Murad Moosa Khan

Case–control study of suicide in Karachi, Pakistan

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

Male gender preference, female gender disadvantage as risk factors for psychological morbidity in Pakistani women of childbearing age - a life course perspective.

BackgroundIn Pakistan, preference for boys over girls is deeply culturally embedded. From birth, many women experience gendered disadvantages; less access to scarce resources, poorer health care, higher child mortality, limited education, less employment outside of the home and circumscribed autonomy. The prevalence of psychological morbidity is exceptionally high among women. We hypothesise that, among women of childbearing age, gender disadvantage is an independent risk factor for psychological morbidityMethodsA cross-sectional catchment area survey of 525 women aged 18 to 35 years living in Islamabad and Rawalpindi. The effect of gender disadvantage was assessed as a latent variable using structural equation modelling. Indicators were parental gender preference, low parental care, parental overprotection, limited education, early age at marriage, marital dissatisfaction and low autonomy. Psychological morbidity was assessed using the 20 item Self Reporting Questionnaire (SRQ).ResultsGender disadvantage was independently predictive of psychological morbidity. Among married women, socio-economic status did not predict psychological morbidity, and the effect of education was mediated through gender disadvantage rather than socioeconomic status (SES). The womens own preference for a male child was strongly predicted by their perceptions of having been disadvantaged by their gender in their families of origin.ConclusionsThe high prevalence of psychological morbidity among women in Pakistan is concerning given recently reported strong associations with low birth weight and infant stunting. Social action, public policies and legislation are indicated to reduce culturally embedded preferences. Neglect of these fundamentals will entrench consequent inequities including gender bias in access to education, a key millennium development goal.

Marital satisfaction in Pakistan: A pilot investigation

The concept of marital satisfaction is an important area of research in the context of marriage and family relationships. This has not been previously examined in Pakistan, a conservative patriarchal Islamic country, where studies examining psychiatric morbidity have shown marital problems as contributing to Common Mental Disorders (CMDs). Young married women under the age of 35 years appear to have a higher prevalence of CMDs than older married women. In this pilot study, using both a quantitative and a qualitative approach, we examined the construct of marital satisfaction and tested the applicability of marital satisfaction scales developed in the West for use in Pakistan. The results indicate that, contrary to cultural beliefs regarding marriage, most women expressed the need to be satisfied within marriage. The fear of hurting or annoying their parents prevented many women from openly expressing their opinion in the choice of husband or unhappiness in their marriage. Pakistani women tend to see marriage as a social and familial obligation requiring them to be prepared to adjust as the man seldom does. The construct of marital satisfaction is a viable concept for study and research in Pakistan, and there is need for further research in this area.

The validity of the Parental Bonding Instrument as a measure of maternal bonding among young Pakistani women.

BackgroundParenting may have an important influence upon women’s mental health in societies characterized by strong male gender preference. The Parental Bonding Interview (PBI) has been very widely used, but not yet formally evaluated in a South Asian context. The purpose of this pilot study was to assess the factor structure, face and concurrent validity of the PBI as an assessment of maternal bonding among young Pakistani women.MethodsA total of 86 women, aged 20–35 years, were identified by door-knocking in two small catchment areas in Islamabad/Rawalpindi, one characterized by higher and one by lower socio-economic status. The PBI, the Clinical Interview Schedule Revised (CIS-R) and the Marital Satisfaction Scale (MSS) were each administered by a female interviewer in the respondent’s home.ResultsAll women agreed to be interviewed privately, the response rate was 100%. Consistent with previous reports, PBI items loaded on two well-characterized internally consistent scales, care and overprotection. In a three-factor solution, the overprotection scale divided into two subscales previously characterized as “Encouragement of Behavioral Freedom” and “Denial of Psychological Autonomy”. Concurrent validity was supported by correlations in the expected direction between PBI care and overprotection subscales and both psychological morbidity (CIS-R) and marital satisfaction (MSS).ConclusionsPakistani women seem to perceive and respond to PBI items as addressing parental “control” or “overprotection” in a similar similar way to respondents from western Anglophone cultures. This study provides further support for the core construct validity of the PBI, and indicates a perhaps surprising degree of sensitivity to cultural nuances.

Suicide and attempted suicide in Pakistan.

