Sociodemographic Characteristics and Patterns of Suicide in Pakistan: An Analysis of Current Trends.

Suicide is a global phenomenon with about 79% of suicides occurring in low and middle-income countries. This study investigated current trends, demographics, and characteristics of completed suicides based on reports from leading Pakistani Newspapers. This study performed a qualitative analysis of completed suicides in Pakistan's four newspapers from January 1st, 2019, through December 31st, 2020. Data about socio-demographic characteristics, methods of suicide, possible motives, and associated features were analyzed. 2295 suicides were reported in Pakistan during 2019 and 2020. About 61.87% were completed by men, and 38.12% by women. The most suicides occurred in individuals ages < 30 years. The predominant method of suicide in this group was ingestion of poisonous substances. The most commonly reported reasons for suicide were domestic conflicts, financial problems, and failure in love/marriage. By providing insight into characteristics of suicide, this study highlights the need for effective suicide prevention policies and programs to tackle rising rates of suicide in Pakistan.

Characteristics and patterns of individuals who have self-harmed: a retrospective descriptive study from Karachi, Pakistan.

BACKGROUND: Self-Harm (SH) is a major global public health problem under-researched in Pakistan due to religious and legal implications. This study aims to identify the characteristics and patterns among patients with SH and factors associated with the intent to die. METHOD: This retrospective descriptive study where SH cases presented to private tertiary care teaching hospital in Karachi, Pakistan, from January 2013 to December 2017 were extracted from HIMS records. Details related to demography, history, associated factors, access to methods used, and intent to die were collected on a structured proforma and analysed using STATA version 14.  RESULTS: A total of 350 cases were analysed. More than half of the reported cases were in the age group 20-39 years. Though only one-fourth of the SH cases had a past psychiatric history, it was found to be significantly (P-value < 0.05) associated with intent to die. Notably, 81% of the cases do not have a history of SH. Drug overdose (61.6%) and insecticides (36.6%) were the two most common methods used. Depression was identified in nearly half of the cases. The most common reason for attempting SH was inter-personal relationship issues (54.3%). CONCLUSION: This paper provides recent data on the characteristics and patterns associated with the intent to die of individuals who have self-harmed. In most cases of SH, past psychiatric history was not evident. Current psychiatric diagnosis and young adults were favoured in this study. The data from this study has limited representation for all demographic representation of SH cases from Pakistan as being from a single private hospital. There is a need for further research on SH in Pakistan.

Suicidal Thoughts, Attempts and Motives Among University Students in 12 Muslim-Majority Countries.

There is a scarcity of research on suicidal phenomena in the Muslim world. Therefore, this study aimed at investigating the self-reported prevalence of suicidal thoughts, attempts and motives in 12 Muslim countries. A total of 8417 (54.4% women) university students were surveyed by means of a self-report questionnaire. Overall, 22% of the participants reported suicidal ideation and 8.6% reported attempting suicide. The odds of suicidal thoughts were elevated in Azerbaijan, Indonesia and Saudi Arabia, while reduced ORs were recorded in Egypt, Jordan, Lebanon and Malaysia. While odds of suicide attempts were high in Azerbaijan, Palestine and Saudi Arabia reduced odds ratios (OR) were detected in Indonesia, Iran, Jordan, Lebanon, Malaysia and Tunisia. Taking drugs and using a sharp instrument were the two most frequently used methods to attempt suicide. Only 32.7% of attempts required medical attention. Escape motives were endorsed more than social motives by participants who attempted suicide. Suicidal behaviors were more frequent in women than in men. Compered to men, fewer attempts by women required medical attention. Moreover, our results show that making suicide illegal does not reduce the frequency of suicidal behavior. Results from this comparative study show that suicidal thoughts and attempts are frequent events in young adults in countries where religious scripture explicitly prohibit suicide and the frequencies of nonfatal suicidal behavior show large variation in nations adhering to the same religion.

Economic Burden of Mental Illnesses in Pakistan.

