Gender Differences Appear in Drug-Dispensing Data

Prescription-drug data analyzed by Medco Health Solutions, one of the country's largest pharmacy-benefit managers, indicates that an increasing number of prepubescent and adolescent girls in the United States are being prescribed drugs to treat psychiatric illnesses, sleep ailments, and behavioral problems such as attention-deficit/hyperactivity disorder (ADHD).

Moreover, compared with young boys, the increase in the prevalence rates of psychotropic prescriptions dispensed to girls, is dramatic. According to Medco, from 2001 to 2006 the percentage increase in the prevalence rate of girls dispensed psychotropic and sleep medications far outpaced the increase for boys prescribed and dispensed the same drugs.

The analysis, which was not peer reviewed, looked at prescription drug claims—for both physical and psychiatric illnesses—managed by Medco from 2001 to 2006 for 370,000 medically insured youth (roughly half boys and half girls) aged 10 to 19 in the United States.

The data that were reviewed and analyzed were culled from Medco's 2007 Drug Trend Report, the ninth in a series of such annual reports. According to Medco, the data are representative of an insured population.

The biggest prescription-dispensing increase for girls over the study period was for medications to treat diabetes. According to numerous reports, diabetes is a growing childhood problem that can have psychological ramifications. The prevalence rate of girls dispensed diabetes medications jumped 167 percent over the study period, compared with 91 percent for boys.

Girls' Health Raises 'Red Flags'

Some experts believe that Medco's large database prescription claims analysis suggests a growing prevalence of psychologically troubled young girls.

“While this may be evidence that more girls are, for the first time, being appropriately diagnosed and treated, it also raises red flags about the physical and psychological problems afflicting this population,” Robert Epstein, M.D., Medco's chief medical officer, said in a press statement.

“Overall, the findings are consistent with previous studies and with impressions from general clinical practice,” David Fassler, M.D., told Psychiatric News. However, “in many ways, the findings raise more questions than they answer.”

Fassler, a child and adolescent psychiatrist, is an APA trustee and a clinical professor of psychiatry at the University of Vermont College of Medicine.

Among the prescription-writing trends revealed by Medco's study were the following:

According to Medco, the antipsychotics primarily being prescribed are the second-generation ones such as risperidone, olanzapine, clozapine, ziprasidone, and quetiapine. They were prescribed to treat, among other conditions, bipolar disorder, conduct disorder, ADHD, depression, and Tourette's syndrome.

Still, by the end of the five-year study period, the rise in the prevalence rate for girls dispensed ADHD medications was double that for boys—74 percent versus 37 percent.

One reason for this change, according to Medco, may be better diagnosis of young girls with ADHD. “New research out of the University of California, Berkeley, found that adolescent girls diagnosed with ADHD are less prone to hyperactivity than boys, but are more likely to exhibit other emotional and behavioral issues, including depression and eating disorders. Additional findings show that girls have historically been underdiagnosed with ADHD because they don't display the impulsive and disruptive behavior often seen in boys with the condition,” Medco researchers said in a statement accompanying release of the findings.

During the study period, concerns over the potential increased risk of suicidal thoughts and behaviors in children and adolescents taking antidepressants became widespread. In late 2003 the Food and Drug Administration (FDA) issued its first public advisory cautioning about the use of antidepressants in children. In 2004 the agency ordered black-box warnings added to antidepressant labeling. According to many experts, the FDA's actions and the resultant publicity created a backlash against prescribing antidepressants for youngsters.

Interpretation Uncertain

Fassler said he is concerned that the design of Medco's analysis was not peer reviewed or published in its entirety beyond the company's Web site.

“In many ways, the findings raise more questions than they answer,” he said. For example, it is important to know whether the population studied remained comparable over time. “I would also want to know who was doing the prescribing and whether the children were receiving other interventions in addition to medication,” he said.

“Ultimately, the real issue is not simply how many prescriptions are being written on an annual basis,” he continued. “The more relevant question is, Are the right children, adolescents, and adults receiving the most effective and appropriate intervention possible?”

Lon Castle, M.D., the lead author of Medco's “2007 Drug Trend Report,” agreed with Fassler.

“Further study will have to answer those questions,” said Castle, director of medical policy and programs at Medco. The purpose of the report, he noted, is to inform payers, primary care and specialty physicians, and other stakeholders about what medications are being prescribed and presumably used right now to “get this information out into the public domain in real time. It's up to the clinicians [and researchers] to determine and explore why it is happening.”

Castle, however, was able to respond to Fassler's question regarding who is prescribing psychotropic medications to young girls, as well as to young boys.

It is mostly the primary care physicians doing the prescribing, and that includes pediatricians, Castle said.

More information about the Medco study can be accessed under“ Latest News” at<www.medco.com>. Medco's 2007 Drug Trend Report can be accessed at the same Web address under“ Media” by clicking on “Drug Trend Resource Center.” ▪