Medication for Attention Deficit/Hyperactivity Disorder (ADHD):
an Analysis by Federal Electorate
Paul Mackey, Social Policy Group
Andrew Kopras, Statistics Group
3 April 2001
Contents
Major Issues
Introduction
What is ADHD?
Causes and Prevalence of ADHD
Medication prescribed to treat
ADHD
Jurisdictional variations in the
number of prescriptions dispensed for dexamphetamine sulfate
Variations between Federal electorates in the number of
prescriptions dispensed for dexamphetamine sulfate
Numbers of prescriptions and socioeconomic factors
Conclusion
Appendix 1: Western Australia
Appendix 2: New South Wales
Appendix 3: Victoria
Appendix 4: Queensland
Appendix 5: South Australia
Appendix 6: Tasmania
Endnotes
List of Tables
Table 1: Number of PBS prescriptions dispensed
for dexamphetamine sulfate, 1999-2000
Table 2: Electoral Divisions ranked by the number
of prescriptions for dexamphetamine sulfate 1999-2000
Major
Issues
For some time, considerable disparity has been
apparent in the prescribing of medication for children with
Attention Deficit/Hyperactivity Disorder (ADHD) in different
jurisdictions in Australia. Despite having a smaller population
than New South Wales, Victoria, Queensland and South
Australia-Western Australia accounts for the highest number of
prescriptions dispensed for dexamphetamine sulfate, a drug
prescribed to treat ADHD that is subsidised under the
Pharmaceutical Benefits Scheme (PBS).
The number of prescriptions dispensed for this
drug in Western Australia is around 4 times higher per 1000
population than the Australian average and almost 10 times higher
than the jurisdiction with the lowest number of prescriptions, the
Northern Territory. It has been suggested that one of the reasons
for this disparity is a better understanding of ADHD among medical
practitioners in Western Australia, although this is not a view
that is universally accepted.
Medication for ADHD has been controversial,
arguably for three main reasons. It is children, often young
children, who are being medicated, the medication being prescribed
is amphetamine-based, and the number of prescriptions for such
medication has been increasing at a quite dramatic rate. Between
1991 and 1998, prescriptions dispensed for dexamphetamine sulfate
increased by 2400 per cent, while prescriptions for Ritalin
increased by 620 per cent over the same period. High rates of
increase have been reported also in the United States. However, the
level of medication in both countries appears still to be below the
estimated prevalence of ADHD, which is believed to affect between
2.3 and 6 per cent of school-aged children.
Data presented in this paper illustrates a
possible further area of concern, namely, the disparity in the
number of prescriptions for dexamphetamine sulfate dispensed in
different parts of Australia. The paper analyses data on the number
of prescriptions dispensed for this drug in each Federal
electorate. The data reveals that the number of prescriptions
dispensed for dexamphetamine sulfate in 1999-2000 ranged from 8463
in the Western Australian electorate of Canning to 271 in the
Victorian electorate of Higgins. In addition to differences between
jurisdictions, considerable variation is evident within each State.
It has been argued that variations such as these indicate that
opinion-based treatment is being practiced, rather than
evidence-based treatment.
A range of socioeconomic data is utilised to
examine whether particular factors can be identified that may
explain the variation evident between different electorates. This
analysis of socioeconomic variables such as the proportion of
school-aged children, level of household income or unemployment
rate reveals that none, either singly or in combination, can
provide a consistent explanation for the differences between
Federal electorates.
What cannot be discounted is the possibility
that a small number of prescribers in each jurisdiction may account
for at least some of the differences between electorates. It should
be stressed also that while dexamphetamine sulfate represents the
majority (72 per cent) of prescriptions for the treatment of ADHD,
it is not the only such drug. Ritalin accounts for a substantial
number of prescriptions but is not subsidised under the PBS and,
accordingly, similar data is not readily available. It is therefore
not possible to establish the total number of prescriptions for
both drugs in each electorate.
Bearing in mind these caveats, the degree of
difference between individual Federal electorates and across the
States and Territories is unlikely to be in the best interests of
Australia's children and their families. It appears that Australia
has some distance to go before achieving best practice in the
prescribing of medication for the treatment of ADHD.
Introduction
Attention Deficit/Hyperactivity Disorder (ADHD)
is a controversial syndrome. Debate has raged in Australia and
other countries over the condition itself, its prevalence and, in
particular, over the use of medication to treat ADHD. Although
often presented as recent phenomena, attention deficit and
hyperactivity disorders have been around for some considerable time
as has the use of stimulant medication to treat the symptoms of the
condition. For example, as early as 1937, researchers were
reporting the use of stimulants in the treatment of children at the
Emma Pendleton Bradley Hospital in East Providence,
USA.(1)
Ritalin (methylphenidate) is the drug most
commonly associated with the treatment of ADHD. In Australia,
Ritalin is not listed on the Pharmaceutical Benefits Scheme (PBS)
and therefore the cost of the drug is not subsidised by the
Commonwealth Government. However, another amphetamine-based drug,
dexamphetamine sulfate, is listed on the PBS for the treatment of
ADHD.(2) Accordingly, a far greater number of
prescriptions are dispensed in Australia for dexamphetamine sulfate
compared to Ritalin.
