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


METHODS
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).


METHODS
Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004.


METHODS
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%.


METHODS
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.


METHODS
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 brand-specific 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.
Kravitz
Richard L
RL
Center for Health Services Research in Primary Care, University of California, Davis, Sacramento, CA 95817, USA. rlkravitz@ucdavis.edu
Epstein
Ronald M
RM
Feldman
Mitchell D
MD
Franz
Carol E
CE
Azari
Rahman
R
Wilkes
Michael S
MS
Hinton
Ladson
L
Franks
Peter
P
D000275:Adjustment Disorders / Q000188:drug therapy; D000329:Advertising; D000928:Antidepressive Agents / Q000627:therapeutic use*; D003865:Major Depressive Disorder / Q000188:drug therapy; D004345:Drug Industry; D011307:Drug Prescriptions; D005194:Family Practice; D006801:Humans; D007388:Internal Medicine; D008402:Mass Media; D010358:Patient Participation; D017060:Patient Satisfaction; D010818:Practice Patterns, Physicians'; D014481:United States
D000928:Antidepressive Agents