A significant amount of print has been devoted in recent weeks to headlines in such respected publications as the Washington Post
and New York Times
, among others, about sales of sedatives and sleeping pills "jumping" or "skyrocketing" in the Big Apple or the nation’s capital in the days and weeks following September 11. Articles have included dire warnings from "experts," noting the drugs’ addictive potential and that physicians should not be too dependent on medications as a quick fix for the traumatic effects of the September 11 attacks.
While that advice is no doubt true, prescription data provided to press outlets, including Psychiatric News, by NDCHealth, an Atlanta-based independent research company, appear to indicate that people in the New York and Washington, D.C., metropolitan areas are not relying simply on medication as a quick fix, but perhaps as a supporting player in a difficult recovery.
Indeed, an analysis of data compiled by NDCHealth for Psychiatric News reveals specific trends that profile, not a growing concern over prescription sedative and antianxiety abuse, but a moderate increase in sales followed by a steady return of sales to pre-September 11 levels.
"These data," Lloyd Sederer, M.D., director of APA’s Division of Clinical Services, told Psychiatric News, "show the profile of a healthy nation. Now, a few weeks after an intense but normal reaction to an extremely abnormal and traumatic event, our society is showing that it is adaptive and resilient."
What is interesting, Sederer remarked, is that the data appear to capture the secondary traumatization that occurred across the nation, not simply in the New York or D.C. regions.
"Everyone saw this happen, and many have been traumatized not simply by the horror of the event itself, but also by the repetitive exposure. There is a wave of fear and distress revealed in the data—marked by a distinct increase in dispensing of medications—more prominent in the areas affected, but also in the nation as a whole. As the weeks have passed, that wave is dissipating," Sederer said.
"As society brings in its own forms of coping—by becoming educated, by finding support mechanisms, by finding some sense of productive safety, the reactions of anxiety, worry, and sleep disturbances, for example, are dissipating, and so dispensing of these medications is not only leveling off but decreasing."
Data provided by NDCHealth showed total numbers of prescriptions dispensed and new prescriptions for each medication within three categories: antidepressants (including SSRIs and SNRIs), antianxiety medications (including the benzodiazepines), and sedative/hypnotic medications (including both barbiturate and nonbarbiturate sedatives). NDCHealth collects its data from more than 35,000 retail and mail-order pharmacy outlets, including small independent pharmacies and large national chains. The data represent two-thirds of prescriptions dispensed by the 55,000 licensed U.S. pharmacy outlets.
Data were compiled as sales figures for each week ending on successive Fridays, beginning with September 7 and ending on October 12. Numbers of new and total prescriptions dispensed and the quantities of medication and their respective dollar costs were provided.
NDCHealth separated the data into a New York City regional data set (which included New York City and Putnam, Rockland, and Westchester counties,) a Washington, D.C., regional data set (which included the city, five Maryland and 11 Virginia suburban jurisdictions, and two West Virginia counties), and a national sales data set.
Psychiatric News calculated and analyzed the number and cost of refilled versus new prescriptions, as well as the changes in dispensing that occurred over the five-week period following the tragedy (see charts).
In the week ending September 14, just three days after events unfolded that Tuesday, the number of antianxiety prescriptions dispensed in the New York area rose by over 18 percent compared with the week ending September 7, while the D.C. area saw an increase of under 8 percent. Antianxiety prescriptions across the country as a whole rose only 4 percent.
Nearly 95 percent of the increase in New York was due to new prescriptions, while 70 percent of the increase in the D.C. area was accounted for by new prescriptions, and just 62 percent of the national increase was made up of new prescriptions being filled.
Sedative/hypnotic dispensing followed a similar pattern that first week with a 5 percent increase in New York (of which about 70 percent were new prescriptions) and less than 1 percent in the D.C. area and at the national level.
Antidepressant dispensing followed a somewhat different pattern for the week ending September 14. A larger increase (just over 6 percent) was seen in the D.C. area, with just under a 5 percent increase in New York and a 2.3 percent increase nationally.
Several experts have noted in media reports that this pattern is appropriate given the "build-up" nature of this class of medications as well as an expected delay in the onset of depressive symptoms. As such, Sederer said, antidepressants would not be expected to be the immediate drug of choice for people affected by the aftermath of the attacks.
Interestingly, while new prescriptions accounted for a slight majority of the antidepressant increase in New York, in D.C. and nationally refills accounted for half of the increase. This could suggest that existing patients were being significantly affected by the acute events, as would be expected, Sederer told Psychiatric News.
"But what you don’t know from these data is whether the people were refilling their existing prescription to actually continue taking it, starting to take it again after having not taken it for a while, or simply stocking up on it because they were worried they might need it later," he said.
Secondly, what is also not clear from the data provided, Sederer pointed out, is any indication of who is writing the extra prescriptions. Sederer suspected that it is mostly primary care physicians.
In the weeks following that initial data point, the pattern is clear for all three types of medications. Antianxiety prescribing peaked in the New York region the week ending September 21, with an increase in dispensing of 25 percent over the week ending September 7. In each of the next three weeks, through October 12 (the most recent data available at press time), dispensing remained at a level above that of September 7 but was steadily falling.
The D.C. region and the nation as a whole did not see a peak in dispensing of antianxiety medications until the week of October 5, two weeks after that occurred in the New York area. However, a significant decrease was then evident by the following Friday.
The trend for dispensing of sedative/hypnotic medications was comparable. Dispensing peaked in New York the week ending September 28, then began to decrease. For both the D.C. region and the nation, however, dispensing peaked, at much lower levels than New York, the following week and then declined significantly by October 12.
As would be expected, antidepressant prescriptions continued to increase for New York, Washington D.C., and the nation until the week ended October 5, with all three seeing a significant decline by October 12. In this case, however, the pattern of increased dispensing was a bit different.
Antidepressant dispensing did not show a greater increase in the first few weeks following September 11 in the New York area or in the Washington, D.C., region. The degree of increase was not statistically significantly different in either the week ended September 21 or September 28 between the two areas.
"So, if this is the profile of a healthy nation, then what might we imagine seeing in future data?," Sederer asked.
"It is very important not to over- or under-pathologize what we are inferring from these data," Sederer cautioned. "Most people will feel better with time and stop taking the medications. However, some people are going to suffer in ways that may reflect resistance to treatment, and they may go on to develop pathology. It is important to make sure that we detect those individuals."
The difficulty, Sederer explained, arises because the traumatization linked to this event is continuing. People are being bombarded on a daily basis with new threats, bioterrorism scares, and news of the war in Afghanistan. "You might expect to see spikes in future data. I would expect one among antianxiety and sedative medications in the D.C. area this week." [As Sederer was interviewed for this story, anthrax continued to be positively identified in local post offices and people who had handled the mail.]
The long-term implications of September 11, and its ongoing traumatization of the nation, are something that the mental health profession is only now learning about.
"These data are, on the surface, fairly reassuring; however, we must make sure that we watch those who are at increased risk for stress disorders and long-term development of major depression and possibly substance abuse," Sederer concluded. ▪