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Original Article
An observational study on drug prescribing pattern of psychotropic medication in psychiatry outpatient department of a medical college in Eastern India
Ujjwal Bandyopadhyay1, Debanjan Bhattacharjee2, Avik Chakraborty3*
1Associate Professor, 2Senior Resident, 3Assistant Professor, Department of Psychiatry, ESI‐PGIMSR, ESIC Medical College and ESIC Hospital and ODC (EZ), Kolkata, West Bengal, India
Abstract
Introduction: There are a few studies on the psychotropic prescription pattern in Eastern India, particularly in West Bengal, with limited statistics and focus, as well as there is no study conducted in health facilities particularly catering to the labor class population. To improve the mental health‐care delivery in laborers and their dependents through policy‐making, information is required regarding psychotropic prescription patterns in laborers suffering from mental disorders.
Materials and Methods: A hospital‐based, cross‐sectional study was conducted for 6 months. A total of 3000 patients were randomly selected from those who consented to utilize their information for study purposes. DSM‐5 was used for psychiatric diagnosis. Descriptive statistic was used to describe drug use pattern. The World Health Organization‐drug use indicators were used for analyzing prescriptions. Results: Among 3000 participants, 1114 (37.1%) and 537 (17.9%) were suffering from somatic symptom disorder and generalized anxiety disorder, respectively. Antidepressants and benzodiazepines (BZDs) with Z‐drugs together form the major bulk of prescriptions. Amitriptyline, olanzapine, and alprazolam were the most commonly prescribed antidepressants, antipsychotics, and BZDs, respectively.
Conclusion: Neurotic and anxiety disorders are major psychiatric morbidity among the labor class population. Antidepressants like amitriptyline and BZDs like alprazolam can meet the majority of mental health needs of laborers. Therefore, policy and provision are required for an adequate availability of these drugs in catering centers.
Keywords: Antidepressants, antipsychotics, benzodiazepines, mental disorders, polypharmacy
Address for correspondence: Dr. Avik Chakraborty, C/l‐1, Jyangra, Ghoshpara (Near Sishu Kalyan Sangha), P.O‐Jyangra B.O, P.S‐Baguiati, Kolkata ‐ 700 059, West Bengal, India.
E‐mail: brain26091986@yahoo.com
Submitted: 18‐Aug‐2022, Revised: 06‐Oct‐2022, Accepted: 12‐Oct‐2022, Published: 28‐Feb‐2023
INTRODUCTION
Laborers have more risk of mental health problems, but lower income compared to white‐collar professionals.[1] Spending on mental disorders takes around 12% of per capita income,[2] which may be cumbersome for them. Irrational
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prescription is one of the causes of an increase in treatment costs.[3] Prescription pattern monitoring studies support a better service delivery through the rational use of medicine.[4] There are a very few studies in West Bengal on psychotropic
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© 2023 Archives of Mental Health | Published by Wolters Kluwer – Medknow
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How to cite this article: Bandyopadhyay U, Bhattacharjee D, Chakraborty A. An observational study on drug prescribing pattern of psychotropic medication in psychiatry outpatient department of a medical college in Eastern India. Arch Ment Health 0;0:0.

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prescription patterns, limited by their scope and statistics.[5,6] There is also no study conducted focusing on laborers. To improve the mental health care delivery in laborers and their dependents through policy‐making, information is required regarding psychotropic prescription patterns in laborers suffering from mental disorders. This study is intended to answer all these data gaps.
Aims and objective
Primary objective
The primary objective was to describe the prescription pattern in the psychiatry outpatient department (OPD).
Secondary objective
The secondary objective was to analyze the prescribing pattern of psychotropic medications.
