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Integrating mental health into primary care in remote rural areas of Pakistan

Rizwan Taj1, Asima Mehboob Khan1, Rachel Jenkins2

1 Pakistan Institute of Medical Sciences, Islamabad, Pakistan.

2 Kings College, London.


Objective: To assess knowledge, attitude and competency among mental health care professionals working in primary care.

Method: Fifty mental health care workers in groups of two participated in the study. Both groups received training for 5 days. Structured pre-test and post-test questionnaires were used as assessment instruments.

Results: On the pre-test, the mental health workers scored 65%. On the post-test after receiving five days primary mental health care training, they scored 74%.

Conclusion: It was concluded that health personnel in or linked to primary health care facilities when trained, can better recognize, assess and manage mental disorders (General practitioners, Paramedical staff and Lady Health workers) and refer if necessary.

Key words: Mental health, Primary care


Pakistan is a low income country with 400 psychiatrists, 300 psychiatric nurses, and 300 psychologists for a population 165 million. Most specialists are concentrated in the cities with minimal access to specialist care in rural areas. This means that most people with mental health problems will need to be assessed and managed by primary care teams and community health workers, with only the more complex cases being referred to the specialist. The capacity of these front line health care staff to deliver mental health care would be greatly strengthened if they receive regular continuing professional development on mental health, accompanied by robust basic training. This has been a policy objective of the Ministry of Health and the WHO country office since 2000, and was piloted in two districts in the early 2000s (Karim et al., 2004).

Integration of mental health care into primary care reduces stigmatization and facilitates the use of the social support system (family and community) as an important resource for healing and rehabilitation of mentally ill patients (Murray and Lopez, 1996, World Health Organization, 1990).


Fifty mental health professionals were recruited from various remote areas of Pakistan. The training programme consisted of a five-day module of multi-method teaching (with an emphasis on practical skills acquisition), which covered depression, anxiety, substance abuse and other common problems. Teaching was done through slides, role-plays and videos. A structured pre-test and post-test questionnaire was used as instrument of evaluation.


Result of the study shows that both groups of mental health professional scored higher marks after receiving 5 days primary mental health care training (See table 1).

Table 1 – Summary of Scores




Total Score







Result shows improvement in knowledge after five-days of primary mental health care training.

General practitioners and other primary care professionals frequently identify, treat and refer people who have severe mental health problems. The basic curriculum for the general health workers needs review to include core competencies for assessment and management of common mental disorders. The mental health professionals need enhanced capacity to conduct training of other workers.

Previous albeit small scale studies have found relatively high rates of mental disorders in Pakistan, especially in women, and it is possible that the recent conflict and instability may have aggravated these rates, and made travel to major urban centers for treatment even more difficult (Mirza and Jenkins, 2004). Personal choice and autonomy are critical in maintaining mental health. Often people want to help themselves, approaching the family and peer group before coming into contact with primary care. When asked, people repeatedly say that they want to learn how to manage their own problems for themselves as well as draw upon resources in the community (Mirza et al., 2006b, Mirza et al., 2006a).

Effective primary mental health care is dependent on a well-functioning general health system. It may be necessary to strengthen that system and provide additional resources at the primary care level so that it can effectively perform the additional tasks of mental health care (Patel et al., 1998). Specific skills and competencies are needed to effectively assess, diagnose, treat, support and refer people with mental disorders. It is therefore essential that a process is put in place to adequately prepare, train and support primary care workers in their mental health work.


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