Actor-Patients' Requests For Medications Boost Prescribing For Depression

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.

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Kravitz RL, Epstein R, Feldman MD, Franz CE, Azari R, Wilkes MS, Hinton L, Franks P. Influence of patients' requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 2005; 293:16, 1995-2002.