High Prevalence of Depression in Pakistan

Experts Caution Against Careless Use Of Sedatives

“Extra care should be taken while prescribing sedatives as injudicious use of medications such as lithium can cause damage to thyroid and kidneys if not monitored properly,” Dr Ehsan Syed, Associate Professor and Consultant Psychiatrist, cautioned a gathering of primary care physicians at a seminar at Aga Khan University (AKU).

The seminar on the uses of psychotropic medication in primary care was organised under the Continued Medical Education (CME) programme of AKU designed to provide current and practical updates on the management of medical problems faced by primary care physicians and specialists.

“Mood stabilisers should not be used for minor psychiatric conditions such as anxiety or depression and should be reserved for cases which are more severe such as manic depression also known as bipolar disorder,” Dr Syed advised the physicians. Careful use of mood stabilisers in primary care requires proper diagnosis preferably in consultation with a psychiatrist. A primary care physician taking care of a person with bipolar disorder requiring mood stabiliser s should always verify with the treating psychiatrist about the dosage and potential drug to drug interactions.

Speaking on Depression, Dr Naim Siddiqi, Assistant Professor and Consultant Psychiatrist, said “ Pakistan is one of those countries where the prevalence of depression is the highest.” He said that depression not only affects a person's psychological health but also can precipitate, worsen and complicate physical illnesses. It can affect occupational and domestic life. At its severest form, people think and commit suicide.

Fortunately, effective treatments like antidepressants are now available. These medicines do not start their beneficial effects for the first 10 to 15 days. Therefore, many people discontinue them prematurely, thinking that they are not affective. There are different side-effects but most of them are manageable. Treatment of depression must continue for at least a year and the medicines should be gradually tapered off. Most of the patients are able to work at their previous level of functioning, once they have fully recovered from their illness.

Talking about the trend of self-prescription for tranquilisers, Dr Haider Ali Naqvi, Consultant Psychiatrist and Senior Instructor, reminded the audience that these medications are not without hazardous side-effects. By a conservative estimate around seven to ten million urban dwellers in Pakistan continue to consume these medications regularly. According to one estimate, psychotropic drug sales in Pakistan for a duration of one year (June 2003-4) were worth 2.76 billion; of these tranquilisers and hypnotics were 1.36 billion with a rising trend of 18 per cent and 137 per cent respectively from previous year. 

Not only in Pakistan but around the world, benzodiazepines are among the most prescribed and consumed medication groups. Individuals taking these drugs for a month or more may develop symptoms of withdrawal, characterised by anxiety, dysphoria, malaise, depersonalisation, and by perceptual changes such as hyperacusis and unsteadiness. Sudden withdrawal of these medications can even lead to epileptic seizures.

In developed countries, Benzodiazepine overdose is the most common way of self-poisoning among the substance induced suicidal attempts, accounting for about 40 per cent of the total.  In a study done in Pakistan , the proportion of Benzodiazepine usage in Para-suicide was more than the double that quoted in the western data; i.e. 80 per cent.

He criticised the role of multinational pharmaceutical companies that are marketing these tablets as ‘absolute recipe for peace of mind.' Most physicians act as ‘agents' for sales and promotion, with their share in the cake. Ultimately it is the patients and their families who have to pay the cost, he said.

Dr Syed Ahmer, Assistant Professor and Consultant Psychiatrist, advised physicians to avoid using antipsychotics for the use of symptoms like anxiety, depression without psychotic symptoms or insomnia. As the name suggests, these should only be used for the treatment of a psychotic illness such as Schizophrenia, Manic Psychosis, Depression with Psychotic symptoms, etc.

He cautioned that antipsychotics are one of the few psychotropics which can give rise to a permanent, irreversible side-effect like Tardive Dyskinesia (TD). The risk of TD increases with duration of use and dose of medication, hence, these should only be used when clearly indicated, in the lowest dose required, and only for as long as is absolutely necessary.