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A study investigating mental health literacy in Pakistan
KAUSAR SUHAIL
Department of Psychology, GC University, Lahore, Pakistan
AbstractBackground: Research on public mental health beliefs has shown marked discrepancies acrosscountries.Aims: This study was conducted to assess pubic mental health beliefs in Pakistan.Method: In a large-scale survey, conducted in three cities of Punjab along with their neighbouringsuburbs, a total of 1750 people from all walks of life were read a vignette describing symptoms of eitherpsychosis or major depression. Survey participants were requested to provide diagnosis, causes,prognosis, and possible treatments for the disorders.Results: The findings showed that depression was four times more likely to be diagnosed than psychosis(18.75% vs. 4.94%). A logistic regression analysis with forward selection for the predictors showed thatthe type of disorder, education status and area of residence contributed significantly to one’s ability todiagnose. More people believed that GPs (23.76%), psychologists (23.92%) and psychiatrists(20.73%) were the right people to consult for these problems. There were also some who consideredhakims and homeopaths (4.22%), magical (13.11%) and religious healers (13.54%) as the appropriatepeople to contact. Those recognizing mental disorders were more likely to identify the underlyingcauses, prognosis and appropriate treatment of the problems. .Conclusions: The current findings suggest a need to initiate large mental health movements in Pakistanto increase the mental health awareness of people, especially targeting uneducated and ruralpopulations.
Keywords: Pakistan, schizophrenia, depression, health, culture.
Background
Mental heath literacy has been used to refer to the knowledge and beliefs about mental
disorders and their management. According to researchers, mental health literacy consists of
several components including the ability to recognize specific psychiatric disorders, judge
the comparative utility of a range of interventions, and make estimates about outcome and
prognostic issues (Yeo, et al., 2001).
Studies investigating public beliefs about the causes and risk factors for many forms of
mental illness have shown a reasonable concordance with the available evidence. Jorm,
Korten, Jacomb, Christensen, Rodgers and Pollitt (1997) found, in a survey of 2031
Australian adults (aged 18 – 74 years), that public beliefs about the causes and risk factors for
depression had a reasonable correspondence with the evidence.
Correspondence: Professor Dr Kausar Suhail, Chairperson, Department of Psychology, GC University, Kechehry Road, Lahore
54000, Pakistan. Tel: + 92 111 000 010, ext. 307. Fax: + 92 42 7243198. E-mail: [email protected]; [email protected]
Journal of Mental Health,
April 2005; 14(2): 167 – 181
ISSN 0963-8237 print/ISSN 1360-0567 online # Shadowfax Publishing and Taylor & Francis Group Ltd
DOI: 10.1080/09638230500085307
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Western populations have not only been reported to have an awareness of the probable
causation of mental disorders, but they also have been shown to possess appropriate
information regarding the treatment of mental illness. Lauber, Nordt, Falcato and Roessler
(2001) conducted a representative opinion survey in Switzerland and presented 18
treatment proposals with respect to a vignette either depicting schizophrenia or depression.
Most of the people proposed that a psychologist, a general practitioner, a psychiatrist and
fresh air were helpful in these disorders.
A few reports from the developing countries on this issue have revealed considerably
different results. Ohaeri and Fido (2001) assessed the opinion of Nigerian relatives of 75
people with schizophrenia and 20 with major affective disorder on different aspects of the
disorders and compared the results with the responses of relatives of people with physical
diseases (i.e., cancer, infertility and sickle cell disease). The responses of the relatives of the
two psychiatric illness groups were similar. The most important etiological factors were that
‘‘it is Satan’s work’’ and ‘‘it is a natural illness’’. Other factors were genetic, witchcraft and
curse by enemies, while the most important causative factors in the case of sickle cell disease
were genetic and natural.
Personal communication with clinical psychologists and psychiatrists working in hospitals
and private clinics in Pakistan indicates that although people are more aware of mental
health problems than ever before, many misconceptions are still prevalent.
People’s beliefs depend on many sociocultural and religious factors. Mental health
problems are neither widely acknowledged nor accepted in Pakistan and a lot of stigma is
attached to being recognized as mentally sick. The majority of the population consults
primary medical care for their mental health problems and many of the staff are not trained
to understand or deal with these problems. Faith healers and religious leaders are often the
people who most mentally ill patients first approach (Mubbashar & Saeed, 2001). In a recent
analysis of mental health profile in Pakistan, Karim, Saeed, Rana, Mubbashar and Jenkins
(2004) point out that mental illness is stigmatized and widely perceived to have supernatural
causes, and that the traditional healers along with psychiatric services are the main mental
health service providers.
