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Original Article

Analysis of the prescription pattern of

psychotropics in an outpatient department of a
general hospital psychiatry unit

A. Tejus a, S.K. Saxena b,*, A.K. Dwivedi c, Md Fadil Salmani d,

Sapna Pradhan e
a
Graded Specialist (Pharmacology), Armed Forces Medical Stores Depot, Lucknow, India
b
Senior Advisor & Head (Psychiatry), Base Hospital, Delhi Cantt, India
c
Graded Specialist (Psychiatry), Base Hospital, Delhi Cantt, India
d
Tutor (Pharmacology), Army College of Medical Sciences, Delhi Cantt, New Delhi, India
e
Associate Professor (Pharmacology), Army College of Medical Sciences, Delhi Cantt, New Delhi, India

article info abstract

Article history: Background: World Health Organization has prescribed drug use indicators for evaluating
Received 1 December 2019 rational prescribing. Very few studies have been conducted on rational prescriptions for
Accepted 19 March 2020 psychotropic drugs; hence, this study was undertaken at a tertiary care center of North India.
Available online 20 May 2020 Methods: After obtaining approval of the Institutional Ethics Committee, all prescriptions
deposited with the dispensary of the psychiatry department of the hospital between 01
Keywords: October 2017 and 31 December 2017 were included in the study. The prescriptions were
Psychotropics analyzed for drug use indicators, namely the average number of drugs per encounter,
Prescription percentage of prescriptions with generic name, percentage of prescriptions from the
Prescription analysis essential drug list, percentage of prescriptions with antibiotics, and percentage of pre-
WHO drug use indicators scriptions with an injection. In addition, the prescriptions were analyzed for patterns of
psychotropics prescribed.
Results: A total of 3770 prescriptions were analyzed. On an average, 2.35 medicines were
prescribed per prescription. Injectable comprised 2.39% of prescriptions and fixed drug
combinations were 0.16% of the total. Of all prescriptions, 91.3% were by generic name,
while 55.02% of prescriptions were from the essential drug list. Polypharmacy constituted
4.53% of prescriptions. Risperidone, escitalopram, sodium valproate, and clonazepam were
the most commonly prescribed drugs.
Conclusion: While we fared well with respect to the percentage of prescriptions with
injections and those with an antibiotic, we have not been able to achieve the prescribed
standards in prescription with generic names, number of drugs per prescription, and
prescriptions from the essential drug list. The study emphasizes that there is scope for
improvement.
© 2020 Director General, Armed Forces Medical Services. Published by Elsevier, a division of
RELX India Pvt. Ltd. All rights reserved.

