Are men under-treated and women over-treated with antidepressants? Findings from a cross-sectional survey in Sweden

Aims and method To examine gender differences in self-reported depression and prescribed antidepressants (ADs). The Hospital Anxiety and Depression Scale was used to assess depression, and information on prescribed ADs was obtained from the Swedish Prescribed Drug Register. Results Depression was reported by 11.7% of the participants (12.3% men and 11.2% women). ADs were prescribed for 7.6% of the participants (5.3% men, 9.8% women). Among men, 1.8% reported depression and used ADs, 10.5% reported depression but did not use ADs, and 3.6% used ADs but did not report depression. The corresponding figures for women were 2.6%, 8.6% and 7.2%. Clinical implications Men report depression to a greater extent than women but are prescribed ADs to a lesser extent, possibly a sign of under-treatment. Women are prescribed ADs without reporting depression more often than men, possibly a sign of over-treatment. Although the causes remain unclear, diagnostic and treatment guidelines should benefit from considering gender differences in these respects.

Self-reported skin diseases, quality of life and medication use: a nationwide pharmaco-epidemiological survey in Sweden

The aim of this study was to determine self-reported consumption of dermatological pharmaceuticals and quality of life (QoL), measured with Short Form 36, in relation to eczema, acne, psoriasis and other inflammatory skin conditions in the Swedish population. A questionnaire containing questions on the occurrence of skin diseases, health-related QoL and the use of pharmaceuticals was sent to a cross-sectional sample of the Swedish population, age range 18-84 years (n = 8,000). The response rate was 61%. The 1-year prevalence of skin diseases was 30-35%, with females reporting a higher prevalence. The prevalence was 11.5% for eczema other than hand eczema, 10.2% for acne, 7.5% for hand eczema, 3.9% for psoriasis and 3.1% for urticaria. QoL was significantly affected and 25% of females and 19% of males had used a dermatological drug. Compared with hand eczema, persons with psoriasis and other eczema reported significantly more use of topical steroids on prescription and more use of dermatological pharmaceuticals in total. Skin conditions are common; they affect QoL and lead to a high consumption of dermatological drugs; which deserves increased awareness in the society.

Self-reported lifetime prevalence of atopic dermatitis and co-morbidity with asthma and eczema in adulthood: a population-based cross-sectional survey

Atopic dermatitis and its co-morbidity with asthma and allergy is well described in younger age groups. However, population-based studies on adults with atopic dermatitis in childhood are sparse. The aims of this study were to determine: (i) the prevalence of self-reported childhood atopic dermatitis in the population; and (ii) its association with present self-reported hand eczema, eczema, allergy, urticaria and asthma. A questionnaire was sent to a cross-sectional random sample of the Swedish population (n=7,985), age range 18-84 years (response rate 61.1%). The questionnaire included the question "Have you had childhood eczema?" and questions on 5 other medical problems (hand eczema, other eczema, asthma, urticaria and allergy). Persons reporting eczema in childhood reported increased odds ratios (OR) for hand eczema (4.01), other eczema (3.88), urticaria (2.50), allergy (2.98), and asthma (2.06) as adults. The combination of eczema, allergy and asthma had an OR of 14.10 (95% confidence interval 8.44-23.54). Adults in the age range 18-84 years reporting childhood atopic dermatitis still have high co-morbidity with eczema, asthma, urticaria and allergy.

Gender differences of axis I and II comorbidity in subjects diagnosed with attention-deficit hyperactivity disorder as adults

OBJECTIVE

To investigate gender differences in psychiatric comorbidity patients diagnosed with attention-deficit hyperactivity disorder (ADHD) as adults.

METHODS

Interviews about current ADHD symptoms and psychiatric comorbidity on axis I and II (Structured Clinical Interview for DSM-IV axis I and axis II) were conducted in a clinical cohort of 168 patients (78 women, 90 men). Independent information on childhood and current symptoms was collected from parents, partners and patient files.

RESULTS

The lifetime prevalence of psychiatric comorbidity on axis I reached 92%, and current comorbidity, including autism spectrum disorders and Tourette's syndrome, was 47%. Women had a higher lifetime prevalence of mood and eating disorders compared with men, where substance-use disorders were more frequent. Ten per cent of patients fulfilled diagnostic criteria for a personality disorder. When excluding the general diagnostic criteria, 46% of the patients endorsed the specific criteria for at least one personality disorder. Gender differences were identified with predominance of histrionic personality traits in women and conduct disorder in men.

CONCLUSION

Patients diagnosed with ADHD as adults display an extremely high lifetime axis I comorbidity with a gender-specific pattern similar to the general population. No gender differences were identified with regard to personality disorders; however, an increased prevalence of deviant personality traits was confirmed. This study stresses the importance of evaluating comorbidity among patients diagnosed with ADHD as adults to secure optimal treatment.

The influence of symptoms of anxiety and depression on medication nonadherence and its causes: a population based survey of prescription drug users in Sweden

PURPOSE

The purpose of this study was to evaluate the associations between self-reported symptoms of anxiety and/or depression, nonadherent (NA) behaviors, and reasons for NA to medication regimens.

METHODS

A population based cross-sectional study with questionnaire was performed in the general Swedish population. The participants were 2,802 prescription drug users aged 18-84 years. The questionnaire covered use of prescription drugs, symptoms of anxiety and/or depression, based on the Hospital Anxiety and Depression Scale (HADS), various NA behavior types, intentional and unintentional, and various reasons for NA.

