Gender Differences in Psychotropic Medicine Dispensing at a Pharmacy
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dose.7 Th is refl ects the need in the fi rst half of the twen- ARTICLE tieth century for safer alternatives to existing psycho- tropic drugs. Gender diff erences in psychotropic During the 1950s, an event referred to as the ‘Psy- medicine dispensing at a pharmacy in chopharmacological Revolution’ forever changed the Melbourne, Australia, 1954 and 1961 face of psychiatric practice.8 In December 1950, French chemist Paul Charpentier synthesised a medicinal sub- Michael Leach and Rebecca Kippen stance called chlorpromazine.9 Over the next two years, this drug was trialled and found to relieve psychotic Abstract agitation, especially manic excitation.10 Chlorproma- An examination of psychotropic dispensing by gender zine was fi rst marketed in December 1952 for the treat- in historic prescription books could help trace the ori- ment of psychiatric disorders and other indications, in- gins of psychopharmacology in Australia. Th is study cluding morning sickness.11 Th e drug was, and still is, examined gender diff erences in psychotropic medicine marketed in Europe and Australia under the brand dispensing at a Melbourne pharmacy during the 1950s name ‘Largactil’. It soon became possible for people suf- and 1960s. Data were sourced from two prescription fering from psychiatric disorders to be successfully books. Numbers of prescriptions dispensed in 1954 and managed with chlorpromazine in the community rath- 1961 were calculated for each gender and adjusted for er than being institutionalised.12 Chlorpromazine be- population size. More prescriptions were dispensed for came the world’s fi rst antipsychotic drug. Th e success females than for males, by factors of 2 and 1.7 to 1 in of chlorpromazine in psychiatry gave birth to the fi eld 1954 and 1961, respectively. Th is diff erential persisted of psychopharmacology and prompted the search for across prescription type (barbiturate psychotropic, non- other targeted psychotropic drugs, with further antip- barbiturate psychotropic, and non-psychotropic). Psy- sychotics and drugs such as tricyclic antidepressants chotropic dispensing shifted from barbiturates (77% in and benzodiazepines becoming available in the 1950s 1954; 38% in 1961) to newer, safer non-barbiturates and 1960s.13 Many of these newly available non-barbi- (23% in 1954; 62% in 1961), irrespective of gender. turate psychotropic medicines had superior safety pro- fi les to the earlier barbiturate drugs. This was a time of Introduction rapid change in the practice of psychiatry and pharma- Prior to the 1950s, there were few eff ective, safe, and cy. humane options for the management of mental health Gender is an example of a demographic factor that disorders. People with mental health disorders were could have infl uenced the uptake of new psychotropic managed to a small extent in the community and to a medicines over the 1950s and 1960s. Compared with large extent in purpose-built asylums, through methods men, women may be less reluctant to seek medical at- such as electroconvulsive therapy and physical restraint tention and more sensitive to market changes.14 In a or through any of a small number of psychotropic prior study of prescription books kept in an English drugs.1,2 Drugs in the barbiturate class were among the community pharmacy over the period 1890-1922, the most commonly used prescription psychotropic medi- drugs of dependence opium, cocaine, and heroin (legal cines in the fi rst half of the twentieth century.3 Th is substances at the time) were more likely to be dispensed drug class takes its name from the fi rst barbiturate bar- to females than to males.15 Th ese results were not, how- bituric acid, which was discovered and named by Ger- ever, adjusted for the sizes of the male and female pop- man chemist Johann Adolf von Baeyer on 4 December ulations in the surrounding geographic area. Many of 1863 – the feast day of St. Barbara.4 the male users of drugs of dependence in this historical Barbiturate use became commonplace in Western study were returned servicemen who served in such society following the marketing of barbitone (brand countries as South Africa and India.16 name Veronal) in 1903.5 While barbiturates have prov- While this study shed some light on gender diff er- en eff ective at inducing sleep, they have also been ences in the utilisation of drugs of dependence between shown to cause a range of adverse eff ects such as un- the 1890s and 1920s, no known studies have examined wanted daytime sedation, comas, and deaths, including gender diff erences in psychotropic use within a com- the deaths of actresses Marilyn Monroe in 1962 and munity pharmacy setting during the 1950s and 1960s Judy Garland in 1969.6 Such a high potential for harm – the period of the Psychopharmacological Revolution. relates to the fact that barbiturates have narrow thera- Women may have been more likely than men to seek peutic indices; there is little