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How to respond to Pakistan's alarming suicide rates
Sualeha ShekhaniUpdated November 29, 2018
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.
Are you a mental healthcare professional? Share your insights with us at blog@dawn.com
Sualeha Shekhani is a lecturer at the Centre of Biomedical Ethics and Culture, SIUT
The views expressed by this writer and commenters below do not necessarily reflect the views and policies of the Dawn Media Group.
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اکثرگہری نیند سے قبل اچانک ایک جھٹکا بیدار کیوں کردیتا ہے؟
'جب وہاں کوئی نہیں تھا تو وہ آوازیں کس کی تھیں؟'
'پاکستان میں شاید ہی کوئی ہو جس نے دو بچوں کے بعد یہ پوزیشن حاصل کی'
Comments (13) Closed
Fayyaz
Nov 29, 2018 08:49pm
Timely reminder
Recommend 0
This probably will be read by 5-10 people. Very informative article, asking one more question about what must be done about our crumbling society.
Nov 30, 2018 02:35am
You have probided no evidence that all suicidal thoughts or tendencies are due to mental illness.
Akil Akhtar
In Australia which is a developed country with good services and social security and there are hardly any poor...there is one suicide per day in a population of only 20 million. This has more to do with modern day pressures and mental health....
Excellent effort to highlight ever growing burden of mental illness. The World Health Organization (WHO) recommends mhGAP training for non specialists to diagnose and treat common mental disorders. It has been successfully implemented in many parts of low and middle income countries. WHO estimates that 7.4 percent of global DALYs (Burden of illness) are caused by disorders in the mental and behavioral disorders category.
Syed Danish Ali
another suggestion is 1) utilize technology for handling common mental problems and let technology be the guide; for instance, chatbot woebot has been made to act as a support for mental health issues. Health professionals cannot scale. But technology can scale rapidly. It takes 20 years to create 1 psychiatrist who is limited to only consultation with patients who can afford her. Technology on the other hand can scale rapidly. 2) increase sense of community by design; that means less atomization of the individuals and more community service, social impact businesses and so on. let there be more startups focusing on making a social impact; Nadeem Hussain is doing great work in this regard and so are some startup accelerators like Nest I/O. 3) many common mental problems arise due to physiological reasons like lack of Vitamin D, Iron, thyroid issues. Given that Pakistan's nutrition profile is so low, it would be good to address this through preventive healthcare. 4) many genetic problems arise due to arranged marriages that are often between close cousins. Opening up our mindset to let the children marry out of their own choice, instead of their parents' choice to retain their control/hegemony/power would provide genetic diversification. It's these same genetic problems that give rise to many chronic health problems including mental ones.
The ways of the world, its order, its rules, its expectations are not manageable by everyone. Even normal citizens find it tough to manage life with myriad of complexities, expectations and the shackles that it binds us all in. Lives are not meant to live a life as per a manual. those who read the manual and act accordingly have less issues. But the others-they wean out. The society must acknowledge this fact. Our society is a concoction of all types of lives that bring color and meaning to its diversity. I always have maintained that most of our cities- at least in South Asia are designed for able bodied young men. It leaves out the old, the young, the women, the girls, the differently abled physically and the differently abled mentally. Just having help centres wont do much. We need to sensitize people on such issues. This is a hard task, but try, we must.
mansoor
This weeks Economist told us that Suicide is a thing of past. How the developed nations have controlled it. But when you look at the efforts placed from health, school, community, society , media I am afraid we are centuries behind.
Pro Democracy
Please take extra care while you choose a title. Otherwise, it was an informative article.
QAP
Sad situation.Pakistan has been a bad performer as far as education is concerned in any field, including medical. Also, there is free flow of brain drain from Pakistan. I find abnormally large number of Pakistani doctors in the USA - a large percentage of them is psychiatrists. Money is the king in any non-socialist system.
S.Subrahmanyam
Psychiatrists help in reducing the instances of suicide. As the recent issue of The Economist confirms, with help from specialists and modern drugs the instances of suicide can be reduced dramatically. Even with more than 6000 psichiatrists in India we have a shortage. We need to do more in developing countries to help the mentally disturbed.
Maha Batool
awareness,treatment as well as immediate approach is needed because in emerging countries like Pakistan its been like not new as previously model anum tanoli and now the student of Bnu lost her life due to depression. Everyone should be open about mental health as it is equally important secondly their should psychiatrist who are accessible so that one can get immediate therapy
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