April 26, 2005

(SACRAMENTO, Calif.) — Patients requesting specific medications can have a profound effect on physicians prescribing medications for major depression, according to a new study, led by researchers at the UC Davis School of Medicine and Medical Center, in the April 27 issue of the Journal of the American Medical Association.

"The short message for patients is to be careful of what you ask for, because you probably will get it," said Richard L. Kravitz, the study's lead author and director of the UC Davis Center for Health Services Research in Primary Care. "That could be a good thing for those who really need medication, but it could be a bad thing for those on the margin. For this latter group, there might be other options that could be just as effective and possibly safer, such as watchful waiting and non-drug therapies."

According to the study, spending on direct-to-consumer (DTC) advertising of prescription drugs in the United States totaled $3.2 billion in 2003. Critics charge that these advertisements lead to overprescribing of unnecessary, expensive and potentially harmful medications, while proponents counter that they can serve a useful educational function and help avert underuse of effective treatments for conditions that may be poorly recognized, highly stigmatized, or both." In fact, Kravitz and his co-authors noted that "antidepressant medications consistently rank among the top direct-to-consumer advertising categories."

The research team conducted a randomized trial using trained actors as standardized patients to determine the effects of patients' direct-to-consumer related requests on physicians' initial treatment decisions in patients with depressive symptoms. The patients were middle-aged, white, non-obese women, most with professional acting experience.

They were trained to portray six roles. They were representing two clinical conditions: symptoms consistent with major depression or adjustment disorder, and three request types: a brand-specific drug request, a general drug request, or not request (control condition). The patients made appointments for office visits with 152 primary care physicians in Sacramento, San Francisco and Rochester, N.Y., between May 2003 and May 2004.

The scenarios included patients telling their doctor that they had seen an advertisement for Paxil on TV and asked for that drug by name; or patients saying they had watched a program on TV about depression and asking the physician if medication might help them. The researchers chose Paxil, a selective serotonin reuptake inhibitor antidepressant, because at the time of the study, it was widely promoted, priced higher than the generic fluoxetine, and available through the participating health-care organizations in all three cities. In the control scenario, the patients reported the same symptoms but made no request for medication.

"In major depression, antidepressant prescribing rates were highest for visits in which standardized patients made general requests for medication (76 percent), lowest for visits in which standardized patients made no requests for medication (31 percent), and intermediate for visits in which standardized patients made brand-specific requests linked to DTC advertising (53 percent)," the study states.

"Among standardized patients portraying major depression, paroxetine was rarely prescribed (approximately 3 percent) unless the standardized patient specifically requested Paxil; if Paxil was requested by name, 14 (27 percent) of 51 received Paxil/paroxetine, 13 (26 percent) received an alternative antidepressant, and 24 (47 percent) received no antidepressant."

For standardized patients portraying adjustment disorder, physicians were less likely to prescribe antidepressants.

"There was a strong prescribing gradient according to request type: 55 percent of standardized patients making a brand-specific request received an antidepressant compared with 39 percent of standardized patients making a general request and 10 percent of those making no request … Overall, physicians recommended primary care follow-up within two weeks of 33 (22 percent) of 149 standardized patients with symptoms of major depression and for 22 (15 percent) of 149 with adjustment disorder."

The authors state, "These results underscore the idea that patients have substantial influence on physicians and can be active agents in the production of quality. The results also suggest that direct-to-consumer advertising may have competing effects on quality, potentially averting underuse, while also promoting overuse.

"The results of this trial sound a cautionary not for direct-to-consumer advertising but also highlight opportunities for improving care of depression (and perhaps other chronic conditions) by using public media channels to expand patient involvement in care. Furthermore, physicians may require additional training to respond appropriately to patients' requests in clinically ambiguous circumstances."

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Video feed details: This week's JAMA video news release on the influence of patients' requests for directly advertised antidepressants will be fed Tuesday, April 26, from 9-9:30 a.m. ET on Intelsat America 6 (formerly Telstar 6), Transponder 11 (C-Band) and from 2-2:30 p.m. ET on Intelsat America 6, Transponder 11 (C-Band). For more information, call (312) 464-JAMA (5262).