Overuse of psychotropic medications among children and adolescents with autism spectrum disorders: perspective from a developing country

The use of psychotropic medications in autistic individuals (21 years and younger) in Western Australia: A preliminary investigation

LAY ABSTRACT

Prescriptions and use of medications to treat mental health conditions in young autistic populations are inconsistent worldwide. This makes it hard to compare findings from international studies to the Australian autistic population, where there are limited relevant studies. Apart from risperidone, there are no other medications specified for direct use in autistic persons. This study aims to gain initial broad understanding of the use of medications, commonly prescribed for mental health conditions, specifically by autistics under the age of 21 years. We analysed data that were previously collected as part of the Western Australian Autism Biological Registry between 2011 and 2015 which amounted to 239 surveys completed on young persons with diagnosed autism. The questionnaires included information on co-occurring conditions, current or previous use of medications and reasons for use of the medications. Only one-quarter of the participants in this study reported using at least one mental health-related medication in their lifetime. The most reported medications were stimulants, antidepressants and antiepileptics. The reasons for using medication included managing attention deficit hyperactivity disorder, challenging behaviours, seizures, sleep difficulties and symptoms of anxiety and depression. The number of individuals reporting medication use in this study was lower compared to other developed countries. Nevertheless, these medications should be monitored due to limited understanding of their use to manage co-occurring symptoms in young autistic persons. The findings highlight the importance of ongoing research to better understand mental health-related medications and inform best practice.

Gender Trends in Psychotropic Medication Use in Autism

Autism is a neurodevelopmental condition that includes differences in social communication and restrictive, repetitive behavior. Its diagnosis is far more common in men than women. Therefore, a female phenotype of autism might not concern caregivers or be detected early by clinical assessments. Given that medications address problematic behaviors rather than autism, different problems associated with autism necessitate other treatments. We reviewed existing literature on gender differences in psychotropic drug usage in autism patients and found that antidepressants, anticonvulsants, and mood stabilizers were more common in females, while stimulants and antipsychotics were predominant in males. This review highlights that autistic men and women receive different pharmacologic agents, likely attributable to gender-specific trends in presenting problematic behaviors.

Psychotropic Medications Use among Children with Autism in Saudi Arabia

Psychotropic medication use is rising among children with autism spectrum disorders (ASD) in Saudi Arabia. Two hundred ninety-three parents of children diagnosed with ASD completed a parental concerns questionnaire (PCQ) online to examine children’s family socio-demographics, health conditions and comorbidities, and past and current exposure to psychotropic medication as prescribed by their primary doctor. Findings revealed that more than one-third of the parents (39.08%) reported that their children were using medications at the time of the survey; risperidone (53%), methylphenidate (30%), and valproic acid (9%) were the most commonly used. A smaller number of parents stated that their children had previously used medications (16.09%). The most often prescribed drugs among this group were risperidone (45%), followed by methylphenidate (32%) and valproic acid (17%). The variables that showed a statistically significant association with the current use of psychotropic drugs were the child’s age (OR = 1.25, 95% CI: 1.12, 1.40, p < 0.001), presence of comorbidities (OR = 7.75, 95% CI: 3.48, 17.24, p < 0.001), communication difficulties (OR = 1.79, 95% CI: 1.09, 2.95, p < 0.021), and anxiety symptoms (OR = 1.70, 95% CI: 1.00, 2.87, p < 0.049). Similarly, the child’s age (OR = 1.23, 95% CI: 1.08, 1.40, p < 0.002) and presence of comorbidities (OR = 2.83, 95% CI: 1.16, 6.29, p < 0.022) showed statistically significant associations with previous use.

Psychotropic Polypharmacy Among Children and Youth with Autism: A Systematic Review

Objectives: Majority of youth with autism are taking two or more medications (psychotropic or nonpsychotropic) simultaneously, also known as polypharmacy. Yet the efficacy and the potential outcomes of polypharmacy in this population are widely unknown. This systematic literature review described the trends of polypharmacy among autistic youth, and identified factors associated with polypharmacy. Methods: Sixteen studies were included, encompassing over 300,000 youth with autism. Results: Rates of polypharmacy varied quite substantially across studies, ranging from 6.8% to 87% of autistic youth. Having psychiatric comorbidities, self-injurious behaviors, and physical aggression, as well as being male and older, were associated with higher rates of polypharmacy. Conclusion: Findings emphasize the importance of further research to determine appropriate practices related to the monitoring of adverse side effects, and the long-term impact of polypharmacy among autistic youth.

