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Karachi Mental Health Report (KMHR)A collaborative project of Dept. of Psychiatry, Aga Khan University and Aman Foundation, KarachiAcknowledgementsWe are grateful to Aman Foundation for the generous grant that made this report possible. In particular we are grateful to Mr. Ahsan Jamil, CEO and Ms. Erum Ghaznavi, Grants Head, Aman Foundation for their help and support throughout the project.Our team of research officers including Dr. Bilawal Ahmed and Dr. Rakshinda Mujeeb worked diligently to gather the required information. In a city as large and as complex as Karachi, and with frequent breakdown of law and order, this was by no means an easy task. Mr. Mohammad Zaman, Research Officer, managed different databases and co-ordinated the post-data gathering part of the project. Drs. Faheem Khan and Mukesh Bhimani, faculty in the Department of Psychiatry provided valuable inputs at different stages of the project. We would like to thank all mental health professionals in Karachi who provided the required information for the report. We hope the Karachi Mental Health Report (KMHR) would be of use not only to the mental health community but also to other stakeholders such as public health professionals, government officials, policy makers, non- government organisations, patients and their families.We also hope that the report can contribute towards formulating a comprehensive mental health strategy for Karachi. Dr. Nargis Asad, PhDDepartment of Psychiatry Dr. Murad M Khan, MRCPsych, PhDAga Khan University, Karachi Dr. Riffat Zaman, PhDOct 2012 CONTENTSAcknowledgements 2Introduction41.Objectives of the report52. Karachi: a brief background63. Methods94. Literature review105. Mental health facilities 226. Recommendations37 References39INTRODUCTIONThe magnitude of the mental health problems of Karachi, Pakistan’s largest city is neither known nor how they are addressed. For example we do not know the number and type of mental health facilities or professionals in the city. Health facilities in Karachi are very variable and consist of a mixture of public-funded government hospitals, private health facilities and those run by charitable and non-governmental organisations (NGOs). Similarly, mental health facilities consist of psychiatric services in government hospitals, psychiatric wards in private hospitals, some private psychiatric hospitals and those run by charitable/welfare organisations. In view of this a need was felt to review the current status of mental health and mental health facilities in Karachi. This report is a result of this endeavor. The purpose of this report is to review the available evidence on mental health and map the existing mental health facilities in Karachi. This survey will serve as a background document to design a large scale epidemiological survey of prevalence of various mental disorders, using a representative sample of all 18 towns of Karachi. We have tried to include as many mental health facilities and professionals in Karachi as we could get the information on. Despite our best efforts it is possible some facilities and professionals have been left out. This is inevitable given the size and spread of a city like Karachi and the lack of an organised health system. If indeed some institutions and/or professionals have been left out, this is inadvertent rather than deliberate. It is hoped that both this survey and the planned larger prevalence survey would contribute towards formulating a comprehensive mental health strategy for Karachi.1. Objectives of the report The specific objectives of the report were as follows:To review and synthesize available literature on epidemiology and burden of mental disorders in Karachi.? To review current resources for assessment and treatment of mental illnesses in Karachi (including geographical location, number of mental health specialists, type of services offered and their costs).To identify gaps in evidence-base and services for mental health problems in KarachiTo give recommendations for addressing mental health issues in Karachi2 KARACHI: a brief backgroundKarachi is Pakistan’s largest city and country’s main commercial and business centre. It is the capital of Sindh province and is located in the southern most part of country on the coast of the Arabian Sea. The ever growing population is a constant drain on its limited resources and a source of stress for its population. This is complicated by frequent ethnic and political violence that disrupts the normal life of its citizens. 2.1Population (Table 1)Over the last 150 years or so and particularly since the time of independence in 1947, the city has undergone major changes in its demography and population. In 1947 the population of Karachi was about 0.45 million. This grew almost overnight as there was a large influx of refugees due to the partition of British India. Over the next four years the city’s population had crossed one million mark and over the next decade the rate of growth was over 80%. Although Islamabad is the capital city, Karachi’s population continues to grow at about 4%-5% annually due to the fact it is the country’s main business and commercial centre. According to last official census in 1998, the population of Karachi was approximately 9.5 million (Population Census Organization, 1998). All figures since then are estimates based on population growth rates.MigrationKarachi has experienced two types of migration: the first one was at the time of partition in 1947 when large numbers of refugees (Mohajirs or immigrants) came across from neighboring India, most of whom settled down in Karachi. They were mostly Urdu speaking and came from different parts of India. The second group comprises of people who move to Karachi from other parts of the country in search of jobs. This makes the population of Karachi quite diverse, with a rich mix of languages, culture, cuisine and customs. On the whole the various ethnic groups live in peaceful co-existence though ethnic conflicts do occur from time to time.2.3Ethnic groupsThe population of Karachi is a mix of various ethnic groups of Pakistan, as people from all over the country come to the city in search of employment. Over the last three decades, since the Soviet invasion of Afghanistan in 1979 and the continued conflict in their country, there has been a steady influx of Afghan refugees who have settled in and around Karachi. They now number more than a million and consist of various ethnic groups, such as Pashtuns, Tajiks, Hazaras, Uzbeks and Turkmen. In addition there are smaller groups of other nationalities as well in Karachi such as the Bengalis (from Bangladesh), Burmese (formerly Burma, now Myanmar), Iranians, Arabs and Africans. Table 1: Town-wise Population in Karachi, Pakistan.Name of TownUC1998 2010 (est.)*1.Baldia Town 8 406,165 ?614,974**2. Bin Qasim Town 7 315,684 514,550 3.Gadap Town 8 289,564 470,767 4.Gulberg Town 8 453,490 618,800 5.Gulshan-e-Iqbal Town 13 1,200,000 ? 