Eating Drugs: Psychopharmaceutical Pluralism in India

This book by Stefen Ecks, Director of the Medical Anthropology Program and Senior Lecturer of Anthropology at the University of Edinburgh, provides a critical evaluation of drug-prescribing practices in Kolkata (formerly known as Calcutta), a major metropolitan city in India. The author has followed up this topic of his interest since 1999. He has traveled to India and personally interacted with psychiatrists, patients, care givers, and friends to understand the effect of multiple schools of medicine (e.g., allopathy, Ayurveda, homeopathy) in an “unregulated private market.” He uses the term “medical pluralism” to describe this phenomenon. The book is “written from a position of skepticism” about the long-term benefits of pharmaceuticals. Much of the book is based on a series of interviews conducted by the author with patients at a general hospital run by a Hindu philanthropic organization, which caters primarily to lower socioeconomic populations. This is an interesting and unusual book, providing a perspective on the realities of psychiatric care in the developing world in the context of a complex, traditional culture.

The book raises questions about the popularity of pharmacologic treatment for the mentally ill and expresses concern about the risks and debatable long-term benefits of continued antidepressant drug use in the population that he explores. This is an interesting debate when use of antidepressant drugs is gaining popularity and sanctity worldwide. The author asserts that the pharmaceutical industry gives strong incentives to doctors for prescribing medicines and almost insinuates that the popularity and pattern of prescriptions are determined by the industry. Some readers may find this a provocative claim. The book then discusses the dynamics of clinical expression of depressive symptoms, social expectations, and doctor-patient communications. The book also explores the role of a complex environment where factors such as medical pluralism, medical capitalism and drug pricing, cost of treatment for the family, frequent tendency to self-medicate, and prevalent tendency of doctor shopping that may interact to create unique dynamics in Kolkata and, by approximation, the rest of India.

The 240 pages of the book are divided into four chapters. The first chapter is on popular practice. The next two chapters are on Ayurveda and homeopathy. The fourth chapter is a critical interpretation of the use of psychopharmacology for mood disorders. It provides a glossary of relevant phrases and expressions and common terms in the Bengali language, with English translations. The bibliography is extensive and impressive.

The first chapter features an interesting discussion of social beliefs regarding the importance of food in health and illness. The author describes culture-specific terms, such as “bad mind,” “ill-tempered mind,” and “moody belly,” and how these are considered or weaved into the etiology of depressive illness. He also describes how a busy clinician would use convenient metaphors like “bad mind” and antidepressant drugs as “mind food” to promote adherence to medication. He quotes a clinician’s observation that such culturally acceptable descriptions or paradigms about medications and their effects help to improve adherence in ways that education about neurochemistry did not or rather may not. The first chapter also includes a description of a clinical incident in which a monk expressed reluctance to accept his psychiatrist’s opinion or the medicines prescribed to him because the monk’s beliefs stressed the impact and “power of practice of yoga” in health. The book uses this incident to open a discussion on the dynamics, social expectations, and interpretation of the doctor’s advice. This makes for interesting reading. The author provides multiple examples of how culture and social beliefs affect expression of depressive symptoms in the population he interviewed. He also visited the outpatient clinic of a general hospital and studied the responses of the patients waiting to meet their consultants. He accompanied a senior consultant on his rounds of the hospitalized mentally ill patients and interacted with psychiatrists in training to understand the dynamics of presentations of mental illness, patterns of evaluating the patients, and prescribing drugs, all within the socially acceptable patterns of communication where the patients and relatives accept that a busy clinician may not have enough time to speak to them at length.

The chapters on Ayurveda and homeopathy provide readers with a background on these systems of medicine and discuss how they conceptualize depressive symptoms and psychopharmacology. The Ayurveda school of medicine is based on a traditional system of biomedical remedies. Practitioners often dispense herbal medicines prepared out of herbs and plants, which are often freshly compounded and individualized, rather than use the mass-produced remedies. The author notes that in the last few decades, Ayurvedic medical colleges have established curricula and now offer degree courses in Ayurveda. Knowledge of the Sanskrit language is essential for obtaining such a degree in Ayurveda. Homeopathy, which originated in Europe, is popular in Kolkata (described by the author as the “world capital of homeopathy”). The book provides detailed discussion on Ayurvedic and homeopathic drugs. However, other systems of medicine, such as the Unani system, which have long been practiced in India, are not discussed here.

In the final chapter, the author notes the high prevalence of somatic symptoms in depressive disorders and provides interesting insight into the relevance of concepts like disruptions in body humors, digestion, bowels, and food as part of the lexicon of the psychiatrists he interviewed. The book underscores the observation that psychiatrists find it easy to explain genesis and management of mental illness in terms of somatic or systemic phenomena that explain emergence of symptoms, rather than offer elaborate explanations of underlying psychobiology. The author underscores that Indian pharmaceutical companies do not have direct marketing access to consumers. The book observes that a common pattern adapted by drug manufacturers is to provide assessment tools and information on indications and safety of antidepressant drugs to the practitioners. Drug companies sponsor campaigns to encourage primary care physicians to identify and treat depressions without referral to a psychiatric facility. The unavoidable conflict of interest of the pharmaceutical companies engaging in such awareness campaigns is discussed.

It is important to keep in mind that most of the author’s conclusions are based on his own experiences, which were restricted to patients and physicians at a relatively small hospital. The focus of this work is depression. Cultural aspects of other mental illnesses like schizophrenia or bipolar disorder are not discussed, and biological topics such as pharmacokinetics or pharmacogenomics are also beyond the purview of this book. It essentially provides an insight into how patients with depressive symptoms and their families respond when the doctor prescribes a drug. There is an inevitable conflict between the importance of true informed consent and providing a simplified explanation of the illness and medication to facilitate increased likelihood of treatment adherence. However, the author makes an important point that both approaches may eventually have the same ultimate goal: to optimize the ability to alleviate symptoms. The difference between the approaches may be more reflective of cultural dissimilarities than the approaches themselves. In a culture where allopathy, Ayurveda, and homeopathy coexist, patients often respond to explanations based in one system of medicine, even though the treatment being prescribed may be from a different medical system (e.g., education based on Ayurvedic concepts being used to promote allopathic medications).

Overall, this book is well written, researched, and referenced. It is a learned critique of medical practice and drug use in Kolkata, and by proxy India. Much of its value is in its presentation of a view that is not likely to be found in medical textbooks or journals but nonetheless reflects the reality of psychiatric practice in India. It is easy to read and is thought-provoking. It will make for interesting reading to psychiatrists in India and other parts of the world where traditional forms of medicine affect psychiatric care. It will also make for meaningful reading for any open-minded psychiatrist with an interest in culture and its impact on care.