MATERIALS AND METHODS
The study was a cross‐sectional, hospital‐based observational study with data collected over 6 months in the psychiatry OPD of our institute’s catering health services to the laborers and their families. Ethical approval was obtained from the Institutional Ethics Committee to conduct this study. Written informed consent was obtained from the participants, and confidentiality of the participant’s data was maintained. Studies on prescription patterns require a minimum of 600 sample size as per recommendation,[7] but similar studies recruited 294–3770 samples;[5‐7] hence, we took 3000 prescriptions, randomly selected using RANDBETWEEN function of Microsoft Office Excel among consented participants of both sex and all ages, suffering from a psychiatric illness and on at least one psychotropic drug, attending the psychiatry OPD during the study [Figure 1]. Patients with pregnancy and lactating mothers were excluded from the study as being at high risk, their prescription usually follows strict guidelines, so may not reflect true day‐to‐day practice. A predesigned data abstraction form was used to collect the required information on prescription patterns including duration of
Figure 1: Flow chart of participant recruitment 2
the prescription, name of the drug, route of administration, and demographic and clinical pro forma used to collect information regarding gender, locality, education, occupation, diagnosis, and duration of illness of these patients. The diagnosis was recorded according to the DSM‐5. The World Health Organization (WHO)‐drug use indicators[8] included to analyze the prescriptions were: 1) the average number of drugs per prescription, 2) the average number of psychotropic drugs per prescription, 3) the percentage of the psychotropic drugs prescribed by generic name, 4) the percentage of injectable drugs prescribed, 5) percentage of prescriptions containing psychotropic fixed‐dose combinations(FDC), 6) percentage of the psychotropic drugs prescribed from essential drug list, and 7) percentage of the psychotropic drugs prescribed from the hospital pharmacy. To determine the proportion of drugs prescribed from the essential list, the prescription is compared with the WHO‐EDL[9] and the National list of Essential Medicine (NLEM).[10,11] The data were then entered and analyzed using SPSS for Windows V 14.0 (SPSS Inc., Chicago, IL, USA).
RESULTS
Our study population comprises 69.8% of female patients and 30.1% of male patients [Table 1.1].Somatic symptom disorder (37.1%) was the most frequent diagnosis encountered, followed by generalized anxiety disorder (17.9%) and major depressive disorder (15.6%) [Table 1.2].
Amitriptyline (42.96%) was the most frequently prescribed antidepressant, followed by escitalopram (39.6%) [Table 2.1]. Olanzapine (45.4%) was the most frequently prescribed antipsychotic, followed by haloperidol (28.2%) [Table 2.2]. Alprazolam (65.3%) was the most frequently prescribed benzodiazepine (BZD), followed by clonazepam (19.05%) and clobazam (10.2%) [Table 2.3].
The most frequently mentioned drug in the prescriptions was antidepressants (28.9%), followed by BZDs and Z‐drugs (18.1%) [Figure 2].
63.01% of psychotropics were mentioned in generic names, whereas 71% of psychotropics were supplied from the hospital pharmacy. 24.66% of prescriptions contained fixed‐drug combinations. The proportion of psychotropics from the WHO EDL, 2021, and NLEM, 2021, was 30.57% and 30.11%, respectively. No injectable drugs were used [Table 3]. Data regarding Duration of illness,Miscellaneous drugs used & Duration of prescription were described in supplementary files [supplementary 1, 2 and 3].
DISCUSSION
In our study, females were more than males; it has been shown in previous studies that the burden of mental illness is more in females than that of males and are more likely to seek outpatient
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Table 1.1: Demographic profile
Bandyopadhyay, et al.: Prescription pattern in psychiatry
and escitalopram were the two most frequent antidepressants
Variables
Sex Locality Education
Occupation
Subgroups
Male
Female
Rural
Urban
Under class X Undergraduate Graduate
No formal education House maker Retired
Skilled worker Student Unemployed Unskilled worker
Frequencies (%)
903 (30.1) 2097 (69.9) 1995 (66.5) 1005 (33.4) 1866 (62.2) 210 (7)
396 (13.2)
528 (17.6) 1160 (38.6) 94 (3.1) 936 (31.2) 78 (2.6) 92 (3.06) 640 (21.3)
Frequency (%)
134 (4.5) 13 (0.4) 75 (2.5) 25 (0.8) 37 (1.2) 24 (0.8) 537 (17.9) 23 (0.8) 24 (0.8) 469 (15.6) 73 (2.4) 88 (2.9) 162 (5.4) 176 (5.9) 13 (0.4) 1114 (37.1) 12 (0.4)
Frequency (%)
37 (1.23) 673 (22.43) 635 (21.2) 1655 (55.2)
prescribed in our sample. The choice of amitriptyline is probably based on the clinician’s preference based on their experience in managing pain symptoms in somatic symptom disorder as it is effective in neuropathic pain, and a significant proportion of our sample had somatic symptom disorder.[16] Amitriptyline is also frequently used for somatic symptom disorders.[17] In our study, amitriptyline was prescribed more than escitalopram. In other studies, where escitalopram was the most commonly prescribed antidepressant; depression and anxiety disorder constituted a significant proportion of diagnoses in the participants.[14,18,19] One reason that escitalopram and amitriptyline were frequently prescribed in our study was their availability in the hospital pharmacy.
The choice of an antipsychotic like an antidepressant is based mainly on its side‐effect profile.[20] Olanzapine is the most common antipsychotic prescribed, which is in concurrence with the previous surveys of the prescription pattern.[14,17,18] One study reported the use of mostly first‐generation antipsychotics which included haloperidol,[21] which is the second most common antipsychotic used in our study. Both olanzapine and haloperidol were available in our hospital pharmacy.
