THE psychiatric profession faces a fundamental question: are we treating people’s distress as a problem located inside their minds when much of what troubles them lies outside, in the conditions of their lives? The question has particular urgency in Pakistan, where a recent national survey of more than 17,000 individuals showed that one in three adults suffers from some sort of diagnosable mental disorder. What is leading to this mental health crisis in Pakistan?
The answer may lie in understanding people’s circumstances rather than assigning diagnoses. Unfortunately, we have become so preoccupied with diagnosing and treating individuals that we have lost sight of the social conditions that make them ill.
What does it mean to treat the anxiety of someone whose future is insecure or offer counselling to a man who cannot provide for his family? How far can psychological therapy help a woman who is in constant fear due to unabated domestic violence? Treatment may offer some relief, at least temporarily, but if the circumstances remain unchanged, we risk helping the person endure a problem that society continues to create — and ignore. This is the central limitation of an individualised approach to mental health: it turns a social problem into a personal responsibility.
Pakistan’s mental health discourse focuses on ‘raising awareness, reducing stigma, increasing access to psychological support, early identification, and referral to specialist services’. While these are important, they can become politically convenient substitutes for confronting the structural determinants of psychological distress. Awareness campaigns do not create jobs. Teaching resilience through mental health apps does not increase household incomes. Screening programmes do not stop domestic violence or child sexual abuse. Counselling cannot substitute for social protection, affordable education and health, or protection against violence.
This is the contradiction in Pakistan’s policies: awareness without accountability. This becomes particularly stark when the government acknowledges mental health as a public health priority but does nothing to address the economic and social factors that people face daily. We need to move beyond the narrow thinking that mental health improves when people become more aware of mental illness and more willing to seek treatment. We must also ask why so many people are exposed to toxic conditions that threaten their well-being in the first place.
Improving mental health requires more than treating the consequences of social and economic failure.
Locating distress primarily within individuals obscures questions of power and responsibility. When social adversity is translated into individual diagnoses, ignoring the person’s context, he/she becomes the site of intervention while institutions and governments escape scrutiny. When we teach people resilience we reinforce that the central task is to help people withstand adversity rather than reduce the adversity itself. In Pakistan, marked by profound inequalities, it turns psychiatry, however unintentionally, into an instrument of adaptation to injustice.
Instead, we should ask: what has happened to this person, and what continues to make their life difficult? Mental health assessments should explore not only symptoms and psychiatric history but also employment, debt, housing, family relationships, violence, etc. It is important to understand the person’s own explanation of their distress rather than assuming that a diagnostic label of ‘depression’ or ‘anxiety’ provides the complete account.
This approach does not eliminate diagnosis or medication. Those experiencing severe symptoms should have access to evidence-based treatment. The distinction is between using biomedical interventions when indicated and treating the biomedical explanation as sufficient in every case. The approach also has important policy implications. Pakistan has a good record of developing policies but an extremely poor one for implementing them. There is no reason to be optimistic that the recently launched National Mental Health Policy will not meet the same fate. It is futile to talk about a mental health policy without integrating social determinants into planning and also having a clear strategy for their implementation. The federal and provincial governments must be held accountable for how they will do so.
Mental health programmes must be evaluated against outcomes that matter in people’s lives, not simply symptom improvement. Mental health professionals and institutions must engage with the political and economic conditions shaping their patients’ lives. It requires them to recognise that suffering has social causes and that their professional obligations do not end at the clinic door. They must be willing to speak truth to power and not simply have their photographs taken with government officials and political leaders.
Pakistan does not face a choice between treating mental illness and addressing poverty, inequality, or violence. It needs both. The mistake is investing in the former while neglecting the latter. A diagnosis is never a complete explanation, and an effective treatment plan must take into account people’s circumstances. How ethical is it to ask people to become more resilient to bear conditions that public policy could make less damaging or ask people to practise relaxation exercises while their livelihoods collapse, to cultivate optimism while their prospects disappear, or to develop coping skills while they remain exposed to violence? Such interventions may provide relief, but they cannot substitute for social justice.
Pakistan’s mental health crisis cannot be addressed solely through more psychiatrists, better access to mental health services (which are poorly organised anyway), more prescriptions, more awareness campaigns, or more screening. These are necessary components of care, but they cannot compensate for policies that perpetuate insecurity and exclusion. Improving mental health requires more than treating the consequences of social and economic failure. It requires taking responsibility for the conditions that produce them.
A society committed to mental well-being must do more than teach people how to endure their circumstances. It must also work to make those circumstances more bearable.
The writer is professor emeritus of psychiatry at Aga Khan University.
Published in Dawn, November 2nd, 2026
