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Pill addiction grips the Balkans The use of tranquillisers and antidepressants appears to be on the rise in south-eastern Europe, as people struggle to recover from recent wars and cope with the stresses of modern consumerism.

"I began with a light tranquilliser in school but it gradually stopped affecting me, so I turned to sedatives, which back then were sold freely," says 'Radost', recalling the start of her long history of addiction.

"The same happened with them--they began to lose their effect, so I had to increase the dosage or get stronger medication," she explains.

"I abused them for years before I started drinking. And when I had to get treated for alcoholism in hospital, I got hooked on anti-depressants."

Radost is a moderator of Bulgaria's first online forum providing psychological help for medication addicts from fellow users or ex-addicts. She believes that many of those seeking help on the Lekarstveno Zavisimi website, which is part of the worldwide Pills Anonymous network--have ended up in a vicious circle of dependency, often as a result of doctors prescribing pills too freely.

Radost's story seems all too common in Bulgaria and other Balkan states, where it appears that a growing proportion of people are becoming hooked on psychoactive medication--pills that act on the central nervous system or change the chemical balance of the brain.

Some family doctors estimate at least 20 per cent of their adult patients are addicted to these forms of medication.

The addicts use them to deal with psychological, personal and social problems, often troubles related to the pressures and anxieties created by the transition to a modern consumerist society.

As stress levels rise in Balkan societies and access to medication remains easy, the number of addicts multiplies. But the scale of the problem remains concealed, partly because of the stigma that surrounds asking for psychological help. Admitting to psychological problems is still a taboo in the region, and so are the methods people use to fight them.

Meanwhile, poor government mental health services combined with overworked and overwhelmed general practitioners appears to have led many doctors to prescribe more and more medications.

Apart from the harm that these medications can cause individuals, there is a wider question about the damage that this rate of addiction is inflicting on society at large.

"Dependence on pills is making people numb, in their family lives and in the workplace," Adriana Kyulevchelieva, a social analyst in Sofia, warns. "Imagine that those people are teaching your children, driving the bus you take to work, or installing electric circuits in your home."

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Soaring sales

Figures reveal that sales of psychoactive pills have soared in recent years in Bulgaria, neighbouring Serbia and Bosnia and Herzegovina.

The Bulgarian Drug Agency, which is part of the health ministry, says medicines dealing with the nervous system are the second most widely-sold drugs after heart disease pills.

Statistics are similar in Serbia. According to Serbia's Medicines and Medical Devices Agency, drugs affecting the central nervous system make up 15 per cent of total sales of medications in 2009. In 2008, for example, 7.3 million packs of bromazepam and more than 4.6 million packs of bensedin, both tranquillisers, were sold in Serbia.

Both figures are up by around 1.5 million packs on figures from the previous year. The number of antidepressants sold in Serbia is still small at fewer than 300 000 packages per year--but sales in this sector are also rising.

Obtaining psychoactive medication is easy in the Balkans, especially in Serbia and Bosnia, where no tough EU regulations are in place.

The most popular tranquilliser, bensedin, can be purchased with the aid of moderate acting skills from most pharmacies in Belgrade outside the centre.

To see if the situation was much the same in Sarajevo, Ines took on the role of pill shopper. She successfully bought diazepam, another popular tranquilliser, from several pharmacies, claiming her grandmother needed it.

Jovana, a young woman from Belgrade, describes how her grandmother often obtained tranquillisers without prescription, which she then handed out to the family.

"Bensedin was part of the household first-aid kit, like aspirin or iodine," she says.

Tranquillisers can no longer be bought over the counter in Sofia.

Since Bulgaria joined the EU almost four years ago, only licensed chemists may sell them, and each sale must be reported to the authorities.

Sales of antidepressants are less controlled. These can still be bought without a prescription in most small neighbourhood pharmacies.

"For years now, a serious businesswoman has been coming in every month for a pack of Deanxit," one pharmacy worker from the centre of Sofia confides, referring to a well-known brand of antidepressant.

"I know her, so I give them to her, and then she doesn't have to go to her doctor every month for a prescription," the pharmacist adds.

Withdrawal pains

The negative consequences of addiction to tranquillisers have been long known. General practitioners in Bulgaria and Serbia--who agreed to talk only on condition of anonymity--say they are aware that prolonged use leads to addiction.

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But they admit that they continue to prescribe them because so many patients depend on them.

Usually, doctors say, these are elderly patients suffering from numerous physical problems as well as age-related anxiety.

Quitting the pills would be more detrimental to their health than keeping them on them, they insist. One Sofia GP estimates that 20 per cent of her patients visit her solely for tranquilliser prescriptions.

Petko Velichkov, a Sofia-based psychiatrist, believes that doctors should not indulge patients in this way because prolonged use of such drugs can lead to dementia, memory loss and further psychological problems.

The debate on the effects of long-term use of antidepressants and on whether they lead to addiction is still open.

