Part ii: research proposals for next budget year

Differences in Prescribing Patterns of Psychotropic
Medication for Children and Adolescents between Rural and
Urban Prescribers

Scott J. Adams, Psy.D.
Stan Xu, Ph.D.
Fran Dong, M.S.

October 2009
Working Paper
Western Interstate Commission for Higher Education
Mental Health Program
3035 Center Green Drive
Boulder, CO 80301
Acknowledgements: The WICHE Center for Rural Mental Health Research is one of seven Rural Health Research Centers supported by the Federal Office of Rural Health Policy (ORHP), Grant No.1 U1CRH03713-01. This project is funded by ORHP, Health Resources and Services Administration, U.S. Department of Health and Human Services. The specific content of this article is the sole responsibility of the authors. Dr. Adams is a researcher for the WICHE Mental Health Program. Dr. Xu is Head of Biostatistics in the Clinical Research Unit of Kaiser Permanente Health Plan and Assistant Professor in the Department of Preventive Medicine and Biometrics at the University of Colorado Health Sciences Center. Fran Dong, M.S., is the Statistical Analyst for the WICHE Mental Health Program. Table of Contents 

Executive Summary 

Multiple studies have indicated a dramatic increase in the number of youth being prescribed
psychotropic medication over the past 15 to 20 years.1-13,17-23 In addition to the increased rate of
prescriptions of psychotropic medications for youth (as well as polypharmacy), there are
differences in prescribing patterns depending on the type of prescriber (e.g., generalist physicians
vs. psychiatrists),2,4,7,11,13,20,23 treatment setting (e.g., inpatient vs. outpatient; community vs.
academic),3,9-10,12 type of insurance coverage,7,11,13 diagnosis,3-6,8,12,19 sex,2,6-7,12-13 age,6-7,12-13,17
and race.6-7,12-13,18-19 However, despite the multiple aspects of prescribing patterns presented in
the research literature, there appear to be no studies examining these issues in the context of rural
vs. urban prescribers.
The purpose of this project was to: 1) determine who are the primary prescribers of psychotropic
medications to youths in both urban and rural areas, 2) identify types of medication being
prescribed broken down by demographic information (e.g., sex, age), and 3) examine trends of
prescribing patterns over time in terms of type of prescriber, medication, and rural-urban
differences.
The method was a secondary analysis of the 1996-2005 National Ambulatory Medical Care
Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) data
files, published by the National Center for Health Statistics.
The study resulted in three primary findings including:
1) The number and percent of rural youth receiving psychotropic medication increased at a comparable level to urban youth over a 10-year period. 2) Compared to their urban counterparts, significantly more rural youth received prescriptions for psychotropic medications from generalists and other prescribers than from psychiatrists. 3) There may have been ethnic/racial, sex, and age differences in which types of psychotropic medications were prescribed.
Rurality was determined using a Metropolitan Statistical Area (MSA) and non-Metropolitan
Statistical Area (Non-MSA) designation. Therefore, the MSA and Non-MSA categories were
used to define our urban and rural samples, respectively. The terms children, adolescents, and
youths for the purposes of this study were defined as anyone age 17 and younger.
In conclusion, prescriptions of virtually all psychotropic drug categories increased significantly
for both urban and rural populations over the 10-year period of the study. Urban youth were far
more likely to be prescribed psychotropic medications by psychiatrists as opposed to generalists
or other prescribers. In contrast, rural youth were far more likely to have psychotropics
prescribed by generalists or other prescribers.
There were also notable differences in type of drugs prescribed according to the racial group to which youths belonged. Minority youth in both rural and urban places had much higher percentages of antipsychotic and/or bipolar medication, and much lower percentages of antidepressant and/or antianxiety medications, compared to their Caucasian peers. A number of differences in prescribing patterns according to sex and age also emerged. Females age 0 to 5 tended to have greater percentages of antidepressant and/or antianxiety medications, as well as CNS stimulants, than their male peers. Overall, males ages 6 to 11 had a smaller percent of antipsychotic and/or bipolar medications, as well as antidepressants and/or antianxiety medications, but a far greater percent of CNS stimulants, than females of the same age. Additionally, rural females had a notably greater percent of CNS stimulants than their urban female counterparts. On average, males ages 12 to 17 had a greater percent of antipsychotic and/or bipolar medications, smaller percent of antidepressants and/or antianxiety medications, and a far greater percent of CNS stimulants, than their female counterparts. Urban females had higher percentages of antipsychotic and/or bipolar medications, as well as CNS stimulants, than their rural female peers. Summary Report  