Alprazolam was the most commonly used, and clonazepam was the second most commonly used BZD in our study. Previous studies found clonazepam to be the most commonly prescribed.[14,17,18] There is a contrasting evidence about the efficacy of alprazolam over other BZDs.[22,23] Availability of alprazolam in the hospital pharmacy is the reason behind its most common prescription.
Among psychotropics, antidepressants were most frequently prescribed, followed by BZDs and Z‐drugs, and antipsychotics. These findings are similar to previous studies of prescription patterns in India.[5,17] The reason for prescribing antidepressants and BZDs is due to a significant proportion of our samples being diagnosed with somatic symptom disorder, anxiety disorders, and major depressive disorder. The average number of drugs and psychotropics per prescription was 3.4 and 1.93, respectively [Table 3]. The results for the average number of drugs are similar to a previous study,[5] but slightly higher than a previous study[19] done in India. The average number of psychotropics used in this study was similar to previous studies,[18,19] but lower than a study where polypharmacy was admitted.[5] These results indicate that avoidance of polypharmacy was nearly achieved in our study. The proportion of drugs prescribed by generic names was higher than in one previous study,[19] but lower than in other studies[5] exploring prescription patterns in India. The fact that more than one‐third of the medications were not prescribed by generic name was due to patients’ feedback to clinicians regarding the inability to understand the generic name by a few of the
Table 1.2: Diagnostic profile
Diagnosis
Adjustment disorder Attention‐deficit/hyperactive disorder Bipolar disorder
Conversion disorder
Dysthymia
Enuresis
Generalized anxiety disorder
Illness anxiety disorder
Intellectual developmental delay Major depressive disorder
Major neurocognitive disorder Obsessive compulsive disorder
Panic disorder
Schizophrenia
Sexual dysfunction
Somatic symptom disorder
Substance use disorder
Supplementary 1: Duration of illness
Duration
1 year
Figure 2: Frequency of prescription
treatment.[12,13] Somatic symptom disorder was the most common diagnosis, followed by anxiety disorders and mood disorders. Studies in the past show a similar pattern of psychiatric morbidity among patients attending the OPD.[14,15] Amitriptyline
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Table 2.1: Antidepressants prescribed
Antidepressants
Amitriptyline Escitalopram Tianeptine Fluoxetine Mirtazapine Sertraline Desvenlafaxine Duloxetine Paroxetine Imipramine Doxepin Trazodone Venlafaxine
Table 2.2: Antipsychotics prescribed
Antipsychotics
Olanzapine Haloperidol Quetiapine Aripiprazole Risperidone Clozapine Amisulpride
Table 2.3: Benzodiazepines and Z‐drugs used
Benzodiazepines and Z‐drugs
Alprazolam Clonazepam Clobazam Lorazepam Nitrazepam Zolpidem
Supplementary 2: Miscellaneous drugs used
Drugs
Multivitamin
Drugs for peptic ulcer Calcium + Vitamin D3 Analgesics Flunarizine
Iron + folic acid Pregabalin Propranolol L‐thyroxine Trihexyphenidyl Gabapentin Piracetam
Valproate
Lithium
Domperidone Atomoxetine Methylphenidate
Supplementary 3: Duration of prescription
Duration
1 year
Frequency (%)
1201 (42.6) 1117 (39.6) 119 (4.2) 106 (3.75) 61 (2.2) 61 (2.2) 37 (1.3) 35 (1.24) 25 (0.9) 23 (0.8) 13 (0.46) 11 (0.4) 11 (0.4)
Frequency (%)
251 (44.5) 156 (27.6) 49 (8.7) 47 (8.33) 25 (4.4) 23 (4.1) 13 (2.3)
Frequency (%)
1152 (65.3) 336 (19.05) 180 (10.2) 48 (2.7) 24 (1.36) 24 (1.36)
Frequencies (%)
1584 (52.8) 1116 (37.2) 732 (24.4) 372 (12.4) 180 (6.0) 143 (4.8) 109 (3.6) 84 (2.8) 73 (2.4) 56 (1.8)
47 (1.5) 42 (1.4) 42 (1.4) 22 (0.73) 12 (0.4) 9 (0.3)
2 (0.06)
Frequency (%)
113 (3.7) 1861 (62.03) 433 (14.43) 593 (19.8)
The proportion of drugs prescribed from the hospital schedule was higher than in one study,[19] but similar to other studies.[5] The higher proportion of prescriptions from the hospital schedule is due to the hospital rules, patient affordability, and availability of drugs in the hospital pharmacy. No injectable drugs were prescribed which is similar to a previous study,[19] but lower than other studies.[5] The reasons can be a concern over adverse effects like pain at the injection site and patients preferring oral over injectable drugs. Prescription of fixed‐drug combinations was similar to previous studies,[19] but higher than a previous study.[5] The main reason for one‐fourth of the prescriptions having fixed‐drug combinations is due to the patients’ preference of taking a single medication rather than taking multiple medications. Our study reported around 30% of the medications being prescribed from NLEM, which is lower than a previous study done in 2014;[5] this may be due to the changes made in the current version of both WHO EDL[9] and NLEM.[10,11] Regarding the strength of our study, while other studies previously done in West Bengal, either of small sample size and used nonrandom sampling,[5,6] our study used random sampling and is of an adequate sample size as per recommendation.[7]
