Copyright © eContent Management Pty Ltd. Health Sociology Review (2011) 20(2): 202–218.

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Medicalisation or under-treatment? Psychotropic medication use by

elderly people in New Zealand

Pauline NorrisSchool of Pharmacy, University of Otago, Dunedin, New Zealand

Simon HorsburghDepartment of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand

Kirsten LovelockSchool of Pharmacy, University of Otago, Dunedin, New Zealand

Gordon BecketPharmacy and Pharmaceutical Sciences, University of Central Lancashire, Preston, UK

Shirley KeownSchool of Pharmacy, University of Otago, Dunedin, New Zealand

Bruce ArrollDepartment of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand

Jackie CummingHealth Services Research Centre, Victoria University, Wellington, New Zealand

Peter HerbisonDepartment of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand

Peter CramptonWellington School of Medicine and Health Sciences, University of Otago, Dunedin, New Zealand

ABSTRACTThe increased use of information technology in health care allows researchers to generate data on rates of med-ication use among population groups, raising questions as to whether these rates are too high or too low. This paper presents fi ndings from a study of records of all prescription medication dispensed in one New Zealand region (Te Tairawhiti) over a one year period. The study examined patterns of psychotropic medication use amongst older people, by age, gender, ethnicity and socio-economic position. It concludes that the chances of being defi ned as needing psychotropic medication, that is, of being ‘medicalised’, are not evenly spread through the elderly population. Gender, age and ethnicity impacted signifi cantly on whether prescriptions were received. Our results suggest the need for a nuanced understanding of the medicalisation of unhappiness and deviant behaviour amongst the elderly which takes into account barriers to treatment for some social groups.

Keywords: sociology; medicalisation; health care inequalities; New Zealand; psychotropic medication; ethnicity

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2006). Conrad (2007) suggests that medicalisa-tion is a not a pejorative term because it does not indicate whether a phenomenon is ‘really’ a medical problem or not. However, others (Illich 1976; Mintzes 2002) view medicalisation as a negative process, by which problems that are ‘really’ social in origin, or related to normal age-ing processes such as male pattern baldness are inappropriately defi ned as medical problems. Authors who write about ‘disease mongering’ (Moynihan and Henry 2006; Moynihan et al. 2002; Tiefer 2006), also regard this as a negative process, the result of pharmaceutical company strategies to increase their markets. By creating new medical conditions such as female sexual dysfunction companies can create large markets in developed countries for new treatments, or can expand markets for previously existing products. For disease-mongering theorists, the pharmaceu-tical industry is the main driver of medicalisation, whereas for Conrad, drivers also include a range of groups such as patient groups. He argues, for example, that in the case of alcoholism, patient groups such as Alcoholics Anonymous were the key proponents of medicalisation (Conrad 2005).

Both views point to the importance of under-standing the structural aspects of medicalisation, particularly the power that both the medical profession and pharmaceutical companies exert to shape understandings of what should or needs to be treated. However, while emphasis is often placed on the force of capitalist entrepreneur-ship which underpins the development and sale of medications, it is equally important to under-stand the socio-cultural factors that might assist or impede this process.

Riska (2003) has drawn attention to the gendered nature of medicalisation, arguing that female bodies have been the main focus of medicalisation. Others have noted the medicalisation of reproduction (menstruation, conception, pregnancy, birth and menopause; Kaufert and Gilbert 1986; Simoni-Wastila 2000; Weisz and Knaapen 2009). But Conrad (2007) notes that male conditions, such as

Introduction

The prescription of medication is an extremely common treatment modality (Crengle et al.

2005; Straand et al. 1998). Prescription medica-tion accounts for high levels of expenditure and expenditure growth in most countries (Morgan et al. 2005; Okunade and Suraratdecha 2006; PHARMAC 2010). Yet surprisingly little is known about patterns of medication use in the community. The increasing use of information technology in health systems now allows research-ers to generate data on rates of use amongst popu-lation groups and raise important questions about how these should be interpreted. The absence of consensus on the ideal rate of prescribing for most, if not all, medications leaves the results of drug utilisation studies open to a wide range of expla-nations. It is unlikely that a stable consensus will be reached about the appropriate rate of prescrip-tion of medication because there is almost always debate about what level of severity of illness or risk factors requires pharmacological treatment. Furthermore, co-morbidities make the ‘ideal rate’ of prescribing even more diffi cult to defi ne.

In this paper we present results from our study of patterns of psychotropic medication use amongst elderly people in a region of New Zealand, and suggest different ways in which this data could be interpreted. The key question is how much psychotropic medication is too much, and how much is too little? We outline two dis-courses, both of which we argue are important for interpreting patterns of medication use.

Medicalisation, disease-mongering and over-use of psychotropic medicationHealth sociologists work from the concept of medicalisation to interpret the social processes by which non-pathological problems come to be understood and treated as medical conditions (Conrad 2005, 2007; Conrad and Leiter 2004). Where treatment for these conditions involves the prescription of medication, the term phar-maceuticalisation is used (Dumit and Greenslit

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work relates primarily to non-elderly women. However Russell (1987) explicitly linked the conditions of elderly women’s lives to their high rate of psychotropic medicine use. Elderly people’s experiences put them at risk of unhappiness, stigmatisation and subsequent mental health problems. These experiences can include bereavement, loss of a socially-valued role, social isolation, loneliness and boredom as well as physical health problems and disabilities (Kivela et al. 1996; Prince et al. 1997).

