Are we taking too many antidepressants?

“There has been a gradual increase in SSRI prescriptions over the past few years,” says Dr Monica Chib, senior consultant, psychiatry, Indraprastha Apollo Hospital, Delhi. She attributes this to greater awareness of mental health, improved access to psychiatric care, and better recognition of anxiety and depression, even in primary care settings. “More people are seeking help earlier, leading to timely diagnosis and appropriate treatment where needed.”

Dr Saurabh Mehrotra, director, mental health, Medanta Gurugram, echoes this assessment, noting that the increase has been visible both globally and in India. He says the pandemic significantly heightened stress, anxiety and depression, while teleconsultations and primary healthcare have made psychiatric evaluation more accessible. At the same time, SSRIs continue to be recommended as first-line treatment for many common mental health conditions.

In India, antidepressants are also accessible and affordable. Indian companies produce quality-ensured generic antidepressants such as fluoxetine, sertraline, and escitalopram, which are sold at a fraction of international brands. A month’s supply of generic fluoxetine in India can cost as little as Rs 15-Rs 30, whereas branded versions in other countries cost between $15 and $30. Sertraline, supplied by Indian firms Sun Pharma and Dr Reddy’s, costs only Rs 20-Rs 40 rupees per month. Similarly, venlafaxine sells for just Rs 25-Rs 50.

SSRIs work by increasing the availability of serotonin, a neurotransmitter that plays a key role in regulating mood and emotions. They are commonly prescribed for moderate to severe depression, anxiety disorders, obsessive-compulsive disorder (OCD), panic disorder and, in some cases, post-traumatic stress disorder (PTSD), Dr Mehrotra explains. However, experts unanimously stress that medication should follow a thorough clinical evaluation – not a quick consultation or self-diagnosis.

“SSRIs should not be prescribed based on first impressions alone,” says Dr Mehrotra. He explains that psychiatrists assess the severity, duration and impact of symptoms using internationally accepted diagnostic criteria, while also considering medical illnesses, substance use and psychosocial factors before recommending medication.

Growing concerns

The growing number of prescriptions has inevitably raised concerns about whether antidepressants are being prescribed too readily. The answer, according to doctors, is multipronged.

Dr Chib believes that the increase in prescriptions does not necessarily indicate overprescription. Improved recognition has simply enabled more patients to receive treatment. Dr Mehrotra, however, points out that there are situations where medication may be started for relatively mild symptoms that could respond well to psychotherapy or counselling alone. “In India the shortage of trained therapists, limited consultation time and pressure to provide quick relief sometimes make medication the first option rather than one component of a comprehensive treatment plan.” Dr Hemang Desai, senior consultant, department of psychiatry, Sterling Hospital, Ahmedabad, offers a similar perspective.  “Nowadays, nearly each and every doctor is prescribing SSRIs,” he says, suggesting that patients with minor anxiety may occasionally receive medication that might not always be necessary.

Researchers in an American 2023 study published in Neuropsychopharmacology found SSRIs increased the risk of suicide attempts threefold for those younger than 18 years and up to twofold for those aged 18-24 years.

The study stated, “Those with a history of suicidal behavior showed greater absolute risks among both initiators and non-initiators. We found no evidence of a difference between initiators and non-initiators in this group in terms of suicidal behavior risk.” Dr Austin Fernandes, consultant psychiatrist and neuropsychiatrist, Saifee Hospital, Mumbai, also believes some overprescription occurs, particularly when general practitioners prescribe SSRIs for mild anxiety or emotional distress without establishing a diagnosis of clinical depression or anxiety disorder. He adds, “In the past few years, particularly post-COVID, the incidence of depression and anxiety have increased.

Safe, but take care

SSRIs are generally among the safest psychiatric medications available when used appropriately, say doctors. Most patients experience significant improvement, although the medicines typically require two to six weeks before their full benefits become apparent, says Dr Mehrotra. “Treatment often continues for six months to a year after recovery, and in some recurrent conditions, longer-term therapy may be recommended.”

Side effects include nausea, headaches, gastric irritation, sleep disturbances, changes in appetite and sexual dysfunction, particularly during the initial weeks of treatment. Most are mild and tend to improve as the body adjusts.

Dr Chib warns, “It is important to inform the doctor about any other medications being taken, pregnancy status, alcohol use, previous psychiatric history, or existing medical conditions to ensure safe and appropriate treatment. SSRIs should not be stopped suddenly or adjusted without medical guidance.”

Abrupt discontinuation can also lead to withdrawal symptoms and recurrence of illness. Patients are also advised to inform their doctors about pregnancy, existing medical conditions, alcohol use and other medications before starting treatment.

Know your medication

Dr Mehrotra explains that a proper diagnosis requiring medication is made using internationally accepted criteria laid down in the World Health Organization’s International Classification of Diseases (ICD-11). “Another widely used diagnostic framework is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Treatment decisions are based on these established diagnostic criteria. Doctors also evaluate substance use and underlying medical conditions before recommending medication.”

While escitalopram and sertraline are among the most frequently prescribed SSRIs in India, psychiatrists caution against thinking of one medication as universally superior. Dr Fernandes lists escitalopram, sertraline, paroxetine and fluoxetine among the most commonly prescribed SSRIs, explaining that while they have similar effectiveness, their side-effect profiles differ slightly.

Dr Mehrotra notes that both escitalopram and sertraline are effective, generally well tolerated, require only once-daily dosing and are widely available as affordable generics. For many patients, psychotherapy, counselling and lifestyle changes remain effective first-line treatments. Medication becomes more important when symptoms are moderate to severe, persistent, recurrent or resistant to non-drug approaches. Dr Chib stresses that medication selection depends on the individual’s symptoms, age, medical history, other medications and previous response to treatment rather than on a single ‘best’ drug.

Ultimately, psychiatrists say the increase in SSRI prescriptions reflects both progress and responsibility. Greater awareness has helped millions seek treatment for conditions that once went unrecognised, but the experts caution that antidepressants are neither quick fixes nor lifestyle medicines.