Summary: A new review examines how advertising prescription psychiatric medications directly to the public influences patient requests and physician prescribing behavior.
Source: Brown University.
Since U.S. rules were relaxed in 1997, direct-to-consumer advertising (DTCA) for prescription drugs has become common in American media. A recent systematic review from Brown University researchers evaluated what is known about DTCA’s impact on psychiatric care. The evidence is limited, but available studies suggest that advertising increases patient requests for advertised psychiatric drugs and often leads to increased prescribing, with mixed implications for clinical quality.
“Our review aimed to address a significant and under-studied public health question,” said lead author Sara Becker, a research assistant professor at the Brown University School of Public Health and the Warren Alpert Medical School. “Does the multibillion-dollar industry of DTCA for psychiatric medications improve or harm public health? We began by examining how these advertisements change patient and physician behavior at the point of care.”
Psychiatry is a particularly relevant field for this question because drugs for mood disorders and related conditions have been among the most heavily advertised and best-selling medications in recent years. The review was published in the Journal of Clinical Psychiatry.
Reviewing the available evidence
Becker and co-author Miriam Midoun searched the literature for studies that measured how DTCA influences interactions between patients and physicians specifically around psychiatric medications. Despite ongoing debate about the benefits and risks of DTCA, they located only a handful of studies that met strict inclusion criteria: the studies had to include advertised psychiatric drugs, measure prescribing behavior linked to patient-initiated requests for those drugs, and record interactions at the point of care rather than relying on general recollection or retrospective data.
Out of nearly a thousand articles initially identified, just four studies across five manuscripts met these criteria. One of these was a randomized controlled trial (RCT) from 2005 that used standardized patients—actors trained to present with varying severity of depression—to evaluate how physicians responded when a patient asked either for a specific advertised drug, asked generally for an antidepressant because of seeing a commercial, or made no request. The RCT found that physicians prescribed significantly more often when patients requested a drug than when they did not. Three observational studies supported this pattern, including a comparative study that contrasted U.S. prescribing patterns with those in Canada, where DTCA is prohibited.
Although these studies indicate that physicians frequently grant patient requests for advertised medications, they also found that such requests are relatively uncommon in routine office encounters. In the observational work, requests for advertised psychiatric drugs occurred in under 10 percent of visits. The U.S.-Canada comparison did show that U.S. patients requested medications at more than twice the rate of Canadian patients, consistent with the greater exposure to DTCA in the United States.
Mixed effects on treatment quality
The RCT’s detailed findings illustrate the nuanced impact of DTCA. Standardized patients presenting with severe depressive symptoms were more likely to receive antidepressant prescriptions when they requested medication—an outcome that could represent improved access to needed treatment. However, the same study found that actors portraying patients with milder, transient depressive symptoms (described as adjustment disorder) were also more likely to receive prescriptions when they asked, suggesting a risk of unnecessary prescribing.
Across the limited body of research, DTCA-related requests are generally accommodated and appear to increase overall prescribing volume. The evidence also indicates competing effects on treatment quality: advertising-driven requests may help people who need medication access appropriate care, while simultaneously promoting prescriptions for patients whose symptoms do not warrant pharmacotherapy.
“A prior editorial called DTCA a ‘huge, uncontrolled public health experiment on American people,’ and our review reinforces that concern,” Becker said. “Very few high-quality, rigorous studies have examined DTCA in psychiatry over the past two decades. The available data do not clearly argue for or against DTCA: effects are not uniformly beneficial or harmful. More methodologically robust research is urgently needed to clarify whether DTCA improves access to appropriate care, increases overtreatment, or does both.”
Funding: The study was funded by the National Institute on Drug Abuse (grant K23DA031743).
Source: David Orenstein, Brown University.
Image source: Photograph by Garyfallia Pagonis; used for illustrative purposes.
Original research: “Effects of Direct-To-Consumer Advertising on Patient Prescription Requests and Physician Prescribing: A Systematic Review of Psychiatry-Relevant Studies” by Sara J. Becker, PhD, and Miriam M. Midoun, ScM. Published online in Journal of Clinical Psychiatry, September 2016. DOI: 10.4088/JCP.15r10325.
Objective: To systematically analyze the effects of direct-to-consumer advertising (DTCA) on patient requests for medication and on physician prescribing within psychiatry-relevant studies.
Data sources: Multiple academic databases were searched for studies from 1999–2014 using terms related to direct-to-consumer advertising and psychiatric medication. Reference lists and repositories of DTCA manuscripts were also reviewed.
Study selection: Included studies were English-language investigations that collected data at the point of service, focused on or included psychiatric medication, and assessed DTCA effects on patient and/or physician behavior. Of 989 articles identified, 69 underwent full-text review; four studies across five manuscripts met inclusion criteria.
Data extraction and quality assessment: Information was extracted on participants, study design, methodological quality, and outcomes. Methodological quality was evaluated using adapted public health criteria, and confidence in cross-study conclusions was assessed using established grading principles.
Findings: Strong conclusions were limited by the small number of rigorous RCTs. With moderate confidence, the authors concluded that DTCA requests are typically granted, that patient requests are associated with increased prescribing volume, that DTCA can promote better adherence to minimally acceptable treatment guidelines for some patients with depression, and that DTCA can stimulate overprescribing for patients with adjustment disorders.
Conclusions: The available evidence suggests that DTCA often leads to accommodated requests and higher prescribing, with mixed effects on the quality of psychiatric treatment. Additional high-quality research is needed to increase confidence in these findings and to inform policy and clinical practice.