Successful strategies found for refusing antidepressant requests
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A patient-based approach is the best way to refuse to prescribe medically inappropriate antidepressants while keeping patient satisfaction high and preserving the physician-patient relationship, a study found.
More than 10% of patient visits involve drug requests, and may involve brands seen in direct-to-consumer advertising. Physicians do not want to jeopardize patient satisfaction, and need strategies to refuse medically inappropriate treatments.
Studies conflict on whether the refusal itself lowers patient satisfaction, so researchers looked at whether satisfaction depends on what the physician says, rather than what he or she writes on a prescription pad.
Researchers looked at 152 primary care physicians from four locations in California and New York between May 2003 and May 2004. They trained 18 insured, middle-aged, white women to play patients with specific complaints; the women then randomly made 298 unannounced visits. The standardized patients were not blinded to the design of the study but were unaware of its hypotheses. The authors reported results in the Feb. 22 Archives of Internal Medicine.
The standardized patients presented with subacute fatigue and insomnia accompanied by an unrelated orthopedic complaint referable to low back strain or carpal tunnel syndrome, and then requested a brand-specific antidepressant or any antidepressant, or made no request. Standardized patients asking for antidepressants did so within the first 10 minutes of the visit or before the physical examination, and repeated their request if the first request did not lead to a prescription.
The standardized patients requested antidepressants in 199 visits; they were not prescribed in 88 visits (44%), 84 of which were available for analysis. In 53 of those visits (63%), physicians used one of three strategies that explicitly incorporated the patient perspective: exploring the context of the request, referring to a mental health professional, and offering an alternative diagnosis. Twenty-six visits (31%) involved biomedical approaches, such as sleep aids or a diagnostic workup. In 5 visits (6%), physicians rejected the request outright.
The relationship between the approach used and visit satisfaction was examined using the Fisher exact test. The 26 visits with scores of 9 or 10 were classified as providing excellent satisfaction, and the remaining 58 with scores of less than 9 were classified as less than excellent satisfaction. The standardized patients were significantly more likely to report excellent visit satisfaction despite denial with a patient perspective-based strategy (43%) over other strategies (10%) (P=0.001).
The authors concluded, “In an era of increasing constraints on health care systems and practitioners and significant influence of [direct-to-consumer advertising], learning to say no to patient requests will become more important.”