This Current Issues Brief examines the wide
disparity in the number of prescriptions dispensed for
dexamphetamine sulfate in different parts of Australia. Data made
available by the Commonwealth Department of Health and Aged Care on
the dispensing of prescriptions for dexamphetamine sulfate, by
postcode of the pharmacy dispensing the medication, has been
converted into Federal electorates. Electorates have been chosen
because they provide an useful base for analysis of differences at
the local level. Data on the dispensing of pharmaceuticals is
generally only published at the national and State and Territory
level.
The analysis in this brief examines the
differences between Federal electorates in the number of
prescriptions dispensed for medication to treat ADHD. Considerable
variation is apparent both across and within the States and
Territories.
In order to provide Senators and Members with a
context for the discussion around the differences between
electorates, some background is provided below about ADHD.
What is
ADHD?
The casual observer's understanding of this
condition has not been assisted by changes over time in the labels
used to describe it. Current thinking uses the term Attention
Deficit/Hyperactivity Disorder (ADHD) as a label that embraces
three subtypes: ADHD, Combined Type; ADHD, Predominantly
Inattentive Type; and ADHD, Predominantly Hyperactive-Impulsivity
Type. A recent report on the mental health of Australia's young
people drew on the definitions in the 4th edition of the
Diagnostic and Statistical Manual of Mental Disorders
issued by the American Psychiatric Association(3) to
describe ADHD as follows:
ADHD is defined as a persistent pattern of
inattentive behaviour and/or hyperactivity-impulsivity that is more
frequent and severe than is typically observed in individuals of
the same developmental level. Children and adolescents with
inattentive behaviour problems make careless mistakes with school
work, find it hard to persist with tasks and are easily distracted.
Those with problems in the area of hyperactivity/impulsivity often
fidget and talk excessively, interrupt others, and are constantly
'on the go'. There are three subtypes of ADHD based on the
predominate symptom pattern for the past six
months.(4)
The names and symptoms of the three sub-types of
ADHD are listed below:
ADHD, Combined Type
symptoms of both inattentiveness and
hyperactivity-impulsivity
ADHD, Predominantly Inattentive Type
primarily inattentive symptoms
ADHD, Predominantly Hyperactive-Impulsivity
Type
primarily hyperactivity-impulsivity
symptoms.(5)
Causes and
Prevalence of ADHD
A key factor in the controversial nature of ADHD
is the type of symptoms and behaviour underlying the condition. The
exhibition of inappropriate behaviour by children with ADHD has
enabled critics to attribute, for example, child rearing practices
and poor parenting skills as prime causes of ADHD. Current
knowledge indicates that it is rarely quite that simple and there
are likely to be several causes of ADHD. For example, a report by
the National Health and Medical Research Council (NH&MRC)
argued that 'evidence suggests that many factors, including
genetic, neurophysiologic, cognitive, familial and environmental
factors are involved'.(6) The relative importance of
these factors is yet to be established by research. The NH&MRC
concludes from the available evidence that 'it is likely that a
variety of contributing factors may operate in a vulnerable child
to result in the behaviours of ADHD'.(7)
Many of the broad range of symptoms that
comprise ADHD occur from time to time in normal children. The
difference for many children diagnosed with ADHD is that these
symptoms 'occur very frequently and in several settings, at home
and at school, or when visiting with friends, and they interfere
with the child's functioning'.(8)
The extent, or prevalence, of ADHD among
school-aged children is not known with any great accuracy. The
NH&MRC reported in 1997 that Australian studies had found
prevalence rates of between 2.3 per cent and 6 per cent of
school-aged children. It noted also that 'widely different
prevalence rates of ADHD have been reported, depending on the
methodology used, ranging from 1.7 per cent to 6 per
cent'.(9)
A recent report on the mental health of
Australia's young people surveyed 4500 children and adolescents
aged 4 to 17 years of age. The report found a much higher
prevalence rate of ADHD, at 11.2 per cent, than found by other
studies. Disaggregated by subtype, 5.8 per cent of the sample were
found to have ADHD, Predominantly Inattentive Type; 3.3 per cent
ADHD, Combined Type; and 2.0 per cent ADHD, Predominantly
Hyperactive-Impulsive Type.(10) The report's authors
suggest, however, that 'the high prevalence be viewed with
caution'. The authors state that they could not incorporate into
their assessment two of the formal criteria for a diagnosis of ADHD
identified in the Diagnostic and Statistical Manual of Mental
Disorders, 4th edition.(11)
School-aged children still represent the vast
bulk of diagnosed cases, although ADHD is becoming recognised as a
condition that may be suffered by adults. In some cases, adult
diagnosis of ADHD may occur only after their children have been
diagnosed and treated for the condition. For others, childhood ADHD
may continue through to the adult years. Research suggests that in
about 10 per cent of cases, ADHD may persist into adulthood and it
is estimated that adults have a prevalence rate of at least 0.3 per
cent.(12)
Medication prescribed to treat
ADHD
Although the use of medication for the treatment
of ADHD continues to be controversial in the public arena, the
safety and efficacy, particularly in the short term, of
psycho-stimulants such as dexamphetamine sulfate and Ritalin is
well established.(13) However, further research into the
long-term safety and efficacy of the drugs is required and at this
stage, 'convincing evidence for long-term benefit is
lacking'.(14) While studies have suggested that
medication alone may be effective as a treatment for ADHD,
consensus holds that a multi-pronged treatment regime of
medication, behaviour management and educational strategies is
likely to provide the most effective results.(15)
One of the concerns about ADHD in Australia is
the growth in the use of medication to treat the condition. For
example, in 1991, less than 10 000 prescriptions were dispensed for
dexamphetamine sulfate. In 1998, nearly 250 000 prescriptions were
dispensed for the same drug, an increase of 2400 per cent. Over the
same period, prescriptions dispensed for Ritalin increased from 13
398 to 96 582, an increase of 620 per cent.(16) It has
been argued by one commentator that 'Australia appears to be the
only nation that has experienced a documented increase in
psychostimulant use that parallels that which has occurred in the
United States'.(17) However, the NH&MRC notes that
overall prescribing rates for ADHD medication in Australia are
'less than one per cent of school-aged children', which is less
than the estimated prevalence of the condition.(18)
Similarly, rapid growth in the use of medication
to treat ADHD has been a feature of the United States' experience.