1,816,920**6.Jamshed Town 13 733,821 ?1,111,078**7.Keamari Town 8 383,788 640,119 8.Korangi Town 9 550,000 755,909 9.Landhi Town 12 666,748 978,857 10.Liaquatabad Town 11 649,091 879,977 11.Lyari Town 11 607,992 735,780 12.Malir Town 7 398,289 618,627 13. New Karachi Town 13 240,000 ?363,384**14. North Nazimabad Town 10 500,000 652,532 15.Orangi Town 13 723,694 1,126,641 16.Saddar Town 11 616,151 1,099,169 17. Shah Faisal Town 7 335,823 563,439 18. SITE Town 9 467,560 759,552 TOTAL1789,537,86013,767575*Population calculated for Extended Program of Immunization (EPI), Govt. of Pakistan**Estimated population increase of 51.41% based on average of other 14 townsUC= Union councils2.4Religions The majority of the population in Karachi is Muslim. Other important minority religious groups in Karachi include Christians, Hindus, Zoroastrians and a small group of Jews.2.5EconomyKarachi is the financial and commercial capital of Pakistan, accounting for about two-thirds of the total national revenue generation (federal and provincial taxes, customs and surcharges). Karachi produces about 42 percent of value added income in large scale manufacturing and contributes approximately 25% to the GDP of the country. 2.6AdministrationIn 1996 Karachi was divided into five districts, each with a municipal corporation. In 2001, five districts of Karachi were merged to form the city district of Karachi. It was structured as a three-tier federation, with the two lower tiers composed of 18 towns and 178 union councils. Each tier focussed on elected councils with some common members to provide "vertical linkage" within the federation. The city was governed by the City District Government (CDG), headed by the city Nazim (Mayor). The CDG had an elected council that oversaw the working of the CDG. In 2011, City District Government of Karachi was de-merged into its five original constituent districts namely?Karachi East, Karachi West, Karachi Central, Karachi South and District Malir. These five districts form the Karachi Division now and is headed by a City administrator and a Municipal Commissioner. There are also six military?cantonments which are administered by the Pakistan Army.2.7Health BudgetAccording to the 18th Constitutional Amendment Bill of 2010-11 and the Devolution Plan the Federal Ministry of Health has ceased to exist and powers have been delegated to provinces for regulation of health services as well as budget allocations. This means health is now the responsibility of the provinces.In the year of 2010-11, the budgetary outlay for health worked out to 0.55 per cent of the national GDP. The 2011-12 budget envisages an even lower ratio at 0.45 per cent of GDP. Mental health does not have a separate budget but it is believed it is 1% of the health budget. This is complicated by poor governance, mismanagement and massive corruption of the meager resources. It needs to be seen how mental health is addressed by the provinces in the new Devolution Plan.3METHODS3.1Evidence-baseA literature search was carried out, using key words, of various bibliographic databases including National Library of Medicine’s Medline (PUBMED), PsycINFO, Applied Social Sciences Index and Abstracts (ASSIA), Cumulative Index to Nursing and Allied Health (CINAHL), Cochrane Trials Register (CRG), ExcerptaMedica (EMBASE), National Library of Medicine Gateway (NLMG), Science Citation Index (SCI), Social Science Citation Index (SSCI). We also retrieved articles addressing the search questions from the references of the retrieved studies. , a Pakistani medical website, was also searched for relevant literature. We also searched the Internet for any relevant articles/information. Local psychiatric and mental health journals, newspaper articles or reports and unpublished data were hand searched. Our search criteria included any original study, case series or reports which focused on any aspect of mental health conducted in Karachi and which were retrospective, prospective, case series or descriptive in design. We were particularly interested in studies that gave prevalence of mental disorders in KarachiMental Health FacilitiesMental health facilities of Karachi were surveyed using a specially designed form to document the information. Facilities in both private and public sectors were mapped. Information was initially obtained through the facilities’ websites (when available), followed by telephone contact and visits to the various facilities. Information on the number and level of qualifications of mental health professionals (psychiatrists, psychologists, counselors, social workers, nurses, occupational therapists) and different modalities of treatment (with their costs) was also documented. Limitations and difficultiesThe process of gathering information on mental health facilities involved many challenges. The general law and order situation of the city meant that the research officers were unable to visit some facilities to gather information. In such cases we had to rely on information gathered over the telephone and through other sources. A number of health professionals and administrators were reluctant to provide information on their facilities and/or their consultation charges and other costs. This was despite the fact that they were reassured that the information we were trying to obtain was for a survey and would be anonymised. LITERATURE REVIEWWe retrieved more than 80 articles that related to some aspect of mental health in Karachi. Our main emphasis was on epidemiological studies (particularly prevalence studies) of mental disorders in Karachi. All studies referred to in the report are included in the list of references.The retrieved studies were grouped in the following broad areas: common mental disorders (CMDs), women mental health, suicidal behavior, domestic violence, child &adolescent mental health. An ‘Others’ category lists those studies that could not be categorized in the above categories but were too few to be grouped under a separate category. . The following section enumerates the studies and their main findingsCommon Mental Disorders (CMDs) Common mental disorders (CMDs) include states of mild to moderate depression and anxiety. Prevalence rates for CMDs in Pakistan are one of the highest in the developing world. A systematic review of the literature from Pakistan (20 studies, of which 17 gave prevalence estimates and 11 discussed risk factors) found that the mean overall prevalence of anxiety and depressive disorders in the community population in Pakistan was 34% (range 29-66% for women and 10-33% for men)1. Rates of depression among Pakistani women have been reported as high as 66%2.Factors positively associated with anxiety and depressive disorders were found to be, female sex, middle age, low level of education, financial difficulty, being a housewife, and relationship problems. Arguments with husbands and relational problems with in-laws were positively associated with depression and anxiety in 3 out of the 11 studies1. There have been a number of studies on prevalence of CMDs in Karachi. Ali et al conducted a prevalence study of CMDs in an urban squatter settlement of Karachi (Azam Basti) on 487 adults and showed an overall prevalence of 30.4%3.An earlier cross-sectional observational systematic study on ambulatory patients at a tertiary care hospital, showed a prevalence of 38.4% for depression and anxiety. Two variables, i.e., female sex and being a housewife were significantly related with the outcome4. A cross-sectional study on status of depression amongst 300 residents, randomly selected from Karachi between May to December 2007 showed that around 22% of the population of Karachi are depressed at any time; 58% of individuals reported depression ‘often’ in their lifetime. Approximately 33.7% of individuals experienced short-lived episodes of depression, and 37.3% experienced moderate episodes of depression, while 29% had prolonged depression5.A facility based study on 1069 patients presenting to a general medical out-patients clinic at a public sector hospital in Karachi showed that 16% of men and 58% of women had ‘medically unexplained symptoms’ (MUS), of which 80% had probable depressive disorder2. There was an average delay of 4.5 years from the onset of symptoms of depression to seeking consultation from a psychiatrist in KarachiImam et al. (2007) studied 225 medical in-patients admitted to a private hospital in Karachi and reported that 30.5% had probably depression (females 36%; males 24%), with majority being housewives6. Female gender also outnumbered males in another small scale cross-sectional study on use of psychoactive drugs presenting to a private university teaching hospital7.Khan et al (2007) carried out a cross-sectional study for anxiety amongst 423 subjects (out-patients and their attendants) at a tertiary care hospital in Karachi. 