Karachi Mental Health Report (KMHR)

A collaborative project of Dept. of Psychiatry, Aga Khan University and

Aman Foundation, Karachi

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Acknowledgements

We 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, PhD Department of Psychiatry

Dr. Murad M Khan, MRCPsych, PhD Aga Khan University, Karachi
Dr. Riffat Zaman, PhD Oct 2012

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CONTENTS

Acknowledgements 2

Introduction 4

1. Objectives of the report 5

2. Karachi: a brief background 6

3. Methods 9

4. Literature review 10

5. Mental health facilities 22

6. Recommendations 37

References 39

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INTRODUCTION

The 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.

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1. Objectives of the report
The specific objectives of the report were as follows:

1. To review and synthesize available literature on epidemiology and burden of mental

disorders in Karachi.

2. 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).

3. To identify gaps in evidence-base and services for mental health problems in Karachi

4. To give recommendations for addressing mental health issues in Karachi

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2 KARACHI: a brief background
Karachi 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.

2.1 Population (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.

2.2 Migration

Karachi 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.

2.3 Ethnic groups

The 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.

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Table 1: Town-wise Population in Karachi, Pakistan.

Name of Town UC 1998 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

1
5. Gulshan-e-Iqbal Town 3 1,200,000 1,816,920**
1
6. Jamshed Town 3 733,821 1,111,078**

7. Keamari Town 8 383,788 640,119

8. Korangi Town 9 550,000 755,909

1
9. Landhi Town 2 666,748 978,857
1
10. Liaquatabad Town 1 649,091 879,977
1
11. Lyari Town 1 607,992 735,780

12. Malir Town 7 398,289 618,627

1
13. New Karachi Town 3 240,000 363,384**
1
14. North Nazimabad Town 0 500,000 652,532
1
15. Orangi Town 3 723,694 1,126,641
1
16. Saddar Town 1 616,151 1,099,169

17. Shah Faisal Town 7 335,823 563,439

18. SITE Town 9 467,560 759,552

TOTAL 178 9,537,860 13,767575
*Population calculated for Extended Program of Immunization (EPI), Govt. of Pakistan
**Estimated population increase of 51.41% based on average of other 14 towns
UC= Union councils

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2.4 Religions

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.

2.5 Economy

Karachi 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.

2.6 Administration

In 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.

2.7 Health Budget

According 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.

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3 METHODS
3.1 Evidence-base

A 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. Pakmedinet.com, 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 Karachi

3.2 Mental Health Facilities

Mental 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.

3.3 Limitations and difficulties

The 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.

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4 LITERATURE REVIEW
We 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 findings

4.1 Common 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.

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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.

Imam 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 There was an average
later than young people and those with lower
education9. The results indicate that more effort is
delay of 4.5 years from
needed to increase prompt initial contact among the onset of symptoms of
people with incident episodes of depression and to depression to seeking
make treatment for mental health problems accessible
and affordable in Karachi and Pakistan.
consultation from a
psychiatrist in Karachi
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.

Summary

Studies 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.

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 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.

4.2 Women Mental Health

Rates 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.

Summary

Rates 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.

4.3 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

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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

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 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.

4.4 Suicidal behaviour

Suicidal 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

14
 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.

Summary

From 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.

4.5 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.

15
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.

4.5.1 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.

4.5.2 Mental Retardation

An 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.

16
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.

4.5.3 Behavioural and Emotional Problems

There 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.

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 Summary

The 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.

4.6 Others

4.6.1 Mental Health of the Elderly

There 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 Schizophrenia

A 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 treatment

4.6.3 Benzodiazepine 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
18
 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 benzodiazepines60.

4.6.4 Complicated 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.

4.7 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
19
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 1 Mental Disorders in Karachi

 Between a third to 40% of adult population of Karachi may be suffering from

common mental disorders (CMDs)
 Rates of CMDs show high prevalence 20 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
5 MENTAL HEALTH FACILITIES IN KARACHI

The following section describes mental health facilities in Karachi, type (private, government or
charitable/NGO), services provided and their costs.

21
5.1 Institutions and Mental Health Professionals

There 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).

5.1.1 Types of services provided

32 (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.

5.1.2 Psychological Assessments

Psychological 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.

5.1.3 Occupational Therapy

Occupational 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.

5.1.4 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.

5.1.5 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.

5.1.6 Mental Health Professionals

22
Our 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- The psychiatrist to
Magistral Diploma (PMD) (21, 38%), Masters in population (adult) ratio
Psychology (6, 13%) or Diploma in Psychology (3,
5%).
is 1:0.32 million in
Karachi. There is only
In addition, there are another thirteen mental health
professionals with, either a background in mental qualified child
health social work (2), speech & language therapy (4) psychiatrist in the city
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.

5.1.7 Area of specialty

The 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).

5.1.8 Training Positions

There 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.