The Use of Psychotropic Medication in Iranian Children with Developmental Disabilities

The use of psychotropic medication in children is increasing worldwide. Children with developmental disabilities seem to be prescribed these medications at a higher rate compared to their non-disabled peers. Little is known about prescribing in non-Western, middle-income studies. In Iran, the file records of 1133 children, aged 2 to 17 years, assessed as having autism spectrum disorder (ASD) or an intellectual disability (ID) in Tehran City and Province from 2005 to 2019 were collated, and information from parental reports of medications was extracted. Upwards of 80% of children with ASD and 56% of those with ID were prescribed a psychotropic medication with around one quarter in each group taking two or more medications. The rates were higher among male children showing difficult-to-manage behaviors such as hyperactivity, but less so for children of fathers with higher levels of education. The lack of alternative management strategies may be a significant driver for the use of psychotropic medications in Iran and other Low and Middle Income countries, despite their known side effects, and their failure to address the developmental needs of the children. Rather, multi-disciplinary, behavioral, therapeutic, and educational interventions are required, but these are not available widely in Iran, although a start has been made.

Medical Overuse in the Iranian Healthcare System: A Systematic Scoping Review and Practical Recommendations for Decreasing Medical Overuse During Unexpected COVID-19 Pandemic Opportunity

Purpose

To perform an inclusive search for original studies that report medical overuse in the Iranian healthcare system and discovering the area of overuse.

Patients and Methods

A systematic search of the literature is conducted in bibliographic databases including PubMed, Embase, Scopus, Web of Sciences, Cochrane and Scientific Information Database using a comprehensive search strategy without time limit until the end of 2018, updated by 1 July 2020, accomplished by reference tracking, author contacting and expert consultation to identify studies on the overuse of medical care.

Results

We reviewed 4124 published articles based on predetermined inclusion criteria. The author’s consensus included a total of 41 articles. Of these, 32 were in English and 9 in Farsi, published between 1975–2019. The result categorized into two distinct clinical areas: treatment (18 articles) and diagnostic (23 articles) services. Almost all of the studies only described the magnitude of unnecessary overuse. Unnecessary overuse of antibiotics, MRI, and CT-scan were the most reported topics. The ranges of their overuse proportion were as follows: antibiotic (31 to 97%); MRI (33 to 88%), and CT-scan (19 to 50%).

Conclusion

Our review showed, even so, the magnitude of unnecessary overuse of medical services is high but there are only a few interventional studies in clinical and administrative level for finding effective methods for decreasing these unnecessary services. Researchers should be encouraged to conducting interventional studies. We suggest the ministry of health to use the golden opportunity of COVID-19 epidemic for designing Iran national policy and action plan for controlling and preventing unnecessary healthcare services and including a section for “Interventional Research” in the action plan.

A Cross Sectional Examination of the Relation Between Depression and Frequency of Leisure Time Physical Exercise among the Elderly in Jinan, China

Depression has become a major global public health problem. Many studies have shown the positive effects of physical exercise on depression. However, few studies have examined the relationship between frequency of leisure time physical exercise and depression without considering the time and intensity of exercise among middle-aged and elderly people of urban communities in northern China. We conducted a cross-sectional survey that included 1604 participants among urban residents aged 50 years or older in China to evaluate how the frequency of physical exercise was related to depression. Our study showed that the prevalence of depression in the urban community of Jinan is 16.52%. For physical exercise, the odds ratios (ORs) and 95% confidence intervals (CIs) for 1~2 times per week, 3~4 times per week and ≥5 times per week were 1.137 (0.661, 1.953), 0.516 (0.304, 0.875) and 0.548 (0.392, 0.768) respectively, with adjustment for age, gender, marital status, BMI, hypertension, previously diagnosed type 2 diabetes, triglyceride, total cholesterol, soy food intake, milk food intake, vegetable and fruit intake and meat intake. We concluded that physically exercising three times a week is associated with a low prevalence of depression.

