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Calls for awareness ought to be accompanied by a push for an increase in professional mental healthcare services.

A few days back, a friend of mine whom I had not talked to in quite a while, reached out to me and enquired whether I could put her in touch with a therapist.

Given my association with a tertiary care hospital, such requests often come my way, and while I am able to suggest a few names, I also add a warning: you would be unlikely to get an appointment before at least two weeks. And the waiting time can also go up to two months.

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This conversation came back to me poignantly when a few days ago, I read about the death of Rushaan Farrukh, a student at Beaconhouse National University, by attempted suicide.

As the news spread, my social media was buzzing with calls for mental health awareness, highlighting the association between mental illnesses and suicide and the importance of reducing stigma and showing empathy to those who are suffering.

Rhetoric vs action

Despite mental illness and suicides being serious issues, there is widespread ignorance among the healthcare services in Pakistan about suicides and suicidal tendencies that occur as a result of underlying mental conditions.

It is partly due to this ignorance that suicide and attempted suicide are considered criminal offences under the Pakistan Penal Code, punishable by a fine of Rs10,000 and/or imprisonment.

While we do not have exact statistics from Pakistan, some estimates suggest that mental illnesses represent four per cent of the total disease burden.

To add to this, we only have, according to a 2009 study, 342 psychiatrists and 478 psychologists in the entire country, which is an abysmally low number. Updated statistics are hard to come by, but the numbers are unlikely to be much better.

So while talk shows can have programmes on mental health awareness and celebrities can stress its importance further, the unfortunate reality on the ground will remain: there is a huge gap between the demand and the supply for mental healthcare services in Pakistan.

Those who require mental healthcare services urgently may find themselves facing the systematic issue of not getting swift appointments with a professional.

And for someone who is mentally distraught, struggling with psychosis or deep sadness, the time between reaching out for help and actually making contact with a professional can also be the time between hope for recovery and profound despair, between life and death.

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While I was conducting research on the experiences of those who provide care to the elderly, one of my respondents, whose mother was suffering from Alzheimer combined with acute psychosis, explained the difficulties he faced trying to find the right healthcare professional who would diagnose and treat the problem.

He had a hard time looking for a rehabilitation facility that could deal with acute psychosis — a disorder that is typically accompanied by behavioural problems, including physical and emotional abuse among patients.

His search revealed that, not only there are just a handful of rehabilitation facilities, but that they are exorbitantly expensive and therefore accessible only to a select few. This inaccessibility (including financial) was the most stressful part of care giving for him.

My intention is not to discount the awareness rhetoric which actually serves as the starting point when it comes to dealing with mental health, but what I contend is that it should not be done in isolation and ought to be accompanied by an incessant push for an increase in professional mental healthcare services.

Main reasons

Limited services of this nature exist in Pakistan for a number of reasons, the main being the shortage of physicians overall in the country.

Psychiatry as a sub-specialty is not considered an attractive field. A survey conducted in 2011 with medical students from four public medical colleges revealed that only 13.1pc out of 771 students showed preference for psychiatry as a career option, with 50.3pc opting for surgery.

Career choices are influenced by various factors such as the financial lucrativeness of the profession and its wider social prestige.

Psychiatry pays little in comparison to other fields, considering that the only way to earn money is through consultations and not through any procedures, as in the case of surgery.

But the irony is that the amount charged for a single consultation varies from Rs500 to Rs10,000, making it beyond the reach of the general population.

While a one-off payment can be negotiated, mental illnesses tend to be chronic and require long-term management.

In the early days of intervention, particularly in severe cases, patients may be required to visit the mental healthcare professional once every week.

This makes the long-term financial cost, combined with sustained use of medications (which are also quite expensive), insurmountably high.

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The apathy of the government towards provision of mental healthcare services is another major factor.

Public healthcare management in Pakistan has largely been reactive, as evidenced in the cases of infectious diseases epidemics that affect large numbers of people at one time and may result in significant morbidity and mortality. Suffering due to mental illnesses, on the other hand, is largely silent.

Official mortality statistics on suicide in Pakistan do not exist since there is no database that collects such information. We simply do not have the numbers to create ripples in the healthcare system for the problem to be noticed.

It should also be noted that maintaining databases and collecting information for rates of suicide is the responsibility of the government.

Public health programmes that attract huge amounts of funding tend to be those that can be cited as success stories of bringing down high rates of morbidity and mortality.

However, this is not the case with programmes for chronic mental conditions, the fruits of which take time to materialise.

Some suggestions

So, what can be done in the face of this huge gap between demand and supply of mental healthcare professionals?

We need to begin by asking a few fundamental questions. Ought the domain of mental healthcare delivery be reserved strictly for specialists, including psychiatrists and psychotherapists?

Given the grim picture of a shortage of specialists, we have to start thinking of innovative solutions to tackle this problem.

A strategy that has shown some promise in a few low- and middle-income countries is task-shifting, particularly in the field of mental health, to overcome the specialist workforce shortage.

Allied healthcare professionals trained by specialists are sought to identify common mental health conditions and provide immediate support and relief. In case of serious conditions, a referral may be made to a specialist.

A recent research reviewing 30 studies illustrated positive findings on mental health using the task-shifting approach.

We have seen some promise of this approach with the use of lady health workers within the domain of family planning in Pakistan.

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However, caution must be exercised while implementing task-shifting in the country. Regulation is essential since untrained and unregulated mental health workers may cause more damage than good.

Provision of basic counselling services that do not require an advanced degree in behavioural sciences, especially in education and professional environments, is essential along with increasing accessibility to specialists in case of severe cases.

A cry for help can be answered by a helpline service operated by an allied healthcare professional.

Family physicians, also known widely as general physicians (GPs), are often the first contact for many medical conditions.

With the advantage of basic medical education, GPs can be provided some additional training within the field of mental healthcare. This can widen the supply net for mental health provision.

Concrete steps must be undertaken by those who are responsible for ensuring the health of the masses.

The first step in this process is recognising that mental illnesses and suicide fall within the scope of healthcare services.

Correction: The article earlier stated that Pakistan has 342 psychiatrists and 478 psychologists per 100,000 people. In fact, these are the figures for the entire country as per a 2009 study.


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