minor case of it.

[rurritable.wordpress.com (from livejournal.com)]

It's important not to confuse sadness with clinical depression. I've known people who suffer from depression, and if it were a matter of just being sad, or down, it would have been a tremendous improvement for them. It's more a matter of mental anguish leaching into your physical pain receptors. You can't fucking move, and if you could move, you'd take the first opportunity to kill yourself. Read Dick Cavett on the subject. He's an articulate victim.
That said, sadness is one of the defining aspects of a person's character. It's frequently the shadow of creativity.
I can't remember the exact quotation, but Nabakov said something to the effect that our sadness is the thing that is most uniquely our own, and up until now, it was inviolable. The effort to monetize it is bound ultimately to result in a society of dipshits.

[cap-scaleman.livejournal.com]

And these days some people get a different type of medication, often one that is cheaper to produce, which is worthless. If they have Parkinson's and get a medication that doesn't work it can go considerably wrong.

My grandmother, for example, got some new medication for Parkinson's and it gives her hallucinations among other things. Completely worthless!

[eclectiktronik.livejournal.com]

the talk of depression instantly reminded me of this marvellous collection of pics of various derelict places in japan -like a sort of metaphor. faded glories and all that. here:http://home.f01.itscom.net/spiral/research.html

Heroes and villains

[dr--ben.livejournal.com]

ooh momus on sociology of medicine, total win.

I'm always a bit dubious about any model in this area where individuals are the unwilling victims of a corporate conspiracy to rebrand subjective human experience. it seems to me that there's something very seductive about reframing our emotions and social problems in reductionist biomedical terms, we need to embrace ownership of that and examine it, also it's not just big pharma, but also quacks and the media, as i argue in this, er, extract from my book.

http://www.badscience.net/2008/09/the-medicalisation-of-everyday-life/

Ben Goldacre

Re: Heroes and villains

[imomus.livejournal.com]

Thank you, Dr Ben, and I totally agree with the points you make in that extract. In fact, I'd like to quote one paragraph here, for anyone whose ADHD prevents them from reading the whole thing:

"The World Health Organisation’s Commission on the Social Determinants of Health reported this week, and it contained some chilling figures. Life expectancy in the poorest area of Glasgow - Calton - is 28 years less than in Lenzie, a middle-class area just eight miles away. That is a lot less life, and it isn’t just because the people in Lenzie are careful to eat goji berries for extra antioxidants, and a handful of brazil nuts every day, thus ensuring they’re not deficient in selenium, as per nutritionists’ advice."

[kumakouji.livejournal.com]

There was a programme on BBC Two recently called How Mad Are You? (http://www.bbc.co.uk/headroom/newsandevents/programmes/horizon_hmay.shtml) in which ten volunteers, half with psychiatric disorders, the other half without lived in a house together under the supervision of experts.

Over five days the group were put through a series of challenges - from performing stand-up comedy to mucking out cows. The events were designed to explore the character traits of mental illness and ask whether the symptoms might be within all of us. Three leading experts in mental health attempted to spot which volunteers of the ten had been diagnosed with a mental health condition.

As expected, The the results were mixed -- the experts didn't always get it right.

I think that behaviour therapy should be the first port of call for anyone who feels they can't deal with things. I think one of the reasons I developed such a deep interest in Buddhism is because it presented me with a reasonable answers to the uncertainties I had about my self, it completely changed my perspective.

That said, I have a friend who had a mental breakdown recently. He's been put on a very high dose of anti-psychotics. It seems to have helped him get his life back on track. Maybe a placebo or therapy would have worked.

[darthhellokitty.livejournal.com]

Severe depression runs in my family on both sides. Until SSRIs were made available, we had at least one suicide (or "hunting accident") per generation. I would not be here if not for medication.

I'm not taking "happy pills" - I doubt I'm any happier, or happy any more often, than anyone else. I have highs and lows like anybody else. I'm just not lying in bed all day figuring out what I have around the house to do myself in with.

[imomus.livejournal.com]

By sheer coincidence, I just got asked today to interview Mike Mills for a magazine next month. So I'll get to ask him about utsu in person.

[pulled-up.blogspot.com (from livejournal.com)]

Is he in Berlin for the film festival?

