Photo of doctor filling our presription for patient

Physician filling out prescription for patient.

AcademyHealth, the national organization for health services research and policy, has honored Richard L. Kravitz with its 2006 “Article-of-the-Year” award for his lead authorship in an article about direct-to-consumer drug (DTC) advertising.

Kravitz, a professor of internal medicine and faculty member of the UC Davis Center for Health Services Research in Primary Care, was recognized with the prestigious honor during the annual AcademyHealth research conference, which was recently held in Seattle. His paper, entitled “Influence of Patients' Requests for Direct-to-Consumer Advertised Antidepressants,” was published in a 2005 issue of the Journal of the American Medical Association. In the study, Kravitz had “standardized patients” — most were trained actors — visit the offices of selected primary care physicians and present a rehearsed set of symptoms. Participating physicians were told they would see a few unannounced standardized patients in the coming months, but were not informed of the nature of those visits.

The standardized patients were divided into two groups and coached to present with symptoms consistent with either major depression or adjustment disorder. Each group (depression and adjustment disorder) was subdivided into groups that would request specific antidepressants (by name), general antidepressants or no specific treatment. The patients made almost 300 visits to 152 family practice physicians and internists from solo and group practices, and from health maintenance organizations.

We recently spoke with Dr. Kravitz to find out why he chose antidepressants in this study, and what he learned about the influence of patient requests for prescriptions resulting from DTC marketing.

Photo of Richard Kravitz

Richard Kravitz, professor of internal medicine.

UC DAVIS: In your study, you looked at initial treatment decisions by primary care physicians for patients with depressive symptoms. Why did you choose to look at depression and antidepressants?

DR. KRAVITZ: One of the top categories for DTC spending is antidepressant medications, so they are an excellent place to start. Also, people supporting DTC advertising believe the advertising provides a public service by educating and motivating patients who otherwise would not seek treatment, especially for diseases that carry social stigma. Depression certainly falls into this category. Of course, on the other side of the argument, critics of DTC advertising worry about over-prescribing and its subsequent health and financial repercussions.

UC DAVIS: How did you structure the study to reveal the way physicians respond to patients' requests for drug therapy?

DR. KRAVITZ: In our study, we had a group of standardized patients present with symptoms of major depression, which can often be effectively treated with antidepressants. Another group visited the doctor with symptoms suggesting adjustment disorder, a much milder condition that generally responds to reassurance and support. As a result, we had a frequently underdiagnosed and, therefore, undertreated group (depression) and a group that was vulnerable to over-treatment (adjustment disorder).

UC DAVIS: What were your findings?

DR. KRAVITZ: Our study showed that patients' requests have a huge impact on physicians' prescribing patterns. We randomly assigned the standardized patients to make brand-specific requests for Paxil® in one-third of visits, general requests for “medication that might help” in another third, and no request in the remainder. We found that in major depression, rates of antidepressant prescribing were 53 percent for standardized patients making brand-specific requests; 76 percent for patients with general requests for medication; and 31 percent for those making no requests. Depressed patients who made requests were also more likely to receive mental health referrals and prompt follow-up. In other words, quality of depression care was higher for patients who made treatment requests than for those who did not. In adjustment disorder, 55 percent of standardized patients making brand-specific requests received requested prescriptions while 39 percent making general requests received prescriptions. Ten percent of the standardized patients making no requests received prescriptions.

UC DAVIS: What should physicians keep in mind when their patients make specific prescription requests?

DR. KRAVITZ: Most physicians went into medicine because they want to make patients feel better. And so of course, they are going to try to comply with patients' requests. This study serves as a reminder that sometimes those requests can lead physicians at least to the margins of clinical appropriateness. Beyond that, doctors can use patient requests as an opportunity for dialogue. Right now more than 80 percent of physicians believe that DTC advertising doesn't provide balanced medical information, so specific prescription requests — whether appropriate or inappropriate — can always serve as starting point for discussion and patient education.