Prescription trends of antidepressants.

What are we doing & what else is required?

Maj (Dr) Dr Prabhakaran K, Col (Dr) Prafull Mohan Col Col (Dr) Harpreet Singh*

(Dr) Sharmila Sinha,

Department of Pharmacology, Armed Forces Medical College, Pune, Maharashtra

*Department of Psychiatry, Armed Forces Medical College, Pune, Maharashtra

1. Introduction:
Depression is an affective disorder affecting about 2.7% population in
India and 4.4 % globally and it’s prevalence is likely to increase( 1,2). The
prescription of antidepressants is also increasing, both because of increasing
incidence of depression and also due to their increasing use for non depression/
non psychiatric indications such as Obsessive compulsive disorder, phobic
states, anxiety disorders, neuropathic pain, attention deficit hyperactivity
disorder, premature ejaculation, enuresis, migraine and pruritus (3) Almost 30% of
patients of depression do not achieve remission with monotherapy, there is
increased effort to develop more efficacious and safer antidepressants. While
this has inflated the antidepressant inventory, a majority of prescriptions in India
continue to be of selective serotonin reuptake inhibitors (SSRIs) (4, 5). With
integration being advocated and mandated by MCI, there is a need to align
teaching and training of Pharmacology during para clinical stint with the current
clinical trends. This study aims to not only facilitate the said objective, but will
also work as appropriation tool for the faculty of Dept of Psychiatry.

The results of the study can also be subsequently utilized for forecasting
and provisioning purposes by administrators. This open label observational study
was carried out on anonymised prescriptions wherein the identity of the patient
was concealed so as to make it ethically viable. Anonymization of prescription
was done at the source itself so that there was no chance of patient identity
being revealed to the study team.

2. Aim & Objectives:

Aim:

To analyze the prescription pattern of Antidepressant drugs.

 Objectives:

a) Identification of commonly prescribed antidepressant drugs along with

their indication.

b) Estimation of defined daily dose and prescribed daily dose of

antidepressants.

c) Identification of common non depression/non psychiatric indications of

antidepressant drugs.

d) Comparison of commonly prescribed drugs in study setting vis-a-vis their

listing in National List of Essential Medicines(NLEM), World Health
Organization-Essential Medicine List (WHO-EML), British National
Formulary (BNF) and National formulary of India (NFI).

3. Materials & method:

Design:

Single Centre Cross sectional observational study based on routinely

generated hospital data (Prescriptions).

Place of study:

Dept of Pharmacology and Psychiatry OPD of Tertiary care hospital in

Western Maharashtra.
Study procedure:

Prescriptions were obtained from Psychiatry OPD by

a third party other than the study team

Prescriptions were photographed masking Physician

details & Patient details

Prescriptions which were illegible & without

diagnosis are discarded

Total of 214 Prescriptions were included in the study

Clearance of institutional ethics committee was obtained before starting

the study.Blinded and anonymised prescriptions of OPD patients, for whom at
least one antidepressant drug has been prescribed (for any indication) during the
months of May and June 2019, were taken for this study. Defined daily dose
(DDD) of each drug was taken from WHO ATC Index dated 16 Dec 2019 (6) and
Prescribed Daily Dose (PDD) was calculated from the prescription. Prescribed
drugs were also checked for their availability in formularies & essential medicine
lists (viz., WHO EML, NLEM (2019), NFI & BNF)
4. Results:

Totally 214 prescriptions were analysed in which a total of 254

Antidepressant drugs have been prescribed. 39 prescription had more than one
antidepressants prescribed. 254 antidepressant drugs were distributed as SSRIs
-150 (59.05%), Atypical antidepressants – 46 (18.11%), TCAs - 43 (16.92%) and
SNRIs - 15 (5.90%).