Representatives of psychiatric associations in Bulgaria, Bosnia and Serbia say the classical definition of addiction--an obsessive desire to acquire the substance and severe physical pain if not under their effect--does not apply to antidepressants.

Nor does the dosage have to be increased--a symptom associated with all types of addiction.

In reality, however, people who have spent years on antidepressants claim they find it impossible to quit. While doctors insist there is no proof that pill addicts go through painful withdrawal, addicts claim they suffer enormously.

Indeed, patients say withdrawal symptoms can be so severe that doctors often confuse them with the return of depression or clinical anxiety. Many fall, therefore, into a vicious circle that lasts for years.

"Not taking the pills leads to a withdrawal crisis, which is highly unpleasant, so people are tempted to get back on them," Slobodan Loga, a clinical psychiatrist from Sarajevo, explains.

"I am an ex-alcoholic, but while I've managed to live without alcohol for six years. I've not had a day off antidepressants," Radost, from the Pills Anonymous forum, says.

She describes her experience of withdrawing from antidepressants: "I went through every bad symptom, from icy sweating to nausea, blurred vision, muscle pain, unbearable cold, faster heartbeat and even problems with breathing. But far worse were the psychological symptoms; the persistent and painful insomnia, as well as the constant fear. It was a feeling of horror."

"Ivana74", a visitor to another online forum where people identify themselves with nicknames only, says the same. "All hell unleashes on the second day that you stop taking them," she recalls.

"It is not only the depression that crushes you," she adds. "You end up in a flu-like condition with muscle pain, no energy and even the light bothers you."

In spite of the scale of the problem of pill addiction in the region, no action is being taken to curb it.

Addicts seeking help in rehab centres in Bulgaria and Serbia most commonly suffer from alcoholism and heroin abuse. They rarely come from the ranks of pill-poppers, representatives of the centres in the two countries say.

Post-traumatic stress

While family tragedies, marital problems and financial difficulties often lead people to abuse prescription drugs, there are other social factors specific to the region that may trigger similar pill addictions. These include the trauma and stress related to the wars of the 1990s and the painful transition from communism to free trade economies.

In Bosnia and Serbia, war-related traumas have left many people with severe psychological problems. According to Bosnian psychiatrist Loga, cases of panic attacks and depression among women have more than doubled since the end of the conflicts of the 1990s. This encourages reliance on psychoactive substances, both legal and illegal.

Milan Milic, a psychiatrist in Pancevo, near Belgrade, who ran the urgent psychiatry unit in Belgrade during the Nato bombings in 1999, says the stress of war initially mobilises the defences of the mind and body.

But both suffer invisible injuries, and when the situation calms down, the body and the psyche can almost collapse.

Milic also connects the worsening mental health of Serbian people to disappointment with the economic transition to capitalism.

"Every day, people hope they'll be better off economically and socially, but months and years pass and things don't improve," he notes. "This is how you accumulate chronic stress."

"Your organism's defence mechanisms are worn out and even the slightest problem can push you onto pills."

Bulgaria did not go through a war in the 1990s, but there is the same dissatisfaction with the economic transition that is felt in Serbia. It is a commonly cited factor behind the depression of many Bulgarians.

Irina Lazarova, a psychologist at a private, Sofia-based psychiatry practice called Adaptation, believes the speed of the modern world places too many burdens on people, and those who are unable to cope find their "systems burnt out".

Isabella Goldrich, of the Mental Health Foundation in Glasgow, a city in Scotland with high rates of economic deprivation, says modern society has mythologised happiness.

Goldrich believes it is more natural for life to be tough, with occasional moments of happiness. But modern culture promotes happiness as a necessary constant, which puts enormous pressure on people who do not feel fulfilled.

"We've developed a consumerist approach to happiness; from a nation of stoics, we've turned into a consumerist nation", she says, referring to Scotland.

According to her, the most socially deprived classes in Scotland are most prone to medication abuse, because they are most likely to be discontented with life, and many believe pills will ease their problems.

Pills, not treatment

Specialists say that another explanation for this apparent increased dependency on pills is that Balkan health systems are too overloaded for doctors to be able to focus on patients with psychological problems.

To save time, they prescribe tranquillisers or antidepressants to suppress what might be the beginning of depression symptoms, instead of opting for more time-consuming or costlier treatments.

The Scottish government raised the alarm on this phenomenon two years ago, when it realised that Scots, on average, took twice as many antidepressants as other Britons.

Goldrich says GPs working in deprived neighbourhoods of Glasgow usually have between seven and 10 minutes to evaluate the condition of their patients.

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"Sometimes, 10 hours wouldn't be enough if you have a patient with multiple physical and psychological complaints," she says. "I don't blame the doctors; they sometimes have no choice but to prescribe antidepressants to relieve the pressures on those patients."

But while Scotland is taking action to reduce prescriptions, and while the nonprofit sector there is raising awareness of the problem among general practitioners, public debate on the abuse of medications is non-existent in the Balkans.

In online forums in the Balkans, a common complaint of those posting messages is that the psychoactive pills they now depend on were prescribed by their GPs for physical, not mental, complaints.

