trends in the use of psychotropic drugs in people with intellectual disability in taiwan: a...
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Research in Developmental Disabilities 35 (2014) 364–372
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Research in Developmental Disabilities
Trends in the use of psychotropic drugs in people with
intellectual disability in Taiwan: A nationwide outpatientservice study, 1997–2007Shang-Wei Hsu a,b,*, Po-Huang Chiang a,b, Yu-Chia Chang a,c, Jin-Ding Lin d,Ho-Jui Tung a,c, Chao-Yun Chen a
a Department of Healthcare Administration, Asia University, Taichung, Taiwanb Department of Public Health, China Medical University, Taichung, Taiwanc Research Center of Health Policy and Management, Asia University, Taichung, Taiwand School of Public Health, National Defense Medical Center, Taipei, Taiwan
A R T I C L E I N F O
Article history:
Received 19 August 2013
Received in revised form 14 November 2013
Accepted 14 November 2013
Available online 13 December 2013
Keywords:
Psychotropic drugs
Intellectual disability
A B S T R A C T
This study aims to examine trends in outpatient psychotropic drug use among people with
intellectual disabilities in Taiwan. The NHI outpatient medication records between
January 1, 1997 and December 31, 2007 for people with intellectual disabilities were
analyzed to observe the percent change, prevalence and prescription trends in
psychotropic drugs. The overall prevalence of psychotropic medication increased from
17.82% to 23.22% during the study period. Results from stepwise logistic analysis
demonstrated that females, the elderly, and individuals suffering from catastrophic
disease were more prone to receive psychotropic drugs and that those with mild
intellectual disability were less likely to receive psychotropic drugs. The percentage
change in prescription rates of antipsychotics, hypnotics/sedatives, and antidepressants
were 85.30%, 127.25%, and 167.50%, respectively, and the trends were statistically
significant (p < 0.05). Taiwan’s NHI program and off-label use of psychotropic drugs might
have attributed to this trend.
� 2013 Elsevier Ltd. All rights reserved.
1. Introduction
Individuals with intellectual disabilities (ID) may have problems with expressing their thoughts, learning, performingdaily tasks, making decisions, and memory. Subsequently, when they experience a mental health issue, it may not berecognized. However, it is generally acknowledged that adults with ID experience a similar distribution of mental disorders,and a similar severity of symptoms as adults in the general population (Fletcher, Loschen, Stavrakaki, & First, 2007). Reportson the prevalence of psychiatric disorders among adults with ID range widely, between 10% and 50%, depending on thesample selection, definition of psychiatric illness, and level
of ID (Australian Institute of Health and Welfare, 2008; Bhaumik, Tyrer, McGrother, & Ganghadaran, 2008; Tonge, Einfeld,Krupinski, Mackenzie, & McLaughlin, 1996).
* Corresponding author at: Department of Healthcare Administration, Asia University, No. 500, Lioufeng Road, Wufeng, Taichung 41354, Taiwan.
Tel.: +886 4 23323456x6312; fax: +886 4 23321206.
E-mail address: [email protected] (S.-W. Hsu).
0891-4222/$ – see front matter � 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ridd.2013.11.011
S.-W. Hsu et al. / Research in Developmental Disabilities 35 (2014) 364–372 365
There is evidence that people with ID have a high prevalence of the full range of mental disorders and challengingbehaviors (Bregman, 1991; Holland, 1999; Matson & Boisjoli, 2007), e.g., bipolar disorder (Matson, Gonzalez, Terlonge,Thorson, & Laud, 2007), pervasive developmental disorder not otherwise specified (Ghaziuddin, 2000), major depression(Matson, Terlonge, Gonzalez, & Rivett, 2006), and attention deficit hyperactivity disorder (Rose, Bramham, Young,Paliokostas, & Xenitidis, 2009). Subsequently, to improve psychological status and problem behaviors, antipsychoticmedication use is especially high in the ID population (Matson & Mahan, 2010).
Over the past several decades, psychotropic drugs have assumed great significance in the treatment of psychiatricdisorders. The most commonly used psychotropic drugs are antipsychotics, mood stabilizers, antidepressants, anxiolytics,hypnotics, and sedatives (Matson & Mahan, 2010). The prevalence rates for psychotropic drug use vary widely betweencountries (Chien et al., 2007; Paulose-Ram, Jonas, Orwig, & Safran, 2007; Richter, Mann, Meyer, Haastert, & Kopke, 2012).
Many studies in Taiwan have found that although people with ID have a higher risk of ill health and physical disease thanthe general population (Chiang, Chang, Lin, Tung, Lin, & Hus, 2013; Lin et al., 2007, 2009, 2010a,b), they also suffer from manypsychiatric or behavioral disturbances, known as ‘dual diagnosis’ (Lin et al., 2005). However, general information regardingantipsychotic medication use among individuals with ID in Taiwan is lacking. The purpose of this study was to describe thetrends in use of psychotropic medicine for treatment of persons with ID in Taiwan.