Media reports have suggested that prescriptions for Ritalin in the
USA have increased by some 700 per cent over the past 10
years.(19) The US National Institute of Mental Health
notes with regard to ADHD medication that 'stimulant use in the
United States has increased substantially over the last 25
years'.(20) A report in 1999 by the US Surgeon General
quotes research which indicates that 'there have been major
increases in the number of stimulant prescriptions since 1989'. The
report notes also that 'most researchers believe that much of the
increased use of stimulants reflects better diagnosis and more
effective treatment of a prevalent disorder', although 'some of the
increase in use may reflect inappropriate diagnosis and
treatment'.(21)
Jurisdictional variations in the number
of prescriptions dispensed for dexamphetamine sulfate
A feature of the Australian experience with ADHD
is the wide disparity between the States and Territories in the
number of prescriptions dispensed for medication. An analysis of
PBS data for 1999-2000 indicates that the number of prescriptions
dispensed for dexamphetamine sulfate was highest in Western
Australia and lowest in the Northern Territory. The table below
indicates the number of prescriptions dispensed under the PBS for
dexamphetamine sulfate in 1999-2000. In addition, an estimate of
the number of prescriptions per 1000 population is presented in
order to highlight differences between the jurisdictions.
There is no simple explanation for the
differences evident in the table below, although it has been
suggested that the higher prescription rates in Western Australia
reflect a better understanding of ADHD among practitioners in that
State.(22) An alternate view expressed by prominent
health commentator Dr Norman Swan, is that:
as soon as you see variations like that in
medicine and health, it's usually the fact that there's
non-evidence-based treatment going on, that there's opinion-based
treatment going on rather than evidence-based treatment going
on.(23)
Jurisdictional differences are apparent also in
the United States. In a study on the use of psycho-stimulant
medication for children with ADHD in Australia, Prosser and Reid
commented also on the United States experience. The authors quoted
several studies and reviews, one of which found that 'rates of
medication prescription varied greatly between the eastern, midwest
and western regions and noted significant increases within these
regions over time'.(24) Prosser and Reid concluded from
these reviews of the US experience that 'as yet there is no
generally accepted rationale behind the pronounced variation in
medication use across region. One possible factor may be the rise
in specialized ADHD clinics'.(25)
Table 1: Number of PBS prescriptions
dispensed for dexamphetamine sulfate, 1999-2000
State/Territory
|
Number of prescriptions
|
Population
|
Number of prescriptions per 1000
population
|
New South Wales
|
61 145
|
6 463 455
|
9.5
|
Victoria
|
31 915
|
4 765 856
|
6.7
|
Queensland
|
29 359
|
3 566 357
|
8.2
|
Western Australia
|
64 695
|
1 497 634
|
43.2
|
South Australia
|
19 225
|
1 883 860
|
10.2
|
Tasmania
|
7 663
|
470 376
|
16.3
|
Northern Territory
|
891
|
195 463
|
4.6
|
ACT
|
2 641
|
310 839
|
8.5
|
Australia
|
217 534
|
19 157 037
|
11.3
|
Sources: Commonwealth Department of Health and
Aged Care; Australian Bureau of Statistics, Population by Age
and Sex, June 2000 (ABS 3201.0).
Variations between Federal electorates
in the number of prescriptions dispensed for dexamphetamine
sulfate
It is to be expected that differences will be
apparent between Federal electorates with regard to the dispensing
of prescriptions for medication to treat ADHD. Electorates differ
substantially, for example, in their proportion of school-aged
children. Differences may also be influenced by the location of
medical practitioners and specialists and to a lesser extent by the
location of pharmacies. In addition, the differences between the
States and Territories evident in the data presented in Table 1
above could be expected to be reflected to some extent in data on
the number of prescriptions by Federal electorate.
Table 2 below provides a ranking of each Federal
electorate by the number of prescriptions dispensed for
dexamphetamine sulfate under the PBS in 1999-2000. This data has
been derived from data on the number of prescriptions dispensed for
dexamphetamine sulfate, by postcode, provided by the Commonwealth
Department of Health and Aged Care. Similar data is not readily
available for Ritalin. It should be noted that the Department of
Health and Aged Care collects data by the postcode of the pharmacy
dispensing each prescription.
The data in Table 2 reveals that the top ten
Federal electorates in terms of the number of prescriptions
dispensed for dexamphetamine sulfate in 1999-2000 are all in
Western Australia. This is perhaps not surprising given that more
prescriptions for this drug are dispensed in Western Australia than
any other jurisdiction. However, considerable differences are
apparent within this group. It can be observed, for example, that
the number of prescriptions in the top ranked electorate (Canning)
are more than double that of the tenth ranked electorate
(Fremantle).