The extensive prescription of psychotropic drugs to solve problems experienced by the elderly can be criticised as an individualistic response to the social conditions that generate mental health symptoms. Rather than address-ing or ameliorating these conditions, prescribed medications may reduce elderly people’s ability to respond to them. Moreover, the prescription of medications may commodify the suffering of elderly people, as it might legitimise the diag-nosed condition as well as giving community sanction to the enterprise and profi ts of the pharmaceutical industry and associated health-care providers.

Like other medications, psychotropic drugs carry the risk of adverse reactions and, for bio-logical reasons such as decreased kidney and liver function, elderly people are at high risk of experiencing adverse reactions (Stein 1998). This risk is heightened for those who consume large numbers of medications. While the elderly in general have high levels of medication use there is some variation internationally. In the United States high rates of use are common in nursing homes,1 yet in Ireland and the United Kingdom rates of use are generally lower in these settings (Martins et al. 2006; Nolan and O’Mally 1989). Various surveys conducted in several countries demonstrate that the use of tranquillisers and sleeping pills are higher amongst women and the elderly and that they are typically used long term. Long-term use is of particular concern

erectile dysfunction have increasingly become the focus of medicalisation.

There has been a dramatic increase in the amount of medication consumed in the Western world in the last few decades (Pharmaceutical Research and Manufacturers of America 2003). Martin (2006) coined the term ‘pharmaceutical person’ to illustrate the extent to which phar-maceuticals have become an integral part of everyday life and personal identity. Women and the elderly are overrepresented in studies show-ing high levels of medication use (Isacson and Haglund 1988; Murray et al. 1982; Vuckovic and Nichter 1997). A recent New Zealand study found that people over 75 living in the community took an average of 7.5 prescription medications and 1.1 non-prescription medi-cines per day (Tordoff et al. 2010). These results included the use of all medications, not specifi -cally psychotropics.

A signifi cant proportion of medication use is for mental health problems. Psychiatry is currently dominated by biological models of mental health problems which are often con-ceptualised as the result of chemical defi cit or imbalance in the brain. Pharmaceuticals seem the obvious solution to these defi cits or imbalances (Cohen 1993). Prescription of psy-chotropic medications has become the pre-dominant response to mental health problems. Whether or not individual prescribers adhere to biological models, they may still see med-ications as the only feasible response to such problems. Feminist authors have analysed the gendered advertising of psychotropic drugs and the infl uence of stereotypical views of women on prescribing (Cooperstock 1976; Herzberg 2006; Rubin 2004). Feminist critiques drew attention to the way in which social problems, such as women dissatisfi ed with the social con-straints on their lives, were being re-framed as individual defi cits, for which psychotropic drugs were the solution. Much of this feminist

1 The term used for residential care for the elderly in New Zealand, and therefore in this paper, is ‘rest home’.

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2002). While genetic differences may partially account for these outcomes, differential access to care or treatment within the health system for ethnic minorities is commonly found (Cass et al. 2003; Jha et al. 2003; Peterson et al. 1997). Similarly, low ulitisation of medication in some groups may be part of a wider pattern of lack of access to, or less optimal interactions with, the health system.

Our study aimed to explore social patterns of use of psychotropic medications in one region of New Zealand: Te Tairawhiti. This region is an area of particularly high socio-economic depri-vation. Around 65 percent of the region’s 45,000 residents live in areas of high deprivation (deciles 8–10 of the New Zealand Deprivation Index; Tairawhiti District Health Board 2010). The median income for people in Te Tairawhiti dur-ing 2006 was $20,600 per year, compared to the national median of $24,400. Nearly 34 percent of the area’s residents had no formal educational qualifi cation, compared to the overall level of 25 percent for New Zealand. Te Tairawhiti has a high proportion of Maori residents (47 per-cent compared to 15 percent for New Zealand in 2006). The median age in Te Tairawhiti was similar to New Zealand as a whole at around 35 years, with 12 percent of the population aged 65 years or over (Statistics New Zealand 2006). Given the high level of deprivation, it is unsur-prising that Te Tairawhiti has one of the worst health profi les in New Zealand. In 2006, the age standardised mortality rate for Te Tairawhiti was substantially higher than for any other area (Ministry of Health 2009).

Demographic variables affect medical pre-scribing patterns. For example, some medica-tions are not suitable for some age groups. Our research aimed to investigate whether patterns of prescribing matched patterns of need for medications. Following the presentation of data through a series of graphs, we discuss our results in light of the two different approaches outlined above, that is, through the concepts of over-use or medicalisation and under-use.

given that drug treatment for insomnia should be episodic rather than continuous (Graham and Vidal-Zeballos 1998).

One approach to understanding levels of psychotropic medication use in the elderly is to interpret widespread use as over-use and as the result of medicalisation. But it is also possible that under-use of medication can be experienced by some groups of elderly people, particularly those in socio-economically deprived areas.

Inequalities in healthcare and ‘under-treatment’Inequalities in health status by socio-economic position and by ethnicity have been well- documented in many countries (Braverman 2006; Eames et al. 1993; Marmot 2007; Wagstaff 2002). In New Zealand, there are clear differ-ences in health status by socio-economic posi-tion (Blakely et al. 2005), and between Maori (the indigenous people) and Pakeha (New Zealanders of European descent; Ajwani et al. 2003; Robson and Harris 2007).

While many causes of health inequalities lie outside the health system (such as poor housing, lack of access to nutritious food, and exposure to work-related accidents), there is increasing evidence that healthcare itself plays an important role in reinforcing and exacerbating inequalities. For example, one New Zealand study showed that although Maori people are slightly more likely to get cancer than Pakeha (9 percent differ-ence after standardising for age and sex), they are much more likely (77 percent) than Pakeha to die from cancer (Robson et al. 2006). This dis-parity is frequently blamed on late diagnosis, but Robson et al. (2006) demonstrate that the differ-ence in survival persists after data are adjusted for stage of diagnosis. Such fi ndings imply that inter-actions with the healthcare system may actu-ally exacerbate inequalities in cancer outcomes. Studies from other countries show similar pat-terns. For example, black women in the USA are less likely to get breast cancer than white women but are more likely to die from it (Newman et al.