2. Methods
This study analyzed psychotropic medication utilization in persons with ID in Taiwan by analyzing data from the nationalhealth insurance ambulatory service, from the National Health Insurance program (NHI), provided by the National HealthResearch Institute (NHRI). The detailed structure of data sets and information safety precautions are described on the NHRIweb site (NHRI, 2011a, b). To eliminate financial barriers to accessing medical services and to solve social problems caused bypoverty and illness, the NHI program was launched in Taiwan in 1995. The NHI program is a compulsory social insuranceprogram, covering 99.60% of the population in Taiwan, with 92.60% of the medical institutions in Taiwan affiliated with theBureau of National Health Insurance (BNHI) at the end of 2011 (BNHI, 2013). The data sets utilized in our study containedambulatory care expenditures by visit and the details of ambulatory care orders, including the dates of visit, medical carefacility, patient’s gender, date of birth, the three major diagnoses, medical expenses, and drug prescribed by the physician foreach visit from all medical care institutions under contract with the BNHI of Taiwan. Psychotropic drugs were recorded basedon the anatomical therapeutic chemical (ATC) classification system (World Health Organization, 2005). Data presented inthis study were limited to four main drug categories: antipsychotics (N05A), anxiolytic drugs (N05B), hypnotics/sedatives(N05C), and antidepressants (N06A).
The NHI outpatient medication records of ID insurers from January 1, 1997 to December 31, 2007 were analyzed toexamine temporal changes in the use of antipsychotics, anxiolytic drugs, hypnotics/sedatives, and antidepressants. Allclaimants who had any record of using psychotropic medications in ambulatory care were identified in each year. Thepercent change, prevalence and trends in prescriptions for psychotropic drugs were assessed. The percent change and theprevalence of use of psychotropic drugs were stratified by gender, age group, ID level and copayment status (Chiang et al.,2013). Percent change was determined by comparing 1997 data with 2007 data (Chien et al., 2007), and the linear model testwas applied to assess trends in the prevalence of use of psychotropic drugs. To estimate the prevalence of psychotropic druguse, the denominator was the total number of persons in the study sample each year, and the numerator was the number ofinsured in each year who had received psychotropic medication treatment. The Cochran–Armitage trend test and stepwiselogistic regression analysis were performed to test the association between receiving or not receiving psychotropic drugtreatment. Statistical analysis was performed with SAS 9.2 for Windows (SAS Institute Inc., Cary, NC, USA).
3. Results
Table 1 shows the demographic characters of the study population from 1997 to 2007. The number of ID subjects utilizingoutpatient services increased from 67,143 to 93,914, a 39.87% increase during the study period. The ratio between male andfemale insured patients included in the study remained constant, at approximately 59–41%. The proportion of preschoolchildren dropped dramatically from 27.03% to 1.83% (p < 0.001). More than half of people with ID resided in urban areas,however, the percentage residing in urban areas decreased from 53.29% to 50.76% (p = 0.003) The proportion of individualssuffering from catastrophic disease and social welfare recipients increased two and three times during the 11-year period(p < 0.001), respectively.
Table 2 presents the prevalence and Cochran–Armitage trend test results of the study population receiving psychotropicmedicine treatment from 1997 to 2007. The overall prevalence of psychotropic medication use increased by 30.30%, from17.82% to 23.22%, and the prevalence of non-psychotropic medication use dropped from 82.18% to 76.78% (p < 0.001) duringthis 11-year period. The Cochran–Armitage trend test confirmed that these shifts were statistically significant. Afterstratification, all variables increased significantly, except in elderly and adolescent subjects (p > 0.05). Stepwise logisticanalysis results demonstrated that females, the elderly, and insured patients suffering from catastrophic disease were moreprone to receive psychotropic drugs, and subjects with mild ID were less likely to take psychotropic drugs. Femaleindividuals with ID had a higher proportion of psychotropic drug use than their male counterparts (OR = 1.032, 95%CI = 1.021–1.043). The percentage of drug use in elderly ID subjects was higher than in any other age group (elderly vs. age
Table 1
Demographic characteristics of the study population.