Differences are apparent also in the location
and characteristics of the top ranked electorates within each of
the other jurisdictions. For example, the top ranked electorate in
New South Wales is the seat of Chifley, located in the western
suburbs of Sydney. Ranked second in New South Wales is the
electorate of Cowper, located on that State's rural mid-north
coast. Of the top ten electorates in New South Wales, seven are
located outside of Sydney.
In Victoria and Queensland, the top ranked
electorates are located outside of the State capitals, in the seats
of Corio and Oxley respectively. Victoria has only 3 electorates in
the national top 50, none of which is located in Melbourne. In
South Australia, the top ranking is held by the seat of Bonython,
located in Adelaide. This is followed by the metropolitan
electorate of Kingston, with the large rural electorate of Grey
ranked third of the South Australian electorates. In Tasmania, the
seat of Bass in the north of the State is the top ranked
electorate.
Even in the ACT, commonly regarded as an
homogenous Territory, differences are apparent. The electorate of
Canberra is ranked 42nd of the 148 Federal electorates,
while the other ACT electorate, Fraser, is ranked 68th.
Eden-Monaro, the NSW rural electorate that abuts the ACT, is ranked
43rd. Finally, the large Western Australian electorate
of Kalgoorlie had almost twice the number of prescriptions
dispensed compared with the electorate of the Northern
Territory.
Numbers of prescriptions and
socioeconomic factors
The tables at Appendix 1 to 6 present, for each
State, the electorates with the highest, second highest and lowest
number of prescriptions for dexamphetamine sulfate, together with
data on a range of socioeconomic variables gleaned from the most
recent Census.(26) These comparisons are provided in
order to ascertain whether there are any factors that might help to
explain why some electorates have a much higher number of
prescriptions for this medication to treat ADHD.
Table 2:
Electoral Divisions ranked by the number of prescriptions for
dexamphetamine sulfate 1999-2000
Rank
|
Electoral Division
|
Party
|
Number
|
|
Rank
|
Electoral Division
|
Party
|
Number
|
|
|
|
|
|
|
|
|
|
1
|
Canning (WA)
|
ALP
|
8643
|
|
75
|
Bendigo (Vic)
|
ALP
|
1027
|
2
|
Brand (WA)
|
ALP
|
7085
|
|
76
|
Mallee (Vic)
|
NP
|
1014
|
3
|
Tangney (WA)
|
LIB
|
5163
|
|
77
|
McPherson (Qld)
|
LIB
|
1012
|
4
|
Pearce (WA)
|
LIB
|
4799
|
|
78
|
La Trobe (Vic)
|
LIB
|
1005
|
5
|
O'Connor (WA)
|
LIB
|
4536
|
|
79
|
Barker (SA)
|
LIB
|
988
|
6
|
Cowan (WA)
|
ALP
|
4324
|
|
80
|
Fairfax (Qld)
|
LIB
|
982
|
7
|
Perth (WA)
|
ALP
|
4272
|
|
81
|
Cook (NSW)
|
LIB
|
979
|
8
|
Stirling (WA)
|
ALP
|
4237
|
|
82
|
Calwell (Vic)
|
ALP
|
977
|
9
|
Moore (WA)
|
LIB
|
4234
|
|
83
|
Wide Bay (Qld)
|
NP
|
971
|
10
|
Fremantle (WA)
|
ALP
|
4083
|
|
84
|
Fowler (NSW)
|
ALP
|
968
|
11
|
Bonython (SA)
|
ALP
|
4054
|
|
85
|
Capricornia (Qld)
|
ALP
|
967
|
12
|
Swan (WA)
|
ALP
|
4010
|
|
86
|
Moncrieff (Qld)
|
LIB
|
955
|
13
|
Curtin (WA)
|
LIB
|
3848
|
|
87
|
Herbert (Qld)
|
LIB
|
947
|
14
|
Chifley (NSW)
|
ALP
|
3129
|
|
88
|
Fisher (Qld)
|
LIB
|
943
|
15
|
Oxley (Qld)
|
ALP
|
3078
|
|
89
|
Boothby (SA)
|
LIB
|
936
|
16
|
Forrest (WA)
|
LIB
|
3057
|
|
90
|
Bowman (Qld)
|
ALP
|
920
|
17
|
Kingston (SA)
|
ALP
|
3041
|
|
91
|
Casey (Vic)
|
LIB
|
908
|
18
|
Corio (Vic)
|
ALP
|
2747
|
|
92
|
Flinders (Vic)
|
LIB
|
907
|
19
|
McMillan (Vic)
|
ALP
|
2717
|
|
93
|
Sturt (SA)
|
LIB
|
904
|
20
|
Cowper (NSW)
|
NP
|
2564
|
|
94
|
Northern Territory (NT)
|
ALP
|
891
|
21
|
Lyne (NSW)
|
NP
|
2457
|
|
95
|
Berowra (NSW)
|
LIB
|
879
|
22
|
Hunter (NSW)
|
ALP
|
2397
|
|
96
|
Hindmarsh (SA)
|
LIB
|
859
|
23
|
Paterson (NSW)
|
ALP
|
2368
|
|
97
|
Sydney (NSW)
|
ALP
|
843
|
24
|
Parkes (NSW)
|
NP
|
2329
|
|
98
|
Groom (Qld)
|
LIB
|
831
|
25
|
Bass (TAS)
|
ALP
|
2270
|
|
99
|
Dawson (Qld)
|
NP
|
817
|
26
|
Lindsay (NSW)
|
LIB
|
2221
|
|
100
|
Mackellar (NSW)
|
LIB
|
811
|
27
|
Calare (NSW)
|
IND
|
2111
|
|
101
|
Wannon (Vic)
|
LIB
|
805
|
28
|
Grey (SA)
|
LIB
|
1937
|
|
102
|
Braddon (TAS)
|
ALP
|
789
|
29
|
Rankin (Qld)
|
ALP
|
1930
|
|
103
|
Parramatta (NSW)
|
LIB
|
774
|
30
|
Charlton (NSW)
|
ALP
|
1897
|
|
104
|
Isaacs (Vic)
|
ALP
|
762
|
31
|
Longman (Qld)
|
LIB
|
1822
|
|
