Confessions of an Ad Writer: How I Helped Turn Atypical Antipsychotics into a Billion-Dollar Industry

I didn’t 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—and its treatment—are 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.

If you’ve ever wondered how this powerful class of drugs ended up being prescribed for everything from adolescent mood swings to agitated nursing home patients, you’re not alone. The rise of atypical antipsychotics was a business and marketing phenomenon—driven 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.

While journalists and regulators have addressed this issue, I want to share my memories of marketing Risperdal—the 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’s 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.

It was also my first realization of the immense power marketers have to shape their version of the truth—and how I eventually came to question the very system I helped build.

The Pressure Cooker: Launching Risperdal in Midtown Manhattan

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’s 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.

Risperdal was our agency’s 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.

When Haldol Failed, the Stakes Shifted to Risperdal

McNeil hoped to maintain Haldol revenues by filing for a new indication—dementia-related agitation. But the FDA denied approval; and the ad campaign we’d spent six months developing was shelved. I can still recall it 30 years later: photographs of elderly patients holding flowers with the headline “Fragile: Handle with Haldol.” A clever, emotionally resonant ad campaign suggesting parents could age at home instead of a nursing home, thanks to Haldol—and all gone in an instant.

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’s price to drop precipitously. The FDA denial meant that Risperdal would have to carry the entire CNS portfolio.

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’s 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—and a redefinition of Risperdal’s role in treating it.

Many people don’t realize that a drug’s 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’s life cycle may be unaware of the corporation’s ultimate marketing intent.

The remainder of this blog will illustrate the various strategies—such as clinical trial design, physician and consumer education, patient advocacy, and market access—used to create a so-called breakthrough therapy for mental health.

Promoting the PANSS Rating Scale: Risperdal’s Rise, Haldol’s Fall

Janssen didn’t just market a new drug—we 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.

In psychiatry, there’s 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’t 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.

Janssen chose the PANSS for many of Risperdal’s 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’t just help Risperdal—it helped usher in the entire atypical antipsychotic era by shifting psychiatry’s focus toward chronic, cognitively framed symptoms as targets for pharmaceutical treatment.

The Rise of Atypical Off-Label Use

This growing awareness of negative symptoms opened the door to something even more consequential: the off-label use of atypical antipsychotics. And it didn’t grow through overt promotional tactics—it grew quietly, through a redefinition of what counted as treatable.

Once doctors viewed Risperdal as a tool to improve cognition, motivation, or emotional balance—not just control hallucinations—atypicals 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—and that Risperdal appeared to lack virtually any side effects—only accelerated the trend.

This expansion may not have been the original plan, but it’s how atypicals started being prescribed for behaviors only loosely related to schizophrenia.

The $1 Million Immersive Exhibit: Selling Negative Symptoms to Doctors

How could we make cognitive symptoms—ones that older drugs like Haldol didn’t seem to touch—feel real to psychiatrists? Academic thought leaders had helped legitimize the PANSS through articles and lectures. But we needed something more visceral.

What followed was one of the most elaborate marketing tools I ever worked on: a jaw-dropping $1 million immersive exhibit at the 1998 APA (American Psychiatric Association) meeting in Toronto.

The idea started at an expensive lunch in New York. We were sitting in a four-star restaurant, brainstorming ways to make Janssen’s exhibit booth stand out at the upcoming APA conference. Someone sketched a concept on a napkin: simulate schizophrenia—specifically, the internal voices patients often describe. If we could make psychiatrists feel what their patients experienced, maybe they’d take negative symptoms more seriously.

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—something psychiatrists would find relatable. The goal was to make the experience feel real.

A consulting psychologist who supervised the exhibit created a script using self-critical, emotionally harsh dialogue—designed to mirror the negative symptoms of schizophrenia.

I always imagined auditory hallucinations as overtly psychotic—like 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.

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—raising 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.

We tricked ourselves into thinking it was about empathy. I’m embarrassed to say I didn’t 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.

The Risperdal Safety Story–Part Fabrication, Part Truth

Walking the regulatory tightrope

Alongside efficacy in negative symptoms, safety was the second pillar of our campaign—specifically, Risperdal’s 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.

Risperdal appeared to cause fewer EPS in early trials compared to Haldol—but those clinical study results were skewed because Haldol was dosed at unusually high doses, almost ensuring worse side effects. The comparison wasn’t just unfair—it 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—often above 12 mg/day—well 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.

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’t make direct claims of superiority in promotional materials. Paid thought leaders could mention “fewer EPS than Haldol” in speaker programs and publications, but we couldn’t make clinical comparisons in ads or sales aids.

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.

Leveraging Pharmacological Pseudo-Science

One of the ways we skirted regulatory limits in promotion was by using a receptor binding story—a pharmacological narrative that hinted at superiority without explicitly stating it. Because we couldn’t 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.

Specifically:

• We emphasized Risperdal’s balanced blockade of dopamine D₂ and serotonin 5-HT₂A receptors, the hallmark of its “atypical” profile.
• We contrasted this with Haldol’s high-potency, nearly exclusive blockade of D₂ receptors.
• We linked strong D₂ blockade to movement-related side effects, such as EPS, while suggesting that serotonin-D₂ balance might reduce these risks.

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, journal articles, and sponsored CME programs.

I personally wrote an advertorial in a leading medical journal suggesting that 5-HT₂A antagonism seen with atypicals “might be associated” with enhanced cognitive function or reduced negative symptoms. In promotional materials, we were very cautious, referring to Risperdal’s “loose binding” to D₂ receptors. The wording was vague enough to pass regulatory review—but the implication was clear.

