Nonspecific nutritional supplements for psychiatric disorders: Addressing the failure of check-gate in low and middle-income countries

Dear Editor,

Ahmadfakhrodin et al.,[1] in their review, discussed about the issue of poly-pharmacy in elderly patients and the factors involved with it. In fact, poly-pharmacy is significantly affecting the clinical practice in various medical conditions irrespective of the age. In some special conditions like psychiatric disorders, where the etiology of the condition is uncertain, the risk of poly-pharmacy is high. Nutritional supplements are one of the prescribed agents that contribute to poly-pharmacy significantly is a rising matter of concern. In this critique, we highlighted the issue of prescription of nonspecific nutritional supplements in psychiatric disorders resulting in poly-pharmacy.

Nutritional supplements are commonly prescribed in various medical conditions including patients with mental illnesses. Patients with mental illnesses often have a deficiency of various nutrients due to their erratic dietary habits, malabsorption and chronic malnutrition[2,3] Existing evidence supports the potential beneficial role of vitamins, micronutrients, antioxidants, probiotics, essential fatty acids and N-acetyl cysteine in psychiatric disorders like schizophrenia, depression, attention-deficit hyperactivity disorder (ADHD), substance use disorder and anxiety disorder.[2,4] International clinical guidelines recommend the use of nutritional supplements as adjuvants and in states of deficiency in selected patients with specific mental illnesses.[4]

The nutraceutical industry is promoting the supplements in such a glorified manner that it creates an illusion in the general public that the use of nutraceuticals will improve the mental well-being of all individuals, irrespective of their mental illness and even improve their mental abilities. Due to the myths and misconceptions related to nutraceuticals, it has been seen that a significant number of people with health issues self-medicate or demand for writing nutraceuticals in the prescription to consulting doctors especially in low and middle-income countries (LMICs) like South Asia with about two billion populations where there are lack of mental health insurance, poor control in selling pharmaceutical products, lack of regulatory bodies to ensure accountability of prescriptions.[5,6] In a recent multi-centric study in India, it was found that about 54% of all prescriptions audited contains at least one multivitamin formulation.[7] A study conducted in Nepal revealed that multivitamin and neutraceutical prescribing is a common phenomenon in medical practice and when a neutraceutic is prescribed; it accounts for 52% of the costs of the total medicines.[8] A similar study from Pakistan also reports that about 38% of prescriptions contain multivitamins as a recommended treatment.[9] When it comes to the prescription pattern of multivitamins and nutraceuticals in psychiatric disorders, an Indian study reports that about 52% prescriptions of patients with psychiatric disorders contain non-psychotropic medications like multivitamins, iron, and calcium supplementations.[10] An Indian study, that evaluated the prescription pattern in patients with dementia, reported that more than 55% of the prescriptions contained folic acid supplementation and more than 61.6% prescriptions contained vitamin B12 supplementation alone.[11] A multicentric study from India, sponsored by Indian Psychiatric Society evaluated the prescription pattern of patients with dementia and found that about 29.4% prescriptions have various supplements and neurotrophic or nootropic agents.[12] These nutraceuticals not only increase the out-of-pocket expenses of patients but also create noncompliance to the pharmacotherapies due to the long duration of treatment where people continue the nutraceuticals and discontinue the psychotropics. This may further increase the deviation from evidence-based practice in treating severe mental illness. Recently, the Supreme Court of India has warned a company involved in the production of healthcare products, for misleading advertisements[13] and issued a directive to the companies that before advertisement of a product, the company will declare that they are not making any unacceptable, false claims about the product.[14]

Public health attention is warranted to nutraceuticals, especially in LMICs on multiple levels like health insurance, evidence-based practice, pharmacovigilance, and clinical audits. It is important to avoid universally or over-prescribing nutritional supplements in severe mental illness if it is not indicated or there is no evidence of deficiency. There should be strict monitoring of advertising agencies on public platforms about the glorified beneficial role of nutraceuticals as a universal measure to improve all mental health conditions and even the mental abilities of otherwise healthy individuals. A survey on 52 countries revealed that majority of psychiatrists and psychologists had not received any formal training in prescribing nutrition.[15] Hence, it is important to incorporate this missing element in the training of the mental health professionals. In addition, all attributing factors of poly-pharmacy[1] need to be taken into account to prevent poly-pharmacy through prescription of non-specific nutritional supplements.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.