Khalid Mahmood^*, Faisal Siraj, Aliya Zafar
National Tuberculosis Control Program, Islamabad, Pakistan.
DOI: 10.4236/psych.2025.166041   PDF    HTML   XML   147 Downloads   1,008 Views   Citations

Abstract

Background: Pakistan faces high rates of mental health disorders, limited awareness and strong social stigma surrounding mental illness. There is a critical need to develop, evaluate and implement strategies aimed at reducing both self-stigma and societal stigma associated with mental health issues. These strategies should prioritize improving mental health literacy, reducing stigma and fostering trust in the effectiveness of mental health services. Aims: The study aims to identify the extent of mental health stigma in Pakistan, highlighted in various studies, contributing to the significant treatment gap and reluctance to seek help for mental illness and attempts to combine the recommendations of the studies for addressing this challenge. Methods: Literature search included articles from 2000 to 2024. PubMed and Google Scholar were the main search engines utilized. From the total articles searched, only the ones showing a link to the study title were included in the study. 57 articles were selected for writing this article. Results: Literature highlighted the importance of community awareness, integration of mental health in primary healthcare, task shifting, research, use of technology, enhancing mental health literacy, community involvement and support. Clear focus on these aspects may lead to reducing the mental health stigma in Pakistan. Conclusions: This paper explores the extent of stigma about mental health illnesses in Pakistan. A number of interventions appear to be effective in cutting down this stigma. The review may serve as an essential resource for program planners and decision-makers in provision of improved services for mental health ailments.

Keywords

Stigma, Mental health, Low- and Middle-Income Countries, Pakistan

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1. Introduction

Pakistan, as a developing country with limited socioeconomic resources and restricted access to mental healthcare, faces significant mental health challenges. Approximately 10% - 16% of adults experience anxiety and depression, with symptoms ranging from mild to severe. Additionally, around 1% - 2% of the population is affected by serious mental illnesses such as schizophrenia and bipolar disorder. About 15% of children and adolescents also suffer from mental health disorders. Key barriers to timely mental health treatment include a lack of awareness, widespread misconceptions and persistent stigma surrounding mental health issues (Siddiqui, 2021). Stigma is defined as a mark of disgrace linked to a specific condition, trait or individual (Khan & Irfan, 2023). Stigma is a major barrier contributing to the significant treatment gap and reluctance to seek help for mental illness (Abd El Salam et al., 2023). Stigma may be considered as a construct involving problems of knowledge, attitudes and behaviour (Koschorke et al., 2022). Globally, huge stigma is attached to various psychiatric illnesses. Comparatively, Asian countries have higher levels of discriminating attitude for people with psychiatric disorders (Laraib et al., 2018). Stigma connected to mental disorders results in poor treatment, social isolation, problems in getting education and employment. Hence, stigma has been recognized as both public health issue and a big challenge for human rights by World Psychiatric Association (Le Glaz et al., 2022). This necessitates the implementation of culture specific interventions that aim to lessen adverse social and cultural norms and stimulate compassion for people with mental ailments. It may be claimed that implementation of appropriate interventions in poor countries can foster an alternate and accurate view of mental ailments resulting in better-quality knowledge and link with services (Waqas et al., 2020).

2. Methods

The literature search included articles from 2000 to 2024. PubMed and Google Scholar were the main search engines utilized using MESH terms mental health, stigma, stigmatization, social stigma, mental health stigma, Pakistan, low- and middle-income countries. Studies that explored views, perceptions and attitudes toward mental health issues and its treatment were identified. Eligible studies included those examining the extent of stigma about mental health, knowledge, help-seeking behaviours and factors influencing mental health and stigma, conducted in Pakistan and other low- and middle-income countries, drawing from peer-reviewed journal articles and dissertations. Out of these, the non-relevant topics and studies were omitted and only the ones showing a link to the study title were included in the review. There were no restrictions on study design. Only papers published in English were screened and extracted, however, studies conducted before the year 2000 or published in languages other than English were excluded from the review. The title and abstract of each article were used to determine initial relevance. From the total articles searched 57 were selected for writing this article.

