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

Culture is sometimes called the personality of a society. There are many factors that collectively contribute towards the development and determination of culture in a society (Peacock et al., 1981). The perceptions, understandings, attitudes, behaviours and practices of the individuals vary across cultures (Peacock et al., 1981). For example, every family, every institution or every country may vary in their cultural norms. We regularly come across terms as Western culture, Eastern culture, American culture and so on that signify various practices, attitudes, behaviours or understandings exhibited by the members of these societies. Some cultural norms significantly vary across societies, for example, an eating delicacy in one culture may be considered a forbidden item in another, consumption of which may be a punishable offence (Squires et al. 2011). Cultural diversity exists in understanding mental health and related issues, across the world (Gopalkrishnan et al., 2018).

Knowledge can be gained about various aspects of culture exhibited or adapted by the members of a community by the application of a variety of scientific tools and measures. In each society, depending upon the group’s personal identification, ethnicity can be decided by various factors for example ethno-religious, ethno-lingual, ethno-racial, ethno-regional and ethno-national. These factors are usually overlapping, and more than one factor may determine the membership of an ethnic group (Peoples et al., 2011). Various ethnic groups then may exhibit various subcultures in a society that differ in their cultural norms and practices including their understanding of mental health and mental health related issues.

Culture significantly influences the understandings, perceptions, conceptualisations, experiences and responses towards mental health and mental illness, in any society (Gaw et al., 1993). Cultural bound syndromes manifest as a unique set of physical or mental presentations of illnesses specific to individual cultures (Brown et al., 1989).

When it comes to understanding the mental health and related issues experienced by people from different cultures, cross-cultural differences need to be appreciated and unique cultural characteristics and norms need to be learnt. Attempts need to be made to adjust cultural characteristics and expectations in care and treatment plans to provide the best possible support where required. Countries like USA and Britain have populations of citizens from varied backgrounds from across the world and understanding cultural background of several ethnic minorities for provision of best possible mental health care is an ongoing challenge in such countries (Cochrane et al., 1996).

One approach of understanding mental illness is appreciating it as the quality of an individual brain, mind or personality; an assumption that provides the underpinnings for current international classifications of diseases. These classifications assume that there is a common natural reality to all mankind that is universal and the symptoms underlying each diagnosis are also comparable universally regardless of the area or situation, for example, Diagnostic and Statistical Manual (DSM) classification by American Psychiatric Association or International classification of diseases by World Health Organisation (APA 2010) (WHO 1992). This view is currently accepted and practiced as an agreed standard across the world, but nevertheless, the recognition of cultural factors and their adjustment in addressing the mental health related issues is considered an essential component for utilising this model to different communities.

Sociologists on the other hand are more focused on sociological meanings attached with mental disorders. The social synthesis of knowledge, therefore, is more focused on intersubjective, collective social understanding of a society that is different from ‘both the subjective inner words of individuals and the objective, universal worlds of natural objects’ (Zerubavel, 1997). This approach follows the exploration of meanings to the roots of a phenomena in group practices or cultural assumptions. (Mannheim, 1936). Social practices have an impact on the synthesis of knowledge as well as behaviours and practices in which the knowledge is embedded.

When it comes to the exploration of literature focused on understanding mental health and related issues in a society, it would be expected to find studies that may take a subjective or objective (or possibly mixed) approach towards exploring how a community appreciates and reacts towards its mental illnesses. On one hand, from service provision perspective, culture sensitivity and cultural appropriateness is sought by such explorations, and on the other hand, from service user’s perspective, the cultural values and preferences are highlighted that the communities can expect to be incorporated in their care and treatment

South Asian communities are unique about their understanding of various cultural phenomena. South Asian culture is diverse and multiple languages are spoken in the Indian subcontinent, and there are multiple known subcultures that identify themselves according to a variety of ethnic factors (Pattanayak, 1990). For example, multiple studies have been conducted on the South Asian population highlighting the difference in explanatory model of mental illness (McCabe et al., 2004), attachment of stigma (Loya et al., 2010) or ascribing of supernatural causes to mental health problems by South Asian community (Penny et al., 2009).