Context
Multiple studies have indicated a dramatic increase in the number of youth being prescribed
psychotropic medication over the past 15 to 20 years.1-13,17-23 For instance, data indicate that the
overall annual rate of psychotropic medication use by children increased from 1.4 per 100
persons in 1987 to 3.9 in 1996, with significant increases found in the use rates of stimulants,
antidepressants, other psychotropic medications, and polypharmacy of different classes of
psychotropic medications.1 In a later study, rates of visits by youth resulting in a psychotropic
prescription increased from 3.4 percent in 1994-1995 to 8.3 percent in 2000-2001, with annual
growth rates rapidly accelerating after 1999.2 These trends were evident for males and females,
and also significant across drug classes.2 Additionally, there appears to be an increase in the
percent of visits by youth to outpatient clinics and emergency rooms that include prescriptions
for psychotropic medications.1-2 Similar trends have been found in other countries.14-16
In addition to the increased rate of prescriptions of psychotropic medications for youth (as well
as polypharmacy), there are differences in prescribing patterns depending on the type of
prescriber (e.g., generalist physicians vs. psychiatrists),2,4,7,11,13,20,23 treatment setting (e.g.,
inpatient vs. outpatient; community vs. academic),3,9-10,12 type of insurance coverage,7,11,13
diagnosis,3-6,8,12,19 sex,2,6-7,12-13 age,6-7,12-13,17 and race.6-7,12-13,18-19 However, despite the multiple
aspects of prescribing patterns presented in the research literature, there appear to be no studies
examining these issues in the context of rural vs. urban prescribers. While it is important and
interesting to know that prescribing patterns to youth are influenced by the aforementioned
factors, it is equally important to understand how these issues play out in rural areas.
Purpose
The purpose of this project was to: 1) determine who are the primary prescribers of psychotropic
medications to youths in both urban and rural areas, 2) identify types of medication being
prescribed broken down by demographic information (e.g., sex, age), and 3) examine trends of
prescribing patterns over time in terms of type of prescriber, medication, and rural-urban
differences.
Hypotheses:
1. The number and percent of rural youth receiving psychotropic medication will increase at a
comparable level to urban youth over a 10-year period. 2. Compared to their urban counterparts, significantly more rural youth will receive prescriptions for psychotropic medications from generalists or other prescribers than from psychiatrists. 3. There may be ethnic/racial, sex, and age differences in which types of psychotropic Methods
The method was a secondary analysis of the 1996-2005 National Ambulatory Medical Care
Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) data
files, published by the National Center for Health Statistics. The unit of analysis is the youth
patient encounter/visit. Descriptive analyses include provider type, patient demographics, and
youth psychotropic medications by urban and rural, and types of medications. These descriptive
statistics were adjusted by weight variables created in the NAMCS and NHAMCS databases.
Odds ratios of receiving psychotropic medications from psychiatrists versus generalists and other
prescribers were calculated from the logistic regressions adjusting for the main interest, urban
versus rural, time, with or without covariates including patient characteristics and clinical
variables.
Operational Definition of Major Constructs in Data Analysis:
Rurality: We were unable to get zip code data from the NAMCS and NHAMCS files. However,
those databases use a Metropolitan Statistical Area (MSA) and non-Metropolitan Statistical Area
