“You’re a great student, you have good scores, you can apply for any specialty. You’re just selling yourself short.”
“Oh! If you want to go into psychiatry, it must mean you need help yourself.”
“If you’re not mad now, you will be by the time you finish.”
These were only some of the pearls of wisdom that peers and preceptors shared with me when I informed them that I wanted to be a psychiatrist. This was their way of guiding me when I was clearly “so lost”.
I put it down to ignorance and the rampant stigma against mental illness in Pakistan, and with the support of my parents and sister, embarked on a career path so many did not understand.
It's been 10 years since I graduated from medical school. Much has changed in Pakistan since then, but the views against psychiatry and psychiatric patients continue to stagnate and fester.
This is my attempt to get a conversation started – an absolute must if we desire change.
People want to avoid being seen in a psychiatrist’s office. They have to be coaxed and pleaded with by family members into seeking help, and indeed, sometimes lied to about the kind of doctor they are going to visit. Although, this is my experience in rural America, I could just as easily have been describing scenarios in Pakistan.
These are the facts: According to the World Health Organisation (WHO), around 450 million people are affected by mental illness globally. The World Bank estimates Pakistan’s population to be upwards of 185 million, accounting for 2.65 per cent of the world's population.
It’s only logical to conclude that some Pakistanis will suffer from mental illness. Sixty-two per cent of Pakistanis live in rural areas, and the majority of them lack exposure and education. The one common thread, of course, is religion and although, I believe it is never polite to discuss politics or religion, one cannot help but comment on Pakistan’s version of both, when talking about important issues that plague the general public.
Consider another fact: Certain mental illnesses affect women twice as much as men, depression and anxiety being at the top of this list.
So, take the facts, throw into it a generous helping of illiteracy, religious inclusions and ignorance, urban legends, old wives tales, misogynistic constructs and a lack of infrastructure, and you have on your hands a recipe for Pakistan’s own brand of stigma against mental illness.
“Sambhalo apnay aap ko”
“Loag kia kahain gay”
“Kaun shaadi keray ga tum se, poori zindagi hum per bojh bani raho gi”
“Tum tou paagal ho, jao wapis apnay maa baap kay paas”
“Baal khol kai darakht kai neechay maghrib kay waqt bethi thi, Jinn ko ishq ho gaya hai”
All of these statements are judgmental and assign blame. It’s much like being told:
“Oh, it’s all in your head”
“Snap out of it”
“Why are you depressed when you have everything?”
“Just think positive thoughts and it will be OK.”
The recipe for stigma doesn’t apply to other medical conditions like diabetes, hypertension, heart disease. There is no judgement or blame, rather, a resignation:
“Allah ki marzi.”
“Jana toh sab ko hi hai, yeh to aik bahana hai.”
That absolves the patient of any direct part in acquiring the illness. Of course, one can also always blame one’s genes. Plus diabetics and hypertensives still behave in socially sanctioned, appropriate ways, even if that means eating maghaz and nihari and paye and other such deadly delicacies.
Humour me while you mull over this simple analogy:
In diabetics, there is an internal organ, the pancreas, that malfunctions; it stops producing the hormone insulin, hence causing increased blood sugars. It’s true that behavioural modification with diet and exercise helps but in a lot of cases, an endocrinologist will prescribe medication.
In the same way, mental illness, too, involves an organ (the brain), as well as receptors and hormones (i.e., neurotransmitters), which malfunction to induce an illness. There is a lot we don’t understand about how exactly this malfunctioning comes about, but there is also a lot that we do understand. Based on that, there are a number of medical treatments which work.
Although making positive changes to your life will improve symptoms, one cannot simply just 'snap out' of a poor state of health. It’s not the patient's fault; or something they did or didn’t do. Neither is having a psychiatric illness a sign of weakness of your faith, just like having hypertension doesn’t mean you are a bad Muslim/Christian/Hindu.
Research has proven that prayers and meditation help depression and anxiety, but this can never be the be all and end all.
Judging, blaming and shaming of individuals with any illness will have two effects: There will be a minority that will be motivated to seek help and improve their health, so people stop taunting them. The majority however – and this is again universal – will hide. They will not seek help and things for them will only deteriorate.
Another unfortunate downstream effect of all the negativity is an aversion to the field of psychiatry.
Many brilliant minds end up opting for other specialties because they are 'well-regarded'. The ratio of psychiatrist to general population in Pakistan is an abysmal 1 to half-a-million people, according to some reports. That is one reason people are forced to seek other avenues.
My neurology colleagues in Pakistan will attest to how many of their patients really need a psychiatrist. Even though it's the same organ, a neurologist cannot do a psychiatrist's job, just like they cannot do a neurosurgeon's job either.
Mental illness will affect you regardless of race, gender, age or ethnicity. It will stop you dead in your tracks whether you are a Bollywood actress or the father of five in a goth in Karachi. It will also inspire judgement, blame and opinions that will in turn affect help-seeking behaviours.
I understand that there is a large section of Pakistanis I’m not reaching with this commentary; the families of schizophrenics who are abandoned at “Gidoo Bander” (Sir Cowasjee Jehangir Institute of Psychiatry in Hyderabad); the communities who frequent mazaars and faith-healers to rid their loved ones of Jinns; the quacks who con money out of these vulnerable people, etc.
However, it would be quite an achievement to force even the educated class of Pakistan to give up their preconceived notions about mental illness.
If even one of you reads this and realises that it's not your fault and it's OK to seek help; if one of you encourages instead of discouraging a medical student wanting to help psychiatric patients, we will indeed witness change.