I didn\u2019t set out to shape the field of psychiatry. I was just a copywriter working in pharmaceutical advertising. But over time, I found myself at the center of a campaign that would help transform how mental illness\u2014and its treatment\u2014are understood in the U.S. This is the story of how we marketed one drug, Risperdal, and how that effort helped turn atypical antipsychotics into a multi-billion-dollar industry.<\/p>\n
If you\u2019ve ever wondered how this powerful class of drugs ended up being prescribed for everything from adolescent mood swings to agitated nursing home patients, you\u2019re not alone. The rise of atypical antipsychotics was a business and marketing phenomenon\u2014driven in part by a wave of pharmaceutical mergers in the 1990s. First introduced for schizophrenia, atypical antipsychotics were promoted as more effective and safer than older drugs like Haldol or Thorazine.<\/p>\n
While journalists and regulators<\/a> have addressed this issue, I want to share my memories of marketing Risperdal\u2014the first widely prescribed atypical antipsychotic. This is the story of how we promoted Risperdal not just as a medication, but as a revolution in psychiatric care. It\u2019s also the story of how we redefined schizophrenia, rewrote the safety narrative of antipsychotics, and helped drive one of the most successful (and concerning) pharmaceutical launches in history.<\/p>\n It was also my first realization of the immense power marketers have to shape their version of the truth\u2014and how I eventually came to question the very system I helped build.<\/p>\n The Pressure Cooker: Launching Risperdal in Midtown Manhattan<\/p>\n In the mid-1990s, I stepped into the kind of job people in pharmaceutical advertising dream about: co-creative director and lead copywriter on the industry\u2019s next big blockbuster. The agency was in Midtown Manhattan. The client was Johnson & Johnson. The drug was Risperdal. From day one, it was a pressure cooker.<\/p>\n Risperdal was our agency\u2019s biggest account, so demanding that one colleague warned me the creative team was burned out, and one of the senior writers was threatening to quit. The problem? J&J had acquired two companies during the merger frenzy of the mid-1990s: McNeil, which marketed aging Haldol, and Janssen, which made the newer Risperdal.<\/p>\n When Haldol Failed, the Stakes Shifted to Risperdal<\/p>\n McNeil hoped to maintain Haldol revenues by filing for a new indication\u2014dementia-related agitation. But the FDA denied approval; and the ad campaign we\u2019d spent six months developing was shelved. I can still recall it 30 years later: photographs of elderly patients holding flowers with the headline \u201cFragile: Handle with Haldol.\u201d A clever, emotionally resonant ad campaign suggesting parents could age at home instead of a nursing home, thanks to Haldol\u2014and all gone in an instant.<\/p>\n We were stunned and disappointed, including the head of the CNS (central nervous system, or psychiatric drugs) franchise at J&J. Without patent protection, generic competition would cause Haldol\u2019s price to drop precipitously. The FDA denial meant that Risperdal would have to carry the entire CNS portfolio.<\/p>\n The ultimate challenge facing us was this: how to convince psychiatrists to substitute a drug that costs ten times more (Risperdal) for a widely accepted and effective drug (Haldol). We would need to justify Risperdal\u2019s premium price tag by positioning it as the next generation option for schizophrenia. But that would require a full reframing of what schizophrenia even was\u2014and a redefinition of Risperdal\u2019s role in treating it.<\/p>\n Many people don\u2019t realize that a drug\u2019s marketing story begins long before FDA approval. Today, drug and device business strategy and planning is backed by an army of researchers, communication companies, and consultants. Often, these strategies are covert and secretive, so much so that those involved at different stages of the drug\u2019s life cycle may be unaware of the corporation\u2019s ultimate marketing intent.<\/p>\n The remainder of this blog will illustrate the various strategies\u2014such as clinical trial design, physician and consumer education, patient advocacy, and market access\u2014used to create a so-called breakthrough therapy for mental health.<\/p>\n Promoting the PANSS Rating Scale: Risperdal\u2019s Rise, Haldol\u2019s Fall<\/p>\n Janssen didn\u2019t just market a new drug\u2014we needed to aggressively differentiate Risperdal from older agents by promoting a new framework for thinking about schizophrenia. And at the center of it all was the PANSS (Positive and Negative Syndrome Scale) rating scale.