Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7443.794 (Published 01 April 2004) Cite this as: BMJ 2004;328:794
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This is an extremely useful contribution to a subject that is rarely
ever discussed in Pakistan. It would be very difficult to assess the true
extent of depression in Pakistan simply because in many cases it is not
even diagnosed or is misdiagnosed. In some rural areas mental distress is
interpreted as possession by evil spirits, requiring a spiritual cure. The
paper is right to identify the causal factors as socio-economic conditions
as well as family relations. Family can be the source of problems, but
very often it can also be a pillar of support in the absence of any other
help. Socio-economic factors, though a source of worry for most
Pakistanis, can also trigger depression. Factors include the absence of a
regular income and providing for a large family, worries about building a
house, arranging and financing marriages for children. One factor
underlying all these is insufficient attention to family planning- another
issue rarely discussed in rural areas.
Competing interests:
None declared
Competing interests: No competing interests
I would like to offer my sincere feelings towards the authors of this
article, but that would evoke a response that psychiatric morbidity is
getting higher and higher in our societies.
I am an Iraqi psychiatrist, and what my country have been through during the
last decades is much worse than any other country in the world. In Iraq we have less than 100 psychiatrists serving a population of more than 24 million, and serious disruption in the health infra structure. The future of mental health programs, in such a traumatised nation, looks gloomy without the
help of the international agencies. This is an occasion, I believe, to ask for more help and understanding of
the needs of mental health services in the developing world. We need combined efforts in order to help them.
Competing interests:
None declared
Competing interests: No competing interests
Mental morbidity in Pakistan: epidemic or false alarm?
One in three people in Pakistan are anxious or depressed. (1) Such
alarmingly high figures raise many questions. Are these findings
artefacts? Do they represent clinical depression or social distress, and
therefore, are the investigators medicalising the normal human condition
of unhappiness? Or, is this a true epidemic of mental morbidity? We
strongly agree with the authors that these figures should be treated with
caution because of methodological issues. Psychiatric disorders are
intrinsically difficult to define because they are based on clusters of
symptoms rather than discrete entities. In the absence of emic
instruments, diagnostic criteria used must be rigorously translated and
culturally adapted. The interview style and setting may influence the
response of research-naïve subjects. Absence of reliable demographic data
may make it is difficult to say if samples are representative. The two-
stage study design used commonly in surveys may be misleading if
inappropriate weighting procedures and statistical software are used (2).
In the absence of impaired functioning as a diagnostic criterion,
discrimination between clinical depression and normal distress may be
difficult. Furthermore, cross-sectional studies provide only limited
epidemiological information. In spite of these methodological issues in
the studies reviewed, Mirza and Jenkins flag up an area that should be of
extreme concern to policy makers in south Asia. The socio-economic cost of
mental disorder is high – more longitudinal and intervention studies are
urgently required.
1. Mirza I, Jenkins R. Risk factors, prevalence, and treatment of
anxiety and depressive disorders in Pakistan: systematic review. BMJ 2004;
328: 794-7.
2. Dunn G, Pickles A, Tansella M, Vazquez-Barquero JL. Two-phase
epidemiological surveys in psychiatric research. Br J Psychiatry 1999;
174:95-100.
Competing interests:
None declared
Competing interests: No competing interests