Variables 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Gender
Female 28,120 31,809 35,378 36,400 37,309 38,239 38,595 38,663 39,713 39,189 38,830
Male 39,023 44,313 49,907 51,463 53,524 54,647 54,792 55,152 56,719 56,095 55,084
Age group
6 < age 18,149 18,823 19,414 17,979 16,217 13,615 10,738 8009 5756 3441 1719
13 > age � 6 14,763 17,282 19,873 20,940 21,904 22,922 23,462 23,103 22,861 21,463 19,330
19 > age � 13 9170 11,174 13,046 13,570 14,022 14,737 15,372 16,089 17,535 18,075 18,575
31 > age � 19 10,414 11,913 13,922 15,369 17,251 18,883 19,856 21,288 23,574 24,808 25,800
65 > age � 31 13,539 15,622 17,613 18,550 19,860 21,001 22,148 23,428 24,707 25,406 26,257
65 & older 1108 1308 1417 1455 1579 1728 1811 1898 1999 2091 2233
Intellectual disability level
Mild (317) 42,220 47,728 53,333 54,851 56,346 57,576 57,667 57,782 59,159 58,301 59,637
Moderate (318.0) 19,380 22,102 24,858 25,665 26,724 27,391 27,585 27,849 28,758 28,384 26,858
Severe (318.1) 4441 4993 5644 5839 6206 6342 6562 6584 6810 6878 6031
Profound (318.2) 1102 1299 1450 1508 1557 1577 1573 1600 1705 1721 1388
Copayment
Catastrophic disease 3564 4270 5232 5391 6418 7693 9124 10,142 11,358 12,224 11,210
Social welfare 2353 2943 3664 4364 5123 6026 6812 7443 9116 9369 9728
Full 61,226 68,909 76,389 78,108 79,292 79,167 77,451 76,230 75,958 73,691 72,976
Total 67,143 76,122 85,285 87,863 90,833 92,886 93,387 93,815 96,432 95,284 93,914
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<6: OR = 3.876, 95% CI = 3.731–4.016; elderly vs. age �6, <13: OR = 4.065, 95% CI = 3.937–4.219; elderly vs. age �13, <19:OR = 2.597, 95% CI = 2.506–2.688; elderly vs. age �19, <31: OR = 1.486, 95% CI = 1.437–1.536; elderly vs. age �31, <65:OR = 1.181, 95% CI = 1.142–1.221). Individuals suffering from catastrophic disease had the highest proportion ofpsychotropic drug use, compared with social welfare recipients and full copayment insurers (catastrophic disease vs.social welfare recipients: OR = 2.088, 95% CI = 2.041–2.137; catastrophic disease vs. full copayment: OR = 3.049, 95%CI = 2.994–3.096). With regards to disease severity, psychotropic drug use rates were lowest in patient with mild ID (mild vs.moderate: OR = 0.957, 95% CI = 0.945–0.968; mild vs. severe: OR = 0.933, 95% CI = 0.931–0.952; mild vs. profound:OR = 0.892, 95% CI = 0.857–0.928).
Fig. 1 displays the temporal trends in the use of antipsychotics (N05A), anxiolytic drugs (N05B), hypnotics-sedatives(N05C), and antidepressants (N06A). The percentage change in use of antipsychotics, anxiolytic drugs, hypnotics/sedatives,and antidepressants were 85.30%, 7.25%, 127.25%, and 167.50%, respectively, and the trends of change were statisticallysignificant(p < 0.05), except for anxiolytic drugs. Tables 3–6 display the change pattern and trends for variables of each classof psychotropic drug.
Table 2
Prevalence and Cochran–Armitage trend test results of the study population receiving psychotropic treatment.
Variables 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 p value of
trend test
Gender
Female 19.79 20.57 22.01 21.81 21.91 22.62 23.22 24.13 24.27 24.69 24.36 <0.001
Male 16.40 17.22 19.15 18.97 19.70 20.36 20.80 21.94 22.23 23.12 22.41 <0.001
Age group
6 < age 9.92 10.47 13.29 12.57 11.48 11.58 11.09 11.32 11.22 12.06 10.70 0.002
13 > age � 6 10.59 11.07 12.16 11.78 11.88 11.64 11.23 11.63 11.18 11.15 9.89 <0.001
19 > age � 13 15.77 16.14 17.12 17.09 16.72 17.23 17.61 18.05 17.62 17.43 15.76 0.086
31 > age � 19 25.61 26.53 27.77 27.20 28.09 28.72 28.50 28.70 28.15 28.39 26.64 0.002
65 > age � 31 30.34 30.99 32.46 32.06 32.59 32.91 33.76 34.51 34.66 34.83 34.58 <0.001
65 & older 34.39 37.00 37.61 36.56 37.30 37.91 38.32 38.62 37.82 38.07 37.17 0.070
Intellectual disability level
Mild (317) 16.65 17.85 19.65 19.45 19.67 20.37 20.74 21.76 21.97 22.73 21.66 <0.001
Moderate (318.0) 19.44 19.56 21.27 21.02 21.76 22.31 22.92 23.84 23.98 24.58 25.27 <0.001
Severe (318.1) 21.08 21.09 22.36 22.25 23.82 24.38 25.57 26.78 27.62 28.15 28.25 <0.001
Profound (318.2) 21.23 21.32 21.86 22.94 22.03 24.67 25.49 28.19 27.86 27.95 28.67 <0.001
Copayment
Catastrophic disease 40.32 41.26 39.51 44.52 46.28 45.95 46.53 47.41 47.45 46.79 51.97 <0.001
Social welfare 26.05 25.35 25.85 26.90 26.63 27.13 27.25 27.54 27.83 28.75 28.16 <0.001
Full 16.20 16.93 18.76 18.09 18.14 18.45 18.41 19.11 18.86 19.31 18.15 <0.001
Total 17.82 18.62 20.34 20.15 20.61 21.29 21.80 22.84 23.07 23.77 23.22 <0.001
Fig. 1. Trends in the use of psychotropic drugs in Taiwan’s ID from 1997 to 2007.
