Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review

Data sources

Using the key words “Pakistan” and (“mental” or “depression” or “anxiety” or “psychiatric”), we searched the following bibliographic databases from the start of each of their time frames: Applied Social Sciences Index and Abstracts, Cumulative Index to Nursing and Allied Health, Cochrane Trials Register, Excerpta Medica, National Library of Medicine Gateway, Medline (Pubmed), PsycINFO, Science Citation Index, and Social Science Citation Index. We searched the reference lists of retrieved articles for relevant studies. We also searched www.Pakmedinet.com, a medical website. These searches were last repeated on 1 March 2002 to keep the review as current as possible. Additionally, we hand searched the Pakistan Journal of Clinical Psychiatry until 1995, when it ceased publication.

Study selection

We selected studies that were conducted within Pakistan and that focused on depression, depressive disorder, or anxiety disorder in adults (ages 18-65). Variables of interest were prevalence, vulnerability factors, protective factors, and effectiveness of treatment and prevention strategies.

Data extraction

Each study received a code based on the relevance of its abstract and title to the study questions. Studies or reviews directly addressing anxiety and depressive disorders were retrieved for data extraction. Potentially useful qualitative and quantitative studies, as well as review articles were also retrieved. (A complete list is available from the authors.)

Validity check

We assessed the methodological quality of the selected studies according to hierarchies of evidence and critical appraisal checklists.6 Since relatively few studies addressed our study questions, we included all studies directly relevant to the questions regardless of their quality.

Study synthesis

A narrative synthesis of the extracted studies was performed to address the questions of the review.

Methods of included studies

Table 1 shows the methodological quality of the studies. Only three of the 11 prevalence studies published in local journals gave adequate details of methods. Because of this, it is difficult to comment on possible biases. Even when basic data were provided it is questionable how representative the study sample was of the population.7 Diagnoses in all the studies were made by either a psychiatrist or a trained worker using a validated instrument, and thus seem to be of reasonably good quality.

Most of the studies discussed the generalisability of their findings but did not interpret any null findings. In the discussions, national comparisons were rarely made with findings of other national research groups; comparisons were usually with studies in other countries.

Prevalence of anxiety and depressive disorders

Table 2 lists the prevalence of anxiety and depressive disorders estimated in the studies. The overall mean prevalence in men and women in the six studies of random community samples (n = 2658) was 33.62%, with the point prevalence varying from 28.8% to 66% for women (overall mean 45.5%) and from 10% to 33% for men (overall mean 21.7%). Women aged 15-49 were studied in a paper with 28.8% prevalence, while young men with a mean age of 18 participated in a study reporting 33% prevalence. Only one study reported adjusted prevalence with 95% confidence intervals.

For those presenting to traditional or faith healers (n = 511), the prevalence of anxiety and depressive disorders among men varied from 2.65% to 27%, and among women from 11.5 % to 52%.

Three studies looked at total psychiatric morbidity in primary care (n = 774). One described women in a rural area, with a prevalence of 50%, while another described 18% prevalence for men and 42.2% for women in an urban area. The third study, with a prevalence of 38.4%, did not specify participants' sex.

Of those presenting to psychiatric outpatients (n = 2430), the prevalence varied between 32% and 66.3%. There were two studies on psychiatric inpatients, one reported a prevalence of depressive illness of 37% (n = 2620), while the other reported 19.1% (n = 177).

Associated social, psychological, and biological factors

Table 3 shows the various factors found to be associated with anxiety and depressive disorders. Sociodemographic factors associated with increased prevalence of anxiety and depressive disorders were female sex, middle age, and low level of education. Loss of husband (being widowed, separated, or divorced), increasing duration of marriage, and being a housewife were also positively associated. Women living in joint households with more than 12 members also showed a positive association; in contrast, one study reported a positive association for women living in unitary households. One study showed a positive significant association for relational problems with in-laws for women compared with other social problems. Chronic difficulties with housing, finances, and health were significantly associated with anxiety and depressive disorders. Absence of a confiding relationship was a significant factor in one study, as were lack of autonomy and arguments with husbands and in-laws in another. A disturbing event in the family was not significantly associated (P = 0.08).

