India has a depression problem. We know that. The National Mental Health Survey 2015-16 showed that nearly 15% of Indians in a country of 1.5 billion need active intervention to treat depression symptoms. 

India has one of the highest rates of suicide, too. Despite regulations, obtaining prescription-only drugs from a friendly pharmacist is easy.

MyndStories spoke with Dr. Suhas Satish, Assistant Professor of Psychiatry at NIMHANS, Bangalore, about just how liberal use of antidepressants can be concerning and dangerous. 

Note: Parts of this interview also appear in Deccan Herald’s Sunday feature. Deccan Herald retains the rights to this content in full.

How common is it for non-psychiatrists to prescribe antidepressants as sleeping pills in clinical and hospital settings?

It is quite common for physicians from various specialties and general practitioners to prescribe antidepressants, often in combination with benzodiazepines, without a formal mental health assessment or referral to a psychiatrist.

The reasons for this practice can include a shortage of qualified psychiatrists, physicians’ confidence in treating mental health conditions, physicians’ concerns about patient reactions to a psychiatric referral due to stigma, or reluctance from patients themselves to see a psychiatrist. 

However, none of these reasons should deny patients the right to receive expert care from a qualified psychiatrist.

A psychiatrist will conduct a thorough evaluation and, through a collaborative decision-making process, prescribe the appropriate psychiatric medications tailored to the patient’s specific needs and for a specified duration. Additionally, psychiatrists will work towards strengthening the person through positive lifestyle measures, psychotherapy, and family interventions.

All these seek to address the core vulnerabilities and strengthen them, making it simpler to de-prescribe medications and ensure recovery. Psychiatric medicines, while important, are just one of the treatment modalities that may be necessary but almost never sufficient in itself to help persons dealing with mental health issues. 

What are the ethical considerations when prescribing antidepressants for off-label uses such as insomnia? I know that doctors can give these, but what do you think may be the larger implications of people who may not have depression being given these?

Prescribing antidepressants for off-label uses such as insomnia is not uncommon. However, it is essential for all healthcare providers to prioritize patient safety and ensure informed consent.

Insomnia can be a symptom of numerous underlying conditions, and treating it with medication before a detailed evaluation can potentially mask or delay the diagnosis of these underlying issues.

This approach can be particularly risky for vulnerable populations, such as the elderly, where antidepressants may increase the risk of falls, decrease blood sodium levels, and cause drug interactions with other co-prescribed medicines that they may be on for chronic physical diseases.

A major ethical concern is the potential for miscommunication or lack of transparency. 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.

This transparency is crucial to maintaining trust and ensuring patients can make informed decisions about their treatment.

What are the dangers of combining antidepressants with other medications, especially for patients already undergoing mental health treatments? 

Combining antidepressants with other medications, especially in patients already undergoing mental health treatments, can lead to complications if done irrationally or without justification. However, it is important to note that not all combinations of treatment are inherently hazardous.

There are clinical scenarios where rationale and justified polypharmacy are necessary, such as in cases of treatment resistance, complex behavioral issues, or when managing co-morbid psychiatric or physical illnesses.

When a psychiatrist opts for combination therapy following a thorough evaluation, it is typically aimed at optimizing either efficacy (how well the medications work to help the patient recover) or safety (minimizing adverse effects).

However, irrational and/or unjustified polypharmacy must be strongly discouraged. The most significant risks associated with irrational or unjustified polypharmacy include a higher risk of serious adverse effects and complex pharmacokinetic drug interactions (this implies how one drug interferes with the metabolism of the other.

These interactions can also lead to therapeutic failure or toxicity from one or more treatments).

Do you think patients are generally aware that they are being prescribed antidepressants for sleep issues?

Patients are frequently unaware when they are prescribed antidepressants for sleep issues. In hospital settings, where medications are administered by healthcare staff, patients may not receive comprehensive information about each drug they receive.

There is also a risk of patients being prescribed combinations of antidepressants and benzodiazepines without a structured psychiatric evaluation and clear therapeutic goals. This lack of transparency can result in patients not fully understanding the potential risks and side effects.

Of greater concern is the continuation of these prescriptions, which can lead to pseudo-dependence and challenges in de-prescribing. This issue is particularly problematic with drugs such as benzodiazepines, where long-term use can pose significant physical health risks as well. 