Prescription Trends of Psychotropics in Children and Adolescents with Autism Based on Nationwide Health Insurance Data

Children with autism are often medicated to manage emotional and behavioral symptoms; yet, data on such pharmacotherapy is insufficient. In this study, we investigated the Korean National Health Insurance Claims Database (NHICD) information related to autism incidence and psychotropic medication use. From the 2010-2012 NHICD, we selected a total of 31,919,732 subjects under 19 years old. To examine the diagnostic incidence, we selected patients who had at least one medical claim containing an 10th revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10) code for pervasive developmental disorder, F84, not diagnosed in the previous 360 days. Psychotropics were categorized into seven classes. Then, we analyzed the data to determine the mean annual diagnostic incidence and psychotropic prescription trends. Diagnostic incidence was 17,606 for the 3 years, with a mean annual incidence per 10,000 population of 5.52. Among them, 5,348 patients were prescribed psychotropics. Atypical antipsychotics were the most commonly used, followed by antidepressants. An older age, male sex, and the availability of medical aid were associated with a higher rate of prescription than observed for a younger age, female sex, and the availability of health insurance. Psychotropic drugs were used for less than one-third of patients newly diagnosed with autism, and prescription differed by sex and age. Increased diagnostic incidence is associated with an increased prescription of psychotropic drugs. Therefore, medication-related safety data and policies for psychotropic drugs in autism should be prepared.

Assessment of Sexual Maturation Among Girls With Special Needs in Tehran, Iran

Background

There is limited data on sexual maturation among girls with intellectual, sensory, or physical disabilities.

Objectives

The present cross-sectional study was conducted to assess the sexual maturation of girls with these disabilities in special schools.

Methods

In this cross-sectional study, we evaluated the onset and progression of sexual maturation in 642 six to 18-year-old girls with intellectual, sensory, or physical disabilities from special schools in Tehran. The participants were selected by multi-stage random sampling. Pubertal stages were assessed by visual inspection and palpation based on the rating scales of Tanner. Stage two (breast budding and pubic hair growth) and stage five were considered the onset and end of puberty, respectively.

Results

The mean ages of onset of puberty indicated by breast budding (B2 stage) and by pubic hair growth (P2 stage) were 10.8 ± 1.48 and 10.79 ± 1.64 years, respectively. The process of puberty based on breast budding and pubic hair growth was completed at 15.58 ± 1.85 and 15.59 ± 1.8 years, respectively. The average height at the onset of puberty (stage B2) among participants was 128 ± 28.79 cm and the average weight was 8.31 ± 36.47 kg.

Conclusions

Among our patients, the mean ages of onset of puberty indicated by breast budding (B2 stage) and by pubic hair growth (P2 stage) were 10.8 ± 1.48 and 10.79 ± 1.64 years, respectively. Compared to the data from healthy Iranian girls, our findings indicate that the mean age of pubertal onset among schoolgirls with disabilities is slightly higher than that of their healthy counterparts.

Use of psychotropic drugs in patients with autism spectrum disorders: a systematic review

OBJECTIVE

The objective of this review was to examine prevalence and patterns of psychopharmacotherapy in individuals with autism spectrum disorder (ASD).

METHOD

A systematic literature search in PubMed, CINAHL, and PsycINFO was performed, including articles published up to November 18, 2015.

RESULTS

A total of 47 studies (data collection: 1976-2012), encompassing >300 000 individuals with ASD, were included. The prevalence of psychopharmacotherapy ranged from 2.7% to 80% (median (overall): 45.7%; median (children): 41.9%; median (adults): 61.5%), with psychotropic polypharmacy occurring in 5.4-54% (median: 23.0%). Regarding drug classes, antipsychotics were most frequently used, followed by attention-deficit/hyperactivity disorder (ADHD) medication and antidepressants. Both older age and psychiatric comorbidity were associated with higher prevalences of psychopharmacotherapy and psychotropic polypharmacy. There were no time trends in psychopharmacotherapy prevalence observable.

CONCLUSION

Despite a lack of pharmacological treatment options for ASD core symptoms, the prevalence of psychopharmacotherapy and polypharmacy in ASD patients is considerable, which is probably due to the treatment of non-core ASD symptoms and psychiatric comorbidities. While there is some evidence for the use of antipsychotics and ADHD medication for these indications, the use of antidepressants should be limited to selected cases.