* Corresponding author.
E-mail address: drsachind2@yahoo.co.in (S.K. Saxena).
https://doi.org/10.1016/j.mjafi.2020.03.006
0377-1237/© 2020 Director General, Armed Forces Medical Services. Published by Elsevier, a division of RELX India Pvt. Ltd. All rights
reserved.
 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) 7 4 e7 9
Introduction
Rational use of medicines as defined by the World Health
Organization (WHO) states that “Patient receive medications
appropriate to their clinical needs, in doses that meet their
own individual requirements, for an adequate period of time,
and at the lowest cost to them and their community”.1,2 Ac-
cording to WHO estimates, more than half of the medicines
prescribed are irrational in nature, leading to an increase in
issues such as drug interactions, development of resistance,
and non-compliance.3 WHO estimates suggest that up to 5% of
country's health expenditure can be saved with practice of
rational prescribing, price control, and improving medicine
quality.4
Psychiatric disorders form an important public health pri-
ority. Mental illness is associated with high level of health
service utilization and associated costs.5 The arena of psy-
chopharmacology is changing rapidly, challenging the tradi-
tional concepts in the research and treatment of psychiatric
disorders. This rapid growth exposes the psychiatrists
continuously to the onslaught of new drugs which claim to be
safer and efficacious.6 Few studies have been carried out in
India, which have evaluated the prescription pattern of psy-
chotropic medications.
Study of prescriptions is considered as part of ‘drug
utilization’, which encompasses the study of marketing,
distribution, and prescription of various drugs in society,
along with evaluation of its medical, social, and economic
consequences.7 The aim of drug utilization studies is to
encourage and facilitate rational use of medicines.8 A
number of studies have been conducted in India covering
different aspects of health care over the last decade using
WHO drug use indicators.9e12 However, drug utilization
studies involving psychotropic use for psychiatry patients
are lacking.8
Hence, this study was undertaken in the context of a
developing country such as India to study the drug utilization
pattern of various psychotropic drugs. The study was also
undertaken as an audit of prescriptions for the hospital in
particular and psychiatry practice in general. The study aimed
to analyze the prescriptions of a psychiatry unit in a tertiary
care hospital, based on the WHO drug use indicators. A sec-
ondary objective was to assess prescription patterns of
various psychotropic drugs.
Materials and methods
This retrospective, prescription-based, descriptive study was
carried out in the dispensary of the psychiatry unit of a ter-
tiary care hospital (general hospital psychiatry unit). The
department of psychiatry runs its dispensary which dispenses
psychotropic medication, separate from the central dispen-
sary of the hospital. This psychiatry unit consisted of four
psychiatrists having MD in psychiatry and five residents in
psychiatry who were working under the supervision of the
psychiatrists. None of the clinicians were exposed to any
program/lecture/seminar on rational drug use or any other
similar topic in the recent past.
75
Patients were attended as usual by all the clinicians, and
the prescriptions were based on the clinicians’ understanding
of the illness, as per existing literature. After obtaining
approval of the Institutional Ethics Committee, all the pre-
scriptions deposited in the dispensary of the psychiatric
department of the hospital between 01 October 2017 and 31
December 2017 were included in the study. According to the
WHO recommendations, a minimum of 600 prescribing en-
counters should be included to evaluate prescribing in-
dicators.13 We included 3770 prescriptions, spread over a
period of 3 months.
Because it was a retrospective study, none of the clinicians
prescribing the medicines were aware about the study being
carried out or planned and hence the prescription pattern was
not affected by the study. Data from the prescriptions were
collated in Microsoft Excel sheet and was analyzed using
functions in the excel software.
All the prescriptions were analyzed for the following pa-
rameters: (1) average number of the drugs per prescription, (2)
average number of the psychotropic drugs per prescription, (3)
percentage of the psychotropic drugs prescribed by generic
name, (4) percentage of injectable drugs prescribed, (5) per-
centage of prescriptions containing psychotropic fixed dose
combinations (FDCs), (6) percentage of the psychotropic drugs
prescribed from the essential drug list, and (7) percentage of
polypharmacy (prescribing 4 or more drugs).9e12 In addition,
the psychotropic drugs in the prescription were classified into
various groups based on classification. The demographic in-
formation available on the prescription (age and sex) was also
recorded.
Results
A total of 3770 prescriptions were analyzed, with a total of
8883 medicines prescribed. The prescription pattern of psy-
chotropics as per age and gender is as per Table 1. The age
group of 30e50 years constituted the maximum users of
psychotropic drugs. On an average, 2.35 medicines were pre-
scribed per prescription, and psychotropic drugs constituted
an average of 1.86 per prescription. A small percentage of
medicines was prescribed as injectable (2.39%) and as FDCs
(0.16%). A significant percentage (91.3%) of medicine was
prescribed by generic name. More than 50% of the psycho-
tropic drugs (55.02%) prescribed were from the essential drug
list. A small percentage (4.53%) of prescriptions constituted
polypharmacy (Table 2).
The second-generation antipsychotics dominated the
prescription of antipsychotics (90.45%) with risperidone being
the most commonly prescribed (26.04%) followed closely by
olanzapine (23.35%) (Table 3). Among the antidepressants
prescribed, selective serotonin reuptake inhibitors (SSRIs)
constitute the most with 61.59% prescriptions (Table 4). Esci-
talopram was the most commonly prescribed SSRI.
Mood stabilizers constitute an important category of drugs
with sodium valproate topping the chart with more than
70% prescriptions. Clonazepam with 72.17% prescriptions
was the most commonly prescribed sedative hypnotic
drug. Anxiolytic drugs include benzodiazepines, sedative
76 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) 7 4 e7 9