28.3% of the study subjects were found to have ‘borderline or pathological anxiety’. Female gender and physical illness were positively related with anxiety8. Sadruddin (2007) studied factors that led to treatment delays for depression in Karachi. There was mean delay of 4.50 years from the onset of first episode of depression to the first contact with a psychiatrist. In the full model, age and education predicted delay. Older people and those with higher education made contact with a psychiatrist later than young people and those with lower education9. The results indicate that more effort is needed to increase prompt initial contact among people with incident episodes of depression and to make treatment for mental health problems accessible and affordable in Karachi and Pakistan.Ali et al (2003) conducted a randomized controlled trial in which minimally trained ‘lay counselors’ (trained in counseling techniques over 11 sessions) were used to counsel anxious and depressed women over 8 weekly sessions from the same community. They found a significant improvement in anxiety and depression in the treatment group compared to the control group. This study is one of the very few intervention studies for anxiety and depression in Karachi and Pakistan10.SummaryStudies on common mental disorders (CMDs) in Karachi (both community based as well as health facility based) show between a third to 40% of the population of Karachi suffer from CMDs. There was a significant delay from the time the first symptoms appear to the time of first contact with a psychiatrist. There were many reasons for this delay but the absence of accessible and affordable mental health care was amongst the more important ones. The absence of any study using a representative sample of the population of Karachi was a major problem and limits the generalisability of results of these studies. Women Mental HealthRates of depressive illness in women of reproductive age are believed to be at least twice those observed in men3, 11. A number of studies conducted in Karachi indicate that there is an increase in psychiatric morbidity, particularly depression, during pregnancy for a proportion of women. Kazi et al (2006) conducted a study on pregnant women in a low income area of Karachi, using both a quantitative as well as a qualitative approach. Prevalence rates for depression were reported as 30.4%. There was significant association with increased age, lower education levels, relationship with husband and in-laws, heavy household work and pregnancy difficulties12. Evidence from a peri-urban community of Karachi indicate prevalence of postpartum anxiety and depression as 28.8 % with domestic violence, difficulty in breast feeding at birth and unplanned current pregnancy as factors that were significantly associated with postpartum anxiety and depression13.A facility based study from Karachi on 132 pregnant women of which 125 pregnant women had both questionnaire and cortisol level data and an additional seven had questionnaire data only. Almost 20% of pregnant women (19·7%) experienced a high level of stress and nearly twice as many (40·9%) experienced depressive symptoms14. Most recently, preliminary findings from a 3-arm intervention study currently under way on women from inner city slum areas of Karachi showed increased self-efficacy (p<0.5) as a result of training in Economic Skill Building (ESB), through a specially developed manual. Study findings also suggested lower rates of depression and domestic violence in this group 15.SummaryRates of common mental disorders in Karachi show high prevalence in women compared to men, with married women outnumbering single women. Domestic violence and depression also appear to increase significantly during pregnancy in women in Karachi. This finding is of particular concern. Domestic Violence ( DV) Domestic violence is the most common form of violence inflicted on women globally and due to its magnitude, is recognized as a substantial public health problem18. In Pakistan the situation is compounded by the already high rates of mental illnesses in women, making them more vulnerable. There have been a few studies on DV from Pakistan. Although these studies are mostly facility-based on relatively small samples, they do indicate high rates of domestic violence.A study from Karachi on 150 women randomly selected from outpatient clinics found that 34% of the study sample had experienced physical abuse at least once in their lifetime. 15% reported being physically abused whilst pregnant. Physical abuse was also a major predictor of anxiety and depression in 72% of this group of women19.A hospital based cross-sectional study on 117 women attending a psychiatry facility of a tertiary care hospital in Karachi showed69.5%of the women had experienced verbal or physical violence. 62% of women reported to be depressed as a result of DV20.Domestic violence amongst married health care professionals in Karachi showed a life time prevalence of 97.7%21.A study on workplace violence against nurses showed that physical, verbal, sexual violence and bullying/mobbing behavior was experienced by 16.4%, 77.1%, 10% and 33.8% of the nurses’ respectively22.A few studies have been carried out on DV on women in the community. A study from semi-urban community on out-skirts of Karachi on 759 women found that figures for physical, sexual and psychological abuse as 57.6%, 54.5% and 83.6% respectively, with high psychiatric morbidity as a result of the DV in the study sample23.A government hospital based study in Karachi showed a lifetime prevalence of domestic violence as 61.8%; physical abuse was reported by 64%, sexual violence by 14.5% and emotional violence by 26.1% of the women studied. Factors found to be significantly associated with violence were substance abuse (tobacco, alcohol and habituating drugs) by husband, poor socioeconomic support, chronic illnesses, low level of education and younger age of women. The husband or the mother-in-law was the perpetrator in more than 94% cases24. A study looking at attitude of Pakistani men about domestic violence from Karachi showed lifetime prevalence of marital physical abuse to be 49.4%; slapping, hitting or punching were the most often reported means of violence by 47.7% of men interviewed. These men belonged to various strata and ethnicities. Data was collected at a vegetable market (largely a lower income group), the