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“Inequality is a key obstacle to mental health globally. Many risk factors for poor mental health are closely associated with inequalities in the conditions of daily life. Many risk factors are also linked to the corrosive impact of seeing life as something unfair.” — Dainius Pras, UN’s special rapporteur on mental health.
IN Pakistan, rising concerns around depression, anxiety, substance use and suicide — particularly among young people — has drawn attention to mental health. International frameworks, especially those promoted through the global mental health movement, have helped bring visibility to this neglected area. Yet as we develop mental health services, it is worth pausing to ask a deeper question: are we addressing the roots of distress, or merely managing its symptoms?
The book Decolonising Global Mental Health: The Psychiatrisation of the Majority World by China Mills,former researcher at the University of Oxford, extorts us to reflect on this question. Mills does not argue against mental healthcare but challenges the assumption that Western psychiatric models — developed in very different sociopolitical and economic contexts can be uncritically applied across countries in the Global South. Her main concern is that distress which is shaped by social and economic injustice, inequality, violence and political oppression runs the risk of being reframed as individual pathology, a process she describes as “psychiatrisation”.
This critique is highly relevant for Pakistan where psychological distress is often inseparable from our lived realities of grinding poverty, unemployment, gender inequality, insecurity, displacement and climate vulnerability. A farmer in Sindh facing crop failure due to uncertain weather patterns, a factory worker in Faisalabad burdened with unemployment-related concerns or a young woman living in an urban slum area of Karachi and enduring domestic violence are not simply facing internal psychological crises. Their distress is rooted in structural conditions.
Are we addressing the roots of distress, or merely managing its symptoms?
Yet mental health responses often put stress on diagnosis and treatment at the individual level. Depression, anxiety and trauma are increasingly identified through standardised screening tools, followed by counselling or medication (or both). These interventions can be helpful and are, in many cases, necessary. The risk arises when they become the primary response, diverting attention from the social drivers that produce distress in the first place.
This dynamic reflects what Mills cautions against: when suffering caused by inequality is reframed as a mental health issue, the responsibility for adaptation subtly shifts from institutions to individuals.
Pakistan doesn’t possess a national mental health policy. However, the WHO explicitly recognises the social determinants contributing to mental ill-health. These include poverty, unemployment, violence, displacement and gender inequality. The situation demands a multisectoral response involving the health, education, social welfare, labour and justice systems. Importantly, it frames mental health not only as a clinical concern, but as a development and rights issue.
However, translating this vision into practice is fraught with challenges. The WHO’s mhGAP (Mental Health Gap Action Programme) programme has played an important role in humanitarian settings and in strengthening basic service delivery in settings like Pakistan where mental health infrastructure remains severely under-resourced. It has expanded access, reduced stigma and saved lives.
At the same time, the operational focus of mhGAP has tended to prioritise individual- and community-level psychosocial interventions — counselling, stress management, psychological first aid and referral pathways. While valuable, these approaches target only part of what is needed to address the mental health challenges of the country.
For instance, in the aftermath of floods or displacement, mhGAP responses emphasise helping the affected people cope with loss and trauma. There is far less focus on the question of why the same communities experience repeated displacement, delayed compensation or inadequate housing. Emotional support may be provided, but issues of land rights, governance failures or climate adaptation policies remain largely outside the mental health response.
Also, frameworks being used in Pakistan rely heavily on diagnostic tools which have been developed in Western settings. The two most popular and widely used tools to screen for depression and anxiety in Pakistan, ie, PHQ-9 (patient health questionnaire) and GAD-7 (generalised anxiety disorder) were developed and validated in Western clinical settings. They measure symptoms while excluding social and economic context. A woman with small children experiencing sleeplessness and fatigue due to domestic violence from her unemployed husband who is on drugs may meet the criteria for ‘depression’ on the PHQ-9; yet the tool provides no insight into the conditions that are driving her distress.
Increasingly, distress is conflated with clinical states of depression and anxiety in Pakistan and these tools risk misclassifying structural suffering as individual disorder. Their use raises important questions about their cultural relevance and usefulness in Pakistan. When despair among young men due to unemployment-related issues is treated primarily as depression, or when women’s distress after being subjected to domestic violence is addressed mainly through trauma counselling, the underlying structures, ie, economic injustice, exploitation, absence of social safety networks, risk fading into the background. This is medicalising of social problems.
A decolonised approach would treat programmes such as mhGAP (and other programmes) as one component of a broader mental health ecosystem, one that includes social protection, human, gender and labour rights, climate resilience and accountable governance. It would invest in local research that captures how distress is understood and addressed in Pakistan, rather than relying solely on imported models of evidence. Most importantly, it would resist the temptation to see mental health solely through the lens of diagnosis and treatment, and would understand it as a reflection of societal conditions.
As we continue to grapple with mental health challenges, China Mills’ call to decolonise mental health is not a rejection of care, but an invitation to rethink priorities. The immense suffering of the poor and distressed in Pakistan requires ensuring that our responses to distress do not merely help people endure hardship but also challenge the conditions that produce it.
The writer is a consultant psychiatrist.
Published in Dawn, February 9th, 2026