Apart from cultural and religious factors, mental health literacy is also influenced by
general literacy rate, mental health policies and the facilities offered. Improved mental health
awareness can be largely attributed to a gradual rise in the overall literacy rate. As far as
mental health services and resources are concerned, developing countries have a long way to
go to achieve the same available services as in developed countries. According to The World
Health Report (WHO, 2001), the median number of psychiatrists for the lower income
countries is 0.6 per 100,000 and for the high-income countries is 9 per 100,000, showing a
wide disparity. Moreover, the median number of beds per 10,000 population is 0.24 in the
low income countries and 8.7 in the high income countries. An analysis of mental health
care system in Pakistan reveals that things improved after the implementation of a new
mental health law, which replaced the lunacy act of 1912 on 20 February 2001, and which
embodies the modern concept of mental illnesses, treatment, rehabilitation, and civil and
human rights. However, mental health services including policies, programmes and
resources are still not in proportion to the total burden of illness in Pakistan. Mubbashar
and Saeed (2001) indicate that the Ministry of Health budget is 5% of the national budget,
while the mental health budget is 0.4% of the health budget. Discussing mental health
services in Pakistan, one report maintains (Karim et al., 2004) that the number of trained
mental health professionals is small compared to the population demands, and specialist
services are virtually non-existent. As the better management of mental health problems
requires a great many reforms and revisions in national policies pertaining to health, it is also
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important that people’s awareness about potential mental health issues is enhanced in order
to maximize the utilization of mental health facilities and to balance demand and supply.
Not many studies in Pakistan have looked at mental health awareness of the general
public. Kausar and Sarwar (1999) carried out a study to examine misconceptions in
Pakistani population about aetiology and treatment of mental disorders. They obtained
equal number of participants from rural and urban populations (n=30 each). The use of a
self-constructed questionnaire revealed that rural populations had more of such
misconceptions. As area of residence is also linked with education, Mubbashar and Farooq
(2001) very rightly indicate that in some developing countries where more than half of the
population may be illiterate the dimensions of mental health literacy are totally different
from those in Western countries.
The current trends in psychiatry favour the preventive rather than the treatment
model. It is, therefore, important for the public to be aware of mental health problems,
so that they are detected at an earlier stage and that appropriate management is possible.
The current work was formulated to investigate the mental health beliefs of Pakistani
people regarding recognition, causes, risk factors, appropriate treatment and prognosis of
two important forms of mental illnesses, psychosis and major depression. By examining
the mental health literacy of Pakistani people, this study aimed to highlight those areas
where the knowledge of people concerning mental health issues is deficient. Another
objective of this work was to identify the less aware sub-groups of the population so that
they are especially reached when mental health campaigns are launched at both an
individual and national level.
Methods
Sample
The sample for this survey was obtained from three main cities of the province Punjab, i.e.,
Lahore (the provincial capital), Multan and Faisalabad. To give some representation to rural
populations, three villages near to these cities were also included. All three cities contain a
rich mix of people ranging from very poor to very affluent as well as illiterate to highly
educated. In villages, with a few exceptions, the people are usually poor and less educated or
illiterate. In cities an attempt was made to give a suitable representation to different areas
ranging from those with better socio-economic status (e.g., Defense, Gulberg in Lahore) to
inner city congested ones (e.g., Bhatti, Rang Mehal in Lahore). A special effort was made to
obtain a good mix of sub-groups pertaining to gender, social class, education and age. A
total of 1750 made the sample for this study.
Design
A door-to-door quasi-random large scale survey was carried out in different localities of the
three cities, eight areas from Lahore and four each from the other two cities. The main data
collection was from the cities, while 8.8% of the sample was obtained from the villages for
comparison purposes. The participation was entirely voluntary both in cities and villages.
The volunteers were informed that this was a study to examine their general awareness about
a number of important issues. The term of mental health was not mentioned at any stage so
that their responses were not coloured by this information. They were assured that their
responses will not be used for any commercial purpose and their identities will be fully
confidential.
Mental Health Literacy in Pakistan 169
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Research tools
The following research tools, all in the national language, Urdu, were employed in the
current study:
1. Demographic information was obtained on a separate sheet about gender, age,
education and profession as well as the monthly income of the family.