BACKGROUND: The economic consequences of mental illnesses are much more than health consequences. In Low and Middle Income Countries (LMIC) the economic impact of mental illnesses is rarely analyzed. This paper attempts to fill the gap in research on economics of mental health in LMIC. We provide economic burden of mental illness in Pakistan that can serve as an argument for reorienting health policy, resource allocation and priority settings. AIM: To estimate economic burden of mental illnesses in Pakistan. METHODS: The study used prevalence based cost of illnesses approach using bottom-up costing methodology. We used Aga Khan University Hospital, Psychiatry department data set (N = 1882) on admission and ambulatory care for the year 2005-06. Healthcare cost data was obtained from finance department of the hospital. Productivity losses, caregiver and travel cost were estimated using socio-economic features of patients in the data set and data of national household survey. We used stratified random sampling and methods of ordinary least square multiple linear regressions to estimate cost on medicines for ambulatory care. All estimates of cost are based on 1000 bootstrap samples by ICD-10 disease classification. Prevalence data on mental illnesses from Pakistan and regional countries was used to estimate economic burden. RESULTS: The economic burden of mental illnesses in Pakistan was Pakistan Rupees (PKR) 250,483 million (USD 4264.27 million) in 2006. Medical care costs and productivity losses contributed 37% and 58.97% of the economic burden respectively. Tertiary care admissions costs were 70% of total medical care costs. The average length of stay (LOS) for admissions care was around 8 days. Daily average medical care cost of admitted patients was PKR 3273 (USD 55.72). For ambulatory care, on average a patient visited the clinic twice a year. The estimated average yearly cost for all mental illnesses was PKR 81,922 (USD 1394.65) and PKR 19,592 (USD 333.54) for admissions and ambulatory care respectively. In the sensitivity analysis productivity losses showed high variability (from USD 1022.17 million to USD 4007.01 million). Assuming a gate keeping role of primary healthcare (PHC) demonstrated a saving of USD 1577.19 million in total economic burden. IMPLICATIONS FOR HEALTH POLICY: This study set out to generate evidence using a low cost innovative approach relevant to many LMICs. In Pakistan, like many LMICs, patients access tertiary care directly, even for illness that can be efficiently managed at PHC level. In economic terms the non-medical consequences of mental illnesses are far greater than medical consequences. Based on these finding we recommend, firstly, that mental illnesses should be prioritized equally as other illnesses in health policy and secondly there needs to be integration of mental health in primary health care in Pakistan.

Depression in the elderly in Karachi, Pakistan: a cross sectional study.

BACKGROUND: Depression in elderly is a major global public health concern. There has been no population-based study of depression in the elderly in Pakistan. The aim of the study was to estimate the prevalence of depression and its association with family support of elderly (age 60 years and above) in Karachi, Pakistan. METHODS: A population based cross-sectional study was carried out in Karachi from July-September 2008. Questionnaire based interviews were conducted with individuals (n = 953) recruited through multi-stage cluster sampling technique, using the 15- item Geriatric Depression Scale (GDS). RESULTS: Prevalence of depression was found to be 40.6%, with a higher preponderance in women than men (50% vs. 32%). Elderly currently not living with their spouses were 60% more depressed than those living with their spouses (Adjusted OR = 1.6, 95% CI = 1.3-2.1). Elderly who did not consider their children as future support were twice as likely to be depressed as those considering their children to be old age security (Adjusted OR = 2.1, 95% CI = 1.4-3.1). An increase in one male adult child showed 10% decrease in depression after adjusting for other variables (Adjusted OR = 0.9, 95% CI = 0.8-0.9). CONCLUSION: A relatively high prevalence of depression was found in the elderly in Karachi. There appeared to be a strong association between depression and family support variables such as living with spouse, considering children as future security and number of male adult children in the sample studied. Mental wellbeing of the elderly in Pakistan needs to be given consideration in the health policy of the country. In collectivistic societies like Pakistan family support plays an important part in mental health of the elderly that needs to be recognized and supported through various governmental and non-governmental initiatives. KEYPOINTS: Assessment of depression in elderly, Cross-sectional study in Karachi-Pakistan.

Health and socioeconomic resource provision for older people in South Asian countries: Bangladesh, India, Nepal, Pakistan and Sri Lanka evidence from NEESAMA.

