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Articles   |    
Educational Gradients in Psychotropic Medication Use Among Older Adults in Costa Rica and the United States
Marisa Elena Domino, Ph.D.; William H. Dow, Ph.D.; Fernando Coto-Yglesias, M.D.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300092
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Dr. Domino is with the Department of Health Policy and Management, University of North Carolina, Chapel Hill (e-mail: domino@unc.edu). Dr. Dow is with the Division of Health Policy and Management, University of California, Berkeley. Dr. Coto-Yglesias is with the Department of Geriatric Medicine, National Geriatrics and Gerontology Hospital, Caja Costarricense de Seguro Social, San Jose, Costa Rica.

Copyright © 2014 by the American Psychiatric Association

Abstract

Objective  The relationship of education, psychiatric diagnoses, and use of psychotropic medication has been explored in the United States, but little is known about this relationship in poorer countries, despite the high burden of mental illness in these countries. This study estimated educational gradients in diagnosis and psychotropic drug use in the United States and Costa Rica, a middle-income country with universal health insurance.

Methods  Analyses were conducted by using data of older adults (≥60) from the 2005 U.S. Medical Expenditure Panel Survey (N=4,788) and the 2005 Costa Rican Longevity and Healthy Aging Study (N=2,827). Logistic regressions examined the effect of education level (low, medium, or high) and urban residence on the rates of self-reported mental health diagnoses, screening diagnosis, and psychotropic medication use with and without an associated psychiatric diagnosis.

Results  Rates of self-reported diagnoses were lower in the United States (12%) than in Costa Rica (20%), possibly reflecting differences in survey wording. In both countries, the odds of having depression were significantly lower among persons with high education. In Costa Rica, use of psychotropic medication among persons with self-reported diagnoses increased by education level.

Conclusions  The educational gradients in medication use were different in the United States and Costa Rica, and stigma and access to care in these countries may play an important role in these differences, although type of insurance did not affect educational gradients in the United States. These analyses increase the evidence of the role of education in use of the health care system.

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Table 1Characteristics of older participants in nationally representative surveys from Costa Rica and the United Statesa
Table Footer Note

a Data for Costa Rica were from the Costa Rican Longevity and Healthy Aging Study (CRELES), a probabilistic sample of noninstitutionalized adults age ≥60, from 2005. Data for the United States were from the Medical Expenditure Panel Survey (MEPS) of the noninstitutionalized civilian population, also from 2005, but only data from respondents who were age ≥60 were included.

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b In the CRELES, the Geriatric Depression Scale was used to identify mild or severe depression, and in the MEPS, the Patient Health Questionnaire–2 was used to identify probable depression.

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c Among U.S. adults, low education was defined as less than high school; medium education, high school graduate; and high education, some college or postsecondary education. Among adults in Costa Rica, low education was defined as ≤2 years of primary education; medium education, completed primary education; and high education, some postprimary education.

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d Defined as living in a metropolitan statistical area (MSA) (United States) or by census block (Costa Rica)

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Table 2Odds of self-reporting a mental health diagnosis and screening positive for depression among older adults from Costa Rica and the United States, by characteristica
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a Data for Costa Rica were from the Costa Rican Longevity and Healthy Aging Study, a probabilistic sample of noninstitutionalized adults age ≥60, from 2005. Self-reported diagnosis was not available for all participants. Data for the United States were from the Medical Expenditure Panel Survey (MEPS) of the noninstitutionalized civilian population, also from 2005, but only data from respondents who were age ≥60 were included.

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b In the CRELES, the Geriatric Depression Scale was used to identify mild or severe depression, and in the MEPS, the Patient Health Questionnaire–2 was used to identify probable depression. Scores were not available for all participants.

Table Footer Note

c Among U.S. adults, low education was defined as less than high school; medium education, high school graduate; and high education, some college or postsecondary education. Among adults in Costa Rica, low education was defined as ≤2 years of primary education; medium education, completed primary education; and high education, some postprimary education.

Table Footer Note

d The reference groups were persons living in a census block classified as rural (Costa Rica) or persons not living in a metropolitan statistical area (MSA) (United States).

Table Footer Note

* p<.05, **p<.01

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Table 3Odds of antidepressant use among older adults from Costa Rica and the United States who did or not self-report a mental health diagnosis, by characteristica
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a Data for Costa Rica were from the Costa Rican Longevity and Healthy Aging Study, a probabilistic sample of noninstitutionalized adults age ≥60, from 2005. Information about self-reported diagnoses were available for 2,812 respondents. Data for the United States were from the Medical Expenditure Panel Survey (MEPS) of the noninstitutionalized civilian population, also from 2005, but only data from respondents who were age ≥60 were included.

Table Footer Note

b Among U.S. adults, low education was defined as less than high school; medium education, high school graduate; and high education, some college or postsecondary education. Among adults in Costa Rica, low education was defined as ≤2 years of primary education; medium education, completed primary education; and high education, some postprimary education.

Table Footer Note

c The reference groups were persons living in a census block classified as rural (Costa Rica) or persons not living in a metropolitan statistical area (MSA) (United States).

Table Footer Note

* p<.05, **p<.01

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Table 4Odds of antipsychotic use among older adults from Costa Rica and the United States who did or not self-report a mental health diagnosis, by characteristica
Table Footer Note

a Data for Costa Rica were from the Costa Rican Longevity and Healthy Aging Study, a probabilistic sample of noninstitutionalized adults age ≥60, from 2005. Information about self-reported diagnoses were available for 2,812 respondents. Data for the United States were from the Medical Expenditure Panel Survey (MEPS) of the noninstitutionalized civilian population, also from 2005, but only data from respondents who were age ≥60 were included.

Table Footer Note

b Among U.S. adults, low education was defined as less than high school; medium education, high school graduate; and high education, some college or postsecondary education. Among adults in Costa Rica, low education was defined as ≤2 years of primary education; medium education, completed primary education; and high education, some postprimary education.

Table Footer Note

c The reference groups were persons living in a census block classified as rural (Costa Rica) or persons not living in a metropolitan statistical area (MSA) (United States).

Table Footer Note

* p<.05, **p<.01

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Table 5Odds of receipt of psychotropic medication available in the GP national formulary or through specialty prescription among older adults in Costa Rica who did or did not report a mental health diagnosis, by characteristica
Table Footer Note

a Data were from the Costa Rican Longevity and Healthy Aging Study, a probabilistic sample of noninstitutionalized adults age ≥60, from 2005. Information about self-reported diagnoses were available for 2,812 respondents. The general practitioner (GP) national formulary includes drugs that public-sector GPs are able to prescribe. Specialty prescriptions require access to a specialist or private physician.

Table Footer Note

b Low education was defined as ≤2 years of primary education; medium education, completed primary education; and high education, some postprimary education.

Table Footer Note

* p<.05, **p<.01

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