CONCLUSION
Neurotic disorders, anxiety disorders, and mood disorders are major mental health concerns among laborers and their dependents. Even in such a specific group population, females are more sufferer than males. The provision of escitalopram, amitriptyline, alprazolam, and clonazepam can meet the majority of mental health needs of the labor class population. Although more studies in similar settings are required to address the mental health needs of laborers properly and subsequent policy‐making. Psychotropic prescription patterns in laborers may be influenced by many factors such as the diagnosis pattern, free availability of medicine from the hospital pharmacy, hospital rules, patient affordability, patient preference as well as clinician preference, requiring further focused study to conclude. Polypharmacy in psychiatry practice catering to laborers can be achieved through an institution‐based mental health delivery.
Limitation
Despite the rigorous methodology adopted, this study is not beyond shortcomings. The limitations of this study lie in prescription patterns for individual diagnoses and differences in prescription patterns between different diagnoses. The cross‐sectional nature of this study could not infer the change in trends of prescription patterns over time for individual diagnoses. Being a hospital‐based study, its result may not reflect a resemblance with the prescription pattern followed by mental health‐care professionals practicing in the community. However, results from this study are important
Bandyopadhyay, et al.: Prescription pattern in psychiatry
pharmacists, who are better acquainted with the brand names.
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Table 3: Drug usage indicators
Indices
Average number of drugs per prescription Average number of psychotropic drugs per prescription
Psychotropics by generic name Psychotropics from hospital pharmacy Injectable drugs
Prescriptions with psychotropic fixed‐drug combinations
Psychotropics prescribed from essential list (WHO EDL, 2021)
Psychotropics prescribed from essential list (NLEM, 2021)
Frequency
3.4 1.93
3291/5223 (63.01%) 3708/5223 (71%) 0 740/3000 (24.66%)
1597/5223 (30.57%) 1573/5223 (30.11%)
from: http://jddtonline.info/index.php/jddt/article/view/535. [Last
accessed 2022 May 02].

7. Tejus A, Saxena SK, Dwivedi AK, Salmani MF, Pradhan S. Analysis of
   the prescription pattern of psychotropics in an outpatient department of a general hospital psychiatry unit. Med J Armed Forces India 2022;78:74‐9.
8. How to Investigate Drug Use in Health Facilities: Selected Drug Use Indicators. Available from: https://www.who.int/publications‐ detail‐redirect/who‐dap‐93.1 [Last accessed on 2022 May 03].
9. WHO Model List of Essential Medicines – 22nd List; 2021. Available from: https://www.who.int/publications‐detail‐redirect/ WHO‐MHP‐HPS‐EML‐2021.02. [Last accessed on 2022 May 03].
10. Centre Releases NLEM 2021 with 39 Additional Drugs and 16 Deletions from Previous List. Available from: http://www.pharmabiz. com/NewsDetails.aspx?aid=142320&sid=1. [Last accessed on 2022 May 03].
11. Essential Medicines. Available from: https://cdsco.gov.in/opencms/ opencms/en/consumer/Essential‐Medicines/[Last accessed on 2022 May 03.]
12. Bursalioglu FS, Aydin N, Yazici E, Yazici AB. The correlation between psychiatric disorders and women’s lives. J Clin Diagn Res 2013;7:695‐9. 13. Ranney ML, Locci N, Adams EJ, Betz M, Burmeister DB, Corbin T, et al. Gender‐specific research on mental illness in the emergency department: Current knowledge and future directions. Acad Emerg
    Med 2014;21:1395‐402.
13. Grover S, Kumar V, Avasthi A, Kulhara P. An audit of first prescription
    of new patients attending a psychiatry walk‐in‐clinic in North India.
    Indian J Pharmacol 2012;44:319‐25.