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(85 percent) received at least one medication in the study period (Horsburgh et al. 2010).

Ethnicity, age and gender were determined by matching patient identifi cation numbers on prescriptions to data in a national dataset. Socio-economic position was ascertained by match-ing addresses in the pharmacy databases with an area measure of socio-economic deprivation (NZDep2006; Salmond et al. 2007). NZDep combines variables from the New Zealand Census into a single measure of deprivation. The vari-ables relate to the numbers of people receiving a means tested benefi t, numbers unemployed, numbers lacking formal educational qualifi cations, household income below a threshold (adjusted for household composition), number of people per bedroom, home ownership, single parent families, telephone access, and access to a car. It should be emphasised that this is an area measure rather than an individual measure. Throughout the paper we have described areas of high socio-economic depri-vation as ‘most deprived’, and areas of low socio-economic deprivation as ‘least deprived’. Where a person had several different addresses recorded in the pharmacy databases, the area deprivation scores for each of those addresses were obtained and then averaged to create a single score. People who had a rest home or residential care institution recorded as an address on their pharmacy records were coded as rest home residents.

Medications were classifi ed using the ATC system. All drugs in the N category were included, except for anaesthetics (N01) and analgesics (N02). This means the following drug groups were included: antiepileptics (N03) anti-Parkinson drugs, (N04) antipsychotics (N05A), anxiolytics (N05B), hypnotics and sedatives (N05C), antidepressants (N06A), psychostimu-lants (N06B), anti-dementia drugs (N06D) and a miscellaneous set of other nervous system drugs (N07). Antiepileptics, anti-Parkinson drugs and anti-dementia drugs were used less frequently

MethodsWe obtained records of all prescription medica-tions dispensed in one New Zealand region, Te Tairawhiti, which has one main city Gisborne, over a one year period. The population of Te Tairawhiti was 44,460 at the time of the study.

The region was chosen because it fi tted sev-eral criteria: geographic isolation, ethnic mix, and a limited number of pharmacies. The region’s major city, Gisborne, is the only place within the region with pharmacies, and anywhere else in the region is more than an hour’s drive to a pharmacy other than those in Gisborne. Thus we assumed that very few people in the region would ever travel to a pharmacy, other than those in Gisborne, to pick up prescription medication and we could therefore capture a very nearly com-plete set of all prescription medications used by the inhabitants of the region. The high propor-tion of Maori in the region (47 percent) meant that meaningful comparisons could be made by ethnicity. Almost all of the rest of the population (referred to as non-Maori in this paper) are New Zealanders of European descent (53 percent).

Gisborne had enough community pharmacies (8) to reduce pharmacists’ concerns about com-mercial consequences of providing us with their dispensing information. Consent was obtained from the appropriate ethics committee,2 the Pharmacy Guild, and the local pharmacy own-ers, subject to strict privacy provisions. A local advisory group was formed to assist in interpre-tation of data. The fi rst two authors and GB vis-ited the pharmacies and downloaded dispensing data for the 12 month period between October 2005 and September 2006.

Records of 619,624 prescriptions to indi-vidually identifi able Te Tairawhiti residents were obtained. Probabilistic matching was used to identify and link records of individuals who had prescriptions fi lled at more than one phar-macy. Overall, 38,027 Te Tairawhiti residents

2 Ethical approval was granted by the Northern X ethics committee, and the study was funded by the Health Research Council of New Zealand.

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ResultsTable 1 presents demographic data on people over 65 in Te Tairawhiti, and those within the study.

Dispensing patterns by age: People 65 years or olderThirty-four percent of people over 65 were dis-pensed one or more psychotropic medications within the study year. The most commonly taken group were antidepressants, followed by hypnotics and sedatives, antipsychotics and anx-iolytics (Table 2).

Dispensing patterns by gender: People 65 years or olderFemales were more likely to be dispensed all cate-gories of psychotropic drugs except anti- epileptics, anti-Parkinson, and anti-dementia drugs. After adjusting for age, ratios changed slightly, but the general pattern held. Age-adjusted ratios for males and females are presented in Table 3.

and are less commonly the subject of debates about medicalisation, so the results and discus-sion in this paper focus on the other medication groups.

Period prevalences of medication use for the study year were calculated using the popula-tion counts obtained from 2006 Census data as the denominator. A person was included in the numerator if they were prescribed one or more medications during the study year. The 65 and over age group was stratifi ed further into three groups: 65–74, 75–84 and 85+. Direct stan-dardisation was used to adjust the prevalences for the 65 and over age group using these stratifi ed groupings, since there were substantial differ-ences in the age structures between ethnic and gender groups. The total Maori population for the region was used as the standard population, as recommended by Robson et al. (2007).

Further details about the study methods are available in Horsburgh et al. (2010).

Table 1: Study and Te Tairawhiti population demographics for people aged 65 years and over (N = 1760 and 5337 respectively)

Number of People in Number of people People in Te people in study study (%) in Te Tairawhiti Tairawhiti (%)

Age 65–74 762 43.3 2916 54.6 75–84 700 39.8 1836 34.4 85+ 298 16.9 585 11.0

Gender Female 1116 63.4 3003 43.7 Male 619 35.2 2334 56.3

Ethnicity Maori 219 12.4 1173 22.0 Non-Maori 1500 85.2 3852 72.2

Socio-economic deprivation Least 345 19.6 969 18.2 Mid 629 35.7 1635 30.6 Most 732 41.6 2742 51.4

Rest home* Yes 266 15.1 390 7.5 No 1494 84.1 4827 92.5

* Rest home population for Te Tairawhiti estimated based on addresses in Pharmacy databases and assumption that all rest home residents will receive at least one prescribed medication while there. Source: Customised Census 2006 data request from Statistics New Zealand.