105
|
Holt (Vic)
|
ALP
|
759
|
32
|
Blair (Qld)
|
LIB
|
1772
|
|
106
|
Mitchell (NSW)
|
LIB
|
751
|
33
|
Greenway (NSW)
|
ALP
|
1726
|
|
107
|
Ballarat (Vic)
|
LIB
|
738
|
34
|
Dobell (NSW)
|
ALP
|
1702
|
|
108
|
Fadden (Qld)
|
LIB
|
729
|
35
|
Gwydir (NSW)
|
NP
|
1676
|
|
109
|
Brisbane (Qld)
|
ALP
|
728
|
36
|
Kalgoorlie (WA)
|
LIB
|
1667
|
|
110
|
Ryan (Qld)
|
LIB
|
714
|
37
|
Forde (Qld)
|
LIB
|
1627
|
|
111
|
Maranoa (Qld)
|
NP
|
693
|
38
|
Franklin (TAS)
|
ALP
|
1554
|
|
112
|
Banks (NSW)
|
ALP
|
691
|
39
|
Denison (TAS)
|
ALP
|
1551
|
|
113
|
Griffith (Qld)
|
ALP
|
691
|
40
|
Macquarie (NSW)
|
LIB
|
1506
|
|
114
|
Prospect (NSW)
|
ALP
|
669
|
41
|
Lyons (TAS)
|
ALP
|
1499
|
|
115
|
Farrer (NSW)
|
NP
|
665
|
42
|
Canberra (ACT)
|
ALP
|
1487
|
|
116
|
Cunningham (NSW)
|
ALP
|
657
|
43
|
Eden-Monaro (NSW)
|
LIB
|
1480
|
|
117
|
Deakin (Vic)
|
LIB
|
647
|
44
|
Petrie (Qld)
|
LIB
|
1452
|
|
118
|
Lilley (Qld)
|
ALP
|
633
|
45
|
Wakefield (SA)
|
LIB
|
1450
|
|
119
|
Moreton (Qld)
|
LIB
|
632
|
46
|
Werriwa (NSW)
|
ALP
|
1444
|
|
120
|
Reid (NSW)
|
ALP
|
612
|
47
|
Riverina (NSW)
|
NP
|
1431
|
|
121
|
Scullin (Vic)
|
ALP
|
597
|
48
|
Burke (Vic)
|
ALP
|
1427
|
|
122
|
Bradfield (NSW)
|
LIB
|
580
|
49
|
New England (NSW)
|
NP
|
1397
|
|
123
|
North Sydney (NSW)
|
LIB
|
571
|
50
|
Adelaide (SA)
|
LIB
|
1369
|
|
124
|
Chisholm (Vic)
|
ALP
|
571
|
51
|
Shortland (NSW)
|
ALP
|
1359
|
|
125
|
Wentworth (NSW)
|
LIB
|
571
|
52
|
Gippsland (Vic)
|
NP
|
1358
|
|
126
|
Gellibrand (Vic)
|
ALP
|
520
|
53
|
Macarthur (NSW)
|
LIB
|
1335
|
|
127
|
Melbourne (Vic)
|
ALP
|
512
|
54
|
Newcastle (NSW)
|
ALP
|
1333
|
|
128
|
Kingsford-Smith (NSW)
|
ALP
|
505
|
55
|
Makin (SA)
|
LIB
|
1302
|
|
129
|
Bruce (Vic)
|
ALP
|
479
|
56
|
McEwen (Vic)
|
LIB
|
1269
|
|
130
|
Leichhardt (Qld)
|
LIB
|
467
|
57
|
Dickson (Qld)
|
ALP
|
1244
|
|
131
|
Barton (NSW)
|
ALP
|
455
|
58
|
Hume (NSW)
|
LIB
|
1244
|
|
132
|
Wills (Vic)
|
ALP
|
455
|
59
|
Mayo (SA)
|
LIB
|
1223
|
|
133
|
Blaxland (NSW)
|
ALP
|
448
|
60
|
Corangamite (Vic)
|
LIB
|
1216
|
|
134
|
Kennedy (Qld)
|
NP
|
439
|
61
|
Gilmore (NSW)
|
LIB
|
1213
|
|
135
|
Bennelong (NSW)
|
LIB
|
434
|
62
|
Hughes (NSW)
|
LIB
|
1194
|
|
136
|
Batman (Vic)
|
ALP
|
421
|
63
|
Page (NSW)
|
NP
|
1191
|
|
137
|
Jagajaga (Vic)
|
ALP
|
412
|
64
|
Aston (Vic)
|
LIB
|
1179
|
|
138
|
Grayndler (NSW)
|
ALP
|
370
|
65
|
Throsby (NSW)
|
ALP
|
1176
|
|
139
|
Watson (NSW)
|
ALP
|
370
|
66
|
Robertson (NSW)
|
LIB
|
1171
|
|
140
|
Maribyrnong (Vic)
|
ALP
|
366
|
67
|
Port Adelaide (SA)
|
ALP
|
1162
|
|
141
|
Warringah (NSW)
|
LIB
|
348
|
68
|
Fraser (ACT)
|
ALP
|
1154
|
|
142
|
Lowe (NSW)
|
ALP
|
346
|
69
|
Hinkler (Qld)
|
NP
|
1137
|
|
143
|
Menzies (Vic)
|
LIB
|
331
|
70
|
Lalor (Vic)
|
ALP
|
1121
|
|
144
|
Goldstein (Vic)
|
LIB
|
292
|
71
|
Dunkley (Vic)
|
LIB
|
1120
|
|
145
|
Melbourne Ports (Vic)
|
ALP
|
292
|
72
|
Indi (Vic)
|
LIB
|
1097
|
|
146
|
Hotham (Vic)
|
ALP
|
286
|
73
|
Richmond (NSW)
|
NP
|
1061
|
|
147
|
Kooyong (Vic)
|
LIB
|
275
|
74
|
Murray (Vic)
|
LIB
|
1035
|
|
148
|
Higgins (Vic)
|
LIB
|
271
|
Some interesting observations can be drawn from
the data in these tables. Electorates covering outer metropolitan
areas(27) account for the highest or second highest
number of prescriptions in each State except Victoria. Electorates
covering inner metropolitan areas account for the lowest number of
prescriptions in New South Wales, Victoria and South Australia, but
rural electorates account for the lowest number of prescriptions in
Western Australia, Queensland and Tasmania. Provincial electorates
account for the highest or second highest number of prescriptions
in Victoria, Western Australia and Tasmania.
In New South Wales, Victoria and South
Australia, the electorate with the lowest number of prescriptions
also has a much lower proportion of children in the 5-14 years age
range and a much lower proportion of persons attending school.
However, the electorates with the lowest number of prescriptions in
both Queensland and Western Australia have only slightly lower
proportions of children aged 5-14 and persons attending school than
the electorates in those States with the highest number of
prescriptions. In Tasmania, the electorate of Braddon has a higher
proportion of children aged 5-14 and a higher proportion of persons
