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Objectives To determine the risk factors of patients presenting with deliberate self harm (DSH) to the emergency departments (EDs) of four tertiary care hospitals of Karachi, Pakistan. To determine the outcome (admission or discharge) of patients presenting with DSH to the EDs of four tertiary care hospitals of Karachi, Pakistan. Methods Study period March 2010 to May 2010. Sample Size An equal number of cases (65) and controls (65) will be enrolled from each centre. Study site Aga Khan University Hospital (AKUH), Abbasi Shaheed Hospital, Civil Hospital Karachi and Jinnah Postgraduate Medical Centre. Study population Inclusion criteria for cases: all patients 18 years and above presenting to the ED of respective hospitals with DSH attempt. Inclusion criteria for controls: for each case, a control will be enrolled in the study, which will be identified with the use of ED admission register and will be matched with cases for gender and age 2 years. Exclusion criteria for both cases and controls: individuals not giving informed consent, critically ill (intubated, obtunded patients, those with third degree burns and life threatening injuries). Study tool DSH-Risk Factors and self-reported questionnaire scale for anxiety and depression. Psychiatric evaluation, treatment and follow-up The information elicited from questionnaires will help reach a tentative psychiatric diagnosis. These patients will be referred to Psychiatry Consulting Clinics at AKUH. These clinics are conducted by senior psychiatry residents under the supervision of consultants.

T he October 2005 earthquake in northern Pakistan traumatised the nation. More than 73 000 people were killed and 3.5 million rendered homeless. As part of the global response to the disaster, many Western mental health professionals of Pakistani origin offered help. Many had left the country years ago, but the earthquake made them return, albeit only for a short time. What moved them? The emotional bond or guilt for abandoning their parent country? One psychiatrist from the US explained “this was our Katrina [US hurricane] and we had to do something.” Whatever it was, there was an incredible “jazba” (spirit) and a desire to help. Many professionals worked in the makeshift camps which housed the survivors, others with children in tented schools. But what …

In less developed societies where poverty, illiteracy, and deeply ingrained cultural beliefs coexist, human distress can take on an unimaginable garb. I saw her in the mental health clinic in Orangi, one of the many slum areas of Karachi, Pakistan's largest city. She was barely 5ft tall and, walking with a slight droop of the shoulders, looked shorter still. The doctors could not find any reason for her complaints—headaches, palpitations, weakness, appetite, and weight loss. Various analgesics, vitamins, tranquillisers, and antidepressants had had no effect. X rays, endoscopies, blood and urine tests were all normal. Married with two grown up sons, she had no other living relatives. I could not understand the cause of her symptoms. I ask about her relationship with her husband. “It's …