India continues to face huge mental health treatment gapAbout 85% of individuals have common mental disorders. no formal care. However, over the past decade, access to antidepressant medications, particularly drugs called selective serotonin reuptake inhibitors (SSRIs), has improved, marking a significant shift toward making treatment more available.
This detail is important because, for moderate to severe depression, antidepressant medications are often necessary, not optional. For many patients, they are one of the most effective and life-changing interventions we have.
Therefore, the concern is not about the drugs themselves. It is about how, when and for whom they are being used in routine practice. emerging evidence shows That a significant portion of prescriptions occur either without a clear diagnosis of major depression, especially in primary care settings, or have poor follow-up.
Indian Psychiatric Society recommends that Stepped Care ModelWhere people with mild issues are managed with psychosocial interventions before starting pharmacotherapy. Yet in practice, this step is often overlooked and medication becomes the first-line response even in situations where other approaches may be more appropriate.
Regular Prescription Results
The distinction between crisis and chaos is important. In busy clinics, it may become blurry. Patients suffer from sleep problems, work stress, interpersonal conflicts or grief. These experiences are real and often debilitating, and deserve attention. Even when they do not meet the threshold for clinical depression, they may still need psychological support. They are not always best addressed through medication alone, especially when they are closely linked to identifiable life circumstances.
In such scenarios it makes sense to schedule regularly. It provides quick, concrete intervention in systems where time is limited and follow-up is uncertain, whether the presentation is mild depression or crisis that does not meet diagnostic thresholds. However, when medication becomes the default response, we risk shifting attention away from understanding the context and toward suppressing symptoms.
Antidepressants are not addictive in the traditional sense. They don’t cause cravings, people don’t feel the need to increase the dosage, and they don’t lead to compulsive use. These details are important and should be clear, especially to the patients who would benefit from them. However, the symptoms of amputation are well known some individuals are experiencing Dizziness, sleep disturbance, or sensory symptoms when attempting to stop.
This concern has been reflected in recent policy discussions, including a UK House of Lords debate, which highlighted issues of long-term antidepressant use, difficulties with withdrawal, and the need for better guidance and less support.
On the other hand, sleeping pills that are usually given along with antidepressants complicate the problem. They are often co-prescribed for sleep or anxiety and may be effective in the short term. However, unlike antidepressants, they can cause true dependenceWhere the body becomes used to them, higher doses may be required over time, and they may be difficult to stop. With prolonged use, they lead Risks of DependencyCognitive slowing, and difficult withdrawal. there are patients too often unknown About the risks of these medicines.
Over time, patterns emerge. What begins as short-term symptomatic treatment may escalate into long-term use, especially in the absence of structured follow-up. In such cases, patients may continue the medication not because it is still clearly indicated, but because it has become difficult to stop.
The cost also appears low. When treatment focuses primarily around medication, there may be less opportunities to develop coping strategies, address maladaptive thinking, and deal with underlying stressors. Many individuals with mild to moderate symptoms benefit significantly from the addition of brief psychological interventions such as behavioral activation or problem-solving therapy, including structured models such as ‘healthy activity programs’, which has been effective In Indian primary care settings. These approaches reduce symptoms and build skills that persist beyond the treatment period.
little choice
It is tempting to simply offer it as an over-prescription by doctors. In fact, it reflects a deeper structural issue.
The mental health workforce in India is limited, and psychiatry is concentrated in urban and specialist settings. In many parts of the country, especially rural and semi-urban areas, pharmaceutical treatment is the only consistently available form of care. When options are scarce, prescribing becomes less a choice and more a necessity.
Public health programs reflect this imbalance. Access to screening and medication has improved but availability of structured psychotherapy remains uneven. Maintaining continuity of care across districts is difficult; Even where frameworks exist, implementation varies widely. This shortage is reflected in the limited number of formal psychiatry training positions, such as M.Phil seats, which remain inadequate relative to the needs of the population.
Antidepressants are also increasingly prescribed by general practitioners and non-psychiatry practitioners, often in busy settings with limited time. If a physician does not have ten minutes, limited follow-up, and access to psychosocial services, medication becomes the most viable intervention, and over time reinforces both clinical habits and patient expectations.
