Lexapro is not a lotion, Geodon is not a hand sanitizer

I had dinner a few months ago at the home of a friend who's wife is a psychologist at a New York City psychiatric hospital. Outside of my NYC therapy office, where I could have made the connection more quickly, I had one of those out-of-context moments when I went to wash my hands in their bathroom. As I reached for the soap I noticed, "Huh, Lexapro lotion?" and a moment later, noticing the hand sanitizer, "Wow, Geodon hand sanitizer!" As my gears turned the association of each of these products came before the realization of just what these bottles were. For one split moment I pondered the merits of anti-depressant lotion and mood-stabilizing hand sanitizer. Until a moment later, of course, I sorted it out.

Lexapro (for the uninitiated) was the go-to anti-depressant for several years and is still widely prescribed by psychiatrists to treat depression and anxiety. Geodon is in a class of medications called atypical anti-psychotics and is used to treat schizophrenia and bi-polar disorder, among occasional other uses. Which is to say neither are brand names for personal health products.

You know what happened here as well as I do: The pharmaceutical rep stopped by the hospital and dropped off some swag for the staff along with samples for the prescribing providers. The swag started to overflow behind the receptionist's desk and my friend's wife took some home figuring she'd save a few bucks at the drug store. No harm done.

Why swag?

It's a great question, but maybe not as complicated as it seems. Branding is everywhere these days (remember those plexiglass screens covered in little logos that were rushed out and placed behind a winning coach or player after a World Cup match?). I don't know much about marketing, but I do figure Nike wouldn't spend billions of dollars a year to have their swoosh plastered  everywhere if it didn't sell sneakers, so likely the same principles apply to prescription drugs.

One common mistake that can obscure the logic of swag is underestimating the massive value and profitability of the marketplace. In 2010 drug companies sold 70 billion dollars in psychiatric drugs alone. Unlike medications used to treat acute conditions like infections, psychiatric drugs tend to be taken by consumers for years, making the initial decision to make about which medication to prescribe a hugely profitable question. (By way of comparison, the cost of your new smartphone represents only a portion of the profitability for the phone's manufacturer, who also takes a cut of the monthly bill you pay as part of your contract, typically two years. Imagine such a "contract" that lasted decades?  If that were the case they'd likely give away the phones for free (plus an awful lot of swag).

Most of the people who use (and take home) the swag sitting around a physicians office aren't physicians, of course, and therefore can't prescribe drugs, but with 70 billion dollars at stake, it's not hard to see the wisdom in betting on an encounter with hand lotion to sway a pharmacologist one way or another in what can be a split-second, highly subjective decision. And it doesn't hurt that swag helps endear the staff to pharmaceutical reps when they "stop by" hoping for some face-time with the doctor.

Forget swag. You like lobster?

While the non-prescribers in the office take home the occasional bottle of (branded) hand sanitizer, and enjoy some pretty nice box lunches, the best perks by far are reserved for the physicians themselves. When I was in a graduate student new to New York City I worked a few days a week on a team with young psychiatrist who had a small but growing private practice. Often the morning office catch-up featured "Where did Dan have dinner last night?" and we would hear about the extravagant nights out at NYC restaurants the rest of us could only dream of eating at, paid for by drug reps eager to win over the good graces (and influence the prescribing habits) of a young psychiatrist.

So what?

Physicians of all sorts receive gifts and solicitations from drug companies. That's not new. The prescribing of medications in psychiatry, however, is especially subjective. There are few tools to empirically measure results that don't rely on a great deal of nuanced interpretation on the part of the clinician and the patient. Psychiatric medicines are powerful tools and undoubtedly improve the quality of life for many who take them. But because they're so powerful and with such subjective effectiveness they are particularly prone to misuse and overuse.

I don't have a beef with psychiatry or psychiatric medications. I have seen astonishing healing and easing of pain happen when patients have found the right medication. At the same time, I'm concerned, as are many of my patients, that too many psychiatrists are too quick to prescribe medication rather slow down and explore other options. The decision is a big one and certainly deserves more thought than we give to the bath products.