Exposure to conflict-of-interest policies during residency reduces rate of brand antidepressant prescriptions

"Our study focuses on antidepressants because they have been among the most heavily marketed drug classes," said Andrew J. Epstein, PhD, research associate professor of Medicine at the Perelman School of Medicine at the University of Pennsylvania, and first author on the study. "Data show that antidepressant use increased nearly 400 percent from 1988 to 2008. The goal for this study was to determine whether exposure to COI policies during residency would influence psychiatrists' antidepressant prescribing patterns after graduation."

In recent years, as a result of the dramatic increase in prescription drug use, relationships between pharmaceutical representatives and physicians have come under extensive scrutiny both within the medical profession and by policy makers. Penn Medicine in 2006 implemented policies placing restrictions on physician interactions with pharmaceutical representatives. In 2008, the Association of American Medical Colleges developed COI policy guidelines for gifts, free meals, and medication samples provided by pharmaceutical representatives to physicians and trainees. The concern was that these interactions could influence clinicians to prescribe brand medications even if they were more expensive or less suitable for patients than generic alternatives.

To assess the effects of COI policies on physicians' prescribing patterns after residency, the research team examined 2009 prescribing data from IMS Health for 1,652 psychiatrists from 162 residency programs. The physicians fell into two categories: about half graduated residency in 2001, before COI training guidelines were implemented, while the other half graduated residency in 2008, after many medical centers adopted COI policies. Physicians were also categorized based on the restrictiveness of the COI policies adopted by their residency programs' medical centers. Results of the study show that, although rates of prescribing brand antidepressants, including those that were heavily promoted and brand reformulations, were lower among 2008 graduates than 2001 graduates in general, the rates were lowest for 2008 graduates of residency programs with very restrictive COI policies.

The results suggest that COI policies reduce the appeal of antidepressant medications marketed heavily by pharmaceutical companies. Because brand-name medications tend to be more expensive, Epstein says a shift away from them could help reduce cost growth. However, he cautions that lower costs achieved through stringent COI policies may come at a price.

"Contact with the pharmaceutical industry may have important informational benefits for physicians. And, by exposing trainees to industry representatives, we may be helping them prepare to navigate these relationships after graduation," said Epstein. "Nevertheless, while these relationships may be useful in some ways, our study clearly shows that implementation of COI policies have helped shield physicians from the often persuasive aspects of pharmaceutical promotion."

The study provides the first empirical evidence of the effects of COI policies, specifically pertaining to antidepressants. Epstein notes that in future research it will be critical to assess whether these policies have similar effects on other drug classes and physician specialties.

In addition to Epstein, co-authors on the study are David A. Asch, MD, Penn Medicine; Susan H. Busch, PhD, Yale School of Public Health; Alisa B. Busch, MD, Harvard Medical School; and Colleen L. Barry, PhD, Johns Hopkins Bloomberg School of Public Health.