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Depression – Career, family life, everything suffers

In a society where mental illness is stigmatised and its treatment is expensive, the harm of not getting treatment for depression can be disastrous

Career, family life, everything suffers

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.

Read also: An overdose of self-medication

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. “In Karachi, Jinnah Hospital and Civil Hospital have psychiatric facilities. Other public hospitals just have OPDs,” says Dr Talib.

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.

Don’t give up hope – Caring for the elderly

Farhanaz Zahidi September 11, 2016

http://tns.thenews.com.pk/dont-give-hope/#.V9_ShvkrLIV

 

geriatric-care

As people age, what can we do to improve their quality of life?
“With the bam of a motorcycle I suddenly became the head of the family,” says Junaid Ahmed Qazi. While caring for the elderly is seen primarily as something that women are expected do, Qazi is defying the norms because life left him no choice. As an only child, life changed for him some 20 months ago when his father, a healthy man in his early 70s, became victim of a hit-and-run case.
“Ten days before the accident we had both climbed five flights of stairs together.” What followed was a brain surgery, weeks in the ICU, and a nosocomial (hospital-acquired) infection his father caught, that left him invalid. “We believe he recognises us and has emotions. He wants to talk but cannot,” says Qazi.
For him the sound of his father’s voice is a far-fetched dream. Yet the optimist in him refuses to give up.
Qazi’s troubles are not unusual. The number of elderly people has risen globally with life expectancy having gone up due to advanced medical interventions. So has the corresponding number of their caregivers. The average life expectancy at birth of the global population in 2015 has risen to 71.4 years according to the WHO’s Global Health Observatory (GHO). HelpAge, a global network of organisations working with and for older people, predicts that by 2050 one in five South Asians will be over 60. The network states that South Asia is growing older faster than any other country in the world.
While HelpAge’s Global AgeWatch Index 2015, that ranks countries by how well their older populations are faring, rates Pakistan at 92 out of 96 countries, healthcare professionals and doctors feel the close-knit family structure in Pakistan mitigates cases of neglect and abandonment of the elderly.
“Caregivers are the unsung heroes when it comes to geriatric care. They are also underappreciated. When Parkinson’s disease or Alzheimer’s strikes a patient, the entire family is affected,” says Dr Nadir Ali Syed, a neurologist at Karachi’s South City Hospital who has been treating elderly people for 25 years. In his experience, if the quality of life of old people in countries like the US and Pakistan is compared, the elderly in Pakistan are much better off, provided their families are taking care of them. “The family is vital for elderly people. Generally, our elderly are not subject to neglect.”
With an increase in urbanisation and more Pakistani women joining the workforce, old homes and healthcare centres for the elderly is a discussion that is expected to come up more and more in the years to come. The need for geriatric medical care and for doctors specialising in the field has also gone up, and related challenges are multilayered.
“There is a lack of awareness and an acknowledgement of geriatrics as a unique specialty with special needs, health issues and care requirements. This exists both at the level of physicians, and at the governmental level. Caregivers often do not understand the needs of their aged family members and the stresses involved in caring for the elderly,” says Dr Saniya Sabzwari who specialises in geriatric care at the Aga Khan University Hospital in Karachi.
“Caregivers are the unsung heroes when it comes to geriatric care. They are also underappreciated. When Parkinson’s disease or Alzheimer’s strikes a patient, the entire family is affected,” says Dr Nadir Ali Syed, a neurologist at Karachi’s South City Hospital who has been treating elderly people for 25 years.
The patience and endurance of caregivers are put to the test in more than one way and, practically, providing satisfactory healthcare to the elderly is an expensive proposition. “The biggest challenge is financial. Nursing care and attendants at home cost a lot. For those who cannot afford to hire professional healthcare at home, the challenge is even more daunting. It becomes physically difficult to look after an invalid person,” says Asma Nazeer, who requested that her real name not be shared.
