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Conservative Prescribing and the Importance of Psychotherapy—Reply

Conservative Prescribing and the Importance of Psychotherapy—Reply In reply We agree with Wlodaver and May that prescribing antimicrobials vividly illustrates the need for conservative prescribing practices. Whether we will have effective antimicrobials in the future depends on avoiding their overuse today. Nearly all of our 24 principles apply to antibiotic prescribing, particularly those recommending treating underlying causes rather than reflexively responding to symptoms, considering drug effects as the cause of symptoms (such as fever), discontinuing drugs when no longer needed or working, recognizing that that not all patients desire or expect drug (antibiotic) prescriptions (rather than reassurance and close follow-up), and considering longer-term risks (including antibiotic resistance). Prescribing antibiotics responsibly is in the best interest of the individual patient and the overall population, although these are often placed in a false opposition. Despite the professional obligation to be responsible stewards of antibiotics,1 clinicians give stewardship insufficient weight compared with short-sighted considerations such as time pressure, convenience, desire to “please” patients to boost patient satisfaction ratings, and pharmaceutical manufacturer promotional messages. Dr Braillon writes from France, where one of the world's leading critical prescribing resources (Prescrire) is produced and widely read.2 He is concerned that direct-to-consumer ads have exacerbated overuse, a concern we share.3 Unfortunately, while many clinicians recognize the ecologic dangers of needlessly prescribing antibiotics to patients for questionable indications, few appreciate a closely related phenomenon recently articulated by Brody and Light,4 relevant to Dr Braillion's admonitions. The “inverse care law” postulates that even nonantimicrobials lose their relative efficacy as use is extended into populations in which benefits are unproven. While risks remain, benefits fall and the ratio of risk to benefit increases. Finally, as Auchincloss and colleagues note, treatment of patients with mental illnesses could also benefit from more conservative prescribing principles and practices. Although we considered psychotherapy to fit under our broad category of underutilized “counseling” therapeutic alternatives, we agree that our article5 (and patients) could benefit from its explicit mention. There is a growing evidence base to support its role and value, although there is a paucity of comparative effectiveness studies and funded research compared with the disproportionate research on drugs, especially newer psychiatry drugs. Many clinicians are not aware that, according to National Institute of Mental Health guidelines, “for mild to moderate depression psychotherapy may be the best option,”6 which is in line with our first conservative prescribing principle of seeking out nondrug alternatives as the initial approach. Back to top Article Information Correspondence: Dr Schiff, Division of General Medicine, Department of Medicine, Brigham & Women's Hospital, 1620 Tremont, Third Floor, Boston, MA 02120 (gschiff@partners.org). Financial Disclosure: Dr Galanter has served as a consultant to Abbott Labs related to drug name confusion. In the past 3 years, Dr Lambert has served as consultant for Abbott Laboratories and Transcept Pharmaceuticals Inc. He owns stock in Pharm I.R. Inc (his own company, specializing in preventing and detecting drug name confusion errors) and has given expert testimony in the cases Hernandez vs Schering (for Hernandez) and Mason vs General Electric Company et al (for Mason). He has received grants from Abbott Laboratories, Novartis, and Ortho McNeil and received patents from BLL Consulting Inc (related to preventing drug name confusions). He has also served as an unpaid member of the board of directors of Med-Errs Inc. References 1. Centers for Disease Control and Prevention. Evidence to support stewardship. 2010. http://www.cdc.gov/getsmart/healthcare/support-efforts/index.html. Accessed November 4,2011 2. Olsson S, Pal S. Drug bulletins: independent information for global use. Lancet. 2006;368(9539):903-90416962866PubMedGoogle ScholarCrossref 3. Schiff GD, Galanter WL. Promoting more conservative prescribing. JAMA. 2009;301(8):865-86719244196PubMedGoogle ScholarCrossref 4. Brody H, Light DW. The inverse benefit law: how drug marketing undermines patient safety and public health. Am J Public Health. 2011;101(3):399-40421233426PubMedGoogle ScholarCrossref 5. Schiff GD, Galanter WL, Duhig J, Lodolce AE, Koronkowski MJ, Lambert BL. Principles of conservative prescribing. Arch Intern Med. 2011;171(16):1433-144021670331PubMedGoogle ScholarCrossref 6. National Institute of Mental Health (NIMH). Depression. 2011. http://www.nimh.nih.gov/health/publications/depression/complete-index.shtml. Accessed November 15, 2011 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Conservative Prescribing and the Importance of Psychotherapy—Reply