2. Two vignettes served as the main data collection tool. Vignettes were employed so that
people could relate to the person represented in the vignette. Each vignette described a
person suffering from either psychosis/schizophrenia or major depression. Although
these vignettes were constructed following relevant DSM-IV diagnostic criteria, three
psychiatrists and two clinical psychologists were also contacted to obtain a culturally
valid profile of both disorders. This consultation did not reveal much disparity except
that the professionals reported that in Pakistan patients suffering from major depressive
disorders show less frequency of cognitive (guilt and low self-esteem) as compared to
physical symptoms associated with depression. The relevant vignette was constructed
accordingly. A previous cross-cultural study of psychosis has also indicated that
although the content of delusions and hallucinations vary across cultures, Pakistani
patients experience the same landmark symptoms of psychosis usually reported across
cultures (Suhail & Cochrane, 2002). With some modifications (professionals’
comments incorporated), the vignettes used by Jorm et al. (1997) were employed in
the current work.
The depression (male) vignette:
Ahmad is 45 years old, he has been feeling unusually sad and miserable for
the last few weeks. He has lost interest or pleasure in all or almost all
activities most of the day, nearly every day. Even though he is tired all the
time, he has trouble sleeping nearly every night. Ahmad doesn’t feel like
eating and has lost weight. He is also experiencing feelings of worthlessness
as well as suicidal thoughts. Physical complaints like neck and shoulder
strains, and backaches are also currently his problems. He can’t keep his
mind on his work and puts off making decisions. Even day-to-day task
seems too much for him. This has come to the attention of Ahmad’s boss
who is concerned about his lowered productivity.
The psychosis (female) vignette was as follows:
Najma is 25 and lives at home with her parents. Over the last six months
she has stopped seeing her friends and has begun locking herself in her
bedroom and refusing to eat with her family or to have a bath. Her speech is
sometime incoherent and disorganized. Her parents also hear her walking
about her bedroom at night while they are in bed. Even though they know
she is alone, they have heard her shouting and arguing as if someone else is
there. When they try to encourage her to do more things, she whispers that
she won’t leave home because the neighbour is spying upon her.
3. The Mental Health Literacy Questionnaire (MHLQ) was designed to assess people’s
awareness and beliefs about mental illness, treatments and prognosis. The items
related to causes and risk populations were taken from Jorm et al. (1997), but the
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questions were formulated according to local linguistic expressions. Two additional
sections were created to evaluate people’s beliefs regarding prognosis and appropriate
treatments. Another section was included to ascertain the level of discrimination
against people with mental disorders. As the questionnaire was in Urdu, it has not been
provided here. However, the section-wise description of the MHLQ is described
below:
(a) This section consisted of one open-ended question. After reading the vignette, the
participant was asked: what do you think is wrong with the person (diagnosis)?
(b) The second section asked about the likely causes of the disorder by providing a
number of options, i.e., virus, allergy, genetic, daily problems, adverse life events,
childhood event and being a morally weak person. The respondent could indicate
more than one cause, and the answers were rated on simple likely/ unlikely
dimensions.
(c) This section explored the respondents’ opinion regarding the appropriate treatment
for such a problem. A number of options regarding the appropriate person to
consult/ possible treatments were provided here. For example, general practitioner,
psychologist, psychiatrist, hakim/homeopath, magical healers, religious healers,
through diet, or any other not mentioned in the list. The respondent was allowed to
select more than one treatment option.
(d) The interviewee was asked about the prognosis of these illnesses. The question asked
was: in your opinion, what is the chance of recovery in a person suffering from such
an illness? The answers were rated along the following dimensions: no chance, to
some extent, to a large extent, and complete.
(e) This part asked the respondents’ views regarding the susceptibility of particular
populations toward these problems, such as particular genders, or ages, marital
status, employment status etc. The answers were rated as likely/unlikely.
(f) The last section, although not directly a part of mental health literacy, was about
people’s perceptions of people with mental disorders in order to investigate the direct
link between stigma and mental health beliefs. The question was about different
levels of social relationship, and whether the respondent would tolerate people
similar to those described in the vignettes. The options provided were: marrying,
being a close friend, colleague, neighbour, friend of a friend and seeing occasionally.
The respondents were requested to indicate only the highest level of accepted
relationship. Their answers were rated on simple yes/no dimensions.
