May, 2008

Mental health: Priorities in Pakistan

  Muhammad Iqbal Afridi  ( Medical Faculty, Jinnah Postgraduate Medical Centre, Karachi, Pakistan. )

Although as a result of the evolutionary process of de-centralisation and de-institutionalisation, mental health services have been shifted from mental asylums to teaching hospitals with an intention to reach at the door-step of the sufferers. The last few decades particularly, have witnessed rapid changes towards rendering of mental health services in Pakistan, yet the situation is not up-to-the-mark both in terms of trained staff, patient's care and facilities. There are a very meagre number of mental health professionals including psychologists and social workers with about 2 or 3 psychiatrists per million of population. Moreover, almost all of them are in the large cities despite the fact that majority of our population belong to the rural regions. In fact there is no female psychiatrist in Baluchistan, one of the four but the largest (in terms of area) provinces of Pakistan.1-2 In addition, unfortunately, the existing hospital-based psychiatric services are also poorly utilised because of social stigma3 attached with the psychiatric patients and popular misconception about mental illnesses i.e. mental illnesses are considered to be due to 'possession' or caused by evil, Jin or so called supernatural evil forces.3-6 Many individuals with mental disorders report not using health services for their mental disorder. There is an enormous gap between the need for treatment of mental disorders and the resources available. In developed countries with well organized health care systems, between 44% and 70% of patients with mental disorders do not receive treatment. In developing countries the figures are even more startling, with the treatment gap being close to 90% despite the fact that four of the six leading causes of years lived with disability are due to psychiatric disorders (depression, alcohol-use disorders, schizophrenia and bipolar  disorder).7-9
The situation in Pakistan regarding improvement in mental health services is not at the pace to reach a satisfactory level. This important field of health is not popular, as it should be if we compare it to some other medical and surgical disciplines such as cardiology and ophthalmology etc. Majority of the people have some knowledge about hypertension, cholesterol, ECG and too often disclose and verbalise at length about their cardiac illness, which were previously used to be a stigma or personal weakness. Similarly using glasses were considered to be a sign of old age until quite recently and their use was avoided especially by women in our country. But now the situation is quite different. At the other end, seeking help regarding mental disorder is avoided. Even consulting for sexual problem is considered immoral and is a taboo. One reason behind this could be that the image regarding mental patients, hospitals and related profession and professionals e.g. psychologists, psychiatrists etc, is depicted in an awkward manner by the novices in a few sections of Pakistan's mass media. It hardly serves the purpose of promoting mental health and, at times, leads to deception and distortion creating abhorrence about the subject. The influx of TV channels accessible to persons of all age and brackets with sometime unethical and non-authentic opinions needs urgent attention.
It is amazing to note that the lexicon and nomenclature of psychiatry, psychology and other behavioural sciences are too strange for common people. It is worth mentioning that our official language is devoid of proper terms and nomenclatures yet to be synonymized from English, so simplified as to be easily understood by common man for deceases such as anxiety, depression. This may be a hindrance in the ability to express feelings/distress by psychiatric patients leading to the phenomena of somatisation, as very rightly described by Sifneos the term 'Alexithymia'.10
Even during the 21st century, many patients in the developing countries are still at the mercy of Quacks and Shrines. The brutality and inhuman treatment of psychiatric patients still prevails. Patients are chained, beaten, burnt and scars are made on their body especially in skulls with serious consequences.
The current situation is that proper epidemiological data regarding mental illnesses which is itself of great importance in order to plan adequate health plan and implication system is by and large lacking.  According to WHO figures, in developing countries like Pakistan, one percent of the population suffers from severe and 10% from mild mental disorders. According to the Global Burden of Disease (GBD)  the mental illnesses constitute 10.5% of GBD, which may rise up to 15% in the year 2020. Among the top ten major causes of disability, five are mental illnesses, contributing 29% of the total disabilities while behavioural problems contribute an additional 34% to the GBD.11-12 These figures do not include cases of mental retardation and drug addicts. It has been estimated that there are 5.1 million chronic drug abusers in Pakistan and according to NSDA (National Survey on Drug Abuse), 51% of the addicts are dependent on opiates particularly on Heroin.13 The importance and gravity of the problems related to mental illnesses can well be estimated from the facts based on scientific studies by WHO that two fifths (40%) of total disabilities at global scale are due to mental illnesses effecting human functionality which may disturb socio-economic scenario of any country.
The legal parameter of mental illness (forensic psychiatry) is yet to be established. Despite the fact that new Mental Health Ordinance was promulgated on 20th February, 2001 with intention to come into force immediately in all Pakistan but is yet to be implemented.14 
Another area that needs serious attention is developing mental health services for children because about half of our population is below 18 years of age and there are hardly a few trained personnel in the field of child psychiatry.
The gap in research and publication can be imagined from the fact that there is hardly a recognised regular local journal of Psychiatry. PPS (Pakistan Psychiatric Society) had started publishing its Quarterly Journal (JPPS) but is yet to be recognised by PMDC.
In this context it may not be inappropriate to mention that we are also facing rapid changes in psycho-social patterns e.g. urbanisation, which are weakening of our traditional values and family system resulting in an increase in emotional instability. The uncertainty, fear of war and nuclear threat in this region and the recent earthquake of 8th 0ctober 2005 may further warrant modification in our future plan for public health in relation to psychiatric care.
Since there are scarce facilities, especially in the public sector and that too are far and distant and a great deal of investment in health portfolio by the private sector, hence most of the population is under-served. Unfortunately, less than 2% of the meagre heath budget is spent on mental health. Despite the fact that chronicity and disability can be avoided in about 80% of psychiatric cases while complete recovery is possible in more than 60% of the mentally ill with modern treatment modalities.15
There should not be two opinions in arriving at a conclusion that situation of mental health in Pakistan is not up-to-the-mark both in terms of trained staff and patients care/facilities. We have, at this stage may not achieve the WHO goal "Health for all" even in the next decades. A country like ours with high percentage of poverty, low literacy rate and inadequacy of trained professionals warrants a revision in approach towards attaining goal in respect of public health and psychiatric care. Moreover, the primary health care programme must be based on active participation of the community-a mental health services, ideally at the door step of the people where they live and work, at the cost which is affordable, and in the form which is acceptable to them. Keeping in mind the social barriers (Belief System and Social Stigma) and professional barriers (trained personnel and adequate services), there is, of course, a dearth of active participation by Government, donors and groups representing mental health workers, patients and their families need to work together to increase mental health services in term of prevention, treatment and rehabilitation. It is high time for our generation of psychiatrists to play their dynamic role towards promotion of mental health awareness with certainly, strongly developed concept of professional responsibility. In this way we can 'identify, prevent, treat and defeat mental illnesses at various levels.