Pakistan is one of the South Asian countries and shares boundaries with India, Afghanistan, Iran and China. Islam is the official religion of the state. Urdu is the official national language. In addition, ethno-lingual, ethno-regional and ethno-racial diversity exists throughout the country. There are many subcultures identifiable, and based on these overlapping ethnic identities, the country is divided into four major parts (Newcomb, 1986). Some work has been done in Pakistan and other areas of the world (that have expatriate Pakistani populations) aimed to learn how the Pakistani community understands their mental illness and mental health problems. For example, the references made to the studies in the above section ‘South Asian community and mental health’ included Pakistani participants, which means that Pakistani community shares many cultural understandings exhibited by the South Asian communities in general. Some other studies have found some unique cultural manifestations with regards to mental health by this community, for example, the concept of ‘high expressed emotions’ is studied significantly in Pakistani community living within the country or abroad (Aisha et al., 2011; Bhugra et al., 2003). This highlights that even though living in a different country, at some level, the Pakistani community tends to hold the same values/attitudes as if they were in Pakistan.

To investigate how Pakistani community perceives their mental health problems, we carried out a systematic literature search on the research databases that are available in Pakistan including PubMed, Cochrane Systematic Reviews Database and Google Scholar. The relevant literature search was carried out between 1st January 2019 and 16th January 2019. The search terms included ‘Pakistan’, ‘Pakistani’, ‘mental health’, ‘mental illness’, ‘mental health problems’, ‘ideas’, ‘views’, ‘understandings’, ‘perceptions’, ‘beliefs’, ‘culture’, ‘cultural views’, ‘attitudes’ and ‘behaviours’. A combination of these terms was used to maximise the probability to identify relevant articles. For example, we combined terms like mental health or mental illness alternatively with one of the other terms described above, that is, to identify the studies that might throw light on the relationship of mental health/mental illness with ideas, or with views or with understandings or with behaviours exhibited by Pakistani community.

On Google scholar, complete phrases can be used as search terms, for example, the phrases like ‘Cultural beliefs about mental health in Pakistani communities’ and ‘Pakistani mental health beliefs’ were used to identify articles and then the search was broadened with more similar kind of phrases.

On PubMed, Boolean logic with Operator terms were used to identify the relevant papers. Words Pakistan OR Pakistani AND Mental illness OR mental health was searched with terms ‘Understandings’ OR ‘Perceptions’ OR ‘Beliefs’ OR ‘Culture’ OR ‘Cultural views’ OR ‘Attitudes’ OR ‘Behaviours’.

Search strategies were refined initially from general to more specific terms, the details of which are described in separate sections below.

On Google scholar, the search was carried out with two separate terms that are described below. The terms produced huge amount of results, for example, the first term produced 37,600 results and second one produced 51,200 results. Google scholar unlike PubMed or Cochrane doesn’t offer much tools for advanced search and filtration of results. Hence, the first few pages were visually searched (Titles read) and some relevant studies were identified, the numbers of which are mentioned in brackets below.

Term 1 – ‘Cultural beliefs about mental health in Pakistani communities’ (20 studies identified)

The author considered to remove the search outcome of Google Scholar from the overall results or not include this database in the list of included databases because it doesn’t generate results that are as organised as the other two databases and shall not be reproducible in a systematic manner. Instead, lots of vague and irrelevant results were generated that were difficult to be fully explored (51,200 results for example). However, this idea of exclusion was dismissed because research was carried out on this database as an overall process as planned initially and it would have been rather unhelpful not to include those studies that were identified and that matched the required criteria. Secondly, as per research ethics and transparency, the author considers it a better practice to inform the reader of the identified limitation and adjust it in overall findings rather removing it from overall plan for above reasons.

Cochrane library provides facility to search with the help of Boolean Logic and Operator terms.