RESULTS

Symptoms of anxiety and depression, independently and in combination, were associated with unintentional and intentional NA, with a stronger association with intentional NA. Regarding the reasons given for NA, for example anxiety, independently or in combination with depression, was associated with a fear of developing adverse drug reactions (ADRs). Depression, independently or in combination with anxiety, on the other hand, was associated with the actual development of ADRs.

CONCLUSION

A cross-sectional design such as this does not allow assessment of causality derived from the results. However, the results indicate that patients experiencing symptoms of psychological distress are at increased risk of NA, especially intentional NA, and could therefore benefit from extra attention from the health care professional. Patients with symptoms of anxiety and/or depression should be identified and monitored for the development and/or fear of ADRs, in order to improve adherence to medication regimens.

Women and men report different behaviours in, and reasons for medication non-adherence: a nationwide Swedish survey

Objective

The aim of the present study was to analyse gender differences in self-reported non-adherence (NA) to prescribed medication in the Swedish general population. We aimed to study unintentional and intentional NA as well as the reasons given for NA.

Methods

A questionnaire was mailed to a cross-sectional, random, national sample of people aged 18-84 years in Sweden (n=7985). The response rate was 61.1% (n=4875). The questionnaire covered use of prescription drugs, NA behaviour and reasons for NA.

Results

Use of prescription drugs was reported by 59.5% (n=2802) of the participants, and 66.4% (n=1860) of these participants did not adhere to the prescribed regimen. No overall gender differences in reporting NA were found. However, when analysing the various types of NA behaviour and the reasons for NA, different gender patterns emerged. Men were more likely to report forgetting [OR=0.77 (95%CI 0.65:0.92)], changing the dosage [OR=0.64 (95%CI 0.52:0.79)] and that they had recovered [14.3%, (OR=0.71 (95%CI 0.56:0.90)] as a reason. In contrast, more women than men reported filling the prescription but not taking the drug [OR=1.25 (95%CI 1.02:1.54)] and reported the development of adverse drug reactions (ADRs) [OR=1.89 (95%CI 1.37:2.59)] as a reason more commonly. The gender differences remained, in most cases, after controlling for confounders such as age, socioeconomic factors, medical problems and attitudes toward drugs.

Conclusions

Women and men have different patterns of NA behaviour and different reasons for NA. Therefore, if adherence is to be improved, a wide knowledge of all the reasons for NA is required, along with an understanding of the impact of gender on the outcomes.

Epidemiology, co-morbidity, and impact on health-related quality of life of self-reported headache and musculoskeletal pain-a gender perspective

BACKGROUND

Headache and musculo-skeletal pain are major public health problems. Substantial proportions of the general population report that they experience pain problems that affect their work, daily living and social life. Epidemiological studies have consistently shown that the prevalence of most pain conditions is higher in women than in men.

DESIGN

Cross-sectional survey in the county of Uppland, Sweden, 1995. Five thousand four hundred and four completed the questionnaire (response rate=68%). In these analyses for persons aged 20-64 years 4506 were included.

RESULTS

Back pain (22.7%) and shoulder pain (21.0%) were the most commonly reported medical problems in the population with pain in arms/legs (15.7%) in fifth and headache (12.5%) in eight place. Major gender differences were found. The prevalence of pain conditions, especially headache, was higher among women. Women reported more severe pain. Co-morbidity between pain conditions and psychiatric and somatic problems was higher among women. Health-related quality of life (SF-36) differed by gender and type of pain condition. The physical dimensions of HRQoL were more affected by headache among men; psychological dimensions were more affected among women. Among both men and women, pain conditions were associated with poorer socioeconomic conditions and life-style factors but there were gender differences. Education and unemployment were important only among men while economical difficulties, half-time work and being married were associated with pain among women. Obesity, early disability retirement, long time sick-leave and lack of exercise were associated with pain conditions generally. Factors associated with pain conditions were unevenly distributed between genders.

CONCLUSION

There are major differences between men and women in the prevalence and severity of self-reported pain in the population. Biological factors may explain some of the differences but the main explanation is presumably gender disparities in work, economy, daily living, social life and expectations between women and men. Although improved working conditions are of importance, deeper societal changes are needed to reduce the inequities in pain experiences between women and men.

Quality of life, use of topical medications and socio-economic data in hand eczema: a Swedish nationwide survey

Hand eczema is common and has an adverse impact on the lives of patients. There is a need for population-based surveys on the pharmacoepidemiological aspects, quality of life and impact of socioeconomic factors in hand eczema. The aim of this cross-sectional study was to investigate these factors. A questionnaire-based nationwide survey of health was performed, including questions on hand eczema, use of pharmaceuticals and socioeconomic factors. Quality of life was estimated with the generic instrument Short Form 36 (SF-36). The questionnaire was sent to 7,985 persons (age range 18-84 years), response rate 61.1% (n = 4,875). The 1-year prevalence of hand eczema in the study population was 7.5%. In this group, quality of life was lower. All dimensions of SF-36 were affected, most markedly general health and those dimensions reporting on mental health. In the group with self-reported hand eczema, 51% reported using topical pharmaceuticals. Hand eczema was more common among women (9.1%, n = 2,630) than among men (5.6%, n = 2,245) and in the age group below 65 years (8.5%, n = 3,274) compared with those aged 65 years and over (4.3%, n = 1,151). This survey clearly demonstrates the impact of hand eczema on several dimensions of life and also highlights age, gender and socioeconomic differences.

ADHD-related symptoms among adults in out-patient psychiatry and female prison inmates as compared with the general population

OBJECTIVE

To compare the prevalence of symptoms consistent with attention deficit hyperactivity disorder (ADHD) and related problems in adults in the general population, out-patient psychiatry (where females are in majority), and female convicts.