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Table 3 shows that antipsychotic use in preschool children did not change during the study period. Individuals agedbetween 31 and 64 years old had the highest percent of change during the study period. Subjects with mild ID had the lowestrate of antipsychotic use. Claimants suffering from catastrophic disease had the highest prevalence rate and percent ofchange compared with social welfare recipients and subjects in the full copayment group. Logistic analysis resultsdemonstrated that compared with male subjects, age, ID level and copayment status were factors that influencedantipsychotic use in female claimants. The percentage of elderly female subjects receiving antipsychotic treatment washigher than in other age groups (elderly vs. age <6: OR = 2.370, 95% CI = 2.114–2.653; elderly vs. age �6, <13: OR = 2.538,95% CI = 2.299–2.793; elderly vs. age �13, <19: OR = 2.062, 95% CI = 1.876–2.262; elderly vs. age �19, <31: OR = 1.883, 95%CI = 1.721–2.058; elderly vs. age �31, <65: OR = 1.157, 95% CI = 1.059–1.266). Female individuals with ID and suffering fromcatastrophic disease had the highest antipsychotic use rates, compared with social welfare recipients and subjects in the fullcopayment group (catastrophic disease vs. social welfare recipients: OR = 1.205, 95% CI = 1.151–1.263; catastrophic diseasevs. full copayment: OR = 1.128, 95% CI = 1.094–1.163). The proportion of females with mild ID taking antipsychotics drugswas lower than female with severe ID (mild vs. severe: OR = 0.940, 95% CI = 0.894–0.986).
Table 3
Temporal change in antipsychotics use rates.
Variables 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 % Change Linear trend
test p value
Gender
Female 7.59 8.07 8.86 8.97 9.87 10.73 11.43 12.48 12.98 13.81 13.60 79.18 <0.001
Male 6.94 7.17 8.17 8.28 9.17 10.02 10.73 11.85 12.42 13.40 13.18 89.91 <0.001
Age group
6 < age 2.23 2.02 2.79 2.39 2.46 2.66 2.53 3.18 2.59 3.28 2.27 1.79 0.124
13 > age � 6 3.66 3.61 4.12 3.82 3.96 4.10 4.40 4.83 4.45 4.82 4.27 16.67 0.002
19 > age � 13 7.42 7.47 8.09 8.20 8.31 8.94 9.09 9.50 9.44 9.57 8.51 14.69 0.002
31 > age � 19 13.96 14.38 15.03 14.97 16.15 16.95 16.98 17.47 17.64 17.59 16.53 18.41 <0.001
65 > age � 31 12.31 13.21 14.46 14.73 16.05 16.88 17.94 19.14 20.01 21.14 21.00 70.59 <0.001
65 & older 8.48 9.86 11.01 10.52 11.84 12.27 13.20 13.54 13.56 15.06 14.33 68.99 <0.001
Intellectual disability level
Mild (317) 6.02 6.34 7.36 7.46 8.13 8.82 9.44 10.47 10.85 11.79 11.50 91.03 <0.001
Moderate (318.0) 9.19 9.49 10.25 10.33 11.46 12.48 13.25 14.22 14.86 15.70 15.90 73.01 <0.001
Severe (318.1) 9.52 9.77 10.56 10.76 12.58 13.81 14.96 16.42 18.15 18.89 19.50 104.83 <0.001
Profound (318.2) 8.71 10.39 9.86 10.54 10.73 13.13 13.41 16.81 16.01 17.26 17.07 95.98 <0.001
Copayment
Catastrophic disease 29.80 30.47 28.42 33.43 36.26 37.29 38.12 39.53 39.72 39.92 45.30 52.01 <0.001
Social welfare 15.38 15.22 14.93 14.73 15.64 16.35 16.34 16.28 16.99 18.75 18.58 20.81 <0.001
Full 5.58 5.80 6.78 6.51 6.89 7.23 7.36 8.05 8.03 8.54 7.75 38.89 <0.001
Total 7.21 7.55 8.46 8.57 9.46 10.31 11.02 12.11 12.65 13.57 13.36 85.30 <0.001
Table 4
Temporal change in anxiolytic drug use rates.