"I'm trying to get off an antidepressant that I started taking to get off a tranquilliser, which in turn was prescribed for my high blood pressure," ivana74 says.

On another forum, "Linamina" says she became dependent on antidepressants after her pelvic surgeon prescribed them for her after she gave birth.

'Short cut to bliss'

Most psychiatrists say pills themselves will not solve any of their patients' root problems. "Tranquillisers do not cure", Slobodan Loga declares.

At the same time, they believe that antidepressants and tranquillisers can play a short-term role in the recovery of patients suffering from deep stress, depression and anxiety.

Depressed people are sometimes so confused that in order to start effective therapy, they have to take pills for a time, just to organise their thoughts properly, Velichkov explains.

Irina Lazarova, of Sofia's Adaptation centre, says people take pills "in order to bear the unbearable".

But regardless of whether they prescribe psychoactive pills as a part of patients' therapy, psychologists are adamant that medications themselves do not cure the essence of people's psychological problems.

"Pills make people allergic to thinking, so they cannot see their real problems," Milic says, describing drugs as "a short cut to bliss maximum satisfaction with minimal effort, but such an attitude does not solve your problem".

Lazarova stresses that therapy must accompany pill intake. The problem in the Balkans is that it is too costly for most people. Even the cheapest therapy session in Bulgaria costs 20 to 35 euros, and many people would need to visit a specialist at least once a week for several months.

This is mission impossible for most Bulgarians whose average wage is less than 300 euros a month.

The chances of accessing therapy are even poorer in Bosnia, where wages are lower and unemployment are higher.

Moreover, depression is most common among those least able to pay--the poor and the unemployed.

Bulgaria's public healthcare fund covers a maximum of two visits to a psychologist every six months. Even that is available only for those with health insurance, which the unemployed and those working off the books do not have. The only day centres are in the private sector.

In Scotland, on the other hand, the state-run National Health Service (NHS), runs free day centres. Major organisations, like Depression Alliance Scotland, run helplines, self-help groups and campaign to raise awareness of depression issues and publish guides for GPs on how to substitute medications with alternative therapies.

Unlike in Scotland, depression is a dirty word in the Balkans. "It is one thing to say I am a bit nervous today, and another to say I'm depressed," Milic notes. "To most people, this means that there is something wrong with you, and people aren't likely to admit that."

Social analyst Kyulevchelieva observes: "We make fun of Americans and their 'shrinks', and often say that we don't need psychiatrists, as we still have friends in the Balkans.

"But the truth is that there are a lot of people [in Balkan countries] that desperately need to visit a shrink sometimes."

Instead of turning to certified psychologists, people in the region turn to online forums, where they can conceal their identities.

But, while sharing problems and talking to others with the same issues can be beneficial, the downside is that website users' anonymous online friends often come up with their own diagnoses for other people's problems and even try to prescribe them "proper" drugs.

Given rising stress levels and already high incidents of depression and anxiety, the prospects for tackling medication addiction in the Balkans look poor.

As far as Serbia and Bosnia are concerned, the process of EU integration will bring with it tougher regulations regarding over-the-counter sales of tranquillisers.

Many believe that once these stricter measures are in place, pressure will grow on general practitioners to issue more prescriptions to their already "hooked" patients. Specialists also predict that if it becomes harder to get tranquillisers in Serbia and Bosnia, people will simply turn to antidepressants.

Many hope, however, that as Balkan societies become closer to their western counterparts, seeking psychological help will not be as stigmatised in future as it is today.

For now, however, a significant proportion of society is likely to remain hooked on pills.

This article was produced as part of the Balkan Fellowship for Journalistic Excellence, an initiative of the Robert Bosch Stiftung and ERSTE Foundation, in cooperation with the Balkan Investigative Reporting Network, BIRN

WHAT ARE TRANQUILLISERS?

Tranquillisers and most commonly used benzodiazepines have the immediate effect of suppressing anxiety by calming the central nervous system. Specialists believe that the maximum period of intake should be a month to six weeks at most. They increase in toxicity when combined with alcohol and there are numerous cases of people overdosing as a result. The most commonly used tranquillizer in the Balkans is diazepam, known in the West as Valium.

WHAT ARE ANTIDEPRESSANTS?

Antidepressants are a relatively new generation of medicines that affect serotonin levels in the brain. They do not act immediately on the central nervous system, as tranquillisers do, but have an accumulative effect. Patients must take them from two to six weeks for the pills to have an impact. They then need to be taken for several months. They often cause unpleasant side effects, such as mouth dryness, vertigo, depression and anxiety. Coming off should start several months after depression symptoms have disappeared. The most popular antidepressant is Prozac, in which the main substance is fluoroxetine.
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Title Annotation:Reading Room
Author:Popova, Mila
Publication:The Sofia Echo (Sofia, Bulgaria)
Geographic Code:4EXBU
Date:Dec 17, 2010
Words:2829
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