METHOD

A questionnaire based on the DSM-IV criteria of ADHD, reported childhood symptoms, reading and spelling problems, difficulties and suffering, and general assessment of functioning (GAF) was distributed to samples of the general population, open care psychiatry, and female prison inmates. Completed questionnaires were received from 517/1000, 349/400, and 50/65 of the three samples, respectively.

RESULTS

Symptoms consistent with ADHD were more than three times higher in out-patient psychiatry than in the general population (6.6% versus 2.1%), with a male-to-female ratio of 1.6-1.7. The severity of symptoms and frequencies of associated disabilities were similar in men and women. ADHD symptoms and related problems occurred in 50% of the female prisoners, which is similar to male prisoners according to the literature.

CONCLUSION

The high prevalence of symptoms and disabilities of ADHD in women should lead to awareness of the disorder in both sexes and be addressed in terms of diagnostic work-up, treatment, and rehabilitation.

Computerised data bases on prescription drug use and health care in the community of Tierp, Sweden: Experiences and challenges from a study of antidepressant-treated patients

 ABSTRACTMuch of our knowledge of drugs originates from clinical trials of drug efficacy performed on stringentlyselected patient groups, often without multiple concurrent diseases. However, the effectiveness of treatmentunder conditions of use in ordinary clinical practice may be very different to conditions in therandomised clinical trial. Use of large computerised data bases and record linkage has thus becomeincreasingly common in pharmacoepidemiologic research. The greatest advantages of using routinelycollected data are the minimisation of study costs and time required to complete a study, considerationsthat are particularly relevant for longitudinal studies. The advantages of using data bases also include thepossibility of obtaining large sample sizes and to retrospectively study long-term outcomes. The risk forrecall bias, a significant problem in interviews and questionnaires, is also reduced. However, computeriseddata bases also have some potentially serious disadvantages, primarily in the areas of data validityand data availability. The Tierp study, including individually based data bases of prescription drug use,will be used here as an example of research. In this paper an example of a comprehensive data base studyconcerning health care and drug utilisation in depressed patients is presented. Methodological considerationsin data base research are discussed in relation to experiences from the antidepressant study. A wellplanned and research oriented computerised data base on prescription drugs represents an important toolin the study of the outcome of drug treatment in real world clinical practice.

Short-term cost and health consequences of duodenal levodopa infusion in advanced Parkinson's disease in Sweden: an exploratory study

Levodopa is the cornerstone treatment for Parkinson's disease, but the short half-life of levodopa limits its usefulness in late stages of the disease. Duodenal levodopa infusion (DLI) allows more stable plasma levels and better motor symptom control. To explore the costs and health benefits of replacing conventional oral polypharmacy with DLI in patients with advanced Parkinson's disease, from a Swedish healthcare payer perspective. Based on a clinical, randomized, crossover study with 24 patients (DIREQT), a decision analytic model predicted 2-year drug costs and QALYs for conventional oral therapy and for DLI. Health-related quality of life (HR-QOL) was recorded using a 15-dimensional (15D) utility instrument at baseline and during the two 3-week trial periods, and then at eight follow-up visits during the subsequent 6 months. Use of medication was based on data from DIREQT and previous studies. Unit costs were based on market prices (drugs) and customary charges in Sweden. All costs were expressed in Swedish kronor (SEK), year 2004 values euro 1.00 approximately SEK9.17, $US1.00 = SEK7.47). Future costs and outcomes were discounted at 3%. One-way and probabilistic sensitivity analyses were conducted. The mean utility scores were 0.77 for DLI and 0.72 for conventional therapy (p = 0.02). A considerable variation in the scores was observed during the study. The expected per-patient 2-year cost of DLI was SEK562 000 while it was SEK172 000 for conventional therapy. The mean number of QALYs was 1.48 and 1.42, respectively, representing an incremental cost of SEK6.1 million per QALY for DLI (all values discounted at 3%). Using other assumptions in sensitivity analyses, the cost per QALY could be as low as SEK456 000. This analysis can be considered exploratory only; it is based on very limited data. Nevertheless, our findings suggest that DLI results in a significant improvement in HR-QOL. However, the cost per QALY is likely to be higher than customary cost-effectiveness thresholds. Whether these benefits justify the additional costs depends on how the health benefits are measured and how these benefits are valued by society.

Fluctuating functions related to quality of life in advanced Parkinson disease: effects of duodenal levodopa infusion

OBJECTIVE

To assess fluctuations in quality of life (QoL) and motor performance in patients with advanced Parkinson disease (PD) treated with continuous daytime duodenal levodopa/carbidopa infusion or conventional therapy.

METHODS

Of 18 patients completing a 6-week trial (DIREQT), 12 were followed for up to 6 months and assessed using electronic diaries and the PD Questionnaire-39 (PDQ-39).

RESULTS

During the trial and follow-up, major diurnal fluctuations were observed, especially for hyperkinesia, 'off' time, ability to walk and depression. Duodenal infusion was associated with significantly more favourable outcomes compared with conventional treatment for satisfaction with overall functioning, 'off' time and ability to walk, with improved outcomes with PDQ-39.

CONCLUSIONS

Relative to conventional treatment, infusion therapy may stabilize and significantly improve motor function and patient's QoL. The potential for daily fluctuation in PD symptoms means single measures of treatment effectiveness can result in bias in effect estimates and hence repeated measures are recommended.

