Mental health care in Pakistan is still in its infancy. With an unfortunate lack of licensed psychologists and licensing bodies, it is unsurprising that stigma is widespread, awareness is at low ebb, and treatment interventions are limited
Mental illnesses in Pakistan are shrouded in obscurity. Though, the past few decades have witnessed a notable change in attitudes surrounding the topic.
From a meagre starting point in 1947, when only a total of three mental hospitals existed in Lahore, Peshawar and Hyderabad, the mental health system has seen a substantial shift. Off course, we still have a long way to go before parallels can be drawn with countries that have excelled in the field.
According to the World Health Report (2001), one in four people will experience a mental illness once in their lifetime, and approximately 450 million people suffer from mental disorders worldwide, putting it at par with other major illnesses. In Pakistan, specifically, 10-66 percent of people experience some degree of mental illness in moderate to severe intensities (Mumford et al., 1997).
Mental illnesses, once left untreated, can have devastating consequences not only for individuals and families, but also for economies that will experience increasing expenditures and loss of productivity. Mental illnesses are also bound to affect society through increasing rates of crime, violence and substance abuse.
Such unfavourable prospects necessitate immediate action, but its progress is largely dependent upon the cultural and religious milieu. Mental illnesses are predominantly unacknowledged and disregarded across the country, and mentally ill patients have to experience not only their own disorders, which undoubtedly lead to distress and turmoil, but also face the stigma attached to these disorders.
Stigmatisation of mental health is an important cause of concern because the derogatory labels associated with these disorders restrict people from reentering their lives. Mental illnesses are chiefly understood through various cultural and religious explanations. Such explanations, for example, include the influence of black magic and evil eye, possession by demons, effect of visitations to graveyards, and the consequences of being exposed to a solar eclipse. Other explanations include the toxic effect of “Western” medications or simply God’s way of testing people. Rather than seeking professional help, most people, especially those in rural areas with little to no education, solicit faith healers or religious figures to find solutions for their problems. Somewhat impractical, spiritual healing does not get to the root cause of the psychological problem and cannot provide the benefits proffered by treatment interventions like psychotherapy and psychiatric medication.
A range of mental disorders prevail throughout Pakistan, with some having higher incidences than others. Depression and anxiety seem to be pervasive, followed by schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).
Depression is a pressing, albeit unrecognised, issue in developing countries like Pakistan, and is considered to be the main cause of disability across the world (World Health Organization, 2019). Depressive disorders can cause persistent sadness and loss of interest in activities previously enjoyed. Anxiety disorders, on the other hand, lead to intense fear and unrelenting worry, and include illnesses like generalised anxiety disorder, panic attacks, and social anxiety disorder.
Akin to anxiety disorders are obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD). OCD involves recurrent distressing thoughts like fear of contamination and the urge to mitigate those thoughts through compulsions like excessive hand washing. PTSD, which includes symptoms of flashbacks, anxiety, and nightmares, tends to develop when an individual experiences a traumatic event such as sexual assault, warfare, or child abuse.
Bipolar disorder is another mental illness that causes severe mood swings ranging from extreme depression to uncontrollable mania. Schizophrenia, on the other hand, causes sufferers to lose touch with reality and undergo symptoms like hallucinations and delusions.
Akin to geriatric mental illness is child psychopathology which is also understood poorly in Pakistan. Various disorders are seen among children in Pakistan, including anxiety, depression, conduct disorders, ADHD and pervasive developmental disorders like autism.
Mental health is overlooked in Pakistan, but this is especially true of marginalised populations like women and Afghan refugees, for example. Social norms, values, and cultural practices are partly responsible for women’s deteriorating health in Pakistan. Women face a plethora of difficulties and obstacles in daily life such as violence, sexual harassment, marital distress and inequality. Such predicaments only increase as focus is shifted from urban to rural areas. A five-year survey conducted by the University Psychiatry Department at Aga Khan University revealed that out of all participants with mental disorders, 65 percent were women (Zaman, 1996). A study assessing suicidal patients revealed high rates of women in the group, with 80 percent of women reporting marital distress as the main cause for their suicidal ideation (Niaz, 1994).
Afghan refugees are another group among a profusion of marginalised populations in Pakistan. Having experienced war, torture, and persecution in their own country, and then being forced to leave their lands and possessions behind, a majority of these refugees (in Pakistan) suffer from some degree of mental health difficulties. Frequently reported conditions include PTSD, depression and anxiety, as well as psychosomatic concerns. A study conducted in Peshawar revealed high rates of PTSD among Afghan refugees (Naeem et al., 2005). Another research found that among 160 female Afghan participants, 81 percent reported mental health concerns and 97 percent reported experiencing depression (Eun-Myo, 2002).
An additional issue that is often pushed aside is geriatric mental health. Depression is common in old age, especially in patients with medical illnesses and cognitive deficits, which leads to severe distress for both patients and their families. Some causes of geriatric depression include financial instability, bereavement, cognitive impairment, sleep disruption, chronic illness, isolation, and dependence on family members.
Pakistan hosts 6.16 million people who are above the age of 65 (DeSa, 2013), and a study by Ganatra et al. (2008) concluded that one in five Pakistani elders suffer from depression.
Akin to geriatric mental illness is child psychopathology which is also understood poorly in Pakistan. Various disorders are seen among children in Pakistan, including anxiety, depression, conduct disorders, ADHD and pervasive developmental disorders like autism. A range of risk factors contributing to child psychopathology include lack of education, child labour, poverty, and malnutrition.
Mental health is also stigmatised in children, with several parents refusing to seek professional help. Furthermore, there is a dearth in mental health resources and facilities that are specifically tailored for children with psychiatric illnesses. For example, autism is treated by various health workers such as physicians, neurologists, psychologists, speech therapists and pediatricians who have little to no expertise and specialisation in child psychiatry.
Taking everything into account, the state of mental health in Pakistan is still in its infancy. With an unfortunate lack of licensed psychologists and licensing bodies, it is unsurprising that stigma is widespread, awareness is at a low ebb, and treatment interventions are limited.
To summarise the entire situation on an interesting note, one can look at somatoform disorders. Such disorders, although unknown in Pakistan, affect a wide range of people from both urban and rural areas. Patients with somatoform disorders present physical symptoms that have no physiological basis.
The intensity of symptoms is often linked to the patient’s mental distress; however, patients with such disorders tend to deny the psychological roots of their problems. Somatoform disorders can be upsetting for patients, especially when they are not able to achieve a medical diagnosis. Interestingly, some people in Pakistan fail to differentiate feelings of anxiety and depression from physical symptoms because they are conditioned to communicate their stresses in somatic ways. For example, someone experiencing anxiety might interpret their problem as palpitations.
Somatoform disorders and their prevalence in Pakistan can be understood through the stigmatisation of mental health. Individuals are reluctant to seek help from psychiatrists, thereby limiting themselves to other specialists who cannot understand the psychological bases of their problems. By and large, this is the ultimate problem that we face in Pakistan and one that should be tackled to ensure a more productive and healthy society.
The writer is a psychologist and researcher based in Lahore