According to the World Health Organization, their data of 2008.Which says as under:
• 43% of the population under the age of 15.
• 7% of the population is over the age of 60.
• 68% population is rural
• The population of health budget to GDP is 39.
• There is less than one hospital bed per 100,000 population and 85 General Practioners are in the country.
624 Community based psychiatric inpatient unit are available in the country for total of 1.926 beds per 100,000 populations. One percent is reserved for children and adolescent. There are 5 mental hospitals available in the country for total of 1.9 beds per 100,000 populations. 100% of these facilities are organizationally integrated with mental health patient facilities. The number of bed has raised 4% in the last 5 years. The patient admitted to mental hospital belongs primarily to the following two diagnosis groups.
1) Mood (affective) disorder. 31%
2) Neurotic, stress related and somatoform disorder. 24%.
100 % of mental health hospitals had at least one psychotropic medicine for each Therapeutic unit (anti-psychiatric, mood stabilizer, anxiolytic and antiepileptic medicine) available in the facility.
Patient treated in mental hospital health facilities by Diagnosis are as under:
The distribution of diagnosis varies across facilities. Out patient facilities, neurotic disorder and mood disorder are most prevalent. Within community based facilities the above two are most common and in mental hospitals mood disorder are more frequent.
According to National Institute of mental health, following are common types of mental disorder:
1) Mood disorder.
- Major depressive disorder.
- Dysthymic disorder.
- Bi-Polar disorder.
- Suicide.
2) Schizophrenia.
3) Anxiety disorder.
- Panic disorder.
- Obsessive-Compulsive Disorder (OCD).
- Post-Traumatic Stress Disorder (PTSD).
- Generalized Anxiety Disorder (GAD).
- Social Phobia.
a) Agor Phobia.
b) Specific Phobia.
4) Eating disorder.
5) Attention deficit Hyperactivity disorder (ADHD).
6) Autism.
7) Personality disorder.
- Antisocial personality disorder.
- Avoidant personality disorder
- Boarder line personality disorder.
The journal of American Medical Association.2003, 289(3):3095-3105. Which explain the various types of depression, and these are also common in Pakistan.
1) Major depressive disorder.
- Dysthymic disorder.
a) Psychotic depression.
b) Seasonal affective disorder (SAD)
2) Premenstrual dysphonic disorder, common among Pakistani women.
3) Post-partum depression. Mostly found in Pakistan and concern with the birth of baby girl.
4) Menopauses. Commonly found in Pakistan.
5) Stress.
As an older adult, women have more depression, organic brain syndromes and dementias. As the sever life events that causes a sense of loss, inferiority, humiliation or entrapment can result into depression.
American psychological Association researcher found that women with anxiety disorder are more likely to internalize emotions, which typically result in, withdrawal, loneliness and depression. Men on other hand more likely to externalize emotion, which lead to aggressive, impulsive, coercive and non-compliant behavior. The researcher demonstrate that it was differences in the abilities to internalize and externalize that account for gender differences in prevalence rates of many mental disorders, and their previous research that found women suffer more than men from depression because women ruminate more frequently than men, focusing repetitively on their negative emotions and problem rather than engaging in more active problem solving.
Women are more prone than men to have a co-existing anxiety disorder (Achieve of General psychiatry, 2003.Feb; 60(2); 184-189.
Depression also co-exists with eating disorder, such as anorexia, nervosa, bulimia and others especially among women. Anxiety disorders, such as Post-traumatic Stress disorder (PTSD), obsessive compulsive disorder, panic disorder, social phobia and generalize anxiety disorder, also some time accompany depression.
Women suffering from (PTSD), which can result after a person endures a terrifying ordeal or event, are especially prone to having depression.
Older women suffer from restricted blood flow a condition called “Vascular depression”. Also stressful/traumatic life events that cause a sense of loss, inferiority, humiliation or entrapment can lead to depression.
Research shows that there are three main factors, which are highly protective against the development of mental problems, especially depression. These are:
1) Having sufficient autonomy to exercise some control in response to sever event.
2) Access to some material resources that allow the possibility of making choice in the face of sever event.
3) Psychological support from family, friends or health provider is powerfully protective.