Suicide and attempted suicide are understudied subjects in Pakistan, an Islamic country where they are considered criminal offenses. National suicide statistics are not compiled nor are suicide mortality statistics reported to the World Health Organization (WHO). Although there are strong religious sanctions against suicide, there are no clear principles against attempted suicide in Islam. Despite this, Pakistan, like many other Islamic countries, has punitive laws against attempted suicide. This has led to both suicide and attempted suicide being underdiagnosed and underreported. Data on suicide and attempted suicide are also difficult to obtain. This article gives an overview of the current state of suicide and attempted suicide in Pakistan, in the context of existing religious and legal factors, high-lighting the main findings of the few studies carried out over the last 50 years. It is important that researchers in Islamic countries like Pakistan not be deterred by the apparent low rates of suicide in these countries, but conduct further research in this important yet neglected public-health problem.

The Effect of Clinical Clerkship on Students' Attitudes toward Psychiatry in Karachi, Pakistan.

ObjectiveAttitudes of medical students toward a specialty is strongly related to their future choice of specialty. In developing countries like Pakistan, where there is a shortage of psychiatrists, there is a need to assess the effect of exposure to psychiatry on medical students.MethodsThe authors conducted a survey of fourth-year medical students at Aga Khan University in Karachi, Pakistan.ResultsPsychiatry clerkship had an overall positive attitude toward psychiatric illness, patients, and psychiatrists, but no effect on students’ choice of psychiatry as a career.ConclusionPsychiatry teaching needs to be made more relevant to the rest of the medical curricula. This may improve students’ interest and their future choice of psychiatry as an area of specialization.

Female Suicide Rates in Ghizer, Pakistan

Suicide is an understudied subject in Pakistan. There are many social, legal, and religious sanctions against it. National rates of suicides are not known. We calculated suicide rates of women in the Ghizer District of the remote Northern Areas of Pakistan. During years 2000 to 2004, 49 women committed suicide. Taking average mean population for women for 5 years as 65,783, we calculated annual crude suicide rates for women as 14.89/100,000/year. For women over the age of 15 years, rates were 33.22/100,000/year; age-specific rates for 15-24 years were 61.07/100,000 per year. These figures are considerably higher than suicide rates in other parts of Pakistan and may be related to high psychiatric morbidity in Pakistani women. This study underscores the need for a standardized system of registration of suicides in Pakistan. There is also urgent need to address high psychological distress in women in Pakistan.

Epidemiology of suicide in Pakistan: determining rates in six cities.

In recent years suicide has become a major public health problem in Pakistan. Despite this there are no official statistics on suicide and national rates are unknown. To determine rates we carried out an analysis of suicide reports from six cities in Pakistan. Rates vary from 0.43/100,000 in Peshawar to 2.86/100,000 in Rawalpindi. Rates for men are consistently higher than women; highest rates for men were 7.06/100,000 between the ages 20–40 years in Larkana, Sindh province. Given the legal, socio-cultural, and religious stigma of suicides in Pakistan, we believe these figures to be an underestimate. There is urgent need for a standard system of recording of suicides in Pakistan, so that true rates can be determined. This will help in informing policy and monitoring effectiveness of suicide prevention programs.

Use of electroconvulsive therapy at a university hospital in Karachi, Pakistan: a 13-year naturalistic review.

There are very few reports of electroconvulsive therapy (ECT) from developing countries, where lack of regulation and misuse has lead to negative publicity. We present our experience of ECT use at a university hospital in Karachi, Pakistan, over the course of 13 years. During the study period, 4013 patients were admitted to our inpatient unit, of which 136 (3.38%) received ECT. ECT was conducted under the supervision of consultant psychiatrist and anesthetist with continuous monitoring during and after the procedure. The most common indications were mood disorders. The average number of ECTs administered per patient was 6 (range, 1-20). A total of 35% of patients had medical comorbidities but did not suffer any deleterious effect from the procedure. A total of 75% patients showed improvement in their clinical condition. No major complication was observed in any of the patients. Our study demonstrates the effectiveness if ECT in a low-income, developing country. We strongly recommend following guidelines to ensure patient safety and minimizing side effects. This will ensure better patient acceptability and compliance.

Attitudes Toward Suicide Bombing In Pakistan

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