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People suffering from depression and psychological illnesses wait for their turn to see doctors at a local clinic in Peshawar, Pakistan. — Photo by AP

PESHAWAR: Liaqat Ali is a victim of one of Pakistan’s worst bombings, but his injuries are not visible to the naked eye.

The 47-year-old government clerk and part-time lab assistant was walking home through the grounds of a hospital in the northwest city of Peshawar in the fall of 2009, when he stumbled upon the carnage left by the blast. Scores of bodies were packed into vehicles. Bleeding survivors with missing limbs and severe burns were scattered everywhere.

He has suffered from severe depression and anxiety ever since and is dependent on antidepressants to make it through the day so he can provide for his wife and four children.

Ali’s plight has become increasingly common in Pakistan’s northwest, where psychiatrists estimate millions are suffering post-traumatic stress disorder and other psychological illnesses after years of militant attacks, army offensives and US drone strikes.

Many don’t receive treatment, largely because of an acute shortage of psychiatrists and psychologists.

“I think what we see is only the tip of the iceberg,” said Firaz Khan, a psychiatrist at the mental health ward at government-run Lady Reading Hospital in Peshawar, where most of the 40 to 50 patients who come in each day are suffering from violence-related trauma. “Most victims remain at home and are not getting help.”

Peshawar is located close to the tribal regions, the militant epicentre, and has been a major target for the Taliban since they started their insurgency in earnest in 2007. At times, the city was bombed almost daily. Violence has fallen significantly in the last 18 months. Fear and anxiety remain.

Ali’s nightmare began on October 28, 2009, when militants detonated a car bomb in a market crowded with women and children. More than 100 people were killed. The dead and wounded he encountered at Lady Reading Hospital on his way home from work are etched in his mind.

“Some of them had lost arms, others legs. Some of them had burned faces,” said Ali, becoming visibly disturbed during an interview at a private psychiatric clinic in Peshawar where he was being treated.

“So many dead bodies were stuffed in a vehicle, as if they were not humans but slaughtered animals.”

Within days, Ali was having trouble sleeping, experiencing flashbacks and intense fear.

“It would come to my mind that everybody will die. The world was going to end,” Ali said.

The northwest is filled with similar cases, according to psychiatrists.

A nine-year-old boy suffered PTSD after witnessing a deadly bomb blast in Peshawar. He became irritable, aggressive and said he wanted to kill someone. He couldn’t sleep, had flashbacks and stopped going to school.

A 30-year-old woman in the North Waziristan tribal area suffered severe depression and fainting spells after her cousin was killed by a mortar shell on his way to Afghanistan. It was unclear whether he was killed by the Taliban or fighting alongside them.

An 18-year-old boy in the Bajaur tribal area suffered PTSD after witnessing a Taliban fighter behead an alleged spy, soak his beard with the man’s blood, lick it off his fingers and roar in satisfaction. He felt severe anxiety every time he recalled the incident.

The psychiatrists asked that the names of the patients be withheld to protect their privacy.

These kinds of experiences have tripled the number of patients seeking help from psychiatrist Mian Iftikhar Hussain since he opened his private clinic in Peshawar in 2004 after a career in public medicine. He now sees over 60 patients each day and cannot handle anymore.

While there are no official figures, Hussain and another psychiatrist with a clinic in Peshawar, Wajid Ali Akhunzada, estimate that up to 60 per cent of the more than 20 million people who live in Pakistan’s northwest could be suffering from violence-related psychological issues.

They base this figure on the number of patients who visit psychiatrists in the area daily.

Only five to 10 per cent of patients treated by Hussain and Akhunzada have PTSD, but almost all of them suffer from some combination of depression, anxiety and lack of sleep caused by the violence around them. They are generally treated with a mix of drugs and psychotherapy.

Use of antidepressants and anti-anxiety medication in Peshawar has more than doubled in the past few years, said Riaz Hussain, president of a wholesale drug association in the city.

“Previously these medications were mainly used by Afghan refugees,” who have declined in number, he said.

The number of psychiatrists and psychologists in Pakistan is far short of the level needed to handle the current crisis. There are about 600 in Pakistan for a population of 190 million, or roughly one for every 315,000 people, according to figures compiled in 2010 by the late Haroon Rashid Chaudhry, former head of psychiatry at Fatima Jinnah Medical College in Lahore.

In the United States, there are about 116,000 psychiatrists and psychologists for a population of 310 million, or one for every 2,700 people, according to figures from the Bureau of Labor Statistics and the American Psychological Association.

There are also few social workers who deal with psychological problems in Pakistan.

“In our country, education and health are both at the bottom priority-wise, and in health, psychiatry is at the bottom,” said Hussain, the psychiatrist, who suffered PTSD himself after being kidnapped in 2009 and held for 11 days.

There are no psychiatrists or psychologists based in Pakistan’s remote tribal region, where fighting between the Taliban and the army has been most fierce and U.S. drones rain missiles down from the sky, said Hussain.

“We never know when a drone will drop a bomb right on our home,” said Soba Khan, a 15-year-old boy who lives in North Waziristan and was visiting Peshawar with his aunt, who was suffering psychological problems.

Many dealing with mental trauma don’t understand why they are feeling miserable and assume they must be physically ill. They often turn to spiritual healers, knowing that seeing a psychiatrist or psychologist can mean social stigma.

Those who decide to visit a mental health specialist can face significant difficulties in getting to a doctor and affording treatment, especially if they live in the tribal region.

The potentially dangerous trip from North Waziristan to Peshawar on a public minibus takes eight to 12 hours and costs about $6.50, a significant sum in a country where the UN estimates about a quarter of the population lives on less than $1.25 per day.

Doctor visits at public-run hospitals are free, but antidepressant or anti-anxiety medications cost at least $5 per month, and can be much more if multiple drugs are prescribed. Each session at a private clinic, where treatment is better, costs roughly $8.50, and can be several times that if the patient needs to be admitted.

Hussain, the psychiatrist, said it was critical to find a way to help the large numbers of people suffering in Pakistan.

“If we don’t understand them, analyse them and address them,” he said, “they will worsen day by day.”