You feel down. You call up a friend or your sister. They suggest you take a tranquiliser that suited them. You go to the pharmacist, get the pill, take it, and wake up slightly fuzzy-minded but happy that you slept. Your chronic fatigue, unexplained aches and pains, and the "feeling down" part are not improving. You are still not getting treated for what your actual issue might be -- the big D -- Depression.

Eventually, you may wander the labyrinth and keep popping pills that sometimes help you sleep and at other times are mood-lifters. By so doing, you become one of the many Pakistanis who pop millions of these "happy" pills to fight a very real and very debilitating illness.

"The total antidepressant market in Pakistan is approximately Rs4 billion, as per annual sales, and is growing at the pace of 16 per cent; the market for tranquilisers or anxiolytics is also around PKR3 billion, with a double digit growth of 10 per cent," says Nouman Lateef, Director, BU-GI Care, Merck.

"Depression is underdiagnosed and undertreated. People suffer needlessly. On the other hand, some people are misdiagnosed and receive medications they shouldn’t," says Dr Nadir Ali Syed, a neurologist at Karachi’s South City Hospital.

However, disagreeing with studies that indicate that between 30-50 per cent of Pakistanis are depressed, he feels the actual figure for patients in need of medical attention is closer to 10 per cent. "That is still very common. Major Depressive Disorder is remarkably common in Pakistan, as it is in the rest of the world."

The disease chooses its prey without disparity on the basis of economics, and strikes people across the board, whether they are rich or poor. In the opinion of Dr Uroosa Talib, Psychiatrist and Head of Medical Services, Karwan-e-Hayat Hospital, the prevalence rate of mental illness is high. "1 in every 4 persons in Karachi suffers. The reasons are many. Lack of basic amenities like water and electricity, poverty, street crime, terrorism and violence," she says, talking about the social reasons for depression.

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Shedding light on the medical causes of depression, Dr Syed says that depression can be the primary illness or frequently also be triggered by other medical problems, such as thyroid disorders or neurological diseases. It can be related to pregnancy or menstruation or even to medications or vitamin deficiency. "All depression is neurological in the sense that it is related to brain abnormality. It is associated with changes in chemicals in the brain, such as serotonin norepinephrine or dopamine. Many neurological disorders can be a reason for depression like stroke, Parkinson’s disease, migraine headaches, dementia, or pain from any cause."

Treatment of depression can be an expensive prospect, and mental healthcare providers are not readily accessible for the underprivileged. "In Karachi, Jinnah Hospital and Civil Hospital have psychiatric facilities. Other public hospitals just have OPDs that prescribe anti-psychotics and that is not enough," says Dr Talib, adding that treatment requires both talk therapy and medication.

Dr. Syed says the most common medicines used in Pakistan are Escitalopram, Citalopram, Fluoxetine, Paroxetine and Sertraline, sold under various brand names.

Medication to treat depression is a potential lifesaver, but must be prescribed by doctors qualified to prescribe them. "Most of the medicines sold over the counter are anxiolytics like Lexotanil, Xanax and Valium. These are more addictive and people use them as hypnotics," says Lateef, talking about the popular benzodiazepines class of medicines that are used and abused readily. "Anti-depressants’ effect is not immediate; their impact takes time to show. However, a new class of anti-depressants has a quicker onset of effect."

"A study shows that 60-65 per cent of the patients visiting primary care physicians are patients of depression and anxiety," says Dr Talib. However, most of those coming to the general physician don’t even know what they are suffering from. "They complain of chronic symptoms like backache or fatigue, which are actually physical manifestations of depression. We go to the doctor and take medicines for physical symptoms, but not for mental illnesses."

Females being at least twice as susceptible to depression in Pakistan, Dr Talib feels that this is because females have to carry heavier emotional loads, particularly in lower income groups. "These women are already struggling so much to survive that their stress tolerance is very low. Their families don’t understand what is happening to them. They have no one to talk to. They have no acknowledgment of emotional issues and no means to relax themselves. Multiple childbirths and hormonal fluctuation add to the problem."

Lateef says that while prescribing an anti-depressant, the age and condition of the patient should be taken into account.

"People should never self-medicate. There are specific medications for specific patient types," says Dr Syed.

"But instead of psychiatrists who should actually be prescribing them, they are mostly prescribed by cardiologists and general physicians," says Dr Talib.

She also advises that one should not discontinue these medicines suddenly. "They should be tapered off, but only after the doctor weighs the pros and cons. Relapse of depression is very common so one might need a maintenance dose of the medicine for life."

The treatment for depression is as complex as the disorder itself. Medication must be coupled with counselling and rehabilitation. Afia Wajahat, therapist, works with Mental and Social Health Advocacy and Literacy (MASHAL), in underprivileged areas of Karachi. It is an initiative linked with the Aman Foundation. Her team goes door-to-door to screen people for mental illnesses, provide them therapy, and help them get a second lease of life through rehabilitation and provision of livelihood to bring them out of the clutches of poverty.

In Wajahat’s experience, rehabilitation is most important in order to avoid a relapse. "For that we have to bring them back towards leading productive lives. We enroll them in vocational trainings, socialise with them as they have to come out of isolation, and counsel them to give them confidence."

The harm of not getting treatment for depression can be disastrous. "We need to make people understand the consequences of depression. Your career, your family life, everything suffers," says Dr Talib. It is time Pakistanis understand this.