<\/p>\n In psychiatry, there\u2019s no blood test or brain scan that confirms a diagnosis or proves a drug is working. Instead, clinicians and researchers use rating scales that convert subjective symptoms into numbers. The choice of scale isn\u2019t neutral. Companies choose the one that is most likely to portray their product in a favorable light. That choice shapes trial results, positioning, marketing claims, and how the product is perceived compared to its competitors.<\/p>\n Janssen chose the PANSS for many of Risperdal\u2019s Phase 3 trials. PANSS broke schizophrenia symptoms into two categories: positive (hallucinations, delusions) and negative (emotional withdrawal, apathy). While older drugs like Haldol primarily treated positive symptoms, we said that Risperdal could also target the harder-to-treat negative symptoms. That positioning didn\u2019t just help Risperdal\u2014it helped usher in the entire atypical antipsychotic era by shifting psychiatry\u2019s focus toward chronic, cognitively framed symptoms as targets for pharmaceutical treatment.<\/p>\n The Rise of Atypical Off-Label Use<\/p>\n This growing awareness of negative symptoms opened the door to something even more consequential: the off-label use of atypical antipsychotics. And it didn\u2019t grow through overt promotional tactics\u2014it grew quietly, through a redefinition of what counted as treatable.<\/p>\n Once doctors viewed Risperdal as a tool to improve cognition, motivation, or emotional balance\u2014not just control hallucinations\u2014atypicals expanded into broader psychiatric markets. It made sense to use them for conditions like ADHD, dementia, and conduct disorder. The perception of superior safety over Haldol\u2014and that Risperdal appeared to lack virtually any side effects\u2014only accelerated the trend.<\/p>\n This expansion may not have been the original plan, but it\u2019s how atypicals started being prescribed for behaviors only loosely related to schizophrenia.<\/p>\n The $1 Million Immersive Exhibit: Selling Negative Symptoms to Doctors<\/p>\n How could we make cognitive symptoms\u2014ones that older drugs like Haldol didn\u2019t seem to touch\u2014feel real to psychiatrists? Academic thought leaders had helped legitimize the PANSS<\/a> through articles and lectures. But we needed something more visceral.<\/p>\n What followed was one of the most elaborate marketing tools I ever worked on: a jaw-dropping $1 million immersive exhibit<\/a> at the 1998 APA (American Psychiatric Association) meeting in<\/a> Toronto.<\/p>\n The idea started at an expensive lunch in New York. We were sitting in a four-star restaurant, brainstorming ways to make Janssen\u2019s exhibit booth stand out at the upcoming APA conference. Someone sketched a concept on a napkin: simulate schizophrenia\u2014specifically, the internal voices patients often describe. If we could make psychiatrists feel what their patients experienced, maybe they\u2019d take negative symptoms more seriously.<\/p>\n By the time of the conference in Toronto, that napkin sketch had evolved into a soundproof booth simulating a high-stakes job interview. I suggested we make it a medical residency interview\u2014something psychiatrists would find relatable. The goal was to make the experience feel real.<\/p>\n A consulting psychologist who supervised the exhibit created a script using self-critical, emotionally harsh dialogue\u2014designed to mirror the negative symptoms of schizophrenia.<\/p>\n I always imagined auditory hallucinations as overtly psychotic\u2014like a voice insisting the government had implanted a tracking device in your skull. But these were different: quieter, crueler, more internal. The kinds of voices that chip away at motivation, confidence, and cognition.<\/p>\n I sat across from psychiatrists as they struggled to answer basic interview questions while those voices whispered in their ears. I adjusted the volume as they squirmed\u2014raising or lowering it depending on their discomfort. Some broke into visible sweat. More than one asked to end the simulation early. The line to try the experience wrapped around the exhibit hall.<\/p>\n We tricked ourselves into thinking it was about empathy. I\u2019m embarrassed to say I didn\u2019t see anything wrong with it at the time. The ultimate goal: to implant the belief that negative symptoms were real and debilitating, and that Risperdal could treat them.<\/p>\n The Risperdal Safety Story\u2013Part Fabrication, Part Truth Alongside efficacy in negative symptoms, safety was the second pillar of our campaign\u2014specifically, Risperdal\u2019s purported lower risk of extrapyramidal symptoms (EPS) compared to Haldol. EPS includes movement disorders like akathisia (restlessness), tremors, rigidity, and tardive dyskinesia. These were the most dreaded side effects of the older-generation antipsychotics.