The purpose of this study was to assess whether the racial differences previously noted for all prescription medication use among young people also exist in the use of psychotropic medications. The study population consists of Medicaid recipients seen in ambulatory settings by physicians for the fiscal year 1991 in Maryland.

African American youths (age 5-14 years) were less likely to receive medication prescriptions than white youths, for both the most common psychotropic and non-psychotropic medications (African American to white ratio for psychotropic medications ranged from 1:2 to 1:2.5, African American to white ratio for non-psychotropic medications ranged from 1:1.1 to 1:1.7). It is noteworthy that among psychotropic medications, racial differences were highest for stimulants.

Since African American youths were more likely than whites to have had continuous Medicaid enrollment, eligibility status did not influence the observed patterns. These findings also persisted after controlling for region (although the differences were stronger in some regions than others).

The authors outline five main hypotheses to explain the provision of fewer mental health services, in particular prescription drugs, to African American youths relative to white youths, and discuss them in light of the current findings. First, it is possible that African American youth have fewer mental or behavioral disorders than whites. However, there is no conclusive evidence that reported differences in rates of disorder are not due to bias in diagnosis. Second, African American youths respond less favorably to psychopharmacological treatment. There is no data supporting or refuting this claim. Third, African American youth receive relatively less psychiatric follow-up care. Since there were no racial differences in continuous eligibility status in this study, it is unlikely that this hypothesis completely explains the findings. Fourth, cross-cultural differences including family attitude toward the mental health system could alter diagnostic and treatment patterns for psychiatric disorders. Finally, fewer behavioral pediatricians and child psychiatrists practice in poor, inner-city neighborhoods.

The authors conclude that these data suggest "clinicians should review, and, where necessary, revise clinical protocols" regarding medication use. The major limitation of this study is its inability to provide data regarding the appropriateness of these prescription patterns.

Storch DD, Storch EA.
Racial disparity in medications prescribed.
J Am Acad Child Adolesc Psychiatry 1998; 37:1241-1242 (letter).

The authors report on data regarding psychiatric medication use among children (aged 2 to 18 years). In this study of 83 blacks and 108 whites, 39.8% of blacks versus 50% of whites were prescribed psychiatric medications (difference is not statistically significant). Further, there was a trend for more blacks than whites to be prescribed stimulants (not significant); significantly fewer blacks were prescribed antidepressants, mood stabilizers, and lithium; and there was no race difference in the use of antipsychotics.

Zito JM and Safer DJ respond to this letter highlighting three limitations of this approach to assessing race patterns. First, a treatment sample cannot be used to assess rate differences in medication use. Second, the sample was based one county in Maryland, and thus not necessarily generalizable. Finally, SES was insufficiently assessed. These authors argue that only community-based psychopharmacological studies are of use for such comparisons.

Zito JM, Safer DJ, dosReis S, Riddle MA.
Racial disparity in psychotropic medications prescribed for youths with Medicaid insurance in Maryland.
J Am Acad Child Adolesc Pscych 1998;37(2):179-84.

A SECOND ANNOTATION - QUOTATIONS

“The authors conducted a retrospective analysis using state Medicaid prescription drug reimbursement claims for youths aged 5 through 14 years according to the race of the recipients of psychotropic and medical drugs…A person-based data set was created from Medicaid administrate data for fiscal year 1991 from the state of Maryland….Five major findings were observed: (1) African-American youths with Medicaid insurance aged 5 though 14 were less than half (39% to 52%) as likely to have been prescribed psychotropic medications as Caucasian youths with Medicaid insurance; (2) the relative difference for nonpsychotropic medication classes was much less pronounced: African-American youths were prescribed more psychotropic medications at a rate of 60% to 87% of the Caucasian youths’ rate; (3) the stimulants (especially methylphenidate) had the most disparate African-American/Caucasian ratio (1:2.5); (4) the racial disparity for psychotropics was not altered by partial (noncontinuous enrollment) eligibility status; and (5) although geographic variation reduced the racial disparity, the substantial racial difference (1:2.0) remained.”

With regard to the observed medical care and prescription utilization patterns, “to explain the lower use among African-Americans compared with Caucasians, a variety of explanatory factors chiefly involving unequal availability of services or unequal access to services has been postulated. Explanations for unequal access often involve questions of quality, discriminatory practices among health care providers, and patient behavior.”

With regard to assessment, treatment, and outcome evaluation of psychiatric and behavioral disorders, “cross-cultural differences, including family attitude toward the mental health system could alter diagnostic and treatment patterns for psychiatric disorders. If, for example, the target behaviors of attention-deficit/hyperactivity) are interpreted differently according to the individual’s cultural background, then diagnosis and its subsequent treatment would differ as well.”

Regarding the clinical implications of these findings, “for the present, clinicians should review their interview techniques to avoid cultural insensitivity and be sure their monitoring includes side effects that may differentially affect the non-Caucasian, e.g., blood pressure of the African-American adolescent receiving methylphenidate.”