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Mental health reforms

December 03, 2018

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

RECENTLY, Lahore was left heartbroken when a young person died after jumping off the roof of a high-rise campus building. Sadly, this was not an isolated event. This case and the media reporting that followed highlighted many failures of mental healthcare in Pakistan even in urban and upwardly mobile segments of the population. These failures range from ignorance, stigma, a failure to recognise symptoms, inadequate psychological support services on university campuses, social and legal criminalisation of self-harm, and the inability of the media to report responsibly and accurately.

For far too long, mental healthcare and the associated, necessary reforms have been neglected in Pakistan. This is not just a public healthcare disaster but also a gross violation of human rights of a highly vulnerable segment, which, according to some estimates, may comprise up to 25 per cent of our population. Pakistan has no mental health policy or plan; it allocates no budget for mental healthcare; even after repealing the Lunacy Act of 1912 and the devolution of powers, no province has been able to implement an iota of its mental health legislation since the passage of the 18th Amendment. Despite a bill passed by the Senate to decriminalise attempted suicide, Section 325 of the Pakistan Penal Code still affirms that self-harm is a criminal act. Professional services that do exist are unregulated, sparse and expensive.

Pakistan has no mental health policy or plan; it allocates no budget for mental healthcare.

With the second-largest young population in the world, 20pc of which is likely to face violence, trauma and psychological challenges in their early years, there are no specialist services for children and adolescents in the country. Moreover, Pakistan has a large sprawling prison system with virtually no forensic psychiatric services. The prevalence of learning disabilities is alarmingly high, but there are few educational or rehabilitation opportunities. Primary care does not offer mental healthcare. A majority of medical graduates in Pakistan are unfamiliar with common mental disorders. Alternative avenues of recourse have led to the growth of rampant quackery.

In 2013, the World Health Organisation made a comprehensive mental health action plan (2013-2020), which was adopted by the 66th World Health Assembly and signed by 194 states including Pakistan. Rooted in the principle of human rights, this action plan was considered a landmark achievement. The four major objectives of the action plan were to “1) strengthen effective leadership and governance for mental health; 2) to provide comprehensive, integrated and responsive mental health and social care services in community-based settings; 3) to implement strategies for promotion and prevention in mental health; and 4) to strengthen information systems, evidence and research for mental health”. Disappointingly, Pakistan has yet to make plans to achieve these objectives.

In order to achieve the first objective of the WHO action plan, there is an urgent need to formulate a national mental health policy that can address key issues by setting goals and implementing effective legislation. All over the world, countries have national legislation that provides a legal framework in pursuit of these objectives. The status of mental health legislation, however, is not on the national radar. Sindh passed its Mental Health Act in 2013 and formed a mental health authority only recently. No definitive action has been taken since. Punjab passed its act in 2014 but is yet to take steps to implement it. Last year, the KP government announced the passage of a mental health act on its website. Where Balochistan, Azad Kashmir and Gilgit-Baltistan are concerned, the less said the better.

The three provincial acts that have been nominally passed were copied and pasted from the draft of the original federal Mental Health Ordinance, 2001. This would suggest that the provinces either have the same needs or that they lack the expertise to draft their own legislation. No provincial government has made a strong or effective case for mainstreaming mental healthcare.

This is not all. The second point of the WHO action plan emphasises the need to integrate mental healthcare into primary care, which means systematically shifting the locus of care away from long-stay mental hospitals and tertiary-care hospitals towards primary-care and non-specialised health settings.

To achieve this: a) an examination in psychiatry should be mandatory in MBBS courses in all public and private medical universities; b) all primary healthcare staff should be trained to recognise and treat common mental disorders, including drug-use disorders (mhGAP-IG training guidelines by WHO); c) trained counsellors must be appointed in primary-care health settings; d) an effective referral pathway should be established so that people suffering from severe mental disorders can be referred to specialist services; and f) essential drugs for mental disorders must be available for primary healthcare.

In addition, there is a dire need to develop and regulate specialist services across the country. To this end: a) all mental health services should be mapped to identify existing gaps; b) post-graduate training schemes for mental health professionals should be qualitatively and quantitatively reviewed; c) comprehensive psychiatric services must be ensured at the district level; and d) specialist services like those for children and adolescents, prisoners and those with learning disabilities should be established at the tertiary-care levels.

The third objective of the WHO action plan solicits strategies for promotion and prevention in mental health. The foremost action needed in this regard is to formulate a national suicide prevention plan to address the lack of public awareness about mental disorders and risk factors that can contribute to mental ill health in society. Over 90pc of suicides in Pakistan result from untreated mental disorders, and are thus preventable. Providing adequate services for early recognition and effective treatment of mental disorders is vital. The training of key personnel involved in the process of investigating or reporting suicides, including the police, medico-legal officers, forensic medical specialists, general/family physicians and media is essential.

Finally, the fourth objective of the plan is directed at strengthening mental health information systems. Mental disorders must be routinely reported in provincial health information systems. We must also initiate a reliable mechanism to collect data and overcome the lack of official statistics on suicides in the country.

The mental health crisis is not going anywhere, and will likely forestall any hopes of national progress. We must act.

The writer is a consultant psychiatrist.

Twitter: @AsmaHumayun

Published in Dawn, December 3rd, 2018