Procedure
As mentioned earlier, all the questions of the MHLQ as well as the vignettes were in
Urdu. First of all, questions related to demographic details were asked from the
respondents. Then the vignette of either psychosis or depression was read out to the
survey subjects. All the questions were read to them one by one in the same order as were
described previously.
As there were many people in the sample who could not read or write, all respondents
were interviewed to keep uniformity. A group of 20 students enrolled in a Masters
programme in Psychology were trained to serve as the interviewers. The sampling was quasi-
random. As up-to-date lists of the population resident in different streets were not available,
a procedure of systematic sampling was adopted. To reduce personal bias every tenth house
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in a street was approached, and anyone available at that time in a house was requested to
participate. The researcher would start from any street of an area (picked non-randomly),
contact the first house in that street (if participation was refused, would contact the next
house) and then the tenth, and so on. When the researcher finished the target number of
households, h/she would stop data collection in that area. Only one person from each
household, present and willing to participate, was included in the study. If no one was
present at home, the next house was approached. As it was not practical to revisit, all
partially completed interviews were excluded. A total of 2000 households were visited out of
which 1750 complete interviews were obtained.
Results
The data were analyzed using the SPSS for windows, version 10.00. A total of 850 men and
900 women participated in this study. The mean age of the total sample was 34.03
(SD=14.19) with an age range of 16 – 72. The mean ages for men and women were 35.82
(SD=14.52) and 32.14 (SD=13.61) respectively. The majority of the respondents were
educated up to the college level. As far as area of residence was concerned, 1595
respondents (92.2%) belonged to urban as compared to 154 (8.8%) living in rural areas.
Out of 1750, 849 participants responded to the vignette of psychosis, while 901 gave their
responses for the depression vignette.
Diagnoses suggested by the respondents are shown in Table I, which shows that 18.75%
and 4.94% were able to diagnose the vignettes describing depression and psychosis. The chi
square analysis indicated significant differences in different diagnoses assigned by people to
the vignettes of depression and schizophrenia w2 (6) = 167.79, p 4 0.0001.
To identify the best predictors for the identification of a disorder, a logistic regression
analysis with forward selection was computed with gender, age, education, area of residence
and type of vignette as the predictor variables and diagnosis (correct/ incorrect) as the
predicted variable. The results of this analysis showed that the type of vignette was the best
predictor, followed by the level of education and the area of residence for making either
correct or incorrect diagnosis (see Table II). The other variables, age and gender, did not
contribute significantly to the prediction.
To understand the direction of these associations, the percentages of people falling
in different subgroups have been plotted for the three significant predictors. Figure 1
shows that the recognition of a mental disorder largely depended on the type of the
vignette used; people were four times more likely to identify depression than
Table I. People’s diagnosis of vignettes of depression and psychosis (N=1750).
Disorder (Vignette)
Disorder identified Psychosis (849) n (%) Depression (901) n (%) Total N (%)
Psychosis 42 (4.94) 19 (2.11) 61 (3.49)
Depression 15 (1.78) 169 (18.75) 184 (10.51)
Some mental illness 180 (21.20) 158 (17.54) 338 (19.31)
Physical illness (e.g., fever, cancer, etc.) 156 (18.37) 186 (20.64) 342 (19.54)
Possessed 68 (8.0) 26 (2.89) 94 (5.37)
Love failure 34 (4.0) 50 (5.55) 84 (4.8)
Not sure 208 (24.5) 279 (32.52) 647 (36.97)
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psychosis. Figure 2 shows that more educated people were able to diagnose the
disorders more frequently than the less educated. Similarly, those living in urban areas
were more likely to recognize mental illness than the residents of rural areas (Figure
3). Table III, IV and V show the frequencies and percentages of people identifying
the likely causes, risk populations and treatments/appropriate persons to consult for
depression and psychosis. The chi square analysis indicated significant differences in
the likely causes suggested by the respondents for depression and psychosis w2
(6) = 25.25, p 4 0.001. The inspection of individual categories, however, showed that
Figure 1. Diagnosis by type of disorder (N=1750).