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Table 2: Frequency and prevalence of psychotropic medicine use in people 65 and over by therapeutic group (N = 1760)

Therapeutic Number of Prevalence group (ATC) people (n) (%)

Antiepileptics (N03) 223 4

Anti-Parkinsons (N04) 77 1

Antipsychotics (N05A) 484 9

Anxiolytics (N05B) 336 6

Hypnotics and sedatives 571 11(N05C)

Antidepressants (N06A) 869 16

Psychostimulants (N06B) 3 0

Anti-dementias (N06D) 29 1

Other nervous system 102 2drugs (N07)

All psychotropics 1760 33

Dispensing patterns by age: Sub-categories of people 65 years or olderDispensing of the four most frequently pre-scribed/dispensed categories of psychotropics

(antipsychotics, anxiolytics, hypnotics and seda-tives, antidepressants) and psychotropic medi-cations as a whole increased with age for both women and men (Figures 1 and 2). In the young-est age group (65–74), 32 percent of women and 20 percent of men were dispensed a psychotropic medication, but this increased to 56 percent of women and 49 percent of men in the oldest age group (85 and older). The dispensing of antipsy-chotics, antidepressants and hypnotics and seda-tives increased markedly with age.

Dispensing patterns by socio-economic position: People 65 years or olderPeople living in the most deprived socio- economic areas had lower levels of use (26 percent) of psy-chotropics than people in other areas (34 per-cent for the middle group and 34 percent for the least deprived). Figure 3 shows age-adjusted rates by socio-economic position. The dispensing of antiepileptics, anti-Parkinson drugs, and anti-dementia drugs did not vary substantially by socio-economic position. However the dispensing

Table 3: Frequency, prevalences (crude and age-adjusted) and gender ratios (using age-adjusted prevalences) of psychotropic medicine use in people 65 and over, by therapeutic group and gender

Therapeutic group (ATC) Females Males

n Prevalence Age-adjusted n Prevalence Age-adjusted

Ratio

(%) prevalence (%) prevalence

females

(%) (%)

to males

Antiepileptics (N03) 118 4 4 101 4 4 0.87

Anti-Parkinsons (N04) 42 1 1 34 1 1 0.93

Antipsychotics (N05A) 305 10 9 168 7 7 1.34

Anxiolytics (N05B) 229 8 7 104 4 4 1.69

Hypnotics and sedatives 381 13 12 179 8 7 1.64(N05C)

Antidepressants (N06A) 557 19 17 287 13 12 1.47

Psychostimulants (N06B) 0 0 0 3 0 0 0.00

Anti-dementias (N06D) 16 1 0 13 1 0 0.87

Other nervous system 58 2 2 44 2 2 1.04drugs (N07)

All psychotropics 1116 37 34 619 27 25 1.38

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0%

10%

20%

30%

40%

50%

60%

65-74 75-84 85+

Una

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Prev

alen

ce (%

)

Age Group

An�psycho�cs (N05A)

Anxioly�cs (N05B)

Hypno�cs and seda�ves (N05C)

An�depressants (N06A)

All psychotropics

Figure 1: Prevalence of psychotropic use in females aged 65 and over, by therapeutic and age group

0%

10%

20%

30%

40%

50%

65-74 75-84 85+

Una

djus

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)

Age Group

An�psycho�cs (N05A)

Anxioly�cs (N05B)

Hypno�cs and seda�ves (N05C)

An�depressants (N06A)

All psychotropics

Figure 2: Prevalence of psychotropic use in males aged 65 and over, by therapeutic and age group

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non-Maori had higher rates of dispensing than urban Maori. This was also repeated with pre-scriptions for antidepressants, hypnotics and sed-atives, anxiolytics and antipsychotics (Table 4).

Dispensing patterns by residence in rest homesElderly people residing in rest homes were more likely to be dispensed psychotropic medications than elderly people not residing in rest homes. Elderly non-Maori were more likely to live in rest homes (9 percent) than elderly Maori (3 per-cent), so rest home residence accounts for some of the differences in overall prevalence between Maori and non-Maori. However, amongst those not living in rest homes, Maori were less likely to take psychotropic medications (Figures 5 and 6).

DiscussionAbout a third of the population over 65 years were dispensed one or more psychotropic medication within the study year. Use was higher for women, and increased substantially with age. Most people over 85 were taking at least one psychotropic drug. People living in the most deprived areas

of antipsychotics increased steadily with socio- economic position (7 percent for most deprived, 9 percent for the middle group and 10 percent for least deprived). Other drug groups showed a more complex pattern, but in all cases levels for those in the most deprived areas were low.

Dispensing patterns by ethnicity: People 65 years or olderMaori were less likely than non-Maori to be dispensed psychotropic drugs. Rates of use of antipsychotics, anxiolytics, hypnotics and seda-tives, and antidepressants were strikingly lower for Maori (6 percent versus 9 percent, 2 percent versus 7 percent; 5 percent versus 12 percent, 8 percent versus 19 percent respectively). Within each ethnicity, use was higher for females than males (Figure 4).

