Bitter (truth) pills

It’s a cloudy Sunday evening in Bengaluru. A stray dog sniffs at a banana peel strewn carelessly on the road. People cluster around a bakery; orders of masala bread and aloo bun echo in the air. 

And Sheela is here — at the local pharmacy next door, ordering something else entirely. A strip of a “popular” anti-anxiety and antidepressant drug.

This pharmacy is an old favourite. They know her. And she knows them. The lanky boy at the counter doesn’t blink when she asks for the drug by its commercial name. He doesn’t ask her for a prescription either. “How many?” he asks. “A strip,” Sheela replies. She gets 15 tablets of a prescription-only drug without any prescription. Sheela does not intend to use them to combat depression or anxiety, however. She simply likes how the drug rescues her from sleepless nights. A family doctor gave her a prescription once, and now she is hooked.

Sheela is not alone. There are ‘friendly’ pharmacists in every city in India where one can obtain prescription drugs for depression without a prescription. A National Mental Health Survey in 2015-16 revealed that 1 in 20 Indians live with depression. The World Health Organisation estimates that 4.5% of Indians suffer from depression (56 million), with another 3.5% suffering from anxiety disorders. Stigma is rampant. This, coupled with a lack of awareness and easy access to antidepressants, means that India is staring at a potentially devastating tsunami of not just mental illness but also addiction and debilitating side effects. 

Market research firm Global Markets Insights estimates that the India depression therapeutics market is expected to grow from $184 million in 2022 to $345 million in 2030 at a CAGR (Compound Annual Growth Rate) of 8.2%. Not all of these sales come from psychiatrists prescribing antidepressants. Doctors also prescribe antidepressants to calm patients before surgery, prolonged illnesses, and also as sleeping aids.

The self-prescription danger

Chennai-based Dr T R Gopalan says that as a general surgeon, he would prescribe these pills as a “pre-medication” the night before surgery. “We also use it for some patients who are in the ICU for longer periods who tend to have a condition called ICU psychosis. Some patients, after amputation of limbs for reasons like infection or trauma, need anxiolytics [anxiety-relieving drugs] as they are depressed after losing a body part. Cancer patients may require these drugs for pain as a palliative therapy,” he explains. Dr Gopalan says he has prescribed antidepressants such as Alprazolam, Diazepam, Tramadol, and Pentazocin [generic names] for these purposes. He admits, however, that while doctors may try and explain the necessity for these drugs, (which are strictly need-based and short-term), patients can “self-prescribe” these drugs for longer durations or misuse the quantity.

Tanmoy Goswami, who is the creator of the mental health storytelling platform Sanity, says while he has never obtained antidepressants without a prescription, in India, where the patient-psychiatrist ratio remains low, patients are forced to beg pharmacies to give them medicines if they are running out of the prescription drug and can’t get an appointment in time. “In some Western countries, GPs are among the biggest prescribers of antidepressants. For instance, in Australia, 85% of antidepressants are prescribed in general practice, often to patients who are experiencing mental distress but aren’t clinically depressed. In India too, there have been reports of mis- and over-prescription of antidepressants,” he adds.

Dr Manjula Battaluri, who is a practising dentist in Boston, is alarmed at how easily one can obtain medicines like the aforementioned anti-anxiety drug. “I see many people in India frequently taking it for insomnia. People with insomnia can have underlying depression, but the drug does not treat depression. On the contrary, it may make it worse.” Getting a prescription itself is difficult in the US, she explains, and it’s almost impossible to obtain medicines without one. Recommending therapy, Manjula notes, is not a taboo there as it is in India. “When it is the loss of a family member or a financial crisis, there usually occurs a single episode that’s medically termed ‘simple reactive depression’. In such cases, people tend to naturally approach therapists,” she adds.

A worrying trend

In India, drugs for mental health can be prescribed by both doctors and psychiatrists. Doctors are plentiful in urban areas, but psychiatrists? Not so many. There are around 9,000 psychiatrists for a population of 1.5 billion. Only 700 psychiatrists are trained every year. (Garg et al., 2019) The current shortfall is around 27,000 psychiatrists. In such a scenario, patients often turn to their (trusted?) local doctor for support who sometimes end up prescribing antidepressants.

The thing is, anti-depressants belong to a group of medicines called psychotropics. They are used not just for the treatment of depression but also for a range of disorders, such as anxiety disorders, OCD, chronic pain, ADHD, eating disorders, and neuropathic pain. Selective serotonin reuptake inhibitors, or SSRIs, form the majority of prescriptions, with Sertraline and Fluoxetine next. A 2016 study published in the Indian Journal of Medical Research found that the prescription rate of Benzodiazepines (a class of medications) remains high in India. It’s recommended that Benzodiazepines be used with caution, with usage recommended only for two weeks. Benzodiazepines are addictive, and patients have been known to use these for years, the study notes. 