Nationwide survey of subjectively reported adverse drug reactions in Sweden

BACKGROUND

Adverse drug reactions (ADRs) and the safety of drugs continue to be widely discussed. However, information on the prevalence of subjectively experienced ADRs (SADRs) and their subsequent burden in the general population is largely lacking.

OBJECTIVE

To analyze, from an epidemiologic perspective, SADRs with respect to occurrence and health status.

METHODS

A cross-sectional mail survey to a random national sample in Sweden of inhabitants aged 18-84 years was conducted; 61% (N = 4875) of the sample answered the questionnaire. Self-reported SADRs occurring during a 2-week period of using prescription, over-the-counter (OTC), or herbal drugs were classified according to Meyler's classification of ADRs. Self-perceived health status was assessed with a visual analog scale graded from 0 (worst possible health/death) to 1 (perfect health).

RESULTS

SADRs were reported by 6.4% of the total study sample, 10.2% of the 2851 users of prescription drugs, 1.0% of the 2862 users of OTC drugs, and 0.1% of the 1352 users of herbal drugs. Of the total sample, 3.3% reported SADRs of the nervous system, 2.6% of the gastrointestinal system, and 0.6% of the cardiovascular system. Users of prescription drugs with SADRs reported a mean health status score of 0.655, while those who did not report SADRs scored 0.744. Among users of OTC and herbal drugs, the corresponding scores were 0.720 and 0.818, respectively. Those in the population who did not use any drugs rated their health status as 0.846.

CONCLUSIONS

Both the prevalence of SADRs and the magnitude of the decrease in subjective health status in respondents experiencing them reflect the importance of individual subjective perceptions for public health. However, in a cross-sectional study like this, causal relationships cannot be firmly established. Further, other factors, such as comorbidity or disappointment with treatment outcomes, could be associated with the decrease in health status.

Using EQ-5D to derive general population-based utilities for the quality of life assessment of growth hormone deficiency in adults (QoL-AGHDA)

OBJECTIVE

Disease-oriented quality of life (QoL) measures that are not preference-based lack legitimacy for direct use in cost-utility analyses. This has prompted the search for other methods for deriving utilities. The QoL Assessment of Growth Hormone Deficiency in Adults questionnaire (QoL-AGHDA) is a disease-oriented measure used to assess impairment in QoL in adults with growth hormone deficiency. The present study was designed to generate a model for deriving utilities from the QoL-AGHDA.

METHODS

The EQ-5D, the QoL-AGHDA, and demographic questions were mailed to a random sample (n = 3005) of the Swedish population (response rate 65%). Multiple regression analysis was used to obtain cross-validated parameters of QoL-AGHDA-based utilities. Two models were developed (simple and full versions). The simple version used the EQ-5D(index) (derived from European values) as the dependent variable, and age, sex, and QoL-AGHDA score as independent variables in a regression analysis. The full model utilized all available demographic information. The QoL-AGHDA scores were thus transformed into a single score (0-1), corresponding to the QoL-AGHDA-based utility.

RESULTS

The simple transformation algorithm was U (QoL-AGHDA-based utilities) = 1.05 - 0.0189 x QoL-AGHDA score - 0.00238 x age - 0.0127 x sex (male = 0; female = 1). The mean of the weighted estimate for the population (n = 1752) was 0.85 (SD 0.10). The estimate for men (n = 861; mean 0.86; SD 0.10) was higher (P < 0.001) than for women (n = 891; mean 0.84; SD 0.10).

CONCLUSION

For practical reasons, the simple model can be recommended for deriving utilities directly from the QoL-AGHDA for the Swedish population.

Mortality among persons with schizophrenia in Sweden: an epidemiological study

The objective of the study was to analyse 10-year mortality among persons with schizophrenia from an epidemiological perspective. This cohort study included all persons with schizophrenia (n=255) living in the northern catchment area in Uppsala in 1991, and 1275 subjects from the national population register matched for sex, age and living area. The prevalence of schizophrenia was 0.37% and the mortality rate for individuals with schizophrenia was higher than for referents: 23.0% vs. 11.2%. The higher mortality among those with schizophrenia was mainly the result of unnatural causes and cardiovascular disease, especially in men. Excess mortality from cardiovascular disease was more pronounced in middle age, irrespective of gender. Multivariate analysis revealed higher mortality among individuals with schizophrenia living in the city than among those living in less urbanized areas. People with schizophrenia die more often than those without schizophrenia from unnatural causes or circulatory diseases. Individuals with schizophrenia die sooner from circulatory diseases than those without schizophrenia. Having schizophrenia and living in the city also results in higher mortality than having schizophrenia and living in other areas. The risk of early death from circulatory disease needs to be studied in more detail to reveal the potential respective contributions of intrinsic patient vulnerability, lifestyle factors and side-effects from psychotropic drugs.

The impact of depression is unevenly distributed in the population

AIMS

The aim of this study was to evaluate the impact of depression on quality of life in the general population by studying its effects on i) health-related quality of life (HRQoL), ii) health state utilities, and iii) the burden of disease in the population according to age, sex, marital status, education, economy and employment.

METHOD

Cross-sectional survey in the County of Uppsala, Sweden. A statistical sample of the general population aged 20-64 years (N=4506) was used. Information on current state of depression was obtained by self-report. HRQoL was measured using Short Form 36 (SF-36). The time trade-off (TTO) method was used to measure health state utilities. The decrease of total health state utilities associated with depression in the population was used as a measure of burden of disease.