3. Results

Pakistan’s healthcare system needs substantial reforms to meet the needs of its population. Key challenges include a limited budget, inadequate staffing and facilities, insufficient emphasis on preventive care, unequal distribution of resources and political instability. To overcome these issues, comprehensive policies should focus on increasing healthcare funding and ensuring fair allocation of resources (Mirza & Lodhi, 2024). Unlike physical ailment, mental illness has an added burden of stigma that increases individual suffering. In cultures like Pakistan when there is lack of awareness about psychological issues, people try to hide their psychological ailment due to fear of having cold response (Nawaz et al., 2021). About 70% of population in Pakistan lives in rural areas within a traditional feudal or tribal system having limited awareness regarding mental health. Mental ailments are generally stigmatized and are supposed to have super natural grounds. Hence, a large number of patients pursue help from traditional faith healers and religious leaders (Aijaz & Ambareen, 2014). Traditional sources of treatment for individuals with mental illness often include seeking help from religious leaders, visiting shrines, purchasing remedies from medical stores, and turning to unlicensed practitioners. Families frequently take affected individuals to religious leaders, who use spiritual or religious methods for treatment. Many people hold strong beliefs in the healing power of graves and shrines, making spiritual visits a common practice for mental health issues (Shah et al., 2022). People are mainly worried about the community gossip which would have a negative impact on their family’s honour (Kiran et al., 2021). Personal and social stigma emerged as a significant barrier to seeking help (Qahar et al., 2020). Pakistan has higher rates of mental ailments, low literacy rate and awareness and social stigma around mental illness. There is also a shortage of specialised mental health providers and units, limited financial resources and budgetary constraints for mental health (Shah et al., 2022). In Pakistani society, the stigma surrounding mental health issues often prevents individuals from seeking help, leading them to suffer in silence (Naveed et al., 2023). Social stigma and the reluctance of individuals to seek help for their health concerns exacerbate the challenges within Pakistan’s mental healthcare system (Aga et al., 2023).

4. Discussion

Addressing mental health stigma in community and sociocultural acceptability of programmes would play an important role in the acceptance and delivery of the mental health interventions. Lacking well-organized anti stigma campaigns and inventiveness at national and subnational levels, it is not easy to change these stigmatizing thoughts (Imran & Haider, 2007). Enhancing mental health literacy serves as an effective intervention against stigma. This can be achieved through greater involvement from both the government and private sectors by organizing awareness walks, public discussions, educational programs, utilizing both print and social media and establishing community centres for mental health screening and treatment. These initiatives can contribute to a more mental health-literate society, reduce stigma, and ensure better mental health care for the population. (Wazir et al., 2023; Raji et al., 2022). Awareness campaigns can have benefit from the involvement of youth and religious leaders. Additional approaches are required to involve parents and make psychosocial support more accessible through community and school-based interventions (Vostanis et al., 2022). Increased knowledge is a key factor in encouraging young people to seek formal mental health support by fostering early familiarity with these concepts and particularly important in reducing stigma (Rabbani et al., 2023). Integrating spiritual perspectives into mental health education could be a valuable approach (Ahmad & Koncsol, 2022). Local and regional mental health advocacy organizations can play a key role in raising awareness and reducing stigma associated with mental illness across countries (Arafat et al., 2022). Media can play an important role in anti-stigma campaigns by apprising the optimistic viewpoints and success stories of patients of mental illness who recovered and became active and productive members of society (Farhat, 2024). Other effective measures for reducing stigma may be efforts by influencers and celebrities, sharing of personal narratives to cultivate mental health efforts and promoting the idea that mental health is a normal part of life and avoiding stigmatizing terms (Husain et al., 2020). Family, friends and peer support are a central part of informal support that may inspire the adolescents to have acceptance, breaking of individual barriers and the facility to find assistance without the strain of damaging outcomes (Nizam & Ali, 2021). Anti-stigmatization strategies for Pakistani adolescents must consider cultural beliefs regarding the causes of mental health conditions (Imran et al., 2015). A more proactive, community-based approach to active case detection is essential (Mohsin et al., 2021). There is a rising evidence on such community-based, psychosocial interventions in various countries (Giebel et al., 2022). Studies recommend that community-based interventions and psychoeducation tailored to address the cultural impact of internalized stigma may be acceptable, effective and impactful and may have value in dropping the effect of stigma (Willmot et al., 2023; Ghanem et al., 2023; Pokharel et al., 2023). Developing culturally relevant psychological interventions to address emotional distress caused by Pakistan-specific stigma and misinformation could help alleviate caregiver burden and improve treatment outcomes (Khan et al., 2023). The encouraging effects of culture related mental health psychosocial support was found for programmes that were able to adjust on the basis of cultural contexts, stigma and vulnerable populations (Rowe & Nadkarni, 2024). Furthermore, community members communicate using shared cultural idioms, which can foster trust, enhance communication and ultimately lower barriers to seeking mental health support, thereby reducing stigma (Van den Broek et al., 2023). Bridging the treatment gap caused by stigma and discrimination requires the dissemination of information in a clear and structured manner, such as psychoeducation for both patient and family. A collaborative approach involving psychiatrists, patients, families, and clinical psychologists is essential (Aziz & Khan, 2021).

