Why clinical decision making in psychiatry is difficult

“All psychiatrists do is push drugs!”

I have heard this repeatedly, from students, wary patients, even family members who don’t pick up on a carefully worded hint that they just might benefit from getting help.  For some reason, no one makes the same complaint about infectious disease specialists, or oncologists, though I wager that the success rates of our drug treatments are roughly equivalent.

As a psychiatrist, I try to treat people with diseases, not diseases that happen to occur in people, but combining drugs with other modes of therapy requires a daily, even hourly balancing act. Add the effects of pharmaceutical marketing, especially direct to consumer advertising (followed by direct potential litigant recruitment)–some days I don’t want to get out of bed.

Beyond a general temptation to rely on drugs as the primary mode of treatment, psychiatrists feel particularly pressed to use the newest, most expensive drug. Many psychiatric patients receive their care in publicly funded clinics, under excruciatingly tight budgets. Having free samples to distribute allows us to provide a few patients with high end drugs. Clinical decision making in psychiatry is difficult because of our lack of objective measures of response. Newer psychotropic medicines do sometimes work where older ones have failed. The side effects of newer medications typically differ from those of older ones, though the overall burden of adverse consequences is arguably the same. These background forces are invisible. In the clinical moment, the selection of a particular remedy is often based more on nonmedical influences—the patient’s response to advertising, the clinic’s necessary concern with costs—than upon the prescribing professional’s careful assessment and detailed discussion with a patient.

Aggressive pharmaceutical marketing has exacerbated the problem of responsible prescribing. All of us who have visited a drug company exhibit at an annual meeting or attended a company sponsored lunch know that these activities sometimes do provide valuable information. However, the “research agenda” of many pharmaceutical and device manufacturers has shifted from developing or improving their products to research meant to increase market share. A careful 2008 study showed that $.24 of every  dollar spent by industry goes to promotion, while $.13 goes for actual research. This knowledge has made me far more wary of accepting company disseminated information.  Direct to consumer advertising has increased the pressure I feel to prescribe brand name over generic medications, new over old.

Although radical reform is still a long way off, section 6002 of the Patient Protection Affordable Care Act requires manufacturers of drugs, devices, supplies and biological materials that are covered under various federal health programs to disclose on an annual basis the payments (of various kinds) they have made to physicians and teaching hospitals.  Some details of how this regulation will be implemented are still being reviewed to ensure that the burden of resolving disputes falls on the manufacturers rather than upon individual physicians and hospitals. Section 3507 sets new standards for drug labeling, to make risk/benefit information easier to understand. These regulations will reshape, though not obliterate, the efforts of manufacturers to influence patients to demand and medical practitioners and institutions to use their  products.

Alone, these elements of the PPACA take only small steps towards redressing the balance between commerce and medical practice.  Making physicians and their patients more aware of the current tactics of the big pharmaceutical firms may simply prompt these firms to develop newer, unregulated marketing strategies—in the real world, this could mean even more direct to consumer advertising. Other provisions of the act potentially foster more substantial, long term reform. Strong federal support for basic and comparative effectiveness research may do much to bring real effectiveness, and efficiency, into the marketplace.  And finally, the law includes tax credits to encourage pharmaceutical firms to rededicate themselves to developing drugs that genuinely improve upon what is available—the best marketing strategy of all.

Julia Frank is a psychiatrist who blogs at Progress Notes.

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  • John C. Key MD

    Good post. I’ve been in practice long enough to remember when psychiatry didn’t have many agents available except phenothiazines, tricyclics and lithium so the advent of new agents in the last two decades has been welcome. But today’s psychiatrist seems to have gone wild for “medication management” with obscenely expensive agents–and lots of them. It grieves me to see patients stumbling around tpday on five or six meds–not that much different from the “thorazine shuffle”, I fear. Psychotherapy, cognitive and behavioral approaches get minimal attention and are being shunted off to non-MD practitioners. Granted, Big Pharma may be to blame for a lot of this–and they’ve done us no favors by introducing so many meds that sell for $10 a pill. But psychiatrists must look to themselves to turn this around–increased restraint from Big Pharma isn’t going to happen, and interventions by the PPACA will not be effective.

  • Homeless

    Receiving care from non-MD practitioners make sense. These providers provided quality care at a more reasonable price.

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