Actor-Patients’ Requests for Medications
Boost Prescribing for Depression
Researchers funded by the National Institute of Mental
Health (NIMH), part of the National Institutes of Health,
have found that requests from patients for medications
have a "profound effect" on physicians prescribing for
major depression and adjustment disorder. These findings
indicate that direct-to-consumer (DTC) marketing of
prescription medications for depression may exert significant
influence on treatment decisions.
Researchers from the University of California at Davis,
the University of Rochester, and the University of California
at San Francisco conducted the study, which appears
in the April 27, 2005, issue of the Journal of the
American Medical Association.
"The use of direct marketing for treatment of depression
may boost familiarity with potential treatments of the
disorder," said Thomas R. Insel, M.D., director of the
National Institute of Mental Health. "However, we must
ensure that treatment is based on evidence-based science
rather than evidence-based marketing."
Critics of direct-to-consumer marketing fear the advertisements
lead to over-prescribing. Proponents believe they can
serve a useful educational function. This study addresses
this issue of over- or under-prescribing. The researchers
randomly assigned actors portraying patients with symptoms
of major depression or adjustment disorder to make 298
unannounced visits to 152 family physicians and general
internists recruited from solo and group practices and
health maintenance organizations in California and New
York.
Actor-patients were randomly assigned a disorder and
a type of medication request based on the assumption
that the direct-market approach could encourage patients
to seek effective care. They made brand-specific requests
for Paxil®, saying they learned about the medication
from a commercial; or general requests for medication,
not a specific brand, saying they viewed a television
program about depression which 'got them thinking'.
Actor-patients assigned "none" made no request concerning
medications.
Two visits were spread over several months so as to
avoid detection by the participating doctors; 13 percent
of the time, the doctors suspected the actor-patient
was from the study. Researchers collected results through
a review of actor-patient written reports, audiotapes
from the visits, medical charts, and written prescriptions
or drug samples.
People with major depression manifest
several symptoms that, in combination, interfere with
the ability to work, study, sleep, eat, and enjoy once
pleasurable activities. Such a disabling episode of
depression may occur only once but more commonly occurs
several times in a lifetime. Adjustment disorder is
an abnormal and excessive reaction to a life stressor,
such as starting school, getting divorced, or grief
(for example, car accidents, natural disasters, medical
conditions). In addition to mental health symptoms,
actor-patients in the study complained of either wrist
or back pain.
Actor-patients exhibiting major depression who made
brand-specific requests (53 percent) or general requests
for medication (76 percent) were more likely to receive
a prescription than those who made no request (31 percent).
In the adjustment disorder group, those who requested
brand-specific medications were more likely to receive
a prescription (55 percent) than those who made a general
(39 percent) or no request (10 percent). When actor-patients
asked for Paxil® and received a prescription, the
prescribed medication was Paxil® or its generic
equivalent about 25 percent of the time in major depression
and 60 percent of the time in adjustment disorder.
Although both brand-specific and general requests significantly
increased prescribing in both major depression and adjustment
disorder, brand-specific requests had a more pronounced
effect on prescribing for adjustment disorder than for
major depression.
"Although several small trials suggest that antidepressants
may deliver modest benefits to patients with minor depression,
there is no evidence to support their use in adjustment
disorder, especially when patients describe a clear
event as the cause of their depression, and exhibit
mild symptoms for only a short period of time," says
Dr. Richard L. Kravitz, lead investigator on the study. "Prescribing
antidepressants for adjustment disorder, as presented
in the study, is at the margin of clinical appropriateness."
In addition to prescribing practices, the study found
that those who made a request for medication were more
likely to receive minimally acceptable initial care
(any combination of antidepressant, mental health referral,
or follow-up visit within two weeks). And physicians
were more likely to consider and record a mental health
diagnosis (depression 88 percent compared to 65 percent
and adjustment disorder 50 percent compared to 18 percent)
if the actor-patient made a request for medication.
Also participating in the study were Drs: Rahman Azari,
Carol E. Franz, Michael S. Wilkes, Ladson Hinton, and
Peter Franks from University of California, Davis; Mitchell
D. Feldman from University of California, San Francisco;
and Ronald Epstein from University of Rochester.
NIMH is part of the National Institutes of Health
(NIH), the Federal Government's primary agency for
biomedical and behavioral research. NIH is a component
of the U.S. Department of Health and Human Services. |