Digital Pills Provide New Possibilities for Coercion but also Resistance

Critical psychologists outline the increased risk of coercion with digital pills while also exploring possibilities for new forms of activism.

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A paper published recently in the journal Economy and Society explores the wide range of possibilities afforded by the recent emergence of digital psychiatric drugs, highlighting new forms of personhood, methods of social control, and acts of resistance.

According to the group of authors, led by Lisa Cosgrove, a Professor of Psychology at the University of Massachusetts Boston, this is simply one recent example in a long history of psychiatric technologies used to surveil those labeled “mentally ill.” 

And yet, the digital aspect of this particular technology evokes a unique set of social, political, and historical questions, including: 

  • Why was a drug used primarily for schizophrenia chosen as the first digital medication? 
  • Is industry gaming the system by creating ever more ingenious ways to effectively extend patents (by adding sensors to blockbuster drugs whose patents have expired)? 
  • What is it about the digital nature of an antipsychotic that engenders such strong negative reactions? 
  • What new forms of psychiatric coercion and resistance are afforded by a digital psychotropic medication and what relational and affective possibilities might become available with its use?

With each pill equipped with its own digital sensor that detects when it has been consumed, data can be collected related to whether, and if so when, the medication was taken. Those who manufacture and market these pills claim this is intended to help individuals remember to take their medication consistently and on time while making them more accountable to their doctors. 

In an earlier published review article, however, Cosgrove et al. (2019) describe the research and proposed applications underlying the FDA approval of the first of such digital pills—a form of aripiprazole (trade name Abilify)—to be misguided, at best. Notably, they point to there being “no prospective, double-blind, randomized, controlled trials comparing digital aripiprazole with the non-digital version, other active comparators, or placebo.” 

The digital nature of the drug has, moreover, fueled more general concerns about how digital technologies will increase coercion in psychiatry, with some lamenting the rise of the digital asylum. Amidst mounting criticism of its approval of the digital version of aripiprazole, the FDA publicly defended its decision, with the head of the Psychiatry Products division stating that public discussion about the drug has been “obscured by sensationalism.” 

Addressing the first two questions listed above, Cosgrove et al. describe the choice to use aripiprazole, a drug often prescribed for those diagnosed with schizophrenia, to be odd given how distrust towards those in authority is already such a common experience among those in this population. Putting something into their body that sends signals to someone in another location would only seem to exacerbate this lack of trust. 

However, the authors provide extensive evidence to suggest this decision was made largely for financial reasons, with the patent for Ability expiring shortly before digital aripiprazole was approved. Not only is the price for generic aripiprazole ($20 a month) considerably less than the recently released digital version, Abilify MyCite ($1,700 a month), but obtaining a new patent for what is essentially the same chemical compound allowed the market monopoly over it to be extended. 

The authors describe this process as “evergreening,” which benefits the company considerably despite offering “little to no therapeutic benefit to patients.” As they explain,

“This stealth culture allows drug manufacturers to develop highly questionable strategies (e.g. slight modifications to existing drugs) to extend market monopoly after a blockbuster drug goes off patent.” 

Next, the authors explore what it is about the digital nature of Ability MyCite that has engendered such strong negative reactions. On the one hand, they explain, “digital technology and self-tracking have become a ubiquitous part of many people’s lives.” Some even enjoy the access to personal data digital technology can provide them. 

And yet, such instances of “private self-tracking,” the authors suggest, must be differentiated from forms of “imposed tracking,” where corporations or government agencies generate data in ways that minimize or ignore the agency of the person being tracked. With imposed tracking, “the spectre of coercion is inevitable and looms large,” especially in the context of psychiatry’s long history using dehumanizing practices to isolate and control those whose experiences are outside the social norm. 

Going further, the authors draw parallels between Abilify MyCite and philosopher Jacque Derrida’s analysis of the concept, pharmakon, which includes substances that, depending on the context, can operate as a poison, a cure, or a scapegoat. From this perspective, whether a substance is harmful or beneficial depends largely on who contributes most to the discourse and practices surrounding it. As they explain: 

“It is not simply that the drugs are ‘spying on us’, their use has the potential to reinforce regressive notions of authority, and to further stigmatize (as anti-citizens) individuals struggling with emotional distress . . . For example, questions such as ‘have they ingested the digital pill at the correct time?’ become more important than understanding lived experience (e.g. ‘Are the side-effects too burdensome?’ and ‘What forms of personhood become unavailable when they are ‘medication compliant’?)”

All too often, writers critiquing the coercive elements of psychiatry themselves rely on a logic of paranoia, concluding with feelings of hopelessness that foreclose new possibilities. This is not the goal of the current article. While the authors acknowledge that vulnerable populations (e.g., incarcerated persons or those using illicit drugs) are likely going to be disproportionately coerced into taking such digital pills, they caution that this is not the only possible outcome. 