BACKGROUND: The global population is ageing rapidly, with low- and middle-income countries (LMICs) undergoing a fast demographic transition. As the number of older adults in LMICs increases, services able to effectively address their physical and mental health needs will be increasingly important. OBJECTIVE: We review the health and socioeconomic resources currently available for older people in South Asian countries, Bangladesh, India, Nepal, Pakistan and Sri Lanka, to identify gaps in available resources and assess areas for improvement. METHODS: We conducted a search of grey and published literature via Google Search, Compendex, EBSCO, JSTOR, Medline, Ovid, ProQuest databases, Scopus and Web of Science. Data on population demographics, human resources, health funding and social protection for older people were extracted. Local informants were consulted to supplement and verify the data. RESULTS: In the study countries, the number of health professionals with expertise in elderly care was largely unknown, with minimal postgraduate training programmes available in elderly medicine or psychiatry. Older adults are therefore cared for by general physicians, nurses and community health workers, all of whom are present in insufficient numbers per capita. Total average healthcare expenditure was 2.5-5.5% of GDP, with 48.1-72.0% of healthcare costs covered by out-of-pocket payments. Pakistan did not have a social pension; only India and Nepal offered financial assistance to people with dementia; and all countries had disproportionately low numbers of care elderly homes. CONCLUSIONS: Inadequate healthcare funding, a shortage of healthcare professionals and insufficient government pension and social security schemes are significant barriers to achieving universal health coverage in LMICs. Governing bodies must expand training programmes for healthcare providers for older adults, alongside increasing social protection to improve access to those in need and to prevent catastrophic health expenditure.

Exploring the phenomenon of suicidal behaviour (SB): An explanatory, mixed-method study in rural Pakistan.

BACKGROUND: Despite scientific literature and media reports of rising cases of suicide and attempted suicide in different parts of Pakistan, the extent of this problem remains unknown, particularly from outside the main urban centres of the country. AIMS: To report data on Suicidal Behaviour (SB) from Malakand Division, a rural and marginalised part of Khyber Pakhtunkhwa (KPK) province, explore aetiological factors and propose preventive strategies. METHODS: This study followed an explanatory, mixed-method study design. The first part quantitative [QUANT] comprised of police reports on suicidal behaviour, from 2001 till first 8 months of 2018. Detailed analysis of only data from 2013 was undertaken, as data prior to 2013 contained insufficient information. The second part that is, qualitative (QUAL) consisted of in-depth interviews with relevant stakeholders. A mixed method of inductive and deductive analytical approach was used. RESULTS: From 2013 until the first quarter of 2018, the police recorded 1,645 attempts of both males and females of which 144 (8.75%) resulted in fatalities. Suicide attempts rose by 83.4% over the 5 years and 8 months. Approximately, 43.3% of the attempts were attributed to 'depression'. Domestic abuse was reported in 49.6% of cases. Of the total victims, 1,049 (63.7%) were females, whereas 60.1% were married. Ingestion of the organophosphates poison (pesticide) was reported in 53.2% (n = 999) of suicide attempts. In more than 90% of the non-fatal suicide attempts, victims were booked under punitive laws. Poor socio-economic status, inter-personal stressors, violence against women and mental illnesses were the major causes of suicidal behaviour in Malakand [QUAL]. Investment in human development, strengthening of the healthcare system, de-stigmatisation of mental illnesses and women empowerment could possibly prevent suicidal behaviour in Malakand [QUAL]. CONCLUSION: SB in Malakand Division is steadily increasing. The increase is more evident in vulnerable populations such as women and the younger population. 'Psychosocial stressors' and 'depression' were the main causes of suicidal behaviour. A broad-based, proactive, multi-sectorial approach is needed to prevent SB in the region.

Respiratory dyskinesia--an under-recognized side-effect of neuroleptic medications.

Respiratory dyskinesia is an under-recognized side effect of neuroleptic administration. There are only few studies that have addressed the prevalence of respiratory dyskinesia in patients with tardive dyskinesia. Our case report highlights the need to regularly examine patients on antipsychotics for any evidence of dyskinetic movements including respiratory musculature. Since RD is underrecognized and misdiagnosed, early detection can improve long term prognosis as treatment options are few and usually of only limited effect. A 62-year-old Asian male, retired civil engineer, had more than 20 years history of depressive illness, developed antidepressant induced hypomania, and was given risperidone upto 1 mg per day. He developed extrapyrmidal side effects as tremors, rigidity and later dyskinetic movements of lips with shortness of breathing, dyspnoea, grunting or gasping. He was referred to the pulmonologist who got the neccessary medical work up done, which was normal. A diagnosis of respiratory dyskinesia was made. Respiratory dyskinesia is an under-recognised and distressing condition that clinicians need to be aware of when treating patients with anti-psychotic medications. And also there is a need to regularly examine patients on antipsychotics for any evidence of dyskinetic movements including respiratory musculature for early diagnosis and better outcome. This case report also is worth reading for professionals of other specialties also because of the presentation of this patient, it can be easily misdiagnosed and result in poor outcome.