Factors perceived by women to be associated with mental distress were low family income, marital disputes, too many children, and verbal abuse by in-laws. Studies that incorporated income found financial difficulties to be a significant factor, except for one study, in which the finding was just non-significant (P = 0.06).

What is the evidence for effectiveness of treatment or prevention in this population?

We could not find any prospective study of the natural course of the disorder or any rigorous controlled study addressing effectiveness of treatment and prevention. We found only one randomised controlled trial in mental health, regarding the ability of schoolchildren to detect mental disorders after having been given health education.8

Limitations of study

Our review may be subject to publication and selection bias as we were unable to systematically contact the experts in Pakistan for unpublished material or grey literature.

The coverage of the studies we identified is low. Despite detailed searches, we found that most studies satisfying our inclusion criteria were from the provinces of Punjab and Sindh, the two provinces with the largest population in Pakistan. The epidemiological data were collected from a handful of villages and urban settlements. There was considerable methodological variation in study design and in the instruments used. Thus one is unable to extrapolate these epidemiological findings to the whole of Pakistan.

Comparison with other low income countries

Using stringent criteria, Harding et al reported an overall frequency of anxiety and depression of 13.9% in four developing countries.9 Community studies from Africa have reported prevalences of 24% in rural Uganda and 20%-24% in rural South Africa. Among patients attending primary care, the prevalence varied from 8% to 29%. Patients attending primary care in India showed prevalences between 21% and 57%.1

In relation to risk factors, Abas and Broadhead found a significant association with formal employment, below average income, overcrowding, and certificate of secondary education in urban Zimbabwe.10 In the same study, they also found a significant association with humiliation or entrapment and with death or other loss.11 Bhagwanjee in rural South Africa found a significant association with age (risk increasing with age, to a maximum among people aged 30-39 years), single marital status, unemployment, low income, and low educational level.12 Similar risk factors were found in studies from Pakistan. However, we found that the reported overall rates were higher in Pakistan and higher among rural than urban populations compared with the above studies. The question is whether these differences are an artefact of measurement or are because of specific factors operating in Pakistan.

Possible reasons for our findings

Pakistan's population has been exposed to sociopolitical instability, economic uncertainty, violence, regional conflict, and dislocation for at least the past three decades.13 These are risk factors for psychiatric disorders3 and may help explain the findings of this review.

As in many other countries, women in Pakistan generally have higher rates of illness than men. In a recent study, the main health problems reported by women were mental tension leading to headache and white vaginal discharge leading to body pains and fatigue.14 In another study, most women perceived that financial, interpersonal, and family problems were causative or contributory factors in their ill health. They also linked their health to broader social institutions and cultural norms and expectations regarding women's roles and relationships between family members.15

The need for stronger evidence and improved research capacity

The argument that health will automatically improve with economic growth is not supported by the current evidence. Diseases will not go away without specific investments in health interventions.3 A coherent mental health policy with a strategic implementation plan is essential for countries that wish to enhance their social, economic, and social capital.16

A major obstacle in formulating effective health policy is the lack of robust epidemiological research in Pakistan.17 Our review highlights the absence of survey evidence and data from wider regions of Pakistan with regard to anxiety and depression, and the lack of outcome studies and prevention and treatment trials. The time is right for Pakistan to build on this research effort by increasing investment in research capacity. It would also be helpful to have a national epidemiological survey of mental disorders. Such surveys are useful to assess the needs of the population, document the use of existing services, obtain valid information on prevalence and associated risk factors, and monitor the health of the population and trends.16

Conclusion

Available evidence suggests a major social cause for anxiety and depressive disorders in Pakistan, and an overall prevalence of 34%. This evidence is limited because of methodological problems. Nationally representative psychiatric morbidity surveys and controlled treatment trials are required to inform policy in order to control morbidity from anxiety and depressive disorders.