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Don't pop that Prozac: The rise of anti-depressant abuse in India

Ever since childhood, Shobana Leelaram Avula, 36, based in Chennai, had suffered severe migraine attacks. After trying various other drugs to ward off the debilitating headaches and not succeeding, two years ago, her doctor prescribed anti-depressants. Once she started on the pills, Shobana found some measure of relief, but to her dismay, she was constantly drowsy.

"It had a numbing effect," she says of the anti-depressants. "I took the tablets whenever I felt like an attack was coming on. However, I realized that though it helped counter the pain, it would take a day and a half for the effects of the pill to wear off and during this time, I simply couldn't function. I felt like a zombie."

Two months later, after an episode of severe giddiness, she discovered that her blood pressure had skyrocketed. In addition to blood pressure medication, she went on a reduced dosage of anti-depressants. But when her blood pressure remained high and the side-effects raged on, Shobana abandoned the pills altogether. Fortunately, she did not experience any withdrawal symptoms.

Image courtesy: AFP

Image courtesy: AFP

Aarthi*, 27, a PR professional in New Delhi, was not quite as lucky. After she failed exams in her first year of college and had difficulty making friends, Aarthi, an honors student in school, took it hard. "Nothing interested me anymore," she says. "I felt tired and lethargic all the time and wasn't inclined on continuing my education." Her general physician prescribed a mild dosage of anti-depressants for six weeks, but Aarthi  confesses that she took the pills in fits and spurts:

"After three weeks on the drugs, I felt I could cope on my own and stopped taking it. Almost immediately afterward, the tiredness and lethargy crept back and it seemed to be more intense than ever. I felt terribly sick, as though I had the flu. Then I'd take the drugs again for a week or so and discontinue again; it was a vicious cycle." Even though the prescribed drugs were not considered addictive in the medical sense, Aarthi's health deteriorated after two years of indiscriminate use, and she struggled to stay drug free.

Rising cases of depression in India has been accompanied by the abuse of anti-depressants. Combine the stigma of consulting a psychiatrist with a new pill-popping generation that veers towards instant gratification and we have the makings of a silent epidemic.

The stigma of psychiatry

In 2011, the World Health Organisation in conjunction with Biomed Central conducted a survey which claimed that India was the most depressed nation in the world, with 36 percent of its citizens having battled a Major Depressive Episode (MDE) at some point in their lives. However, mental illnesses like depression have been wrongly stigmatized in our country and still considered a malady that only afflicts the affluent. Most Indians never seek help.

That may explainswhy in a nation of a billion people, there are only 5000 registered psychiatrists. The dearth of psychiatrists in our country also adds to the potential for misdiagnosis by physicians who do try to fill in that gap.

"There is a growing trend of physicians, gastroenterologists, cardiologists, neurologists, surgeons all adding an antidepressant to their prescriptions. Sometimes it is justified but in many cases, unnecessary. Often, these are prescribed in inadequate or inappropriate doses," says Dr Dheep, Madurai-based psychiatrist and founder of  TOPKIDS Youth/Child Guidance & Counselling Centre.

The danger of anti-depressant abuse is all the more higher in a country where powerful drugs can be procured over-the-counter without a prescription. This problem is further compounded by the popular tendency to think of an anti-depressant as a wonder pill that can magically alter your mood. Self-medication can prove disastrous and in some cases, even fatal.

No magic pill

Anti-depressants quite simply regulate our brain chemistry. As depression is a condition that is associated with a decrease in the brain chemical (a neuro-transmitter) called serotonin, the current crop of popular antidepressants provide relief mainly by increasing the quantity of serotonin in the brain.

"Commonly referred to as SSRIs (Specific Serotonin Reuptake Inhibitors), these are the agents of choice today because of their effectiveness, ease of use and relative lack of side effects," says Dr Dr Dheep. "Prozac (fluoxetine) is an example. The older class of antidepressants (TCAs – Tri/Tetra Cyclic Antidepressants) were very effective, but came with unpleasant side effects such as cardiac toxicity, rapid fall in BP, sexual problems like loss of libido,erectile dysfunction, dryness of the mouth.These are also more likely to be lethal if an overdose is taken. The newer drugs are preferred because they have fewer side effects in comparison, while (almost) matching the efficacy of the older antidepressants."

SSRIs may be safer, but they are no less dangerous when prescribed incorrectly or without required monitoring.

Prescription for disaster

"Anti-depressants are best prescribed by psychiatrists after they make a detailed case history and diagnosis. But since visiting a psychiatrist is still considered taboo (in many parts of India), many of these prescriptions are filled by general practitioners who may only suspect an underlying depression," says Dr Pratiksha K. Gandhi,  preventive cardiologist and the Founder and chairperson of IPC HeartCare in Mumbai.

Today, prescriptions for anti-depressants are becoming increasingly common in many other areas of clinical therapy--for instance, the treatment of migraine headaches.  But even here, indiscriminate use can cause problems, as seen in Shobana Avula's case.

"Antidepressants are effective in treating migraines only if the pain is triggered by chronic depression," says Dr K Ravishankar, head of the Headache and Migraine Clinics at the Jaslok Hospital & Research Centre and the Lilavati Hospital & Research Centre, Mumbai. "But if your headache is caused by other triggers and you don't have a family history of depression, it's unlikely that these drugs will help."

The dangers inherent to non-specialist treatment is not just misdiagnosis, but also the lack of close monitoring afterwards--you may not be getting adequate expert care that you may need while on the drug.

"Monitoring the dosage is crucial for heart health," says Dr Gandhi, "An overdose can lead to rapid or irregular heart beat and can severely affect cardio respiratory system leading to collapse or even death. Certain anti depressants can cause changes in your ECG, so a basic ECG should be prescribed before starting treatment to help monitor the effects on the heart, but rarely are people aware of these issues."

A general practitioner may have neither the time nor the inclination to closely monitor a patient on anti-depressants -- nor are they able to treat the underlying mental issues. "That's why (psychiatric) counselling plays an important role in treating anxiety," says Dr Gandhi. "A patient needs to learn techniques to control their mind rather than just depending blindly on drugs."

According to research published in 2009 in the Archives of General Psychiatry, one in ten Americans takes antidepressant pills, earning these the distinction of being the most commonly prescribed drugs in the United States. As a country where most people are too poor to afford decent medical care, we are in no danger of matching those statistics. But those who can afford to indiscriminately and increasingly pop pills without a prescription or adequate monitoring may be in far greater danger.