We are currently facing the problem of drug-resistant organisms, which have resulted from indiscriminate prescription of antibiotics. The practice of prescribing antibiotics for the slightest indication of cough and fever is rampant in India, and you get to see combinations of antibiotics given together to combat a simple infection. Cases due to organisms such as MRSA (methicillin resistant Staphylococcus aureus) and MDR-TB (multi-drug resistant tuberculosis) are on the rise, adding to the existing morbidity and mortality due to these conditions.
Similarly, we are now faced with the problem of overprescription of antidepressants to treat minor mental illnesses. Most antidepressants work by upping the serotonin levels in the brain. This neurotransmitter is found to be either deficient or inappropriately utilised by the brain cells in those with clinical depression and anxiety disorders. Since the mechanism of causation of depression and anxiety disorders is similar, antidepressants can also be used in the treatment of anxiety disorders such as panic disorder, phobias and obsessive-compulsive disorder.
However, these conditions need to be confirmed by a thorough assessment of the patient’s mental state, and with the use of certain diagnostic criteria – most notably Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and International Classification of Diseases, Version 10 (ICD-10).
What Does the Study Reveal?
A recent study conducted in the US and published in the Journal of Clinical Psychiatry has concluded that 69% of people taking antidepressants did not meet the criteria for a depressive disorder, while 38% of them did not have any of the anxiety disorders that warrant the prescription of antidepressants.
The authors of the study mainly looked at selective serotonin reuptake inhibitors (SSRIs), a popular group of antidepressants that is widely prescribed, and assessed the patients taking these drugs for the presence of depression and anxiety according to DSM-5 criteria.
While this was a study conducted in the US, the findings can as well be applied in the Indian clinical scenario. Akin to antibiotics, antidepressants are prescribed for just about any mental illness, including minor problems such as stress, temporary problems such as bereavement reactions, or short-term conditions such as acute stress reaction. There could be several reasons for this.
What is the Right Way To Treat Psychiatric Illnesses?
In India, there is an expectation of immediate and permanent cure from all ailments when one visits a medical practitioner. While this may work well with medical or surgical problems, it rarely ever applies to psychiatric illnesses. Still, owing to the huge expectations and the need to allay the suffering of the patient, practitioners sometimes prescribe the pill even after a superficial assessment.
Also, the psychosocial aspects of management, which requires the involvement of a clinical psychologist, social worker, occupational therapist and other members of the multidisciplinary team, are underdeveloped in India. This makes biological treatment in the form of drugs necessary to somehow cover for the absence of equally important psychosocial treatments. Besides, the fact that SSRIs are probably the safest group of antidepressants with hardly any serious adverse effects makes it easy for the practitioner to dole out prescriptions indiscriminately.
Doctors also face immense pressure from the pharmaceutical companies, which spend millions in clinical trials, patenting and marketing the drugs, to prescribe their products. Inducements in the form of material gifts and sponsorship of educational materials and conferences are routinely put forth, with a tacit understanding that this would translate into higher sales rates of their pharmaceutical products.
What Could Be the Imapct of Unwarranted Use of Antidepressants?
Fortunately, over-prescription of antidepressants – unlike antibiotics – does not result in resistance to treatment. Nor does it result in dependence as you do not get addicted to antidepressants. However, there may be other repercussions.
Self-medication is a major problem in India, and patients who have been initiated on an antidepressant are known to continue taking the drug, even without the doctor’s advice. Even though these are prescription-only medications, there are a number of pharmacies that dispense the drugs over-the-counter, or if the patient shows the old prescription, or even if they happen to know the patient personally.
This may then result in needless treatment with drugs, some of which may have adverse effects and interactions with other medications that the patient may be taking. Suddenly discontinuing the antidepressants without the doctor’s advice can cause a withdrawal syndrome, which the patient may be ill-equipped to handle.
Certain other groups such as tri-cyclic antidepressants have known cardiac side-effects and can cause ECG changes and sudden death. Those with epilepsy may have more seizures, since most antidepressants are known to lower the seizure threshold. These are but a few examples of what might go wrong with the prolonged and unwarranted use of antidepressants.
Do All Psychiatric Problems Need Medication?
It is therefore important to recognise that not all psychiatric problems need medication. Stress and strain, and milder forms of depression and anxiety can very well be addressed through psychotherapy, relaxation therapy, exercise and lifestyle modification. Medical practitioners should make use of standardised criteria and rating scales for making the diagnosis and monitoring the progress made by the patient while taking medication.
Prescription in psychiatry is about the right medication given for the right condition, in right dose, and for the right amount of time – something which requires clinical acumen on part of the practitioner, and co-operation from the patient.