In 2002, prescribing risperidone meant fighting through layers of resistance. I had to argue with formulary doctors, armed with a special copy of the New England Journal of Medicine article where my own name was highlighted, just to gain permission. That was the level of scrutiny these drugs once demanded. The article itself was not obscure, it was a landmark trial demonstrating risperidone’s efficacy in children with autism spectrum disorders.

Yet even with clear evidence, formulary committees resisted, citing cost and risk. I remember the tension in those meetings: The burden of proof fell entirely on the clinician, and every prescription was a battle. Highlighting my name was both tactical and symbolic, a way of saying: I helped generate this evidence, and I am accountable for its use.

The shift from specialized scrutiny to casual prescribing

Today, the pendulum has swung to the opposite extreme: Any MD, DO, NP, or APRN can prescribe risperidone or aripiprazole, often without specialized psychiatric training. What was once tightly controlled is now casually dispensed, and the result is a complete loss of oversight for medications that carry profound risks. This is not progress, it is abdication, and patients are left to bear the consequences.

Big Pharma has engineered this shift. The advertising machine spends billions each year to normalize antipsychotics and biologics as lifestyle fixes. Rexulti topped U.S. TV drug ad spending in April 2024 with $30.2 million in a single month. AbbVie’s Vraylar campaign generated 1.9 billion TV impressions in 2024, with $24.2 million in monthly ad spend. Antipsychotics as a class generate $1 billion to $5 billion annually per drug in global sales.

Meanwhile, biologics for psoriasis, such as Humira, Skyrizi, and Cosentyx, are marketed as liberation from the “heartbreak of plaque psoriasis,” while glossing over the reality of immune suppression and infection risk. Skyrizi’s “Nothing is Everything” campaign is a perfect example: Sleek visuals, upbeat music, and smiling patients are all designed to erase the fact that the drug suppresses the immune system and leaves patients vulnerable to infection.

These ads do not just target physicians, they target patients directly, bypassing clinical judgment. Families see the commercials, demand the drugs, and prescribers, especially in primary care, are pressured to comply. Advertising reframes risk as lifestyle liberation, and the boundary between specialist and generalist prescribing collapses under the weight of marketing.

Profits vs. prescribing reality

Big Pharma profits and marketing	Prescribing reality and risks
Rexulti topped U.S. TV drug ad spending in April 2024 with $30.2 million in one month.	Many prescriptions are written by primary care physicians, not psychiatrists, despite limited training in complex psychopharmacology.
AbbVie’s Vraylar campaign generated 1.9 billion TV impressions in 2024, with $24.2 million in monthly ad spend.	PCPs often prescribe antipsychotics for off-label uses (insomnia, anxiety, dementia), outside approved indications.
Antipsychotics as a class generate $1 billion to $5 billion annually per drug in global sales.	Patients discharged from hospitals on antipsychotics are frequently handed off to PCPs without psychiatric follow-up.
Pharma spends $6 billion to $8 billion annually on TV ads across all drug categories.	PCP prescribing shows poor concordance with psychiatric guidelines, increasing risks of metabolic syndrome, diabetes, and tardive dyskinesia.
Marketing normalizes dangerous drugs as lifestyle fixes, erasing specialist boundaries.	Systemic coercion: Insurance formularies and pharmacy chains push marketed drugs, regardless of safety.

The result is predictable: Patients bear the risks, corporations reap the rewards, and safety is eclipsed by profit. What was once a guarded frontier of specialist prescribing has become a free-for-all, driven not by evidence but by advertising.

The global echo of supply manipulation

Direct-to-consumer pharmaceutical advertising is banned in most countries, yet the United States allows it to dominate primetime television. This is not new; it began decades ago with baby formula. First-world companies marketed formula aggressively in the developing world, hooking parents on products that displaced breastfeeding and left children vulnerable when supplies ran short.

The same logic of profit over safety now drives Big Pharma’s campaigns. And the consequences echo beyond medicine: Even in conflict zones, formula itself becomes a weapon. Hamas hoarded baby formula, keeping it from starving infants to stage a TV spectacle that blamed Israel. Advertising and supply manipulation converge on the same ledger, suffering packaged as spectacle, profit eclipsing stewardship.

The true cost of abandoned specialist care

Until safety eclipses profit, Big Pharma remains complicit in murder and suffering. And unless we restore specialist oversight, regulate advertising, and confront the coercion of formularies, patients will continue to pay the price for corporate gain.

I was reminded of this just days ago, when I received a plea via LinkedIn from a mother whose child I diagnosed with autism nearly two decades ago. She wrote because there is no one left in Phoenix to help her. That absence is the true cost of a system that has surrendered control to advertising and abandoned specialist care. Families are left stranded, forced to navigate complex conditions without guidance, while corporations continue to profit.

Ronald L. Lindsay is a developmental-behavioral pediatrician.