HPQ0010.1177/1359105319869819Journal of Health PsychologyBibi et al. 869819research-article2019 Article Journal of Health Psychology 1 –12 Mental health, suicidal ideation, © The Author(s) 2019 Article reuse guidelines: and experience of bullying among sagepub.com/journals-permissions DOI:https://doi.org/10.1177/1359105319869819 10.1177/1359105319869819 university students in Pakistan journals.sagepub.com/home/hpq Akhtar Bibi , Simon E Blackwell and Jürgen Margraf Abstract This study investigates mental health, access to treatment, suicidality, and bullying among Pakistani university students. Data were collected from a sample of 355 university students in Pakistan. For reference, we compared these data to a sample previously collected from German and Chinese students. Results indicated relatively poorer mental health and access to mental health treatments among the Pakistani sample, including a higher rate of recent suicidal ideation and bullying. Acknowledgment of these issues in Pakistani culture would be a good starting point to work on developing solutions to enhance the overall mental health of Pakistani students. Keywords bullying, mental health, Pakistan, suicide, treatment Introduction students in Lahore and found that 24 percent reported “severe” and 13 percent “very severe” While there is evidence to suggest that prob- levels of problems. Although the authors sug- lems with mental health pose a major challenge gest that “very severe” reflects a need for clini- among university students in Pakistan, these cal attention, given the bespoke nature of the problems have rarely been addressed. Previous scale used, it is difficult to know how these data investigations of mental health problems among would compare to results from student surveys university students in Pakistan have suggested in other countries. Bukhari and Khanam (2015) high prevalence. For example, Saleem et al. administered the Center for Epidemiological (2013) investigated the mental health problems Studies Scale for Depression (CES-D; Radloff, of 1850 Pakistani university students in Lahore 1977) to 331 students in Karachi, and found that using the “Student Problem Checklist” (SPCL), 33.5 and 28.7 percent scored within the scale’s which asks questions about anxiety proneness, lack of self-regulation, loss of confidence, and a sense of being dysfunctional (Mahmood and Ruhr-Universität Bochum, Germany Saleem, 2011). They found that 31 percent reported “severe,” and 17 percent “very severe” Corresponding author: Akhtar Bibi, Mental Health Research and Treatment levels of problems according to the cut-offs for Center, Faculty of Psychology, Ruhr-Universität Bochum, the SPCL. Similarly, Rehman et al. (2018) Massenbergstraße 9-13, 44787 Bochum, Germany. administered the SPCL to 1662 university Email: [email protected] 2 Journal of Health Psychology 00(0) cut-offs for moderate and severe depression, health professionals (Burr, 2002). The treat- respectively. Kumar et al. (2016) found similar ment gap (percentage of people who need care figures using the short version of the Depression but do not receive treatment) for psychological Anxiety Stress Scales (DASS) in a sample of disorders has been estimated 90 percent in 398 students in Karachi, with 32 and 21 percent Pakistan (Whiteford et al., 2013). The mental scoring within the scale’s cut-offs for moderate health budget in Pakistan is only 0.4 percent of and severe/very severe depression, respectively. the total budget, which is far less than that in In terms of the anxiety scale, 26 percent scored other south Asian countries (Jooma et al., within the cut-off for moderate anxiety, and 2009). There are only five mental hospitals 54 percent scored as having severe or very with 1.9 beds per each 100,000 of the popula- severe levels of anxiety. Thus, the existing data tion, and 400 psychiatrists with 0.23 per each suggest high levels of problems such as depres- 100,000 of the population, and similar figures sion and anxiety. This article provides a prelim- have been reported for psychologist and other inary investigation of mental health problems psychiatric services staff (Jooma et al., 2009). and access to treatment among Pakistani uni- Only a small number of urban mental health versity students, including consideration of one care centers are able to provide treatments particularly severe potential consequence of such as psychotherapy or pharmacotherapy mental health difficulties, suicidality, and one (Jooma et al., 2009), and there is a shortage of potentially important risk factor, bullying. mental health professionals, such as certified Several factors such as the transition to and professionally trained psychologists adulthood, academic stress, and problems with (Ahmad, 2007). Finally, due to