Following search strategies were used

First: Cultural beliefs, AND mental health or mental illness, AND Pakistani or Pakistan (outcome two results)

Following terms were searched on PubMed using the advanced search category:

((Pakistan[Title] OR Pakistani[Title])) AND (Mental Health[Title] OR Mental Illness[Title])

PubMed search with broader terms like Pakistan or Pakistani AND Mental Health or Mental Illness generated too many results, that is, 570,434. However, it was noticed that this strategy picked all the entries that contained either of the four terms in the title or abstract of the articles. The search strategy was therefore refined to specific terms, for example, the final strategy is copied below:

(((Pakistan[Title/Abstract] OR Pakistani[Title/Abstract])) AND (‘Mental health’[Title/Abstract] OR ‘mental illness’[Title/Abstract])) AND (aptitudes[Title/Abstract] OR ideas[Title/Abstract] OR beliefs[Title/Abstract] OR understanding*[Title/Abstract] OR perception*[Title/Abstract])

I included the papers that followed an observational or interventional study design and offered details that how did the authors conclude their findings about the understanding of Pakistani community about their mental illness or mental health problems. Regarding the study design, all study designs were aimed to be included, for example, quantitative and qualitative, cross-sectional, experimental, quasi experimental, RCTs and so on

Studies exploring heterogenous group of South Asian communities including Pakistani nationals but not offering separate set of results for Pakistani community were excluded.

The following papers were excluded for the reasons described next to each:

One study was excluded because although it involved Pakistani community, but the total number of Pakistani participants was only 15%, whilst the other participants were Indian nationals and had different religious denomination.

Total relevant articles identified on Google Scholar were 23, on Cochrane Database were 3 and on PubMed were 45, making a total of 71. When it came to organise the studies under the four broader categories of Identified, Screened, Found Eligible and Included, the Prisma Flow Diagram was found helpful. Out of 71, twenty-eight records were found to be duplicated hence removed. 43 records were screened and out of these, 17 were excluded for various reasons. Number of Full-text articles that were assessed for eligibility were 26, and out of those 26 articles, 7 articles were excluded on full text review for various reasons. Finally, the number of studies that were included in the qualitative synthesis were 19, and these were included for interpretation and gathering knowledge.

They are summarised in the form of a table labelled as Table 1.

Overall, the combined knowledge from all studies (some indicating directly directly and others indirectly) suggest that Pakistani community living within the country seem to show negligible to little understanding of mental health problems including mental illness. Those living abroad also appear to show differences in their model of understanding compared to the countries of emigration. For example, Naeem et al. (2007) report that in their study, people had very little knowledge of mental illness in general and depression in specific. The authors report that there was a striking feature noted in the description of the participants that comprised of lack of name for the condition that they were experiencing, though description of physical symptoms was offered, and they felt that they suffered from some sort of physical illness. In the same study, researchers found that participants typically used expression like ‘weakness of brain or illness of brain’, ‘illness of suffocation’, ‘illness of poor sleep’ or ‘tension’ as the cause of their problem. When asked if they heard or knew anything about ‘Depression’, they answered in negative. Somatisation was also reported by Rashda et al, (2000) in the first and second-generation Pakistani community living in the United Kingdom. The researcher concluded that somatisation is a part of the model of understanding of this community. Choudhry et al. (2013, 2018) worked with two ethnic minority groups, one of which had a different religious identity compared to the dominant group in the country; however, the findings seem to suggest that with regards to the perceptions of mental illness, these minority groups also had more or less similar kind of views as that of the majority population, for example, one of the identified themes comprised of complete denial of the mental illness altogether. Some studies attempted to find illness perceptions about Depression and Schizophrenia in particular. Cinnirella et al. (1999) conducted their study on Pakistani community in the UK and reported that beliefs about Schizophrenia and depression were ambiguous, contradictory and subject to confirmation by personal experience rather than tested via falsification. In Pakistan, Zafar et al. (2008) focused on finding perceptions of people about Schizophrenia and reported that only 30% of participants attributed mental illness as the main cause of psychotic symptoms, whilst the majority attributed Schizophrenia to ‘God’s will’, ‘superstitious ideas’, ‘loneliness’ or ‘unemployment’.

