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A silent epidemic

October 15, 2016

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COMMEMORATED on Oct 10, this year’s World Mental Health Day focused on ‘psychological first aid’, with an aim to generate awareness about this theme: simple psychosocial interventions that can be learnt by anyone, including laypeople, to provide support to others in times of distress.

Unfortunately, mental health issues remain poorly understood in Pakistan, and the stigma surrounding mental illness continues to hurt families. This makes it even more incumbent on the government, in collaboration with NGOs and mental health professionals, to do more to educate and train communities in psychological first aid. Broadly speaking, this is just one component of wider comprehensive mental health and psychosocial support structure, which includes appropriate training, services and referral systems at all tiers of healthcare structures.

Mental healthcare is not simply restricted to treating mental disorders. Pakistan is a signatory to the UN’s 2030 Agenda for Sustainable Development, which addresses poverty, health and well-being, quality education, gender equality, economic growth, peace and justice, and reduced inequalities. Mental health — which includes mental well-being, positive behavioural and attitudinal change — is a crucial rung in the stepladder towards achieving these goals.


The Pakistan Psychiatric Society needs to assume greater responsibility in prioritising national needs.


It is encouraging that the culture of silence and shame around mental health issues is slowly beginning to dissipate. That said, complex social challenges such as sexual violence against women and children, domestic violence, pathological fatalities from suicide and so-called ‘honour’ killings remain. Such episodes mainly reflect public mental health issues, where entire families and communities may be involved in the background. These are now increasingly documented by a public media and mainstreamed into the national discourse with the aim of spurring legislative action. Essentially, public health officials need to advocate a therapeutic-judicial model that can create awareness while enabling attitudinal change, early reporting, comprehensive interdisciplinary assessment and the provision of medical help, if needed.

In contrast to other low- and middle-income countries, Pakistan faces the additional challenge of multiple conflict zones, both at the borders and deeper inland. We rank among the top 10 countries hosting more than half the world’s refugee population. As a neighbour to one of the world’s largest producers of opium, we are also vulnerable to the global opiate trade.

Five per cent of Pakistan’s productive population is estimated to suffer from addiction. These challenges are compounded by vulnerabilities to natural catastrophes. War and disasters have a huge psychological impact, where 40pc of those affected may need attention. It is crucial that an emergency mental health response is integrated into national disaster management plans. Our tendency to rely on cursory ‘counselling services’ for survivors of abuse, conflicts, displacement, terrorism or natural disasters remains an insufficient avenue of recourse in the delivery of sustainable care.

It is simply unacceptable for us, in 2016, to ignore or dismiss anomalies within our national system; international reports documenting the plight of people with mental illnesses, relegated to the primordial practices offered at Sufi shrines, only damage Pakistan’s public health credibility. The case of death-row prisoner Imdad Ali goes far beyond questioning the death penalty or the court’s ability to assess an individual’s mental capacity. It raises innumerable questions about the lack of mental healthcare provisions in our prison systems. Similarly, the lack of such provisions in our school systems, the development sector and basic health reforms is also standard.

In this vacuum, flourishing quackery is leading many to sham therapists, disingenuous drug rehabilitation centres and self-proclaimed trauma specialists. The role of psychiatrists revolves around rudimentary practices: attending to dozens of patients each day, offering little more than a few minutes’ consultation to each patient. Alarming pharmaceutical influences foster trends of irrational and callous polypharmacy. Commercial drives endorse unnecessary hospital admissions and expensive investigations, like EEG and MRI, without adequate clinical indication.

To remedy these trends, the Pakistan Psychiatric Society needs to assume greater responsibility in prioritising national needs and ensuring ethical and accountable processes for professional conduct. The society’s stark absence from print, broadcast and social media reflects a complete disconnect from emerging mental health issues and evolving public needs. While the dearth of mental health resources is hardly unique to our case, it is not an adequate defence for allowing the status quo to continue. The absence of a sincere vision and community-based priorities is leading to a miscarriage of the public mental health practice.

Having committed to the World Health Assembly’s Comprehensive Mental Health Action Plan for 2013-2020, Pakistan needs an effective national mental health policy and comprehensive provincial mental health legislations across all the provinces to ensure the delivery of basic mental health care, treatment for the severely ill, and protection of their human and civil rights. The World Bank has declared mental health to be a global development priority because it imposes an enormous burden on society.

One-third of the global disability burden (years lived with disability) stems from mental, neurological and substance-abuse disorders. In addition to indeterminate distress, the economic cost of this disability in terms of treatment and reduced productivity is significantly high. WHO has projected that depression will be the second leading cause of disability in the world by 2020. Global attention on mental health is also evident from the fact that next year, World Health Day will be dedicated solely to depression.

On average, most countries spend at least 3pc of their health budget on mental health, whereas Pakistan has allocated nothing. The World Bank suggests that national governments should work with international development partners to bridge the gap in funding to implement cost-effective mental health interventions. An encouraging example is that of the health department of Khyber Pakhtunkhwa, which is collaborating with international agencies to assess the province’s mental health needs and propose effective strategies for implementation. These are positive steps, but more needs to be done. Can Pakistan please wake up to the challenge?

The writer is a consultant psychiatrist.

Twitter: @AsmaHumayun

Published in Dawn, October 15th, 2016