Decisions to use (or not use) digital pills occur at the intersection of increasingly complex cultural, scientific, economic, and historical systems in ways that, the authors suggest, demand a model of agency that is more nuanced than traditional individualistic/humanistic accounts.

Drawing on posthumanist scholars like Donna Haraway and Karen Barad, they rethink agency as something that must be both enacted and negotiated, a social practice rather than individual capacity. As they explain: 

“There is always the possibility that one can reconfigure the material-discursive practice that is Abilify MyCite. Meaningful relationships, renewed self-understandings, and/or various forms of resistance could emerge through these reconfigurations.”

In this sense, any account of digital pills that focuses exclusively on the harmful consequences of the technology would itself serve to minimize the agency of those prescribed it. Whether or not Abilify MyCite serves as a tool for psychiatric coercion, they suggest, depends as much on the society, local ecology, and unique creative capacities of the person prescribed it as anything intrinsic to the technology. 

To illustrate this point, the authors cite Michel Foucault’s (1984) now popular quote, “It’s not that everything is bad it’s that everything is dangerous” (p. 231). While it is important to keep a watchful eye on how psychiatric technologies reconfigure individual bodies on both biological and behavioral levels, while following the money to who benefits most from such reconfigurations, the authors likewise urge an open mind regarding how: 

“New forms of personhood and relations to healthcare providers, caregivers, and kin might be rearticulated in ways that are meaningful and important to people taking the digital version of aripiprazole.”

There is a long history of psychiatric survivors and other activists inventing creative ways to subvert the coercive mechanisms of the profession of psychiatry. This often involves negotiating identity in what can be complicated ways.

Whether it is by hacking the technology embedded in the pills or simply refusing to take them outright, there will certainly be possibilities for new forms of resistance opened up in the era of digital pills.

 

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Cosgrove, L., Morrill, Z., & Karter, J. M. (2021). Digital aripiprazole as a human technology. Economy and Society, 50(3), 359–373. https://doi.org/10.1080/03085147.2021.1908767 (Link)

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Tim Beck, PhD
MIA Research News Team: Tim Beck is an Instructor in psychology at the University of West Georgia, where he earned a PhD in Psychology: Consciousness and Society. For his dissertation, he traced a critical history of the biomedical model of mental health, focusing on diagnostic representations of autism, and became interested in the power of self-advocacy movements to reshape conventional assumptions about mental suffering. In fall 2019, he will start a new position as Assistant Professor at Landmark College, where he will collaborate with students and faculty at their Center for Neurodiversity.

19 COMMENTS

  1. I had never heard of digital pills before. This is terrifying.
    I was already considering cancelling my upcoming primary care appointment because I’m afraid of the mandatory depression screening. It’s this sort of thing that reminds me that my fear of the medical system is in no way based on paranoia. It’s perfectly rational.

    • Nothing irrational about being afraid of people who are dangerous to you!

      As for depression screenings, my understanding is that it’s totally OK to refuse to do them. It is also completely legit to just answer in the way that reflects best on you – they have no right to know your inner thoughts and feelings!!! So if they ask me, “Have you felt depressed in the last three weeks?” of course, I always say, “No” no matter what I’m feeling. I’m sleeping fine, my appetite is fine, etc, etc. until they are done. But the more I think about it, the next time I hear them starting in on this, I’m going to say, “Is this a ‘depression screening?’ If so, I decline to participate and will not answer any questions on the screening.”

      That may or may not be realistic for you. I find it obnoxious that they have the temerity to do such a screening when they have no idea what to do with a “positive” outcome (and of course are screening in the first place for something so vague and subjective that no one can tell if you “have it!”) But I do know I’m in charge of my own medical care, and the more I assert that right, the better I feel about my interactions.

      • Yes, I’ve been advised many times to either refuse the screening or give false responses, but the idea of doing either scares me. Decades of experience have shown me that I’m not in charge in those situations, and making any attempt to be assertive has often ended very badly. Having lived with a diagnosis that is code for non-compliant, lying, drug seeking, hysterical, delusional patient and the impact that that has had on the way I’ve been treated in healthcare situations, I can’t even envision having healthcare that would meet my needs and not feel dangerous. The only reason I was going to go was because of a blood blister on my lip that I’ve had for over a year. But I decided today I’d rather continue to live with the deformity than face another interaction with the system that has done enormous damage to me already. I also know that, in the mind of my primary care provider, I have too long put off screenings. I haven’t had a mammogram or pap smear or colonoscopy in years. I know she’ll bring that up if and when I ever have an appointment with her again. The truth is that any screening would be pointless because if I did have a positive screening result, I would not seek treatment for it. But because I can’t say that, it’s another thing I need to lie about. The risk reward ratios are so far out of whack that unless I’m in an immediate life or death situation, I need to avoid these people like the plague. I’ve heard many other psych survivors say the same thing.

