Direct-to-consumer advertising of psychotropics An emerging and by baa17504

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Direct-to-consumer advertising of psychotropics                                                                                       compared prescribing patterns and con-
                                                                                                                                      sultations in Canada (where direct-to-
                                                                                                                                      consumer advertising is banned) and the
An emerging and evolving form of pharmaceutical company                                                                               USA (where it is well established). They
influence                                                                                                                             showed that in the USA patients often re-
                                                                                                                                      quested drugs that were promoted through
SIMON GILBODY, PAUL WILSON and IAN WAT T                                                                                              direct-to-consumer advertising and that
                                                                                                                                      clinicians were likely to acquiesce to these
                                                                                                                                      requests, despite feeling at best ‘ambivalent’
                                                                                                                                      about the drug. No empirical research has
                                                                                                                                      ever demonstrated better communication
                                                                                                                                      and improved health outcomes. Direct-to-
      ‘Advertising may be described as the science of                          ARGUMENTS                                              consumer advertising therefore undermines
      arresting the human intelligence long enough to                          FOR AND AGAINST                                        efforts to improve the efficiency gained
      get money from it’ (Leacock,1924).                                                                                              from finite health budgets through cost-
                                                                               Proponents of direct-to-consumer advertis-             conscious guidelines and the use of generic
                                                                               ing claim that advertisements are a legiti-            drugs where branded drugs confer marginal
Until recently, the main targets of phar-                                      mate source of quality patient information             benefit.
maceutical advertisements were clinicians                                      (Bonaccorso & Sturchio, 2002). Informing
                                                                               and empowering patients are major themes               DIRECT-TO- CONSUMER
and the major vehicles for ‘educational
                                                                               in the new National Health Service. In                 ADVERTISING OF
promotion’ were advertisements in aca-
                                                                               psychiatry, the treatments offered have                PSYCHOTROPICS
demic and professional journals and visits
and gifts from pharmaceutical represent-                                       both benefits and side-effects, and rational           Psychotropics are heavily marketed, with
atives. All is now changed and patients                                        decisions regarding concordance might be               paroxetine being the fourth most advertised
have become legitimate targets of adver-                                       enhanced through information targeted at               of all prescription-only medicines – at a
tising.    Direct-to-consumer    advertising                                   patients. Additionally, many individuals               cost of US$91.8 million in direct-to-
represents a new and expanding area of                                         do not seek help for psychiatric conditions,           consumer advertising alone (National
pharmaceutical promotion that harnesses                                        either through stigma or poor knowledge                Institute of Health Care Management,
the mass media.                                                                about illness or effective treatments.                 2001). Direct-to-consumer advertising has
     In the USA, direct-to-consumer adver-                                     Direct-to-consumer     advertising     might           increased disproportionately among psy-
tising has become a $2.5 billion per year                                      therefore help to address unmet needs.                 chotropics, with expensive magazine adver-
business (National Institute of Health Care                                        Arguments against direct-to-consumer               tisements and television commercials. A
Management, 2001), and serious concerns                                        advertising principally centre on concerns             few examples of specific campaigns give
about its impact on appropriate pres-                                          about the pharmaceutical industry’s ability            some insight into what we might expect
cribing, health resources and patient–                                         to produce unbiased information. Given                 from direct-to-consumer advertising.
professional relations have been voiced                                        the nature of market economics, the pri-                   In 1997, Eli Lilly began a US$15–
(Hoffman & Wilkes, 1999). Increased sales                                      mary aim of advertising campaigns is to                20 million print advertising campaign in
of 50 of the most heavily marketed drugs                                       increase market share and profit, rather               major magazines for fluoxetine (Prozac).
were responsible for almost half of the                                        than enhance well-being (Findlay, 2001;                Their advertising text played on negative
$20.8 billion increase in spending on                                          Wolfe, 2002). Hence, advertisements may                public perceptions of benzodiazepines,
prescription drugs between 1999 and                                            not look at all treatment options, including           while reassuring readers that Prozac is more
2000 (National Institute of Health Care                                        non-drug treatments, or provide a consu-               innocuous: ‘It’s not a tranquilizer: It won’t
Management, 2001).                                                             mer with comprehensive information on                  take away your personality. Depression
     Patients in the UK and the rest of the                                    potential adverse effects. Concerns about              can do that, but Prozac can’t’. Non-drug
European Union have been ‘protected from’                                      the quality of information in advertise-               treatments were presented as a secondary
or ‘denied’ direct-to-consumer advertising                                     ments are justified, with one in four                  measure for use after a patient had begun
(depending on one’s perspective) for at least                                  products violating US Food and Drug                    to respond to fluoxetine, rather than as a
the next 3 years. Despite this ban, patients                                   Administration
                                                                               Administration regulations (Aitken & Holt,             genuine alternative (source: Advertisement
can receive information about new and ex-                                      2000).                                                                 Cosmopolitan,
                                                                                                                                      for Prozac. Cosmopolitan, US edition,
isting treatments and services from a wide                                         Hoffman & Wilkes (1999), reflecting                September 1997). Other campaigns have
range of media, and psychotropic brands                                        on the experience in the USA, assert that              specifically targeted the use of generic drugs
have become household names. Addition-                                         direct-to-consumer advertising                         and the risk of ‘generic substitution’, asking
ally, the internet has made national restric-                                      ‘unreasonablyincreases consumer expectations,      patients to insist on a specific drug ‘by name’.
