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Trends in Drug Prescriptions Among Elderly Residents of Ontario in the Weeks After September 11, 2001
To the Editor: Many residents of Manhattan appear to have experienced symptoms of acute posttraumatic stress and depression following the September 11, 2001, attack,1 similar to those experienced by survivors of other terrorist attacks and natural disasters.2-3 Following the events of September 11 and the ensuing anthrax infections, a survey found that 1 in 4 Canadians was "always or often stressed and overwhelmed," and that 4% reported visiting a health professional to help cope with their reaction to the events.4
Such events may be reflected in use of prescription medications. For instance, 29% of long-term evacuees following a volcanic eruption received prescriptions for psychotropic drugs.5 Insomnia, for which benzodiazepines may be prescribed, is known to occur after local or distant disasters,6 and one survey found that 11% of US citizens reported having difficulty sleeping in the days following September 11.7 We examined changes in the frequencies of related drug prescriptions among elderly residents of Ontario in the weeks following the September 11 attacks.
Methods
We studied claims for antidepressants, sedatives, and antibiotics submitted to Ontario's universal Drug Benefit program for seniors (ODB), which tracks medication use by all 1.3 million residents of Ontario aged 65 years or older. While prescriptions for psychoactive drugs provide direct evidence of symptomatic anxiety, antibiotics were examined under the hypothesis that, in the absence of documented infections, an increased use was a proxy indicator of anxiety regarding anthrax. We also used prescriptions for lipid-lowering drugs as a comparator.
We examined relative changes in claims volume for each of the 4 medication classes, compared with the previous week, from September 11 to November 26, 2001, and for the same periods 52 and 104 weeks earlier. Secular trends in the use of ciprofloxacin, antidepressants, and lipid-lowering agents necessitated the use of relative changes rather than absolute numbers of prescriptions dispensed. Absolute rates of ciprofloxacin use had declined following the March 2001 introduction of a policy requiring physicians to indicate that it was being used for one of a limited number of indications.
Results
For each medication class, secular changes in number of prescriptions in 2001 were similar to historical trends (Wilcoxon signed rank test on weekly relative change, P>.45 for each class) (Figure 1). In all 3 years, the second week of October was associated with a large relative increase in the number of prescriptions. This pattern has been observed historically and has been popularly attributed to relatively large numbers of patients obtaining medication prior to traveling south for the winter. The effect was exaggerated in 2001 for ciprofloxacin, for which we observed an excess of 227 prescriptions over the predicted numbers based on previous years.
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Figure. Trends in Drug Prescriptions in the Weeks After September 11, 1999-2001
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Comment
In the 7 days following October 4, 2001, when the first anthrax infection in the United States was reported, we observed an increase in prescriptions for ciprofloxacin despite restrictive new policies that required physicians to indicate an authorized reason for its use. The proportional change in ciprofloxacin prescriptions was unaffected, however, after subsequent anthrax infections were reported in the United States. We did not find any significant changes in the number of prescriptions for antidepressants or anxiolytics.
We acknowledge some limitations to our study. First, because it is limited to prescriptions that were dispensed, it cannot estimate either the number of prescriptions that patients obtained with the intent of filling only if a threat became imminent, or the number of drugs purchased at personal expense. Second, in the case of psychoactive drugs, patients with a history of anxiety may have already had an anxiolytic medication at hand, and thus a sporadic increase in refills would have been difficult to detect. Finally, while pharmacy utilization is a sensitive measure of moderate or severe anxiety or depression, its use is less well established as a marker for mild anxiety or depression.
While Ontarians frequently wait for specialty services, it is unlikely that delays in access to primary care for symptomatic patients would have influenced our findings. Furthermore, we feel that comprehensiveness of the ODB database counterbalances many of these limitations, as it reflects the experiences of the entire population of Ontarians aged 65 years or older.
AUTHOR INFORMATION
Funding/Support: The Institute for Clinical Evaluative Sciences is funded in part by an operating grant from the Ontario Ministry of Health and Long-Term Care.
Peter C. Austin, PhD
Institute for Clinical Evaluative Sciences
Department of Public Health Sciences
University of Toronto
Toronto, Ontario
Muhammad M. Mamdani, PharmD,MA,MPH
Institute for Clinical Evaluative Sciences
Faculty of Pharmacy
University of Toronto
Liisa Jaakkimainen, MD,MSc,CCFP
Institute for Clinical Evaluative Sciences
Department of Family and Community Medicine
University of Toronto
Janet E. Hux, MD,SM,FRCPC
Institute for Clinical Evaluative Sciences
Department of Medicine
University of Toronto
Clinical Epidemiology and Health Care Research Program
Sunnybrook & Women's College Health Sciences Centre
Toronto
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2. North CS. The course of post-traumatic stress disorder after the Oklahoma City bombing. Mil Med. 2001;166(suppl):51-52.
3. Shore JH, Tatum EL, Vollmer WM. Psychiatric reactions to disaster: the Mount St. Helens experience. Am J Psychiatry. 1986;143:590-595.
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4. Picard A. Poll finds rising fear and stress in Canada. The Globe and Mail. October 22, 2001.
5. Araki K. Mental health activities of evacuees of the volcanic eruption of Mt. Unzen-Fugen—crisis intervention of a psychiatrist [in Japanese]. Seishin Shinkeigaku Zasshi. 1995;97:430-444.
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6. White DP. Tragedy and insomnia. N Engl J Med. 2001;345:1846-1848.
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7. Schuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med. 2001;345:1507-1512.
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Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.
JAMA. 2002;288:575-577.
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