(Non-MSA) designation. Therefore, the MSA and Non-MSA categories were used to define our
urban and rural samples, respectively.
Children, adolescents, and youths: These terms for the purposes of this study are defined as
anyone age 17 and younger.
Physician Type: This variable subdivided physicians into three mutually exclusive groups:
psychiatrists, generalists, and other prescribers.
Psychotropic Drug Visit: A psychotropic drug visit was defined as a visit in which at least one
psychotropic medication was prescribed, ordered, supplied, administered, or continued. Table 1
lists the medications we will include.
Psychotropic medications were classified according to the most recent version of the Physicians’
Desk Reference.
Antidepressants
Antipsychotic Agents
CNS Stimulants
Bipolar Agents
Antianxiety Agents
Antipanic Agents
OCD Management
Diagnosis: The primary diagnosis field was searched for any ICD-9-CM diagnostic code representing childhood disorders (e.g., ADHD, autism), depression, anxiety disorders, psychotic disorders, bipolar disorders, eating disorders, personality disorders, and substance use disorders. Covariates: Sociodemographic variables included age, sex, race/ethnicity, and insurance. Clinical variables included visit reason, presenting symptoms, primary diagnoses, and secondary diagnoses. Data Sources
A nationally representative group of visits to nonfederally employed physicians in office-based
practices, as well as to the emergency departments and outpatient departments of noninstitutional
general and short-stay hospitals, exclusive of Federal, military, and Veterans Administration
hospitals, located in the 50 States and the District of Columbia is sampled in the NAMCS and
NHAMCS databases, respectively.
Findings
The findings of this study are presented below. “Outpatient” signifies the sample of outpatient
visits composed in the NAMCS and part of the NHAMCS, whereas “ER” refers to the sample of
emergency room visits composed entirely in the NHAMCS database. Not all hypotheses were
applicable to both outpatient and ER samples. Where this is the case, the abbreviation “N/A” is
used.
1. The number and percent of rural youth receiving psychotropic medication will increase
at a comparable level to urban youth over a 10-year period.
Over the 10-year period, there were significant increases in the prescription of any psychotropic medication for the combined outpatient and ER sample of both urban and rural youth. Urban youth had an average increase of 8.1% a year (p < .0001), while rural youth had an average of 7.6% per year (p < .04). There was no significant difference between urban and rural youth for a prescription of any psychotropic. In the combined outpatient and ER sample, urban youth had significantly higher prescriptions of
six out of seven of the drug categories. These were CNS stimulants, OCD agents,
antidepressants, antipsychotics, and bipolar agents (see table below). Rural youth had
significantly higher prescriptions of four of the seven drug categories, which included
antidepressants, antipanic agents, antipsychotics, and bipolar agents. There were no significant
differences between urban and rural youth for any particular drug category.
Subdividing the samples into outpatient and ER samples indicated a similar pattern for the
former and only one significant trend for the latter. Specifically, the urban outpatient trend was
the same in terms of specific drug categories as that reported above for the combined samples,
while urban ER prescriptions of bipolar agents decreased by an average of 7.6% per year during
the study period. Rural outpatient trends were mostly the same as the combined sample, except
that there was also a significant increase in antianxiety agents. There were no significant trends
for the ER sample and no significant differences between the urban and rural samples.