The cure of depression is based on causes, medication and protective factors. The percentages of females patients treated in mental health facilities are: 74% in mental hospitals. 75% in community based psychiatric inpatient unit and 69%, out patient facilities. This means that female patients make-up over 69% of population in all mental health facilities in the country. The population of female patients in highest in inpatient unit and lowest in outpatient facilities.
According to World health organization, the overall psychiatric disorders are almost identical for men and women but striking gender differences are found in the pattern of mental illness.
Gender difference have been reported in age of onset of symptoms, frequency of psychotic symptoms, cause of disorder, social adjustment and long term outcome. Mental health risk is based on the social position, status and treatment in society and their exposure to specific mental health risk. Gender specific risk factors for mental disorder are: gender based violence, income inequality, low or subordinate social status and un-remitting responsibility for the care of others.
Women have more psychiatric illness (mood disorder, neurotic and somatoform disorder.)Than a man in Pakistan and this is the same as research findings have confirmed in the developed countries. These facts are as under:
The following are research work in which both the gender having same psychological illness:
a. According to the World Health Organization, they found no mark difference in schizophrenia and bi-polar disorder
b. Condition such as ADHD (Attention deficit hyperactivity disorder) and schizophrenia did not have statistically significant difference between genders in adults.
c. Although the bi-polar disorder is equally common in women and men, research indicate that approximately three times as many women as men experience rapid cycling ( journal of clinical psychiatry, 58, 1995 (suppl.15).
d. Professor Kathryn Abel , of the center for women mental health at Manchester university said that while disparities between rate of particular conditions, were well-established in research, she had not seen evidence of significant differences in the overall rate of mental health disorder across lifetimes. She added that age was also a significant factor in different ratios, particularly given physical and social changes at different stages of life. She also noted that thanks for modern health care and society particularly in the developed world were much of data on rate of mental disorder comes from “ stress” by the formal definition (survival stress) is lower for women and men than at virtually any point in history.
Research which indicate the following psychiatric illness is more in men than women.
• According to World Health Organization, men are three times more having antisocial personality disorder than women.
• Although more common among men than women, alcohol and substance abuse or dependence may occur as the same time as depression. (Achieves of General psychiatry, 2003. Feb; 60 (2); 184-189.
• Men are more likely to report substance miss-use disorder around two and a half times more frequently than women.
Psychiatric illness is more in women than men.
The following researches confirm this statement, these are as under:
• Sarah Rosen field used the object relation theory that postulates that because women are mostly responsible for parenting, mother hood, emphasizing the importance of relationship to their daughters, while pushing their sons into independence which leads to the theory to argue that males and female develop different types of symptoms, when they are mentally ill. Men tend to display externalized symptoms, expressing problematic emotion in outward behavior; women tend to develop internalized symptoms, where problematic feelings are directed toward the self.
• According to the World Health organization, depression, anxiety and somatoform disorder, in which women predominate.
• Uni-polar depression, twice common in women.
• Disability associated with mental illness, more in women than men.
• According to World Health organization, high prevalence of ual violence having high rate of post-traumatic stress disorder (PTSD), more in women than men. Mood altering psychotropic drug use is more in women than men; women also have more emotional problems.
• Depressive disorder account for close to 41.9% of the disability from neuropsychiatric disorder among women compared to 29.3% among men.
• According to new study published online in APA; journal of abnormal psychology by the American psychological Association, their research shows that when it comes to mental health, the es are different. Women are more likely to be diagnosed with anxiety or depression, while men are diagnosed with substance abuse or antisocial disorder.
• The American psychological Association research indicate that women report more neuroticism and more frequent stressful life event than men do before the onset of a disorder, indicating that environmental stressors may also contribute to internalizing.
• Women are up to 40% more likely than men to develop mental health condition, according to new analysis by a clinical psychologist at Oxford University.
• According to Freemen, a clinical psychologist at Oxford University, study, women were approximately 75% more likely then men to report having recently suffered from depression, and around 60% more likely to report an anxiety disorder.
• Freemen a clinical psychologist at Oxford university said that because the conditions affecting women were more common than those affecting men, overall mental illness were more common in women than men, by a factor of 20% to 40%.
• According with internalize-externalize dictionary, women are more commonly diagnose with mental illness, such as anxiety, depression and phobias.
