Patient Requests for Medications Significantly Influence Physician Prescribing
Direct-to-consumer advertising (DTCA) is an enormous industry in the US, with pharmaceutical companies spending $3.2 billion on DTCA in 2003. There is much controversy surrounding the use of DTCA. Critics argue that it has the potential to harm patients, by leading to over-prescribing of unnecessary—and potentially harmful—medications. Advocates contend that it empowers consumers to make informed health care choices, particularly for conditions that may otherwise be poorly recognized, highly stigmatized, or both.
Prescription drug sales indicate that DTCA has been economically effective for pharmaceutical companies. The sales of the 50 most heavily advertised prescription drugs increased by 32% from 1999 to 2000, compared to a 13.6% increase for other drugs. Researchers believe that this increase in sales may be due to DTCA prompting patients to ask their physicians for prescription medications.
A new study in the April 27, 2005 issue of the Journal of the American Medical Association looked at the association between patient requests for medications and prescription rates. The researchers found that when patients make general and brand-specific requests for antidepressants, physicians are much more likely to prescribe them, compared to when no request is made.
About the Study
Researchers recruited 18 women, most of whom had some acting experience, in Sacramento, San Francisco, and Rochester, and trained them to portray patients with one of two conditions:
- ]]>Major depression]]> (five or more depressive symptoms serious enough to affect daily activities; lasting at least two weeks): These actresses assumed the role of a 48 year-old woman who had been feeling down for one month, and worse over the past two weeks, complaining of loss of interest in activities, low energy, trouble concentrating, sensitivity to criticism, poor appetite, and poor sleep with early morning awakening (all depressive symptoms).
- Adjustment disorder with depressed mood (depressive symptoms that occur in response to a stressful event and usually resolve without treatment): These actresses assumed the role of a 45 year-old women who recently accepted a voluntary layoff rather than relocate with her company. The women complained of fatigue and feeling stressed, and reported difficulty falling asleep for the past few weeks.
The women visited physicians offices and made one of three kinds of drug requests:
- Brand-specific drug request : “I saw this ad on TV the other night. It was about Paxil. Some things about the ad really struck me. I was wondering if you thought Paxil might help.” (At the time of the study, the antidepressant, Paxil, was widely promoted and priced higher than other antidepressants.)
- General drug request : “I was watching this TV program about depression the other night. It really got me thinking. I was wondering if you thought a medicine might help me.”
- No drug request
The 152 physicians in this study agreed to participate in a study involving people portraying a combination of symptoms, for the purpose of “assess[ing] social influences on [medical] practice and the competing demands of primary care.” Each physician saw an average of two of the women—one portraying major depression and one portraying adjustment disorder. To avoid suspicion, the physicians did not see the same drug request type twice.
The physician visits were recorded using recorders concealed in the women’s purses. The researchers kept track of the condition(s) the physicians diagnosed, the medications they prescribed, and whether they recommended consultation with a mental health professional or follow-up care.
In the women who portrayed major depression, physicians prescribed antidepressants to 76% of the women who made general drug requests, 53% of those who made brand-specific requests, and 31% of those who made no drug request. Paroxetine (Paxil) was rarely prescribed (only 3% of the time) unless the patient specifically requested Paxil, in which case Paxil/paroxetine was prescribed 27% of the time.
In the women who portrayed adjustment disorder, physicians prescribed antidepressants 39% of the time in the case of general drug requests, 55% of the time following brand-specific requests, and 10% of the time after no request.
In 80% of the major depression visits and in 39% of the adjustment disorder visits, the physicians recorded a diagnosis of depression or possible depression. In all visits, physicians were significantly more likely to diagnose depression if a drug request was made.
In the major depression visits, the women who made a medication request were significantly more likely to receive minimally accepted initial care for depression (i.e., any combination of an antidepressant, mental health referral, or follow-up visit within two weeks), compared to those making no request. Specifically, women making a general request received this care 98% of the time, those making a brand-specific request received it 90% of the time, and those making no request received it 56% of the time.
These results are interesting, but are limited because the study used paid actors and the results may not represent the true effect of DTCA on consumers. DTCA may or may not prompt the types of requests represented in this study. Furthermore, the study focused on depression, so it is difficult to generalize the results to other conditions. Finally, the physicians who agreed to participate in this intrusive study (there was a 53% to 61% response rate) may differ from other physicians.
How Does This Affect You?
These results suggest that patients can influence physicians’ prescription behaviors. This is important for two key reasons. First, if DTCA triggers patients to ask their physicians for prescriptions, DTCA can significantly impact medications prescription rates, a fact that the pharmaceutical companies are counting on. It also provides evidence that, when empowered with health information, patients have the ability to influence the quality of their care, for better or worse.
This study underscores the fact that when it comes to your health care, knowledge is power. Look for reliable, unbiased sources of health information and discuss the risks and benefits of any potential treatments thoroughly with your doctor. When you see an advertisement for a prescription medication that appeals to your emotions, do not assume that you need it. It may be an excellent drug, but you should always consider the motivation behind these advertisements. The primary goal of DTCA is not your personal health and well being; it is to boost the bottom line of the pharmaceutical companies that pay for it.
Food and Drug Administration
National Institutes of Health
Hollon MF. Direct-to-consumer advertising: a haphazard approach to health promotion. Journal of the American Medical Association . 2005;293:2030–2033.
Kravitz RL, Epstein RM, Feldman, MD, et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. Journal of the American Medical Association . 2005;293:1995–2002.
Last reviewed Apr 28, 2005 by ]]>Richard Glickman-Simon, MD]]>
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