India continues to face a large mental health treatment gap, with nearly 85% of individuals with common mental disorders receiving no formal care. However, over the past decade, access to antidepressant medication, especially drugs called selective serotonin reuptake inhibitors (SSRIs), has improved, marking an important shift toward making treatment more available.

This expansion is important because, for moderate to severe depression, antidepressants are not optional but often essential. For many patients, they remain one of the most effective and life-changing interventions we have.

The concern, therefore, is not about medications themselves. It is about how, when, and for whom they are being used in routine practice. Emerging evidence suggests that a significant proportion of prescriptions either occur without a clear diagnosis of major depression, particularly in primary care settings, or have poor follow-up.

The Indian Psychiatric Society recommends a stepped-care model, where people with milder issues are first managed with psychosocial interventions before initiating pharmacotherapy. Yet in practice, this step is often bypassed and medication becomes the first-line response even in situations where other approaches may be more appropriate.

Consequences of routine prescribing

The distinction between distress and disorder is important. In busy clinics, this may blur. Patients present with sleep problems, work stress, interpersonal conflicts or grief. These experiences are real and often impairing, and deserve attention. Even when they don’t meet the threshold for clinical depression, they may still require psychological support. They are not always best addressed through medication alone, especially when they are closely tied to identifiable life circumstances.

Routine prescribing in such scenarios is understandable. It offers a quick, tangible intervention in systems where time is limited and follow-up uncertain, whether the presentation is mild depression or distress that does not meet diagnostic thresholds. However, when medication becomes the default response, we risk shifting focus away from understanding context and towards suppressing the symptoms.

Antidepressants are not addictive in the conventional sense. They don’t cause cravings, people don’t feel the need to keep increasing the dose, and they don’t lead to compulsive use. These details are important and must be clear, especially for patients who benefit from them. However, discontinuation symptoms are well-known, with some individuals experiencing dizziness, sleep disturbances or sensory symptoms when attempting to stop.

This concern has been reflected in recent policy discussions, including a U.K. House of Lords debate, which highlighted issues of long-term antidepressant use, withdrawal difficulties, and the need for better prescribing guidance and tapering support.

On the other hand, sleeping pills that are usually prescribed alongside antidepressant medications complicate the problem. They are frequently co-prescribed for sleep or anxiety and can be effective in the short term. Unlike antidepressants, however, they can lead to true dependence, where the body gets used to them, higher doses may be needed over time, and stopping them can be difficult. With longer use, they carry risks of dependence, cognitive slowing, and difficult withdrawal. Patients are also often unaware of the risks of these medications.

Over time, patterns emerge. What begins as short-term symptomatic treatment can extend into prolonged use, particularly in the absence of structured follow-up. In such instances, patients may continue medication not because it is still clearly indicated, but because stopping it has become difficult.

There is also a less visible cost. When treatment is centred primarily around medication, opportunities to develop coping strategies, address maladaptive thinking, and engage with underlying stressors may be reduced. Many individuals with mild to moderate symptoms benefit significantly with addition of brief psychological interventions such as behavioural activation or problem-solving therapy, including structured models like the ‘Healthy Activity Program’, 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 frame this as just overprescription by doctors. In reality, it reflects a deeper structural issue.

India has a limited mental health workforce, and psychotherapy remains concentrated in urban and specialist settings. In many parts of the country, particularly in rural and semi-urban areas, pharmacological treatment is the only consistently available form of care. When alternatives are scarce, prescribing becomes less a choice and more a necessity.

Public health programmes illustrate this imbalance. Access to screening and medication have improved but the availability of structured psychotherapy remains uneven. Continuity of care is difficult to maintain across districts; even where frameworks exist, implementation varies widely. This shortage is further reflected in the limited number of formal psychotherapy training positions, such as M.Phil seats, which remain insufficient relative to the population’s needs.

Antidepressants are also increasingly being prescribed by general physicians and non-psychiatric practitioners, often in busy settings with limited time. If a clinician has ten minutes, limited follow-up, and no access to psychosocial services, medication becomes the most feasible intervention, and over time reinforces both clinical habits and patient expectations.

Where options are available, prescribing patterns tend to shift even in non-psychiatric practitioners, with reduced reliance on antidepressants. This suggests that clinicians do incorporate these options when they are accessible. Thus, if psychotherapy were more easily available, many patients could be referred for it, sometimes even before medication.

Therapy beyond the clinic

Expanding access to psychotherapy can’t rely solely on increasing specialists’ numbers, which is a slow and resource-intensive process. Decentralising psychotherapy offers a more immediate pathway, based on identifying core, evidence-based components of psychological support that can be delivered by trained non-specialists within community settings.

There is growing evidence to support this approach. In low- and middle-income countries, brief interventions delivered by non-trained counsellors, such as behavioural activation, problem-solving, and psychoeducation, have demonstrated meaningful reductions in depression and anxiety. In 2006, after losing a patient who could not afford to travel for care, a senior psychiatrist, Dixon Chibanda in Zimbabwe, recognised the need to take mental health services into communities rather than wait for patients to reach hospitals. The Friendship Bench in Zimbabwe trained old women to deliver structured therapy to people with mild levels of mental distress on park benches, showing reductions of almost 43% on depression scales within six months. In India, the ‘Atmiyata’ programme uses community volunteers to provide basic emotional support and identify individuals who may need referral, linking local care with formal services.

These interventions are intentionally simple. Skills like active listening, validation, sleep hygiene, and structured activity scheduling can be manual and scaled up, and delivered in schools, workplaces, primary care centres, and community groups, bringing support closer to where people actually live and struggle. When these approaches are adapted to local culture, they become easier to understand and accept. Using familiar language, social roles, and everyday examples helps people engage with care more naturally.

Nearly 85% of people don’t access formal care and turn elsewhere for help. A significant fraction seek help from faith-based healers, traditional practitioners or community elders, who often serve as the first point of contact for distress. Rather than viewing this in opposition to medical care, there is value in engaging with these systems, especially for distress, while building pathways to identify and refer more severe afflictions to formal mental health services.

At the same time, limits must be clear. Complex conditions, trauma-focused therapies, and individuals at high risk 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 substantial component of ongoing supportive care can be safely and effectively task-shared within the community.

A stepped-care model can ensure decentralised care complements, rather than replaces, professional psychotherapy. Even in instances of seemingly simple distress, if the signs that an individual presents with fall outside the provider’s level of training or if they fail to improve, they must be referred in timely fashion to more expert care. Expanding non-specialist roles must overall be a cautious venture. New cadres risk overstepping competence and delaying referrals, however, underscoring the need for clear safeguards, supervision, and referral pathways.

Not less treatment

For moderate to severe depression, medications remain central and often indispensable. In many cases, the best outcomes arise from combining pharmacological treatment with psychotherapy. This integrated approach should remain the standard rather than the exception.

For milder presentations, the sequence can differ. Psychosocial interventions can be tried first, with medication introduced when needed. Even when antidepressants are started, regular review allows for dose adjustment or tapering in appropriate instances.

Training frontline providers in brief psychosocial interventions, embedding counselling within primary care, strengthening community support systems, and introducing basic prescription monitoring can collectively shift practice without major structural disruption. Digital platforms can extend 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 ensuring that this access is balanced, thoughtful, and responsive to different levels of need. Medication should remain available when it is needed. But it should not be the default option, especially when it is possible to have alternatives available.

A system that offers 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 across rural, tribal, and urban mental health care. Dr. Madhurima Vuddemary is an MBBS doctor with a special interest in public health. All three are associated with the Association for Socially Applicable Research (ASAR).