Dispensing patterns by residential location: People 65 years or olderFor both Maori and non-Maori elderly people, the rate of dispensing was lower in rural areas than in urban areas, except for hypnotics and sedatives. For psychotropics as a whole even rural

0%

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30%

40%

Most Mid Least

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(%)

Socioeconomic Depriva�on

An�psycho�cs (N05A)

Anxioly�cs (N05B)

Hypno�cs and seda�ves (N05C)

An�depressants (N06A)

All psychotropics

Figure 3: Age-adjusted prevalence of psychotropic medicine use in people aged 65 and over, by therapeutic group and socio-economic deprivation

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0%

10%

20%

30%

40%

An�psycho�cs (N05A)

Anxioly�cs (N05B)

Hypno�cs and seda�ves (N05C)

An�depressants (N06A)

Allpsychotropics

Age

-Adj

uste

d Pr

eval

ence

(%)

Therapeu�c Group

non-Māori

Māori

Figure 4: Age-adjusted prevalence of psychotropic medicine use in people aged 65 and over, by therapeutic group and ethnicity

were less likely to be taking psychotropics, and there were striking differences between Maori and non-Maori. Elderly Maori were much less likely to be taking psychotropic medications than elderly non-Maori. We will argue that both med-icalisation and inequality discourses are relevant to understanding these patterns.

It should be noted that the study looked at dispensed medications, not medications that are actually consumed. Some people may collect their medications from the pharmacy but never take them (or do so sporadically), so consump-tion rates may be lower than dispensing rates. Information about the use of non-prescription medications such as fi sh oils and St John’s Wort which are often used for mental health symp-toms was not captured in the study.

The level of use of psychotropics amongst the elderly seems particularly high and raises

concerns about over-prescribing. These con-cerns, however, are not new. Very high levels of use were reported in earlier studies published in the 1970s (Cooperstock 1976; Skegg et al. 1977). In comparing data from these 1970s stud-ies with this study, there seems to have been a marked decrease in the consumption of hypnotics and sedatives in the general population since the 1970s, suggesting the de-medicalisation of sleep-ing problems and anxiety.

Our results suggest that, within each of the age groups studied, the chances of being defi ned as needing psychotropic medications, that is, being ‘medicalised’, are not evenly spread across the population. Gender, age and ethnicity had a signifi cant infl uence on whether prescrip-tions were received. It appears that diagnoses that lead to prescribing in the elderly seem to be gendered; higher levels of use of psychotropics

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Tab

le 4

: Fre

que

ncy

and

ag

e-ad

just

ed p

reva

lenc

es o

f psy

cho

tro

pic

med

icin

e us

e in

peo

ple

65

and

ove

r by

ther

apeu

tic g

roup

, eth

nici

ty a

nd re

sid

entia

l lo

catio

n

The

rap

euti

c g

roup

(AT

C)

No

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ao

ri

Ma

ori

O

vera

ll

R

ural

U

rban

R

ural

U

rban

R

ural

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sted

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sted

adju

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adju

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p

reva

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pre

vale

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pre

vale

nce

pre

vale

nce

pre

vale

nce

pre

vale

nce

(%)

(%

)

(%)

(%

)

(%)

(%

)

Ant

iep

ilep

tics

(N03

) 14

3

154

4 11

2

26

4 25

3

186

4

Ant

i-P

arki

nson

s (N

04)

6 1

56

1 4

1 4

1 10

1

61

1

Ant

ipsy

chot

ics

(N05

A)

32

8 35

6 9

14

3 42

6

46

5 41

4 8

Anx

ioly

tics

(N05

B)

24

6 28

0 7

3 1

17

2 27

3

301

6

Hyp

notic

s an

d s

edat

ives

49

12

44

0 11

19

4

32

5 69

7

488

10(N

05C

)

Ant

idep

ress

ants

(N06

A)

55

13

677

18

17

3 59

9

72

7 75

0 16

Psy

chos

timul

ants

(N06

B)

0 0

3 0

0 0

0 0

0 0

3 0

Ant

i-d

emen

tias

(N06

D)

0 0

23

1 1

0 1

0 1

0 24

0

Oth

er n

ervo

us s

yste

m

13

3 70

2

2 0

11

2 15

2

82

2d

rugs

(N07

)

All

psy

chot

rop

ics

129

31

1325

35

52

11

14

1 21

18

2 19

15

04

32

Not

e th

at t

he o

vera

ll co

lum

n in

clud

es p

eop

le w

hose

eth

nici

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in elderly women compared with elderly men have also been reported in other studies (Aparasu et al. 2003).

The National Medical Care study also found lower rates of prescribing of antidepressants to Maori compared with non-Maori patients

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appropriate to the communities they served. Before this study was carried out, lower fees for GP visits and for prescriptions had been introduced in Te Tairawhiti. However even though many Maori were eligible for lower cost prescriptions before the changes, Maori were more likely than Pakeha to report not picking up prescribed medication because of cost (Jatrana et al. 2010). Research also suggests that not having a car is a barrier to care for many rural Maori (Rameka 2006).

Other barriers to access may exist in the consultation process. It seems likely that Maori patients feel less comfortable reporting mental health symptoms to their doctors, and GPs may be less likely to ask about symptoms or to pick up on patient cues. The National Primary Medical Care Survey found that Maori people’s visits to GPs tended to be shorter, and GPs reported feel-ing less rapport with Maori patients (Crengle et al. 2005). Pakeha doctors may not feel comfortable discussing mental health problems with Maori patients, because the patients may have very dif-ferent world-views and may tend to ascribe their mental health problems to causes outside the doctor’s experience, such as breaches of cultural practices. A re-analysis of the National Primary Medical Care Survey found Maori patients were much less likely to be diagnosed with depression. The diagnosis rate for depression as a percentage of all visits and all ages was 0.7 percent for Maori men, 2.8 percent for non-Maori men, 3.1 percent for Maori women and 4.5 percent for non-Maori women (Thomas et al. 2010). This difference in medical diagnosis is likely to account in large part for our survey’s reporting of lower prescribing rates for antidepressants among Maori.

