When John D. Abramson was practising family medicine in Hamilton, Mass., he prided himself on how conscientiously he selected the drugs that he prescribed. He closely followed pharmaceutical research. He kept track of the latest medical guidelines. And he maintained his distance when company salespeople, with promotional pitches at the ready, appeared at the practice that Abramson shared with several colleagues during the 1980s and 1990s. He typically didn’t speak to pharmaceutical sales agents, although he did let them leave behind free samples of drugs that their companies sold.

Abramson knew that the companies wanted him and his colleagues to prescribe new and often expensive drugs rather than their older, less costly alternatives. But he saw no harm in stockpiling the freebies and banding them out to patients who were without health insurance and unable to buy drugs on their own.

“I thought I was being Robin Hood,” Abramson says. Before long, however, he grew so familiar with administering the free drugs that he found himself writing prescriptions for the same substances for insured patients, whose coverage would then pay for the medications. For pharmaceutical companies, Abramson’s behavior meant new customers. “That’s what they wanted,” he says. “They were playing me like a violin.”

Abramson left medical practice nearly 4 years ago to write Overdosed America: The Broken Promise of American Medicine (2004, HarperCollins), which trains a critical eye on pharmaceutical companies’ influence on medical research and practice. He now teaches at Harvard Medical School.

At least two pharmaceutical marketing strategies converge to alter doctors’ prescribing habits. On one hand, sales representatives target physicians with visits and samples, and ads tout drugs in journals. On the other, mass media advertisements urge people to ask their doctors about specific brand-name medications. This direct-to-consumer (DTC) advertising, which is not permitted in Europe and strictly limited in Canada, has in the past decade grown into a multibillion-dollar industry in the United States.

Pharmaceutical companies and some health researchers say that promotional activities make doctors and patients better aware of available treatments. Other researchers and consumer advocates counter that the ads and giveaways goad doctors into giving patients drugs that may be unnecessarily expensive or sub-optimal in effect.

If nothing else, says internist Richard L. Kravitz of the University of Caiifornia, Davis, the consequence of drug promotions is that the medicines that are most profitable for drug companies end up being overprescribed.

ASK THE DOCTORS Eighteen actors were dispersed to physicians’ offices by Kravitz and his colleagues during 2003 and 2004. Such actors are known in the medical literature as standardized patients; they aren’t sick, but they’re trained to describe certain realistic sets of symptoms. Medical schools use standardized patients to test students’ diagnostic skills.

Kravitz had a different test in mind. He and his fellow investigators instructed the actors not only to fake specific symptoms but also, in some cases, to ask for a particular drug or a general class of drugs. The researchers wanted to know how physicians would respond to supposedly media-driven inquiries. The researchers recruited 152 family physicians and general internists practicing in San Francisco, Sacramento, Calif., or Rochester, N.Y. Each participating doctor was told that he or she would be sent two standardized patients during the next year. But the doctors weren’t told the study’s purpose or how to identify the fake patients.

The actors then scheduled appointments with the physicians. Once in a participating doctor’s office, some of the fake patients described symptoms of major depression, a long-lasting mood disorder that’s often treated with antidepressant medications. Other standardized patients complained of symptoms of a less serious psychiatric ailment, which is called adjustment disorder with depressed mood. This condition generally disappears within months without medication.

When standardized patients faking major depression didn’t specifically request an antidepressant, 31 percent received a drug prescription. However, when others claimed that a television show about depression had encouraged them to seek drug treatment, 76 percent received a prescription of some kind.

In those two groups, about 6 percent of the actors who received a prescription got one for paroxetine (Paxil), one of several drugs in a class frequently used to treat major depression.

However, when members of a third group reporting identical symptoms asked specifically for Paxil, saying that they had seen it advertised on television, more than half the resulting prescriptions were for that drug.

In standardized patients who reported symptoms of adjustment disorder and didn’t raise the subject of antidepressant drugs, just 1 in 10 got any medication. But nearly half of the actors who asked for medication got it. Most who asked for Paxil walked out with a prescription for that drug, while most who made a nonspecific request were prescribed some other antidepressant.