Antipsychotic Use Trends in Youth With Autism Spectrum Disorder and/or Intellectual Disability: A Meta-Analysis

OBJECTIVE

Although irritability and aggression are relevant treatment targets in autism spectrum disorders (ASDs) and intellectual disability (ID) that may prompt antipsychotic use, antipsychotic prescribing patterns in such youth have not been systematically reviewed.

METHOD

We systematically searched PubMed/MEDLINE/PsycInfo until March 2015 for studies reporting data on the frequency of youth diagnosed with ASDs and/or ID among antipsychotic-treated youth, as well as antipsychotic use in youth with ASD/ID, conducting a meta-analysis and meta-regression analysis of potential moderators, including publication year, study time point, country, setting, sample size, age, sex, and race/ethnicity.

RESULTS

A total of 39 studies were meta-analyzed (n = 365,449, age = 11.4 ± 6.2 years, males = 70.0% ± 10.0%). Among 27 studies (n = 273,139, age = 11.9 ± 8.0 years, males = 67.0% ± 12.9%) reporting on antipsychotic-treated youth, 9.5% (95% CI = 7.8%-11.5%) were diagnosed with ASD/ID. In 20 studies (n = 209,756) reporting data separately for ASD, 7.9% (95% CI = 6.2%-9.9%) had an ASD diagnosis. In 5 longitudinal studies, the proportion of antipsychotic-treated youth with ASD did not change significantly from 1996 to 2011 (6.7% to 5.8%, odds ratio = 0.9, 95% CI = 0.8-1.0, p =.17). However, later study time point moderated greater ASD/ID proportions (β = 0.12, p < .00001). In 13 studies (n = 96,688, age = 9.8 ± 1.2 years, males = 78.6% ± 2.0%) reporting on antipsychotic use in ASD samples, 17.5% (95% CI = 13.7%-22.1%) received antipsychotics. Again, later study time point moderated higher antipsychotic use among patients with ASD (β = 0.10, p = .004).

CONCLUSION

Almost 1 in 10 antipsychotic-treated youth were diagnosed with ASD and/or ID, and 1 in 6 youth with ASD received antipsychotics. Both proportions increased in later years; however, clinical reasons and outcomes of antipsychotic use in ASD/ID require further study.

Using venlafaxine to treat behavioral disorders in patients with autism spectrum disorder

OBJECTIVE

To test the efficacy of venlafaxine at a dose of 18.75 mg/day on the reduction of behavioral problems such as irritability and hyperactivity/noncompliance in patients with intellectual disabilities and autism spectrum disorder (ASD). Our secondary hypothesis was that the usual doses of zuclopenthixol and/or clonazepam would decrease in the venlafaxine-treated group.

METHODS

In a randomized double-blind study, we compared six patients who received venlafaxine along with their usual treatment (zuclopenthixol and/or clonazepam) with seven patients who received placebo plus usual care. Irritability, hyperactivity/noncompliance, and overall clinical improvement were measured after 2 and 8 weeks, using validated clinical scales.

RESULTS

Univariate analyses showed that the symptom of irritability improved in the entire sample (p = 0.023 after 2 weeks, p = 0.061 at study endpoint), although no difference was observed between the venlafaxine and placebo groups. No significant decrease in hyperactivity/noncompliance was observed during the study. At the end of the study, global improvement was observed in 33% of participants treated with venlafaxine and in 71% of participants in the placebo group (p = 0.29). The study found that decreased cumulative doses of clonazepam and zuclopenthixol were required for the venlafaxine group. Multivariate analyses (principal component analyses) with at least three combinations of variables showed that the two populations could be clearly separated (p b 0.05). Moreover, in all cases, the venlafaxine population had lower values for the Aberrant Behavior Checklist (ABC), Behavior Problems Inventory (BPI), and levels of urea with respect to the placebo group. In one case, a reduction in the dosage of clonazepam was also suggested. For an additional set of variables (ABC factor 2, BPI frequency of aggressive behaviors, hematic ammonia at Day 28, and zuclopenthixol and clonazepam intake), the separation between the two samples was statistically significant as was the Bartlett's test, but the Kaiser–Meyer–Olkin Measure of Sampling Adequacy was below the accepted threshold. This set of variables showed a reduction in the cumulative intake of both zuclopenthixol and clonazepam.