                                                                                  forces doctors to spend time disabusing patients
tions and regulations seem increasingly
                                                                                  of misinformation, diminishes the doctor^           ADVERTISING, PATIENT
irrelevant.
                                                                                  patient relationship because a doctor refuses to    EDUCATION AND PATIENT
     So what are the costs and consequences                                       prescribe an advertised drug, or results in poor    CARE ^ BLURRING THE
of direct-to-consumer advertising, and what                                       practice if the doctor capitulates and prescribes
                                                                                                                                      BOUNDARIES
does blurring of the boundaries between                                           an inappropriate agent’.
formal and informal direct-to-consumer                                         Research evidence tends to support this                The Association of British Pharmaceutical
advertising pose for psychiatry?                                               assertion. Mintzes et al (2001) have                   Industries (ABPI) has reformulated the




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G I L B O DY E T A L




arguments against direct-to-consumer ad-
                                                         SIMON GILBODY, DPhil, Academic Unit of Psychiatry, University of Leeds; PAUL WILSON, BA, Centre for
vertising by claiming that they oppose
                                                                                                 York; IAN WATT, FFPHM, Department of Health Sciences,University
                                                         Reviews and Dissemination,University of York;
advertising and instead present direct-to-                  York,
                                                         of York, UK
consumer communication as a legitimate
form of ‘patient education’.                                                                              Psychiatry, 15
                                                         Correspondence: Simon Gilbody, Academic Unit of Psychiatry,15 HydeTerrace,University of Leeds,
                                                                                   s.m.gilbody @
                                                         Leeds LS2 9JT,UK. E-mail: s.m.gilbody@leeds.ac.uk
    ‘Anyone else can supply information about medi-
    cines to patients ^ but those who know most          (First received 15 October 2003, final revision 12 January 2004, accepted 2 February 2004)
    about them, the pharmaceutical companies, are
    forbidden by law from doing so. . . .This form of
                                                         therapist, and Paxil [US brand name for                  to be left to the pharmaceutical industry’.
    censorship is outdated, and it is high time it was
    abolished’ (ABPI Press Release 23 October
                                                         paroxetine]’ (source: GlaxoSmithKline                    Wolfe called on the National Institutes of
    2002, www.abpi.org.uk/press/press%20releases__       website      http://www.paxil.com/sad/sa_                Health and the US Food and Drug Admin-
    02/ 021023.asp).
    02/021023.asp).                                      ricky_Q1.html,
                                                         ricky_Q1.html, accessed 10 March 2003).                  istration to ‘replace tainted drug company
                                                         The website also provides consumers with                 ‘‘education’’ with scientifically based, use-
What might we expect in psychiatry when                  a social anxiety disorder test, with the                 ful information that will stimulate better
the boundaries between patient education,
                                                         encouragement to consult a professional                  conversations between doctors and patients
advertisement and patient care become
                                                         following a positive score.                              and lead to true empowerment’ (Wolfe,
blurred? Some examples should make us
                                                                                                                  2002).
concerned.
                                                         WHAT IS TO BE DONE ?                                          We believe that the advent of direct-to-
     The advent of patient information
                                                                                                                  consumer advertising should not be seen as
groups and the ready access that they pro-
                                                         Direct-to-consumer advertising exploits an               progress. Psychiatry is likely to be changed
vide to consumers has been harnessed by
                                                         information void that has been left by clin-             for the worse and patient care is likely to be
the pharmaceutical industry. Marc Czarka,
                                                         icians, health care providers and policy ma-             compromised as a consequence. There re-
a director for Eli Lilly in the Benelux, said
                                                         kers. Creating more informed patients is an              mains an onus on us all to strive to produce
in 1997 that Lilly funds the American Psy-
                                                         aspiration with which no reasonable clini-               more informed patients and to provide un-
chiatric Association and it sponsors and
                                                         cian can argue. This is especially needed                biased information that is understandable
helped to create the Belgian League of
                                                         in psychiatry, where stigma and misconcep-               and informative for those who require our
Depression in 1995. ‘It’s useful for us be-
                                                         tions about the value of drug treatments                 care.
cause, unlike American law, European law
                                                         contribute to poor compliance or prevent
does not allow us to talk directly to poten-                                                                      DECLAR ATION
                                                                                                                  DECLARATION OF INTEREST
                                                         patients from seeking help. Whether formal
tial patients. . . .The league does it for us’
                                                         or informal direct-to-consumer advertising
(cited in Thomson, 1997). Examples of                                                                             None.