Drugs Prescribed
6%

17% SSRIs
Atypical antidepressants
TCAs
SNRIs
59%
18%

Escitalopram was the most commonly prescribed drug followed by

Mirtazapine. Out of 254 instances of antidepressant prescription, PDD was equal
to DDD in 46 % cases, less than DDD in 28 % cases and more than DDD in 26
% cases.

Both Escitalopram & Mirtazapine are listed in NFI and BNF but not in
NLEM & WHO-EML. Fluoxetine (an SSRI) is the only drug which was listed in all
the formularies.
 DDD & PDD
25.98

PDD > DDD

46.45
PDD < DDD
PDD = DDD

27.55

Out of a total of 214 analysed prescriptions, 209 prescriptions were for

indications of depression/ other psychiatric illness while the rest 5 were for non
psychiatric indications. SSRIs, being the most widely prescribed group, were further
analysed.

Table 1: Indications of different classes of antidepressants.

Total Prescribed for Prescribed for Prescribed for

Prescriptions Depression other non
psychiatric psychiatric
illness illness
SSRIs 146 78 68 0
Atypical 46 28 15 3
Antidepressant
s
TCAs 61 19 37 5
SNRIs 15 8 7 0

5. Discussion:

In this study number of prescriptions in which more than one

antidepressant were prescribed was 40 (18.86%). This is in consonance with
other studies (7). A majority of prescriptions continue to be of selective serotonin
reuptake inhibitors (SSRIs). Escitalopram is the most commonly used drug of all
SSRIs. This result is similar to another multicentric observational study ( 8).
 A comparison of a drug’s defined daily dose (DDD) with its PDD provides
an insight into the actual use of the drug. In this study, 46% prescriptions were as
per defined daily doses, 26% more than DDD (mostly SSRIs) and 28% less than
DDD (mostly TCAs). The inherent relative safety of SSRIs is reflected in their
being prescribed more than DDD whereas higher incidence of Adverse drug
reactions(ADRs) associated with TCAs appear to be the reason behind their
being prescribed less than their DDD. This way, pharmacological aspects rightly
get reflected in clinical practice.

Other studies have also concluded that TCAs are frequently used below
their dose levels & SSRIs near/ above their dose levels (Tripathi et al 8). The
relative safety of SSRIs vis-a-vis TCAs is well known & has been outlined in
other studies also (3).

The fact that the most commonly used antidepressant do not find mention
in NLEM & WHO-EML, reflects that the drug formularies/ lists need to be synced
with clinical usage data. There may also be a case for aligning clinical practice
with EMLs & formularies.

Clinical use of both SSRIs & TCAs is expanding to include various non
depression indications (for SSRIs) & chronic painful conditions (for TCAs) ( 9).
Results of our study also allude to this fact (Table 1).

6. Conclusion:

This study describes the clinical use of antidepressant drugs in a tertiary

care hospital in western Maharashtra.Despite being traditionally labeled as
‘Antidepressants’ these drugs are acquiring other indications also. Being drugs
for chronic use, their alignment with prescription parameters needs to be
optimum, something which is largely happening in this study site. Drug
formularies & lists of essential medicines and clinical usage derive from each
other and need to be in mutual sync. The need of same has been highlighted in
this study as well.
7. References:

i. Depression in India. Press Information Bureau. MoHFW, Govt of India.

Available on URL: http://www.pib.nic.in/newsite/PrintRelease.aspx?
relid=159850. Accessed on 14 July 2019.
ii. Depression in India. Let’s talk. Available at URL:
http://www.searo.who.int/india/depression_in_india.pdf. Accessed on 14
July 2019.
iii. Chattar KB, Karve AV, Subramanyam A, Tondare SB. Prescription pattern
analysis of antidepressants in psychiatric outpatient department of tertiary
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Available at URL:
https://www.icmr.nic.in/sites/default/files/guidelines/Handbook_on_ICMR_Et
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URL:https://www.whocc.no/atc_ddd_index/
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retrospective drug utilization study of antidepressants in the psychiatric unit
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October, Vol-5(5): 1069-1075.
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