Studies highlight the potential for collaboration between the education and health sectors to develop joint policies that promote school mental health (Imran et al., 2022). School-based interventions can improve mental health literacy and reduce stigma in the short term (Ma et al., 2023; Gallego et al., 2020). A lack of awareness and training among teachers in recognizing and supporting students with common mental health conditions, coupled with the stigma surrounding mental health issues, serves as a major barrier to seeking professional help. Programs that pursue psychosocial interventions to susceptible populations, the combination of an educational element that emphases on challenging fallacies about mental illnesses is significant for dropping stigma (Siddiqui et al., 2022). According to World Health Organization, School-based mental health programs should be inclusive and tailored to meet the diverse needs of children and adolescents of all genders and must also address the needs of marginalized and vulnerable children to prevent reinforcing stigma, discrimination and exclusion (World Health Organization [WHO], 2022). In Pakistan, increasing awareness of mental health has led to growing concerns among university students, addressing these issues requires an intervention that fosters resilience by helping students utilize their inner resources. Mindfulness offers a stigma-free, self-exploratory approach that cultivates acceptance and balance (Sarfraz et al., 2023). Stigma is not only prevalent among the general public but is also widespread in sectors such as healthcare, where research highlights the need for specialized training in medical and healthcare education (Gallego et al., 2020). To effectively reduce stigma, mental healthcare should be made accessible to medical students from the start of their education (Berliant et al., 2022). Notably, media portrayals of mental illness have been found to have the strongest association with reducing negative perceptions among medical students (Azad et al., 2022). Workplace health promotion programs specifically designed for healthcare workers should be introduced to minimize stigma associated with mental illness. Additionally, organizations should endorse anti-stigma while providing mental health training that emphasizes social interaction to help reduce workplace stigma (Malik et al., 2023). Reforms of legislation, trained manpower, enhanced resource allocation, and improved services are vital for better results (Naveed et al., 2020).

Youth participation favoured the use of digital technology effective in enhancing knowledge, engagement and uptake of interventions (Vostanis et al., 2022). Digital mental health is far more accepted among the younger population. Flexibility and anonymity of digital platforms enable them to interact with healthcare professionals without fear of social stigma. This accessibility allows them to receive therapy conveniently through their smartphones from the comfort of their homes (Imran & Haider, 2022). Computerized interventions that may be done from home may be useful for an individual to pursue help from healthcare professionals (Bibi et al., 2020; Pokharel et al., 2023). By embracing telepsychiatry, which utilizes phone calls and virtual consultations to deliver mental healthcare to patients gain improved access to qualified mental health professionals while reducing both time and financial burdens (Aga et al., 2023). Virtual consultation will be specifically useful for persons with restricted access to mental healthcare because of disabilities and geographical or time limitations and for those who desire secrecy due to stigma around mental illnesses (Usmani et al., 2022). Digital health interventions are gradually making their way into Pakistan’s healthcare landscape. However, numerous challenges still hinder their widespread adoption. These include limited internet access, low rates of phone ownership, poor network coverage, the absence of regulatory frameworks, inadequate data protection and security measures and issues related to accessibility, affordability and reliance on paper-based health records—all of which restrict the effective use of digital technologies. Despite these obstacles, digital health is progressing steadily, driven by collaborative efforts from both public and private sector stakeholders (Kazi et al., 2020).

Further research is needed to fully explore the interplay between knowledge, beliefs and attitudes across diverse cultural settings and the relationship between specific types of stigma and active help-seeking (Renwick et al., 2024). It is vital to improve mental health facilities with well-designed research investigating psychopathology of various population clusters (Naveed et al., 2020). Mental health research can greatly benefit from the expertise of local researchers, particularly their deep understanding of sociocultural dynamics. Local researchers, being more attuned to these sociocultural nuances, can guide intervention development efforts to navigate societal stigma and other region-specific challenges (Osborn et al., 2020). Stigma experts stress the importance of interventions that are localized, culturally relevant, and precisely targeted (Ciftci et al., 2013). Given the excessively raised burden of mental ailments and the stigma associated with it, it is necessary to address this universal health issue by building on the sparse evidence base, development of cost-effective prevention policies and strategies (Khoso et al., 2023).

