Thursday, April 28, 2005

Blame the Doc, Not DTC!


"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."

Results of the study were published in JAMA ("Influence of Patients’ Requests for Direct-to-Consumer Advertised Antidepressants," JAMA. 2005;293:1995-2002)/

The study employed actor patients who visited physicians in 2 states, presented themselves with some medical complaints and asked (or did not ask as the case may be) for a specific drug by name.

I won't get into the details of this research -- you can read the full NIH News Release yourself -- but suffice it to say that the research does NOT prove that "marketing of prescription medications for depression may exert significant influence on treatment decisions."

Rather it proves that physicians, more often than not, will prescribe a drug if the patients asks for it. That says more about the practice of medicine than it odes about DTC advertising. I agree, therefore, with Dr. Richard L. Kravitz, lead investigator on the study who said "Prescribing antidepressants for adjustment disorder, as presented in the study, is at the margin of clinical appropriateness."

The press, however, is making DTC the culprit rather than the physicians! See, for example, the LA Times story: "TV Ads for Drugs Help Boost Prescriptions, Researchers Say."

The very first paragraph of this article states: "Doctors are easily persuaded to prescribe antidepressants — often unnecessarily — when patients mention having seen them in television advertisements, researchers reported Tuesday.'

I haven't read the full text of the JAMA article, only the abstract. However, the researchers do not say the actors specifically said anything about seeing the drug advertised on TV. The abstract only says: "The [actor patients] made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits."

The researchers came to these conclusions:

1. Patients’ requests have a profound effect on physician prescribing in major depression and adjustment disorder.

OK, I will give them that.

2. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.


I don't see where the study supports conclusion #2. Maybe I need to see the full text of the JAMA article -- if you have a copy, please send it to me at johnmack@virsci.com.

"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."

I'm not sure what "evidence-based marketing" means (see future post), but it sounds like a good thing, not a bad thing. Anyway, I would say that treatment of patients should be based on good medical practice rather than on "give patients what they want and get them out of the office."

[BTW, the FDA did a much better survey of physicians about the influence of DTC advertising on their prescribing behavior ("Results from FDA Physician Survey on DTC Advertising").]

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