• According to Sansone, R.A;Sansone, L.A (2011), innovation in neuroscience. 8(5):16-20, the boarder-line personality disorder has been found to be equally prevalent among men and women.
• Women are more prone then men to have a co-existing, anxiety disorder (Achieves of General psychiatry, 2003, Feb. 60 (2); 184-189.
• Before adolescence, girls and boys experience depression at about the same frequency. By adolescence however girls become more likely to experience depression than boys. Research point out to several possible reasons for this imbalance. The biological and hormonal changes that occur during puberty likely contribute to the sharp increase in rate of depression among adolescent girls. (National survey of psychiatric morbidity. International review of psychiatry, 2003.Feb.-May; 15(1-2); 74-83.
• According to achieve of general psychiatry: 2000.Jan; 57(1); 21-27.Girlds may undergo more hardships such as poverty, poor education, ual abuse and other traumas than boys. One study found that more than 70% of depressed girls experienced a difficult or stressful life event prior to a depressive episode, as compared with 14% of boys.
• National survey of psychiatric morbidity. International review of psychiatry, 2003.Feb.-May;15(1-2):74-83.They said that as with other age groups more older women than older men experience depression but rate decreases among women after menopause.
• Journal of clinical psychiatry, 58, 1995 (suppl.15); their research findings indicate that women with bi-polar disorder may have more depressive episodes and more mixed episode than men with the illness.
• According to better or worse: A longitudinal study of mental health of adult in Great Britain, National statistics, 2003, which says women are more likely to have been treated for a mental health problem than men (29% compare 17%).This could be because, when asked women are more likely to report symptoms of common mental health problem.
• National institute for clinical excellence, 2003, they say that depression is more common in women than men 1 in 4 women will require treatment of depression, compared to 1 in 10 men. The reason for this is unclear, but is thought to be due to both social and biological factors.
• An estimated 80% of 50 million people affected by violent conflicts, civil wars, disaster and displacement are women and children and suffer more from PTSD.
• Gender discrimination and associated factors, poverty, hunger, malnutrition, domestic violence, and ual abuse all combine to account for women poor mental health.
Freeman a clinical psychologist at Oxford University said “Where we think it has an effect is particularly on women self-esteem or self worth, women tend to view themselves more negatively than men and this is a vulnerability factor for many health problems.”
Martha Long, 2006, said that both men and women are more likely to be institutionalized if their diagnosis is not typically of their gender.
Chronic illness, emotional imbalance, less willing to discuss feeling of sadness or grief, hence women is less likely to report to a doctor. Poverty and education had little to do with domestic violence as it even occurred in educated and rich families.
Munziae Jahangir, quoted, Mukhtarn Mai, who once claimed that if there was any change, that had come, it had come in society, in fact, and it had come in women, who had stood-up against violence and injustice.
In cities across Europe, same true to Pakistan as well, women started doing traditionally “male jobs”, waiting on tables, sorting out the mail, call centers, teaching in boy schools or handling cash as bank clerk. As the historian Michael Howard said: “women rapidly become indispensible, not only in the nursing and welfare services but in offices, factories, agriculture and changing the whole blame of society in the process. (Janet Mecoy and Pascale Juillard; news in DAWN, women man the home front in world war.1).
In Pakistan, working women suffer from double burden; they not only have to fulfill their professional requirements but also have to manage their home and family life. In most of the cases this brings them under stress, which is predominate in women. For survival every body needs security, self-esteem, love, self-expression, intellectual and spiritual well beings, these factors also affect on in personal and professional life , education, family, social life and relationships if not dealt with properly result into stress.
In order to reduce stress, we can perform following relaxation techniques.
• Deep breathing exercises.
• Exercise regularly.
• Maintain healthy diet.
• Develop support group.
• Listen to music.
• Talk to a friend.
• Thought diary.
• Go to entertainment outside.
• Indulge in hobbies. Talk to therapist.
• Get adequate sleep.
• Stop taking alcohol and drugs.
• Go to see your doctor.
• Be willing to compromise.
• Be more assertive.
• Think positively.
• Learn to forgive.
• Go for a walk.
• Relaxing activities (take a long bath and get a message.)
According to the “WHO”, Aim report on mental health system in Pakistan .2009.
