Direct-to-consumer (DTC) prescription drug advertising — a $3.2 billion industry in the United States — not only sways patients to ask for certain medications, but profoundly influences the way doctors make initial treatment decisions, according to an April 27 study in the Journal of the American Medical Association.
University of Rochester Medical Center Professor Ronald M. Epstein, M.D., had a lead role in the research, which focused on antidepressants, as they consistently rank among the top advertised drugs. The study showed that doctors prescribed antidepressants far more often when patients asked for them. Furthermore, the study revealed that consumer advertising may have competing effects on health-care quality, by promoting the overuse of drugs in some cases while also averting under use and raising consumer awareness of disease.
The study was a collaborative effort between the UR Department of Family Medicine and University of California, Davis, Center for Health Services. The corresponding author is Richard L. Kravitz, M.D., MSPH, at UC/Davis.
“One thing is clear: patients can prompt physicians to provide better care. Drug ads are one way of getting patients to prompt their physicians – but it is not the best way,” Epstein says. “When patients brought up non-commercial information they were more likely to get the correct treatment than if they brought up the drug advertisement.”
The study was conducted from May 2003 to May 2004. The research team trained actors to pose as patients for the randomized trial, in which 298 visits were made to 152 primary care and general internists offices in Rochester, Sacramento and San Francisco. The actors surreptitiously audio-recorded the visits with small devices hidden in their purses. Doctors were recruited to take part and were reimbursed $100 per visit, plus $100 for completing surveys and $75 for staff expenses. When doctors agreed to participate and to being secretly audio-recorded, they were only told that the study would involve seeing patients who would present with a “combination of common symptoms” over the course of a year. After the study was completed, physicians were debriefed and they gave permission to use the data.
The actor-patients were assigned to portray either major depression with moderate severity (described in the study as Role 1), or adjustment disorder with depressed mood (Role 2). They were divided into groups, and instructed to either ask for a certain drug, Paxil (at the time it was widely promoted), or to make a general request for medication, or no request. The actor-patients also mentioned they had seen a TV advertisement for Paxil, or a special TV segment on depression, and were struck by whether a prescription medicine might help them.
The Role 1 model was based on the case of a 48-year-old divorced white woman with two children who worked full time and had no chronic health problems. She complained of wrist pain and feeling “down” for a month or so, loss of interest in activities, fatigue, low energy, poor appetite and poor sleep. Role 2 was a 45-year-old divorced white woman with low back pain, who accepted a voluntary job layoff rather than relocate, and reported feeling “stressed,” and had trouble sleeping occasionally.
The results showed that in major depression (Role 1), doctors prescribed antidepressants 53 percent of the time when Paxil was requested, 76 percent of the time when the actor-patient made a general request for drugs, and 31 percent of the time when no drug request was made.
As expected, prescribing antidepressants was less common in those cases in which the actors portrayed the less-serious adjustment disorder (Role 2): 55 percent when Paxil was requested, 39 percent when a general drug request was made, and 10 percent when no drugs were requested. But the study notes that prescriptions for Paxil accounted for two-thirds of all antidepressant prescriptions given to the Role 2 actors making brand-specific requests.
The Role 2 results raise a troubling aspect of care, according to the authors. No scientific data supports the use of antidepressants for adjustment disorder, particularly when symptoms are mild and of short duration, and there is a clear, precipitating event such as job loss. “The prescription of antidepressants in this context is at the margin of clinical appropriateness,” the study says.
Indeed, “If patients can sway physicians to prescribe drugs they would not otherwise consider, physicians may not be the stalwart intermediary that the law assumes,” the article cautions.
Also, doctors were significantly more likely to consider diagnosing depression, and recording that diagnosis, if the actor-patient made a request for medication compared with no request. Although other studies have examined the effects of DTC advertising on consumer and clinician behavior, this was the first to examine the tendency to over-prescribe or under-prescribe a medication. The National Institute of Mental Health funded the project.
The researchers noted a few drawbacks to the study, however. Chiefly, they cannot determine whether DTC advertising actually produces the kinds of behaviors in real patients that were portrayed by the actors. Yet, they write, the results “sound a cautionary note for DTC advertising and also highlight opportunities for improving care of depression (and perhaps other chronic conditions) by using public media channels to expand patient involvement in care.”