Influence of patients' requests for direct-to-consumer advertised antidepressants: A randomized controlled trial

Richard L Kravitz, Ronald M. Epstein, Mitchell D. Feldman, Carol E. Franz, Rahman Azari, Michael S Wilkes, W Ladson Hinton, Peter Franks

Research output: Contribution to journalArticle

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Abstract

Context: Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized. Objective: To ascertain the effects of patients' DTC-related requests on physicians' initial treatment decisions in patients with depressive symptoms. Design: Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none). Setting: Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004. Participants: One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%. Interventions: The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits. Main Outcome Measures: Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics. Results: Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brandspecific request, and 56% of those making no request (P<.001). Conclusions: Patients' requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.

Original languageEnglish (US)
Pages (from-to)1995-2002
Number of pages8
JournalJournal of the American Medical Association
Volume293
Issue number16
DOIs
StatePublished - Apr 27 2005

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Antidepressive Agents
Randomized Controlled Trials
Adjustment Disorders
Depression
Physicians
Prescription Drugs
Mental Health
Referral and Consultation
Group Practice
San Francisco
Health Maintenance Organizations
Private Practice
Family Physicians
Primary Care Physicians
Pharmaceutical Preparations
Cluster Analysis
Linear Models
Primary Health Care
Outcome Assessment (Health Care)
Delivery of Health Care

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Influence of patients' requests for direct-to-consumer advertised antidepressants : A randomized controlled trial. / Kravitz, Richard L; Epstein, Ronald M.; Feldman, Mitchell D.; Franz, Carol E.; Azari, Rahman; Wilkes, Michael S; Hinton, W Ladson; Franks, Peter.

In: Journal of the American Medical Association, Vol. 293, No. 16, 27.04.2005, p. 1995-2002.

Research output: Contribution to journalArticle

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abstract = "Context: Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized. Objective: To ascertain the effects of patients' DTC-related requests on physicians' initial treatment decisions in patients with depressive symptoms. Design: Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none). Setting: Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004. Participants: One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53{\%} to 61{\%}. Interventions: The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits. Main Outcome Measures: Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics. Results: Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13{\%}. In major depression, rates of antidepressant prescribing were 53{\%}, 76{\%}, and 31{\%} for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55{\%}, 39{\%}, and 10{\%}, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98{\%} of SPs in the major depression role making a general request, 90{\%} of those making a brandspecific request, and 56{\%} of those making no request (P<.001). Conclusions: Patients' requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.",
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