Cultural and interpersonal risk factors for suicide ideation and suicide attempts among Muslim college students from 11 nations.

BACKGROUND: Research on suicidality in low to middle-income countries is scarce. We addressed this issue by investigating suicidality in a cross-national college student samples from 11 predominantly low to middle-income majority Muslim countries. METHODS: The sample consisted of 7427 college students (56% female) who reported to be affiliated with Islam. Data on self-construal, social support, negative life-events, acceptability of suicide, suicidal ideation, and suicide attempts were collected with self-administered questionnaires. RESULTS: Acceptability of suicide and the experience of negative life-events were positively, and perceived social support was negatively associated with suicidal ideation. Interdependent self-construal was negatively related to the acceptability of suicide and positively associated with perceived social support, implying a negative indirect effect on suicidal ideation although its direct effect was positive. The number of negative life-events was the strongest positive predictor of ever attempting suicide. The interdependent self-construal moderated the association of negative life-events with suicide attempts. LIMITATIONS: Cross-sectional and self-report nature of the study were its major limitations. Participants may have suppressed their responses about suicide because of religious and legal reasons. CONCLUSION: Remarkable similarities across 11 country samples emerged in the linkages between cultural and interpersonal factors with suicidality. Our findings highlight the value of a nuanced approach to suicidality, that can recognize the differences in the processes associated with suicidal ideation and suicide attempts, as well as the need to consider the interplay of a broad range of personal, interpersonal, and cultural influences.

Suicide Prevention in the Eastern Mediterranean Region.

The WHO Eastern Mediterranean Region (EMR) consists of 22 countries including Afghanistan, Bahrain, Djibouti, Egypt, Iraq, Islamic Republic of Iran, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates (UAE), and Yemen. According to Global Burden of Disease (GBD) data, death from self-harm has increased by 100% between 1990 and 2015 in this region. Although this increase is substantial, it appears trivial in comparison to the 1027% increase in deaths due to war and legal interventions. This might partly explain why suicide prevention does not have a high priority in these countries and why there are currently no suicide prevention strategies in place. Despite the above, some important activities in the area of suicide prevention have been carried out in the region. And while peace and stability may take time to come to the region, it should not prevent suicide prevention programs from being developed and implemented.

Liaison psychiatry in low & middle income countries: Experiences at the Aga Khan University Hospital (AKUH), Karachi, Pakistan.

AIMS AND METHODS: Our study investigated the pattern of referrals made to psychiatric services from the general wards of Aga Khan University Hospital (AKUH). Data on all cases referred between years 2015 to 2016 was collected retrospectively from the medical records. Information included socio-demographic details, reason for referral, past psychiatric history, treatment, management suggested and outcome of referral. SPSS version 19.0 was used for data entry and analyzing. RESULTS: During the study period 1166 cases were referred for psychiatric consultations of which 995 were analyzed. The results show an almost equal distribution of females and males. Most referrals were from Internal Medicine. The most common reason for referral was behavioral problem and the most common psychiatric diagnosis made was delirium. CLINICAL IMPLICATIONS: Review of the service has identified areas that need improvement such as late referrals, problems with documentation, and issues in following through with the recommended management and will help us improve the existing services.

Associations of religiosity, attitudes towards suicide and religious coping with suicidal ideation and suicide attempts in 11 muslim countries.

OBJECTIVE: The study investigated the associations of religiosity, religious coping and suicide acceptance to suicide ideation and attempts in 7427 young adults affiliating with Islam from 11 Muslim countries. METHOD: A self-administered questionnaire was used to collect the data. We used F and χ2 tests and correlation analyses to report descriptive statistics. Multi-group path models with (i) a zero-inflated Poisson distribution and, (ii) a Binomial distribution were used to model the number of occurrences of suicidal ideation, and occurrence of a suicide attempt, respectively. RESULTS: Religiosity was negatively associated with acceptability of suicide, but it was positively related to punishment after death across the 11 countries. Religiosity was negatively associated with ever experiencing suicidal ideation, both directly and indirectly through its association with attitudes towards suicide, especially the belief in acceptability of suicide. Neither positive nor negative religious coping were related to suicidal ideation. However, religiosity was negatively related to suicide attempts among those who experienced suicidal ideation at least once. This association was mediated through the belief in acceptability of suicide and religious coping. Negative religious coping was positively associated with suicide attempts probably because it weakened the protective effects of religiosity. CONCLUSIONS: Findings from this study suggest that the effects of religiosity in the suicidal process operate through attitudes towards suicide. We therefore conclude that clinical assessment as well as research in suicidology may benefit from paying due attention to attitudes towards suicide.