CONCLUSION

Despite the small sample sizes, this study documented a statistically significant effect of venlafaxine. Moreover, we showed that lower doses of zuclopenthixol and clonazepam were needed in the venlafaxine group, although this difference was not statistically significant. This was confirmed by multivariate analyses, where this difference reached statistical significance when using a combination of variables involving zuclopenthixol. Larger-scale studies are recommended to better investigate the effectiveness of venlafaxine treatment in patients with intellectual disabilities and ASD.

Depression and Exercise: A Clinical Review and Management Guideline

CONTEXT

There is an increasing interest to detect how exercise affects depression symptoms. Although recent findings confirm the positive effect of exercise on depression, there is no clear guideline regarding advice on exercise for patients with depression. The following review aims at presenting the contemporary literature regarding the nature of depression, exercise, the underlying mechanisms and the management of an exercise program in individuals with depression.

EVIDENCE ACQUISITION

We searched electronic databases including Cochrane Library, PubMed, ISI web of knowledge and PsychInfo (from January 2000 to October 2014). We reviewed the systematic reviews, meta-analyses, and large-scale randomized control trials on effects of exercise on depression.

RESULTS

Recent evidence has emerged on characteristics of effective exercise programs and those patients with depression that will most benefit from the exercise programs. However due to the methodological weaknesses and inconsistencies of studies, conclusions must be made with caution.

CONCLUSIONS

We have provided a number of recommendations for clinicians and researchers who plan to use exercise protocols in depression.

Psychotropic medication use among adolescents and young adults with an autism spectrum disorder: parent views about medication use and healthcare services

OBJECTIVE

Psychotropic medications are frequently used to treat mental health and behavioral issues in adolescents and adults with an autism spectrum disorder (ASD). Although parents of individuals with ASD frequently take on medication management for their child, there is limited literature on parent perspectives of their child's medication use or their views about the healthcare services they receive, particularly in adulthood. The current study examined and compared parents of adolescents and of young adults with ASD regarding their child's psychotropic medication use and their views about healthcare services.

METHODS

One hundred parents of adolescents and young adults with ASD (ages 12-30 years) completed an online survey about their experience with their child's healthcare services and medication use.

RESULTS

Parents of young adults were less likely to use nonpharmacological services before using a psychotropic medication than were parents of adolescents. Parents of young adults were also less likely to believe that their prescribing healthcare provider had adequate expertise in ASD, and were less satisfied with how their prescriber monitored their child's medication use.

CONCLUSION

Findings highlight the need to build capacity among healthcare providers supporting individuals with ASD as they transition into adulthood. There is also a need for improved medication monitoring and increased awareness of the different mental health challenges that individuals with ASD encounter as they age.

Child, parent, and service predictors of psychotropic polypharmacy among adolescents and young adults with an autism spectrum disorder

OBJECTIVE

This study examined the child, parent, and service factors associated with polypharmacy in adolescents and young adults with autism spectrum disorders (ASD).

METHODS

As part of an online survey examining health service utilization patterns among individuals with ASD, parents provided demographic and clinical information pertaining to their child. This included information on current medication use, as well as information on clinical services received, clinical history, and parent well-being. Analyses examined the bivariate association between individual child, parent, and service variables and polypharmacy. Variables significantly associated with polypharmacy were included in a multiple variable logistic regression.

RESULTS

Of the 363 participants sampled, ∼25% were receiving two or more psychotropic drugs concurrently. The patient's psychiatric comorbidity, history of hurting others, therapy use, and parent burden were predictors of polypharmacy.

CONCLUSIONS

Adolescents and young adults with ASD are a highly medicated population with multiple factors associated with psychotropic polypharmacy. Although there may be circumstances in which polypharmacy is necessary, a richer understanding of what predicts polypharmacy may lead to targeted interventions to better support these individuals and their families. Findings also highlight the need to support families of children with ASD prescribed multiple psychotropic medications.

Cognitive flexibility impairments in children with autism spectrum disorders: links to age, gender and child outcomes

There are still many questions about the cognitive flexibility in autism spectrum disorder (ASD) that remain unanswered. The goal of current study was to evaluate cognitive flexibility patterns and their demographic, clinical and behavioral correlates in large sample of children with ASD. A total of 123 children (94 boys and 29 girls) with ASD aged 7-14 years were assessed on the Wisconsin card sorting test (WCST). Findings showed that gender but not age was associated with the cognitive flexibility performance in ASD. Individuals who had more parent-reported language deficits, lower level of intelligence and education, and showed lower daily sleep time or more engagement in solitary instead of social daily activities were more likely to demonstrate perseveration. Findings provide tentative evidence of a link between cognitive flexibility deficits and sociodemographic or clinical child outcomes in ASD.

