Bridging the divide: unveiling treatment gap and barriers to mental health care for medical students in Pakistan: a cross-sectional study

INTRODUCTION

Mental health is a vital part of overall health and well-being.¹ Conditions that impair mental health are considered as mental health problems. In Pakistan, an estimated 67 million people, suffer from mental illness, including anxiety and depression.² The treatment gap-the difference between those needing care and those receiving it is a major global challenge and especially severe in Pakistan, where over 90% of individuals with mental disorders do not receive treatment.^3,4 Compared to other diseases like diabetes and hypertension, mental health treatment rates remain much lower.⁵ The COVID-19 pandemic has further worsened the situation. Many who do seek care often do not consistently adhere to treatment plans. Stigma is a major barrier unique to mental illness. It involves societal devaluation and discrimination, which prevent many from seeking help. People with mental illness face a dual burden: managing symptoms such as hallucinations or anxiety, which impair daily functioning, and coping with stigma rooted in societal misunderstanding and prejudice.^6,7 Pakistan’s shortage of mental health professionals worsens the crisis, with just 0.19 psychiatrists per 100,000 people and services largely limited to urban areas.⁸ World Health Organization (WHO) studied major depressive disorders in 21 countries and found that 52.6 % of individuals in low-income countries received treatment after recognizing their need, only 20.5 % received minimally adequate care.¹⁰ Globally, more than 56 % of people with depression do not receive adequate treatment.¹¹ Students in health professions experience significant stress, due to academic demands, competition, limited leisure time, and other factors affecting their mental health.¹² Worldwide, about 12–50 % of undergraduate university students experience one or more mental health challenges.^13,14 Research shows that physician burnout, a serious issue among medical professionals, begins early. Approximately 44.2 % of global medical students, even before residency, show signs of burnout.^15,16 Despite generally being aware of mental health issues, many medical students hesitate to seek or use mental health services during medical school.^17,18 While access to mental health services is expected to be greater for medical students, financial worries, personal dilemmas, access challenges, and insufficient awareness reduce their willingness to seek help. Additionally, cultural factors such as family background, social norms, and religion influence how they deal with mental health issues.^19-22 A meta-analysis of 183 studies across 43 countries found the prevalence of depression among medical students to be 27%. Moreover, 11% reported suicidal ideation, and over 80 % felt under-supported.^23-26 The aim of this study is to examine how barriers to accessing and navigating mental health services arise and intersect with challenges to service provision in the unique context of medical student mental health.

METHODS

This cross-sectional study involved 144 medical students from various medical colleges across Pakistan, selected between March and July 2025 using stratified multistage sampling. Participants ranged from first to fifth academic year and completed the Barriers to Access to Care Evaluation (BACE v3) and Rosenberg Self-Esteem Scale (RSES) questionnaires. The sample size was calculated based on a 92.8% prevalence of stress among medical students, resulting in a required size of 113 at a 95% confidence level using Cochran’s formula. Both instruments demonstrate strong psychometric properties, including validity, reliability, and acceptability, reflecting good participant engagement. The questionnaires assessed factors that might have hindered, delayed, or discouraged participants from seeking professional mental health care in the previous three months. A pilot study was conducted to refine the questionnaire, followed by consultations with a mental health expert experienced in adapting such tools. Statistical analyses were performed using SPSS version 28, a reliable software for data analysis. The study adhered to strict ethical guidelines, ensuring participant confidentiality and protection. Ethical principles of beneficence, non-maleficence, and justice were followed, which contributed to the validity and integrity of the research findings.

RESULTS

Out of total 144 participants, 76.4% were females and 23.6% were males. Table 1 displays the demographic characteristics of the sample.

Tables 2-4 illustrate the frequency with which all participants reported the extent to which each barrier item would "stop, delay, or discourage" them from seeking professional help. Over two-thirds of participants anticipated that each stigma item would serve as a barrier to some degree if they were to seek help in the future. The most highly rated stigma barrier was 'concern about what my family might think, say, do, or feel', with 79.9% (n=115) of participants anticipating that this would prevent or delay them from seeking professional help. The most commonly-anticipated attitudinal barrier was ‘wanting to solve my problem on my own’, whereby 95.8% (n=138) of participants anticipated that this would serve as a barrier to some degree and 39.6% (n=57) thought that it would act as a major barrier to them seeking professional help in the future. The most commonly-rated instrumental barrier was ‘being unsure where to go to get professional care’ involved in seeking professional help, with 73.6% (n=106) of participants anticipating that this would serve as a barrier to some degree and 16% (n=23) thinking that it would act as a major barrier to help-seeking.