<\/p>\n Risperdal appeared to cause fewer EPS in early trials compared to Haldol\u2014but those clinical study results<\/a> were skewed because Haldol was dosed at unusually high doses, almost ensuring worse side effects. The comparison wasn\u2019t just unfair\u2014it seemed deliberately manipulated to make Risperdal seem dramatically better than Haldol in terms of safety. In various trials, Haldol was routinely dosed at very high levels\u2014often above 12\u202fmg\/day\u2014well past the point of added benefit. Studies show that once haloperidol exceeds approximately 5 mg\/day, the risk of EPS increases steadily, while efficacy plateaus; in other words, EPS is dose-dependent.<\/a><\/p>\n One important thing to note is that when the FDA approved Risperdal in December 1993, the agency stated that it would consider any advertising or promotion suggesting that Risperdal was superior to Haldol to be false and misleading. This restriction meant we couldn\u2019t make direct claims of superiority in promotional materials. Paid thought leaders could mention \u201cfewer EPS than Haldol\u201d in speaker programs and publications<\/a>, but we couldn\u2019t make clinical comparisons in ads or sales aids.<\/p>\n Since the FDA had made its position clear, our advertising copywriters learned to imply superiority without explicitly stating it. Through carefully chosen language, we crafted a message that stayed within regulatory boundaries without crossing them.<\/p>\n Leveraging Pharmacological Pseudo-Science<\/p>\n One of the ways we skirted regulatory limits in promotion was by using a receptor binding story\u2014a pharmacological narrative that hinted at superiority without explicitly stating it. Because we couldn\u2019t claim that Risperdal was safer or more effective than Haldol, we contrasted differences in how the newer atypicals and the older antipsychotics interacted with brain receptors.<\/p>\n Specifically:<\/p>\n We emphasized Risperdal\u2019s balanced blockade of dopamine D\u2082 and serotonin 5-HT\u2082A receptors, the hallmark of its \u201catypical\u201d profile. This allowed us to tell a compelling, science-based story without stepping over regulatory lines. Risperdal thought leaders, however, could link the receptor narrative to clinical advantages in abstracts<\/a>, journal articles<\/a>, and sponsored CME programs.<\/p>\n I personally wrote an advertorial in a leading medical journal suggesting that 5-HT\u2082A antagonism seen with atypicals \u201cmight be associated\u201d with enhanced cognitive function or reduced negative symptoms. In promotional materials, we were very cautious, referring to Risperdal\u2019s \u201cloose binding\u201d to D\u2082 receptors. The wording was vague enough to pass regulatory review\u2014but the implication was clear.<\/p>\n Most doctors lack the time to scrutinize every scientific claim made in advertising, at CME programs, or in published articles. If you gave them a plausible story, they\u2019ll fill in the rest.<\/p>\n Market Access Strategy: The Linchpin of Risperdal\u2019s Success<\/p>\n Convincing doctors to prescribe Risperdal wasn\u2019t enough. Someone needed to pay for it. Since most patients with schizophrenia didn\u2019t have private insurance, government programs would be footing the bill.<\/p>\n I was impressed when Janssen provided our ad agency with a white paper highlighting the bureaucratic obstacles families face in accessing mental health services. It was created by a major healthcare consulting firm. Janssen then asked me to turn it into a practical, consumer-friendly brochure which we titled \u201cThe Informed Consumer: A Practical Guide to Paying for Mental Healthcare.\u201d<\/a> The brochure was distributed in doctors\u2019 offices, handed out to psych nurses, and to patients enrolled in the Janssen Pathways Program.<\/p>\n At first, I believed this was an altruistic effort\u2014helping families navigate the complexities of healthcare insurance. At the time, I felt proud of it. We were doing something good for vulnerable people seeking mental health coverage.<\/p>\n But over time, I saw the intent more clearly. The brochure\u2019s underlying message was clear: start the Medicaid and Medicare enrollment process immediately after a psychotic episode. On the surface, it sounded like public health advice. In reality, it was designed to ensure the individual was enrolled in Medicaid, so that their outpatient Risperdal prescriptions would be paid for after being released from the hospital. Janssen\u2019s profits were dependent on reimbursement from public health insurers, including Medicaid, Medicare, the VA, and the Department of Corrections.<\/p>\n The Business of Compliance: How Medication Adherence Helped the Bottom Line<\/p>\n After we\u2019d laid the groundwork\u2014proving efficacy, managing safety concerns, and securing reimbursement\u2014the next challenge was keeping patients on Risperdal continuously. Janssen\u2019s solution was a program called \u201cPathways to Change.\u201d \u201cPathways\u201d purported to be an educational resource. In reality, it was a sophisticated patient retention strategy.