Five-fold increase in national prevalence rates of attention-deficit/hyperactivity disorder medications for children and adolescents with autism spectrum disorder, attention-deficit/hyperactivity disorder, and other psychiatric disorders: a Danish register-based study

OBJECTIVE

The purpose of this study was to estimate the prevalence and time trends in prescriptions of methylphenidate, dexamphetamine, and atomoxetine in children and adolescents, within three diagnostic groups: 1) autism spectrum disorder (ASD), 2) attention-deficit/hyperactivity disorder (ADHD), and 3) other psychiatric disorders.

METHODS

Data from six different national registers were used and merged to identify a cohort of all children and adolescents born in Denmark between 1990 and 2001 (n=852,711). Sociodemographic covariates on cohort members and their parents and lifetime prescriptions of methylphenidate, dexamphetamine, and atomoxetine were extracted from the registers. Prescriptions were also stratified by duration (<6 months. vs.≥ 6 months).

RESULTS

Sixteen percent of 9698 children and adolescents with ASD (n=1577), 61% of 11,553 children and adolescents with ADHD (n=7021) and 3% of 48,468 children and adolescents with other psychiatric disorders (n=1537) were treated with one or more ADHD medications. There was a significant increase in prescription rates of these medications for all three groups. From 2003 to 2010, youth 6-13 years of age with ASD, ADHD, and other psychiatric disorders had 4.7-fold (4.4-4.9), 6.3-fold (6.0-6.4), and 5.5-fold (5.0-5.9) increases, respectively, in prescription rates of ADHD medications.

CONCLUSION

This is the largest study to date assessing stimulant treatment in children and adolescents with ASD, and is the first prospective study quantifying the change over time in the prevalence of treatment with ADHD medications in a population-based national cohort of children and adolescents with ASD. The prevalence of stimulant treatment in youth with ASD of 16% is consistent with earlier studies. The past decade has witnessed a clear and progressive increase in the prescription rates of medications typically used to treat ADHD in children and adolescents in Denmark. This increase is not limited to only those with ADHD, but includes others with neuropsychiatric disorders, including ASD. The risks and benefits of this practice await further study.

Psychopharmacological treatment in children and adolescents with autism spectrum disorders in Germany

Data on psychopharmacological treatment of individuals with autism spectrum disorder (ASD) are scarce, especially for European countries. This study evaluated psychopharmacotherapy utilisation in children and adolescents with a diagnosis of ASD in Germany. Data of a large statutory health insurance company were analysed and outpatients aged 0-24 years with a diagnosis of ASD during a 1-year-period (2009) were identified. For this cohort, the prescription of psychopharmacotherapy was evaluated. Aditionally, we analysed time trends in prescriptions from 2004 to 2009. One thousand one hundred twenty-four patients (75.4% male; mean age: 11.1 years) matched the inclusion criteria. The prevalence of ASD was 0.37% in males and 0.12% in females, respectively. Of all ASD patients, 33.0% were prescribed psychotropic drugs in 2009. 12.5% of ASD patients were treated with stimulants or atomoxetine, 11.7% with antipsychotics, 9.1% with antiepileptics, 6.8% with benzodiazepines, and 3.8% with antidepressants/SSRI. Regarding substances, methylphenidate (24.4% of all psychotropic prescriptions), risperidone (13.3%) and valproate (9.1%) were most frequently prescribed. Psychopharmacologic treatment prevalence was age-related and increased from 16.3% in individuals aged 0-4 years to 55.1% in 20-24 year olds. From 2004 to 2009, the proportion of ASD patients treated with psychotropic drugs rose from 25.9% to 33.0%. This naturalistic study furnishes evidence that the proportion of ASD patients treated with psychotropic drugs has grown considerably in Germany over the least years, with methylphenidate and risperidone being the most frequently prescribed substances. Compared with data from the USA, the proportion of ASD patients with psychopharmacological treatment is noticeably lower in Germany.