Economic barriers to psychiatric care: A comparative cost analysis of essential psychiatric drugs and Janaushadhi alternatives

ABSTRACT

Background:

Access to affordable medications is an important determinant of treatment adherence and continuity of care. High out-of-pocket expenditure and cost disparities pose barriers and contribute to poor treatment adherence.

Aim:

We aimed to (1) analyze cost variation among different brands of essential psychiatric medications listed in the National List of Essential Medications (NLEM) 2022, and (2) compare market prices with corresponding generic drugs from the Janaushadhi Scheme.

Methods:

A cross-sectional price analysis was conducted using the current index of medical specialties (CIMS) and the Janaushadhi database.

Results:

There was high variation in market costs, ranging from 20.8% (Carbamazepine liquid) to 1604.4% (Clonazepam 0.5 mg). Median branded costs were higher than generic Janaushadhi prices. The cost ratio (branded price/generic price) was highest for Escitalopram 10 mg tablet (>7).

Conclusion:

Substantial price variation exists even among essential psychiatric medications, potentially undermining equitable access, particularly for economically disadvantaged groups.

INTRODUCTION

Psychiatric disorders contribute significantly to the global health burden, being one of the leading causes of disability worldwide.[1] Treatment adherence is an essential aspect during the management of these disorders, as poor adherence leads to increased risk of relapse, poor quality of life, and poor outcomes.[2] However, medication non-adherence rates are as high as around 50% for major psychiatric illnesses.[2] Among other factors, medication cost is a key factor involved in poor medication adherence for psychiatric disorders.[3] This is particularly relevant for India, as a significant portion of healthcare-related costs is managed through out-of-pocket expenditures.[4]

High variation in the market costs of psychiatric medications has been reported in India. A study on antipsychotics in India found a wide cost variation among different brands of antipsychotics, ranging from 2.63% for Loxapine 10 mg to 2282.35% for Risperidone 4 mg.[5] Similar findings have been reported for antidepressants.[6,7]

In India, the National Pharmaceutical Pricing Authority (NPPA) sets the ceiling prices of scheduled medicines.[8] The Ministry of Health and Family Welfare publishes the National List of Essential Medicines (NLEM) used for the treatment of illnesses with public health importance for the country. The latest NLEM in India was released in 2022.[9] Inclusion in NLEM is expected to reduce cost variation by bringing medications under the ambit of regulated ceiling prices. However, there is a lack of research on the cost variation of psychiatric medications listed in NLEM (2022).

The availability of low-cost generic medications is important for ensuring access and reducing treatment nonadherence. The Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP), also known as the Janaushadhi scheme, is a government scheme launched in 2008 to provide affordable generic medications.[8] Studies have reported that the prices of PMBJP medications are lower compared to the average market prices.[10,11] However, there is a lack of studies assessing the availability of essential psychiatric medications in the scheme.

To the best of our knowledge, no other study has specifically assessed the cost variation of psychiatric medications listed in NLEM 2022. The present study aimed to analyses the cost variation of essential psychiatric medications listed in the NLEM 2022. One objective was to find the cost variation of essential psychiatric medications among different brands in the market. Another objective was to find the availability of these essential psychiatric medications under the PMBJP scheme, and to compare the generic costs with the market prices.

MATERIAL AND METHODS

For conducting this cost analysis study, we included the drugs mentioned in section 23 of the NLEM under the heading “Medicines used in the treatment of psychiatric disorders.”[9] All medications with their respective doses, as mentioned in this section, were included for analysis, except Buprenorphine that was excluded as it is a regulated drug under the Narcotic Drugs and Psychotropic Substances (NDPS) Act and has limited commercial availability. A total of 14 medications, each with different strengths, were included in the study. As the study did not involve human participants and utilized data from publicly available online databases, ethical approval was not required.

