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Kravitz RL, Epstein RM, Feldman MD, et al. Influence of Patients’ Requests for Direct-to-Consumer Advertised Antidepressants: A Randomized Controlled Trial. JAMA. 2005;293(16):1995–2002. doi:10.1001/jama.293.16.1995
Author Affiliations: Center for Health Services
Research in Primary Care (Drs Kravitz, Franz, Azari, Wilkes, Hinton, and Franks)
and Departments of Internal Medicine (Drs Kravitz and Wilkes), Statistics
(Dr Azari), Psychiatry (Dr Hinton), and Family and Community Medicine (Dr
Franks), University of California, Davis, Sacramento; Departments of Family
Medicine and Psychiatry and Center to Improve Communication in Health Care,
University of Rochester School of Medicine and Dentistry, Rochester, NY (Dr
Epstein); Division of General Internal Medicine, Department of Medicine, University
of California, San Francisco (Dr Feldman).
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
Objective To ascertain the effects of patients’ DTC-related requests on
physicians’ initial treatment decisions in patients with depressive
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
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 brand-specific request, and 56% of those making no request
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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