RESULTS

Depression was reported by 4.0% of the population. Those with depression scored significantly lower (P<0.001) than those without on all eight of the SF-36 domains. The depressed group also rated their health state utilities significantly lower than the others: 0.796 versus 0.933 (P<0.001). In the multivariate analysis of decrease in utilities with various medical disorders, depression was associated with the greatest decrease (-0.090, P<0.001). Persons with depression accounted for 10.9% of the total decrease in utilities in the whole population, but this proportion varied according to the specific subgroup. For example, 16.4% and 8.6% of the total burden of disease was linked to depression among single and married people, respectively. The corresponding figures for those with the lowest and highest incomes were 15.0% and 7.9%, respectively. Among the unemployed, persons reporting depression accounted for 15.3% of the decrease in utilities in contrast to 4.9% among the employed.

CONCLUSIONS

Depression has a strong impact on the quality of life and total disability in the general population. Further, the impact of depression is unevenly distributed in the population.

Paternal Laboratory Work and Congenital Malformations

Animal studies indicate male-mediated teratogenicity for certain carcinogens/mutagens. Nevertheless, paternal occupational determinants of malformations in humans have been sparsely investigated. Data on male employees at Swedish universities from 1970 to 1989 were linked to the Medical Birth Register. The relationship between major malformations and exposure to laboratory work and to specific laboratory agents/techniques before the third trimester were analyzed using logistic regression. For major malformations, "laboratory work in general" (n = 3237) gave an adjusted odds ratio (OR) of 1.3 (95% CI = 0.8-2.1) and carcinogenic solvent use (n = 2489) of 2.0 (95% CI = 0.8-4.9) around the time of conception. For carcinogenic solvents and neural crest malformations, OR was 4.9 (95% CI =1.5-15.8). In conclusion, the prevalence of congenital malformations was not increased in offspring of males with laboratory work in general (1970-1989). Paternal work with agents such as carcinogens could, however, be of concern.

A Swedish population-based study on the relationship between the SF-36 and health utilities to measure health in hypertension

The aim of this study was to determine the relationship between a psychometric health-related quality-of-life instrument (the SF-36)-and two health utility measures [the time trade-off (TTO) and rating scale (RS) methods) among hypertensives in a general population. In the analyses were adjusted for comorbidity. The study was based on a postal questionnaire that was sent to a random sample of 8000 inhabitants aged 20-84 years (response rate 68%) in Uppsala County, Sweden, in 1995. The results showed only a moderate correlation between the TTO and the RS methods. The different dimensions of SF-36 were overall lower correlated with the TTO method than with the RS method. Co-morbidity was not associated with the RS or the TTO method among hypertensives. The regression equations explained 58% of the variance in RS among hypertensives. The corresponding value for the TTO method was about 20%. In conclusion, our study found that among hypertensives the SF-36 is low to moderate correlated to the TTO and RS methods. Health utilities and psychometric measures represent different attributes of health. It is therefore important to be aware of the differences between psychometric and utility measures when interpreting results from studies using different methods. More work is needed to explicate if health utilities can be obtained from the SF-36.

Self-reported Dermatological Problems and Preferences for Health: An Epidemiological Survey

Patient preferences for health can be assessed and expressed in quantitative terms known as health state utilities. In this epidemiological study, we demonstrate the importance of dermatological problems for health state utilities. A cross-sectional survey including 5,404 individuals aged 20-84 years was conducted in the County of Uppland, Sweden. Information on dermatological problems and use of prescription-only topical drugs was obtained by self-report. Dermatological problems were reported by 20.5%. A rating scale used to assess utilities showed that persons reporting dermatological problems had lower health state utilities than those not reporting such problems (p<0.001). Persons using prescription-only topical drugs had lower health state utilities than others with dermatological problems. Dermatological problems had an independent and statistically significant effect on health state utilities when age, sex, somatic and psychiatric co-morbidity, and pain were included in the multivariate analysis. It is shown that skin disorders are a considerable problem in the population and results in a significant decrease in health state utilities.

Epidemiology of analgesic use: a gender perspective

BACKGROUND AND OBJECTIVE

Women consistently report significantly more frequent analgesic use in epidemiological studies. The aim of this study was to analyse the influence of medical and non-medical factors on the difference in use of analgesics between women and men from a population perspective.

METHODS

Cross-sectional survey. Postal questionnaires were sent to a random sample of the general population in the country of Uppland, Sweden (5404 answered the questionnaire, response rate: 68%).

RESULTS

34.8% of the women and 21.4% of the men had used analgesics during the two week recall period (Odds Ratio = 1.96). Social structure, social status, marital status, educational level, economic situation, lifestyle, attitudes toward drugs, medication knowledge and self-care orientation were of minor importance for the difference in use between women and men. Difference in prevalence of various types of pain and ache and the degree of pain experienced were the most influential factors affecting the difference in use. However, when all factors were analysed there remained a substantial difference in use between women and men (OR = 1.39, CI (95%) 1.20 to 1.60).

CONCLUSIONS

In the population, women use analgesics much more frequently than men. Consequently women may be at greater risk for adverse effects and dependency. Some of the gender difference is explained by the greater frequency of pain conditions among women, but a significant difference in use still remains to be explained.

Dosage patterns of antipsychotic drugs for the treatment of schizophrenia in Swedish ambulatory clinical practice--a highly individualized therapy

OBJECTIVE

To analyse the dosage pattern of antipsychotic drugs for schizophrenia in ambulatory care in Sweden.

METHOD

The study was based on a nationwide consecutive weekly random sample of physicians during the period 1991-98 comprising 265,331 visits.