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’ll fill in the rest.

Market Access Strategy: The Linchpin of Risperdal’s Success

Convincing doctors to prescribe Risperdal wasn’t enough. Someone needed to pay for it. Since most patients with schizophrenia didn’t have private insurance, government programs would be footing the bill.

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 “The Informed Consumer: A Practical Guide to Paying for Mental Healthcare.” The brochure was distributed in doctors’ offices, handed out to psych nurses, and to patients enrolled in the Janssen Pathways Program.

At first, I believed this was an altruistic effort—helping 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.

But over time, I saw the intent more clearly. The brochure’s 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’s profits were dependent on reimbursement from public health insurers, including Medicaid, Medicare, the VA, and the Department of Corrections.

The Business of Compliance: How Medication Adherence Helped the Bottom Line

After we’d laid the groundwork—proving efficacy, managing safety concerns, and securing reimbursement—the next challenge was keeping patients on Risperdal continuously. Janssen’s solution was a program called “Pathways to Change.” “Pathways” purported to be an educational resource. In reality, it was a sophisticated patient retention strategy.

“Pathways to Change” had multiple components, including brochures for patients, caregivers, and healthcare professionals. But the central message running through all materials was consistent: don’t 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.

I wrote several handouts with input from the Risperdal Advisory Board—a 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’t 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—or who took a more cautious stance—did not have a seat at the table.

One of the patient materials, a brochure titled “Transitions,” 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.

I also wrote a piece for psychiatrists titled “The Therapeutic Alliance,” 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—where 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’s objections based on earlier consent.

In hindsight, it was a masterstroke in “messaging”—cast 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—into the relationship between patient and provider.

The NAMI Factor

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.

In the late 1990s, NAMI—the National Alliance on Mental Illness—was 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, whose daughter had schizophrenia. With support from Janssen and other atypical antipsychotic manufacturers, NAMI began advancing a powerful message: schizophrenia wasn’t caused by trauma or poor parenting—it was a biologically-based brain disorder, treatable with medication.

It was a compassionate narrative intended to remove stigma. But it also aligned with Janssen’s commercial goals. If schizophrenia were purely biological, it would require lifelong medication. Risperdal was positioned as essential.

I became close with Ken Steele, Janssen, and NAMI’s 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’s unofficial poster boy—traveling the country, giving interviews, and telling the story of how he was “cured” by Risperdal.

I liked Ken a great deal. He was warm, brilliant, and funny. But there’s a tragic footnote to his story: Ken died in 2000 of complications tied to Risperdal—obesity, diabetes, and heart disease.

We never told that part of the story.

The Cracks Start to Show

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’s claims started to show.

Early on, we emphasized two key points: Risperdal was more effective than Haldol, and it caused far fewer side effects—especially the tremors and stiffness associated with older antipsychotics. Sales representatives echoed this—as did medical conferences, educational materials, and journal reprints that positioned Risperdal as psychiatry’s future: modern, safer, and better.

However, larger-scale, independent studies began to paint a different picture. Research from Canada and the National Institute of Mental Health’s CATIE trial (2005–2006) suggested that the efficacy differences between atypicals and traditional antipsychotics were not nearly as dramatic as we had originally claimed.

The safety story began to falter as well. While Risperdal had shown fewer EPS in early trials, those studies had used high—and arguably unrealistic—doses of Haldol, virtually guaranteeing worse outcomes for the comparator drug.

Roughly five years after launch, a more serious concern surfaced: metabolic side effects. Risperdal was increasingly associated with significant weight gain, diabetes, and in adolescent boys, gynecomastia—breast development linked to elevated prolactin levels.

What’s telling is that initial warnings to doctors didn’t originate from the FDA or medical watchdogs. Instead, they came from sales representatives—particularly those from Eli Lilly—who were promoting Zyprexa and attempting to undermine Risperdal’s safety profile. This is a detail often overlooked outside the industry: often, doctors hear about a medication’s risks not from regulators or journals, but from drug reps seeking to discredit a rival’s drug.

Restoring Trust in a Broken System

This is the story of how we turned a schizophrenia drug into a mental health blockbuster—and how marketing reshaped mental health practices.

Many believe the loss of trust in medicine began during the pandemic—with government missteps on one side and extremist disinformation on the other. But I don’t think it started there. The truth has been eroding for decades—it just hadn’t been declared dead yet.

We didn’t just promote Risperdal. We helped launch a new era of medical marketing—one where disease education, clinical research, and sales strategy blurred into a single message. And we convinced ourselves it was all in the name of better care.

This marketing approach transformed mental health. Atypical antipsychotics—initially approved for adult schizophrenia—eventually came to dominate the market, accounting for nearly 93.2% of all Medicaid antipsychotic prescriptions by 2021. Much of that use was off-label. In some states, psychiatrists prescribed so many atypicals for children in foster care that state legislators had to intervene.

If we genuinely want to rebuild trust in medicine, we can’t just blame one bad actor or a single scandal. We need comprehensive reform, including transparency in science, independent oversight, stricter control of marketing claims, and government funding for clinical trials. As long as those with financial interests control the design of studies, influence the narratives, and manage the messaging, no one—whether it’s doctors, patients, or the public—can truly know what to believe.

That’s what I learned from working inside the system.

And it’s why I left.