In Pakistan, societal attitudes and norms, as well as cultural practices (Karo Kari, exchange marriages, dowry, etc.), play a vital role in women's mental health¹. The religious and ethnic conflicts, along with the dehumanizing attitudes towards women, the extended family system, role of in-laws in daily lives of women, represent major issues and stressors. . Such practices in Pakistan have created the extreme marginalisation of women in numerous spheres of life, which has had an adverse psychological impact. Violence against women has become one of the acceptable means whereby men exercise their culturally constructed right to control women. Still, compared to other South Asian countries, Pakistani women are relatively better off than their counterparts². Violence against women is very common in Pakistan. The violation of women's rights, the discrimination and injustice are obvious in many cases. A United Nations research study found that 50% of the women in Pakistan are physically battered and 90% are mentally and verbally abused by their men. A study by Women's Division on "Battered Housewives in Pakistan" reveals that domestic violence takes place in approximately 80% of the households. More recently the Human Rights Commission report states that 400 cases of domestic violence are reported each year and half of the victims die³.

In Balochistan and Sindh provinces, Karo Kari is practiced openly. A woman suspected of immorality is declared a Kari while the Karo is a man declared to be her lover. A woman suspected of adultery or infidelity is liable to face the death penalty at the hands of her husband or in-laws. Usually the killer goes scot-free as he is regarded to have committed the crime in order to retrieve the lost family honour, which a woman is expected to uphold at all costs⁴. South Asian people in the UK under-utilize health services compared with White people. Also, where services are accessed, they may not adequately meet cultural and religious needs. In exploring the relationship between the cultural and religious beliefs of South Asian service users about perceptions, beliefs about aetiology, cause and treatment of mental illness, past studies have illustrated a wide range of expectations, experiences, beliefs and attitudes⁵.

World wide the previous three decades witnessed great advances in female betterment covering all aspects of life and yet they continue leading complexly difficult lives. The cause of female suffering can be grouped under the heading "Contradictory Expectations"
Globalization and international capitalism portray the pathological difference between the first world woman's material comforts and the third world woman's wide spread exploitation. Whereas the former is coaxed into spending atrocious amounts "out of loathing for their bodies" the latter are sometimes "bought and sold, beaten and mutilated, even killed with impunity and social approval, disposed and disinherited despite legal safeguards.⁶"
Analyzing the scenario of female status in Pakistan and the consequential effects on their mental health, one finds a marked diversity in the lives of the urban and rural women, be it their identity, self-image, political awareness, freedom of expression or social status².

Rapid urbanization, impact of information explosion, along with increasing literacy rates, job opportunities and programs for women's empowerment both at government and NGO levels has had a positive impact on the lives of urban Pakistani women, placing them almost at par with women of the developed countries. Yet keeping in touch with their culture and tradition they uphold their social values rigidly, synchronizing between the cultural, religious, and modern socio- economic needs and the intellectual and social demands of time. Despite the many irritants and constraints both at home and the societal level, where they are still not ready to accept woman-empowerment, the urban womeen strives to achieve their goals. Understandably in the absence of such hindrances the urban woman would have realized her inherent potential and personality strengths in a more positive, productive and balanced manner-yet the struggle goes on⁷.

Factors Contributing to Psychological Issues of Women

Factors contributing to such doubts include societal and family pressures. Following are only a few to illustrate the point.

• Societal Pressures
  1. Restricted mobility for women, affects their education and work / job opportunities; this adds to the already fewer educational facilities for women.
  2. Concept of "chadar and chardiwari", veil and being restricted to the safety of the home has further suppressed women.
  3. Rampant violence in society, ethnic riots and political unrest has clearly affected the Pakistan woman's progress.
  4. Sexual harassment at home, at work and society has reached its peak for lack of awareness or denial of its existence, further confining women.
  5. Violence like rape, assault, acid burns and Karo Kari further adds to their restrictions thereby lowering prospects of women's empowerment in society.
  
• Family Pressures
  1. Birth of a baby boy is rejoiced and celebrated while a baby girl is mourned resulting in guilt and despair in many families.
  2. Boys are given priority over girls for better food, care and education. Subservient behavior is promoted in females.
  3. Early marriage (child-brides), Watta Satta (exchange marriages), Dowry and Walwar (bride price).
  4. Divorcees and widows are isolated and considered "bad omens" and are victims of both male and female rejection especially in villages.
  5. Marriage quite often leads to wife battering, conflict with spouse, conflict with in laws, dowry deaths, stove burns, suicide/homicide and acid burns to disfigure women in revenge.
  6. Issues related to fertility and second marriage.
  
• Health Care Facilities
  1. Poor treatment leading to high maternal mortality rate (MMR) and infant mortality rate(IMR)
  2. Women have no control over contraception or the number of children they want.
  3. Anemia and poor physical health due to poor nutrition, multiple births, miscarriages etc.
  