The probability plot of RSES scores, which shows a normal distribution with a significant p value of 0.02. The mean score for RSES (N=144) was 18.27, with a standard deviation of 5.637. Tables 5 and 6 illustrate the self-esteem categories and average RSES scores by demographic groups.

DISCUSSION

Mental health needs, when not addressed, are believed to place a significant stain on the health and productivity of the community.²⁹ Medical students are believed to have a higher prevalence of mental health disorders compared to individuals in the general population.³² It is widely known that doctors and medical students are reluctant to engage when it comes to mental health issues. Furthermore, there is a belief that doctors stigmatize mental illness more than the general population because they fear that seeking care for a mental health condition could negatively impact their legal license to practice medicine.^17,33

In our study, results showed that the most prominent and major three reasons in regard to stigma-related barriers that were deterring the students from seeking psychological help are “concern about what my family might think, say, do, or feel” (22.9%), “not wanting a mental health problem on my medical records” (12.5%), and “concern that people I know might find out” (11.8%).

The aforementioned findings align with a Saudi Arabian study that showed mental illness as a consequence of inadequate religiosity. This belief persists among a significant number of individuals who are hesitant to seek professional assistance, despite notable progress in the mental health care system.¹⁹ The study on Egyptian medical students, in which the primary concern was what the family might think, further supports this finding.³⁴

Moreover, in regard to attitudinal barriers, “wanting to solve the problem on my own” (39.6%) ranked on top. This observation is in line with a previous study that identified a preference for self-management as a significant obstacle to seeking formal mental health care among university students experiencing depression and anxiety.³⁵ Furthermore, stigma may primarily contribute to the urge to independently resolve the problem, even if it received a high score. So, a continuous effort to improve the accessibility and acceptance of mental health services early in their careers is crucial. Lastly, the most significant barrier to seeking mental health care was "not knowing where to go for professional care," as reported by 16% of respondents.

The participants rated instrumental barriers the lowest overall, but in contrast, the Egyptian medical students identified them as their most significant barrier.³⁴ It is worth noting that affordability and financial costs for seeking professional mental health care were not a major barrier (3.5%). Uncertainty about where to seek professional health support and insufficient knowledge in this area posed a significant concern (16%). Self-esteem predicts a series of outcomes, and in the social sciences, it is one of the most widely studied constructs.^36,37 Nearly half of the empirical studies published in major scientific journals that assess self-esteem use the Rosenberg Self-Esteem Scale as their main instrument.³⁸

Converging evidence indicates that phrasing all questions in the same direction can lead to the emergence of response artifacts like social desirability, potentially leading to questionable test outcomes. We intentionally designed the RSES to include five positively worded items and five negatively worded items to help reduce the potentially invalidating impact of acquiescence.³⁹ However, using both positive and negative wording to assess the same dimension may introduce response bias, potentially compromising validity; this phenomenon is known as the wording effect.⁴⁰ A large-scale cross-cultural study, which included nearly 17,000 participants from 53 countries, discovered that people tended to respond honestly to positively worded items, while they significantly concealed their true responses to negatively worded items. This suggests that individuals from various cultures often exhibit a bias against negatively worded items. Moreover, a study conducted across three countries found that some respondents struggle to effectively answer negatively worded questions, leading to significant issues such as reduced scale reliability.

Most individuals in our study scored between 12 and 16, with the highest crowding at 14. A study on demographic groups living in the US calculated the average self-esteem score among a sample of 503 adults to be 22.62 (SD=5.8). The mean score in our study was 18.27 (SD=5.6), which is near the cut-off point (a score of 20 or more), indicating generally positive self-evaluation but proving that the self-esteem levels in medical students are comparatively less than the general population. In general, participants performed well on the RSES. The majority of the participants fell in the category of average self-esteem (60.42%), in contrast to those with low self-esteem (29.17%). The statement most strongly agreed with was “I feel that I am a person of worth at least on an equal plane with others” (43.7%).