As a psychiatrist, of course, you can prescribe antidepressants. But how easily can antidepressants be procured in India without a prescription, and what are the implications of this accessibility?

Psychiatric medications should not be available over the counter, and current Indian laws are in place to prevent this. While there has been a positive trend toward greater adherence to these laws in recent decades, much progress still needs to be achieved.

It is crucial for the concerned regulatory agencies and stakeholders to continue to work towards enforcing the existing laws while continuing to sensitize pharmacists about the importance of strict adherence to these regulations. 

What advice would you give to patients who are prescribed such medications by non-psychiatrists? What can we generally do?

Before I address the issue of what can be done, I will address two key issues.

1. ‘Antidepressants’ are not restricted for use in depression

Strictly speaking, assigning a label to a drug based on its use for a particular indication can be overly simplistic. Many medications categorized as antidepressants serve multiple purposes beyond treating depression.

For instance, physicians often prescribe tricyclic antidepressants for managing diabetic neuropathy and migraines. Similarly, gastroenterologists often use levosulpiride, which is classified as an antipsychotic, in combination with treatments for irritable bowel syndrome.

These classifications initially stemmed from the primary indications for their use. However, using these medications for different conditions is ethical and appropriate as long as healthcare providers inform patients accordingly and adhere to evidence-based guidelines.

2. Non-psychiatrists will continue to prescribe psychotropics for the management of common mental disorders for the foreseeable future

India is a country of 1.4 billion, with a mental health burden of almost 10%. The number of psychiatrists in the country is less than 12000.

Given the scarcity of psychiatrists in India relative to the population, it is increasingly likely that primary care physicians and other specialists will continue to prescribe certain first-line medications for psychiatric conditions in the foreseeable future.

We must, therefore, focus our efforts towards rational and ethical first-line treatment of common mental disorders by non-psychiatry physicians.

Severe psychiatric disorders, behavioral emergencies, and common psychiatric disorders that are not responding to first-line treatment should always be referred to psychiatrists.   

To better equip all physicians in first-line mental healthcare, the Indian medical curriculum needs to incorporate comprehensive training on the spectrum of psychiatric symptoms and also about psychotropics.

This includes understanding that mental health symptoms can occur in normal individuals (most symptoms, therefore, lie on a dimension) and that the severity of symptoms, the presence of symptom clusters for weeks, and the accompanying presence of distress or dysfunction are key factors in making syndromal psychiatric diagnoses.

Non-psychiatrist physicians can be trained to implement a stepped-care model, starting with first-line interventions following thorough first-line evaluations.

Now, From a patient’s perspective:

Public awareness regarding the use of psychotropic medications needs to be heightened. It is essential for everyone to understand the medications they are prescribed and the reasons behind their administration, promoting informed decision-making and adherence to treatment plans.

One key measure that can drastically improve the chances of informed decision-making is the presence of package inserts for all psychotropics, indicating their mechanism of action, dose range, common duration of treatment, and safety profile.

When they are prescribed psychiatric medications, it is important to approach the situation with informed decision-making and proactive engagement. Some tips for patients include

#1 Seek clarification and understanding on diagnosis and the treatment

Understand why the medication is being prescribed, its intended benefits, potential side effects, and how long you may need to take it.

If you have any doubts or concerns about the medication or its effects, discuss them openly with your healthcare provider.  

#2 Request referral to a psychiatrist

Advocate for Specialist Care: Request a referral to a psychiatrist for a comprehensive evaluation at the earliest and especially if the symptoms persist or worsen despite initial treatment and lifestyle changes.

#3 Educate yourself

Educate yourself about your diagnosis, treatment options, and self-care strategies that complement medication use. Additionally, it is important to use reliable Sources of information: Seek information from reputable sources such as healthcare professionals, reliable websites, or patient education materials.

#4 Engage in positive lifestyle modifications

This is an often neglected area. Consider lifestyle changes that can complement medication therapy, such as regular exercise, avoidance of recreational drugs, healthy diet, stress management techniques, and adequate sleep. 

#5 Seek help for mental health support. It is now available for free and a phone call away

Enhanced access to mental healthcare and even to psychiatrists is being facilitated through initiatives like Tele-MANAS. This program offers convenient access to mental health guidance via a toll-free helpline (14416 or 18008914416), making it easier for individuals to seek support and connect with local psychiatrists as needed.