RESULTS

In 515 visits (0.19%), antipsychotics were prescribed for schizophrenia. More than one antipsychotic (50 different combinations) was prescribed in 20% of the visits. Patients received higher total daily doses when prescribed more than one antipsychotic drug; mean dose in monotherapy was 210.7 chlorpromazine equivalents (CPZeq) and in polytherapy 406.8 CPZeq.

CONCLUSION

Antipsychotics, in contrast to current recommendations, were prescribed as highly individualized therapies in a wide variety of doses and with a high frequency of polypharmacy. The combinations used are often unsuitable and may lead to unnecessary adverse effects.

On the measurement of relative and absolute income-related health inequality

In recent work on international comparisons of income-related inequalities in health, the concentration index has been used as a measure of health inequality. A drawback of this measure is that it is sensitive to whether it is estimated with respect to health or morbidity. An alternative would be to use the generalized concentration index that is based on absolute rather than relative health differences. In this methodological paper, we explore the importance of the choice of health inequality measure by comparing the income-related inequality in health status and morbidity between Sweden and Australia. This involves estimating a concentration index and a generalized concentration index for the eight-scale health profile of the Short Form 36 (SF-36) health survey. We then transform the scores for each scale into a measure of morbidity and show that whether the concentration index is estimated with respect to health or morbidity has an impact on the results. The ranking between the two countries is reversed for two of the eight dimensions of SF-36 and within both countries the ranking across the eight SF-36 scales is also affected. However, this change in ranking does not occur when the generalized concentration index is compared and we conclude with the implications of these results for reporting comparisons of income-related health inequality in different populations.

Self-reported dermatological problems and use of prescribed topical drugs correlate with decreased quality of life: an epidemiological survey

BACKGROUND

Skin problems are common in the population. Although a substantial fraction of the population suffers from skin conditions, we still have little information on how this affects the everyday life of the individuals concerned.

OBJECTIVES

To evaluate the impact of skin disease on health-related quality of life (HRQOL) measured with the Short Form-36 (SF-36), a multidimensional generic HRQOL instrument, from an epidemiological perspective. A further aim was to study differences in HRQOL by use of non-prescription and prescription dermatological drugs.

METHODS

The survey was carried out in the county of Uppland, Sweden in a random sample of 8000 individuals aged 20-84 years, of whom 5404 (68%) answered the questionnaire.

RESULTS

A large part of the population (20.5%) reported dermatological problems and/or use of topical dermatological drugs, with a higher frequency among women (23.3%) than men (17.3%). Persons reporting dermatological problems scored lower on all eight dimensions of the SF-36. This pattern, although weaker, persisted after adjusting for comorbid somatic as well as psychiatric diseases and complaints. Those using topical dermatological drugs on prescription generally scored lower than the other groups with skin problems: in particular, they evaluated personal health as poorer (general health perceptions), perceived more limitations in daily activities (role limitation because of emotional health problems) and felt more tired and worn out (vitality).

CONCLUSIONS

The study shows that skin disorders constitute a substantial problem in the population and cause a significant decrease in HRQOL. Furthermore, the results of this population survey point out the need for further population-based studies more specifically aimed at dermatological problems and HRQOL.

Attitudes towards drugs--a survey in the general population

BACKGROUND

Studies have shown that many drugs have a lower effectiveness in clinical practice than would be expected from results reported in randomised controlled clinical trials. Many factors influence the use of drugs. Personal factors such as knowledge, attitudes, motivation, expectations are considered to be of particular consequence. The aim of the study was to analyse attitudes towards drugs from an epidemiological perspective.

DESIGN

Cross-sectional survey

SETTING

The county of Uppsala, Sweden, 1995.

RESULTS

5,404 completed the questionnaire (response rate = 68%). A majority either considered drugs as something positive, a help (60%), or as something necessary but evil (38%). A small proportion--around 2%--considered drugs as a danger. There were differences in attitudes according to education and income, self-care orientation, medication knowledge, and state of health. We also found differences in attitudes between users and non-users of certain types of drugs. Users of hypertensive drugs more often considered drugs as necessary but evil than did non-users of these drugs, while users of psychotropic drugs more often viewed drugs as something positive than did patients who did not use psychotropic drugs.

CONCLUSION

A better understanding of the general attitudes towards drugs is important when giving both written and oral information to patients and to the public at large. It is also important to be aware of differences in attitudes between various patient groups and that certain patients, e.g., patients prescribed hypertensive drugs, could require more attention from health care professionals.

Oral contraceptives and compliance: reaction to cardiovascular alarm among users

The effectiveness of oral contraceptives (OC) is dependent on correct daily intake as well as continuous use. The latest cardiovascular alarm in 1995 led to discontinuations, presumably due to concerns about the long-term safety of OCs. The aim of this study was to investigate women's experiences and concerns about OCs in general as well as after the latest cardiovascular alarm. In 1993 and 1996, questionnaires were offered to 645 and 644 consecutive women visiting a midwife or a gynecologist at eleven family planning clinics in order to get their first prescription of oral contraceptives or to renew their prescription. The study was carried out in Uppsala, a city in Sweden with 180000 inhabitants. In 1993, 95%, answered the questionnaire and in 1996 the corresponding figure was 92%. Change of brand was common and increased from 38% in 1993 to 44% in 1996. Mild side-effects were reported by about 25%. Concerns about oral contraceptives increased from 36% to 41% (p < 0.01), particularly regarding the risk for thrombosis. Fewer than 1% expressed this concern in 1993 but 29% did so in 1996. Negative media coverage leads to increased concerns and declining confidence among users of oral contraceptives and has to be met by adequate oral and written information by the counsellor.