consulting clinics of a private hospital (largely a middle-income group) and the executive clinics of a private hospital (largely a high-income group) 25.In the same study, almost half of the men surveyed (46%) thought that husbands had a right to hit their wives, while 88.6% believed the general public tolerated the abuse. However 74.4% also believed that domestic violence is a common problem in society and 65.3% felt that there was a need to create awareness about DV25.Summary Available evidence from studies on domestic violence from Karachi suggest high prevalence of DV, with figures varying from 33% to 97%, depending on the study sample and the setting (community or health-facility based). Also, most of the studies report life time prevalence rather than for past year or past six months. Despite the limitations these studies present DV as a serious public health issue in Karachi. Suicidal behaviourSuicidal behavior (suicidal ideation, suicide attempts and completed suicide) is another serious public health problem that has been growing in Pakistan over the last couple of decades. Both DSH and suicide are considered criminal acts, liable for prosecution with a jail term and financial penalty. There is also strong religious and social stigma against suicidal behavior in Pakistan. Due to these factors, the true extent of the problem is not known. However, there have been a number of studies on suicidal behavior that indicate this is a growing problem in Karachi. These reports are based on various sources of information and they are reviewed in this section.There have been several studies of patients who have been admitted to various hospitals in Karachi following a suicide attempt (also called deliberate self-harm or DSH) 26-31. These studies show that more females than males attempt DSH acts and that there are more young married women than single women. Benzodiazepine medications (tranquillisers and sleeping pills) are one of the most commonly used methods in DSH cases in Karachi, followed by ingestion of ‘poisons’ (mostly organophosphorous insecticides). These are commonly present in most households in Karachi and are easily accessible. They are very dangerous when ingested due to their anti-cholinesterase effects and can lead to high fatality32-36.A report based on forensic autopsies conducted on 51 cases of suicide in Karachi showed a male to female ratio of 6.1:1, with hanging (69%), drowning (12%) and cutting of throat (7%) to be the most common methods37. Three other studies of suicides were based on Karachi police records26, 38, 27.These studies show that the most common methods of suicide in Karachi are self-poisoning, hanging, use of firearms and drowning. While the use of poisons and hanging has remained the same over the last three to four decades, firearms are being used more frequently now, perhaps reflecting their increased availability in the society in general. A recently conducted case-control study of risk factors for suicides using the psychological autopsy method in Karachi showed that out of the 100 cases studied, 79 were suffering from clinical depression and that people who were depressed were 77 times more likely to commit suicide than those who were not depressed. Other risk factors identified included being single and male, low education, being unemployed, having a disrupted social network and experiencing two or more recent life-events. Only three victims were in contact with a health professional at the time of suicide and none with a mental health professional39.As far as numbers of suicides in Karachi is concerned, it is difficult to give precise figures. Ahmed & Ahmed (2003) reviewed Karachi Police data over seven years (1995- 2001). During this period there were 1389 suicides in Karachi (with a high of 310 suicides in 1999 and a low of 144 suicides in 2001) with an average of 198 per year. However given the social and religious stigma attached to suicides coupled with poor registration/recording and diagnostic systems for suicides this is probably an underestimate. The real figure is probably closer to 350-400 suicides annually and annual rates of approximately 2/100,000in Karachi 38. It is also estimated that for every suicide there are 10-20 DSH attempts. By this measure there may be between 3500 to 8000 DSH attempts in Karachi every year. Due to the legal, religious and social sanctions against suicidal behavior, many cases of medically non-serious cases are taken to private clinics and hospitals that neither diagnose such cases as suicidal nor report them to the police. Also, psychological assessment of these patients is not carried out, with the result that the stressor/conflict that precipitated the act in the first place remains unaddressed. SummaryFrom the available evidence it appears that both DSH and suicide happen regularly in Karachi and their numbers may be increasing. While more females attempt suicide, more males commit suicide in Karachi. Amongst females there are more young married than single females in both DSH and completed suicide. Most victims of suicidal behavior are under the age of 30 years. The most common methods in DSH are tranquillisers, sleeping pills and insecticides while in completed suicide they are hanging, ingestion of insecticides and use of firearms. The most common psychiatric disorder in completed suicides is depression and majority of people who commit suicide in Karachi are not in contact with either health or mental health services. Child and Adolescent Mental Health (CAMH)Pakistan has a relatively young population with approximately 50% of population under the age of 25 years. Despite this, mental health problems in this age group have not been well studied. There have been 17 published articles on CAMH in Karachi and they can broadly be classified into studies on prevalence of Attention Deficit Hyperactivity Disorders (ADHD), Mental Retardation (MR) and Behavioral and Emotional Problems. These studies were published between 1998 and 2011, with the bulk of them in the last 6 years.Almost all the studies used a descriptive, cross sectional method, a relatively inexpensive and convenient method. Participants included teachers and parents of children from public, private and community schools and foster mothers of orphanages.In the majority of studies, besides demographic information, participants were required to complete the Strengths and Difficulties Questionnaire (SDQ) which is the most widely used questionnaire to assess children’s mental health. The SDQ is a brief, behavioral screening questionnaire which yields scores on conduct problems, inattention, hyperactivity, emotional symptoms, peer problems and pro-social behavior. Data collected from hospital outpatient clinics was based on psychiatrist’s assessment at the time of the child’s visit. Attention Deficit Hyperactivity Disorder (ADHD)Four studies conducted in the outpatient clinics of a private40-43 and a public hospital44 found high prevalence rate of ADHD, ranging from 25% to about 50%. In a community study of school going children based on parent’s rating the prevalence rate of ADHD was 18.8%45. This is in contrast to prevalence rates of some other developing countries such as India46, Bangladesh47 and Al Ain, UAE48where community prevalence rates are reported as 1.6 %, 2.0% and 0.2 to 1.2% respectively. In a worldwide pooled prevalence of ADHD, authors report a prevalence of 5.29 % with significant variability49. It is postulated that in the case of Karachi, the variability may be due to the assessment methods as well as the setting. A common finding in all Karachi studies was the high male/female ratio and the wide range of psychiatric co-morbidities associated with ADHD. Syed et al (2010) carried out a pilot study on the development and evaluation of a 10-hour training program for teachers in 3 schools of Karachi. They found a significant increase in the teachers’ knowledge of ADHD symptomatology50. This finding has important implications for future studies in raising awareness of this disorder.Mental RetardationAn epidemiologic study on severe mental retardation in developing countries showed a prevalence rate of 15.1/1,000 children in Pakistan, 16.2/1,000 children in Bangladesh and 40.3/1,000 children in India 51.There have been two studies on mental retardation in Karachi. Durkin et al (1998) studied a sample of 6,365 children using a screening scale for disabilities followed by a structured medical and psychological assessment of those screened positively. Estimates for severe mental retardation was 19.0/1,000 children and for mild/moderate retardation as 65.3/100052.Khan et al (2009) conducted a study on a sample of 570 children in a tertiary care hospital in Karachi. Mental retardation with behavioral problems was the most frequent diagnosis in 36.14% children42.Estimates of severe mental retardation in Karachi is considerably higher compared to those in developed countries (approx. 3.5/1,000 children). Among the factors identified as potential antecedents to mental retardation in Karachi were lack of mothers’ education, poor prenatal care, medically unattended birth, neonatal infection and malnutrition of the child. Many of these risk factors are commonly associated with poverty51.Behavioural and Emotional ProblemsThere have been two studies on behavioral and emotional problems in children in Karachi. Both were carried out in tertiary care hospitals and used a structured interview based on DSM-IV. In one study 26.3% and 15.7% of children showed disruptive behavior and behavioral problems respectively, with the majority being males42. In the second study, 15.9% children were reported to be depressed, 9.3% were found to be suffering from an anxiety disorder, while ADHD was found to be the most frequent diagnosis40.Two studies in which parents and/or teachers rated the children showed that in one, 34.4% and 35.8% of children were rated ‘abnormal’ in private and government primary schools respectively with boys being in majority in the sub-category of conduct disorders53. In the other study, that compared emotional problems in children at private and community schools, 34% children were rated as “abnormal” by parents. Community schools had a higher percentage of “abnormal” rating than private schools and majority being boys. In a study on working children (mostly males) in three urban squatter settlements in Karachi, the overall prevalence of behavior problems was estimated to be 9.8%,with peer problems (16.9%) and conduct problems (16.7%) being the most common54.An epidemiologic study was carried out in two orphanages in Karachi. Multiple independent variables were explored, such as children’s malnutrition, wasting and the foster mothers’ mental health. Based on the foster mothers’ ratings, the overall prevalence of behavioral problems in both settings was approximately 33% with 50% on sub-scale of conduct problems and 84% on peer problems. Foster mothers’ depression and child’s malnutrition was associated with conduct problems55. This association has been found in many other studies as well.SummaryThe overall prevalence of child and adolescent mental health problems in Karachi fall in the range of those reported in other developing countries but much higher than those in developed countries. Prevalence of some child mental health disorders such as ADHD are much higher compared to other countries of the region. Similarly, mental retardation has high prevalence in Pakistan. Up to a third of school going children in Karachi may have undiagnosed emotional and behavioral problems. While some of the high figures could be explained by the study design and sample selection, there does appear to be high prevalence of child and adolescent mental health problems in Karachi. These findings have important implications for preventing, identifying and addressing CAMH problems in Karachi. OthersMental Health of the ElderlyThere are only a handful of studies on the mental health of the elderly in Karachi. Two studies surveyed people (both patients and attendants) 65 years and older, visiting a tertiary care health facility and showed prevalence of depression as 22.9% (females=27.9%; males=20.7%)56and 19.8% respectively57.Factors associated with depression in the elderly included higher number of daily medications, total number of health problems, financial problems, urinary incontinence and ‘inadequately fulfilled spiritual needs’56. Living in a nuclear family (as opposed to joint family) was also seen as a risk factor for depression in one of the studies57.4.6.2 SchizophreniaA study on duration of untreated psychosis (DUP) of 93 patients suffering from schizophrenia at a tertiary care hospital in Karachi showed that the average interval from the onset of symptoms to making contact with a mental health professional was 14.8 months58. Lack of awareness of psychiatric disorders and inaccessible and unaffordable mental health services led to unnecessary delays with consequent inadequate treatmentBenzodiazepine use Iqbal et al (2011) conducted a cross-section household survey (749 adult subjects) of two residential districts of Karachi and found prevalence of benzodiazepine usage as 14%. Only 3% were using the medicine on the advice of a psychiatrist (3%), while majority had been using these on advise of general practitioners (40%) or self-medicating (24%). 22% were using it for depression, 21% for insomnia and 8% for anxiety 59.In another observational study on 475 healthy adult visitors to a tertiary care hospital in Karachi, 30.4% had used a benzodiazepine at some point in their lives and 42.2% had been using it for more than a year60. Commonest reason for use was sleep disturbance. Frequency of usage was higher for females, married individuals, educated (>grade12), high socioeconomic status and housewives. 