The study’s findings contribute significantly to the literature addressing the stigma and barriers faced by medical students when it comes to seeking help for mental health issues. This could potentially aid in comprehending and providing guidance on how to lessen the impact of mental health problems on medical students. The study revealed that the primary barriers to unmet treatment needs were student attitudes and stigma, not the availability of mental health care.

Therefore, university mental health service providers could benefit from taking specific steps to address this issue. This can include providing comprehensive orientation sessions about available services and their locations, as well as encouraging them to seek appropriate mental health treatment. Moreover, we can organize workshops to enhance awareness and reduce stigma while also emphasizing the roles of mentorship and counseling.

CONCLUSION

Medical students face significant mental health challenges, often hindered by stigma and attitudinal barriers. Cultural and regional factors strongly influence their reluctance to seek help. Improving awareness, reducing stigma, and enhancing access to mental health services in universities are essential. Early intervention and supportive environments can help safeguard their mental well-being and academic success.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Markoulakis R, Kirsh B. Difficulties for University Students with Mental Health Problems: A Critical Interpretive Synthesis. Rev High Ed. 2013;37(1):77–100.
2. 2. Patel V. Global mental health: from science to action. Harvard review of psychiatry. 2012;20(1):6-12.
3. 3. Qin X, Hsieh CR. Understanding and addressing the treatment gap in mental healthcare: economic perspectives and evidence from China. Inquiry: The J Health Care Org, Prov, Finan. 2020;57:566..
4. 4. WHO. Mental disorders. Available at: https://www.who.int/news-room/fact-sheets/detail/mental-disorders. Accessed on 12 July 2025.
5. 5. Alangari AS, Knox SS, Kristjansson AL, Wen S, Innes KE, Bilal L, et al. Barriers to Mental Health Treatment in the Saudi National Mental Health Survey. Int J Env Res Publ Heal. 2020;17(11):859.
6. 6. Frank RG, McGuire TG. Economics and mental health. Handbook Heal Econom. 2000;1:893-954.
7. 7. Abdullah T, Brown TL. Mental illness stigma and ethnocultural beliefs, values, and norms: An integrative review. Clin Psychol Rev. 2011;31(6):934-48.
8. 8. Ben-Zeev D, Young MA, Corrigan PW. DSM-V and the stigma of mental illness. J Ment Heal. 2010;19(4):318-27.
9. 9. Rüsch N, Angermeyer MC, Corrigan PW. Mental illness stigma: Concepts, consequences, and initiatives to reduce stigma. European Psych. 2005;20(8):529-39.
10. 10. Thornicroft G, Chatterji S, Evans-Lacko S, Gruber M, Sampson N. Undertreatment of people with major depressive disorder in 21 countries. The British J Psych. 2017;210(2):119-24.
11. 11. Luitel NP, Jordans MJ, Kohrt BA, Rathod SD, Komproe IH. Treatment gap and barriers for mental health care: a cross-sectional community survey in Nepal. PloS one. 2017;12(8):183223.
12. 12. Almanasef M. Mental health literacy and help-seeking behaviours among undergraduate pharmacy students in Abha, Saudi Arabia. Risk Man Health Policy. 2021:1281-6.
13. 13. Bruffaerts R, Mortier P, Kiekens G, Auerbach RP, Cuijpers P, Demyttenaere K. Mental health problems in college freshmen: Prevalence and academic functioning. Journal of affective disorders. 2018;225:97-103.
14. 14. Oláh B, Rádi BM, Kósa K. Barriers to seeking mental help and interventions to remove them in medical school during the COVID-19 pandemic: perspectives of students. Int J Environmen Res Publ Heal. 2022;19(13):7662.
15. 15. Dahlin ME, Runeson B. Burnout and psychiatric morbidity among medical students entering clinical training: a three-year prospective questionnaire and interview-based study. BMC Med Edu. 2007;7:1-8.
16. 16. Berliant M, Rahman N, Mattice C, Bhatt C, Haykal KA. Barriers faced by medical students in seeking mental healthcare: a scoping review. Med Ed Publish. 2022;12:75.