Incorporating mental health in primary healthcare (PHC) will make it readily accessible and eliminate stigma related with obtaining mental health care (Farhat, 2024). There is significant potential to incorporate essential elements of mental health promotion in Lady Health Workers Program curriculum, which could help reduce the stigma (Rabbani et al., 2023). Since many individuals with mental health conditions first seek care through PHC, its integration can lead to earlier identification and appropriate treatment while minimizing stigma (World Health Organization [WHO], 2008). This task-shifting or task-sharing model involves redistributing responsibilities traditionally assigned to mental health professionals to trained non-specialists (Ussif et al., 2021). This approach helps reduce stigma, enhance access and quality of care, minimize the chronicity of mental illness and improve social integration (Rameez & Nasir, 2023). Strengthening collaboration between general physicians and specialist psychiatric services can further improve understanding of mental health disorders (Waqas et al., 2022). Refining the knowledge and skills of non-health professional volunteers in mental health care will have a very encouraging impact regarding prevention, early detection, decreasing stigma and discrimination (Teixeira-Santos et al., 2022). In recent years, numerous studies have demonstrated the effective delivery of psychological interventions by non-specialists who have little or no formal training (e.g., community or lay health workers, peer support workers) (Atif et al., 2022). The task-shifting should integrate inclusive and flexible supervision, well defined referral system and a consistent managerial team (Willmot et al., 2023).

The key recommendations of the various studies are summarized in Table 1.

Table 1. Summary of key recommendations.

An integrated psychological, biological and societal opinion of health care identifying patients as unique persons and not as ailments, without stereotype and have stigmatizing attitudes for mental illness.

Fighting stigma with update knowledge of mental health issues, attend to what patients say about mental illness and its impacts, to be a supporter for those with mental ailment and to challenge stigma on media

Task-sharing providers who have strong community ties, credibility, shared lived experiences, and non-stigmatizing attitudes for mental health issues.

Raising awareness about mental disorders for the general public, healthcare students and professionals. There is a need for a stronger emphasis on psychiatric education into healthcare curricula both undergraduate and postgraduate training.

Utilization of digital tools and literacy-based interventions in addressing stigma among adolescents.

An evidence-based approach for mental health to identify necessary changes, implementing effective solutions, and measuring their impact. Further research into caregiver support and awareness-raising initiatives to combat stigma and social isolation.

Community driven interventions and collaborative approach involving patients, families, clinicians, psychiatrists, psychologists, media, government agencies and organizations, launching initiatives targeting all segments of the population considering cultural beliefs regarding the causes of mental health conditions.

Integrating mental healthcare into primary healthcare centres, aligns with recommended models designed to overcome challenges including service accessibility and affordability.

Improving access to care by reducing financial constraints and increasing the number of mental health professionals, upgrading the procedure of accessing care by reducing wait times, telehealth facilities for inaccessible areas, and formation of online communities and support groups.

A more proactive, community-based approach to active case detection is essential.

5. Conclusion

This paper explores the extent of mental health stigma in Pakistan. A number of interventions appear to be effective in cutting down this stigma. Interventions can offer specific components that may be tailored to meet the diverse needs and local contexts of target populations. Amid the ongoing pandemic and the rise in mental health issues across the general population, the development and implementation of sustainable and effective psychosocial interventions are more crucial than ever. Literature highlighted the importance of community awareness, integration of mental health in primary healthcare, task shifting, research, use of technology, enhancing mental health literacy, community involvement and support. Clear focus on these aspects may lead to reducing the mental health stigma in Pakistan. However, without a well-planned anti stigma campaign and initiatives at national and local levels, it may not be easy to change these stigmatizing opinions. The review may serve as an essential resource for program planners and decision-makers in provision of improved services for mental health ailments. Although, review articles remain a critical tool for summarizing knowledge and identifying gaps in research, pilot studies of various interventions may play a crucial role in improving the quality, efficiency and success of larger, more definitive research efforts. A lot needs to be done to change people’s perception about stigmatization of mental health and to promote mental health in Pakistan.

One notable limitation of this study is the absence of randomized controlled trials (RCTs) or cost-effectiveness analyses among the cited studies, which are considered the gold standard for evaluating the effectiveness of interventions. Consequently, the conclusions drawn from this review should be interpreted with caution, and further research incorporating rigorous experimental designs is recommended to validate and strengthen the findings.

Ethical approval

Being a review article, not applicable.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

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