poverty at both interpersonal relationships may make univer- an individual and national level, neither par- sity students a particularly vulnerable group for ents nor the state is able to provide support to developing mental health difficulties address these issues among students (Clement (Eisenberg et al., 2007). This in turn can impair et al., 2015). students’ social functioning and academic One particularly severe potential outcome of achievement, leading to longer-term conse- poor mental health is suicide. Recent studies quences over the subsequent course of their life suggest that suicide rates in Pakistan have been (e.g. Tosevski et al., 2010). In Pakistan, these rapidly increasing (Shahid and Hyder, 2008). problems and their impact may be amplified by However, the only official data available come a number of other factors related to social and from police records, which are likely to be cultural pressures, mental health stigma, and under-estimates due to cultural and religious lack of potential treatments (Ahmad, 2007). factors (Jordans et al., 2014). Ironically, The available data suggest the need for the Pakistani newspapers report instances of sui- development of policies and interventional cide every day, and have been suggested by programs to tackle the problem of poor mental some to be the only useful source of basic infor- health among university students in Pakistan. mation about death by suicide (Khan and Reza, However, due a variety of factors, including 2000). Other estimates may come from non- financial constraints and political instability, government organizations, for example, a report there are no comprehensive health policies and issued by the Lawyers’ Committee for Human interventional programs to deal with mental Rights estimated that there were about 5800 health problems. suicides within the 9-month period from Despite their prevalence, mental health January to September 2006 (Khan, 2007). problems in Pakistan are often ignored and Given the paucity of data and the indication that misinterpreted as “Jinn possession,” social rates may be extremely high, it is extremely ineptness, ordinary shyness, and ill-fate, which important to further investigate suicidality prevents individuals seeking help from mental among university students. Bibi et al. 3 Apart from broader societal and cultural fac- Pakistan’s score of 14; Hofstede, 2001), but tors, individual negative life events in the life of with many economical and societal differences an individual may also increase the risk of men- from Pakistan, such as a strong economy and tal health problems and suicide. One kind of education system. negative life event that may be particularly per- tinent in the context of Pakistani students is bul- lying, which is considered both a social problem Methods and an important public health concern Participants and data collection (Srabstein and Merrick, 2013). Victims of bul- lying have an elevated risk of suicidality, pos- Data were taken from Bochum Optimism and sibly because of their higher risk of developing Mental Health (BOOM) study program in psychological disorders (Owusu et al., 2011), Pakistan, which is a large scale cross-sectional reduced impulse control, and intensified emo- and longitudinal study program investigating tional arousal (Wolke et al., 2001). Khan and protective and risk factors of mental health Reza (2000) investigated Pakistani school and across several countries. The Ethics Committee college students and found adverse effects of of the Faculty of Psychology, Ruhr University bullying similar to those indicated by studies in Bochum, approved the study. All participants North America and Europe (e.g. Wolke and provided informed consent for their participa- Lereya, 2015), such as reduced academic tion in the study. Data were collected via achievement, lower self-esteem, and elevated online questionnaires, and the measures pre- symptoms of depression. Thus, to generate a sented here form part of a larger dataset. comprehensive picture of mental health and Participant characteristics are presented in suicide risk among students in Pakistan, it is Table 1. Participants were provided with infor- important to incorporate data about bullying. mation encouraging them to contact a relevant This study aimed to further delineate the service, for example, the counseling service of problems of poor mental health, lack of treat- their psychology department, if they felt they ment, and suicidality among university students were experiencing psychological difficulties. in Pakistan, including an investigation of the potential prevalence of history of bullying in Pakistan sample. The study was advertised on this population. An anonymous online survey social media such as Facebook. Data for this