The following Newsletter was written by a Pakastian psychologist. I found the article to be a clear description of treatment in that country. I believe very strongly that it is important to be aware of treatment with schizophrenia throughout the world. I found this person’s understanding of this condition to be progressive and I hope that the reading audience will appreciate, as I do, this presentation.

Schizophrenia in Pakistan
Written by Shakila Akhtar
sapkwah@hotmail.com

Schizophrenia, characterized by gross distortion of thought, perception and emotion is also prevalent in Pakistan with all its symptoms and dramatic features. About 1.5% of the population is suffering from this ailment. Schizophrenia occurs in both male and female with same frequency and the onset usually occurs between the ages of 15-40 years. Out of all four types of schizophrenia__catatonic, hebephrenic, paranoid and undifferentiated, paranoid schizophrenia is the most common. One o f the study done by a local doctor reveals that 6% of the schizophrenics run the risk of committing suicide due to depression hich sets in when problem aggravates and due to lengthy treatment, he loses hope.

All the above mentioned data is based on the studies conducted only on the patients reported to hospitals and clinics. But there are a lot of patients who are suffering from schizophrenia but they never come in contact with psychiatric services because about 70% of the population lives in rural areas. The literacy rate over there is low and they don’t have any knowledge of schizophrenia. So when ever anyone of them is suspected of this disorder they always attribute it to magic or possession of spirit or demon. As they have their own etiology so they have their own therapies and therapists. Instead of consulting psychologist or psychiatrist they go to faith healers and religious quacks who gave them holy water or sanctified ointment. Sometimes they visit holy shrine and believe that their visit can help them in getting rid of possession of spirits. Sometimes patients are punished brutally by their so called therapist with the notion that they are inflicting pain to evil spirit and not to the patients and their punishment will force the spirit or demon to run away and leave the possessed. Some even believe that marriage is the best remedy for schizophrenia. It is not known how the Hippocrates’s remedy for female suffering from hysteria (wondering of the uterus to various parts of the body longing for children) has transformed in to its deteriorated form, in this part of world for both male and female schizophrenics Such practices are also prevalent in other countries even in the most developed and modern countries but the ratio of such people is very low as compared to Pakistan. Here majority has these Stone Age primitive believes.

The stigmas attached to schizophrenia such as rejection, humiliation, isolation etc also don’t let people to see a psychologist. Even if they know that there is something wrong with them, they are reluctant to accept the truth and thus hide their problem. Schizophrenia is increasing alarmingly due to poverty, unemployment, political instability, violence, urbanization, sexual abuse and other social evils besides genetic and biological vulnerability.
In Pakistani rural society caste and bradri (people belonging to same caste) system is deep rooted. Due to bradri a strong feeling of ethnocentrism exists among its members. As more and more people have started moving to ward urban areas, their mobility is weakening their bond with bradri because in urban areas people are stratified on the basis of the socio-economic group and not on the basis of caste. Thus the feeling of oneness, belongingness, and love which are characteristic features of ethnocentrism are also declining and creating a number of emotional and mental problems. These problems are inducing stresses that may sometimes lead to schizophrenia.

Due to bradari system endogamous marriages (marriages within family) are also in common practice over here. People always prefer their first cousin for marriage if mate is unavailable among first cousins than they look for second and so forth. Such practices are increasing the risk of both biological and mental disorders. Though a couple of organizations are trying to educate people through media about ill consequences of intermarriages and people have started realizing the fact yet the majority still prefers it.

Investigators have found that sexual abuse is also crucial in causing schizophrenia in women. women after going through the trauma of rape experiences a lot of mental stress because she has to keep her lips tight against the victim because he is usually strong and powerful and can easily mould the facts in court proceedings in such a way that the victim herself turns out to be the cause of the crime. So due to negative consequences, a lot of social stigmatizations, crude and insulting treatment of police, and cheap interrogation by the defense attorney during the court proceedings prevent the victim from taking any step against the victim.

There are some investigators who are more interested in genetic and biological causes of schizophrenia. They firmly believe that schizophrenia is solely caused by a biological or a biochemical or a neurophysiologic factor so the best therapy for schizophrenics is either drug therapy or electro convulsive therapy. It’s true that in schizophrenics biological changes can be seen but they can never be attributed as the main causal factors. Studies have revealed that even in the presence of genetic predisposition for schizophrenia, people tend to have adequate mental health throughout their life and manifest these symptoms only when they come in contact with stressful environmental factors responsible for precipitating schizophrenia. Similarly biochemical changes can be observed in these patients but it can’t be said that it is these changes that stimulate schizophrenia or vice versa.