59% of the sample had been prescribed the medicine by a doctor, 58.5% of whom were general practitioners. Only 36.5% of those surveyed were specifically informed about the long-term addiction potential of plicated Grief (CG)Although there are no studies on the effect of exposure to violence or post-traumatic stress disorder (PTSD) like conditions in Karachi, Prigerson et al (2002) studied complicated grief (a syndrome comprised of symptoms of separation distress e.g., yearning, searching, loneliness) and traumatic distress (e.g., numbness, disbelief, anger, mistrust, insecurity) amongst 151 (53% females) out-patient psychiatric patients in Karachi. All had survived the death of a close relative or friend in the past year. In 48% cases, the cause of death were ‘acts of violence’ (armed robbery, ‘police encounter’, shooting, beating etc.) reflecting the high rates of violent death in this sample and the consequent effects of this on survivors61.GAPS IN AVAILABLE EVIDENCE Although there is evidence on common mental disorders, reproductive mental health (including domestic violence), suicidal behavior and child mental health problems in Karachi, there are also significant gaps in knowledge base regarding other important mental disorders such as schizophrenia, bipolar disorders and dementia which have significant financial and psycho-social consequences. There is very little information on the number of people in Karachi abusing illicit drugs such as heroin and marijuana or alcohol. Anecdotal evidence suggests the problem may be much more widespread than generally believed. From a developmental perspective there is dearth of information on elderly as well as adolescent mental health. There is need for more robust data on psychiatric disorders in children and adolescents. In the midst of present day crisis with deteriorating law & order situation, crisis intervention assumes a central role in mental health. However, there is no empirical data on post-traumatic stress disorder (PTSD) despite the fact that large numbers of general public are exposed to violence on streets of Karachi every day. The enormous burden of psychiatric disorders remains unidentified and unaddressed across all sections of the population of Karachi. In view of the diverse population and complex socio-economic composition of Karachi, there is need to obtain representative data on psychiatric morbidity to inform policy and devise appropriate interventions. Epidemiological studies should ideally be supplemented by qualitative data in order to develop in-depth understanding of mental health phenomenon across the cosmopolitan. For example since violence has been shown to be a repeated experience of many women, using validated instruments to record their recent experiences is important. Most instruments adapted from the West need significant modifications for face and content validity. Similarly, many studies have used either convenience sampling, are health-care facility based or surveyed people in squatter settlements or those on the outskirts of the city. There is need for surveys that are representative of the city as a whole, and that include urban, semi-urban, squatter settlements, as well as different income areas of the city. The effectiveness of lay counseling as an intervention for common mental disorders holds much promise and there is need to build on the initial lessons learnt from the study that was carried out in Karachi. Given the high levels of psychological distress and the limitations that a biological model poses, this intervention could potentially address the psychological distress of a large number of people. One of the major factors that hinder help seeking for mental health is stigma of mental illness, compounded by cultural beliefs about mental illness. In many instances, particularly where marriage is concerned this has serious implications. Many parents do not reveal the mental illness of their off springs to the prospective in-laws with disastrous consequences. There is need to study the nature of stigma, the socio-cultural factors related to it and how to reduce it.Most psychiatric patients are managed at home in Karachi, cared for by their families. Carer burden is a recognised phenomenon, with the carers themselves undergoing a range of mental health problems that remain largely unaddressed. Studying factors related to carers’ mental health and devising interventions to address them is an area that needs further research. Most health care (including mental healthcare) in Pakistan is out-of-pocket expenditure. Many mental disorders are chronic in nature and the financial burden of psychiatric care can be very significant for families. There is need to study the economic burden of mental illness in Karachi.Box 1Mental Disorders in KarachiBetween a third to 40% of adult population of Karachi may be suffering from common mental disorders (CMDs)Rates of CMDs show high prevalence in women compared to men, and higher rates in married compared to single women. Studies suggest high rates of domestic violence in women in Karachi and both domestic violence and depression appear to increase significantly during pregnancy in women in KarachiStudies suggest there may be at least 250-300 suicides and 2,500 to 6000 attempted suicides every year in KarachiChild mental health problems such as ADHD, mental retardation and emotional and behavioural problems show high prevalence but remain largely undetectedMental health of the elderly is also a neglected area and needs to be addressedSelf-medication with tranquillisers is common in KarachiStudies show that on an average there could be a treatment delay of up to 4.5 years for depression and 14.8 months for schizophrenia in KarachiThere are significant gaps in research evidence and little is known about a number of mental disorders in KarachiMENTAL HEALTH FACILITIES IN KARACHIThe following section describes mental health facilities in Karachi, type (private, government or charitable/NGO), services provided and their costs.Institutions and Mental Health ProfessionalsThere are 47 institutions providing mental health services in Karachi. 31 (66%) of these are in the private sector while eight each are either government or charitable/NGO based (Table 2).Types of services provided32 (56%) institutions provide general adult psychiatry services, while 7 provide child & adolescent mental health services (CAMHS). In addition, four institutions provide psychiatric rehabilitation services while three provide drug addiction services primarily. All (except two) centers provide out-patient facilities for assessment and follow-up of patients. 28 (60%) centers cater to psychiatric emergencies. Psychological AssessmentsPsychological assessment (personality testing, IQ testing, neuropsychological testing etc.) is available at thirty five of the 47 facilities surveyed. Psychological testing forms an important part of overall assessment of psychiatric patients. Occupational TherapyOccupational therapy, an important component of multi-disciplinary approach to psychiatric care (particularly in psychiatric rehabilitation), is available at slightly less than half (23.5%) of the facilities. Electro-convulsive Therapy (ECT)Facilities for ECT (a treatment modality for a number of psychiatric disorders) are available at 18 of the 47 centers surveyed. However, the quality of equipment and the standard of treatment are very variable. In-patient facilities Thirty (64%) institutions provide in-patient hospitalization facilities. The total number of beds in all these centers is 855. Of these, the majority (398, 47%) are in the private sector, 283 (33%) are in the charitable or non-governmental organisations sector and only 174 (20%) are in the government sector. Mental Health ProfessionalsThe psychiatrist to population (adult) ratio is 1:0.32 million in Karachi. There is only qualified child psychiatrist in the cityOur survey revealed that there are 58 psychiatrists, 56 psychologists and 13 counselors in active practice in Karachi. However, the qualifications of professionals in each of the three groups are very variable. Only 28 (48%) psychiatrists have a major diploma (Fellowship of College of Physicians &Surgeons, Pakistan, US Board Certification or UK Membership of Royal College of Psychiatrists). The rest (17, 29%) either have a minor qualification (MCPS or Diploma in psychiatry) or only basic medical qualification (MBBS) (13, 22%) with some