Informed consent, anyone?

Dr Wilona Braganza, a consultant psychiatrist in Thane, opines that 30%-55% of non-psychiatrists include a psychiatric drug. Sleeping pills or Benzodiazepines are most prescribed, she says, and this is something that worries her. “The prescription of antidepressants for off-label uses like insomnia raises significant ethical concerns. While doctors may intend to alleviate symptoms, they must consider the potential risks and consequences, especially when prescribing to patients without a depression diagnosis. Informed consent is crucial, and this is practically a huge challenge in our country, where everyone hides behind the ‘I did it for your own good’ statement. Patients have the right to know they’re being given antidepressants, their intended use, and potential side effects. Failure to disclose this information can lead to unintended harm and addiction,” Dr Wilona explains.

A dangerous cocktail

And the implications are alarming. “Widespread use of antidepressants as sleeping pills can contribute to over-reliance on medication, masking underlying issues rather than addressing the root causes of insomnia. This may also divert resources away from evidence-based treatments. Also, antidepressants can have serious interactions with other medications, posing a significant risk to patients already taking mental health medications. The lack of monitoring and follow-up care can exacerbate mental health issues, leading patients to consume a dangerous cocktail of drugs.”

Dr Suhas Satish, an Assistant Professor of Psychiatry at NIMHANS, can’t agree more, noting that it is quite common for physicians and general practitioners to prescribe antidepressants in combination with Benzodiazepines without a formal health assessment. The reasons for this can be varied, he explains. From a shortage of psychiatrists to physicians’ confidence in treating mental health conditions and the reluctance of patients to consult a psychiatrist. “However, none of these reasons should deny patients the right to receive expert care from a qualified psychiatrist,” Dr Suhas avers. “Patients must be fully informed that they are receiving an antidepressant, even if it is prescribed off-label for insomnia after detailed evaluation, and all first and second-line non-pharmacological interventions have not yielded any benefits.” However, as Tanmoy says, doctors rarely have the time to explain the side effects or other implications to patients.

“Every treatment plan should offer the patient clarity on how the doctor intends to prevent over-dependence on medication, for instance, by recommending therapy or discussing a pathway to slowly reduce pills. Educating patients on how to manage sub-clinical mental health conditions without over-reliance on pills should be table stakes. Sadly, far too many doctors don’t do that,” he explains.

Janani K S, a research scholar from Chennai, says that she was prescribed antidepressants and antipsychotics as sleeping aids. “And no, I wasn’t informed that they were being prescribed off-label; I had to figure that out myself. If it were someone else with a lower internet literacy, they wouldn’t have been able to do it.” The key thing that Janani mentions? “Internet literacy.” In a country where mental health awareness remains low, understanding what medicines we are consuming is a challenge.

Dr Pubali Chaudhuri is a consultant neuro-psychiatrist based in Kolkata who has been practising for six years. For her, the most shocking aspect is that people can get antidepressants like Escitalopram easily from pharmacies, even though regulations, of course, prohibit the sale of these drugs without relevant prescriptions.

Highly addictive

India has a comprehensive Narcotics Drugs and Psychotropic Substances Bill that was passed in 1985. Here, psychotropic substances refer to any substance that alters the mind. Examples include Diazepam and Alprazolam, which are meant to be strictly regulated. “Amitriptyline and Gabapentin are available sometimes over the counter, and we are seeing patients procuring them either directly from the pharmacy through a GP prescription or through using old prescriptions.” Pubali worries that patients can self-prescribe medicines like Clonazepam, which are highly addictive. “So, once they get addicted to Clonazepam, they keep consuming the drug for maybe 10-20 years at a stretch, and when they come to us for sleep problems, they are already addicted to it badly.” This sounds dire and ominous, so what is the solution? For Dr Pubali, some of the problems may be lessened if we know which doctor to go to for which symptoms. “When a person is talking about mental health issues or sleep problems, I would definitely recommend a psychiatric consultation, and I think this needs to become more commonplace. What we can do as a community is encourage psychiatric consultations.” But of course, that brings us back to the beginning of this story: With stigma and with not enough psychiatrists, that may not always be possible. This is why, as Tanmoy says, education and awareness are key.

Along with education, Dr Gopalan believes that law enforcement authorities, doctors, and pharmacies must work together to bring about lasting change. And change is needed. Necessary. Vital. Especially for those like Sheela who will sleep tonight on yet another dose of her favourite drug. What she does not know or perhaps realise is that she may obtain the drug easily but its effects won’t be so easily erased. 

Note: Some names have been changed on request. The drugs mentioned in the story are either generic names or are a class of medications and are not specific brand names.