Some researchers from University of Jamshoro, Pakistan in collaboration with Australian researchers are studying a number of large highly inbred, multiply effected schizophrenia pedigrees from Pakistan for the purpose of identifying new susceptibility genes. According to them these pedigrees are exceedingly rare in western countries because of low birth rate, small sib ship sizes and rarity of consanguineous marriages. Some other investigators are interested in genome-wide linkage analysis by using a set of microsatelite markers in several extended multiply-affected families from Pakistan and Scotland.

Professionals here are using both physical and psychological therapies for schizophrenics. But in government hospitals psychiatrists usually employ electro-convulsive therapy and drug therapy for schizophrenics because they consider psychotherapies as ineffective for schizophrenia. Some of them don’t even bother to take their complete case histories and just recommend them either drugs or ECT after noticing the symptoms of schizophrenia with the predetermined believe that schizophrenia is a biological disorder so it should be treated with biological methods. In addition to these there are some who do believe in the importance of psychotherapies but are unable to practice them at public hospitals because of the large number of indoor patients. There is only one doctor for 15 patients, 1 clinical psychologist for 158 patients, 1 social worker for 425 and 1 paramedical person for 8 patients.

Some professionals on the other hand are totally against ECT and chemotherapy. They consider ECT as brutal and inhuman due to its mode of technique and the side effects associated with it such as memory impairment and brain damage. They even recommend the use of chemotherapy only if it is desperately needed and emphasize the importance of psychotherapy. Drugs which are used for the treatment of schizophrenia are known as narcoleptics. They are divided in to two main groups __ typical and atypical according to the side effects precipitated by them. typical drugs have more side effects but less expensive as compared to atypical antipsychotic drugs that’s why they are more popular. The common short term side effects associated with drugs are feelings of drowsiness, sedation and apathy ,blurred vision and dizziness, akathisia., menstrual disruption (irregular/painful periods),breast enlargement (male and female),reduced sexual desire and weight-gain.

Although the government’s contribution toward mental health is quite unsatisfactory yet some non government organizations are performing remarkable services in this regard. They are conducting researches and surveys, organizing conferences on mental health, educating masses about mental health through media, and performing a lot of other activities.
Unfortunately there is no single institution that is solely working for schizophrenia but Fountain House Lahore, Pakistan is performing a lot of services for schizophrenics. There are a large number of schizophrenics whom they are offering not only treatment but also the rehabilitation services so that after recovery they can integrate back in to the society at large. Some of the common therapies that they are offering to schizophrenics are as follows:

Art and music therapy
Cognitive behavior therapy
Token economy
Gestalt’s empty chair technique
Social skill training
Occupational therapy
Family therapy

The patients in Fountain House are working on different projects which after completion are sent to market for sale. Patients are also assisting the administration in different minor works like running the Fountain House canteen, maintaining the garden and lawn of Fountain House e.t.c.

Another important project working at private level is the Manora Heath Project. It is a joint venture of Hamdard University Karachi, Pakistan and Knoll pharmaceutical company. The aim of the project is to conduct door to door survey and provide mental health to those who need it. . The team working on the project is to live with the community to observe their habits, attitudes and disease patterns. Initially they are working in Manora, an island near Karachi, Pakistan where no heath facilities are available. The members of the project are helping them in private capacity. Soon they will broaden their services to other remote areas of the province and country.

The realization of the seriousness of schizophrenia is persuading the NGO’s and private sector to do more and more for this. Hope their efforts will have good repercussions in terms of mental health promotion.

Prognosis in this part of world is more positive as compared to developed countries due to joint family system, strong family ties and adequate and due support from family and friends. Raynond cochraine, a professor of psychology at the University of Birmingham, U.K. has researched many Pakistanis living in Britain and has found that they have low rate of illness but have relatively good chances of recovery due to their strong and supportive family structure. Schizophrenia can be reduced to a significant level by working patiently about it. The patients as well as their relatives want immediate recovery. Prolonged hospitalization and medication are considered as the sign of either incurability feature of the disease or incompetency of the therapist. Sometimes even the therapist gives up hope if he can’t achieve desired outcomes of his therapy in desired predetermined period of time. Family intervention and regular follow up can reduce relapse.

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