Case-control study of suicide in Karachi, Pakistan.

BACKGROUND: In recent years suicide has become a major public health problem in Pakistan. AIMS: To identify major risk factors associated with suicides in Karachi, Pakistan. METHOD: A matched case-control psychological autopsy study. Interviews were conducted for 100 consecutive suicides, which were matched for age, gender and area of residence with 100 living controls. RESULTS: Both univariate analysis and conditional logistic regression model results indicate that predictors of suicides in Pakistan are psychiatric disorders (especially depression), marital status (being married), unemployment, and negative and stressful life events. Only a few individuals were receiving treatment at the time of suicide. None of the victims had been in contact with a health professional in the month before suicide. CONCLUSIONS: Suicide in Pakistan is strongly associated with depression, which is under-recognised and under-treated. The absence of an effective primary healthcare system in which mental health could be integrated poses unique challenges for suicide prevention in Pakistan.

Attitudes toward suicide bombing in Pakistan.

Although suicide bombing is a historical phenomenon, there has been a recent upsurge in such incidents. In Pakistan, over the last year, more than 1,000 people have been killed in suicide bombing incidents. Assessing the attitudes and perceptions of people toward suicide bombing can help understand some of the root causes of this phenomenon. In this pilot study, we conducted a cross-sectional survey of people (N = 215) in Karachi, Pakistan, to assess their attitudes and perceptions toward suicide bombing. The majority of the respondents condemned suicide bombing and disagreed with the notion that Islam or any other religion supports it. Belonging to the Sunni Muslim sect and strong adherence to religion predicted support for suicide bombing. The majority believed suicide bombing to be a result of religious fundamentalism. Opinion was divided as to whether suicide bombers have an underlying psychiatric illness. Further studies with larger sample sizes are needed to determine the attitudes and perceptions of the Pakistani population regarding this important issue.

Awareness and perceptions of electroconvulsive therapy among psychiatric patients: a cross-sectional survey from teaching hospitals in Karachi, Pakistan.

BACKGROUND: Electroconvulsive therapy (ECT) is shown to be effective in many psychiatric illnesses, but its distorted projection by the Pakistani media and its unregulated use by many physicians across the country have adversely affected its acceptability. Given this situation we aimed to assess the awareness and perceptions regarding ECT as a treatment modality among the psychiatric patients. METHODS: This was a questionnaire based cross-sectional study carried out at 2 tertiary care hospitals in Karachi, Pakistan. RESULTS: We interviewed 190 patients of which 140 were aware of ECT. The study showed that the level of education had a significant impact on the awareness of ECT (p = 0.009). The most common source of awareness was electronic and print media (38%), followed by relatives (24%) and doctors (23%). Physical injuries (42%) and neurological (12%) and cognitive disturbances (11%) were the commonly feared side effects. The most popular belief about ECT was that it was a treatment of last resort (56%). Thirty-nine percent thought that ECT could lead to severe mental and physical illness and 37% considered it inhumane. Patients' willingness to receive ECT was dependant on whether or not they were convinced of its safety (p = 0.001) and efficacy (p = 0.0001). CONCLUSION: We identified a serious lack of dissemination of information regarding ECT by the psychiatrists and the mental health care providers. This may be the result of an inadequate postgraduate training in Pakistan or just a lack of concern about the mentally ill patients. The media seemed to be the major source of information for our patients. We also saw the prevalence of a variety of myths regarding ECT in our society, which we feel may be responsible for the patients' adverse attitudes. Given the widespread applicability of ECT there is a dire need to dispel these misconceptions and improve its acceptability.

Liaison psychiatry and depression in medical inpatients.