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References (7)

Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2011.1564
Publisher site
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Abstract

In reply We agree with Wlodaver and May that prescribing antimicrobials vividly illustrates the need for conservative prescribing practices. Whether we will have effective antimicrobials in the future depends on avoiding their overuse today. Nearly all of our 24 principles apply to antibiotic prescribing, particularly those recommending treating underlying causes rather than reflexively responding to symptoms, considering drug effects as the cause of symptoms (such as fever), discontinuing drugs when no longer needed or working, recognizing that that not all patients desire or expect drug (antibiotic) prescriptions (rather than reassurance and close follow-up), and considering longer-term risks (including antibiotic resistance). Prescribing antibiotics responsibly is in the best interest of the individual patient and the overall population, although these are often placed in a false opposition. Despite the professional obligation to be responsible stewards of antibiotics,1 clinicians give stewardship insufficient weight compared with short-sighted considerations such as time pressure, convenience, desire to “please” patients to boost patient satisfaction ratings, and pharmaceutical manufacturer promotional messages. Dr Braillon writes from France, where one of the world's leading critical prescribing resources (Prescrire) is produced and widely read.2 He is concerned that direct-to-consumer ads have exacerbated overuse, a concern we share.3 Unfortunately, while many clinicians recognize the ecologic dangers of needlessly prescribing antibiotics to patients for questionable indications, few appreciate a closely related phenomenon recently articulated by Brody and Light,4 relevant to Dr Braillion's admonitions. The “inverse care law” postulates that even nonantimicrobials lose their relative efficacy as use is extended into populations in which benefits are unproven. While risks remain, benefits fall and the ratio of risk to benefit increases. Finally, as Auchincloss and colleagues note, treatment of patients with mental illnesses could also benefit from more conservative prescribing principles and practices. Although we considered psychotherapy to fit under our broad category of underutilized “counseling” therapeutic alternatives, we agree that our article5 (and patients) could benefit from its explicit mention. There is a growing evidence base to support its role and value, although there is a paucity of comparative effectiveness studies and funded research compared with the disproportionate research on drugs, especially newer psychiatry drugs. Many clinicians are not aware that, according to National Institute of Mental Health guidelines, “for mild to moderate depression psychotherapy may be the best option,”6 which is in line with our first conservative prescribing principle of seeking out nondrug alternatives as the initial approach. Back to top Article Information Correspondence: Dr Schiff, Division of General Medicine, Department of Medicine, Brigham & Women's Hospital, 1620 Tremont, Third Floor, Boston, MA 02120 (gschiff@partners.org). Financial Disclosure: Dr Galanter has served as a consultant to Abbott Labs related to drug name confusion. In the past 3 years, Dr Lambert has served as consultant for Abbott Laboratories and Transcept Pharmaceuticals Inc. He owns stock in Pharm I.R. Inc (his own company, specializing in preventing and detecting drug name confusion errors) and has given expert testimony in the cases Hernandez vs Schering (for Hernandez) and Mason vs General Electric Company et al (for Mason). He has received grants from Abbott Laboratories, Novartis, and Ortho McNeil and received patents from BLL Consulting Inc (related to preventing drug name confusions). He has also served as an unpaid member of the board of directors of Med-Errs Inc. References 1. Centers for Disease Control and Prevention. Evidence to support stewardship. 2010. http://www.cdc.gov/getsmart/healthcare/support-efforts/index.html. Accessed November 4,2011 2. Olsson S, Pal S. Drug bulletins: independent information for global use. Lancet. 2006;368(9539):903-90416962866PubMedGoogle ScholarCrossref 3. Schiff GD, Galanter WL. Promoting more conservative prescribing. JAMA. 2009;301(8):865-86719244196PubMedGoogle ScholarCrossref 4. Brody H, Light DW. The inverse benefit law: how drug marketing undermines patient safety and public health. Am J Public Health. 2011;101(3):399-40421233426PubMedGoogle ScholarCrossref 5. Schiff GD, Galanter WL, Duhig J, Lodolce AE, Koronkowski MJ, Lambert BL. Principles of conservative prescribing. Arch Intern Med. 2011;171(16):1433-144021670331PubMedGoogle ScholarCrossref 6. National Institute of Mental Health (NIMH). Depression. 2011. http://www.nimh.nih.gov/health/publications/depression/complete-index.shtml. Accessed November 15, 2011

Journal

Archives of Internal Medicine – American Medical Association

Published: Feb 13, 2012

Keywords: psychotherapy,prescribing behavior

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