Table II. Logistic regression analysis with forward selection showing the effect of various predictors on diagnosis
Predictors B SE Wald df p Exp(B)
Step 1 Type of vignette(1) 1.49 0.18 68.77 1 0.0001 4.44
Step 2 Education 24.47 3 0.0001
Education(1) 7 1.46 0.48 9.31 1 0.0001 0.23
Education(2) 7 0.89 0.22 15.86 1 0.0001 0.41
Education(3) 7 0.56 0.17 11.00 1 0.0001 0.57
Type of vignette 1.49 0.18 68.05 1 0.0001 4.45
Step 3 Education 22.83 3 0.0001
Education(1) 7 1.40 0.48 8.51 1 0.0001 0.24
Education(2) 7 0.86 0.22 14.79 1 0.0001 0.42
Education(3) 7 0.56 0.17 10.68 1 0.0001 0.57
Area of residence(1) 0.70 0.34 4.26 1 0.05 2.03
Type of vignette(1) 1.50 0.18 68.88 1 0.0001 4.49
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the respondents showed similar responses on a number of dimensions, for example on
day-to-day problems, adverse life events and being a morally weak person (Table III).
Figure 3. Diagnosis by the area of residence (N=1750).
Figure 2. Diagnosis by education (N=1750).
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A separate analysis on the category of ‘‘magic’’ indicated that more people considered
magical spells as a likely cause for the symptoms of psychosis than those for
depression w2 (1) = 8.19, p5 0.01.
Table IV shows the risk populations as identified by the respondents. People responding
to both vignettes reported that the unemployed, poor and divorced/separated are at greater
risk for developing these symptoms. However, never-married and women were identified as
more likely to suffer from a psychosis w2 (6) = 27.45, p 4 0.001.
Table V displays the appropriate treatments suggested by the respondents for both
disorders. A significant value of chi square indicated that people considered different
Table IV. People’s perceptions regarding population at risk (N=1750).
Disorder
Population at risk Psychosis (849) n (%) Depression (901) n (%) Total (1750) N (%)
Women 546 (64.31) 481 (53.39) 1027 (58.69)
Younger 356 (41.93) 349 (38.73) 705 (40.29)
Older 324 (38.16) 384 (42.62) 708 (40.46)
Poor 485 (57.13) 563 (62.49) 1048 (59.89)
Unemployed 619 (72.91) 708 (78.58) 1327 (75.83)
Divorced/separated 450 (53.0) 570 (63.26) 1020 (58.29)
Never married 524 (61.72) 493 (54.72) 1017 (58.11)
Table V. Appropriate treatments (persons/modes) suggested by the respondents (N=1750).
Disorder
Appropriate persons/treatments Psychosis (849) n (%) Depression (901) n (%)
GP 214 (25.21) 201 (22.31)
Psychologist 213 (25.08) 205 (22.75)
Psychiatrist 190 (22.38) 172 (19.09)
Hakim/homeopath 34 (4.00) 40 (4.44)
Magic healers 120 (14.13) 109 (12.10)
Religious healers 97 (11.43) 141 (15.65)
Diet 25 (2.94) 42 (4.66)
Table III. Likely causes of depression and psychosis as identified by the respondents (N=1750).
Disorder
Likely causes Psychosis (849) n (%) Depression (901) n (%) Total (1750) N (%)
Virus 172 (20.3) 240 (26.64) 412 (23.54)
Allergy 152 (17.9) 198 (21.98) 350 (20.0)
Day-to-day problems 762 (89.75) 827 (91.79) 1589 (90.8)
Adverse life events 631 (74.32) 642 (71.25) 1273 (72.74)
Childhood problems 641 (75.50) 586 (65.04) 1227 (70.11)
Genetic 397 (46.76) 398 (44.17) 795 (45.43)
Magic 165 (19.43) 129 (14.32) 294 (16.8)
Morally weak person 539 (63.49) 563 (62.49) 1102 (62.97)
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treatments for both disorders w2 (6) = 14.76, p 4 0.05. For example magical healers as
well as mental health practitioners and GPs were thought to be more appropriate for
the patients suffering from a psychosis. On the other hand, religious healers were
considered more suitable for people suffering from depression. It is important to point
out here that the majority of the participants who suggested a psychiatrist or a
psychologist as a main source of consultation for the problem in question were the
same 95% of the time.
People’s beliefs about the likely prognosis varied for depression and psychosis; more
people (45.6%) thought that depression could be treated completely, whereas half of the
participants responding to the schizophrenic vignette believed that psychosis can be cured to
a large extent (50%) but not completely (28.6%).