To find the market prices of various medications, the current index of medical specialties (CIMS) online database was used, which is a commonly used platform in the country for accessing drug-related information and has been utilized in previous cost analysis studies.[11,12] From this database, information on the prices of different brands of the included drugs (price per package unit for each included strength) was obtained in April 2025.

The PMBJP prices are determined by the principle that the price of a drug can be a maximum of 50% of the average price of the top three brands of that drug.[13] The actual prices of the PMBJP generic medications are available at the PMBJP website.[14] From this website, the prices of essential psychiatric medicines were collected during the month of April 2025 and were used for comparison.

For comparison of prices across different brands, cost ratios and percent cost variation were calculated.[7] Cost ratio was calculated by dividing the price of the costliest brand by the price of the cheapest brand.[7,15] Cost variation between the brands of a particular drug was calculated using the following formula:

To compare the branded prices with generic prices, we calculated the Median branded price (and interquartile range) for each strength of the drugs. The cost ratio was obtained by dividing the median branded price by the generic price.[15] Cost variation between branded and generic prices of drugs was obtained using the following formula:

RESULTS

Medications listed in the NLEM 2022 with availability of at least two different brands were included in the study. A total of 14 medications with their different strengths were analyzed [Table 1]. The number of brands ranged from 2 (for Haloperidol and Carbamazepine oral liquids) to 119 (for Valproate 500 mg modified release tablets).

Table 1.

Cost analysis of psychiatric medications listed in NLEM 2022 and comparison with PMBJP prices

