Great expectations: the psychology of switching

The late Canadian novelist Robertson Davies once remarked that the eye sees only what the mind is prepared to comprehend. He could almost have been referring to oft-reported negative experiences of patients switching from branded to generic drugs. 

But look beyond the shiny packaging - branded drugs are biochemically the same as generic equivalents. Both have the same active ingredient, delivered to the body in the same way. Both have the same effects.

Auckland University’s Keith Petrie is one of New Zealand’s experts in health psychology. He says low patient expectations about generics are largely explained by perception and unconscious brand bias. Feedback from others, including fellow patients, and availability of choice can also influence patients’ assessment of a medication’s effectiveness.

In 2013, a group of subjects in an Auckland University study were consciously changed from branded to generic beta-blockers. They reported more symptoms and side effects, despite both versions being placebos. The difference was all in the subjects’ heads.

At the heart of this is the ‘nocebo effect’ - described by Petrie as “things that arise from our negative expectations of a treatment not working or having bad side effects”. He notes that because patients are often told about all possible side effects without information on the likelihood of them occurring, negative expectations can be set up quite early in the treatment cycle.

The psychology of perception is important because generic drugs are an important part of affordable health care, and the brands of medicines can change from time to time.  Change like this can be a psychological minefield for some patients. Petrie says subtle changes of cognition around the look and feel of a medication can make people more aware of possible side effects. In other words, they start looking for things that could go wrong, rather than go right.

Importantly, Petrie says when people report side effects it may not necessarily be a pharmacological issue. It's often the context of the drug - the things that surround it, including lack of branding, the fact they didn't know about it, and other people reporting problems.

That's why it’s important for health care professionals to help patients positively reframe their expectations. Luckily, medical professionals are well-positioned to inject a dose of reality into those who doubt the efficacy of generic drugs.

“Telling a patient that the generics have the same active ingredients and although the tablet might look different they can be reassured they're getting the same chemical compound as before,” says Petrie.

He says while change is always difficult, having a conversation about how branding can influence us is useful to put on the table - especially the scientific research into how brand bias has been shown to impact bodily symptoms. 

The beauty of perception, of course, is that it cuts both ways. Robertson Davies’ adage about perception stands - because the truth is that generic drugs work the same as branded drugs. The more people that know it, the better.