experience in psychiatry. Similarly, of the 56 psychologists only 25 (45%) have a doctorate (PhD). The remaining either have the Post-Magistral Diploma (PMD) (21, 38%), Masters in Psychology (6, 13%) or Diploma in Psychology (3, 5%).In addition, there are another thirteen mental health professionals with, either a background in mental health social work (2), speech & language therapy (4) or training in counseling (7) who are currently in practice in Karachi.There are very few nurses with specialized mental health nursing training, though mental health is part of the curriculum of the general nursing training.Area of specialtyThe majority of the mental health professionals (92, 64%) work with adults, while about a quarter (36, 25%) work with children (there is some overlap between the two: some mental health professionals work with both adults and children). Specialty of 12 mental health professionals could not be determined. Interestingly, there are only a couple of trained and qualified child psychiatrists in Karachi (those who have completed fellowship training in child psychiatry and have passed the specialty Boards). Training PositionsThere are a total of 42 College of Physicians &Surgeons, Pakistan (CPSP) approved training positions for trainee psychiatrists in Karachi. About three quarters of these (27, 65%) are in government institutions while 15 (35%) are in private institutions. For psychologists there are approximately 35 and 45 positions for Diploma and MS/MPhil (leading to PhD) in clinical psychology in Karachi respectively. This is provided by two institutions only.There are 2 schools of Occupational Therapy (OT) in Karachi, graduating approximately 20-25 students each every year. There is no separate curriculum for psychiatry occupational therapy but some of the main psychiatric disorders are covered as part of the general curriculum. There are approximately 8 OTs who are working in adult mental health facilities and approximately 35-40 OTs who are working with children and adolescents with a range of mental and neurological disorders. Mental health nursing is not taught separately anywhere in Pakistan. According to the Pakistan Nursing Council and Higher Education Commission, mental health nursing is part of curriculum of both Diploma as well as BScN general nursing programs. In Karachi, a couple of nursing schools offer a post-Diploma one year specialization in mental health nursing.Table 2: Mental Health Facilities in Karachi._____________________________________________________________________________________Mental Health Facilities No. (%)_____________________________________________________________________________________1. Public/Private/NGO/Charity (n=47)Government08 (17.0)Charitable/NGO08 (17.0)Private 31 (66.0)3. Type of Services Provided (n=47) Adult Psychiatry32 (56.1)Child & Adolescent Psychiatry07 (12.2)Rehabilitation 04 (07.0)Addiction (specialized)03 (05.2)Remedial education 01 (02.1)4. Psychological Assessment (n=47)Yes35 (74.5)No 12 (25.5)5. Services for Substance Abuse (Alcohol/Drugs) (n=47)Yes 22 (46.8)No 25 (53.2)6. Occupational Therapy (n=47)Yes 23 (48.9)No 24 (51.1)7. Electro-Convulsive Therapy (ECT) (n=47)Yes 18 (38.1)No 29 (61.7)8. Speech Therapy (n=47)Yes 12 (25.5)No 35 (74.5)9. Out-Patients Facility (n=47)Yes 45 (95.7)No 02 (04.3)10. In-Patients Facility (n=47)Yes 30 (63.8)No 17 (36.2)11. Total Number of In-Patients Beds (n=855)Private398 (46.5)Charitable/NGO283 (33.1)Government 174 (20.4)21. Psychiatric Emergencies (n=47)Yes 28 (59.6)No 16 (34.0)N/A03 (04)12. Number of Psychiatrists (n=85)*Charitable/NGO organisations14 (16.4)Privatesector57 (67.0)Government sector14 (16.4)13. Psychiatrists: Qualifications (n=58) **Major Diploma28 (48.2)Minor Diploma17 (29.3)MBBS13 (22.4)14. Psychologists (n=56)PhD25 (44.6)PMD/MPhil21 37.5)Masters07 (12.5)Diploma03 (05.4)15. Others (n=13)Mental Health Social Work02 (16.6)Speech & Language Therapy04 (25.0)Counselors07 (58.3)16. Specialty (n=144)Adults92 (63.8)Child/Adolescents36 (25.0)Others04 (2.7)Not Known12 (8.3)17. Number of training positions: Psychiatry (FCPS) (n=42)Private15 (35.7)Government 27 (64.3)18. Number of training positions: Psychology Diploma35MS/MPhil (leading to PhD)45 *Psychiatrists working in more than one setting e.g. in government hospital as well as private clinic**Major: FCPS/MRCPsych/US Boards; Minor: MCPS/DPMRemedial educationChildren who suffer from learning/reading disabilities and those with mental retardation need special education (also referred to as ‘remedial education’). We have included details of remedial education facilities in Karachi in this report as many children may also have associated mental health problems (Table 3). Table 3: Remedial schools in Karachi.Type of FacilityNo. (%)Public/Private/NGO/Charity (n=11)Private 06 (54.5)Charitable/NGO05 (45.5)Government00 (00.0)Psychological Assessment (n=11)Yes04 (36.3)No 07 (63.6)Occupational Therapy (n=11)Yes 09 (81.8)No 02 (18.2)Speech Therapy (n=11)Yes 08 (72.7)No 03 (27.3)Total no. of students currently enrolled2103Others (n=336)Speech & Language Therapy26 (07.7)Teachers (Special Education)310 (92.3)Table 4: Remedial Schools - ChargesCharges (in Rs.)Min. Max. Speech Therapy / session02500Occupational Therapy / session02500Psychotherapy / session02500Music Therapy / session0400Assessment Fees5004000Admission Fees (for regular attendance to facility)50016000Monthly Fees (for regular attendance)50010000Transport Charges (for regular attendance) / month10002500Location of facilities in KarachiKarachi is a large and spread out city and travelling time and costs add to the burden of problems. Hence the geographical location of a facility is critical as it may facilitate or impede help seeking. Mental health facilities are unevenly distributed in Karachi with more than half of the facilities being located in just 3 of the 18 towns of Karachi. Table and map below shows the location of mental health facilities and remedial education centres in Karachi (Table 5). Table 5: Location of mental health facilities in KarachiAreaNo. of Mental Health FacilitiesNo. of Remedial Education CentresClifton Town15 03Gulshan-e-Iqbal Town1002Jamshed Town0101Kemari Town0100Korangi Town0100Landhi Town0300Liaquatabad Town0800Lyari Town0100Malir Town0200N Nazimabad Town0101Saddar Town0403Shah Faisal Town0001TOTAL4711Map 1: Location of Mental Health Facilities & Remedial Centers in Karachi Remedial Education Centers Mental Health FacilitiesGulshan TownJamsheed TownNorth Nazimabad TownShahfaisal TownConsultation ChargesOut-Patient Consultation Charges (Table 6)There are varying charges for out-patient consultations, varying from a low of Rs. 200 to a high of Rs. 2500/ visit (depending on the facility and type of visit). Table 6: Consultation Charges: Out-PatientsInitial visit (in Rs.)Follow-up visit (in Rs.)Min. Max. Min. Max. Charitable/NGO*65025005001500Private20022502001800Government*06000350*While there is free consultation in some charitable/NGO & government facilities, others have varying charges for ‘private’ patients. Consultation charges: mental health professionals (Table 7)Consultation charges of various mental health professionals are quite variable. For psychiatrists they vary from a minimal of Rs. 150 per visit to a maximum of Rs. 2500 per visit. Psychologists’ consultation fees also start at a minimal Rs. 150. However psychological testing is relatively expensive with some psychologists