Successfully Pushing Paxil on Television

Physicians will prescribe medication for more than half of patients with only minor forms of depression who ask for a particular drug because of a TV ad, according to a recent study. The results raise questions about whether doctors are unduly influenced by patients making requests because of direct-to-consumer advertising.

In the study, about 55 percent of standardized patients (see below for definitions and details of study methodology) with “adjustment disorder” — a temporary feeling of depression brought on by situational factors — who requested the antidepressant Paxil received some kind of antidepressant medication, two-thirds of them getting Paxil itself. By contrast, doctors wrote prescriptions for only 10 percent of patients (none for Paxil) who described the exact same symptoms but made no request for medicine. In other words, patient requests for a specific heavily-advertised drug caused a 5.5-fold increase in prescriptions for antidepressants, mainly for the advertised drug.

Among patients describing major depression, 76 percent of the standardized patients who made a general request for medication were actually prescribed an antidepressant, only two percent for Paxil. In contrast, only 53 percent of the standardized patients who requested Paxil received a prescription for some brand of antidepressant drug, one half for Paxil. Thirty-one percent of the standardized patients who made no request were prescribed an antidepressant.

According to experts, the study, published in the Journal of the American Medical Association, is troubling because prescribing serious drugs that carry the risk of significant adverse effects is usually not appropriate for adjustment disorder — a condition that often clears up if certain problems in the patient’s life are resolved or if appropriate counseling is given. The results suggest that advertisements can trigger consumers to seek medical attention for ailments that do not necessitate prescription drugs; and, furthermore, that doctors have a propensity to over-prescribe if patients make requests after having seen TV or magazine ads.

The study goes to the heart of the controversy over direct-to-consumer advertising.

Since widespread direct-to-consumer advertising from drugmakers was permitted by the Food and Drug Administration starting in 1997, its impact on actual treatment patterns has been the subject of wide speculation and debate in the health-care industry. Proponents say that ads help educate consumers and prompt them to seek treatment for disorders they would otherwise ignore. Others are concerned that the advertising is contributing to the over-medication of Americaand that consumers are asking by name for drugs to “cure” ailments they can change with lifestyle improvements or better diets. These drugs often carry the risk of major side effects.

About $3.2 billion was spent on direct-to-consumer advertisements in 2004, with a seemingly endless stream of ads blitzing television screens, radio stations, and magazines, urging consumers to seek treatment for everything from heartburn to erectile dysfunction to anxiety.

The drug industry continues to spend and has tried to measure the effectiveness of their messages: one study by IMS Health showed that among 70 percent of brands that were the subject of DTC ads, the return-on-investment — a Wall Street term for how much a business can reap from spending money — was in excess of $1.50 for each dollar the drugmaker spent. Other studies have showed a substantially higher increase in prescriptions for consumers requesting a particular drug because of an advertisement.

But the recent study addresses a problem with varying levels of severity, for some of which medication is not always appropriate — depression.

In the experiment, actors called “standardized patients” visited participating doctors in San Francisco, Sacramento, and Rochester, N.Y.at random times. They spaced out their visits so the doctors wouldn’t suspect they had just seen two standardized patients in, say, the same week. Each “patient” presented doctors with one of two scenarios — major depression and the less-serious condition known as adjustment disorder. Standardized patients in each group made one of three requests: they either requested the prescription antidepressant Paxil, they made a general request for medication, or they made no request at all.

Requests for Paxil, made by GlaxoSmithKline Plc, started out: “I saw this ad on TV the other night. It was about Paxil...”

The patients with major depression described themselves to the doctors as 48-years-old, divorced with two young adult children. They said they had been feeling “down” over the past month, had recently lost interest in everyday activities, had low energy and fatigue, felt sensitive to criticism, and sometimes had a poor appetite and sleeping patterns. They did not describe any acute symptoms, such as distorted thinking or suicidal thoughts.

The standardized patients presenting adjustment disorder to the doctors described themselves as 45-year-old divorced white women who felt fatigued, stressed and have had difficulty falling asleep three to four nights per week over the past few weeks. They said they had back pain and had curtailed physical exercise recently because of the pain and fatigue.

Each physician in the study saw one standardized patient with major depression and one standardized patient with adjustment disorder, and never heard the same type of request (Paxil, general medication, or no request at all) from both of the two standardized patients they saw. In all, 298 visits were made, and researchers recorded the outcomes of these visits.

Boiling down these results, it is clear that prescribing patterns were influenced by patient requests: many more standardized patients received Paxil if they actually requested it than if they simply requested a drug or made no request for medication at all.  

As mentioned above, among the adjustment-disorder group — patients less likely to benefit from medication — physicians were more than five times more likely to prescribe a drug if the patient requested Paxil than if they made no request at all. This led the researchers to conclude that “DTC advertising may stimulate prescribing more for questionable than for clear indications.”

Moreover, common adverse effects experienced by Paxil users since it was approved by the FDA in 1992 have included sweating, nausea, decreased appetite, somnolence, dizziness, insomnia, tremor, nervousness, sexual dysfunction, and general physical weakness.

The results of the study suggest that both doctors and patients ought to be more critical when digesting direct-to-consumer ads and considering what the patient really needs — whether or not it was what they saw on TV last night. Better yet, both groups should put their TV sets on mute during these ads.