Nazeer does not want people to know that she served her mother who had Parkinson’s and related dementia for 10 years, since she feels that it will take away from her award. “I was the only one, as all my siblings are abroad, so they sent help in the form of finances and sporadic visits but basically it was just me for 10 years.”
Nursing care at home for the elderly who suffer from a lack of mobility is expensive. Yet more and more people are opting for it. “The biggest determinant for better geriatric care is affordability — to be able to pay for quality healthcare,” affirms Dr Syed.
Two round-the-clock certified nurses take care of Qazi’s father who, he shares, are pampered by him so that he does not have to go through the process of changing nurses and teaching them the ropes repeatedly. The price of nursing care at home is exorbitant but it still costs him less than the hospital would. His father’s room is now nothing less than the Intensive Care Unit of any hospital emanating the smell of medicines and sterilising liquids. Oxygen cylinders and the feeding tube through which liquefied food is transferred to his father’s stomach, like most elderly patients who are no longer able to eat by mouth due to multiple reasons, are maintained by nurses.
On average, depending on the level of expertise and seriousness of the patient’s illness, a certified nurse for a 12-hour shift costs anywhere between Rs1,200 to 1,800 or more, and are hired through an agency. The monthly cost can run into more than Rs100,000 if two staff nurses and two attendants are hired. “Many nurses are now turning towards attending to bedridden elderly patients at home because it pays well,” says 24-years-old Zaiba Kiran, a staff nurse who has been caring for elderly patients who are mostly bedridden. “We go through agents because it suits both the family of the patient and the nurse in case the nurse needs a day off or either of the parties has any complaints.”
Just like it is tough for caregivers, caring for debilitated elderly patients is not easy for nurses either. “With an elderly patient we have to be extra careful. They are very fragile. They can choke easily. We have to keep a constant watch over their vitals. Anything can happen at any time. It also takes more energy and time to learn how to deal with an elderly patient; they are often impatient like children.”
But perhaps the biggest side effect of seeing your loved parent become a shadow of who they used to be is psychological. “We saw the stages where my mother would hallucinate and there were behavioural changes. But the most painful was the stage when she could not even lift her finger. For the last three years of her life she was fed through a nasal tube,” reminisces Nazeer.
One of the jolts a family may receive is when they are told their loved one is now on what is called palliative or end-of-life care, a concept that is often not fully understood. The term does not mean that these are the final hours or days of the patient’s life. It means that the patient suffers from a terminal disease, and there is no hope of a cure. However the dying process may take years.
“With patients of Alzheimer’s the process may take seven to 12 years,” says Dr Syed. The aim of doctors and family, at this stage, is that the quality of life be improved and the patient be made comfortable. “In Pakistan you get drugs like heroine everywhere but intravenous morphine is not available to a dying patient to help relieve a dying patient’s suffering,” says Dr Syed, explaining the obstacles.
The goal, as Dr Sabzwari explains, is not longevity of life, unlike what families or patients want. “Most important is the quality of life.”
To see a loved one in pain takes its toll. “Till my father had the accident, I was a carefree guy. I can safely say I aged at least 10 years within days. I have lost a lot of hair ever since. I do feel depressed inside at times but I cannot afford the luxury to sit and cry because the responsibility of my family is on me,” says Qazi.
Luckily for him, his supportive wife has been his biggest strength. Even families of the elderly are psychologically impacted. “My six-year-old daughter is affected as well; she can’t understand why dada won’t play with her anymore.” Yet, Qazi refuses to give up on giving the best possible care to his father. “My father didn’t stop caring for me when I was a child and was totally dependent on him. How can I stop taking care of him?”
In Dr Syed’s opinion, one must not give up on the treatment and care of the elderly because a lot can be done to improve their quality of life. “A few years ago dementia was considered incurable and some of the treatments available now were not available then. Now, we can drastically improve the patient’s quality of life as well as slow down the dementia.”
The biggest challenge, then, is to not give up hope.