Variables 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 % Change Linear trend
test p value
Gender
Female 14.73 15.17 15.98 15.58 14.96 15.15 15.17 15.70 15.32 15.14 15.05 2.17 0.990
Male 11.22 11.85 12.89 12.55 12.66 12.67 12.57 12.97 13.08 13.28 12.60 12.30 0.012
Age group
6 < age 7.24 8.06 9.91 9.53 8.47 8.36 8.01 7.60 8.13 8.05 7.97 10.08 0.489
13 > age � 6 6.03 6.39 6.70 6.52 6.26 6.02 5.55 5.58 5.37 5.00 4.51 �25.21 <0.001
19 > age � 13 10.13 10.20 10.67 10.07 9.83 9.56 9.76 9.63 9.47 9.02 8.11 �19.94 <0.001
31 > age � 19 17.76 18.22 19.05 18.28 18.17 18.20 17.47 17.70 16.91 16.85 15.59 �12.22 0.004
65 > age � 31 23.71 23.99 24.65 23.92 23.33 23.14 23.00 23.28 22.70 22.24 21.57 �9.03 <0.001
65 & older 29.60 30.66 31.69 30.03 29.32 28.59 28.66 28.93 27.76 27.31 26.02 �12.09 <0.001
Intellectual disability level
Mild (317) 12.48 13.25 14.16 13.77 13.60 13.68 13.55 13.99 13.94 14.08 13.35 6.97 0.148
Moderate (318.0) 13.00 13.23 14.11 13.81 13.56 13.64 13.63 14.06 13.91 13.84 13.93 7.15 0.04
Severe (318.1) 13.29 13.36 14.69 14.01 13.91 13.91 14.42 14.82 14.54 14.45 14.36 8.05 0.023
Profound (318.2) 13.16 12.86 13.86 14.26 13.17 14.01 13.92 15.31 15.78 14.53 15.35 16.64 0.002
Copayment
Catastrophic disease 23.46 24.52 23.24 25.13 25.01 24.06 23.71 24.30 23.68 22.49 23.41 �0.21 0.247
Social welfare 16.70 16.55 17.47 17.92 16.42 16.05 16.32 17.10 16.99 16.87 16.45 �1.50 0.608
Full 11.91 12.40 13.40 12.79 12.50 12.50 12.22 12.44 12.20 12.28 11.73 �1.51 0.214
Total 12.69 13.24 14.17 13.80 13.60 13.69 13.64 14.09 14.00 14.04 13.61 7.25 0.076
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Anxiolytic drug use among individuals older than 6 years old decreased significantly from 1997 to 2007, although thepercentage of males and subjects with moderate or severe ID receiving anxiolytic drug treatment increased (Table 4).Stepwise logistic regression analysis results demonstrated that compared with male subjects, age and copayment statuswere factors influencing anxiolytic use rates in female claimants. The percentage of elderly female subjects receivinganxiolytic treatment was higher than of any other age group (elderly vs. age < 6: OR = 1.923, 95% CI = 1.795–2.062; elderly vs.age �6, <13: OR = 1.953, 95% CI = 1.825–2.092; elderly vs. age �13, <19: OR = 1.961, 95% CI = 1.835–2.096; elderly vs. age�19, <31: OR = 1.848, 95% CI = 1.739–1.965). Females with ID suffering from catastrophic disease had the highest anxiolyticuse rates, compared with social welfare recipients and subjects in the full copayment group (catastrophic disease vs. socialwelfare recipients: OR = 1.366, 95% CI = 1.299–1.436; catastrophic disease vs. full copayment: OR = 1.157, 95% CI = 1.120–1.196).
The growing trend in the use of hypnotics/sedatives treatment was notable among all groups, except subjects youngerthan 19 years (Table 5). Stepwise logistic regression analysis results demonstrated that compared with male subjects, ageand copayment status were factors influencing hypnotic/sedative use rates in female claimants. The percentage of elderly
Table 5
Temporal change in hypnotic and sedative drug use rates.