Commencing in 2004, the Ministry of Health funded 26 Primary Mental Health Initiatives that aimed to increase the role of general practice in responding to mental health problems in the community, particularly among patients with mild to moderate problems. High needs groups, such as Maori were to be a particular focus of these services. Although the services were very successful in improving outcomes for users, few

(Crengle et al. 2005).There are many possible explanations for low rates of use of psychotro-pic medications amongst Maori. These low rates might be due to the different incidence of men-tal health symptoms, barriers to access to general practitioner (GP) consultations and to prescrip-tion medications, lower tendency to mention mental health symptoms in consultations with GPs, lower tendency for GPs to notice and discuss symptoms mentioned, or to ask about symptoms, and GPs making different prescribing decisions for Maori patients. Perhaps Maori are less likely to interpret undesirable mental health states as symptoms of illness, or they may have a particu-lar aversion to accepting pharmaceutical solutions for mental health problems. Some evidence exists which can shed light on these possibilities. We go on to discuss this evidence in the following para-graphs but we point out that conclusions about these patterns are beyond the scope of this study.

First, it is unlikely that the low levels of pre-scribing for Maori is due to lower rates of mental health symptoms. Evidence suggests that Maori have higher rates of serious mental health prob-lems resulting in admissions to acute psychiatric in-patient care (Wheeler et al. 2005). Te Rau Hinengaro: The New Zealand National Mental Health Survey, which used a variety of screen-ing tools to determine the incidence of men-tal health problems in the community, found much higher rates of mental health problems amongst Maori than Pakeha (Oakley-Browne et al. 2006). Furthermore, the 12-month preva-lence of any disorder amongst those over 65 was higher for Maori than for the sample as a whole.

Second, lack of access to treatment is highly likely to be part of the explanation for the low rates of psychotropic use amongst Maori despite their higher rate of mental health problems. Recently, considerable resources have been put into reduc-ing patient fees in New Zealand, as part of the Primary Health Care Reforms (King 2001). These reforms also led to the development of Primary Care Organisations, in which a range of providers (as well as GPs) were intended to deliver services

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We believe that discourses of ‘over-use’ and ‘under-use’ are important in interpreting these patterns of medication use. On-going public discussion is needed about the level and extent of prescribing of psychotropic medications in the elderly: is this really the best way to deal with the problems of ageing? Attention needs to be paid to social conditions that increase the risk of mental health problems. At the same time, the focus needs to be on inequalities in access to, and outcomes of, health care. Even if we think that psychotropics are over-prescribed, the difference in utilisation between people, depending on their deprivation level or ethnic-ity, is evidence of unacceptable differences in access to healthcare or unacceptable differences in the way people are treated by health care practitioners.

Further quantitative research is needed to explore whether the patterns found in this study are also found in other regions. Qualitative research is needed to understand how elderly people come to see, or be told, that their unhap-piness or other feelings are symptoms of mental health problems, and how this varies by ethnic-ity and deprivation.

AcknowledgementsThe authors would like to thank the Health Research Council of New Zealand for funding the study, the pharmacists in Gisborne for allow-ing us access to data, Ngati Porou Hauora and our local advisory group in Gisborne.

ReferencesAjwani, S.; Blakely, T.; Robson, B.; Tobias, M.;

and Bonne, M. (2003) Decades of disparity: Ethnic mortality trends in New Zealand 1980-1999 Ministry of Health and University of Otago: Wellington.

Aparasu, R. R.; Mort, J. R.; and Brandt, H. (2003) ‘Psychotropic prescription use by community-dwelling elderly in the United States’ Journal of the American Geriatric Society 51:671–677.

services were provided to those over 65 years of age (Dowell et al. 2009).

Different prescribing practices for Maori patients have also been reported in other stud-ies. Wheeler et al. (2008) found differences in the prescribing of antipsychotics by ethnicity in her study of community-based treatment of schizophrenia. Maori tended to be prescribed higher doses and more use of depot (long-acting, injection-based) rather than oral fi rst-generation antipsychotics (Wheeler et al. 2008). This might be due to GPs believing that Maori patients will be less compliant with prescriptions for mental health problems, although we know of no evi-dence to support this.

Te Rau Hinengaro also found lower rates of contact with health services for mental health reasons amongst Maori (Oakley-Browne et al. 2006). This supports the contention that Maori may be less likely to consult healthcare practi-tioners for assistance with mental health prob-lems. Overall, it can be argued that Maori may not have accepted the medicalisation of mental health symptoms to the same degree as non-Maori, and may be less likely to interpret problems of mood, thinking and behaviour as medical problems requiring GP visits and medication.

ConclusionOur results suggest the need for a nuanced understanding of the medicalisation of unhappi-ness and deviant behaviour amongst the elderly. Viewed from the point of medicalisation, our results suggest that mental health symptoms in non-Maori, the very elderly, and women have been medicalised to a considerable degree.

From the point of view of inequalities in healthcare, it appears that Maori and people liv-ing in the most deprived areas are missing out on treatments for mental health problems. There is some evidence that people from these groups suffer higher rates of mental health problems, but fi nancial and other barriers appear to be prevent-ing them from accessing effective treatments.

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(1985-1991): The relationship with gender, age and use of other substances’ Social Science and Medicine 46(3):381–395.

Herzberg, D. (2006) ‘“The pill you love can turn on you”: Feminism, tranquilizers, and the valium panic of the 1970s’ American Quarterly 58(1):79–103.