27%of the training for medical doctors is devoted to mental health in comparison to 3% nurses and 11% non-doctor/non-nurse primarily health care workers.
S.No. Profession Per 100,000 population.
1 Total no.of human resources working in mental health or private practice is 203.07. The breakdown according to profession is as following.
2 342 Psychiatrists. 0.2
3 25782, other medical doctors 8.13
4 478, psychologist. 0.28
5 22, occupational therapist. 0.01
6 102597, other mental health workers, assistant, medical assistant, professional, Para-professional and psychological counselors. 61.15
• 45% of psychiatrist work only for government administered mental health facilities.
• 51% working only NGO’s/for profit mental health facilities practice.
• 4% work for both the above two sectors.
The distribution of human resources between urban and rural area is disproportionate. The density of psychiatrist in or around the largest city is 2.29 times greater than the density of psychiatrist in the entire country.
Joint support from private and government sector is needed to improve the human resources in the field of mental illness. This will help the government to bring changes in the polices, for the protection and cure of mentally ill patients and improve it services.
Polices for the protection of mentally ill patient and improve gender position.
The following legislative and financial provision exists to protect the mental health and mental disorder patients and provide support for uses.
• Provision concerning a legal obligation for employers to hire a certain percentage of employees that are disabled.
• Provision concerning protection and discrimination (dismissal lower wages) solely on account of mental disorder.
• Provision concerning priority in state housing and in subsidized housing schemes for people with severs mental disorder.
• Provision concerning protection from discrimination in allocation of housing for people with severs mental disorder.
Mental health policies, plan and legislation do exist in the country but are not implemented. Since psychiatric illness is more in women than men, so we have to bring change in economic and social polices and address the gender inequality, which may be the cause of increases mental illness in female.
Promote the formulation and implementation of health polices that address women’s need and concern from childhood to old age. Women have lack of basic education and poverty, which often affect their awareness of rights. We have to make policies which will increase and improve decision making power of women.
MNA Pervez was talking on the occasion of women’s day he stated that the slow procedure which assemblies passed women rights bills, but also defended the provincial government, saying that work was definitely being done on these matters.
On the occasion of international women day held on 20th Feb.2014, pledges for “women need mechanism to implement laws”.Ms.Jilani said the introduction of new pro-women laws had definitely brought about a change but mostly at psychological level. She gave the example of 2002, women protection act, where the section of rape was amended, which lead to reduction of post-traumatic stress disorder, she also said that one major flaw in laws is that although they stated penalty, they do not give women the mechanism to lodge a complaint.
Mr.Rehman also on the same occasion said that mass media had not helped decrease the number of acid attacks on women, the reason was that the mentality of the people had not changed. He suggested that the best way to go about with the situation was to sensitize law makers, law implementers and media. He also suggests that all provinces must have a council for common interest, instead of having separate laws and rights for citizens.
Future plan
• Women get low wages, so their should be waggle defined reform and law need to implement.
• Long term cumulative psychosocial adversity need to be investigation.
• We have to put emphasis on violence related mental health problem which are poorly identified.
• Many health workers are tend to have gender biases, we have to remove this barrier.
• Enhance the competence of primary health care provider to recognize and treat mental health consequences of domestic violence, ual abuse, acute or chronic stress in women.
• Nicholas R.Eaton.MA of the university of Minnesota their findings support gender-focused prevention and treatment efforts, the study said “in women, treatment might focus on coping and cognitive skills to help prevent rumination from developing in to clinically significant depression or anxiety. “In men, treatment for impulsive behavior might focus on regarding planned actions and shaping aggressive tendencies in to non-destructive behavior.
• More research needed on differences, related to any specific physiological factors in different mental health conditions.
• Psychiatric training in Pakistan is at very early stage it both undergraduate and post-graduate level.Psychartry as a separate subject in the medical curriculum, can help future doctors to recognize to some extent treat mental health problems.
• Lack of training consultants in the field of Forensic psychiatry, psychotherapy, geriatric psychiatry, drug and alcohol abuse, child psychiatry and learning disabilities, need to put more emphasis on the training of consultants in the above fields.
• More community based training is needed.
• Government and NGO’s and communities need joint efforts to open more psychiatric care and rehabilitation centers, especially for women and girls, to meet the growing demands of psychiatric illness in females population of the country.