Cost analysis of branded psychiatric medications									Cost variation between branded and PMBJP prices*
Medication	Strength	Formulation	Package Unit	No. of brands	Highest Price (INR)	Lowest Price (INR)	Cost Ratio	%Cost Variation	No. of brands with price < PMBJP	Median retail price (INR)	IQR	PMB-JP price (INR)	Cost Ratio	%Cost Variation
Clozapine	25 mg	Tab	10	23	35	15	2.33	133.33	1	25.0	10.05	15	1.67	66.67
	50 mg	Tab	10	18	58.13	28	2.08	107.61	0	46.94	14.31	25	1.88	87.76
	100 mg	Tab	10	23	94.64	45	2.10	110.31	0	68.57	24.30	40	1.71	71.42
Fluphenazine	25 mg/ml	Inj	1 ml	8	80	25.41	3.15	214.84	-	-	-	-	-	-
Haloperidol	2 mg	Tab	10	0	NA	NA	NA	NA	-	-	-	-	-	-
	5 mg	Tab	10	34	57.11	9.25	6.17	517.40	-	-	-	-	-	-
	10 mg	Tab	10	23	53.75	18.55	2.90	189.76	-	-	-	-	-	-
	20 mg	Tab	10	5	72.5	45.7	1.59	58.6	-	-	-	-	-	-
	2 mg/5 ml	O L	30 ml	2	69	32.48	2.12	112.44	-	-	-	-	-	-
	5 mg/ml	Inj	1 ml	7	8.52	4.5	1.89	89.33	-	-	-	-	-	-
Risperidone	1 mg	Tablet	10	36	36	9	4	300	0	18.30	16.25	8	2.29	128.75
	2 mg	Tab	10	44	75.5	12.9	5.85	485.27	0	29.18	20.40	10	2.92	191.8
	4 mg	Tab	10	29	81.57	25.46	3.20	220.38	0	48.0	31.05	9	5.33	433.33
	1 mg/ml	O L	60 ml	6	237.32	108	2.20	119.74	-	-	-	-	-	-
	25 mg	LAI	1 vial	0	NA	NA	NA	NA	-	-	-	-	-	-
	37.5 mg	LAI	1 vial	0	NA	NA	NA	NA	-	-	-	-	-	-
Amitriptyline	10 mg	Tab	10	38	29.5	10	2.95	195	0	22.18	8.99	6.6	3.36	236.06
	25 mg	Tab	10	44	34	9	3.78	277.78	0	22.98	3.73	5.87	3.91	291.48
	50 mg	Tab	10	14	66	19	3.47	247.37	0	31.44	25.12	15	2.10	109.6
	75 mg	Tab	10	14	84	28.12	2.99	198.72	0	50.62	28.18	20	2.53	153.1
Escitalopram	5 mg	Tab	10	66	76.78	23.8	3.23	222.60	0	41.82	15.01	8	5.22	422.75
	10 mg	Tab	10	98	151.02	30	5.03	403.4	0	71.25	26.94	10	7.12	612.5
	20 mg	Tab	10	58	215	63	3.41	241.27	0	130.02	29.88	20	6.50	550.1
Fluoxetine	10 mg	Tab/Cap	10	17	37.07	12.47	2.97	197.27	0	25.99	11.54	0	-	-
	20 mg	Tab/Cap	10	67	68.01	4.93	13.80	1279.51	2	34.50	12.91	8.8	3.92	292.04
	40 mg	Tab/Cap	10	12	72.69	35.49	2.05	104.82	-	-	-	-	-	-
	60 mg	Tab/Cap	10	14	124.32	55.8	2.23	122.80	0	78.15	39.66	0	-	-
Lithium	300 mg	Tab	10	19	26	7.18	3.62	262.12	0	15.90	2.37	0	-	-
Sodium Valproate	200 mg	Tab	10	8	48	19.9	2.41	141.21	0	26.02	18.53	17	1.53	53.06
	300 mg	Tab	10	4	70	33	2.12	112.12	-	-	-	-	-	-
	500 mg	Tab	10	6	104	48.9	2.13	112.68	-	-	-	-	-	-
	300 mg	Tab (MR)	10	47	80	31	2.58	158.06	0	56.18	18.50	22	2.55	155.36
	500 mg	Tab (MR)	10	119	216.08	32	6.75	575.25	2	94.38	38.40	42	2.25	124.71
Carbamazepine	100 mg	Tab	10	17	70	6.19	11.31	1030.86	6	8.89	4.28	8	1.11	11.12
	200 mg	Tab	10	29	120	11.57	10.37	937.16	-	-	-	-	-	-
	400 mg	Tab	10	7	39.76	24.77	1.60	60.52	-	-	-	-	-	-
	200 mg	Tab (MR)	10	17	26.77	12.5	2.14	114.16	4	17.0	6.12	15	1.13	13.33
	400 mg	Tab (MR)	10	14	57.18	24.1	2.37	137.26	2	31.52	14.02	26.1	1.21	20.77
	100 mg/5 ml	O L	100 ml	2	25.65	21.24	1.21	20.76	-	-	-	-	-	-
Clonazepam	0.25 mg	Tab	10	66	27	10	2.7	170	1	18.50	4.60	10	1.85	85
	0.5 mg	Tab	10	110	168.74	9.9	17.04	1604.4	0	29.50	10.17	5.5	5.36	436.36
	1 mg	Tab	10	53	60	12.5	4.8	380	0	40.50	13.05	8.8	4.60	360.23
Zolpidem	5 mg	Tab	10	29	100.21	20	5.01	401.05	0	41.29	19.66	10	4.13	312.9
	10 mg	Tab	10	36	139	30	4.63	363.33	0	70.00	30.30	18	3.89	288.89
Clomipramine	10 mg	Tab	10	5	31.81	16.6	1.92	91.63	0	21.00	10.33	12	1.75	75
	25 mg	Tab	10	16	66	13.96	4.73	372.78	1	43.82	29.87	20	2.19	119.1
	75 mg	Tab	10	10	184.24	87.5	2.10	110.56	0	141.43	66.88	55	2.57	157.14
Nicotine	2 mg	G/L/T	10	10	104.2	50	2.08	108.4	0	77.80	40.50	46.7	1.67	66.70
	4 mg	G/L/T	10	10	120	62.42	1.92	92.25	0	103.13	44.20	0	-	-