To assess the effect of recognizing a mental disorder on identification of causes,
treatments, prognosis and risk populations, a series of chi square analyses were conducted
separately for depression and psychosis. The results did not show a significant effect of
correct diagnosis on identification of the likely causes for depression except that those
unable to identify the disorder more frequently (23.6 vs. 15.4%) believed that allergy could
be a likely cause for depression w2 (1) = 5.43, p5 0.05. On the other hand, those recognizing
a psychosis believed more often (83.3 vs. 68.3%) that losing parents in childhood might be a
likely cause for this disorder w2 (1) = 4.32, p5 0.05. People recognizing depression believed
that divorced/separated people are at greater risk for this disorder w2 (1) = 7.61, p5 0.01.
Those identifying psychosis frequently believed that psychiatrists could be the best people to
consult for the treatment, although the difference did not reach statistical significance.
Moreover, the ability to recognize a psychosis had a significant effect on beliefs about
prognosis w2 (3) = 16.46, p5 0.001; those able to identify reported that this disorder could
be cured to a large extent (52%), whereas those not being able to identify thought more
often that it could be cured completely (37.2).
Analysis on the maximum level of social relationships people could tolerate with people
with mental disorders showed more accepting attitudes towards the patients with
depression. However, the analysis with both disorders together showed 54% of the
respondents reporting that they would not mind seeing such a person occasionally. As far as
other relationships were concerned, 3%, 5%, 15% and 23% reported that they could tolerate
the following relationships with such a person respectively: marrying, close friendship, friend
of a friend and a neighbour.
Discussion
This is the first large scale survey on mental health literacy in Pakistan. It indicates that there
is a great need to enhance mental health awareness in Pakistan as the current rates of mental
health literacy on various dimensions differ from those reported from the developed
countries. These differences were more apparent in the case of psychosis; people diagnosing
the depression vignette exceeded those diagnosing psychosis by a ratio of 4:1. Although the
majority of the respondents reported that the symptoms seemed to be related to ‘‘some kind
of mental illness’’, they were unable to name it.
There were also some individuals in both categories who diagnosed both disorders as a
physical illness. A few believed that the persons described in the vignettes were possessed by
some supernatural power; this appeared more often in the case of psychosis. It seems that
the symptoms of psychosis including delusions and hallucinations appear very bizarre and
weird to those possessing little information about mental health problems. Astonishingly,
some respondents believed that the symptoms described in the vignette are caused by a love
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failure. Sadness, withdrawn attitude and irritation may well be associated with love failure,
however expecting bizarre and weird behaviour as a result of an unsuccessful love affair
seems very much a cultural response and shows a poor understanding of a normal life
experience in some people. This overlap between normal and abnormal behaviours/
experiences is also suggestive of insufficient mental health information in general public.
Type of disorder appeared to be the best predictor of correct recognition with more
people identifying symptoms of depression. Education and area of residence also appeared
to be the significant predictors of recognition. Education showed a linear association with
correct diagnosis, with more educated being able to identify the disorder. Those living in
cities also appeared to be more aware and were able more frequently to name the relevant
disorder. It has also been reported elsewhere that the attitudes of respondents towards
psychosis were more negative in lower educational and socio-economic groups (Sagduyu,
Aker, Oezmen, Oegel, & Tamar, 2001). In developed countries, rural and urban areas are
not much different in facilities regarding quality education as well as of living. In Pakistan
however, villages are very deprived in nearly all facets of life. For example, some villages do
not have high schools (up to grade 10). Similarly, newspapers usually do not reach the
villages, and if they do, are only read by a minority. Moreover, there is no concept of having
a library either in schools (whether elementary or high) or in the community. Less mental
health awareness in such circumstances should not be unexpected in people living in rural
areas. Confirming this, Kausar and Sarwar (1999) indicated that rural populations in
Pakistan had more misconceptions about mental disorders as compared to urban
populations. Analyzing this situation in Pakistan, Akhtar (2004) points out that this attitude
is directly linked with literacy rate that is very low in villages.
Magical spells were also considered as a likely cause of the symptoms of psychosis and
depression in a few respondents (19.40% & 14.32%), thus magical healers were considered
the appropriate people for seeking help (14.13% for psychosis and 12.10% for depression).