          • KateL, I too feel that way, as a psych survivor, in regards to the mainstream medical community, which I agree is sad.

            I was, thankfully, able to get the head of family medicine at a very well respected hospital, to take my psych misdiagnosis off my medical records, by medically explaining the prior malpractice to him.

            But I did later deal with a moronic, likely psychiatrist, from that hospital – after I’d been diagnosed as physically healthy (I’d gone to the hospital due to pain caused by a pulled muscle over my heart) – ask me “are you depressed?”

            That “Dr. Paine” was easily dismissed, by telling him no, and politely explaining I was allergic to the anticholinergic drugs.

            But I agree with you, once psychiatrically misdiagnosed, attempting to maintain a mutually beneficial and truthful relationship with the mainstream medical industry is seemingly fruitless.

            At least my medical records have theoretically been cleared, but my trust in mainstream medical doctors has largely been destroyed.

            So I’m at the point of looking into alternative medical doctors. Since mainstream medicine’s trust and profiteering, based upon the scientifically “invalid” DSM, has largely destroyed my trust in mainstream medicine.

            And since I already know mainstream medicine’s trust in the psychiatric DSM theology, is all based upon their desire to have psychiatry cover up their easily recognized iatrogenesis.

        • ….”There is always the possibility that one can reconfigure the material-discursive practice that is Abilify MyCite. Meaningful relationships, renewed self-understandings, and/or various forms of resistance could emerge through these reconfigurations.”….”…. <-from the article. That 1st sentence is PURE WORD SALAD. Psycho-babble. Gobbledy-gook…. Those people who talk that way are over-educated idiots. It is their brutality inflicted towards myself, and others of my kin, that has EARNED ME the RIGHT to express myself thus…. Psychiatry is the personification of MEDICAL FASCISM. Only Otsuka PhRMA "needs" cyborg Abilify. And, I understand that the RFID chip in each pill is only strong enough to travel a few short feet to a wearable device. So, who thinks it's a good idea to fill the bellies of so-called "mental patients" up with digital debris? Certainly not good, loving, natural persons! Psychiatry is a pseudoscience, a drug racket, and a mechanism of totalitarian social control. It's 21st Century Phrenology, with potent neuro-toxins. Psychiatry has done, and continue to do, FAR MORE HARM than good…. So-called "schizophrenia" is just as "real" as presents from Santa Claus, but NOT more real…. The World WILL BE a better, healthier, happier place when psychiatry is finally flushed down the toilet bowl of history, along with Otsuka PhRMA, and digital medical fascism in pill form…. Go ahead, prove me wrong! I DARE YOU!….

      • Fear is not a rational response to any situation. It is an understandable response, but will not result in rational behavior. To rationally handle an evil or destructive threat you must be able to recognize the threat and take quick and effective action. Fear paralyzes people.

        In this example, if you need a checkup, get a checkup but refuse any mental health screenings. If the screening cannot be refused, just leave. Acting terrified in that situation could only get one in more trouble. But I must admit, I have been staying away from doctors unless I know exactly what their beliefs are regarding certain basic subjects. That leaves some people who “care” about me worried about me. But at least I don’t have to go around feeling worried about myself!

        • I actually screen my doctors ahead of time. I let them know that I’m in charge of decisions, they’ll advise me but I may or may not take their advice, and if that’s not OK with them, they should let me know right away and I’ll find another provider.

          Though I prefer to avoid doctors altogether. I usually get a nurse practitioner or a physician’s assistant to be my PCP. I actually now have a naturopath as my PCP. The less I see of doctors, the happier I am, generally speaking.

    • Don’t be scared. Fear is pointless. You are an individual. As an individual, you know what you have to do and say in order to survive. They cannot read your mind. Doctors have a tendency to misunderstand what you are saying and over-medicate. Always say no, or yes. If you don’t answer, they will assume the worst and medicate you even if you don’t need it. Recently, I went for an eye exam to get glasses. The doctor misunderstood me and gave me a prescription for prism glasses. So all I did is I went online, and ordered glasses myself, without the prism part that I don’t need! Psychiatry is much worse, since they legally pressure you to take the drugs. Nothing you can do about that, except lie to them!