Note. MR: Modified Release Tablets; LAI: Long-acting Injection formulation; NLEM: National List of Essential Medications; G/L/T: gum/lozenge/tablet; Tab: Tablet; O L: oral liquid; INR: Indian Rupee; IQR: Interquartile range. *: Only those medications which were available in PMBJP were analyzed

Among different brands, a wide variation in cost was observed [Figure 1] that was highest for Clonazepam 0.5 mg tablet (1604.4%). After Clonazepam 0.5 mg, the highest cost variation was found for Fluoxetine 20 mg (1279.5%) and Carbamazepine 100 mg tablet (1030.9%). The lowest cost variation was observed for Carbamazepine oral liquid (20.8%), followed by Haloperidol 20 mg (58.6%), and Carbamazepine 400 mg (60.5%). Among antipsychotics, the maximum cost variation was found for Haloperidol 5 mg, followed by Risperidone 2 mg and Risperidone 1 mg. Among antidepressants, the maximum cost variation was found for Fluoxetine 20 mg, followed by Escitalopram 10 mg, and Clomipramine 25 mg. Among mood stabilizers, maximum cost variation was found for Carbamazepine 100 mg, followed by Carbamazepine 200 mg, and Valproate 500 mg. Among sedatives, maximum cost variation was found for Clonazepam 0.5 mg, followed by Zolpidem 5 mg, and Clonazepam 1 mg. While considering the maximum prices per package unit of different drugs, the highest price was found for Risperidone oral liquid (237.32 Rupees), followed by Valproate 500 mg (216.18 Rupees), and Clomipramine 75 mg (184.24 Rupees).

Figure 1.

Price distribution (market brands) of essential psychiatric medications. Note. This figure represents the market prices of psychiatric medications. The X—axis displays individual medications and their dosage strengths. The Y-axis represents the distribution of the market prices (per 10 tablets/capsules) of individual medications and their dosage strengths. Length of the boxes represents the interquartile range. “X” inside the box represents the mean market price, while the line inside the box represents the median value

Among the 14 medications included in the analysis, 12 were available in the PMBJP medication list. Haloperidol and Fluphenazine were notable exclusions. Apart from these two medications, few strengths and/or formulations were also not available in the PMBJP including Risperidone (oral liquid formulation and long-acting injection), Fluoxetine (40 mg), Valproate (immediate release 300 mg and 500 mg), and Carbamazepine (immediate release 200 mg and 400 mg, and oral liquid). Prices of some medications (Fluoxetine 10/60 mg, Lithium 300 mg, and Nicotine gum 4 mg) were mentioned as 0 in the PMBJP list. When the median market prices were compared to the PMBJP prices, high variation was observed [Table 1]. The cost variation was highest for Escitalopram 10 mg (612.5%), followed by Escitalopram 20 mg (550.1%), and Clonazepam 0.5 mg (436.4%). The lowest cost variation was seen for Carbamazepine 100 mg (11.1%). Fluoxetine (10 mg and 60 mg), Lithium (300 mg), and Nicotine gums (4 mg) were excluded from the analysis as their prices were listed as 0 in the PMBJP list. Very few medications had brands with prices that were cheaper or equal to the PMBJP prices [Table 1]. Most such cheaper alternatives were found for Carbamazepine.

DISCUSSION

We found substantial variation in the number of available brands and the cost of different psychiatric medications in the market, despite being listed in the NLEM 2022. Also, there was a wide variation between different formulations and different brands of the same medication. We also found considerable differences between the branded prices and the generic prices offered through the PMBJP.