Although Western populations do not usually report supernatural explanations, in Asian
countries such ideas are quite prevalent (Westermeyer, 1988). Other studies have also
reported widely held beliefs in the supernatural causes of mental disorders and sources of
help in the developing countries (Alem, Jacobsso, Araya, Kebede, & Kullgreen, 1999,
Razali, Khan, & Hasanah, 1996). Kausar and Sarwar (1999) found that the majority of their
participants who lived in villages believed in possession by ghosts (27%), taveez (treatment
by magical or holy writings written on some paper) and magic (67%) as the main reasons of
mental disorders. Regretfully, this study cannot present a true representation of those
possessing such ideas with only 8.8 % rural population represented in the sample. In Kausar
and Sarwar (1999) some rural participants held misconceptions about the causation of
mental disorders, for example, visiting graveyard (30%), visiting gardens during night
(19%), being influenced by an evil eye (63%), eclipse (13%), and so on. These
misconceptions are cultural and not religious as Islam forbids people from holding such
beliefs. Since this study Pakistan has modernised now the old and contemporary means of
communication (TV, radio, newspaper, Internet) are available in many remote villages.
However, channels in the Urdu language do not normally show programmes pertaining to
mental health awareness, and the majority do not understand English channels. It is
therefore essential that the media present such programmes in local languages to create
general awareness of mental health problems. An increase in general literacy rate will, of
course, be an additional force to eradicate the mistaken beliefs.
The current survey participants considered the immediate social environment, day-to-day
problems, childhood environment and adverse life events, as more likely to cause both
depression and psychosis. As far as depression is concerned, these results are consistent with
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those shown in other studies about mental health literacy (Jorm et al., 1997) as well as with
general surveys on depression (Sims, 1993). In the former study, the causes most often rated
as likely for schizophrenia were all in the social environment like they were for depression,
but at the same time, genetic factors attracted more support as a cause of schizophrenia than
of depression. For depression, more than half of the Australian population believed that
being unemployed, divorced/separated and poor put people at greater risk, while for
schizophrenia, this was true of the unemployed, divorced/separated and young people.
Moreover, respondents who identified schizophrenia were less likely to support these social
environmental causes (Jorm et al., 1997). In contrast, identification of the disorder in the
current sample did not make much contribution, as those identifying as well as those not
identifying psychosis both considered genetic factors as less important contributors.
It is a matter of concern that a large number of people believed that being a morally weak
person could also be a cause of depression and psychosis; this was rated even more
frequently as a cause than genetic factors for psychosis. These views, also reported by over
half of the Australian population (Jorm et al., 1997), are similar to the ideas prevalent in so
called ‘‘dark ages’’ in the history of abnormal psychology. These public beliefs should be
specially targeted in the campaigns related to mental health literacy as the weakness of
character generally implies a negative evaluation of the sufferer as a person and such a causal
attribution may lead to shame and stigma in the sufferers. Similarly in Pakistan also, blame is
often placed on the sufferer who is generally considered responsible for the ‘‘odd’’
behaviour. It is often expected from the patient that they should be able to control their acts.
Cognitive symptoms of depression are not very much reinforced by society. This may be one
of the reasons why depression is somatized in South Asian countries (Rack, 1982). Often
symptoms of depression are interpreted as a way of avoiding duties, especially in the case of
married women.
The treatments suggested for depression and psychosis were not very different. However,
more people thought that GPs, psychologists and psychiatrists should be consulted for a
psychosis, while the religious healers were considered more suitable for treating depression.
Consistent with this, the majority of the public in Turkey saw psychiatrists as providing the
main solution for schizophrenia (Sagduyu et al., 2001). It seems that the symptoms of
psychosis appeared more serious to the respondents so they advised medical and
professional help more often. On the other hand, religious healers (unprofessional help)
were considered more suitable for less severe problems. Anyway, religious treatment is
expected for all kind of problems, mental or physical, in a Muslim country where people’s
strong conviction is in the sovereignty of God.
The treatment choice is also very closely linked with the perception of possible etiological
factors underlying different disorders. As many people in the current sample believed that
these symptoms are manifestations of some physical illness, for example, fever, cancer, etc.,
so their beliefs about the suitable treatment would obviously be affected by this.
Being a woman was seen as risk more for psychosis than for depression, a finding that
is not consistent with the available evidence. Studies from North America and Europe
report that men are more likely to be diagnosed as schizophrenic/psychotic (Iacono &
Beiser, 1992; Kendler & Walsh, 1995). Although the majority of these studies have
reported a ratio of 2:1 for men and women, a more recent study has reported a strikingly
high male to female ratio for schizophrenic disorders (6.3:1) in the island of Kosrae,
Micronesia, in the Western Pacific Ocean (Waldo, 1999). Similarly, the literature
showing the predominance of women in affective disorders is extensive (Weissman &
Klerman, 1977). Studies from South East Asia have also shown a higher prevalence of
depression in women (Kinzie et al., 1992; Mumford, Saeed, Ahmad, Latif, &
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Mubbashar, 1997). It is possible that respondents of the current work were influenced by
the gender of the schizophrenic vignette.