charging as much as Rs. 8000 ( includes a report of the assessment). Counselors’ charges vary from a minimum of Rs. 1000 to 2500 per session while those for speech and language therapists can vary from Rs. 150 to Rs. 1500 per sessionTable 7: Consultation chargesInitial (in Rs.)Follow-up (in Rs.)Min. Max. Min. Max. Psychiatrists15022501502000Psychologists1508000*2006000*Counselors***100010000**10005000**Occupational Therapists7001000675810Social Workers2000200020002500Speech & Language Therapists15015005001200Special Educators50020005002000* For psychological assessment (includes several sessions & report writing)**For a pre-defined number of sessions*** Individuals who have a completed a counseling courseIn-Patient charges (Table 8)Charges for in-patient treatment in private facilities are dependent on the type of room (basic level/general, intermediate level/semi-private or high level/private). The charges vary from Rs. 1500 per day for a basic level/general ward bed to Rs.7000 per day for a high level/private room. In some facilities food and physician consultation fees is included in this charge, in others there is an extra charge for this. Table 8: Charges: In-PatientsCharges (in Rs/day)Min. Max. Basic level (General) 15003000Intermediate level (Semi- Private)30004000High level (Private)50007000Box 2Mental Health Facilities & Professionals in KarachiThere are 47 institutions providing mental health services in Karachi, of which about two-thirds (66%) are in the private sectorThere are 855 in-patient beds in Karachi, of which 47% are in the private sector, 33% in the charitable/NGO sector and only 174 (20%) in the government sectorThere are 126 mental health professionals in practice in Karachi. Of the 58 psychiatrists, only 28 (48%) have a major diploma, while 25 (45%) of 56 psychologists have a PhDMental health facilities are unevenly located in KarachiPrivate psychiatric care is very expensive and out of reach of the common manThere are only a handful of psychiatric rehabilitation and day care centres, all in the private sectorSub-specialties services such as child psychiatry, forensic psychiatry, psychiatry of elderly and addiction psychiatry are severely lacking in KarachiOther mental health professionals who form part of a multi-disciplinary mental health team such as occupational therapists, community psychiatric nurses or psychiatric social workers are either non-existent or very few in numbers.SummaryKarachi lacks mental health facilities as well as mental health professionals. There are only 27 psychiatrists (with a major diploma) in Karachi. With the current population of Karachi estimated to be about 18 million (with 50% being adult population over the age of 18 years), this works out to be approximately one psychiatrist to about 0.33 million population and about the same for a psychologist. For children and adolescents the ratio is even wider with only a couple of trained and qualified child and adolescent psychiatrists in the city. Psychiatric treatment in Karachi is relatively expensive. Our survey shows that consultation charges for psychiatric disorders puts many mental health professionals and facilities out of reach of the common man. Given the fact that many psychiatric disorders are chronic and may require life-long treatment, this puts an enormous economic burden on patients and their families. Similarly, in-patient facilities for psychiatric patients are expensive. The quality of care is very variable and there is no regulation of these facilities. Mental health services are not well organised in Karachi. There are no defined catchment areas or a referral system. Primary care physicians who have little or no exposure to psychiatry are known to prescribe second and third generation psychotropics. Facilities in government hospitals are lacking. The private sector appears to be filling the vacuum created by lack of facilities in the public sector. 80% of the in-patient beds are provided by either the private sector (47%) or charitable/NGO sector (33%). Most psychiatrists who work in public sector institutions have their own private practices. There are few well established sub-specialty services such as child psychiatry, psychiatry of the elderly, learning disability or substance abuse services in Karachi. Forensic psychiatry services, which deal with psychiatric patients who come in conflict with the law, are virtually non-existent. There is need to develop services for all these groups of patients. Other components of a multi-disciplinary mental health team such as psychiatric nursing, occupational therapy, music and art therapy, psychiatric social workers and community mental health nursing are also severely lacking in Karachi. There is need to develop all of these different services to improve patient care as well as support and guide families who appear to be the main care givers for psychiatric patients in Karachi. 6RECOMMENDATIONSBased on the results of the survey the following recommendations are put forward for consideration and further discussion:There is need for a comprehensive city-wide mental health strategy, which should be linked with an overall health strategy for Karachi. The development of this strategy should involve all stakeholders.The mental health strategy should focus on health promotion and disease prevention models of mental health. There is need for low-cost community mental health programs that are culturally relevant, accessible and affordable. The considerable delay between the onset of symptoms and seeking help for mental disorders could be addressed by such programs. Mental health facilities in the city are severely lacking. The existing facilities need to be strengthened and new facilities need to be established, particularly in the public sector.There is need for more mental health professionals in Karachi including psychiatrists, psychologists, psychiatric nurses and occupational therapists. In particular there is a need to develop separate curriculum for psychiatric nursing and occupational therapists. There are very few day care or rehabilitation facilities in the city. There is need to develop low cost rehabilitation facilities in different parts of the city so that people do not have to travel long distances to access them.There is good evidence to show that low-cost counselling for common mental disorders, using lay counsellors, is effective in Karachi. There is need to build on this and incorporate it in treatment models for mental health problems in Karachi. There is need to develop sub-specialties and services for different groups of psychiatric patients such as child and adolescent psychiatry, old-age psychiatry, forensic psychiatry and mental retardation. Our survey shows that psychiatric care in Karachi is very variable. There is no regulation of private psychiatric facilities in Karachi. There is need to regulate psychiatric care in Karachi. Minimal acceptable standards need to be developed that should be applied to all mental health professionals and institutions. Since the devolution of health to provinces, a provincial mental health authority needs to be established that could regulate and monitor such facilities in the city and province.There has been no large scale prevalence study of mental disorders using a representative sample of the population of Karachi. There is urgent need for such a study. 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