• Lack of Social Support
  1. Nuclear families in urban families lack extended family support.
  2. At government level there are no community social support centers or day care centers for children of working mothers. Dual career families suffer the most^8,9.

The psycho-social stressors of Pakistani women are present throughout their life-cycle from childhood to adolescence, adulthood, middle age and old age. The following table¹⁰ illustrates the same:

Table : Psycho-social Stress in Pakistani Women

Psychological Problems in Women Physicians in Pakistan

Women practicing medicine are known to have high-stress lifestyles. Medicine is an inherently stressful profession with long hours, pressing clinical problems, ethical dilemmas, difficult patients and conflicting demands. Several studies have reported elevated rates of depression, anxiety, marital problems and higher suicide and addiction rates among physicians compared to other professionals¹¹. There is little published work quantifying either the effects of stress on doctors or the results of interventions designed to reduce stress. Grol demonstrated poor clinical performance in those doctors with negative feelings of tension, lack of time and frustration as evidenced by having a high prescription rate and give little explanation to the patients⁴. The effects of stress on practice are evidenced as increased errors in prescribing, increased staff turnover, limited team working, more patient's complaints, poor time- keeping and sickness absence. Stressed GPs may develop problems in their relationships with their partners and family at home, these include becoming uncommunicative at home or work and more withdrawn and isolated¹².

Psychological Problem, Anxiety and Depression in Non-Working Women with Reference to their Education, Family System and Number of Children in Pakistan

There is anecdotal evidence that housewives frequently complain about the monotony of their lives. They feel that they have to look after children and do the housework and they do not have time for themselves. Compared to the working women, their social environment is limited. Their husbands are the only ones to appreciate their intense efforts they make for their homes. A woman, for instance, with six children and a husband, and with no help from others and no money for the most costly labor-saving devices, simply can not organize her necessary duties so that she will have leisure for pleasures and activities outside the daily routine. In such a house the most modest requirements for food, shelter, and clothing become a driving force that pushes aside relentlessly any irrelevant longing. The working women, however, have the chance of being appreciated by the society and behave independently and earn money. On the other hand, many working women find that children provide a common focus of interest for them and their husbands and many of them feel that the time devoted to children resulted in less sharing and companionship and less spontaneity in the marital relationship^13,14.

A study showed that both working and non-working women living in a joint family system were more frequently diagnosed with anxiety; but that association was not statistically significant.

A highly significant association was observed between anxiety in women and the number of their children. This study showed that majority of non-working women (79.5%) diagnosed with anxiety had more than three children as compared to working women (11.1%)¹⁵.

Anxieties in Pregnant Women of Pakistan

Pregnancy has dramatic emotional and psychological consequences for the individual. There is evidence of increased incidence of anxiety and depression in pregnancy. Mental disorders are more common in pregnant women who have a past history of psychiatric illness, family psychiatric history, past obstetric/gynaecological complications, caesarean section and those who lack marital, family or social support¹⁶.
A large number of studies have reported prevalence of anxiety and depression in pregnancy from different parts of the world. There are few studies on this topic from Pakistan. It is important to estimate the prevalence of anxiety and depression in pregnant women in Pakistan because it has effects on both mother and child.

The aims of the present study were as follows:

1. To investigate the prevalence of anxiety and depression in pregnant females presenting in the antenatal clinic of a teaching hospital
   
2. To find out risk factors associated with anxiety and depression in the above group.
   
3. To assess the relationship of different demographic variables with anxiety and depression in the above group^17,18.
   

Marital Problems and Their effect on Women's Mental Health

The concept of marital satisfaction is an important area of research in the context of marriage and family relationships. This has not been previously examined in Pakistan, a conservative patriarchal Islamic country, where studies examining psychiatric morbidity have shown marital problems as contributing to Common Mental Disorders (CMDs).

Young married women under the age of 35 years appear to have a higher prevalence of CMDs than older married women. In this pilot study, using both a quantitative and a qualitative approach, we examined the construct of marital satisfaction and tested the applicability of marital satisfaction scales developed in the West for use in Pakistan. The results indicate that, contrary to cultural beliefs regarding marriage, most women expressed the need to be satisfied within marriage. The fear of hurting or annoying their parents prevented many women from openly expressing their opinion in the choice of husband or unhappiness in their marriage. Pakistani women tend to see marriage as a social and familial obligation requiring them to be prepared to adjust as the man seldom does. The construct of marital satisfaction is a viable concept for study and research in Pakistan, and there is need for further research in this area¹⁹.

From the above discussion we concluded that factors positively associated with anxiety and depressive disorders in women of Peshawar were mainly social problems, cultural taboos. The religious and ethnic conflicts, along with the dehumanizing attitudes towards women, the extended family system, role of in-laws in daily lives of women, represent major issues and stressors. Other factors are female sex, middle age, low level of education, financial difficulty, being a housewife, and relationship problems.