Horsburgh, S.; Norris, P.; Becket, G.; Crampton, P.; Arroll, B.; Cumming, J.; Herbison, P.; and Sides, G. (2010) ‘The equity in prescriptions medicines use study: Using community phar-macy databases to study medicines utilisation’ Journal of Biomedical Informatics 43(6):982–987.

Illich, I. (1976) Medical nemesis Pantheon: New York.

Isacson, D.; and Haglund, B. (1988) ‘Psychotropic drug use in a Swedish community: The importance of demographic and socioeco-nomic factors’ Social Science and Medicine 26(4):477–483.

Jatrana, S.; Crampton, P.; and Norris, P. (2010) ‘Ethnic differences in access to prescription medication because of cost in New Zealand’ Journal of Epidemiology and Community Health doi:10.1136/jech.2009.099101

Jha, A. K.; Varosy, P. D.; Kanaya, A. M.; Hunninghake, D. B.; Hlatky, M. A.; Waters, D. D.; Furberg, C. D.; and Shlipak, M. G. (2003) ‘Differences in medical care and disease outcomes among black and white women with heart disease’ Circulation 108(9):1089–1094.

Kaufert, P.; and Gilbert, P. (1986) ‘The context of menopause: Psychotropic drug use and menopausal status’ Social Science and Medicine 23(8):747–755.

King, A. (2001) The Primary Health Care Strategy Ministry of Health: Wellington.

Kivela, S.; Kongas-Saviaro, P.; Laippala, P.; Pahkala, K.; and Kesti, E. (1996) ‘Social and psychosocial factors predicting depression in old age: A longitudinal study’ International Psychogeriatrics 8(4):635–644.

Marmot, M. (2007) ‘Achieving health equity: From root causes to fair outcome’ The Lancet 370(9593):1153.

Martin, E. (2006) ‘The pharmaceutical person’ Biosocieties 1(3):273–287.

Blakely, T.; Fawcett, J.; Atkinson, J.; Tobias, M.; and Cheung, J. (2005) Decades of disparity II: Socioeconomic mortality trends in New Zealand, 1981–1999 Ministry of Health: Wellington.

Braverman, P. (2006) ‘Health disparities and health equity: Concepts and measurement’ Annual Review of Public Health 27:167–194.

Cass, A.; Cunningham, J.; Snelling, P.; Wang, Z.; and Hoy, W. (2003) ‘Renal transplanta-tion for Indigenous Australians: Identifying the barriers to equitable access’ Ethnicity and Health 8(2):111–119.

Cohen, C. (1993) ‘The biomedicalization of psy-chiatry: A critical overview’ Community Mental Health Journal 29(6):509–521.

Conrad, P. (2005) ‘The shifting engines of medi-calization’ Journal of Health and Social Behaviour 46:3–14.

Conrad, P. (2007) The medicalization of society: On the transformation of human conditions into treatable disorders The Johns Hopkins University Press: Baltimore.

Conrad, P.; and Leiter, V. (2004) ‘Medicalization, markets and consumers’ Journal of Health and Social Behaviour 45(extra issue):158–176.

Cooperstock, R. (1976) ‘Psychotropic drug use among women’ Canadian Medical Association Journal 115:760–763.

Crengle, S.; Lay-Yee, R.; Davis, P.; and Pearson, J. (2005) A comparison of Maori and non-Maori patient visits to doctors: The National Primary Medical Care Survey (NatMedCa): 2001/02 Report 6 Ministry of Health, Wellington, p. 140.

Dowell, A.; Garrett, S.; Collings, S.; McBain, L.; McKinlay, E.; and Stanley, J. (2009) Evaluation of the Primary Mental Health Initiatives: Summary report 2008 University of Otago and Ministry of Health: Wellington.

Dumit, J.; and Greenslit, N. (2006) ‘Informated health and ethical identity management’ Culture, Medicine and Psychiatry 30:127–134.

Eames, M.; Ben-Shlomo, Y.; and Marmot, M. G. (1993) ‘Social deprivation and premature mor-tality: Regional comparison across England’ British Medical Journal 307(6912):1097–1102.

Graham, K.; and Vidal-Zeballos, D. (1998) ‘Analyses of use of tranquilizers and sleeping pills across fi ve surveys of the same population

Psychotropic medication use by elderly people in New Zealand

Volume 20, Issue 2, June 2011 217

H

SRH

SR

H

SRH

SR

use of coronary-revascularization procedures: Are the differences real? Do they matter?’ The New England Journal of Medicine 336:480–486.

PHARMAC. (2010) Annual Report for the year ended 30 June 2010 PHARMAC: Wellington.

Pharmaceutical Research and Manufacturers of America. (2003) Pharmaceutical Industry Profi le 2003 Pharmaceutical Research and Manufacturers of America: Washington, DC.

Prince, M.; Harwood, R.; Blizard, R.; Thomas, A.; and Mann, A. (1997) ‘Social support defi cits, loneliness and life events as risk factors for depression in old age. The Gospel Oak Project VI’ Psychological Medicine 27(02):323–332.

Rameka, R. (2006) He Arakanihi ki te Oranga: Report of health research council rangahau Hauora award Te Ropu Rangahau Hauora a Eru Pomare: University of Otago, Wellington.

Riska, E. (2003) ‘Gendering the medicalization thesis’ Gender Perspectives on Health and Medicine 7:59–87.

Robson, B.; and Harris, R. (2007) (eds.) Hauora: Maori Standards of Health IV. A study of the years 2000-2005. Te Ropu Rangahau Hauora a Eru Pomare, Wellington.

