Gender Differences in Predictors of Self-Medication with Tranquillizers and Sleeping Pills: Results of the Population-Based Study in Serbia

The World Health Organization (WHO) has defined the term ‘responsible self-medication’ as a practice in which individuals treat their illnesses and conditions with medicines that have been approved for use and are available without a prescription, but are also safe and effective when used as directed (1). In spite of the many benefits of responsible self-medication, actual practice in medication use provides opportunities for improper use of medicines, e.g. self-medication with drugs approved as prescription drugs. This practice was recognized as a typical example of drug misuse by the WHO (2). Accordingly, preventative actions are of high importance as they align with potential risks at the individual and community level, where such practice induces a higher prevalence of drug-induced diseases and subsequent increases in public expenditure (3,4,5).

It was recorded that the practice of self-medication in Serbia includes not only over-the-counter medicines but also prescription medicines. Luković et al. reported that medical students used sedatives (13%) and antidepressants (2%) without a doctor’s prescription in the year previous to the study taking place (6). This practice is very worrying as it correlates to a wide range of adverse effects such as changes in blood pressure, heart rate, sweating, insomnia (7), sedation (8), and sexual dysfunction (9). Moreover, benzodiazepines are identified as a contributing factor in suicides and poisoning deaths, while withdrawal and dependence of benzodiazepines have raised particular concerns (8, 10). Since self-medication with sedatives and antidepressants could be a threat to both individual and public health, this phenomenon should be investigated in detail to reveal the most common causes and strategies for reducing such practice.

Studies on predictors of self-medication with tranquillizers and sleeping pills are rare and commonly associated with the investigation of alcohol and opioid abuse (11,12,13). It was shown that self-medication of anxiety disorders was associated with lower mental health-related quality of life and a higher use of health services (14). The timely screening and treatment of mental health problems are well-recognised preventive factors for substance-use disorders (15). Additionally, the lack of medicines was revealed as primary unmet healthcare needs among patients with mental health problems (16). It was also shown that adolescents who were prescribed anxiolytics during their lifetime were 12 times more likely to use another’s anxiolytic medication, which was recognized as a risk factor with significant implication to later substance-use problems (17). The abuse of tranquillizers or sedatives in adults was shown to be directly associated with a higher prevalence of substance use disorder later on (18). Female gender was a well-confirmed risk factor for self-medication in general (19,20,21,22,23,24). Up-to-date research suggests that females also seem to be at a higher risk from self-medication with tranquillizers and sleeping pills, but such studies are rare (25). Studies that investigated predictors of self-medication with tranquillizers and sleeping pills only in males are missing. Highlighting the prevalence, determinants and gender differences in self-medication with tranquillizers and sleeping pills could be very useful in the creation of targeted interventions and prevention of such addictive disorders. The aim of the current analysis is to identify gender-related socio-demographic, health and health service associated predictors in self-medication with tranquillizers and sleeping pills in the Serbian population.

Females and males have been almost equally distributed in the study sample; 7,570 (51.77%) and 7,053 (48.23%), respectively. In sum, 579 (4%; 95% CI: 3.6–4.3) of the study population reported self-medication with tranquillizers and sleeping pills. While 421 of the female population (5.6%, 95% CI: 5.0–6.1), only 158 of the male population (2.2%, 95% CI: 1.9–2.6) reported such self-medication practice (p<0.001).

Further analysis has shown that self-medication with selected drugs among females (Table 1) and males (Table 2) was significantly associated with investigated socio-demographic and health-related characteristics, as well as unmet healthcare needs in the past 12 months due to the long waiting time for health service, distance or transportation barriers. However, it was not associated with the satisfaction with public and private health service among females, and with education and satisfaction with private healthcare service among males (p>0.05).

Based on our knowledge, this is a rare study highlighting gender differences in predictors of self-medication with tranquillizers and sleeping pills controlled for socio-demographic factors, health status and satisfaction with the healthcare system. Our study has shown that self-medication is a more frequent practice among the female population compared to males in cases of self-medication with tranquillizers and sleeping pills. Health-related factors (chronic disease and physical pain) and environmental stress were revealed as independent predictors of self-medication with observed drugs in both men and women. However, gender differences have been shown through two discriminatory factors, age, and employment status. While an age of above 45 years has been revealed as a strong predictor of self-medication with tranquillizers and sleeping pills in women, a similar effect was not confirmed among males. On the contrary, unemployment has been shown as a significant determinant of self-medication with tranquillizers and sleeping pills in males, but without significant influence in females.