Table 1. Trend analysis for prescribing psychotropics to youths in rural and urban areas after covariate adjustment*
Rural Urban
Pr > ChiSq
Pr > ChiSq
Pr > ChiSq
<.0001
<.0001
<.0001
<.0001
*Covariates are age, PAYTYPE, region, SEX, minority, provtype, season only since ED data has the following variables in missing, PRIVATE,
SOLO, dPRIMCARE, HMO, routine, specialty. In the model, time is treated a continuous variable. We used both linear time model and also
quadratic term model to the data and found that linear time model is a better fit to our data.
**OR=Odds Ratio
2. Compared to their urban counterparts, significantly more rural youth will receive
prescriptions for psychotropic medications from generalists and other prescribers than
from psychiatrists.

Over the 10-year period of the study, 71.3% of prescriptions of any psychotropic medication to
urban youth were made by psychiatrists, as compared to 45.4% for rural youth. Psychiatrists
prescribed to urban youth the vast majority of psychotropics from specific drug categories, with
a low of 68.8% (CNS stimulants) to a high of 90% (antipsychotics). By contrast, psychiatrists
prescribed to rural youth a much smaller percent of psychotropics, with a low of 42.6% (CNS
stimulants) to a high of 79.4% (antipsychotics). In rural, generalists prescribed a higher percent
of antipanic agents than psychiatrists.
Table 2: Prescriber Type of Medication
Prescriber
Prescriber
Any Psychotropic
CNS Stimulant
OCD Agent
Antianxiety Agent
Antidepressant
Antipanic Agent
Antipsychotic
Bipolar Agent

3. There may be ethnic/racial, sex, and age differences in which types of psychotropic
medications are prescribed.
There were similarities between urban and rural Caucasian youth populations in terms of the specific drugs prescribed and drug categories to which they belong. Table 3 below indicates the top 10 medications prescribed to each population. The drugs listed composed 71.1% of all medications prescribed for urban youth and 72.9% for rural, Caucasian youth. When grouping specific medications by drug categories, CNS stimulants were the clear majority for both populations (30.9% for urban, 34% for rural). These medications are typically prescribed for Attention Deficit-Hyperactivity Disorder(s). Medications prescribed for either depressive or anxiety disorders were the second largest group, composing 21.6% for urban and 21.5% for rural. Finally, 18.6% of the top 10 medications prescribed for urban youth were for psychotic or bipolar disorders, while 17.4% of the same kinds of medications were prescribed for rural youth. There were also similar trends between urban and rural minority populations. Table 4 indicates the top 10 medications prescribed for these two groups. The drugs listed composed 73.7% of all medications prescribed for urban youth and 77.4% for rural, minority youth. Similar to Caucasian populations, CNS stimulants were the most frequently prescribed medications (31.8% for urban, 33.6% for rural). However, there are striking differences in the percent of antidepressant or antianxiety and antipsychotic or bipolar medications between the Caucasian and minority populations across rural and urban (see Table 5). Of the top 10 medications for minority groups, antidepressants and/or antianxiety medications composed 15.7% and 14.1% for urban and rural minority youth, respectively. However, antipsychotic or bipolar medications
composed 26.2% and 29.7% for urban and rural minority youth, respectively.

Table 3: Top 10 most prescribed drugs for both NAMCS and NHAMCS (1996 to 2005) for Urban and Rural Caucasian Youth
Caucasian
Drug Class
Drug Class
CNS = CNS Stimulant; A-Dep = Antidepressant; A-Anx = Antianxiety; Bipolar = Bipolar Agent;
A-Psy = Antipsychotic; OCD = OCD Agent; A-Pan = Antipanic Agent
Table 4: Top 10 most prescribed drugs for both NAMCS and NHAMCS (1996 to 2005) for Urban and Rural Minority Youth
Minority
Drug Class
Drug Class
CNS = CNS Stimulant; A-Dep = Antidepressant; A-Anx = Antianxiety; Bipolar = Bipolar Agent;
A-Psy = Antipsychotic; OCD = OCD Agent; A-Pan = Antipanic Agent