Patient compliance with drug therapy in schizophrenia. Economic and clinical issues

The effectiveness of drug treatment in clinical practice is considerably lower than the efficacy shown in controlled studies. The lower effectiveness in practice presumably leads to lower cost effectiveness of drug treatment in real-life situations compared with that demonstrated by studies based on results from controlled trials. Improved cost effectiveness in routine clinical practice would be a significant advantage in the treatment of schizophrenia, one of the most costly diseases in society. The aetiology of schizophrenia is unknown, and there is no cure. The main aims of therapy with antipsychotic medication include the effective relief of symptoms without the introduction of adverse effects or serious adverse events, improved quality of life, cost effectiveness and a positive long term outcome. The older classical antipsychotic drugs do not always meet these requirements because of their well-known limitations, such as a lack of response in a subgroup of individuals with schizophrenia and intolerable adverse effects. There has long been a need for new antipsychotics that can ameliorate more symptoms and have no or few adverse effects. Some of the recently introduced antipsychotics have been shown to be more effective in certain clinical situations and to have a more favourable adverse effect profile than the classical antipsychotics. A major factor contributing to the lower effectiveness of drug treatment is noncompliance, which may be very high in schizophrenia. There are several factors influencing compliance, including drug type and formulation, patient, disease status, physician, health care system, community care and family. There have been very few studies of compliance improvement strategies in schizophrenia or, indeed, in medicine in general. Current methods are relatively complex and there are differing opinions on their effectiveness. There are several ways to increase compliance in schizophrenia--the evidence is strongest for psychoeducative methods, changing to a new drug or using a depot formulation. However, considerably more research is needed in the field of compliance strategies.

Concomitant prescribing of tranquilizers and hypnotics among patients receiving antidepressant prescriptions

OBJECTIVE

To evaluate concomitant prescribing of tranquilizers and hypnotics in antidepressant treatment with particular focus on the relationship to drug class in patients prescribed antidepressant treatment for depressive disorders.

DESIGN AND METHODS

Repeated cross-sectional surveys of Swedish physicians in ambulatory care from 1991 to 1996, including specialty practices. The participation rate was 65-70%.

RESULTS

Tranquilizers and hypnotics were prescribed in 36.1% of the visits in which the intention was to treat depression. Concomitant prescribing increased with the patient's age for all antidepressant drug classes. Women received more concomitant prescriptions than men when treated with nonselective monoamine-reuptake inhibitors (NSMRI), mainly tricyclic compounds. Psychiatrists prescribed more concomitant tranquilizers and hypnotics than other physicians, and general practitioners fewer, when treating depression with selective serotonin-reuptake inhibitors (SSRIs), mainly citalopram. A logistic regression model showed that the risk for concomitant prescribing was higher when an NSMRI was prescribed than with other antidepressants.

CONCLUSIONS

Concomitant prescribing of tranquilizers and hypnotics was common among antidepressant-treated patients. The most plausible reasons for the high rate of concomitant prescribing were the symptoms of the depression itself and/or the common comorbidity with anxiety disorders seen in this group of patients. The results of this study indicate that the concern about increased tranquilizer and hypnotic use among patients treated with SSRIs suggested in other studies seems to be unfounded in Sweden.

Use of calcium channel blockers and risk of suicide: ecological findings confirmed in population based cohort study

OBJECTIVE

To investigate possible associations between use of cardiovascular drugs and suicide.

DESIGN

Cross sectional ecological study based on rates of use of eight cardiovascular drug groups by outpatients. A population based cohort study including users of drugs to control hypertension.

SUBJECTS

The ecological study included 152 of Sweden's 284 municipalities. The cohort study included all inhabitants of one Swedish municipality who during 1988 or 1989 had purchased cardiovascular agents from pharmacies within the municipality. Six hundred and seventeen subjects (18.2%) were classified as users of calcium channel blockers and 2780 (81.8%) as non-users.

MAIN OUTCOME MEASURES

Partial correlations (least squares method) between rates of use of cardiovascular drugs and age standardised mortality from suicide in Swedish municipalities. Hazard ratios for risk of suicide with adjustments for difference in age and sex in users of calcium channel blockers compared with users of other hypertensive drugs.

RESULTS

Among the Swedish municipalities the use of each cardiovascular drug group except angiotensin converting enzyme inhibitors correlated significantly and positively with suicide rates. After adjustment for the use of other cardiovascular drug groups, as a substitute for the prevalence of cardiovascular morbidity, only the correlation with calcium channel blockers remained significant (r = 0.29, P < 0.001). In the cohort study, five users and four non-users of calcium channel blockers committed suicide during the follow up until the end of 1994. The absolute risk associated with use of calcium channel blockers was 1.1 suicides per 1000 person years. The relative risk, adjusted for differences in age and sex, among users versus non-users was 5.4 (95% confidence interval 1.4 to 20.5).

CONCLUSIONS

Use of calcium channel blockers may increase the risk of suicide.

Medicated hypertensive patients' views and experience of information and communication concerning antihypertensive drugs

Semi-structured interviews with mostly open-ended questions were conducted with 21 medicated hypertensive patients regarding their views and experience of information and communication with respect to antihypertensive medicines. The results showed that the physician was the person from whom the patients preferred to receive information about medicines. Pharmacy personnel were not regarded as an information resource and few patients had ever talked to them about drugs. The interviewees expressed a desire to receive information at the beginning of the pharmaceutical treatment, especially concerning possible side-effects. Except for this, information concerning the medicine itself was thought to be relatively unimportant, although patients expressed a desire to know whether the drug after a period of time could accumulate in the body or if the internal organs could be affected.

