Perceptions of Pakistani community towards their mental health problems: a systematic review

1) denial of illness altogether,

2) description of mental health as medical or spiritual problems,

3) causation of mental illness due to unfulfilled needs mainly inadequate education and lack of opportunity for spiritual activities, and

4) psychological disturbances that emanate from lack of sharing, that is, rich don’t share with poor and with self-downing, that is, what can we do, it's all circumstantial.

1) psychological resilience/cultural protective Factors buffering against mental health problems (intra-communal bonding and sharing; Kalasha festivals and traditions; purity concept; behavioural practice of happiness and cognitive patterns),

2) perceived causes of mental health issues (biological & psychosocial; supernatural and spiritual; environmental), and

3) preferred interventions [Shamanic treatment; Ta’awiz (Amulets); communal sharing and problem solving; medical treatment; herbal methods].

1) Beliefs about depression and schizophrenia were seen to be ambiguous, contradictory, and subject to confirmation through personal experience rather than tested via falsification.

2) Religious affiliation intertwines with ethnic origin or results in some important differences in the beliefs prevalent in different ethnic and religious communities in Britain.

3) In terms of religion, Muslim participants in particular felt that religion did have an impact on their choice of strategies for dealing with depression.

4) Participants indicated a fear of community stigma associated with mental illness or even to the act of seeking help, that impacts the actual coping strategies and help-seeking behaviours.

5) In terms of help-seeking behaviours, a tendency for members of ethnic/religious communities to prefer consultations with professionals of the same ethnic background was noted.

6) Fear of being misunderstood due to ignorance of cultural and religious practices, intertwines in a complex fashion with a fear of being the target of racism.

1) Theological reasons for disability included gift from God, test from God, chosen parents, punishment, curse and so on.

2) There could be more than one reason for disability including biomedical reasons, individual responsibility or catching disability.

3) There is a relationship between theological and biomedical belief that results in the development of stigma.

1) The rules of izzat need to be abided by women.

2) Participants need to be negotiating tensions considering izzat, to enable them to self-manage or seek help. Even for those possible life experiences that might lead to self-harm and attempted suicide.

3) Participants need to be speaking out/breaking the ‘rules’ specially attached to izzat. The rules appear to vary over the life course and are influenced by migration.

1) Mental health is linked to each of the themes of izzat, shame, subordination and entrapment.

2) Various themes were linked to mental health; such as having to meet obligations, feeling a failure in roles, and lacking support.

3) Some participants felt that it would be better to commit suicide than to leave an abusive relationship, to protect izzat.

1) With regards causation of illness stress, family problems, lack of friends & financial worries were endorsed strongly by patients as cause of their mental illness.

2) Ambiguity regarding their mental illness duration and personal control was observed.

3) Patients’ perceived significant negative consequences, negative emotional response, as well as had poor understanding of their mental illness and treatment effectiveness.

1) It was noticed that males had significantly higher scores on timeline and emotional representation, suggesting strongly held beliefs about chronicity of their illness and anger and worry about their condition.

2) Adolescents’ own emotional state, stress, family problems and bad luck were endorsed by participants as some of the causal factors in their mental illness.

1) Individual's use of integrated mental health and other care was modest. Principal (self-rated) supply-side factors were the cost of care, distance from treatment centre, a perception that care would not be effective and concerns regarding stigma.

2) Perceptions improved over three months, accompanied by an increased preference for public over private providers. but this was not restricted to the integrated care localities.

3) The use (and therefore, effectiveness) of mental health services integrated into primary care is influenced by the health-seeking behaviours and perceptions of the local population.

a) describe the types of mental health care providers in rural Punjab, Pakistan,

b) appreciate patients’ perception of the different types of treatments used, and

c) find out about their effectiveness.

1) General practitioner (GP)

2) Religious Healer (Maulvi, Peer, Fakir)

3) Hakim (A form of Unani/Greek medicine)

4) Homeopathic Doctors

5) Faith healers (Amil, Sinyasi)

1) The authors discovered that patients had very little knowledge of mental illnesses in general, and depression in particular.

2) They believed that mental health problems were the result of stress or trauma, and that only medicines could help them.

3) Patients had no knowledge of the roles of psychologists or psychotherapy.

4) Their model of understanding mental illnesses appeared to represent a psychosocial understanding, with physical symptoms being their main concern.

1) The researchers found that the classification used by faith healers is based on the mystic cause of disorders: saya (27%), jinn possession (16%) or churail (14%).

2) Sixty one percent of attenders were given a research diagnosis of mental disorder: major depressive episode (24%), generalized anxiety disorder (15%) or epilepsy (9%).