Table 5: Percent of Top 10 most prescribed drugs for both NAMCS and NHAMCS (1996 to 2005) for Urban and Rural
Minority Youth by Drug Category
Caucasian
Minority
Urban Rural Urban
Drug Category
Includes antidepressants, antianxiety, antipanic, and OCD medications A comparison of prescribing patterns of drug categories between rural and urban youth populations broken down by age and sex is presented in Table 6. Urban female youth age 0 to 5 had a greater percent of antipsychotic or bipolar medications than their rural counterparts. However, rural female youths from this age group had far greater percentages of antidepressants 1 The data is based on the top 10 medications for each age group subdivided by gender and rurality. Therefore, the percentages typically do not add up to 100. and antianxiety medications, as well as CNS stimulants. Male urban youths from the same age
group had a similar percentage of antipsychotic medications to urban female youths and a greater
percentage than rural male youth. Although urban and rural male youths had similar percentages
of CNS stimulant medications, rural males in this age group had a far greater percent of
antidepressants and/or antianxiety medications. Males tended to have, on average, a smaller
percent of antidepressants and/or antianxiety medications and greater percent of CNS stimulant
medications than females.
Rural and urban females age 6 to 11 had similar percentages of antipsychotic and/or bipolar
medications, as well as antidepressants and/or antianxiety medications. However, rural female
youths in this age group had a far greater percent of CNS stimulants than their urban peers. Rural
and urban male youths in this age group had similar percentages of medication from all three
categories, although rural males had a slightly higher percent of CNS stimulant medication.
Overall, males in this age group had a smaller percent of antipsychotic and/or bipolar
medications, as well as antidepressants and/or antianxiety medications, but a far greater percent
of CNS stimulants, than females.
Urban females age 12 to 17 had a higher percent of antipsychotic and/or bipolar medications, as
well as CNS stimulants, than their rural peers. However, rural females had a much higher percent
of antidepressant and/or antianxiety medication than their urban counterparts. Urban and rural
males in this age group were mostly similar in all three categories, with urban males having
slightly higher percentages of antipsychotic and/or bipolar medications, as well as antidepressant
and/or antianxiety medications. Rural males had a slightly higher percent of CNS stimulants than
their urban peers. Overall, males in this age group had a greater percent of antipsychotic and/or
bipolar medications, smaller percent of antidepressants and/or antianxiety medications, and a far
greater percent of CNS stimulants, than their female counterparts.

Table 6: Percent of Top 10 most prescribed drugs for both NAMCS and NHAMCS (1996 to 2005) for Urban and Rural
Youth by Drug Category, Age, and Sex
Urban Rural
Drug Category
Conclusions
Prescriptions of virtually all psychotropic drug categories increased significantly for both urban
and rural populations over the 10-year period of the study. Urban youth are far more likely to be
prescribed psychotropic medications by psychiatrists as opposed to generalists or other
prescribers. In contrast, rural youth are far more likely to have psychotropics prescribed by generalists or other prescribers. Rural youth did have psychiatrists prescribing the majority of more intensive medications, such as antipsychotics and bipolar agents. There were also notable differences in type of drugs prescribed according to the racial group to which youths belonged. Minority youth in both rural and urban places had much higher percentages of antipsychotic and/or bipolar medication, and much lower percentages of antidepressant and/or antianxiety medications, compared to their Caucasian peers. A number of differences in prescribing patterns according to sex and age also emerged. Females age 0 to 5 tended to have greater percentages of antidepressant and/or antianxiety medications, as well as CNS stimulants, than their male peers. Urban females and males from this age group had higher percentages of antipsychotic medication and/or bipolar medication than their rural counterparts. Urban females had greater percentages of antipsychotics than their rural peers, but rural females in this age group had greater percentages of antidepressant and/or antianxiety medications, as well as CNS stimulants, than their urban peers. A similar trend exists comparing urban and rural males in this age range, although CNS stimulant percentages were similar between these two groups. Overall, males ages 6 to 11 had a smaller percent of antipsychotic and/or bipolar medications, as well as antidepressants and/or antianxiety medications, but a far greater percent of CNS stimulants, than females of the same age. Additionally, rural females had a notably greater percent of CNS stimulants than their urban female counterparts. On average, males ages 12 to 17 had a greater percent of antipsychotic and/or bipolar medications, smaller percent of antidepressants and/or antianxiety medications, and a far greater percent of CNS stimulants, than their female counterparts. Urban females had higher percentages of antipsychotic and/or bipolar medications, as well as CNS stimulants, than their rural female peers. Literature Citations  