Antidepressant dose patterns in Swedish clinical practice

The Swedish Diagnosis and Therapy Survey was used to analyse the prescribing of antidepressants from 1991 to 1996. There were considerable differences in doses prescribed depending on diagnosis. Adequate dosage is an important factor in antidepressant treatment, and this study showed that tricyclic antidepressants are often prescribed at lower than recommended doses for the treatment of depression. Significantly higher doses were prescribed in continued treatment, as opposed to in new treatment, indicating dose titration when using tricyclic antidepressants and the most common selective serotonin reuptake inhibitors in depression. The findings from the present study suggest that the optimal dosage for some of the new antidepressants in clinical practice has not yet been determined and that costs of treatment in a natural setting might be considerably higher than costs calculated from dose recommendations.

Antidepressant-treated patients in ambulatory care. Mortality during a nine-year period after first treatment

BACKGROUND

Non-institutionalised patients treated with antidepressants have been shown to have indicators of a generalised vulnerability, such as high rates of health service use and excessive prescription drug use. Therefore, mortality in this patient group is of interest.

METHOD

All first-incidence antidepressant users in a defined population during a five-year period were identified. Their total mortality during a nine-year follow-up was analysed. Cox proportional hazards regression was used to analyse total mortality, and mortality in cardiovascular disease, controlling for baseline chronic medical disease.

RESULTS

Antidepressant treatment at the index date was a statistically significant predictor for increased long-term mortality in the over-65s, even when controlling for pre-existing chronic medical disease. Baseline ischaemic heart disease and concurrent antidepressant treatment significantly predicted mortality from cardiovascular causes.

CONCLUSION

Prescribed antidepressant treatment identifies patients who are at risk of increased mortality. For the physician in ambulatory care, knowledge of a patient's antidepressant treatment history may be a valuable tool in managing patient care.

Antidepressant-treated patients in ambulatory care long-term use of non-psychotropic and psychotropic drugs

BACKGROUND

Despite the problems involved in treating depression and concomitant medical disease, there are virtually no longitudinal studies on drug utilisation among depressed patients.

METHOD

Use of prescription drugs among all first-time users of antidepressants in a defined population five years before and six years after the index (first) treatment was compared to a referent group without antidepressant treatment. The generalised estimating equations (GEE) method was used for analysis.

RESULTS

The antidepressant-treated group used considerably more non-psychotropic drugs during the whole study period than the referent group. They also used more psychotropic drugs, a use which increased in connection with the initiation of antidepressant treatment, and stayed high for a further five years.

CONCLUSIONS

The high use of prescription drugs indicated widespread somatic and psychiatric health problems during the whole study period. Antidepressant-treated patients are at risk for drug interactions and adverse effects, and would benefit from a closer collaboration between psychiatry and medicine.

Factors associated with high-quantity prescriptions of benzodiazepines in Sweden

An important aspect, when discussing the prescribing and use of psychotropics, is the amount of drug prescribed at each visit. In this study the Swedish Diagnosis and Therapy Survey was used in order to analyze high-quantity prescriptions of benzodiazepines. The total amount of benzodiazepines prescribed--measured as defined daily doses (DDD)--was calculated for each visit. Prescriptions with quantities equal to or greater than the 90th percentile applied on the distribution of prescribed DDD per visit were defined as high-quantity prescriptions. Using this definition, prescriptions on 200 DDD or more--14.9% of all--were classified as high-quantity prescriptions. In the analysis the proportions of high-quantity prescription in different subgroups were compared. The study showed that there was a strong relationship between age of the patient and high-quantity prescriptions while the sex of the patient was of minor importance. Doctors specializing in internal medicine and psychiatrists prescribed high-quantity prescriptions to a greater extent than other doctors but differences with regard to the doctor's ages were small. Patients with sleeping disturbances obtained high-quantity prescriptions to a greater extent than other patients while patients with nervous problems obtained fewer. Patients with new prescriptions on benzodiazepines obtained high-quantity prescriptions to a lesser extent than patients making repeat visits. In addition the study showed that it was not as common with high-quantity prescriptions in the three major cities and in the most sparsely populated communities as in mid-sized communities.

Small-scale preparations in Sweden. Extemporaneous preparations and stock preparations at eleven community pharmacies

Small-scale preparations, i.e. non-registered drugs that are extemporaneously prepared for each patient or made in larger batches for stock keeping, form a small but important group of drugs, especially for patients with rare diseases or allergies. Small-scale preparations are not included in the otherwise comprehensive statistics compiled by the National Corporation of Swedish Pharmacies and this makes knowledge of the use of these drugs limited. The occurrence of small-scale preparations was studied at eleven community pharmacies over a three-year period (1987-1989) by analysis of the orders from the pharmacies to the four production units of the National Corporation of Swedish Pharmacies in the first quarter of each study year. The number of small-scale preparations dispensed were compared with the total sales of drugs at each pharmacy. The proportion of small-scale preparations in the total drug sales was about 1.5% throughout the study period, but there were fluctuations over time at the individual pharmacies. The most common dosage forms were creams, liniments and mixtures. Dermatological drugs in different dosage forms were the most frequent (almost 50%). This was probably because of the necessity for a great variety of different strengths among these drugs.

The influence of a hospital drug committee's recommendations on the use of analgesics as evaluated by drug-use data

Drug-use data in a large university hospital have been used as a means for evaluating the influence of the recommendations given by a drug committee on the use of analgesics. The results generally show a reasonable adherence to the recommendations in the hospital. A selected clinic, the Department of Oncology, where special efforts were directed, showed particularly close adherence to the guidelines given.