Time to invest in mental health

Published October 11, 2020
The writer is a consultant psychiatrist.
The writer is a consultant psychiatrist.

AT least three events this year have underscored the need for Pakistan’s leaders to urgently and proactively invest in mental health. The first is the global pandemic: despite Pakistan’s relative success in tackling the pandemic, like elsewhere around the world Pakistanis too have experienced a widespread and heightened state of stress, anxiety, fear and uncertainty as a result of Covid-19 — a state yet to be systematically addressed as part of a national response.

The second is climate change-induced flooding in Pakistan’s financial capital, which placed Pakistan’s largest urban population in the crosshairs of a host of environmental stressors from which recovery remains to be seen.

The third is the steep rise in gender-based violence reported across the country, amplified most tragically by the gruesome events of the motorway case and the reaction it spurred among certain government and police officials.

Our national response to all three events could have, and ought to have, been better. Consider the human suffering that could have been mitigated had the events described above been met with a trained workforce, to support front line workers during the pandemic, or had we been capable of integrating psychosocial support into flood relief and disaster management, or institutionalising effective and sensitive responses to gender-based violence.

Implications of mental health for development need to be understood in the public and political spheres.

These are just a few examples that highlight the enormous need for Pakistan to politically invest in mental healthcare, beyond what the statistics are already telling us (ie every fifth Pakistani, including children and adolescents, suffers from a mental disorder).

Some of the mental health disorders in Pakistan are leading causes of illness and disability, and are responsible for immense suffering, premature death and suicides. More than 75 per cent of Pakistanis with mental disorders do not receive any treatment. Worryingly, many are vulnerable to stigma and human rights abuses. This serious gap in mental healthcare is a result of a consistent lack of investment in both prevention and care on the one hand, and political attention to the issue on the other.

Coincidentally, yesterday, Oct 10, was World Mental Health Day. This year, World Mental Health Day was dedicated to getting all countries to invest in mental health. Mental health is critical to Pakistan’s successful national development, if we truly aspire to join the league of developed countries and commit to the pledge that we ‘leave no one behind’. Mental health is not just a public health issue, it is now widely recognised as a developmental issue. While Pakistan’s leaders were quick to recognise that easing the lockdown was difficult but necessary given the risk of lost productivity, in the same vein it is imperative we recognise that mental health conditions too cost Pakistan significantly in terms of lost productivity.

The implications of mental health for development need to be understood across both our public and political spheres. It is a fact that Pakistan’s policymakers are constantly challenged to respond to pressing national priorities in the context of developmental budgetary constraints. But political investment at the highest levels of government is a prerequisite for budgetary allocation. There is an opportunity here for Pakistan’s leaders to cash in on a growing global momentum for investing in mental health, and the investors who may be willing to supplement Pakistan’s own national health policy and budget, should the government commit to prioritising mental health.

While this is not a big ask, the cost of delivering even the most basic mental health services to Pakistan’s population has been calculated to be at least $1 per person per anum (pppa), which is five times the amount we are spending at the moment on mental health.

Compare this with a developed country like the United Kingdom, which spends $278 pppa on mental healthcare, but which still believes this is insufficient and inadequate relative to its spending on physical health. In addition to the alleviation of human suffering, Pakistan’s policymakers should recognise other returns from investing in mental health. There is a potential return of $5 for every $1 invested in scaled-up treatment for depression and anxiety, and a return of $7 in reduced crime and criminal justice costs for every $1 invested in evidence-based treatment for drug dependence.

In addition to investing in mental health, how this investment takes place is of critical importance. At present, all mental health spending is on developing specialist services at the tertiary level. But these services will never be able to shoulder the huge burden of mental health conditions in the country. Without effective referral pathways, these services will remain inaccessible for the vast majority of those who need them the most. Furthermore, there is little to no quality assurance, resulting in ineffective treatments centred on irrational prescriptions.

Since the onset of Covid-19, there has been an upswing in investment by donors to provide mental health support. Multiple tele-counselling services are being offered without a thoughtful sustainable plan for implementing evidence-based interventions, or setting up pathways of care to support such services. This problem is compounded by a blitz of Psychological First Aid (PFA) trainings, which is effective only when it is part of a multi-level intervention plan aimed at training community workers to act as guides to basic support services.

Logically, the first step should be to set up these support services and implement a multiple-level mental healthcare plan, before training community members in PFA. Finally, there is noticeable disconnect between existing psychiatric services and upcoming counselling services; ideally both should be integrated.

While investment must happen, it is necessary to ensure this through a whole-of-systems approach. We must find solutions that are practical, costed and realistic. To do this, Pakistan must assess its domestic mental healthcare needs and leverage available resources. Funds must be allocated after careful calculations, and not whimsically. In view of competing health priorities in the country, mental health is best integrated into existing development priorities. This requires deft coordination between policymakers, development partners and mental health experts. The overarching objective should be to implement scalable, rights-based community mental healthcare that is systematically linked to specialist services. Mechanisms to monitor, evaluate and report emerging evidence are vital. This is the only way forward if Pakistan is to see real change, and real progress.

The writer is a consultant psychiatrist.

Twitter: @AsmaHumayun

Published in Dawn, October 11th, 2020

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