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Prescription of psychotropic drugs in adolescent psychiatry wards in Finland. Nordic Journal of Psychiatry, 58(3): 213-218. 17 Coyle, JT (2000). Psychotropic drug use in very young children. Journal of the American Medical Association, 18 DelBello MO; Soutullo CA; Strakowski SM (2000). Racial differences in treatment of adolescents with bipolar disorder. American Journal of Psychiatry, 157(5): 837-838. 19 Patel NC; DelBello MP; Keck P; Strakowski SM (2005). Ethnic differences in maintenance antipsychotic prescription among adolescents with bipolar disorder. Journal of Child and Adolescent Psychopharmacology, 15(6): 938-946. 20 Cummings NA; Wiggins JG (2001). A collaborative primary care/behavioral health model for the use of psychotropic medication with children and adolescents: The report of a national retrospective study. Issues in Interdisciplinary Care, 3(2): 121-128. 21 Irwin CE Jr. [Ed] (2005). Editorial: Clinical preventive services for adolescents: Still a long way to go. Journal of 22 Rappaport N; Chubinsky P. (2000). The meaning of psychotropic medications for children, adolescents, and their families. Journal of the American Academy of Child & Adolescent Psychiatry, 39(9): 1198-1200. 23 Walkup JT (2003). Increasing use of psychotropic medications in children and adolescents: What does it mean? Journal of Child and Adolescent Psychopharmacology, 13(1): 1-3. The WICHE Center for Rural Mental Health Research was established in 2004 to develop and disseminate scientific knowledge that can be readily applied to improve the use, quality, and outcomes of mental health care provided to rural populations. As a General Rural Health Research Center in the Office of Rural Health Policy, the WICHE center is supported by the Federal Office of Rural health Policy, Health Resources and Services Administration (HRSA), Public Health Services, grant number U1CRH03713. The WICHE Center selected mental health as its area of concentration because: (1) although the prevalence and entry into care for mental health problems is generally comparable in rural and urban populations, the care that rural patients receive for mental health problems may be of poorer quality, particularly for residents in outlying rural areas and (2) efforts to ensure that rural patients receive similar quality care to their urban counterparts generally requires restructuring treatment delivery models to address the unique problems rural delivery settings face. Within mental health, the Center proposes to conduct the research development/dissemination efforts needed to ensure rural populations receive high quality depression care. Within mental health, the Center will concentrate on depression because: (1) depression is one of the most prevalent and impairing mental health conditions in both rural and urban populations, (2) most depressed patients fail to receive high quality care when they enter rural or urban treatment delivery systems, (3) outlying rural patients are more likely to receive poorer quality care than their urban counterparts, (4) urban team settings are adopting new evidence-based care models to assure that depressed patients receive high quality care for the condition that will increase the rural-urban quality chasm even further, and (5) urban care models can and need to be refined for delivery to rural populations. The WICHE Center is based at the Western Interstate Commission for Higher Education. For more information about the Center and its publications, please contact: WICHE Center for Rural Mental Health Research 3035 Center Green Drive Boulder, CO 80301 Phone: (303) 541-0311 Fax: (303) 541-0230 http://wiche.edu/wicheCenter The WICHE Center for Rural Mental Health Research is one of seven Rural Health Research Centers supported by the Federal Office of Rural Health Policy (ORHP), Grant No. 1 U1CRH03713-01. This project is funded by ORHP, Health Resources and Services Administration, U.S. Department of Health and Human Services. The specific content of this paper is the sole responsibility of the authors.

Source: http://www.wiche.edu/info/publications/AdamsWorkingPaperYr4Proj2.pdf