Question: Do you think there is a difference between generic and brand name medications? I’ve been on the same medication for a long time. All of a sudden, my doctor prescribed a generic version. It did not work, and I started getting very depressed and anxious, and I had my first panic attack in years. What do you think? My pharmacist says the generic is exactly the same as the brand name. My primary care said it’s all in my head.
Anne Fenton, MD: First, it is important to realize that your doctor did not prescribe the generic version of your medication. Your doctor filled out the same prescription as you have always had. However, as soon as the patent on a brand name medication expires, a generic version is produced, and pharmacies are automatically mandated by insurance companies to dispense only the generic unless the doctor specifies “dispense brand name only” This is because the generic is less expensive for the insurance company to pay for than the brand name drug.
Often, we prescribers do not even know that a generic has been released to the market until patients come in telling us of experiences like yours. We are not informed by either the product manufacturer or the insurance companies of these developments.
There can in fact be significant variability between the generic and brand name for many medications. I have been told that the FDA allows for up to a 20% variability in active ingredient, which may explain why equivalent doses of the generic medication are not as effective as the brand name dose. In addition, fillers and additives can vary among generics and brand names and may account for allergic reactions to some generics but not to others nor to the brand name medication.
I am aware that a great deal of marketing effort and dollars go into letters sent by insurance companies to patients advising them to ask their doctor about the generic, or about prescribing an alternative medication used for the same diagnosis. When doctors do request that the brand name medication be dispensed, we receive countless letters and faxes from insurance companies requesting us change the prescriptions to generic. Regardless of how we respond, or how we explain that the patient requires brand name, we are still bombarded with these letters and faxes. Letters like these are very misleading, since not all antidepressants are alike, and not all patients with depression or other “like” diagnoses respond the same way to the same medications. In fact, even antidepressants or anti anxiety agents in the same family (SSRI’s, or benzodiazapenes,) for example, have significantly dissimilar chemical compositions to justify customizing treatment.
So it is simply not true that all generic medications are exactly the same as the brand name medications. To be fair, they are generally similar enough that most people do not have a problem switching. Nevertheless, a significant percentage of people do notice a difference in benefit or side effects, and this difference should be taken seriously. A case in point is that of a young adult who is mentally retarded and emotionally unstable. His symptoms include self mutilating behavior. For years, these symptoms were well controlled with a certain medication. According to U.S. patent law, pharmaceutical companies are allowed to produce generic versions of brand name medications after a specified number of years after the brand name medication has been patented. When the generic version becomes available, the patient generally receives the generic version from the pharmacy instead of the brand name version. In this case, his mother was initially happy, since she is not a rich woman and was grateful for the decreased cost of her co-pay. However, after years of stability, the young man began to have severe rage attacks, and was mutilating himself to the point of bleeding, all because of the decreased efficacy of the generic. After battling the insurance company by having to send numerous and repeated requests to authorize payment for the brand name, the company finally consented authorized the pharmacy to dispense the brand name medication. Within two weeks, the patient was stabilized, with no further incidents of violent or self mutilating behavior. Clearly, this mentally retarded patient’s dramatically different responses to generic vs. brand name medication were not attributable to being “all in his head,” since he is cognitively incapable of understanding, knowing, or expecting that there was any change in the medication prescribed.
This is not to suggest that patients should in all cases request only brand name medications. For economic reasons, the generic may be worth a try. If you do notice a difference, though, talk to your prescriber about requesting an override from your insurance company to pay for the brand name. This process, though not trivial, is worth the effort to provide better treatment or fewer side effects when indicated.