Variables 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 % Change Linear trend
test p value
Gender
Female 3.67 4.28 5.22 5.43 6.29 6.62 7.52 8.01 8.41 8.45 8.34 127.25 <0.001
Male 3.10 4.32 5.37 5.69 6.58 7.28 8.09 8.76 9.15 9.71 9.57 208.71 <0.001
Age group
6 < age 0.65 0.73 0.88 0.98 0.81 0.91 0.82 0.76 0.80 1.05 0.76 16.92 0.365
13 > age � 6 0.94 0.85 0.98 0.85 0.95 0.86 0.96 0.86 0.89 0.87 0.79 �15.96 0.1474
19 > age � 13 3.04 3.12 3.06 3.21 3.42 3.41 3.49 3.53 3.15 3.03 2.66 �12.50 0.659
31 > age � 19 6.66 7.56 9.14 9.00 10.34 10.73 11.08 11.00 10.69 10.28 9.51 42.79 0.013
65 > age � 31 6.77 8.26 10.42 10.84 12.06 12.42 13.93 14.58 15.14 15.14 14.77 118.17 <0.001
65 & older 8.30 9.79 10.59 12.37 11.91 14.64 16.40 15.81 16.76 17.03 16.21 95.30 <0.001
Intellectual disability level
Mild (317) 2.77 3.32 4.07 4.43 5.09 5.51 6.19 6.66 7.07 7.34 7.07 155.23 <0.001
Moderate (318.0) 4.13 4.61 5.77 5.78 6.59 7.01 7.67 8.07 8.34 8.49 8.87 114.77 <0.001
Severe (318.1) 4.91 5.61 5.63 5.84 7.32 7.81 9.02 9.60 9.59 9.65 10.01 103.87 <0.001
Profound (318.2) 4.72 5.39 6.69 7.03 6.74 7.74 10.11 9.75 9.62 9.70 10.95 131.99 <0.001
Copayment
Catastrophic disease 16.08 18.24 18.75 23.85 24.03 24.45 24.50 24.72 24.41 23.32 25.53 58.77 0.002
Social welfare 7.10 7.65 9.17 8.27 9.45 9.71 10.51 10.57 10.39 11.08 10.99 54.79 <0.001
Full 2.45 2.83 3.54 3.47 3.99 4.10 4.50 4.71 4.84 4.93 4.69 91.43 <0.001
Total 3.33 3.88 4.71 4.96 5.71 6.15 6.89 7.34 7.67 7.89 7.83 127.25 <.001
Table 6
Temporal change of antidepressant drug use rates.
Variables 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 % Change Linear trend
test p value
Gender
Female 2.21 2.65 3.20 3.29 3.72 4.19 4.59 5.23 5.54 5.68 5.68 157.01 <.001
Male 1.85 2.35 2.88 2.97 3.59 4.02 4.24 4.86 4.92 5.16 5.13 177.30 <.001
Age group
6 < age 0.28 0.32 0.47 0.50 0.43 0.48 0.59 0.79 0.63 0.73 0.70 150.00 <0.001
13 > age � 6 1.52 1.88 2.35 2.32 2.57 2.62 2.43 2.74 2.72 2.63 2.22 46.05 0.026
19 > age � 13 1.86 2.26 2.88 3.04 3.29 3.95 4.20 4.74 4.60 4.22 4.17 124.19 <0.001
31 > age � 19 2.82 3.56 4.55 4.44 5.57 5.95 6.17 6.60 6.60 6.80 6.28 122.70 <0.001
65 > age � 31 3.91 4.71 5.00 5.09 5.62 6.06 6.40 7.09 7.27 7.47 7.62 94.88 <0.001
65 & older 6.59 6.65 8.26 7.84 8.61 9.14 9.61 9.11 8.85 8.66 8.64 31.11 0.011
Intellectual Disability level
Mild (317) 2.00 2.56 3.09 3.15 3.78 4.40 4.68 5.31 5.44 5.80 5.66 183.00 <0.001
Moderate (318.0) 2.05 2.43 3.09 3.12 3.55 3.72 3.98 4.54 4.85 4.80 4.93 140.49 <0.001
Severe (318.1) 1.87 1.98 2.07 2.71 3.11 3.14 3.67 4.56 4.51 4.38 4.48 139.57 <0.001
Profound (318.2) 1.72 2.08 2.55 2.79 2.25 3.11 3.56 4.13 4.22 4.30 4.32 151.16 <0.001
Copayment
Catastrophic disease 5.39 6.74 7.15 8.92 9.55 9.94 11.07 11.90 12.34 11.94 13.03 141.74 <0.001
Social welfare 2.97 3.26 4.23 3.92 4.47 5.59 5.61 6.29 6.83 7.03 6.88 131.65 <0.001
Full 1.77 2.18 2.67 2.66 3.11 3.41 3.49 3.97 3.91 4.07 3.97 124.29 <0.001
Total 2.00 2.48 3.01 3.10 3.64 4.09 4.38 5.01 5.18 5.37 5.35 167.50 <.001
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female subjects receiving hypnotic/sedative treatment was higher than any other age group (elderly vs. age < 6: OR = 1.686,95% CI = 1.456–1.957; elderly vs. age �6, <13: OR = 2.004, 95% CI = 1.767–2.268; elderly vs. age �13, <19: OR = 1.773, 95%CI = 1.603–1.961; elderly vs. age �19, <31: OR = 2.041, 95% CI = 1.869–2.227). Females with ID suffering from catastrophicdisease had the highest hypnotic/sedative use rates, compared with social welfare recipients and subjects in the fullcopayment group (catastrophic disease vs. social welfare recipients: OR = 1.190, 95% CI = 1.120–1.263; catastrophic diseasevs. full copayment: OR = 1.125, 95% CI = 1.083–1.169).