Table 1 e Prescription patterns based on age and gender. Table 3 e Prescription patterns of Antipsychotic drugs.
Male:females 1690:2080 (44.82%:55.17%) S.No Antipsychotic drugs No. of prescriptions
(%age of total prescriptions)
Age group (in yrs) No. of prescriptions
(a) First-generation antipsychotics (9.54%)
1 to 10 61
i. Chlorpromazine 03
11 to 20 300
ii. Trifluperazine 15
21 to 30 593
iii. Haloperidol 165 (Injectables e 72)
31 to 40 810 (21.48%)
iv. Pimozide 02
41 to 50 836 (22.17%)
v. Loxapine 01
51 to 60 602
vi. Levosulpiride 13
61 to 70 394
(b) Second-generation antipsychotics (90.45%)
71 to 80 156
i. Clozapine 68
81 to 90 15
ii. Risperidone 543 (26.04%) (Injectables e 33)
91 to 100 03
iii. Quetiapine 400
The age group with maximum prescription of psychotropic drugs iv. Aripiprazole 265
represented as bold. v. Ziprasidone 11
vi. Amisulpiride 92
vii. Olanzapine 487 (23.35%) (Injectables e 32)
antihistaminics, beta blockers, and azapirones. Clonazepam viii. Paliperidone 20 (Injectables)
Total 2085
was the most prescribed benzodiazepine, and propranolol was
the most commonly prescribed drugs for anxiety (Table 5).

systemic analysis of WHO prescribing indicators at primary

health centers of African region from 2006 to 2015 showed that
Discussion
the average number of medicines prescribed per patient was
2.6 or public centers which was higher than that in private
Our results suggest that there is polypharmacy, use of FDCs,
centers (2.5).14 In the Indian context, Jhanjee et al. in their
and suboptimal use of medicines from the essential drug list
study on psychotropic prescriptions conducted at a tertiary
at this center. Although polypharmacy reflects the individual
care center at Delhi had reported the figure as 6.24.15 While a
clinicians’ preferences and attitudes, availability of medicines
more recent study by Kumar et al. again from Delhi had re-
in the hospital may affect other two aspects found wanting at
ported the figure as 3.12.16 It may be noted that in the current
this center.
scenario, this center appears to be doing better though
In our study, an average of 2.35 drugs was prescribed per
improvement is still warranted.
prescription which is higher than the WHO standard of less
Generally more number of drugs per prescription points
than 2 (1.6e1.8) drugs per prescription.12,14 Sisay et al. in their
toward, the practice of polypharmacy, which is a global phe-
study to evaluate rational drug use using WHO core drug use
nomenon and associated with undesirable consequences.
indicators in public health hospital reported an average of 2.34
Polypharmacy is measured numerically, which often fails to
drugs prescribed per prescription.12 Ofori-Asenso et al. in their
indicate the appropriateness of prescribed medications. Spe-
cific indicators such as Beer's criteria and Medication Appro-
priateness Index may be more suitable.16In our study,
Table 2 e Analysis of prescriptions based on WHO drug
although the number of drugs prescribed per prescription was
use indicators.
higher, the same is concordant with other similar studies.
S.No Drug use indicators Result of analysis Moreover, the use of greater than four medications was
1 Total no. of prescriptions 3770 encountered in less than 5% of prescriptions in our study.
2 Total no. of drugs 8883 Here, it may be noted that the average number of psychotro-
3 Total no. of psychotropic drugs 7030
pics per prescription was only 1.864, but the average number
4 Average no. of drugs per 2.356
of medicines per prescription was higher, which shows sig-
prescription
5 Average no. of the psychotropic 1.864 nificant use of medicines other than psychotropics (e.g., lev-
drugs per prescription othyroxine, promethazine, trihexyphenidyl, thiamine, and so
6 Percentage of the psychotropic 91.30 on) which are often used to augment treatment or to counter/
drugs prescribed by generic name prevent side effects of psychotropics. Given the high rate of
7 Percentage of injectable drugs 2.39 adverse effects with psychotropics, these drugs are prescribed
prescribed
as per indications. Possibly a closer look at the prescription
8 Percentage of prescriptions 0.16
pattern of these drugs may be warranted, which calls for
containing fixed drug
combinations further research.
9 Percentage of the psychotropic 55.02 Medical Council of India emphasizes the use of generic
drugs prescribed from essential names of drugs (vide Indian Medical Council Regulations
drug list (National List of Essential related to ethics, professional conduct, and etiquettes).17,18 In
Medicines -e2015, India) our study, 91.30% of psychotropic drugs was prescribed by
10 Percentage of polypharmacy 4.53
generic name, which is again less than the WHO standard of
WHO, World Health Organization. 100% but similar to the results in a study by Sisay et al.12,14
 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) 7 4 e7 9 77