The wide variation in market prices of these essential psychiatric medications may potentially result in a substantial financial burden on patients if price differences are not considered while prescribing.[5,6,7] This may have a greater impact on patients belonging to the lower socioeconomic status.[7] Higher costs may lead to increased caregiver burden, as a sizeable portion of patients depend on their caregivers for financial support.[16] Moreover, as many patients with psychiatric illnesses are on polypharmacy,[17,18] this can further increase the expenditure and, therefore, the financial burden of treatment. There is a need to increase awareness among clinicians about the variation in market prices of medications. Routine follow-ups should include information about the treatment costs and financial burden on the patients and caregivers. Pharmacoeconomic aspects of treatment should be included in the medical training curriculum.[5,7]

Furthermore, it is important to assess the practical affordability of psychiatric treatment, especially when multiple medications are prescribed. For instance, a combination of an antidepressant and antipsychotic (Escitalopram 10 mg and Risperidone 2 mg) has a combined median monthly cost of 301.29 Rupees, assuming one tablet per day of each. Considering the per capita monthly income of 14,124.67 Rupees (as per the Net National Income data of India),[19] this treatment expenditure equals to approximately 2.13% of the monthly income. Despite appearing low, this can result in a major cost burden for low-income individuals or those who require polypharmacy.

We also found that most psychiatric medications listed under NLEM 2022 are available as generic medications under the PMBJP scheme, and had substantially lower costs compared to market prices. Notably, very few medications and strengths had branded alternatives with cheaper prices compared to the PMBJP medicines. This is in line with a previous study comparing branded prices with PMBJP prices.[10]

As per the National Mental Health Survey (NMHS) of India, the lifetime prevalence of psychiatric illnesses in India is 13.6% and there is a huge treatment gap ranging from 28% to over 80%.[20] It should be noted that the PMBJP prices for psychiatric medications are following the Drugs (Prices Control) Order (DPCO) guidelines and have prices within the DPCO ceiling limits. However, as our findings suggest, despite listing essential medications under the NLEM and regulating prices through the DPCO, a high variation in the market cost of these medications still exists. This highlights the need for ensuring stricter regulation and monitoring of prices through DPCO. It has been reported that in India, around 80% of treatment expenditure is borne by the patients.[21] Regulation of prices may help in enhancing treatment adherence, social security, and regularity of follow-ups.[5,11]

It is also important to consider the potential benefits of a free market. Reduced regulatory policies may lead to more interested manufacturers entering the market. This can increase the competition and potentially lower drug prices.[22] However, there should be mechanisms to prevent monopolies and cartelization. A balanced strategy of promoting market competition, while ensuring affordability may be the most sustainable way for improving access to psychiatric medications.

Limitations

Our data source is limited to online databases and does not involve information directly collected from medical stores. The actual market prices may differ from the rates available in the CIMS database, as discounts may offset some costs. No stratification between the therapeutic categories was performed. Further, the analysis did not ascertain the volume of sales of different brands or the coverage/utilization of PMBJP. As few of the essential psychiatric medications are not included/available in PMBJP at the time of the study, we could not include those medications in the analysis. Prices of some medications, such as lithium 300 mg and fluoxetine 10 mg and 60 mg, were mentioned as 0 on the PMBJP website, and hence these were not analyzed. Moreover, market prices of haloperidol 2 mg tablets and risperidone long-acting injection were not available through the online database and were not included in the study. Our study also does not include factors like patients’ or clinicians’ perceptions about different brands, as well as generic medications. Finally, the quality of medications was not considered in the current study.

CONCLUSION

We analyzed the cost variation of essential psychiatric medications included in NLEM 2022 and found a substantial variation in the costs of different brands. This may have serious implications for treatment adherence, as a large portion of health expenditure in India is borne by out-of-pocket expenditure. Enhancing the availability and awareness of affordable generic medications through the PMBJP scheme, along with stronger regulatory measures, can play an important role in improving medication adherence, reducing treatment costs, and bridging the mental health treatment gap in India.

Use of generative artificial intelligence

The authors attest that there was no use of generative artificial intelligence (AI) in the generation of text, figures, or other informational content of this manuscript.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.