Robson, B.; Purdie, G.; and Cormack, D. (2006) Unequal impact: Maori and non-Maori cancer statis-tics 1996-2001 Ministry of Health: Wellington

Robson, B.; Purdie, G.; Cram, F.; and Simmonds, S. (2007) ‘Age standardisation - An indigenous standard?’ Emerging Themes in Epidemiology 4(1):3.

Rubin, L. (2004) ‘Merchandising madness, pills, promises, and better living through chemistry’ Journal of Popular Culture 38(2):369–383.

Russell, C. (1987) ‘Aging as a feminist issue’ Women’s Studies International Forum 10(2):125–132.

Salmond, C.; Crampton, P.; and Atkinson, J. (2007) NZDep2006 Index of Deprivation Department of Public Health, University of Otago: Wellington, p. 61.

Simoni-Wastila, L. (2000) ‘The use of abusable prescription drugs: The role of gender’ Journal of Women’s Health and Gender-Based Medicine 9:289–297.

Skegg, D.; Doll, R.; and Perry, J. (1977) ‘Use of medicines in general practice’ British Medical Journal (1):1561–1563.

Martins, S.; Soares, M.; Foppe, J.; and Cabrita, J. (2006) ‘Inappropriate drug use by Portugese elderly outpatients – Effect of the Beers criteria update’ Phamacy World and Science 28:296–301.

Ministry of Health, New Zealand. (2009) Mortality and demographic data 2006 Ministry of Health: Wellington.

Mintzes, B. (2002) ‘Direct to consumer advertis-ing is medicalizing normal human experience’ BMJ 324(7342):908–911.

Morgan, S. G.; Bassett, K. L.; Wright, J. M.; Evans, R. G.; Barer, M. L.; Caetano, P. A.; and Black, C. D. (2005) ‘“Breakthrough” drugs and growth in expenditure on prescrip-tion drugs in Canada’ British Medical Journal 331(7520):815–816.

Moynihan, R.; Heath, I.; and Henry, D. (2002) ‘Selling sickness: The Pharmaceutical industry and disease mongering’ British Medical Journal 324:886–891.

Moynihan, R.; and Henry, D. (2006) ‘The fi ght against disease mongering: Generating knowledge for action’ PLoS Medicine 3(4 e191):0425–0428.

Murray, J.; Williams, P.; and Clare, A. (1982) ‘Health and social characteristics of long-term psychotropic drug takers’ Social Science and Medicine 16(18):1595–1598.

Newman, L.; Mason, J.; Cote, D.; Vin, Y.; Carolin, K.; Bouwman, D.; and Colditz, G. (2002) ‘African-American ethnicity, socio-economic status, and breast cancer survival: A meta-analysis of 14 studies involving over 10,000 African-American and 40,000 white American patients with carcinoma of the breast’ Cancer 94(11):2844–2854.

Nolan, L.; and O’Mally, K. (1989) ‘The need for a more rational approach to drug prescribing for elderly people in nursing homes’ Age and Ageing 18:52–56.

Oakley-Browne, M.; Wells, J.; and Scott, K. (2006) Te Rau Hinengaro: The New Zealand mental health survey Ministry of Health: Wellington.

Okunade, A. A.; and Suraratdecha, C. (2006) ‘The pervasiveness of pharmaceutical expen-diture inertia in the OECD countries’ Social Science and Medicine 63(1):225–238.

Peterson, E.; Shaw, L.; Delong, E.; Pryor, D.; Califf, R.; and Mark, D. (1997) ‘Racial variation in the

Pauline Norris et al.

Volume 20, Issue 2, June 2011218

H

SRH

SR

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SRH

SR

amongst community-dwelling people 75 years and older in an urban setting in New Zealand’ Age and Ageing 39(5):574–580.

Vuckovic, N.; and Nichter, M. (1997) ‘Changing patterns of pharmaceutical practice in the United States’ Social Science and Medicine 44(9):1285–1302.

Wagstaff, A. (2002) ‘Poverty and health sector inequalities’ Bulletin of World Health Organisation 80:97–105.

Weisz, G.; and Knaapen, L. (2009) ‘Diagnosing and treating premenstrual syndrome in fi ve western nations’ Social Science and Medicine 68:1498–1505.

Wheeler, A.; Humberstone, V.; and Robinson, E. (2008) ‘Ethnic comparisons of antipsy-chotic use in schizophrenia’ Australian and New Zealand Journal of Psychiatry 42(10):863–873.

Wheeler, A.; Robinson, E.; and Robinson, G. (2005) ‘Admissions to acute psychiatric inpa-tient services in New Zealand: A demographic and diagnostic review’ New Zealand Medical Journal 118(1226):1–9.

Received 02 December 2010 Accepted 04 March 2011

Statistics New Zealand. (2006) QuickStats about Gisborne region Statistics New Zealand: Wellington.

Stein, J. (ed.). (1998) Internal medicine Mosby: St Louis.

Straand, J.; Sandvik, H.; and Rokstad, K. (1998) ‘General pracitioners’ offi ce consultations with elderly patients – diagnoses and prescrip-tions: A report from the More and Romsdal Prescription Study’ Norwegian Journal of Epidemiology 8(2):121–126.

Tairawhiti District Health Board. (2010) Annual plan 2010–11 Tairawhiti District Health Board: Gisborne.

Thomas, D.; Arlidge, B.; Arroll, B.; and Elder, H. (2010) ‘General practitioners’ views about diagnosing and treating dpression in Maori and non-Maori patients’ Journal of Primary Health Care 2(3):208–216.

Tiefer, L. (2006) ‘Female sexual dysfunction: A case study of disease mongering and activist resistance’ PLoS Medicine 3(4):e178.

Tordoff, J.; Bagge, M.; Gray, A.; Campbell, A.; and Norris, P. (2010) ‘Medicines taking

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