Research article
Adverse Childhood Experiences and Prescribed Psychotropic Medications in Adults

https://doi.org/10.1016/j.amepre.2007.01.005Get rights and content

Background

Prescription drugs are one of the fastest growing healthcare costs in the United States. However, the long-term influence of child abuse and related traumatic stressors on prescriptions for psychotropic medications in adults has not been described. This study assessed the relationship of eight adverse childhood experiences (ACEs) to rates of prescriptions for psychotropic medications throughout adulthood. These ACEs included: abuse (emotional, physical, or sexual), witnessing domestic violence, growing up with substance abusing, mentally ill, or criminal household members, and parental separation/divorce.

Methods

Data about ACEs were collected between 1995 and 1997 from adult health maintenance organization patients; prescription data were available from 1997 to 2004. The number of ACEs (ACE Score: maximum 8) was used as a measure of cumulative traumatic stress during childhood. The relationship of the score to rates of prescribed psychotropic drugs was prospectively assessed among 15,033 adult patients eligible for the follow-up phase of the study (mean follow-up: 6.1 years). Data were analyzed in 2006. Multivariate models were adjusted for age, race, gender, and education.

Results

Prescription rates increased yearly during the follow-up and in a graded fashion as the ACE Score increased (p for trend <0.001). After adjusting compared with persons with an ACE Score of 0, persons with a score of equal to or more than 5 had a nearly threefold increase in rates of psychotropic prescriptions. Graded relationships were observed between the score and prescription rates for antidepressant, anxiolytic, antipsychotic, and mood-stabilizing/bipolar medications; rates for persons with a score of equal to or more than 5 for these classes of drugs increased 3-, 2-, 10-, and 17-fold, respectively.

Conclusions

The strong relationship of the ACE Score to increased utilization of psychotropic medications underscores the contribution of childhood experience to the burden of adult mental illness. Moreover, the huge economic costs associated with the use of psychotropic medications provide additional incentive to address the high prevalence and consequences of childhood traumatic stressors.

Introduction

Prescription drugs are one of the fastest growing healthcare costs in the United States, with total spending for these drugs in 2003 estimated to be $180 billion, or 11% of national health expenditures. This amount was more than four times greater than the amount spent in 1990.1 Antidepressants, anxiolytics, and antipsychotics are among the top-selling prescription drugs, with retail sales of these medications during 2000 totaling $10.4, $3.1, and $2.4 billion, respectively.2 Similarly, the impact of mental illness on disability and quality of life is also being increasingly recognized and quantified as a national public health priority.3

Increased spending on psychotropic medications and the disability and morbidity associated with mental illness highlight: (1) the cost of mental illness to affected individuals, the healthcare system, and society; and (2) the increasing importance of identifying preventable contributors to these disorders.

Childhood abuse and related traumatic stressors are well-established risk factors for developing acute and chronic mental illness. Numerous studies have documented these relationships and have been reviewed elsewhere.4, 5 Data from the Adverse Childhood Experiences (ACE) study,6, 7, 8 have demonstrated that an integer count of the number of categories of abuse, exposure to domestic violence, and other forms of serious household dysfunction (ACE Score)9 experienced during childhood has a strong, graded relationship to a wide variety of health and social problems from adolescence to adulthood6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 including depressive disorders,6, 8, 11, 19 suicide attempts,11 anxiety,6 hallucinations,6, 20 panic reactions,6 sleep disturbances,6 and memory disturbances.6, 21

The relationship of child abuse and related traumatic stressors to prescriptions for psychotropic drugs in adulthood has not been described. This analysis used data from the ACE study to prospectively assess the relationship of the ACE Score to prescription rates for four classes of psychotropic medications.

Section snippets

Study Population

The ACE study methods have been described in detail elsewhere.6, 7, 8 Briefly, >50,000 adult members of the Kaiser Health Plan in San Diego, California, are evaluated annually at Kaiser Permanente’s San Diego Health Appraisal Clinic, which includes a standardized health history, psychosocial evaluations, and physical examination. The ACE study was approved by the institutional review boards of Kaiser Permanente and the Office for Protection from Research Risks at the National Institutes of

Characteristics of Study Population

The study population included 8134 women (54%) and 6899 men (46%). The mean age (standard deviation) was 57 (15) years. Seventy-six percent of participants were white, 11% Hispanic, 4% black, 7% Asian, less than 1% Native American, and 2% other; 40% were college graduates, 36% had some college education, and 17% were high school graduates. Only 7% had not graduated from high school. The mean follow-up was 6.1 (SD, 2.4) years.

Prevalence of ACEs and the ACE Score

The prevalence of each of the eight individual ACEs and the ACE Score

Discussion

Prescription rates for antidepressant and anxiolytic drugs increased in a dose–response fashion as the ACE Score increased for young, middle-aged, and older adults. This finding suggests that the cost of prescription psychotropics extends throughout adulthood. Such relationships were also found among younger and middle-aged adults for antipsychotic and lithium-based drugs. The lack of a relationship between the score and antipsychotics in older adults is likely explained by the use of these

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