      • It’s been 3, maybe 4 years, since I last read up on Otsuka PhRMA’s digital “Abilify”. They use a low power, RFID-type “chip”, such as in store loyalty cards. They are very low-power , and can transmit only as far as a wearable device. But that was as of a few years ago, so….maybe they are higher powered & longer range now…. Otsuka also pays/ bribes doctors directly. They paid one local psychiatrist a total of over $10,000., in one, 2-year period, for “consultant” work….etc.,

  2. What worries me the most about articles of this type is that in their fascination around the power dynamics of various technologies, there is no particular mention of whether they will actually help people get better.

    I see a practice being criticized but with no sense of how it could be replaced with something better.

    The main author (Cosgrove) on her academic web page talks about both social justice and human rights. Yet it has been demonstrated that these two ideas in many ways conflict.

    Sometimes I get the feeling that some of these people live in a different world (like a video game) and have no interest in inviting others who don’t just “get it” in.

      • Exactly, Steve. Now that I think about it, could this be the first entry in what will eventually become a replacement of all standard prescription pills with digital pills? After all, wouldn’t the medical argument (doctors can monitor compliance) apply to ALL prescribed pills? I can even imagine insurance companies and other third-party payers refusing to pay for prescriptions not taken as directed. I’m going out on a limb and predicting within 20 years, digital pills will be common across medicine, adding many dozens of extra billions to pharma profits. I hate to be cynical but when it comes to psychiatry’s biomedical paradigm, my experience is that the reality is always much worse than you think no matter how cynical you are.

    • With a price difference so drastic, I don’t think it will be an “easy sell.” That means potential customers will have to be forced to pay this price. How will this be done? I see some sort of new extortion racket brewing. Pure profit motive? I don’t think so.

  3. What is anyone doing to help the people who are the literally dying from this? It’s all opinions? it’s all advice? That’s great .what a wonderful world this is. Psychiatry fits right in. “You’re doing it wrong. just do it the right way and maybe you’ll survive”. Okay.

  4. What is the purpose of “digital pills”? Simple: They don’t want anyone to try to stop taking their medicine because then society might discover the truth, that the medicine is just a highly addictive neurotoxin that treats nothing! Over the past 18 years, I tried to stop the medicine multiple times and failed. Then, a few years ago, I started doing an ultra-slow taper. So far, I am doing very well. My psychiatrist even says that I am in complete remission, but she doesn’t know I am done with the antidepressant and I am down to 14% dosage of the aripiprazole! I have found alternative ways of dealing with any symptoms such as listening to music. Furthermore, I have found that certain kitchen spices seem to help, which is strange because most people think they are just for flavoring. I am expecting it will take another 7 years of this slow tapering before I am done with meds completely.

    I also wanted to say, that as a patient, having your meds tracked is the last thing you would want, unless you want to become a drooling zombie with no hope of recovery. They will probably only try to track your meds, if you admit that you refuse to take them. This society lies about many things, but they also force some of us to lie, in order to survive.

    I am not sure how the digital pills work, but assuming they function using a temperature sensor, you could easily defeat them with a small electronically controlled heating chamber.

  5. Well the digital meds have been around for a while. So has that vague and open ended sort of leading question.

    After over a year dealing with a woodsy skin issue, I finally saw a dermatologist. The “new patient” question list was quite ordinary until the last one: “Are you safe?”. What does that mean? It seems to be vague so that the patient will spill just about anything. I wanted to ask: “why the question:, but we all know that that would invite inappropriate prying.

    The PCP will tell us that the ‘council on XYZ’ has listed tests and investigations for different demographics. Say:”No thank you” and you risk a “non-compliant” tag or worse, paranoia.
    These people do seem to be trawling for “mental disease” and its subsequent treatment. We still can simply not do what is ordered. We can avoid medical contacts.. well usually. I still will be sewn up for injuries and accept the tetanus booster “every ten years or ” time of injury”.

    However, if we have young children, the landscape is full of question landmines. Pediatricians will question children about their parents’ lives. Example: Do your parents drink? Do they scare you? It does get worse. Children may not know the answers and may make up a response to make the doctor happy. Still kids do get sick, and they need patching up especially in the summer time. Maybe parents can help children by explaining and offering standard responses that will satisfy the doctor. We ask: Can this happen in our country? It does; so let us be calm and ready.

    One medical office exclaimed: “You haven’t seen a doctor in two years?” Oh my goodness, my internal organs will fall out if not billed by a “provider”!

    It’s wonderful to hear that false entries can be deleted. In my state, entering false information in a client’s record is a misdemeanor at the first offense. Report the offense and present the primary-sourced evidence to the state and what happens? Nothing happens. If the charge is sexual abuse, there is a deal. The offender can make a deal and not appear on the list of offenders. Hey, I acquired a transcript of the state’s investigations…… from the state.
    What can we do to really protect against silly accusations? Walk softly and carry a big bag of evidence and have an attorney ready, or just try not to be noticed. I am doing that last one…for now.

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