Regardless of correct or incorrect identification, beliefs regarding the prognosis of both
disorders were in reasonable accordance with the evidence. This finding is unexpected
considering the low mental health literacy of this sample on other issues. It seems more
appropriate to speculate that the beliefs of the survey participants pertaining to prognosis
might have been influenced by the description of both disorders, i.e., poor prognosis for
apparently severe symptoms (for psychosis) and better prognosis for less severe symptoms
(for depression).
Although rates for the recognition of depression and psychosis were not very high,
18% and 21% of the current sample recognized depression and psychosis as some form
of mental illness. Taken together, 37% and 26% of the population recognized the
presence of some form of mental illness for the depression and psychosis vignettes. As
compared to Pakistan, other countries have reported comparatively better understanding
of their populations regarding mental health problems For example, in Bahrain 20% of
the caregivers of schizophrenia in-patients believed that the patients were suffering from
specific mental disorders, while without naming the disorder in question the majority
believed that psychosocial stresses were of major etiological importance (Al-Faraj & Al-
Ansari, 2002). In Turkey, the majority of the public (76.5%) identified schizophrenia as
a mental disorder (Sagduyu et al., 2001). In an Australian survey also, most of the
participants recognized the presence of some sort of mental disorder: 72% for the
depression vignette (labelled as depression by 39%) and 84% for the vignette of
psychosis (labelled by 27%). Although the current rates of recognition of psychiatric
disorders are much lower than have been reported from other countries, the rates are still
promising as they are from a developing country, where considerably less budget is
allocated to mental health, and also where the literacy rate has started rising only
recently.
Discussing differences between developed and developing countries on mental health
beliefs, Mubbashar and Farooq (2001) pointed out that mental health literacy is a part of
general literacy. In some developing countries where more than half of the populations may
be illiterate, the dimensions of mental health literacy are very different from those in western
countries. This notion was evidenced in the current study as education was found to be a
significant predictor for identifying a mental disorder. It has been suggested that the mental
health professionals in developing countries will have to adopt innovative approaches to
mental health literacy, including approaches designed to create awareness at all levels of
health personnel, including primary health care physicians, as well as in schoolteachers and
teachers in the community and by collaborating with other sectors like traditional faith
healers (Saeed, Gater, Hussain, & Mubbashar, 2000).
Analysis on the level of social relationships, people could tolerate with mental patients,
showed that only 3% could consider marrying such a person, while only 5% would accept
the patient as their close friend, and so on. This stigma was expressed more for the person
showing symptoms of psychosis. It has been indicated elsewhere that the stigma attached to
schizophrenia such as rejection, humiliation, isolation, etc also do not encourage people to
seek help from a psychologist. The disabling nature of psychiatric stigma suggests the need
to run public education programs and awareness campaigns on an individual and national
level to challenge the negative stereotypes and discriminatory responses of the public.
Studies have shown great utility of such interventions (Pinfold et al., 2003). To improve this
understanding in Pakistan mental health awareness campaign should be initiated within
primary health care. Moreover, educating the traditional faith healers can assist
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tremendously in identification and referral of people with mental illnesses for proper
psychiatric treatment.
The findings of this study need to be interpreted cautiously because of the following
limitations. Firstly, lay knowledge about mental disorders were generated through people’s
responses to a vignette, however the way people respond to a vignette may not be the way
they respond personally to distress. Moreover, this technique of eliciting responses may not
be comfortable for some people, especially for less educated and rural residents. Secondly,
rural population which constitutes 70% of the total population (Akhtar, 2004) had a very
small share of the total sample (8.8%), which indicates that results generated from this work
may not be truly representative of the larger segment of general population. Future
government-funded large-scale surveys with improved methodology can be helpful in
establishing links suggested in the current study.
Conclusions
The findings of this study have important implications for government, health agencies,
mental health professional, NGOs and also for individuals. The results point toward the
potential target areas where the mental health beliefs of the general public need to be
improved. The findings of this work suggest that the health awareness campaigns in Pakistan
should especially target less educated and those living in rural areas. Moreover, future
educational programs regarding mental health literacy should especially focus on spreading
awareness about schizophrenic disorders. Short educational workshops on various levels for
diverse populations can produce positive changes in participants’ reported attitudes towards
people with mental health problems.
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