attending school but has around only one-third the number of
prescriptions for dexamphetamine sulfate than does the electorate
of Bass.
Examining income, the electorates with the
highest number of prescriptions in New South Wales, Victoria and
Western Australia all have a significantly higher proportion of
families with a weekly income below $500 than the electorate with
the lowest number of prescriptions. However, this is not the case
in Queensland, South Australia and Tasmania. A comparison of the
unemployment rate in each electorate reveals a similar picture,
with the exception of Queensland. The electorate with the lowest
number of prescriptions in Queensland also had a significantly
lower rate of unemployment, a situation similar to that in New
South Wales, Victoria and Western Australia.
Two caveats need to be placed upon the foregoing
discussion. It is possible that the prescribing practices of a
small number of practitioners in each jurisdiction could be
responsible for some of the variation evident in the figures in
table 2 and the appendices. For example, a study on medication for
ADHD in Adelaide found that five prescribers accounted for 61 per
cent of patients in 1996.(28) It has also been suggested
that while there may be a variety of reasons that contribute to the
regional differences:
often it comes down to small numbers of high
profile, often academic individuals at a teaching hospital who
maybe believe strongly in the benefits of medication, and teaching
the trainees for a generation in that particular town that
stimulants are good and therefore you get lots of children being
prescribed. Whereas you might have in another town more
psychologically based clinicians who are less inclined to use
medication.(29)
In addition, it was noted earlier that around 96
000 prescriptions for Ritalin were dispensed in Australia in
1999-2000. Because this drug is not subsidised under the PBS,
national data similar to that for dexamphetamine sulfate is not
readily available. It is likely, however, that a different pattern
would be apparent between electorates for prescriptions dispensed
for Ritalin than is evident for dexamphetamine sulfate.
Conclusion
It is clear from the data in the attached tables
for each State and the discussion above that socioeconomic data
alone do not explain why such wide differences exist between
electorates in the number of prescriptions dispensed for
dexamphetamine sulfate. None of the socioeconomic factors examined
in this paper can explain consistently the reasons why such
differences exist. Particular factors such as a higher unemployment
rate and lower levels of family income appear to be significant in
some jurisdictions, but this is not consistent across all States.
The picture is similar for the proportion of school-aged children
in different electorates.
Outer metropolitan electorates have the highest
or second highest numbers of prescriptions in each State except
Victoria. This is intriguing, but there do not appear to be any
other factors present that help to explain consistently why this
should be the case. While the location of particular prescribers
cannot conclusively be ruled-out as an important factor, the mix of
electorates with high and low numbers of prescriptions would seem
to indicate that it does not consistently explain the variations
evident in the data.
If it is accepted that practitioners in Western
Australia are more highly skilled in recognising ADHD than their
counterparts in other States, it might be expected that greater
consistency would be evident in the number of prescriptions
dispensed in WA electorates. While this is true to an extent, there
is still considerable variation; from in excess of 8000
prescriptions in the electorate of Canning to less than 2000 in
Kalgoorlie.
It appears from the data discussed in this paper
that decisions on the treatment of ADHD with dexamphetamine sulfate
may not always be evidence-based. If this is the case, the one
conclusion that does appear to be sustainable is that the interests
of Australia's children and their families are unlikely to be well
served by such variation between electorates. Australia appears to
be some way from best practice in the prescribing of such
medication for the treatment of ADHD.