diff erence between the dose newly available treatments for mental health disorders, required to eff ectively sedate a patient and the lethal whereas returned servicemen with conditions such as PHARMACEUTICAL HISTORIAN · 2019 · Volume 49/3 65 posttraumatic stress disorder may have also been regu- to 1 June 1956, while the more recent book covers the lar users of psychotropics at this time. Such information period 20 May 1960 to 24 July 1963. Both volumes is of interest in that it lays the foundation for the high contain handwritten information on prescriptions dis- levels of psychotropic use in modern day Australia. pensed by several pharmacists, or pharmaceutical Modern day Australia has been found to have the sec- chemists as they were known at the time. Th e handwrit- ond highest consumption of antidepressants in the ten information includes patients’ titles, patients’ world,17 with women being signifi cantly more likely names, dispensing dates, medicines dispensed, costs, than men to use these medicines.18 An examination of and directions for use. Th e pharmaceutical chemists psychotropic dispensing by gender in historic prescrip- wrote this information in ink on ruled pages, using the tion books could help trace the origins of psychophar- conventional academic language of Latin. Th e dis- macology in Australia. pensed prescriptions appear in each book in chrono- Th is study aimed to examine gender diff erences in logical order. psychotropic medicine dispensing at an Inner South East Melbourne pharmacy during the Psychopharma- Study Design and Data Collection cological Revolution of the 1950s and 1960s. A descriptive study was conducted to examine the vol- ume of medicine dispensing over the calendar years Methods 1954 (book 1) and 1961 (book 2) by gender, prescrip- Data Source tion type, and year. Th ese years were chosen to examine Prescription books can be considered rich yet underu- changes in psychotropic drug utilisation over a period tilised sources of primary historical data on medicine coinciding with the rapid introduction of new psycho- dispensing.19 Prior to the availability of dispensing soft- tropics (antipsychotics, benzodiazepines, and antide- ware, prescription books were used to record all pre- pressants) into the Australian market during the 1950s scribed medicines supplied to customers. Previously, and 1960s. For each prescription recorded in the two 20 21 prescription books dating from the 1850s, 1860s, books over the years 1954 and 1961, the following data 22 23 1900s, and 1960s have been used to broadly describe items were collected: dispensing date, patient title, and the medicines dispensed in individual Australian phar- name of medicine dispensed. Th e title of patients (e.g. macies. In the United Kingdom, meanwhile, prescrip- Mr, Mrs, Sir, and Lady) was used as a marker of gender. tion books dating back to the nineteenth and twentieth Among all medicines dispensed, barbiturate psycho- centuries have been examined to better understand tropics, non-barbiturate psychotropics, and non-psy- temporal changes in the use of diff erent dosage forms chotropic medicines were identifi ed using a published 24, 25, as well as the dispensing of drugs of dependence. list of psychotropics in common use in 195929 as well 26, 27, 28 as the editions of the British Pharmacopoeia30, 31 and Th e data source for the present study is a pair of Martindale: Th e Extra Pharmacopoeia32, 33 that were cur- mid-twentieth-century prescription books that were rent at the time. kept at a community pharmacy in an inner south east suburb of Melbourne, Australia (Figure 1). Each book Inclusion and Exclusion Criteria is bound in leather and measures 41 x 18.7 x 9.7 centi- For each prescription, the inclusion criterion was med- metres. Th e elder of the two books details prescription icine supply during the calendar years 1954 or 1961 medicines dispensed over the period 25 November 1953 while the exclusion criteria were unknown gender (no title), a cancelled prescription, a prescription intended for veterinary use, and handwriting that could not be deciphered by a pharmacoepidemiologist with experi- ence in community pharmacy. Data Analysis A descriptive analysis of eligible prescriptions was con- ducted. Firstly, raw numbers of prescriptions dispensed in 1954 and 1961 were calculated and stratifi ed by pre- scription type (barbiturate psychotropic, non-barbitu- rate psychotropic, or non-psychotropic medicine), year of dispensing, and gender of the patient. Th e raw num- Figure 1. Th e prescription books used to source primary bers were then adjusted for the size of the male and fe- data male populations resident in the local government area 66 PHARMACEUTICAL HISTORIAN · 2019 · Volume 49/3 (LGA) City of Stonnington – where the pharmacy was analysis. In the later period, between 3/1/1961 and located – using Australian census data for the years 29/12/1961, 2,783 prescriptions were recorded in the 195434 and 1961.35 What is now Stonnington com- second Melbourne pharmacy ledger.