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Life stress and depression in a tribal area of Pakistan

  • N. Husain (a1), I. B. Chaudhry (a1), M. A. Afridi (a2), B. Tomenson (a3) and F. Creed (a3)...

Depression is common in Pakistan but no research on this subject has been reported from the North West Frontier Province (NWFP), host to numerous Afghan refugees.


To measure depressive symptoms and associated features in a population-based sample.


A Pushto translation of the Self Reporting Questionnaire (SRQ) was administered to 471 adults living in a village in one of the federally administered tribal areas. Respondents were also assessed with a life events checklist for social problems, a social support questionnaire and the Brief Disability Questionnaire.


Sixty per cent (95/158) of women and 45% (140/313) of men scored 9 or more on the SRQ. High SRQ score was associated with few years of education, higher social problem score, less social support and greater disability. High social problem score was the strongest correlate.


This population reports more depressive symptoms than other communities in Pakistan and this probably reflects the very high degree of social stress experienced in the NWFP, which has been affected by years of turmoil in neighbouring Afghanistan.

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Corresponding author
Dr N. Husain, Division of Psychiatry, Rawnsley Building, University of Manchester, Oxford Road, Manchester M13 9WL, UK. Email:
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Life stress and depression in a tribal area of Pakistan

  • N. Husain (a1), I. B. Chaudhry (a1), M. A. Afridi (a2), B. Tomenson (a3) and F. Creed (a3)...
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Transcultural Validity: Depressive Disorder or Social Deprivation?

There are two issues related to this study, which merit some further consideration.

(A): Self Reporting Questionnaire (SRQ) is one of the health questionnaires validated by WHO for screening of psychiatric symptoms. Authors translated SRQ in Pushto language using a designated protocol. Authors claimed that SRQ had been validated in Pakistani population by Husain et al, 2000, which used standardized Urdu version of SRQ and was done in Punjab province. Pushto is a very distinct language from Urdu. It is known that “Lay terminology regarding subjective experiences and perceptions is strongly tied, through language, to cultural values, attitudes, norms, beliefs, and customs” (Westermeyer 1997). Authors themselves have enumerated some key cultural differences between FATA and Punjab. These culture and language variations have substantial bearing on screening questionnaire like SRQ. Validation of Urdu version of SRQ does not automatically validate Pushto version. “Some studies had to empirically validate the SRQ20 against in-depth psychiatric interviews because there was no previous validation in the country or because previous studies had been in a very different part of the same country” (HARPHAM 2003)Non-validation of SRQ in Pushto predisposes the study to systematic bias resulting from a flaw integral to the study questionnaire, which might have led the study to a systematic error.

(B): Authors have clearly mentioned that SRQ scores had strong correlation with socioeconomic stress. They went on to give identifiable reasons of high SRQ scores in the form of “very high degree of social stress” and “years of turmoil in neighbouring Afghanistan”. Nevertheless, it did not prevent them from asserting that 60% of women and 45% men of the target population were depressed. It is questionable to label such a huge proportion of people as mentally ill based on a cross-sectional survey using self-administered questionnaires. It is common to experience depressive symptoms in the face of socioeconomic hardships particularly when there are no foreseeable prospects of improvement. It does not necessarily mean that people have depressive disorder. It is medicalisation of a very natural human response and such labels can be misleading. “some human beings will always need labels to support their continued suffering in an unfair world. These non-diseases clearly contribute to the development of co-dependent suffering” (Murphy 2002). Authors deserve commendations for highlighting the utter neglect of rural masses and a desperate need of some socio-political development in FATA. However, they do not have a robust scientific evidence to claim that more than half of the people in FATA are depressed.

References: HARPHAM, TRUDY; et al (2003)How to do (or not to do) Measuring mental health in a cost-effective mannerHEALTH POLICY AND PLANNING; 18(3): 344–349

Husain, N., Creed, F. & Tomenson, B. (2000) Depression and social stress in Pakistan. Psychological Medicine, 30, 395 –402.