reported that 92.66% of the drugs were being prescribed by

Table 4 e Prescription patterns of antidepressant drugs.
generic names. Our results are similar to those reported by
S.No Antidepressant No. of prescriptions Kumar et al. indicating that there is still scope for improve-
drugs (%age of total prescriptions)
ment.16 Kumar et al. have argued that marketing pressures
(a) Selective serotonin reuptake inhibitors (SSRIs) (61.59%) from the pharmaceutical industry drive the writing of brand
i. Fluoxetine 300 names.16 While there is no pressure of the pharmaceutical
ii. Fluvoxamine 97
industry at our center, some drugs are manufactured by one
iii. Paroxetine 370
company which has a monopoly over it. Writing those names
iv. Sertraline 360
v. Escitalopram 573 has become so automatic that often the clinicians do not
(b) Tricyclic antidepressants (16.66%) realize the folly while writing brand names, possibly
i. Imipramine 21 explaining 8.7% prescriptions containing brand names. Ex-
ii. Amitriptyline 152 amples are Inderal (propranolol) and Pacitane (Trihex-
iii. Doxepin 94 yphenidyl). Because it has become a habit, a conscious effort is
iv. Dothiepin 02
required to break it by actively spreading this message
v. Clomipramine 115
vi. Nortryptyline 76
among the clinicians to use generic names instead of brand
(c) Serotonin and noradrenaline reuptake inhibitors names.
(SNRIs) (5.90%) In our study, injectable medicines were prescribed in just
i. Venlafaxine 57 2.39% prescriptions, well within the WHO recommended
ii. Desvenlafaxine 18 value of <20%.14 This result was in contrast to result of Ofori-
iii. Duloxetine 88
Asenso R, et al. 14 who in their analysis reported a proportion
(d) Other antidepressants (15.65%)
of 25% for overall encounter with injectables. Kumar et al., 19
i. Trazodone 05
ii. Mirtazapine 370 reported 4.59% injectable use in their study, while
iii. Bupropion 27 Kumar et al, 16 reported 0.44% prescriptions with injectables.
iv. Tianeptine 30 Among psychotropics, injectables are used either in emer-
Total 2760 gencies or as long acting injectables for maintenance. Their
use at various centers depends on the type of patients, avail-
This result was significantly different from Kumar et al. 16 who ability of injectables, and local policies. Considering the recent
brought out in their study that only 16.22% antipsychotic evidence of better tolerability and efficacy of newer long
prescription was by generic name. Another study from Delhi acting injectables, their use indicates better patient care.
by Jhanjee et al. 15 had reported this figure as a mere 25.12%, Although the data are insufficient to indicate such a pattern of
while a similar study from West Bengal by Kumar et al. 19 had use, the authors assume that to be the case.
The use of FDCs in our study was just 0.16%, which points
toward rationality in prescriptions. Solanki et al. reported that
Table 5 e Prescription patterns of mood stabilizers, more than 50% of the antipsychotic FDCs sales internationally
sedative hypnotics, and anxiolytics drugs. include formulations with banned drugs.20 A relook at the
S.No Mood stabilizers No. of prescriptions data revealed that these FDCs were mainly multivitamin, iron
(%age of total prescriptions) with folic acid, and calcium plus vitamin D3 tablets often
(a) Lithium carbonate 100 prescribed along with the psychotropics for various reasons.
(b) Sodium valproate 578 (71.80%) As a policy of the center, FDCs are discouraged and seldom
(including divalproex sodium) written by the psychiatrists. However, there are some in-
(c) Carbamazepine 89 stances when the hospital supply consists of such combina-
(d) Lamotrigine 38 tions and the clinicians use them as per availability.