[qscrisp.livejournal.com]

This is a subject close to my heart. Of course, recently we've had news that research suggests anti-depressants are no more effective, generally, than placebos. This is something I've believed for a long time, having taken many, many different kinds. The definition of depression is, well, a delicate and touchy thing. I certainly don't believe depression is all about 'chemicals in the brain', which is utterly facile. You might as well say that politics is all about 'chemicals in the brain', that the situation in Gaza is all about 'chemicals in the brain', and so on. If I have taken many, many kinds of anti-depressant, it's largely because I've been advised to do so, and it seems as if not to do so sends out the message that you don't want help, or don't want to change. And yet, again and again, the only thing that was ever offered me, was pills.

I never found them to work. Never, over a period of many, many years, except for a brief period in Japan. I took prescription drugs in Japan in the year 2002, not long after Mike Mills says Japanese depression was invented. I didn't have the impression that the doctor was unfamiliar with utsu-byo at all, though he asked if I minded medical students sitting in on the consultation - I said I didn't. I have a vague impression, from the Japanese people I spoke to, that 'depression' is not seen so much as a household medical term as it is in the west. People are ever so slightly unfamiliar with it, or were in 2002, and fumbled for a word they'd heard somewhere - utsu-byo.

Medicalising depression is, in my view, a way of not dealing with its implications. Others disagree with me. Many who have suffered depression have recommended pills to me. In the end, I have been baffled by such recommendations. But then, different people respond differently to different substances. Commerically available anti-depressants seem like a really, really bad one-size-fits-all treatment, and there lies behind them the philosophy, or the lie, that a substance can make everything all right. It can't.

By the way, enjoying Joemus.

[(Anonymous)]

Read up on Traditional Chinese Medicine: these "diseases", ADD/ADHD, Autism, Bipolarity, and Depression, all have the same root cause: Jing Deficiency.

wiki Jing (TCM)


And all of them can be addressed with diet, herbs, acupuncture, and lifestyle practices.

The drugs deplete more Jing to simply metabolize and thus entrench the issue further; like putting out fire with gasoline...burning down the house. It's a case of building up the belfry with the foundation stones. Pharmaceuticals deplete Jing by unnaturally sucking it out from the stores in the body and pipelining it to the brain which makes one feel..."more". It's this flatline of "more" that allows some to bootstrap their way back into normalcy...but for some it only amplifies the psychosomatic symptoms of the real problem thus suicide, mania, etc....but all are just doing irrevocable damage to their genetic makeup which...if you haven't noticed... has created a population rife with autistics, Riltalin-jockies, and social inepts. You'll also come to see that it creates a nation of people sterile-without-assitance and more short-lived. Jing is that thing in the body that is like the honey jar of life; once its gone, you are too.

The only thing that will turn this around is by implementing TCM concepts which so far only has analongs in the Green movement: local, in season, not too far, clean air, low stress, limited caffiene, meat only to tonify deficiency & sickness, processed foods no longer created thus imparting an economic/worldhunger/povertry coloration to some of these issues...and then even more so the further you study this paradigm of the body-in-the-world that TCM acts as lense. The most important element remedied from TCM practices as covered in your "capitalism/sick" piece: sustainable emotional palettes. Food creates emotional latitude directly. Low-efficiency nutrition, aka empty calories, creates the empty feelings, in short. One feeds into the other and creates a vicious cycle. And the Western medical paradigm of "unintended consequences" used to "fix minds" is as stated, a dangerous state of palliative abuse. Arsenic can make you sleep at night, too.

Depression Symptoms in terms of TCM

[(Anonymous)]

SSRI WITHDRAWAL PROCEDURE
http://www.itmonline.org/arts/ssri.htm

In pills we trust

[thomascott.livejournal.com]

Good post, Momus does Ben Goldacre.
This CH4 doc, which I saw a number of years ago examined similar themes, only from the perspective of the U.S.
http://www.liontv.co.uk/_london/productions/documentaries/in_pills.html

I have a friend, who after several years of battling depression, did with great reluctance agree to taking medication and did with find SSRIs helpful.
The problem is of course is that people like this are more the exception than the rule; antidepressants are prescribed for the monday-morning-blues and it makes sense, that with U.S. markets saturated, drug companies should seek to propagate the culture of pathologisation in Japan.