Using of antidepressants in patients with ID increased remarkably among all groups (Table 6). Stepwise logisticregression analysis results demonstrated that compared with male subjects, age, level of ID, and copayment status werefactors influencing antidepressant use rates in female claimants. The percentage of elderly female subjects receivingantidepressive treatment was higher than any other age group (elderly vs. age <6: OR = 1.724, 95% CI = 1.406–2.114; elderlyvs. age �6, <13: OR = 1.754, 95% CI = 1.555–1.980; elderly vs. age �13, <19: OR = 1.458, 95% CI = 1.295–1.458; elderly vs. age�19, <31: OR = 1.582, 95% CI = 1.414–1.770; elderly vs. age �31, <65: OR = 0.716, 95% CI = 0.641–0.800). Individualssuffering from catastrophic disease had the highest proportion of antidepressant drug use rates, compared within socialwelfare recipients and subjects in the full copayment group (catastrophic disease vs. social welfare recipients: OR = 1.492,95% CI = 1.373–1.621; catastrophic disease vs. full copayment: OR = 1.100, 95% CI = 1.043–1.160). The percentage of subjectswith mild ID taking antidepressant drugs was lower than in subjects with moderate ID or severe ID (mild vs. moderate:OR = 1.124, 95% CI = 1.070–1.181; mild vs. severe: OR = 0.940, 95% CI = 0.894–0.986).
4. Discussion
There has been scant research on trends in psychotropic drug use in the ID population in Taiwan. Our study is the first toanalyze the NHI claims data to detect trends in the use of psychotropic drugs among patients with ID in Taiwan. Our resultsrevealed that between 1997 and 2007, the prevalence of psychotropic drug use increased by 30.30%, from 17.82% to 23.22%, afinding consistent with other studies showing similar increases. The prevalence of psychotropic drug use among Taiwan’sgeneral adult population increased by 69%, from 7.1% at the beginning of 1997 to 12.0% at the end of 2004 (p < 0.001) (Chienet al., 2007). Mamdani et al. found that the prevalence of psychotropic drug use among Canada’s elderly population increasedby 34.8% over the study period, from 2.2% at the beginning of 1993 to 3.0% (p < 0.01) at the end of 2002 (Mamdani, Rapoport,Shulman, Hermann, & Rochon, 2005). The percent change in our study was 30.30%, less than in two previous studies. The highpercentage of people with ID taking psychotropic drugs may explain this discrepancy. With regards to prevalence, severalinvestigations revealed that over 30% of individuals with ID had received psychotropic medicine treatment, higher than wefound in our study (Doan, Lennox, Taylor-Gomez, & Ware, 2013; Holden and Gitlesen, 2004; Pyles, Muniz, Cade, & Silva,1997; Tsiouris, Kim, Brown, Pettinger, & Cohen, 2013). This difference could be due to differences in the characteristics of thestudy population and methodology used.
This study found that the prevalence of antipsychotic (N05A) usage significantly increased during the study period, by85.30%, from 7.21% to 13.36% (p < 0.001), in contrast to previous research in Taiwan. Chien et al.’s survey found thatantipsychotic use rates among Taiwanese adults did not change from 1997 to 2004 (Chien et al., 2007). The study populationChein chose was adults and the elderly, and the research was targeted at people with ID. However, the prevalence of
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antipsychotic use in Taiwan was higher than in the United States (0.7%; Paulose-Ram et al., 2007), Canada (0.5%; Mamdaniet al., 2005) and Europe (1.2%; Alonso, Angermeyer, Bernert, Bruffaerts, & Brugha, 2004). One possible explanation for thisdiscrepancy is that more people with psychotic disorders seek treatment under the NHI program, which is a comprehensivehealth insurance program covering medication costs. Another possible explanation is the greater off-label use rates ofantipsychotics in Taiwan (Chien et al., 2007). Antipsychotics may be used in the treatment of nonpsychotic disorders,including manic state without psychosis, dementia without delusion, nonpsychotic major depression, severe anxietydisorder, and severe insomnia (Warren, Serrato, & Maguire, 2012; Weiss, Hummer, Koller, Ulmer & Fleischhacker, 2000). Theprevalence of antipsychotic use in the Netherland was 32.2% (De Kuijper et al., 2010), 2- to 3-fold higher than the rate in ourstudy. This difference may be due to sample variation between the two studies. The study conducted in the Netherland usedmedical records of individuals with ID living, whereas our study analyzed claims data from the NHI.