Where alternatives are available, there is a change in prescribing patterns, with reduced reliance on antidepressants even among non-psychiatrist physicians. This suggests that physicians do Include these options When they are accessible. Thus, if psychotherapy were more readily available, many patients might be referred for it, sometimes even before medication.
Therapy beyond the clinic
Expanding access to psychotherapy cannot depend solely on increasing the number of specialists, which is a slow and resource-intensive process. Decentralized psychotherapy offers a more immediate route, based on the identification of core, evidence-based components of psychological support, which can be provided by trained non-specialists within community settings.
There is growing evidence to support this view. In low- and middle-income countries, brief interventions delivered by non-trained counselors, such as behavioral activation, problem-solving, and psycho-education, have shown meaningful reductions in depression and anxiety. In 2006, after losing a patient who was not able to travel for care, Dixon Chibanda, a senior psychiatrist in Zimbabwe, recognized the need to take mental health services into communities rather than waiting for patients to reach hospitals. Friendship Bench in Zimbabwe trained elderly women to deliver structured therapy to people with mild mental distress on park benches, showing a reduction of approximately 43% on a depression scale. within six months. in india, ‘‘Atimiya’ program Uses community volunteers to provide basic emotional support and identify individuals who may need referral, linking local care to formal services.
These interventions are intentionally simple. Skills such as active listening, validation, sleep hygiene and structured activity scheduling can be manualized and scaled up, and delivered into schools, workplaces, primary care centers and community groups, bringing support closer to where people actually live and struggle. When these approaches are adapted to the local culture, they become easier to understand and accept. Using familiar language, social roles and everyday examples helps people connect with care more naturally.
About 85% of people do not access formal care and go elsewhere for help. A significant portion seek help from faith-based practitioners, traditional healers or community elders, who often serve as the first point of contact for those in crisis. Rather than seeing it in opposition to medical care, there is value in it. Connect to these systemsParticularly for crisis, while creating pathways to identify and refer more serious suffering to formal mental health services.
Also, boundaries should be clear. Complex conditions, trauma-focused treatment and high-risk individuals require specialist expertise. Primary diagnosis and treatment of conditions such as schizophrenia, bipolar disorder and obsessive compulsive disorder should remain within specialist care settings – but a large component of ongoing supportive care can be safely and effectively task-shared within the community.
A stepped care model could ensure decentralized care complementing rather than replacing professional psychotherapy. Even in cases of seemingly simple crisis, if the signs a person presents are outside the level of the provider’s training or if they fail to improve, they should be referred for more specialist care in a timely manner. Expanding non-specialist roles should overall be a cautious venture. However, new cadres run the risk of exceeding their capacity and delaying referrals, emphasizing the need for clear safeguards, supervision and referral pathways.
no less treatment
For moderate to severe depression, medications are central and often indispensable. In many cases, combining medicinal treatment with psychotherapy produces the best results. This integrated approach should remain the standard rather than the exception.
For lighter productions, the order may vary. Psychosocial intervention can be tried first, and medication can also be given if needed. Even when an antidepressant is initiated, regular review allows dosage adjustment or reduction in appropriate cases.
Training frontline providers in brief psychosocial interventions, embedding counseling within primary care, strengthening community support systems, and introducing basic prescription monitoring could collectively change practice without major structural disruption. Digital platforms can take this further, supporting both delivery and follow-up in areas with limited specialist access.
India has already made progress in improving access to treatment. The next step is to ensure that this approach is balanced, thoughtful and responsive to different levels of need. Medicine should be available when needed. But it should not be the default option, especially when alternatives are available.
A system that provides both clearly, appropriately, and at scale is far more likely to serve patients well.
Dr. Jeel Vasa is a psychiatrist from AIIMS Nagpur. Dr. Richa Shete is an MD in Community Medicine and Founder of Make A Conversation Foundation with experience in rural, tribal and urban mental health care. Dr. Madhurima Vuddemari is an MBBS doctor with special interest in public health. All three are associated with the Association for Socially Applicable Research (ASAR).