<\/p>\n \u201cPathways to Change\u201d had multiple components, including brochures for patients, caregivers, and healthcare professionals. But the central message running through all materials was consistent: don\u2019t stop taking your medication. Our medication adherence strategy included a toll-free service, Person-to-Person, which offered families and providers live support for questions about Risperdal treatment and reimbursement issues.<\/p>\n I wrote several handouts with input from the Risperdal Advisory Board\u2014a group of well-known clinical research thought leaders supportive of the drug. Bringing in this respected board lent the materials an authoritative tone. All members were paid, but that didn\u2019t necessarily make them shills. Many were genuinely enthusiastic about Risperdal, which is why they were chosen in the first place. Medical experts with reservations about Risperdal\u2014or who took a more cautious stance\u2014did not have a seat at the table.<\/p>\n One of the patient materials, a brochure titled \u201cTransitions,<\/a>\u201d was handed out to people being discharged from hospitals after a psychotic episode. It provided relapse prevention tips, including reminders to keep taking medication after leaving the hospital.<\/p>\n I also wrote a piece for psychiatrists titled \u201cThe Therapeutic Alliance,\u201d<\/a> developed in collaboration with our advisory board. Its core premise was simple: medication adherence improves when patients trust their providers. The brochure recommended doctors make Ulysses agreements\u2014where a patient consents in advance to future treatment, including forced hospitalization or medication, during periods of decompensation. Just as Ulysses instructed his crew to ignore his future pleas, these agreements allowed clinicians to override a patient\u2019s objections based on earlier consent.<\/p>\n In hindsight, it was a masterstroke in \u201cmessaging\u201d\u2014cast in the language of empathy, but one with a clear marketing objective. By encouraging medication adherence in therapeutic partnership, we extended our influence far beyond the prescription itself\u2014into the relationship between patient and provider.<\/p>\n The NAMI Factor <\/p>\n The final linchpin in our marketing strategy involved aligning with a mental health advocacy group. Risperdal would not have become a household word without NAMI.<\/p>\n In the late 1990s, NAMI\u2014the National Alliance on Mental Illness\u2014was still relatively small, with pharmaceutical funding; that changed quickly. As the creative lead on the Risperdal account, I worked with NAMI and Executive Director Laurie Flynn<\/a>, whose daughter had schizophrenia. With support from Janssen and other atypical antipsychotic manufacturers, NAMI began advancing a powerful message: schizophrenia wasn\u2019t caused by trauma or poor parenting\u2014it was a biologically-based brain disorder, treatable with medication.<\/p>\n It was a compassionate narrative intended to remove stigma. But it also aligned with Janssen\u2019s commercial goals. If schizophrenia were purely biological, it would require lifelong medication. Risperdal was positioned as essential.<\/p>\n I became close with Ken Steele, Janssen, and NAMI\u2019s most visible spokesperson. Ken had spent much of his life in psychiatric wards, after being locked in his room as a teen by grandparents who believed he was possessed. Ken became Janssen\u2019s unofficial poster boy\u2014traveling the country, giving interviews, and telling the story of how he was \u201ccured\u201d by Risperdal.<\/p>\n I liked Ken a great deal. He was warm, brilliant, and funny. But there\u2019s a tragic footnote to his story: Ken died in 2000 of complications tied to Risperdal\u2014obesity, diabetes, and heart disease.<\/p>\n We never told that part of the story.<\/p>\n The Cracks Start to Show<\/p>\n For a while, the strategy held. We had the talking points, the scientific language, the educational tools, and the belief system to back it all. But belief can only carry a brand so far. Eventually, reality sets in. By the late 1990s, the cracks in Risperdal\u2019s claims started to show.<\/p>\n Early on, we emphasized two key points: Risperdal was more effective than Haldol, and it caused far fewer side effects\u2014especially the tremors and stiffness associated with older antipsychotics. Sales representatives echoed this\u2014as did medical conferences, educational materials, and journal reprints that positioned Risperdal as psychiatry\u2019s future: modern, safer, and better.<\/p>\n
\nWalking the regulatory tightrope<\/p>\n
\nWe contrasted this with Haldol\u2019s high-potency, nearly exclusive blockade of D\u2082 receptors.
\nWe linked strong D\u2082 blockade to movement-related side effects, such as EPS, while suggesting that serotonin-D\u2082 balance might reduce these risks.<\/p>\n