Appendix 1: Western
Australia
Variable
|
Canning
|
Brand
|
Kalgoorlie
|
Demographic rating
|
Outer metropolitan
|
Provincial
|
Rural
|
Number of prescriptions
|
8643
|
7085
|
1667
|
Prop. children aged 5-14 years
|
17.2 %
|
17.2%
|
15.1%
|
Proportion persons attending school*
|
18.5%
|
18.2%
|
14.2%
|
Proportion couple families with dependent children
|
41.9%
|
40.0%
|
48.1%
|
Prop. one parent families with dependent children
|
10.9%
|
11.2%
|
10.4%
|
Prop. families weekly income below $500
|
33.2%
|
39.6%
|
24.2%
|
Prop. families weekly income $1500 and above
|
7.8%
|
7.0%
|
20.4%
|
Unemployment rate (Census 1996)
|
9.6%
|
11.9%
|
5.8%
|
*infants, primary and secondary school
Sources: A Kopras, Electorate Rankings: Census
1996; Department of Health and Aged Care, Electorate
Profiles, June 2000.
Appendix 2: New South
Wales
Variable
|
Chifley
|
Cowper
|
Warringah
|
Demographic rating
|
Outer metropolitan
|
Rural
|
Inner metropolitan
|
Number of prescriptions
|
3129
|
2564
|
348
|
Prop. children aged 5-14 years
|
18.3%
|
16.4%
|
10.5%
|
Proportion persons attending school*
|
20.5%
|
18.8%
|
12.5%
|
Proportion couple families with dependent children
|
46.3%
|
37.2%
|
35.9%
|
Prop. one parent families with dependent children
|
15.1%
|
13.0%
|
6.8%
|
Prop. families weekly income below $500
|
31.9%
|
51.2%
|
16.8%
|
Prop. families weekly income $1500 and above
|
9.1%
|
3.9%
|
34.8%
|
Unemployment rate (Census 1996)
|
10.5%
|
17.9%
|
3.8%
|
*infants, primary and secondary school
Sources: A Kopras, Electorate Rankings: Census
1996; Department of Health and Aged Care, Electorate
Profiles, June 2000.
Appendix 3:
Victoria
Variable
|
Corio
|
McMillan
|
Higgins
|
Demographic rating
|
Provincial
|
Rural
|
Inner Metropolitan
|
Number of prescriptions
|
2747
|
2717
|
271
|
Prop. children aged 5-14 years
|
14.2%
|
17.0%
|
9.6%
|
Proportion persons attending school*
|
17.0%
|
19.4%
|
11.7%
|
Proportion couple families with dependent children
|
38.8%
|
43.7%
|
36.3%
|
Prop. one parent families with dependent children
|
11.0%
|
10.7%
|
7.8%
|
Prop. families weekly income below $500
|
37.5%
|
38.1%
|
20.6%
|
Prop. families weekly income $1500 and above
|
8.0%
|
7.8%
|
33.3%
|
Unemployment rate (Census 1996)
|
12.9%
|
12.6%
|
6.8%
|
*infants, primary and secondary school
Sources: A Kopras, Electorate Rankings: Census
1996; Department of Health and Aged Care, Electorate
Profiles, June 2000.
Appendix 4:
Queensland
Variable
|
Oxley
|
Rankin
|
Kennedy
|
Demographic rating
|
Outer metropolitan
|
Outer metropolitan
|
Rural
|
Number of prescriptions
|
3078
|
1930
|
439
|
Prop. children aged 5-14 years
|
16.3%
|
17.6%
|
15.7%
|
Proportion persons attending school*
|
17.5%
|
19.0%
|
16.4%
|
Proportion couple families with dependent children
|
42.1%
|
46.1%
|
41.7%
|
Prop. one parent families with dependent children
|
13.5%
|
13.5%
|
9.8%
|
Prop. families weekly income below $500
|
34.1%
|
31.8%
|
34.8%
|
Prop. families weekly income $1500 and above
|
6.6%
|
8.1%
|
10.3%
|
Unemployment rate (Census 1996)
|
10.7%
|
11.5%
|
7.6%
|
*infants, primary and secondary school
Sources: A Kopras, Electorate Rankings: Census
1996; Department of Health and Aged Care, Electorate
Profiles, June 2000.
Appendix 5: South
Australia
Variable
|
Bonython
|
Kingston
|
Hindmarsh
|
Demographic rating
|
Outer metropolitan
|
Outer metropolitan
|
Inner metropolitan
|
Number of prescriptions
|
4054
|
3041
|
859
|
Prop. children aged 5-14 years
|
17.1%
|
16.7%
|
9.4%
|
Proportion persons attending school*
|
19.2%
|
19.4%
|
11.4%
|
Proportion couple families with dependent children
|
41.3%
|
42.9%
|
28.8%
|
Prop. one parent families with dependent children
|
14.4%
|
11.4%
|
9.1%
|
Prop. families weekly income below $500
|
42.8%
|
34.6%
|
37.3%
|
Prop. families weekly income $1500 and above
|
3.5%
|
6.0%
|
9.2%
|
Unemployment rate (Census 1996)
|
16.2%
|
11.3%
|
10.3%
|
*infants, primary and secondary school
Sources: A Kopras, Electorate Rankings: Census
1996; Department of Health and Aged Care, Electorate
Profiles, June 2000.