When we combine the knowledge from all the studies that were conducted on majority ethnic groups that throw light on causation of mental illness, four themes regarding the causation of mental illness emerged. These include mental illness as an outcome of medical or physical health problem, mental illness as an outcome of spiritual or supernatural problems, mental illness as an outcome of religious problem and mental illness as an outcome of psychological problem. Even when we incorporate the understanding of minorities living within Pakistan, Choudhry et al. (2013, 2018) reported that participants identify biological/medical reasons more as possible cause of mental illness, instead of psychological or psychiatric reasons.

Indirectly, the same information emerged from some studies that aimed to find the choice of practitioners that Pakistani people preferred to address their mental health problems, for example, some studies found that participants chose the General Practitioners and Hakims (those who deal with nonallopathic medications), as the findings reported by Mirza et al. (2006). Pakistani people living within Pakistan or outside as immigrants also like to consult faith healers and religious leaders for the experiences and presentations that might be indicative of mental health problems.

Supernatural and spiritual reasons are also consistently identified by the researchers as one of the major causes of mental health problems. If we think of minorities first, Choudhry et al. (2013, 2018) reported supernatural reasons in both papers as causative factors identified by participants for their mental health problems. Studies conducted on majority also confirm the same; for example, Saeed et al. (2000) found that the faith healers have a classification of spiritual and supernatural causes that they offer to the participants that might be causing mental illness, such as ‘Saya’, ‘Jinn possession’ and ‘Churail’ are separate entities that faith healers may offer solutions for to individual participants.

Multiple studies highlight the importance of religion when it comes to understanding or addressing the mental health problems. Religion appears to be playing a vital role in the understanding of the Pakistani population with regards to their mental health problems. For example, Cinnirella et al. (1999) reported that religious affiliation intertwines with ethnic origin or result in some important differences in the beliefs prevalent in Pakistani community living in Britain. Croot et al. (2008) attempted to find the reasons participants (parents and grandparents) ascribe to the learning disability of their children/grandchildren and found that participants felt that there could be theological reasons for the disability of their children, including disabilities being ‘gift from God’, ‘test from God’, ‘chosen parents’, ‘punishment’ and ‘curse’.

Participants in a few studies identified psychological reasons responsible for their mental health problem, though the proportion of such participants in the included studies were remarkably low. For example, Naeem et al. (2007) discovered that participants believed that mental health problems were the result of stress or trauma. Again, with a minority group, Choudhry et al. (2013, 2018) reported that participants identified that psychological disturbances emanate from lack of sharing caused mental illness, further elaborating that the rich don’t share with poor and with self-downing, that is, what can we do, it’s all circumstantial. Imran et al. (2015) found in the younger aged participants that adolescents’ own emotional state, stress, family problems and bad luck were endorsed by the participants as some of the causal factors in their mental illness. Sadia et al. (2017) report that stress, family problems, lack of friends and financial worries were endorsed strongly by the participants as the cause of their mental illness.

Gunasinghe (2018) reported that their research interviews illustrated tensions that the participants experienced when considering ‘izzat’ (a culture specific concept), that is, how issues related to izzat are negotiated to enable them to self-manage or seek help, and possible life experiences that might lead to self-harm and attempted suicide. These culture specific concepts also point towards the psychological causation of mental health problems.

Religion, faith and cultural customs have been reported by the participants as protective factors against mental illnesses. For example, Cinnirella et al. (1999) found that in terms of religion, it emerged that the Pakistani participants felt that religion did have a positive impact on their choice of strategies for dealing with depression. Choudhry et al. (2018), on their study on Kalasha ethnic minority community, found that psychological resilience and cultural protective factors were identified by the participants as buffers against mental health problems including intra-communal bonding and sharing; Kalasha festivals and traditions; purity concept; behavioural practice of happiness and cognitive patterns unique to Kalasha community.

