"We always live in fear": antidepressant prescriptions by unlicensed doctors in India

In India, psychopharmaceuticals have seeped deep into both formal and informal pharmaceutical markets, and unlicensed "quack" doctors have become ready prescribers of psychotropics. These ethnographic insights trouble policies that aim at closing the treatment gap for psychiatric medications by "task shifting" to low-skilled health workers as if medications were exclusively available by prescription from public sector psychiatrists. This article describes what these doctors, known as rural medical practitioners (RMPs), know about psychotropics and how they use them in everyday practice. Unlicensed doctors learn about psychopharmaceuticals through exchanges with licensed doctors, through visits by drug companies' sales representatives, and through prescriptions brought by patients. Although the RMPs exist outside the margins of legitimacy, they are constrained by a web of relations with patients, licensed doctors, pharmacists, drug wholesalers, and government agents. The RMPs do not only prescribe but also dispense, which leads to conflicts with licensed medicine sellers. They "always live in fear" both because they are illegal prescribers and because they are illegal sellers of medications. The article shows that any form of strategic ignorance among policy makers about the local importance of informal practitioners in India can only lead to lopsided interventions.