1. Achakzai A.M.  Biographical directory of Pakistan Psychiatric Society-1998.
2. (accessed December 26. 2007)
3. Mubbashar, M.H. Development of mental health services in Pakistan. International Psychiatry, 2003, issue 1, p: 11-14.
4. Gadit AA, Callanan T S. Jinni Possession: A clinical enigma in mental health. J Pak Med Assoc. 2006, vol 56, number 10, p: 476-8.
5. Gadit AAM. Psychiatry in Pakistan: 1947-2006: A New Balance Sheet. Journal of Medical and Biological Science. 2007, Volume 1, Issue 2;1-21.
6. Ahmed S H. Mental Health: the impact of culture and diversity. Pakistan Association for mental Health. 2007; 1-4.
7. Demyttenaere, K., Bruffaerts, R., Posada-Villa, J., et al. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA, 2004; 291, 2581-90.
8.  Alonso J, Codony M, Kovess V, Angermeyer M C, Katz SJ, Haro JM, et al. Population level of unmet need for mental Health care in Europe. British J Psychiatry 2007;190 , 299-306.
9. Sartorius N. Iatrogenic stigma of mental illness. BMJ 2002; 324: 1470-71.
10.  Sifneos PE. Alexithymia: Past and Present. Am J Psychiatry 1996;153:137-42.
11. WHO.Fact sheet 2007. (accessed December 4. 2007)
12. WHO. Investing in Mental Health.2003. Geneva.
13. Narcotic Control Division Govt. of Pakistan, U.N .Drug Control Programme. Master plan for drug abuse control in Pakistan 1995-2000.
14. Ministry of Law, Justice, Human Rights and Parliamentary Affairs, Islamabad. Mental Health Ordinance. 20th February, 2001. Registered No.  M- S02, L-7646`

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Shahid beheshti University of Medical sciences, Tehran-Iran Otology/Neurotology Fellowship Program

The Division of Otology/Neurotology is currently seeking candidates for the one-year clinical fellowship position in Otology/Neurotology/Skull Base Surgery.

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