Several previous studies investigated the determinants of regularly prescribed medication use for depression, anxiety, stress, and sleep problems in the female population (27, 28). They also found age, stress, and physical pain as predictors of regular use of hypnotics/anxiolytics/sedatives, as well as other predictors like social tension, hormone replacement therapy, headaches, palpitations, mood swings or increased muscular tension, anger, duration of symptoms lasting longer than one week, consulting a specialist, and mental health-related quality of life. In line with the abovementioned predictive factors, one potential area of intervention may be a focus on timely and proper patient education interventions by healthcare professionals with special warnings about side effects. This may aid in the prevention of future self-medication in women already prescribed drugs for depression, anxiety, stress, or sleeping problems.

This study has also shown that self-medication with tranquillizers and sleeping pills is significantly higher in males and females who have reported chronic diseases and physical pain. Since these patients are most likely already prescribed some other medicines, the possibility of drug-drug interactions is increased. This could be of particular concern if an already prescribed drug is a suppressor of the central nervous system (CNS), because of the well-known CNS suppressive effect of tranquillizers and sleeping pills (29, 30). Along with warnings about side effects, patient education interventions should include descriptions of prescribed therapy purposes, with the aim to decrease the rate of therapy duplication or harmful effects.

The results of our study have shown that the risks from self-medication in women increase significantly for those over 45 years of age, which coincides with the start of the menopause. This risk reaches a peak at 55–64 years of age when women predominantly cope with unpleasant menopausal symptoms. Additionally, many with symptoms of non-communicable diseases maintain overwhelming amounts of work and family responsibilities with little to no focus on personal health. The decline of risk starts after 65 years of age, which could be linked to the end of women’s working engagement and a decrease in the level of family stress, as well as to the end of the menopause. Most middle-aged women suffer from high demands in personal and professional responsibilities and, accordingly, need specialised support. A similar phenomenon may be observed with unemployed males. In spite of Serbia’s many modern ways of thinking about traditional gender roles, some traditional elements continue to dominate within Serbian society. One example is the attitude that males are consistently expected to serve as dominant breadwinners in the family. For this reason, the male population requires additional healthcare support in the effects of unstable employment status. Our study directly confirms previous data that self-medication with tranquillizers is not supported by the hypothesis of gender role convergence and expectations (11).

Environmental stress is the only modifiable factor revealed as the predictor of self-medication with tranquillizers and sleeping pills in both women and men. Although coping with stress is stressful by itself, psychotherapy, meditation, and other relaxing techniques are showed as helpful (31). However, such techniques are not yet widely accepted in the Serbian population. Concurrently, Šantrić-Milićević et al. reported that almost half of the Serbian adult population assessed their mental health as poor and 5% had diagnosed chronic anxiety or depression (32). Accordingly, well-tailored public health actions, specifically targeting middle-aged women and unemployed males and their ability to cope with stress and pressure in healthy ways, could potentially reduce the high level of self-medication with tranquillizers and sleeping tablets and prevent unwanted behaviours and consequences.

While previous studies have established the association between unmet healthcare needs and self-medication in general or with self-medication with illicit drugs, our results have not confirmed previous findings (15, 21, 23, 33). Nevertheless, a relatively high prevalence of unmet healthcare needs has been recorded. Unmet healthcare needs due to barriers related to lack of time or geographic accessibility were not potential predictors, perhaps because of the presence of chronic disease that requires continuous monitoring by health professionals. Accordingly, further research should explore the relationship between self-medication and the kind of unmet healthcare needs (e.g. prescription of medication, check-up, consultation etc.) and concerning the type of chronic disease condition. This would be of particular benefit for well-targeted preventive measures, especially in developing countries with lower standards and rationalisations of public health expenditures within where the high impacts of unmet healthcare needs could be expected (34).

The study findings highlighted different predictors of self-medication with tranquillizers and sleeping pills for men and women. Gender-related socio-demographic differences in predictors were shown (higher age in females and unemployment in males), while the same health-related characteristics were shown as predictors in both genders (presence of chronic disease, physical pain, exposure to stress). While revealed practices and predictors may be useful in improving healthcare professionals’ consulting practice, observed gender differences may be utilised to inform the design of gender-sensitive surveillance, identification, and prevention of such undesirable practice through well-tailored public health actions.