The prevalence of depression varied between 0.4 and 15.7% across countries (Rai, Zitko, Jones, Lynch, & Araya, 2013), andtreatment rates were increased in some national studies (Olfson, Marcus, Druss, Elinson, & Tanielian, 2002). Our study foundthat the prevalence of antidepressant (N06A) usage significantly increased during the study period, by 167.50%, from 2.00%to 5.35% (p < 0.001), similar to Chien’s finding (Chien et al., 2007) and consistent with the findings by Olfson et al. (2002).Both our study and Chien’s work revealed that the prevalence of antidepressant use in Taiwan was similar to the prevalenceof use in the United States (2.3%), Canada (5.8%), and Europe (3.7%) (Alonso et al., 2004; Beck et al., 2005; Paulose-Ram et al.,2007). The lifetime prevalence of major depressive disorder was 1.20% in Taiwan (Liao et al., 2012), which was lower than theprevalence of antidepressant use. The reason for this difference is that antidepressants are extensively utilized clinically forconditions other than depression; physicians might use them for general anxiety disorder, panic disorder, phobic states,neurotic depression, obsessive-compulsive disorder, eating disorder, migraine, or insomnia (Chien et al., 2007).
This study revealed that the prevalence of anxiolytic (N05B) use increased from 12.69% to 13.61% (p > 0.05), and theprevalence of hypnotics/sedatives (N05C) increased by 127.25% (3.33% to 7.83%, p < 0.001) among Taiwan’s ID population.The increase in the use of hypnotic/sedative drugs in Taiwan was due to the higher prevalence of psychiatric disorders inrecent years, including general anxiety disorder, neurotic depression, and insomnia (Chien et al., 2007). Rodrigues, Facchini,and Lima (2006) found that the use of anxiolytics and hypnotics/sedatives decreased from 57.9% at the beginning of 1994 to52.1% at the end of 2003 in a Brazilian city. Ravera, Visser, Gier, and Berg (2010) demonstrated that the prevalence of use ofanxiolytics and hypnotics/sedatives in the general population of the Netherlands slightly decreased from 2000 to 2005. Thisdiscrepancy may be explained by the following two reasons: psychotic conditions, hyperactivity and attention-deficithyperactivity disorder, autistic-type behaviors, stereotypes, self-injurious behaviors, and violent outbursts, are verycommon in ID, and both hypnotics/sedatives and anxiolytics were often prescribed to help reduce symptoms (Gillberg &Soderstrom, 2003). Additionally, epilepsy is a common comorbidity among individuals with ID, and such individuals areoften prescribed anxiolytics along with antiepileptic drugs (Leunissen et al., 2011).
A strength of our study is the use of a nationwide health insurance claims database to evaluate shifts in psychotropic druguse. Compared with community surveys, this method is more timely and cost-effective, with reliable results and minimalrisk of recall bias. However, our study has several limitations. First, prescription behavior of physicians may be affected bythe NHI policy. After the NHI program implemented a global budget plan and drug pricing system, high-cost second-generation antipsychotics were replaced (Chu, Lee, Huang, Yeh, & Huang, 2007). Second, because of the off-label use ofpsychotropic is common, the prevalence of psychotropic drug use does not reflect the prevalence rate of psychiatricdisorders among people with ID in Taiwan. As assessment of mental disorders in persons with ID is complex, as theprescription of antipsychotic drugs has been shown to exceed the expected prevalence of psychotic symptoms in people withID (Malfa, Lassi, Bertelli, & Castellani, 2006). Lastly, the NHI claims data did not indicate any results of treatment, makingevaluation of the outcomes and cost-benefit ratios of psychotropic therapy impossible.
5. Conclusions
The prevalence of use of antipsychotics, hypnotics/sedatives and antidepressants among individuals with ID increasedgreatly between 1997 and 2007 in Taiwan. Low copayments and covered medication costs by Taiwan’s NHI programencourages more insured patients to seek medical services, resulting in higher health service utilization. The off-label use ofpsychotropic drugs may have been the other important factor attributing to this finding. Future studies should focus on thedetection of factors and diagnostic criteria associated with psychotropic drug use, including dosage, duration of treatment,and indications for use.
Acknowledgments
The authors declare that they have no conflicts of interest with regards to the content of this article. This study is part ofthe project, Geospatial analysis of health data: Determinants in health disparity, from National Health Insurance Research(NHRI-PH-102-PP-26), and was supported by funding from the National Science Council, Taiwan, Republic of China (NSC-101-2410-H-468-018). The data were provided by the Bureau of National Health Insurance, Department of Health, andmanaged by National Health Research Institutes. The interpretation and conclusions herein do not necessarily representthose of the Bureau of National Health Insurance, the Department of Health, or the National Health Research Institutes.
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