Appendix 6:
Tasmania
Variable
|
Bass
|
Franklin
|
Braddon
|
Demographic rating
|
Provincial
|
Outer metropolitan
|
Rural
|
Number of prescriptions
|
2270
|
1554
|
789
|
Prop. children aged 5-14 years
|
14.4%
|
17.4%
|
16.1%
|
Proportion persons attending school*
|
16.6%
|
19.4%
|
18.0%
|
Proportion couple families with dependent children
|
38.6%
|
42.0%
|
39.8%
|
Prop. one parent families with dependent children
|
11.0%
|
11.8%
|
10.0%
|
Prop. families weekly income below $500
|
38.7%
|
35.2%
|
42.5%
|
Prop. families weekly income $1500 and above
|
7.2%
|
8.9%
|
5.6%
|
Unemployment rate (Census 1996)
|
10.9%
|
10.1%
|
12.5%
|
*infants, primary and secondary school
Sources: A Kopras, Electorate Rankings: Census
1996; Department of Health and Aged Care, Electorate
Profiles, June 2000.
Endnotes
-
- G. Fritz, 'The time is right to dispel myths about ADHD',
Brown University Child and Adolescent Behavior Letter,
vol. 16, issue 9, September 2000, p. 8.
- Dexamphetamine sulfate is listed on the PBS for the treatment
of ADHD and narcolepsy. More than 95 per cent of prescriptions are
dispensed for the treatment of ADHD.
- American Psychiatric Association, Diagnostic and
Statistical Manual of Mental Disorders, 4th
edition, 1994.
- M. Sawyer et al., Mental Health of Young People in
Australia, Department of Health and Aged Care, Canberra, 2000.
- ibid., p. 19.
- National Health and Medical Research Council, Attention
Deficit Hyperactivity Disorder, NH&MRC, Canberra, 1997, p.
xi.
- National Health and Medical Research Council, op. cit., p. 17.
- US Surgeon General, Mental Health: a Report of the Surgeon
General, 1999.
- National Health and Medical Research Council, op. cit., p. xi.
- Sawyer, op. cit., p. 20.
- Sawyer, op. cit., p. 26.
- National Health and Medical Research Council, op. cit., p. 99.
- U.S. National Institute of Mental Health, Long term effects
of stimulant medications on the brain: possible relevance to the
treatment of ADHD: notes of a NIMH workshop, December 1999, at
www.nimh.nih.gov/events/adhdworkshop.cfm
- P. Hazell, 'ADHD: Diagnosis and treatment', in
Psychological Medicine: a companion to management of mental
disorders, edited by P. Beumont, G. Andrews, P. Boyce, V.
Carr, WHO Collaborating Centre for Mental Health and Substance
Abuse, Sydney 1997.
- National Health and Medical Research Council, op. cit., p. 41.
- Commonwealth Department of Health and Aged Care, Australian
Statistics on Medicine, various years.
- L. Diller, Running on Ritalin: a physician reflects on
children, society and performance in a pill, quoted in B.
Prosser and R. Reid, 'Psychostimulant use for children with
Attention Deficit hyperactivity Disorder in Australia', Journal
of Emotional and Behavioral Disorders, vol. 7, 1999, p.
110-117.
- National Health and Medical Research Council, op. cit., p. 69.
- See for example, M. Riley, 'Kiddie cocaine: it's the drug of
the new generation', Sydney Morning Herald, 21 February
2001, p. 1, 10.
- US National Institute of Mental Health, Attention Deficit
Hyperactivity Disorder (ADHD)-Questions and Answers, at
www.nimh.nih.gov/publicat/adhdqa.cfm
- US Surgeon General, Mental Health: a report of the Surgeon
General, 1999.
- C. Sparke, 'The ADHD epidemic', Australian Doctor, 26
April 2000, p. 31-33.
- Dr N. Swan, The Health Report, 23 October 2000.
- K. Gadow and J. Loney eds, Psychosocial aspects of drug
treatment for hyperactivity, quoted in B. Prosser and R. Reid,
'Psychostimulant use for children with Attention Deficit
Hyperactivity Disorder in Australia', Journal of Emotional and
Behavioral Disorders, vol. 7, 1999, p. 110-117.
- B. Prosser and R. Reid, 'Psychostimulant use for children with
Attention Deficit hyperactivity Disorder in Australia', Journal
of Emotional and Behavioral Disorders, vol. 7, 1999.
- Rankings of electorates against a wide range of census data can
be found in: A Kopras, 'Electorate Rankings: Census 1996',
Background paper No. 14, 1997-98, Department of the
Parliamentary Library, Canberra, 1998.
- Electorates are classified by the Australian Electoral
Commission into four socio-demographic categories: inner
metropolitan (comprising well established built-up suburbs); outer
metropolitan (containing areas of more recent suburban expansion);
provincial (majority of enrolment in major provincial cities, or in
non-metropolitan urban conglomerates); and rural (without a
majority of enrolment in major provincial cities). Australian
Electoral Commission, National Electoral Division
Profiles, Australian Electoral Commission, Canberra December
1998, p. v.
- B. Prosser and R. Reid, 'Psychostimulant use for children with
Attention Deficit hyperactivity Disorder in Australia', Journal
of Emotional and Behavioral Disorders, vol. 7, 1999.
- Dr D. Efron, Paediatrician, Royal Children's Hospital,
Melbourne, interviewed on The Health Report, ABC Radio, 23 October
2000.