17. 17. Hankir AK, Northall A, Zaman R. Stigma and mental health challenges in medical students. Case Reports. 2014;2:5226.
18. 18. Rodriguez ML, Corse AK, Rosen LD. Mental health services use among medical students: perceived stigma and barriers to care. Med Sci Educator. 2017;27:267-72.
19. 19. Alshahrani SS, Alrajhi MM, Alshehri MA, Alotaibi FM, Altwerqe MS. Challenges and barriers in primary mental health services in Saudi Arabia: a narrative review. Adv Human Biol. 2023;13(4):309-12.
20. 20. Noorwali R, Almotairy S, Akhder R, Mahmoud G, Sharif L, Alasmee N. Barriers and facilitators to mental health help-seeking among young adults in Saudi Arabia: a qualitative study. Int J Env Res Publ Heal. 2022;19(5):2848.
21. 21. Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Academic Med. 2002;77(9):918-21.
22. 22. Alaqeel M, Alkhudairy FA, Basuliman AS, Alsubaie AM, Alqahtani FN, Almkainzi HA. The barriers to seeking mental health Services at King Saud bin Abdulaziz University for health sciences. Cureus. 2023;15(9):47.
23. 23. Billingsley M. More than 80% of medical students with mental health issues feel under-supported, says Student BMJ survey. BMJ. 2015;3:5187.
24. 24. Taylor A. Overstretched NHS services are sending suicidal students back to universities for help. BMJ. 2020;36:3958.
25. 25. Broglia E, Millings A, Barkham M. Student mental health profiles and barriers to help seeking: When and why students seek help for a mental health concern. Counsel Psyc Res. 2021;21(4):816-26.
26. 26. Hong V, Busby DR, O’Chel S, King CA. University students presenting for psychiatric emergency services: Socio-demographic and clinical factors related to service utilization and suicide risk. J American Coll Heal. 2022;70(3):773-82.
27. 27. Husain W. Barriers in seeking psychological help: public perception in Pakistan. Comm Ment Health J. 2020;56(1):75-8.
28. 28. Siddiqui F. Barriers and challenges to mental health care in Pakistan. Pakistan J Neurol Sci. 2021;16(3):1-2.
29. 29. Alsalman Z, Shafey MM, Al-Khofi A, Alessa J, Bukhamsin R, Bokhuwah M, et al. Barriers to mental health service utilisation among medical students in Saudi Arabia. Front Publ Heal. 2024;12:1371628.
30. 30. Das A. Treatment gap or service deficit: What is meant by the treatment gap in mental illness. Indian J Psychiat. 2023;65(9):982-3.
31. 31. Salaheddin K, Mason B. Identifying barriers to mental health help-seeking among young adults in the UK: a cross-sectional survey. British J Gen Pract. 2016;66(651):686-92.
32. 32. Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA. 2016;316(21):2214-36.
33. 33. Wijeratne C, Johnco C, Draper B, Earl J. Doctors’ reporting of mental health stigma and barriers to help-seeking. Occupationa Med. 2021;71(8):366-74.
34. 34. Abdel-Hady D, Baklola M, Terra M, El-Gilany AH. Patterns and barriers of mental health service utilization among medical students: a cross-sectional study. Middle East Current Psychiatry. 2022;29(1):98.
35. 35. Negash A, Khan MA, Medhin G, Wondimagegn D, Araya M. Mental distress, perceived need, and barriers to receive professional mental health care among university students in Ethiopia. BMC Psych. 2020;20:1-5.
36. 36. Freire T, Tavares D. Influência da autoestima, da regulação emocional e do gênero no bem-estar subjetivo e psicológico de adolescentes. Arch Clin Psych. 2011;38:184-8.
37. 37. Bleidorn W, Buyukcan-Tetik A, Schwaba T, Van Scheppingen MA, Denissen JJ, Finkenauer C. Stability and change in self-esteem during the transition to parenthood. Soc Psychol Personal Sci. 2016;7(6):560-9.
38. 38. Donnellan MB, Trzesniewski KH, Robins RW. Measures of self-esteem. Meas Personal Soc Psychol Constr. 2015;2:131-57.
39. 39. Hinz A, Michalski D, Schwarz R, Herzberg PY. The acquiescence effect in responding to a questionnaire. GMS Psycho-Social Medicine. 2007;4:857.
40. 40. Nieto MD, Garrido LE, Martínez-Molina A, Abad FJ. Modeling wording effects does not help in recovering uncontaminated person scores: a systematic evaluation with random intercept item factor analysis. Front Psychol. 2021;12:685326.