OBJECTIVE: To assess the frequency of depression among hospitalized patients, the socio-demographic variables associated with depression and the number of cases referred by physicians to Psychiatry. METHODS: A cross-sectional study was carried out at the Aga Khan University Hospital Karachi. An anonymous Urdu version of the WHO-developed self-reporting questionnaire (SRQ) was administered to inpatients meeting the inclusion criteria. Data was analyzed by SPSS version 13.0. RESULT: Of the 225 patients approached, 178 completed the questionnaire (men= 45.2%, women = 54.8%). The mean age of the sample was 45.2 years. Out of the total 30.5% of patients were identified as having probable depression, among which housewives were more likely to be depressed compared to others (p=0.031). Among variable comparison, there with secondary school education or below and those with psychiatric co-morbidities, showed significantly greater prevalence of depression (p=0.003) and (p=0.005) respectively. Attending physicians correctly diagnosed 7 (13%) patients and referred only 3 patients to Psychiatry over the previous month. CONCLUSION: The prevalence of depression among inpatients is comparable to that in the general population. Being a housewife, level at or below secondary school education and having a past psychiatric history are significant factors associated with depression in medical inpatients. A very small number of depressed cases were referred to a psychiatrist.

Suicide and deliberate self-harm in Afghanistan.

BACKGROUND: Suicide and deliberate self-harm (DSH) are major public health problems globally. There is limited information on suicide and DSH from Afghanistan. AIMS: To review available literature on suicide and DSH in Afghanistan. METHODS: Using online resources and literature on suicidal behavior (suicide, DSH and suicidal ideation) was searched. RESULTS: There were only seven published studies identified on suicidal behavior in Afghanistan. Six of these have been published since 2003 and majority has focused on suicidal behavior in women. CONCLUSIONS: Both DSH and suicide are underreported and understudied subjects in Afghanistan. There is need for more research in this area.

Suicides in the developing world: case study from Pakistan.

There are no official data on suicide from Pakistan, a conservative South Asian Islamic country with traditionally low suicide rates. Both suicide and attempted suicide are illegal acts, as well as socially and religiously condemned, making research in this area difficult. Recent reports suggest an increase in suicide rates. In this study, police data from the Sindh province were examined to provide a unique picture of trends of suicide over 15 years (1985-1999). During this period there were 2,568 reported suicides (71% men, 39% women; ratio 1.8). The lowest number was 90 in 1987 and maximum was 360 in 1999. Poisoning by organophosphates was the most common method followed by hanging. This study, although limited in scope, provides evidence of an increase in suicide rates in Pakistan, from one data source. There is urgent need for further research on suicide in Pakistan; interventions for suicide prevention in the country can then be planned.

Gender differences in age at onset of schizophrenia.

OBJECTIVE: To evaluate the gender differences in age at onset of schizophrenia. DESIGN: Prospective case control study. PLACE AND DURATION OF STUDY: Department of Psychiatry, Aga Khan University Hospital, Karachi between January to December 2002. PATIENTS AND METHODS: Sixty patients admitted consecutively to psychiatry ward and meeting the inclusion criteria were enrolled for the study. Age at onset of illness was defined as age at onset of gross psychotic symptoms, age at first contact with psychiatrist and age at index admission. Statistical method included two independent samples t-test. Data was dichotomized into those with family history of schizophrenia versus those without family history of illness and then Chi-square test of association was applied. RESULTS: The mean age of onset of illness was 23.96 years in females and 24.13 years in males. In all other measures used to assess the onset of illness, females were overrepresented at the younger age group. 56.7% patients had a family history of psychotic disorder. Among them the mean ages at onset of illness were 20.59 years in females and 21.85 years in males ( c 0.04 df =58). The illness occurred at a younger age in those with positive family history of schizophrenia (21.22 years) than those without it (25.14 years) with dissipation of gender difference in the former. CONCLUSION: There was no significant gender difference in age at onset of disorder in this study. Family history of schizophrenia appears to be the most significant factor that eliminates the gender differences in age at onset of schizophrenia.

Depression in primary care: difficulties and paradoxes.

The presentation of depression in primary care is in many ways different from that seen in psychiatric settings. The process of detection and treatment is also different. This is particularly so in developing countries like Pakistan, which has high prevalence rates of depression but poorly organized primary health care services and primary care physicians (PCPs) who have little psychiatric training, either at undergraduate or postgraduate levels. There is a need to review difficulties faced by primary care physicians in detection and management of depression. It is hoped this would lead to better and more effective management of depression at primary health care level.