Not a priority

09 Oct 2014


The writer is a psychiatrist.
The writer is a psychiatrist.

EACH year the world observes Mental Health Day on Oct 10; this year’s theme is ‘living with schizophrenia’, a major mental disorder, which causes significant impairment of function, and disability, immeasurable distress for the family and loss of productivity.

Mental disorders contribute to early mortality: suicide resulting from these disorders is a major cause of death for all ages. But, like most mental illnesses, early detection and treatment of schizophrenia is both possible and inexpensive. Mental disorders contribute 14pc of the global burden of disease. Over 70pc of this is borne by low- and middle-income countries such as Pakistan. This is because four out of five people with severe mental disorder do not receive any treatment.

WHO has declared mental health a ‘public health priority’ for developing countries. This means that the problem, while highly common, is preventable or treatable. Therefore, comprehensive efforts must be directed towards promoting positive mental health, preventing mental health problems, detecting disorders early and offering prompt treatment and regular follow-ups.

This far-sighted approach is holistic and directed at focusing on entire populations, not on individual patients or disorders. It is concerned with the entire system, not only the eradication (treatment) of a particular disorder. This approach stretches far beyond specialist-led psychiatric services based in tertiary-care hospitals or the private sector.

Mental health is neglected in Pakistan.

Pakistan’s mental health challenges are acute — as a nation facing internal and geopolitical conflict, socioeconomic convulsions and huge internal displacement triggered by war and natural disaster. These realities make it all the more necessary for the state to develop an effective emergency mental health response.

Existing mental health services in Pakistan need to be understood in the context of the official status of mental health in the country. The national mental health programme was first initiated in 1986. Mental health was very much part of the country’s 1997 national health policy, and since then it was supposedly an integral component of primary healthcare in subsequent five-year plans.

Unsurprisingly, this did not materialise meaningfully and was never revived at the provincial levels after the devolution of health to the provincial governments. As a result, there is currently no mention of a mental health policy and there’s non-existent priority for mental healthcare across Pakistan.

Currently, the mental health infrastructure exists mainly at the tertiary-care level in the form of academic psychiatric departments. These institutes focus on delivering hospital-based psychiatric care and train medical graduates in silos from primary healthcare or other community services.

Today in Pakistan, there are an estimated 400 psychiatrists to serve the general mental healthcare needs of 200 million people. As for special needs, for example of young people, who comprise almost half our population, there are only half-a-dozen trained child psychiatrists available. The role of psychiatrists has also been whittled down to undertaking clinical and teaching responsibilities in academic departments. These underdeveloped clinical services focus on a biological model of practice, and revolve around prescribing medications, often unscientifically.

The psychiatric service in Bannu is a classic example of the most peripheral Pakistani districts: a teaching hospital with a ‘professor’ who has no faculty or staff to support him; the professor himself carries an academic title but a non-academic job description; his time is largely taken up by administrative and medico-legal responsibilities; the quality of clinical care is far from satisfactory; there is little teaching/training conducted by the department. Mean­while, the medical college was closed for the summer holidays despite the huge IDP challenge there.

The growing trend of expensive specialist services in the private sector further contributes to the inequitable mental healthcare at the cost of developing public services, since most academic psychiatrists invest their time and energy in after-work lucrative private practices.

In the larger context of a failing healthcare system, poorly developed mental healthcare is often rationalised, almost defended. But now that the international community has rec­o­gnis­ed mental health as a priority, Pakistan cannot justify it as a misplaced priority in the face of its ineffective health systems.

Urgent attention is needed to make mental health a priority at the provincial level. This includes articulating and advancing a mental health policy that emphasises the need for integrating mental health in primary care, prioritising all specialised resources towards developing a public health approach to addressing this burden, redefining and broadening the role of mental health professionals, and enacting a legislative framework to support scientific and ethical services.

In systems where mental health is not a priority, adversity can provide a window of opportunity to review and strengthen existing services. It is time for us to act.

The writer is a psychiatrist.

Published in Dawn, October 9th, 2014