Saima, a Lahore-based senior schoolteacher in her mid-30s, has to juggle between work and home. To ease her anxiety, she frequently takes a sedative. “I take an anti-anxiety pill whenever I’m stressed,” she says.

Doctors usually prescribe relaxants for short-term management of anxiety disorders. But, in case of Saima (not her real name), there is no prescription. She purchases it over the counter.

“I’m aware that continuous use of such medicines may cause dependence,” Saima adds. But she is lucky not to have experienced any so far.

The fact that anxiety-prone people in Pakistan can purchase medicine without prescription is convenient but alarming. A doctor may record a patient’s detailed medical history and conduct a physical examination. He may order laboratory investigations. He prescribes medicine after weighing benefits and potential side effects. Monthly follow-up visits help her adjust the dose or change the medicine. But, in the case of self-medication, these safety devices are not available.

Self-medication is described as “an act of procurement and consumption of medical drugs without the advice of medical physician for diagnosis, prescription and surveillance of treatment.” The side effects can be hazardous, especially in the case of antidepressants.

“Continuous use of sedatives by those suffering from depression can actually increase the risk of suicidal trends,” warns Dr Areeba Farrukh, a pediatric resident at the National Institute of Child Health (NICH), Karachi. “Obesity is a common side effect, which worsens the state of depression in many patients, particularly females. Hormonal cycles and reproductive functions may also get disturbed.”

“Even more serious side effects may also occur — reduced blood clotting which can lead to internal bleeding, especially if taken with anti-inflammatory drugs,” elaborates Dr Obaidullah Saeed, a hypno-psychotherapist.

“The most important side effect is a rebound effect or a withdrawal reaction which occurs when medicine is suddenly discontinued. It may cause dizziness or insomnia or blurred vision,” says Dr Saeed.

A 2016 study conducted by medical students in Karachi found the frequency of self-medication among university students to be as high as 80.4 percent.

“Although, in my experience antidepressants do not fall into this trend, other psychiatric medications for instance, for the relief of anxiety or sleep problems do follow this trend,” says Dr Saeed. “A person may take an antidepressant without knowing what they are taking.”

So, why are sensitive drugs easily bought and sold without prescription in Pakistan?

“I think because of the lack of rules and regulation in the country,” says Dr Saeed. “Most of the staff employed at pharmacies across the country are untrained. While major outlets ask for prescription before selling the medicine, this is not the case at every pharmacy.”

From the demand side, there may also be reluctance on the part of the patient to consult a doctor. There is generally a stigma attached to consulting a psychiatrist. Others justify the use by consuming it on sporadic basis or after gaining information from a quick google search. Some avoid consulting a doctor because of the cost.

In some cases, medical practitioners may act irresponsibly in recommending a drug but not warning the patient of its potential consequences.

In an article published last year in Dawn, celebrity Nausheen Shah, while discussing her battle with anxiety and depression, blamed such callous medical practice for worsening her condition. The first doctor Shah went to did not diagnose the cause of her distress. Instead, he handed her a quick-fix in the form of a commonly consumed drug. When she sought, a second opinion, the doctor not only approved the medicine, he told her to take as many pills as she felt she needed.

Initially, the medicine brought her relief. Over time, she built up a tolerance to it and eventually she was taking 10 to 12 pills daily just to function. It was only when she “fell apart” on a set that a fellow actor introduced Shah to a doctor, who gave her a safer anti-anxiety medication.

The author of the article Maria Kari offered her own story about a time she was visiting Pakistan from abroad and went to the airport pharmacy in search of a sleep aid.

“The guy behind the counter offered me Xanax because, according to him, that was what everyone takes to help them sleep,” writes Kari. “I’m no stranger to Xanax. It’s something I’ve been prescribed in the past by my own doctor in Washington DC for my generalized anxiety disorder (GAD). I know what Xanax can do to a person, which is why I remember standing there at the airport with my mouth hanging open, shocked to see such a heavy-duty, highly addictive sedative being sold so carelessly at a tiny stall.”

Drug Regulatory Authority of Pakistan (DRAP) controls the sale of drugs in the country. It is an autonomous body under the administrative control of the federal government. DRAP accords approval for clinical trials and import of drugs to be used.

A 2007 World Health Organisation (WHO) report on the Health System Profile of Pakistan mentions that with the exception of Drug Act of 1976, most ordinances were relatively new. The report, while acknowledging various measures and initiatives taken by federal and provincial governments, points the cause of the missing link between legislation and positive health outcomes as “the lax regulatory environment and issues with the implementation of laws… There is a clear absence of minimum standards for provision of care and compliance mechanisms that ensure conformity with these standards. The weakest link in the regulatory mechanism is the minimal protection against hazards from personal health services — patient safety.”

Decades later, patient safety continues to be at risk. Highly addictive sedatives continue to be sold and purchased without prescription. Clearly, more awareness as well as stricter enforcement of preventive laws remains a dire need.