Total 805
The medicine expenses constitute 72% in rural and 68% in
S.No Sedative-hypnotic drugs urban areas’ health expenses.4 Essential medicines as defined
(a) Diazepam 02 by the WHO are those that satisfy the priority healthcare
(b) Alprazolam 08 needs of majority of the population and are selected with due
(c) Lorazepam 74 regard to public health relevance, evidence on efficacy and
(d) Zolpidem 153 safety, and comparative cost-effectiveness.4,21 To provide
(e) Etizolam 10
guidance to its member countries, the WHO brought out the
(f) Clonazepam 695 (72.17%)
(g) Chlordiazepoxide 21
first list of essential medicines in 1977, amended from time to
Total 963 time. Following the footsteps of the WHO, the Indian National
List of Essential Medicines (NLEM) was introduced in 1996 with
S.No Anxiolytics
latest amendments in 2015.4,21
(a) Buspirone 95
In our study, the compliance of psychotropics prescription
Miscellaneous to the NLEM 2015 was 55.02% and was similar to the study by
(a) Propranolol 259 Dutta et al. who reported 55.39% psychotropic drugs pre-
(b) Trihexyphenidyl 524 scribed from the NLEM.22 Pugazhenthan et al. in their study of
(c) Promethazine 52 drug use pattern in dermatology reported 95% drugs pre-
(d) Atomoxetine 68 scribed were from the NLEM. the NLEM 2015 consists of only
Total 903
four antipsychotics and three antidepressants.23 While this
78 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) 7 4 e7 9
list of medicines may be adequate for smaller peripheral
centers, it becomes inadequate for providing standard of care
at a tertiary care center such as ours where we attempt to offer
the best medicines in terms of tolerability and efficacy. There
appears to be a need to enhance psychotropic prescriptions
from the NLEM at this center; however, it would be prudent to
consider inclusion of more psychotropics in the next revision
of the NLEM.
Kumar et al. in their study of prescription pattern of anti-
psychotics reported that maximum antipsychotics were pre-
scribed in the age group of 31e40 yrs (31.4%), followed by
41e50 yrs (27.5%), and 18-30 yrs (28.6%).16 Our study results
show maximum psychotropic drugs prescription to the age
group of 41e50 yrs (22.17%) followed closely by the age group
of 31e40 yrs (21.48%). Our results closely match the National
Mental Health Survey of India, 2015e2016 report which states
that individuals in the age group between 40 and 49 yrs are
affected predominantly by psychotic, bipolar, neurotic, and
stress-related disorders.24
Roberts et al. in their study of antipsychotic prescription
trends reported that atypical antipsychotics constitute 79.9%
of antipsychotic prescriptions.25 In line with this trend, our
study results reveal that atypical antipsychotics constitute
90.45% of the prescriptions. Similar to our results, Kumar et al.
in their study have demonstrated risperidone to be the most
prescribed antipsychotic (44.71%) followed by olanzapine
(34.81%).16
Yoon et al. in their study of antidepressant prescription
pattern have reported escitalopram to be the most commonly
prescribed antidepressant.26 Tripathi et al. in their study of
antidepressant prescription pattern in India report 62.2% pa-
tients on SSRIs and escitalopram to be the most commonly
prescribed SSRI.27 We have similarly reported SSRIs as the
most commonly prescribed antidepressants (61.59%) and
escitalopram as the most commonly prescribed SSRI.
About 25% of the prescriptions contained a benzodiaze-
pine. This may be because benzodiazepines are used in ther-
apeutic doses in a variety of illnesses for short-term symptom
relief. A community pharmacy-based Swiss study reported