If we combine the relevant information regarding the treatment options, the most common types of practitioners preferred by the Pakistani community are quite succinctly summarised in the study conducted by Mirza et al. (2006), who found that five different types of health care providers are offering their services including general practitioner (GP), Religious Healer (Maulvi, Peer, Fakir), Hakim (a form of Unani/Greek medicine practitioner), Homeopathic doctors and Faith Healers (Amil, Sinyasi). They found that all these five main types of primary mental health care providers were using a range of physical, spiritual and psychotherapeutic treatments. Shah et al. (2018) reported that the majority (86%) of patients having significant symptoms of major mental illness visited a traditional healer prior to their engagement with the mental health services.

In a separate study, Tareen et al. (2008) found that participants in their study consulted medically qualified practitioners, Homeopathic doctors and Hakims, who mainly prescribed physical treatments such as tablets, syrups, powders and pastes; and religious and faith healers, who relied mainly on psychotherapeutic methods such as prayers or giving amulets.

Worryingly, in a small minority of cases, physical beating was used as a part of the treatment process in the above mentioned study.

Saeed et al. (2000) noted that the classification used by faith healers is based on the mystic cause of disorders: saya, jinn possession or churail. In their study, they interviewed participants following their interactions with faith healers and found that sixty one percent of attenders were given a research diagnosis of mental disorder. They also noticed in their study that there was little agreement between the faith healers’ classification and DSM-IIIR diagnosis.

For expatriate Pakistanis, the choice to seek help from not medically qualified traditional practitioner in the community was also found by Rashda et al. (2000), who reported that in Pakistani community living in the UK, treatment expectations varied with some emphasis on traditional Pakistani treatments such as Faith Healers and Hakims, as well as general practitioners and hospital treatments. The researchers found that language difficulties, religious practices and cultural practices were also identified as barriers in treatment of mental illnesses especially in case of female patients.

Naeem et al. (2007) reported that the participants believed that mental health problems were the result of stress or trauma, and that only medicines could help them. Zafar et al. (2008) found that only 22% of the participants reported mental illness as the single most important cause of their mental health problems. When they talked about management with same set of participants, only 40% reported psychiatric consultation to be a considerable management step. Other responses included spiritual healing and social changes, whilst 14.8% of respondents said that they would do nothing.

Pakistani communities don’t dismiss the possibility of treatment by mental health professionals altogether, for example, Suhail et al. (2019) reported that in their study population, more people believed that general practitioner’s (23.76%), psychologists (23.92%) and psychiatrists (20.73%) were the right people to consult for these problems. Compared to the above, there were also a lesser proportion who considered Hakims/Homeopathy Practitioners (4.22%), Magical Healers (13.11%) and Religious Healers (13.54%) as the appropriate people to contact, but their percentage was less as compared to those who preferred medical and mental health professionals.

Findings of choosing the non-medical means of treatment were also replicated in the studies conducted with ethnic minority groups as well; Choudhry et al. (2018) found that participants from Kalasha community identified a variety of preferred interventions including shamanic treatment; ta’awiz (amulets); communal sharing and problem solving; medical treatment and herbal methods for management of their mental difficulties or problems.

With regards to treatment seeking behaviour in the expatriate Pakistanis, Cinnirella (1999) reported that the Muslim Pakistani participants in their study indicated a fear of community stigma associated with mental illness or, more worryingly, even the act of seeking help, which according to authors must surely have an impact on the actual coping strategies and help-seeking behaviours. In terms of help-seeking behaviours, their study has also highlighted a tendency for the members of Pakistani community to prefer consultations with professionals of the same background. Here, fear of being misunderstood due to ignorance of cultural and religious practices, intertwines in a complex fashion with the fear of being the target of racism, and a general feeling that it is easier to talk to professionals with whom one shares a common group identity. Sheikh et al. (2000) carried out their study in the UK and reported that positive attitudes toward seeking professional help for psychological distress were similar for British Asians, Westerners and Pakistanis. However, they found significant differences between the three groups in the causal attributions of mental distress.

James et al. (2002) studied the acceptance of an integrated mental health service at a three month’s follow up period and reported that individuals’ use of integrated mental health and other care was modest. Perceptions improved over three months.

Description of some culturally specific terms used in results section is as follows:

Hakims are a kind of health care professionals in Pakistan that deal with non-allopathic medications; they claim to be using Greek (locally called Unani) medications.