Pressured to prescribe

Special to The Times

LOOKING at my supply closet, I was suddenly struck by the boxes of Zyprexa samples piled high inside. I’m an internist, a doctor who treats sore throats and high blood pressure. This medication was an antipsychotic drug designed to treat the severe delusions and agitation of bipolar disorder and schizophrenia.

What are these doing here? I asked my office nurse. The drug rep brought them, she said. She wants to speak to you.

I had long ago developed the time-saving habit of ignoring the drug reps who appeared in the hallways of my office offering unsolicited advice on what I should prescribe. I accepted their free samples to give to my poorer patients and their free lunches to feed my staff -- but I ignored their advice. I, not they, had studied drug pharmacology.


But on this particular afternoon several years ago I had an opening in my schedule, so I invited the rep into my consultation room. I wanted to know why she was suddenly bringing me Zyprexa.

Like all the drug salespeople who came to visit me, she was better dressed and younger than I was -- and eager to recommend treatments.

Sitting across from my desk on the small blue couch, the Eli Lilly rep tried to convince me that there was a good reason those boxes should be piled next to my coveted cholesterol drugs. She said that I was likely seeing bipolar patients, as well as demented patients who were agitated.

I acknowledged that one 85-year-old patient, Anne, who had been coming to see me for 20 years, had been placed on Zyprexa when she became demented and paranoid that ruffians who had harassed her as a child had somehow re-entered her life (they hadn’t). A small dose of Zyprexa had helped Anne enormously, and she was now much calmer and no longer paranoid.

But I told the rep that I hadn’t prescribed the drug, that I had sent Anne to a psychiatrist who had prescribed it. Bipolar disorder and agitated dementia (for which Zyprexa is sometimes used off-label) are in a psychiatrist or a neurologist’s domain.

I mentioned that most of the psychiatrists I knew used milder and better-tolerated mood-stabilizing drugs such as Depakote for bipolar disorder, that they didn’t rely on the more powerful and side-effect-plagued Zyprexa as a mainstay of treatment. And neurologists had told me that antipsychotics such as Zyprexa are often over-prescribed for dementia and are not indicated if the patient is relatively calm.


When the drug rep persisted in trying to persuade me to prescribe the drug, I grew angry. Raising my voice, I accused her of trying to jeopardize patient care.

At that point, she said the company had given her a directive to reach out to as many internists as possible. The company felt that we internists as a group were underutilizing the drug, she said.

That’s dangerous thinking, I replied. I told her that such persistence would no doubt lead to the drug being wrongly prescribed -- that it would hurt patients. She seemed insulted by my charge, and left, and I gave all her sample boxes to Anne, the one patient I had who was clearly benefiting from the drug.

I was reminded of the incident last week when news reports emerged that Eli Lilly had reportedly urged primary care doctors to use the drug for elderly patients with symptoms of dementia. The company has denied promoting the drug for off-label uses.

The reports highlighted for me the crucial role that internists and other primary care doctors play in screening for psychiatric illnesses but also in knowing when to refer these patients for proper treatment. Although psychiatrists are not always available and not all patients are willing to see them, doctors must carve out our areas of expertise in keeping with our training and experience, and depression and psychosis are simply not my areas as an internist.

Not everyone agrees. Several years ago at a dinner, I was introduced to William Styron, the author who penned, along with his novels, the groundbreaking memoir on depression, “Darkness Visible.” When Styron heard that I was an internist, he remarked that it was an internist who had diagnosed his depression, and that it was the internists and primary care doctors on the front lines of medicine who he felt are best equipped to treat depression.


I don’t deny I can play a role in the treatment of mental illness, but this is best accomplished in conjunction with a true expert. For instance, when I learned that Zyprexa can cause weight gain, I called Anne’s psychiatrist and together we made the decision not to stop Anne’s prescription because she had not gained weight on it. She already had diabetes, which has recently been associated with Zyprexa, but the pill had not worsened her condition.

Prescribing medicines requires a cost-benefit analysis, and patients like Anne clearly benefit from Zyprexa. With others the decision is not so clear, and I have received several calls recently from relatives of Zyprexa patients who fear these patients will gain more weight, develop diabetes or even die prematurely.

I tell them that this cost-benefit decision should be made in conjunction with the patient’s psychiatrist, not solely by an internist placed under pressure by a salesperson.

Dr. Marc Siegel is an internist and an associate professor of medicine at New York University’s School of Medicine. He can be reached at marc@