How Social Factors Affect Overprescription in India

By Paromita Goswami, Shiv Nadar University and Anindita Chaudhuri, University of Calcutta

KOLKATA, Oct. 24 – India is afflicted by a depression boom. A breathtaking 56 million of its inhabitants suffer from the disease, 38 million others suffer from an anxiety disorder. It was among the top 15 early causes of death in 2019. Unsurprisingly, antidepressants are rampant: prescriptions grown up 23% over the past year.

In Japan, drug companies coined the term “kokoro no kaze,” meaning “a cold of the soul,” for depression. This carefully crafted campaign to raise awareness of the disease has led to a growing acceptance of depression and antidepressants to treat it, according Professor Hiroshi Ihara.

In India, interviews with health professionals, clinical psychologists or even traditional healers show how the pharmaceutical industry is adopting new measures to try to develop its market.

Physicians described how pharmaceutical companies keep prescription records and, in many cases, pay physicians a percentage of the value of prescriptions.

“If someone writes a prescription for 100 rupees, he gets 10 rupees; the amount is added…[and] paid for through conference sponsorships, overseas travel, books and gifts,” said a clinical psychologist.

GPs are often willing and able to prescribe low dose antidepressants and hence “liberal prescribing of antidepressants by non-psychiatrists” is rampant in India, according psychiatrist Gopala Sarma Poduri.

But the pharmaceutical industry is not entirely responsible for the overprescription of antidepressants in India. The situation is more complex and nuanced.

Patients may turn to an antidepressant because of the stigma associated with seeing a mental health professional. Mihir*, a general practitioner, reports that even if he recommends the services of a specialist psychiatrist, patients are often in denial.

“[Patients] do not recognize themselves as having this kind of problem. … [They would say] I have loose stools or heart palpitations, why are you sending me to doctors for the crazy? »

Patients often prefer to take medication rather than psychotherapy. A clinical psychologist said, “People think that if they don’t take medicine and only go to the therapist to talk, then they don’t have depression; if there are no drugs, there is no problem.

Indian medical education has been criticized for its lack of emphasis on psychiatric issues. “People go to a GP first…but GPs have a limited understanding of psychiatric medicine and may continue to switch drugs and resort to polypharmacy,” Prabir said.

Often, the lack of economic resources to afford therapy leads patients and their families to consult a general practitioner or non-specialist whose lack of adequate training makes them particularly prone to misdiagnoses and the over-prescription of antidepressants.

With 0.3 psychiatrists and 0.07 psychologists per 100,000 people in India, there is no way to effectively manage workloads. Suggested figures for these categories, recommend a minimum of one to four per 100,000.

A shortage of trained mental health professionals makes it impossible to meet the needs of hard-to-reach people rural population. The problem is so acute that in 2010, the Ministry of Health proposed a bachelor’s degree program in community health and rural health care.

This program suffered a launch failure. In remote areas, researchers have show much of antidepressant sales are “generated not by licensed physicians, but by an amorphous group of unlicensed prescribers who have never been formally trained in medicine”.

In many ways, these unlicensed prescribers are inevitable. A surgeon put it this way: “Our rural population depends on ‘charlatans’. We are unable to provide qualified doctors, so the so-called unlicensed, or the so-called quacks, cannot be eliminated overnight.”

Patients are often forced to switch to antidepressants even when they don’t really need that level of treatment. Medicines are cheaper than therapy.

“A therapy session lasts 30 to 45 minutes, and that has cost implications. A person might then think “I have to set aside 2,500-3,000 rupees for advice, and I’m just going to talk… On the other hand, if I’m taking antidepressants, my monthly medical bills won’t exceed thousands rupees,” the psychologist said.

Clinical depression is a sad and growing reality in India. The promotion of prescription products by pharmaceutical companies has certainly taken place and continues unabated, despite changes to Indian Medical Council regulations in 2002.

But big pharma cannot be blamed alone. There is a clear case of socio-cultural economic causes, including stigma, lack of affordable care, and infrastructural constraints such as the unavailability of skilled healthcare professionals, creating fertile ground for the proliferation of over-prescribing.

Paromita Goswami is Professor of Marketing and Social Innovation at Shiv Nadar University. Anindita Chaudhuri is an Associate Professor in the Department of Psychology, University of Calcutta.

Article published with the kind permission of 360info.

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