3) There was little agreement between the faith healers’ classification and DSM-IIIR diagnosis.

4) Faith healers use powerful techniques of suggestion and cultural psychotherapeutic procedures.

1) The most significant finding on the Perceived Public Stigma Scale related to carers believing that people view receiving mental health treatment as a sign of personal failure.

2) Carers believed that people in the community would treat someone who has received mental health treatment just as they would treat anyone. Someone who has received mental health treatment is just as trustworthy as the average person. People would accept someone who has fully recovered from a mental illness as a teacher of young children in a public school.

3) In relation to patients, no socio-demographic factor including age, gender, or marital status or level of religious affiliation had a significant effect on the intensity of conventional beliefs towards mental health services (prior to or after attending). Similarly, with carers, no socio-demographic factors impacted on the intensity of conventional beliefs or attitudes towards their relative attending the mental health service

4) The majority (86%) of patients having significant symptoms of major mental illness had visited traditional healers prior to engagement with the mental health services.

1) Positive attitudes toward seeking professional help for psychological distress were similar for British Asians, Westerners and Pakistanis.

2) There were significant differences between the three groups in the causal attributions of mental distress. Culture, as a variable, was not a significant predictor of a positive attitude to seeking professional help.

3) Causal beliefs of mental distress were significant predictors of attitudes to seeking help for the British Asian and the Pakistani groups.

4) Beliefs were not significant predictors for seeking help for the Western group.

5) Culturally determined causal beliefs of mental distress contribute to attitudes towards seeking professional help for psychological problems for Asians.

1) Depression was four times more likely to be diagnosed than psychosis.

2) The type of disorder, education status and area of residence contributed significantly to one's ability to diagnose. More people believed that GPs, psychologists, and psychiatrists were the right people to consult for these problems.

3) Some participants considered Hakims and Homeopaths, Magical and Religious Healers as the appropriate people to contact.

4) Those recognizing mental disorders were more likely to identify the underlying causes, prognosis and appropriate treatment of the problems.

1) There were differences in the models of mental illness being employed with greater somatisation of symptoms in the Pakistani group and an emphasis on aggressive behaviour as a significant symptom.

2) Treatment expectations also varied with some emphasis on traditional Pakistani treatments such as Faith healers and Hakims as well as General Practitioners and hospital treatments.

3) Language difficulties, religious and cultural practices were also identified as barriers to female treatment in particular.

1) Various frontline healthcare providers included medically qualified practitioners, Homeopathic doctors and Hakims (Greek medicine, traditional herbal medicine), who had prescribed mainly physical treatments such as tablets, syrups, powders and pastes;

2) Religious and faith healers relied mainly on psychotherapeutic methods such as prayers or giving amulets. In a small minority of cases, physical beating was used as part of the treatment process.

3) The effectiveness of these treatments, as rated by the patients and their families, was variable, with highest reported effectiveness for general practitioner treatments.

1) It was noted that the majority claimed to be aware of psychotherapy as a treatment option for psychiatric disorders but 47.5% of these failed to identify its correct definition.

2) Concerns voiced by the participants about psychotherapy included stigma and breech in confidentiality; 60.7% opined it cost effective and 86.5% favoured its use as an adjuvant modality.

3) A preference for psychotherapy as the treatment strategy for psychiatric disorders was demonstrated by 46.6%. Younger, more educated, financially independent and female participants were more likely to prefer psychotherapy as were those who deemed it cost effective.

4) Positive attitudes regarding the acceptability, clinical utility and cost-effectiveness of psychotherapy were observed in a sample representative of general public of Karachi, Pakistan.

1) Majority of participants were graduates and employed. Only 30% of the participants attributed ‘mental illness’ as the main cause of psychotic symptoms while a large number thought of ‘God's will’ (32.3%), ‘superstitious ideas’ (33.1%), ‘loneliness’ (24.8%) and ‘unemployment’ (19.3%) as the main cause.

2) Mental illness as the single most important cause was reported by only 22%.

3) With regards to management, only 40% reported psychiatric consultation to be the single most important management step.

4) Other responses regarding management included spiritual healing (19.5%) and Social changes (10.6), while 14.8% of respondents said that they would do nothing.

5) Gender, age, family system and education level were significantly associated with the beliefs about the cause of schizophrenia.

6) These variables plus ‘religious inclination’ and ‘beliefs about cause’ were significantly associated with the help seeking behaviour of the participants.

7) Despite majority of the study population being well educated, only a few recognized Schizophrenia as a mental illness and many held superstitious beliefs.