Antidepressant prescribing patterns and patient-reported adverse effects: a cross-sectional study from Pakistan

Antidepressant prescribing practices and Adverse-effect profiles are poorly characterised in Pakistan, highlighting the need for systematic evaluation. This study aimed to assess prescribing patterns, validate the Urdu version of the Antidepressant Side-Effect Checklist (U-ASEC), and document patient-reported adverse effects.

A cross-sectional questionnaire-based study was conducted at two psychiatry clinics in Lahore and Rawalpindi. All adult patients diagnosed with MDD according to the DSM-5-TR were invited to participate. Sampling was done through a convenient method. The Urdu-translated Antidepressant Side-Effect Checklist (U-ASEC) was developed through forward-back translation, expert panel review and pilot testing, and its psychometric properties such as internal consistency, construct validity were examined. Descriptive statistics were used to summarize demographic and clinical characteristics. Differences in adverse-effect scores across demographic and clinical groups were assessed with Kruskal-Wallis tests followed by Dunn's test with Bonferroni adjustment. Multivariable logistic regression models were fitted for each adverse-effect item to explore associations with antidepressant classes, adjusting for age, sex, tobacco use, comorbidity and duration of MDD. Multicollinearity was checked using variance inflation factors (VIF) (< 3 for all variables), and false discovery rate (FDR) control was used to account for multiple testing.

Among the 457 participants, 54.9% were male and 60% of participants were married. Escitalopram was the most frequently prescribed single agent (12.9%), and Selective serotonin reuptake inhibitors as a class accounted for 32.1% of monotherapy prescriptions. Combination therapy was used by 26.7% of participants; typical pairs included mirtazapine + escitalopram (12.2%) and mirtazapine + fluoxetine (5.5%). The U-ASEC demonstrated good internal consistency (Cronbach's alpha = 0.78). Factor analysis identified three clusters of adverse effects: autonomic dysfunction, Central Nervous System effects, and metabolic effects. Dry mouth and insomnia were the most frequently reported adverse effects of SSRIs. Adverse effects varied by class: TCAs had higher rates of nausea/vomiting (41.3%); SNRIs were associated with a higher prevalence of urinary difficulties (32.4%); atypicals reduced dry mouth (18.8%) but increased dizziness (10.4%); and dual therapy showed more metabolic effects, including weight gain (29.5%) and increased body temperature (20.5%). Significant associations were identified for dry mouth (p = 0.0059), nausea and vomiting (p = 0.0202), problem with urination (p = 0.0248), feeling like the room is spinning (p = 0.041), and Tremor (p = 0.0382). Multivariable analysis showed TCAs increased odds of nausea (OR 3.96, 95% CI 1.72-9.03, p = 0.001), urination problems (OR 2.77, 1.10-6.63, p = 0.025), orthostatic symptoms (OR 2.59, 1.07-6.01, p = 0.030) and tremor (OR 2.66, 1.22-5.94, p = 0.015). SNRIs were associated with increased odds of urinary difficulties (OR 12.92, 1.19-284.32, p = 0.040). Atypicals reduced dry mouth (OR 0.18, 0.02-0.94, p = 0.050) but increased dizziness (OR 8.42, 1.47-48.41, p = 0.012).

Escitalopram was the most commonly prescribed antidepressant, with dry mouth and insomnia as the most reported adverse effects. This study provides a culturally relevant tool, U-ASEC, for adverse effect monitoring, addressing critical gaps in Pakistan's clinical practices. Our findings underscore the importance of tailoring antidepressant choice to patient characteristics.

Not applicable.