                                                         fills this void with unbiased information is
more direct influence over individual pa-
                                                         far from clear. In fact the opposite is likely           REFERENCES
tient care have also been seen in the USA.
                                                         to be true. Canada, which despite its geo-
Janssen-Cilag has developed a programme                                                                           Aitken, M. & Holt, F. (2000) A prescription for direct
                                                         graphical proximity to the USA has thus
of information leaflets, telephone support                                                                                                 Quarterly,
                                                                                                                  drug marketing. McKinsey Quarterly, 22 March, 82.
                                                         far resisted formal direct-to-consumer
and crisis intervention, but only to those                                                                        Association of British Pharmaceutical Industries
                                                         advertising, has funded research into the
in receipt of their product, risperidone.                                                                                                   2002.
                                                                                                                  (2002) ABPI Annual Review 2002. London: ABPI.
                                                         costs and consequences of such advertising.
The ‘person to person’ programme was                                                                              Bonaccorso, S. N. & Sturchio, J. L. (2002) For and
                                                         Mintzes, the author of this work,                        against: direct to consumer advertising is medicalising
launched, with a good deal of support from
                                                         concluded:                                                                                   BMJ, 324,
                                                                                                                  normal human experience: against. BMJ, 324, 910^911.
both the largest US patient representative
                                                             ‘We could find no evidence of improved drug uti-     Findlay, S. D. (2001) Direct-to-consumer promotion of
group (the National Alliance for the Men-                                                                         prescription drugs: economic implications for patients,
                                                             lization, improved doctor/patient relations, or
tally Ill) and the American Psychiatric Asso-                                                                                           Pharmacoeconomics, 19,
                                                                                                                  payers and providers. Pharmacoeconomics, 19, 109^119.
                                                             reductions in hospitalization rates, serious
ciation. In the UK, a similar collaborative                  morbidity or mortality attributable to [direct-      Hoffman, J. R. & Wilkes, M. (1999) Direct to
initiative exists with the National Institute                to-consumer advertising]. The aim of the prohi-                                                  BMJ, 318,
                                                                                                                  consumer advertising of prescription drugs. BMJ, 318,
                                                                                                                  1301^1302.
of Mental Health’s ‘1 in 100’ campaign,                      bition of prescription drug advertising in Canada
which is dedicated to helping ‘people with                   is health protection. Any legislative change that                                     Folly.     York:
                                                                                                                  Leacock, S. (1924) The Garden of Folly. New York: Dodd
                                                             would weaken the current restrictions on such        Mead.
schizophrenia, their families and friends’
                                                             advertising should be based on strong evidence       Mintzes, B., Barer, M. L., Bassett, K., et al (2001) An
(ABPI, 2002).                                                                                                     Assessment of the Health System Impacts of Direct-to-
                                                             that concerns about potential harm are un-
     One widely publicised development in                                                                         Consumer Advertising of Prescription Medicines (DTCA).
                                                             founded, and ^ ideally ^ evidence of health
quasi-direct-to-consumer advertising has                     benefits. On the contrary, we found a consider-
                                                                                                                  Volume III: Patient Information on Medicines Comparative
                                                                                                                                                          Sacramento.
                                                                                                                  Patient/Doctor Survey in Vancouver and Sacramento.
been ‘celebrity endorsement’. Ricky                          able body of evidence suggesting that such con-      Vancouver: University of British Columbia Health Policy
Williams, an American football player, reg-                  cerns are warranted, and no evidence that            Research Unit.
ularly appears on television to discuss his                  [direct-to-consumer advertising] is likely to
                                                                                                                  National Institute of Health Care Management
‘social anxiety disorder’, while being paid                                                                 al,
                                                             improve the health of Canadians’ (Mintzes et al,     (2001) Prescription Drugs and Mass Media Advertising
                                                             2001).                                               2000.Washington,
                                                                                                                  2000.Washington, DC: NIHCM.
by GlaxoSmithKline to publicise their pro-
duct, paroxetine. In an industry website,                    Sidney Wolfe, a clinician and director               Thomson, C. (1997) Woke up this morning feelin’ so
                                                                                                                                                                  Bulletin,
                                                                                                                  blue. Took an antidepressant but what’ll it do? Bulletin,
Williams says: ‘It’s amazing at how much                 of the Public Citizen Health Research
                                                                                                                  5 June, 24^31.
I’ve grown and how much I’ve changed                     Group, writing in the New England Journal
                                                                                                                  Wolfe, S. M. (2002) Direct-to-consumer advertising ^
and how much I went through. And of                      of Medicine said ‘The education of                       education or emotion promotion? New England Journal
course I owe a lot of that to Janey, my                  patients – or physicians – is too important                 Medicine, 346,
                                                                                                                  of Medicine, 346, 524^526.




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