23
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. (%)

24
_____________________________________________________________________________________

1. Public/Private/NGO/Charity (n=47)

Government 08 (17.0)

Charitable/NGO 08 (17.0)

Private 31 (66.0)

3. Type of Services Provided (n=47)

Adult Psychiatry 32 (56.1)

Child & Adolescent Psychiatry 07 (12.2)

Rehabilitation 04 (07.0)

Addiction (specialized) 03 (05.2)

Remedial education 01 (02.1)

4. Psychological Assessment (n=47)

Yes 35 (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)

25
 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)

Private 398 (46.5)

Charitable/NGO 283 (33.1)

Government 174 (20.4)

21. Psychiatric Emergencies (n=47)

Yes 28 (59.6)

No 16 (34.0)

N/A 03 (04)

12. Number of Psychiatrists (n=85)*

Charitable/NGO organisations 14 (16.4)

Private sector 57 (67.0)

Government sector 14 (16.4)

13. Psychiatrists: Qualifications (n=58) **

Major Diploma 28 (48.2)

Minor Diploma 17 (29.3)

MBBS 13 (22.4)

14. Psychologists (n=56)

PhD 25 (44.6)

26
 PMD/MPhil 21 37.5)

Masters 07 (12.5)

Diploma 03 (05.4)

15. Others (n=13)

Mental Health Social Work 02 (16.6)

Speech & Language Therapy 04 (25.0)

Counselors 07 (58.3)

16. Specialty (n=144)

Adults 92 (63.8)

Child/Adolescents 36 (25.0)

Others 04 (2.7)

Not Known 12 (8.3)

17. Number of training positions: Psychiatry (FCPS) (n=42)

Private 15 (35.7)

Government 27 (64.3)

18. Number of training positions: Psychology

Diploma 35

MS/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/DPM

5.2 Remedial education

27
Children 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 Facility No. (%)

Public/Private/NGO/Charity (n=11)

Private 06 (54.5)

Charitable/NGO 05 (45.5)

Government 00 (00.0)

Psychological Assessment (n=11)

Yes 04 (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 enrolled 2103

Others (n=336)

Speech & Language Therapy 26 (07.7)

Teachers (Special Education) 310 (92.3)

Table 4: Remedial Schools - Charges

28
 Charges (in Rs.)

Min. Max.

Speech Therapy / session 0 2500

Occupational Therapy / session 0 2500

Psychotherapy / session 0 2500

Music Therapy / session 0 400

Assessment Fees 500 4000

Admission Fees (for regular attendance to facility) 500 16000

Monthly Fees (for regular attendance) 500 10000

Transport Charges (for regular attendance) / month 1000 2500

5.3 Location of facilities in Karachi

29
Karachi 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 Karachi

Area No. of Mental No. of Remedial

Health Facilities Education Centres
Clifton Town 15 03

Gulshan-e-Iqbal Town 10 02

Jamshed Town 01 01

Kemari Town 01 00

Korangi Town 01 00

Landhi Town 03 00

Liaquatabad Town 08 00

Lyari Town 01 00

Malir Town 02 00

N Nazimabad Town 01 01

Saddar Town 04 03

Shah Faisal Town 00 01

TOTAL 47 11

30
 Map 1 : Location of Mental Health Facilities & Remedial Centers in Karachi

Remedial Education Centers

Mental Health Facilities

North Gulshan
Nazimabad Town Town

Jamsheed Shahfaisal
Town Town

31
 5.4 Consultation Charges

5.4.1 Out-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-Patients

Initial visit (in Rs.) Follow-up visit (in Rs.)

Min. Max. Min. Max.

Charitable/NGO* 650 2500 500 1500

Private 200 2250 200 1800

Government* 0 600 0 350

*While there is free consultation in some charitable/NGO & government facilities, others have varying
charges for ‘private’ patients.

32
 5.4.2 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 session

Table 7: Consultation charges

Initial (in Rs.) Follow-up (in Rs.)

Min. Max. Min. Max.

Psychiatrists 150 2250 150 2000

Psychologists 150 8000* 200 6000*

Counselors*** 1000 10000** 1000 5000**

Occupational Therapists 700 1000 675 810

Social Workers 2000 2000 2000 2500

Speech & Language Therapists 150 1500 500 1200

Special Educators 500 2000 500 2000

* For psychological assessment (includes several sessions & report writing)

**For a pre-defined number of sessions
*** Individuals who have a completed a counseling course

33
 5.4.3 In-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-Patients

Charges (in Rs/day)

Min. Max.

Basic level (General) 1500 3000

Intermediate level (Semi- Private) 3000 4000

High level (Private) 5000 7000

34
Box 2 Mental Health Facilities & Professionals in Karachi

 There are 47 institutions providing mental health services in Karachi, of which

about two-thirds (66%) are in the private sector
 There 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 sector
 There 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 PhD
 Mental health facilities are unevenly located in Karachi
 Private psychiatric care is very expensive and out of reach of the common man
 There are only a handful of psychiatric rehabilitation and day care centres, all in
the private sector
 Sub-specialties services such as child psychiatry, forensic psychiatry, psychiatry of
elderly and addiction psychiatry are severely lacking in Karachi
 Other 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.

35
Summary

Karachi 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.

36
6 RECOMMENDATIONS

Based on the results of the survey the following recommendations are put forward for
consideration and further discussion:

1. 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.

2. The mental health strategy should focus on health promotion and disease prevention
models of mental health.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

37
11. There are large gaps in research evidence of mental disorders in Karachi. These need to
be filled through a strategic research agenda involving researchers from different
institutions of the city.

12. Crisis intervention centres, including telephone hotlines for patients in crisis situations for
e.g. those who are actively suicidal or undergoing intra/interpersonal crisis need to be
established.

13. There is need to raise awareness and reduce stigma related to mental health problems in
Karachi. Both electronic and print media as well as public awareness programs can be
utilised for this.

14. In Karachi, most patients with psychiatric disorders are looked after by their families, in
the process undergoing a range of emotional and financial problems themselves. There is
no state support for these carers, who are left to fend for themselves. There is need to
make provisions within the provincial health budget for financial support for such
families.

38
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