When the 11-year-old Sana (not her real name) began complaining that she was "too sad, tired and lonely" to go to school, her family didn’t understand what she meant. Her mother often reacted to Sana’s "laziness" by pouring cold water on her to drag her out of bed. It was only when Sana failed school for two consecutive academic terms, that her family sought help.

Sana’s Karachi-based upper middle class family, headed by a practising family doctor, opted to take the 12-year-old girl to a pir who handed her an onion with a string drawn through it. Sana was supposed to wear the onion around her neck and peel off a layer every day. The idea was that her "laziness" would peel away, much like layers of the onion.

Her condition deteriorated, meaning "she grew even thinner, slept barely a few hours a night, spoke only when absolutely necessary, and always wanted the lights off. Dark circles under her eyes grew so deep and made her appear so strange, that we feared to take her in public," says her mother.

It was then that her mother took her to see a psychiatrist. In hiding from her grandparents and her father, under the pretext that they were going to the park for fresh air, Sana was taken to a psychologist for Cognitive Based Therapy (CBT) and given psychiatrist-prescribed medication. Finally, when Sana’s health improved and she restarted school, her mother told the family the truth. The mother and the daughter were humiliated that she had hung the family’s dirty laundry out to dry. "My in-laws said, ‘Well, now we know the mother and daughter are both crazy,’" remembers Sana’s mother.

The stigma against depression and the therapy and medicine one requires to try and defeat this multi-factorial disorder that could be attributed to one’s genes, one’s environment or both, starts from within our homes. Family members refuse to recognise signs and symptoms due to ignorance, stigma and denial.

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Since no blood tests can prove you have depression, it’s possible for family members to remain in denial. Another common problem of dealing with depression is that there is no code book. Dr Daniyal Asad, a neurology resident who has worked in various hospitals in Lahore, explains that a lot of the prescription for depression is based on trial-and-error, and similarly, there is no perfect way to behave with someone who is suffering.

A Karachi-based woman who has a 25-year-old brother suffering from depression since he was 13, says that often her family disagrees about how her brother should be treated. "Are we mollycoddling him; should we instead force him to work and be distracted? Or are we not giving him enough love and attention, we shouldn’t even bring up stressful topics in front of him," are questions she and her family struggle with. There is no way to know the exact ratio of love and discipline he needs.

The stigma, denial and ignorance that surround depression ensure that everyone comes up with their own ways of treating family members who are suffering. Be positive, think happy thoughts, be grateful, and pray regularly, are the most common pieces of advice.

And then there are some more ‘creative understandings’ of the ailment. There’s the one about the clinically depressed woman who told her boyfriend that her medication and therapy will probably continue for the rest of her life. He promised it made no difference to him and they had a beautiful December wedding. A few months into their marriage, he no longer understood "why she would still need her medicine if she now has him to keep her happy"?

There’s the one about the Islamabad-based mother-of-three whose eldest son suffered from manic depression, the second from persistent depressive disorder and the daughter from depression coupled with extreme anxiety. Because all three exhibited different symptoms she didn’t realise that they are all manifestations of similar disorders. She "treated" the first son with extra care, love and affection; the second son by sending him to boarding school abroad so that "us ka dil behal jae"; and the daughter by marrying her into a "perfect family". All three were diagnosed only after their attempted suicides.

There’s also the one about the 40-something Lahore-based rikshaw driver who came home one day and after an ordinary meal of daal and roti, went to sleep. The next day he refused to go to work. "He said he had been engulfed in darkness for weeks and he couldn’t take it any longer. He clung on to me and repeatedly asked me to help him," says his wife who, after trying many homeopathic and then allopathic medications to cure him, has given up and left him to sleep 15 hours a day. She says she’s not angry at him, she understands that he is helpless. "I see him try, whenever he feels better he takes the rikshaw and goes to work and brings back some money."

She says she may be empathising with him because she’s seen her father-in-law act similarly. "But my father-in-law was much older when his zehni tawazun was upset, so it didn’t impact our family economically."

Dr Asad explains that age has a lot to do with how family members treat a depressed person. Since mental resilience is perceived to be inversely proportional to age, the older someone is, the more likely the family is to accept that they have depression. "It’s easier for families to accept that a 65-year-old retired male has depression than to admit that their young son has a zehni kamzori," says Asad. If a young male exhibits signs of depression he is often reminded that "he shouldn’t act this way, he should be stronger".

Asad cites a case of a 40-year-old banker, the sole breadwinner of the family, who was suffering from depression but his economic constraints wouldn’t allow him to take time out. "It boils down to the ‘boys don’t cry’ mentality where men simply aren’t allowed to express that they are feeling down, until they have physical symptoms to prove it," he says.

A man in his late 20s who experiences persistent depressive disorder, and has been undergoing therapy for a few years, shares that despite having told his parents about his disorder, "their ignorance, stigma and denial prevents them from understanding his struggle". To his parents, being clinically depressed is associated with "bad, abusive, and even violent behaviour," and since they have never seen him exhibit his depression in that particular way, they can’t relate the medical term to his behaviour.

"Or maybe, it’s too difficult for them to accept that they have a son who will be unhappy for the rest of his life," he says. Who knows? After all, much like every other family, his is rarely willing to talk about depression.