In many countries, direct to consumer advertising (DTCA) of prescription drugs is either prohibited or tightly restricted. The United States is a notable exception, along with New Zealand. For tv ads, the standard pattern is to talk about the illness, talk about the amazing benefits of the drug, and then provide the required long list of side effects in an upbeat tone of voice while cheerful music plays and people are shown happily living their wonderful lives. The ad closes with something along the lines of “ask your doctor if _____ is right for you”. If you haven’t seen this kind of pharmaceutical advertising before, there are a couple of examples at the end of this post.
Drug company marketing to health care providers is a related but distinct issue that’s deserving of its own post, so I’ll set it aside for the sake of this post and focus solely on issues around DTCA.
Prescription drug advertising
Wikipedia cites a study that reported drug expenditures in the U.S. grew from $1.1 billion in 1997 to $4.2 billion in 2005. In the last ten years, four major pharmaceutical companies have reached settlements of greater than $1 billion with the U.S. Food and Drug Administration (FDA) over allegations of illegal marketing. Psychiatric medications were among the drugs involved in all of these settlements.
Prescription drug ads do not need to be pre-screened by the FDA before they can be printed or broadcast, so even if an ad is later found to be in violation of the laws, it will have already been seen by large numbers of consumers.
In Canada, there’s a loophole of sorts that allows pharmaceutical advertising to the public as long as there’s no mention of what medical condition the drug is used for. In 2006 the independent Health Council of Canada published a report looking at the public health implications associated with direct to consumer advertising of prescription drugs. They recommended closing this loophole and prohibiting all DTCA of prescription drugs.
What are the potential benefits?
Clearly the winner here is the drug companies themselves. But what are the supposed benefits to consumers from this kind of pharmaceutical advertising? According to the Health Council of Canada report, some of the benefits that are claimed are consumer education, increased autonomy in health care decision making, earlier diagnosis of illnesses, and increased medication compliance.
Public service announcements may be educational, but commercial advertisements are not. Whether its drugs or laundry detergent, the purpose is to sell a product. Any information that is gained through commercial advertising is only to support the primary sales purpose and will likely heavily biased.
In terms of autonomy, I’m not sure that going to the doctor and requesting drug X truly represents autonomous decision making. In fact, if patients are forming spurious judgments about the state of their health and the treatment they need, they lose the true autonomy that comes from getting a well-reason diagnosis and being presented with appropriate treatment options in a way that allows them to make informed decisions.
As for earlier diagnosis, this brings to mind issues with misleading advertising for Paxil (the SSRI antidepressant paroxetine) that essentially claimed that everyone (and probably their dog too) had social anxiety disorder and needed to be medicated. Social anxiety disorder is a very real and potentially debilitating condition, but the makers of Paxil were casting a much wider net than that. People who are unwell will make their own decisions about whether or not to seek medical help, but there’s no need for the masses to go rushing to their doctor asking for drugs because pharmaceutical marketing campaigns told them they were most likely sick.
I fail to see how compliance could be improved, unless the line of thinking goes that if a patient asks their doctor for drug X (whether they need it or not), they’re more likely to take drug X? Or does seeing a Pristiq ad on tv remind someone that they forgot to take their medication that morning? It all seems rather flimsy.
What are the potential harms?
According to studies cited in the Health Council of Canada report, direct-to-consumer advertising influences both patient demand and physician prescribing. A study of general practitioners in New Zealand found that almost 70% felt pressured by their patients to prescribe medications. A study conducted in the U.S. and Canada found that when patients went into an appointment requesting a drug, they were 17 times more likely to be prescribed a drug by the end of that appointment.
Pharmaceutical ads that claim Drug X is wonderful for condition Y are targeting consumers who likely don’t have the medical knowledge base to determine whether Drug X is in any way appropriate for them, and may have no idea if they actually have condition Y or not. If they go to their doctor requesting Drug X, a prescriber may order Drug X rather than the more appropriate Drug Z in order to appease the patient, or they may try to appease the patient by giving them Drug X even though they don’t actually meet the full diagnostic criteria for condition Y.
While this may seem like poor practice on the part of physicians, it’s certainly not unheard of. As an example, overprescribing of antibiotics is driven in part by patients who are going in to see their doctor and demanding antibiotics even though they most likely have a viral illness that antibiotics will do nothing for. Doctors are busy enough without having to spend time trying to re-educate patients who have been misinformed by drug company ads.
Decisions about an individual’s medication treatment should be made by that person and their healthcare provider based on their specific health concerns. Pharmaceutical companies should not have the opportunity to interfere in that process. The whole reason drugs are prescription-only is that medical professionals need to determine whether or not they are appropriate for a given patient. If patients are going into their medical appointments having actually researched treatment options, that’s great, but watching pharmaceutical advertising is not research. It’s a sales pitch.
A 2013 opinion piece in the New York Times says that “biased pill-pushing messages are a public health menace.” I agree, and it would be nice to see regulators in the U.S. and New Zealand stand up to the powerful pharmaceutical lobby and put an end to direct to consumer advertising. Sales tactics have no place in mental health care.
What are your thoughts?
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