that 9.1% of all prescriptions contained a benzodiazepine.28
Dutta et al. reported in their study on depression that 72% of
the prescriptions included a benzodiazepine.29 Although there
is no available data for direct comparison, a likelihood of
overuse and misuse of benzodiazepines at this center cannot
be ruled out and calls for research. In our study, clonazepam
was the most commonly prescribed benzodiazepine with
72.17% prescriptions.
It can be noted that, on the one hand, there are some
encouraging results, whereas there are areas for improvement
as noted ante. The purpose of drug utilization studies is to
assess the pattern of prescription of a center or a group of
centers for correctness viz a viz standards laid down and to
compare with other centers/organizations/countries. We have
noted that there is a need to increase prescription by generic
names, discourage polypharmacy, and to increase prescrip-
tion from the NLEM. We also noted that we have been faring
well as compared with other centers in India and abroad. With
respect to classes of drugs, our results are similar to studies
conducted in India and abroad. Although the ideal pattern of
prescription is difficult to achieve in a real-world scenario, a
scrutiny into the same paves way for a gradual process of
improvement, which we think will continue in the future.
There were certain limitations in the study. Not being a
prospective study, we missed out on the illness-related data
which could have given further insight into rational drug use.
In addition, we may have missed some data for patients who
did not collect medicines from the dispensary because of non-
availability, or other reasons. Because the study was carried
out at one center only, the prescription pattern was guided by
local policies and reflected the knowledge and attitudes of a
few clinicians practicing at this center. This is a possible
source of bias. Using WHO indicators, we were able to collect
data which could be compared directly with other studies
worldwide. Very few studies in the past have conducted a
scrutiny of prescription pattern using drug use indicators,
which makes for strength for this study. We suggest similar
multicentric studies with prospective design in future to
assess the prescription patterns for the whole organization.
Such a study is likely to bring uniformity and standardization
in the prescription patterns of various psychiatry centres
across the country, in addition to improving the practice of
individual clinicians.
Conclusion
Our prescriptions were not as per the ideal standards with
respect to average number of drugs per prescription, per-
centage of prescriptions with generic names, and pre-
scriptions from the essential drug list. We fared well in
prescriptions with injections and prescriptions with antibi-
otics. Although we have not been able to meet the ideal sce-
nario, compared with other studies, the results point toward a
practice of rational prescription in line with the national and
international trends for psychotropics. There is a scope for
improvement in prescription of drugs by generic name, pre-
scription from the NLEM and reducing polypharmacy. This
study provides a baseline data on psychotropic drugs and can
be used to carry out further studies on individual psychotro-
pics. Further, multicentric prospective studies in similar lines
can be conducted to achieve better results.
Acknowledgements
The authors acknowledge the support and guidance of the
Head of the hospital where the study was carried out because
of which a detailed audit could be performed.
Disclosure of competing interest
The authors have none to declare.
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