Murphy, Kevin C (2002)Labels create legitimacy and produce dependenceBMJ 2002;324:912

Westermeyer, Joseph and Janca, Aleksandar (1997)Language, Culture and Psychopathology: Conceptual and Methodological IssuesTranscultural Psychiatry, Sep 1997; 34: 291 - 311.
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Conflict of interest: None Declared

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Low SES and other factors to consider.

Archana Jauhari, Staff Grade, Psychiatry
01 February 2007

I read the article by Husain et al with interest. It is quite interesting study as mental illness is quite neglected in low socioeconomic and tribal areas. Because of taboo of mental illness and social system people find it hard to accept having mental health problems and keeping this in mind self-reported questionnaire (used in this study) might under estimate the problem.

In developing world, mental illnesses may present in a more socially acceptable manner of physical symptoms. It has been seen that low socioeconomic status, literacy rate and psychological sophistication are associated with high prevalence of conversion disorder, as evident in developing countries compared with developed world.

On the other hand, confounding factor in the study could be physical illness like anaemia. Many of the women in child bearing age group in low socioeconomic area suffer from low haemoglobin level that can present withsymptoms similar to depression.

In this study, as most of these people are from refugee area, it willbe interesting to see if their depressive symptoms are related to PTSD or not.

Over all the study is appreciated as it raises the awareness of need for mental health support for these people.
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Conflict of interest: None Declared

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Psychiatric Morbidity in Afghan Refugees

01 February 2007

I would like to congratulate N.Husain,for their recently published study "Life stress & depression in a tribal area of Pakistan".It reflects that most of the participants in this study were Afghan refugees who have been living in North West Frontier Province (NWFP) of Pakistan.The authors have done a commendable job as very few studies in the past have concentrated on this neglected cross section of people.Afghans have been refugees in different countries after Afghanistan was invaded by former Soviet Union in 1979.A large number of Afghans migrated to Pakistan & have been living in under developed & poor areas like NWFP.This already war traumatised population have been through different types of stressors since,resulting in psychological & emotional problems.Depression & PTSD are the most common.It seems that the present study has covered a tribal population which included both Afghan refugees & local Pakistanis in NWFP.There are previous studies which have concentrated mainly on Afghan refugees living in different parts of world,especially US.The Afghan refugees in Pakistan have been poorly studied.Therefore present study is an enlightment for researchers to focus on this traumatised population.A study done by Farooq Naeem,in 2004 (Psychiatric morbidity among Afghan refugees in Peshawar,Pakistan)found that 80% of the people who attended a Psychiatric clinic met the diagnosis of PTSD which is quite significant.A WHO fact-finding mission to Pakistan found that 30% of Afghan refugees are presenting psychosomatic complaints resulting from psychological illness.It is quite astonishing that 60% of women & 45% of men scored 9 or more on SRQ in the present study.This study also reflects the poor living conditions of these people with lack of education & social problems which adds to their trauma.There is a desperate need to improve their living conditionsand educate these people,so they could recognise their symptoms & seekhelp, as the condition like Depression is treatable & will improve their quality of life significantly.In doing so, help is need from worldwide.There is also a need for future research which could compare thepercentage of psychiatric illness in Afghan refugees in developed countries (like US)with refugees living in poor areas like NWFP (Pakistan).

Declaration of interest : None.


David Sahar,MD,San Francisco CA,Depression Among Afghan refugees in West,June 1998,Afghan Mosiac Magazine.

Hussain,N.,Choudhry,I.B.,Tomenson,B.,et al(2007)Life stress and depression in a tribal area of Pakistan,The British Journal of Psychiatry,190:36-41.

Mghir R, Freed W, Raskin A, Katon W. (1995) Depression and posttraumatic stress disorder among a community sample of adolescent and young adult Afghan refugees. J Nerv Ment Dis. 1995 Jan;183(1):24-30.

Naeem,F.,Mufti,K.A.,Ayub,M.,,2004 Psychiatric morbidity among Afghan refugees in Peshawar Pakistan.
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