14. Sood M, Ranjan R, Chadda RK, Khandelwal SK. Changing
    pattern of clinical profile of first‐contact patients attending outpatient services at a general hospital psychiatric unit in India over the last 50 years. Indian J Soc Psychiatry 2017;33:213‐8. Sep Available from: https://www.proquest.com/docview /1940903676. [Last accessed on 2021 Oct 29].
15. Moore RA, Derry S, Aldington D, Cole P, Wiffen PJ. Amitriptyline for neuropathic pain in adults. Cochrane Database Syst Rev. 2015;2015:CD008242.
16. Grover S, Avasthi A, Sinha V, Lakdawala B, Bathla M, Sethi S, et al. Indian Psychiatric Society multicentric study: Prescription patterns of psychotropics in India. Indian J Psychiatry 2014;56:253‐64.
17. Ramamurthy P, Alexander A, Solomon S, Thilakan P, Rudravaram VV. Prescription pattern, follow‐up pattern, and medication adherence in psychiatric outpatients. Ann Indian Psychiatry 2021;5:67‐73
18. Javedar P, Raikar SR, Dass P. Prospective study of prescription patterns in outpatients of psychiatry department in a teaching hospital in Gulbarga. Indian J Pharm Pharmacol 2019;6:65‐72.
19. Edlinger M, Hofer A, Rettenbacher MA, Baumgartner S, Widschwendter CG, Kemmler G, et al. Factors influencing the choice of new generation antipsychotic medication in the treatment of patients with schizophrenia. Schizophr Res 2009;113:246‐51.
20. Rukat A, Musisi S, Ströhle A, Mundt AP. Prescription patterns of psychotropic medications for the treatment of psychotic disorders in the largest mental health institutions of Uganda. J Clin Psychopharmacol 2014;34:571‐6.
21. Jonas JM, Cohon MS. A comparison of the safety and efficacy of alprazolam versus other agents in the treatment of anxiety, panic, and depression: A review of the literature. J Clin Psychiatry 1993;54 Suppl: 25‐45.
22. Moylan S, Staples J, Ward SA, Rogerson J, Stein DJ, Berk M. The efficacy and safety of alprazolam versus other benzodiazepines in the treatment of panic disorder. J Clin Psychopharmacol 2011;31:647‐52.
    Bandyopadhyay, et al.: Prescription pattern in psychiatry
    WHO EDL: World Health Organization essential drug list, NLEM: National list of Essential Medicine
    for policy‐making for providing a better mental health‐care delivery to laborer by ensuring an adequate availability of psychotropics in catering centers.
    Acknowledgment
    We thank Dr. Chandan Chatterjee, Professor, Department of Pharmacology of ESI‐PGIMSR, ESIC MC, and H, for guiding us and providing us necessary literature during the synopsis preparation of this study. We also thank Dr. Paramita Patra, Ex‐Senior Resident, Dr. Wasim Islam, and Dr. Sikandar Ali Ex‐Junior Resident of our department for helping us in data collection process.
    Financial support and sponsorship
    It is a self‐funded study by all authors.
    Conflicts of interest
    There are no conflicts of interest.
    REFERENCES
23. Ahn J, Kim NS, Lee BK, Park J, Kim Y. Relationship of occupational category with risk of physical and mental health problems. Saf Health Work 2019;10:504‐11.
24. Sarkar S, Mathan K, Sakey S, Shaik S, Subramanian K, Kattimani S. Cost‐of‐treatment of clinically stable severe mental illnesses in India. Indian J Soc Psychiatry 2017;33:262. Available from: https://www.indjsp. org/article.asp?issn=0971‐9962;year=2017;volume=33;issue=3;spage= 262;epage=268;aulast=Sarkar;type=0 [Last accessed on 2022 Apr 30].
25. Shafie AA, Hassali MA, Azhar S, See OG. Separation of prescribing and dispensing in Malaysia: A summary of arguments. Res Social Adm Pharm 2012;8:258‐62.
26. Jain S, Upadhyaya P, Goyal J, Kumar A, Jain P, Seth V, et al. A systematic review of prescription pattern monitoring studies and their effectiveness in promoting rational use of medicines. Perspect Clin Res 2015;6:86‐90.
27. Mukherjee S, Sen S, Chatterjee SS, Biswas A, Sinha S, Ghosal M, et al. Prescribing pattern of psychotropic medications in psychiatry outpatients at a tertiary care teaching hospital in India: A prospective cross‐sectional study. Int J Hospital Res 2014;3:113‐22.
28. Ghosh S, Bhattacharyya S, Dalai C. Antipsychotic prescribing pattern in a tertiary care hospital of Eastern India. JDDT 2013;3:38‐2. Available
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