Special Report

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[post_content] => Sometimes we hear about a death — a result of a suicide — making news headlines in Pakistan. But not all suicides make news. Lack of proper care facilities, along with social, legal and religious stigmas create an invisible barrier in the reportage of these cases. Like this barrier, mental health problems are also invisible and so are the national official statistics of suicides committed in Pakistan.
Add to it negligence of mental health on a governmental level and we are left with absence of any official data on suicides in Pakistan. Lack of official data creates an impediment for research and policy creation which also affects the treatment of the issue.
Dr. Habib Ullah Chaudhry, a senior psychiatrist based in Lahore and ex-president of Pakistan Psychiatric Society explains that hospitals have their own data for patients admitted due to mental illnesses or suicidal tendencies. Yet, he says, data is not adequate because most suicides aren’t reported as suicides, but as accidents due to the stigmas attached. This leaves a hole in data gathering. World Health Organization (WHO) collects data from governments around the world to create a database of the numbers. “It is also hard to find exact suicide numbers in Pakistan because when suicide cases occur in rural areas, they don’t even make it to the hospitals,” he says.
According to a recent review titled, Suicide and Its Legal Implications in Pakistan, suicide deaths are not included in the national annual mortality statistics that are provided to the WHO. National rates are neither known nor reported, the review states.
Dr Iftikhar Minhas, a Lahore-based psychiatrist and the Public Relations Secretary of Pakistan Psychiatric Society elaborates that another reason why hospitals have a difficult time in recording suicide cases is because if a suicidal patient undergoes screening, chances are that they will refuse to be admitted or deny treatment because of their belief systems.
Sualeha Siddiq Shekhani, lecturer at Center of Biomedical ethics and culture, Sindh Institute of Urology and Transplantation (SIUT) in Karachi has done extensive research on mental health issues. She explains that one of the major reasons why Pakistan lacks official data is because, “mental health is not a priority on a governmental level, neither is suicide. Secondly, the stigma associated with suicide plays a major role,” she points out. To avoid an encounter with medico-legal centers and police cases, as suicide is a criminal offence in Pakistan, the families resort to private hospitals where these cases are not reported, Shekhani explains.
[box type="shadow" align="alignright" class="red_lines" ]In 2015, suicide mortality rate per 100,000 population in Pakistan was reported at 2.1, where as the country’s psychiatrists per inhabitants number is one of the lowest in the world. [/box]
Dr. Murad Moosa Khan, President of International Association for Suicide Prevention (IASP) and Professor of Psychiatry at the Aga Khan University in Karachi, says that focus of the government when it comes to catering towards health is mostly towards communicable diseases. Maternal and child health are another top priority, and most of the donor funding also goes towards efforts catering to maternal mortality rate, child mortality rate, and infant mortality rate. “Mental health is at a low priority, which has a close link with suicide, which has an even lower priority,” he says.
Dr Khan has done extensive work in gathering statistics on suicide in Pakistan. According to a research paper that he wrote, “While official rates of suicide are lacking, it has been possible to calculate rates of suicide in at least six different cities of Pakistan. Crude rates vary from a low of 0.43/100,000 per year (average for 1991-2000) in Peshawar to a high of 2.86/100,000 for Rawalpindi (in 2006), with other cities falling in between: Karachi, 2.1/100,000 (1995- 2001); Lahore, 1.08/100,000 (1993-95); Faisalabad, 1.12/100,000 (1998-2001) and Larkana, 2.6/100,000 (2003- 2004).”
It is also important to note that according to Pakistan’s Federal Budget (2017-2018) report, the total revised budget for healthcare is Rs12. 379 billion, out of which 418 million is reserved for public health services. While 0.255 percent of the total budget goes towards health, out of that only 3.37 percent is given to mental health. This shows that mental health is at the very bottom of the pyramid when it comes to budget allocation by the government and explains the lack of research and the absence of statistics on suicide.
Dr Yasir Abbasi, a UK-based consultant psychiatrist and clinical director who works with Mersey Care NHS Foundation Trust explains that “in order to tackle the problem of suicides in Pakistan, it is essential to have a prevalence rate. When there is a prevalence rate, you can determine the enormity of the problem.” Dr. Abbasi quoted WHO data, according to which, Pakistan has only 0.19 psychiatrists per 100,000 inhabitants. It is one of the lowest numbers in WHO Eastern Mediterranean Region, and in the whole world.
In addition to lack of government expenditure, the social, religious and legal stigmas push the problem deeper into the pits. Dr Khan recommends a multi-pronged approach which can tackle the issue. “The government needs to establish a task force of experts and make them come up with recommendations on how to address mental illness,” he says. Dr Khan also recommends decriminalisation of suicide and for religious scholars to address that self-harm inflicting people have a mental illness and they need to be given medical attention and forgiven.
Most of the data available online on suicide rates and mental illness in Pakistan is outdated. A few individual doctors or a handful of NGOs are working on estimates they gather through their own findings and methodologies. No standardised methodology for collection of data exists at the moment.
According to a WHO mental health report, the last time Pakistan’s mental health policy was revised was fifteen years ago in 2003 and the disaster/emergency preparedness plan for mental health was last revised twelve years ago in 2006. The mental health legislation was enacted in 2001 after it replaced the colonial Lunacy Act of 1912.
Also read: Campus disorders
In 2015, suicide mortality rate (per 100,000 population) in Pakistan was reported at 2.1, according to the World Bank collection of development indicators, compiled from officially recognised sources. WHO estimates that 24 million people in Pakistan are in need of psychiatric assistance, which makes roughly 13 percent of the total population. But according to Dr Khan’s report, almost 34 percent of Pakistani population suffers from common mental disorders and depression is implicated in more than 90 percent of suicides.
Pakistan is listed among the world’s top ten most depressed countries and it is hard to estimate if this national depression will subside if a policy is not created to deal with the issue at hand and for that, numbers are needed.
[post_title] => Notes on suicide
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[post_content] => It’s hard to breathe. It seems your lungs have decided they don’t remember how to function anymore. Your heart is a completely different story — you can feel it attempting to erupt its way out of your chest, and you wonder how many more minutes it can last. Worse, the inside of your throat is tightening and if you didn’t know any better you’d say someone has their hands around your neck to choke the life out of you. There’s no way your body isn’t going to implode in on itself any moment now. There’s no way you’re surviving this one. This must be a heart attack. It has to be.
Except it’s not. It feels like a heart attack, but this is a panic attack, and an experience that an alarmingly high number of students are going through on campuses of universities across Pakistan. “We’re seeing an increase in both the quantity and severity of high risk mental illness patients,” the head counsellor from one of Lahore’s well-known private universities said, “and although there are several reasons for this, the systematic ignorance in our administrations and in our student culture is a huge factor.”
Panic attacks and generalised anxiety disorders are common amongst the student populace, but just one of the many issues that have cropped up recently. Suicidal tendencies stemming from clinical depression, agoraphobia, bipolar and borderline personality disorder, and even post-traumatic stress disorder are the realities that students are facing consistently. The worst part about all of this is that they are facing these quandaries entirely on their own.
“I’ve only told a childhood friend about this. The rest of my friends, and even my family, are complete strangers to me when it comes to these issues,” a student from a private university confessed about his battle with post-traumatic stress disorder.
All the students interviewed had similar answers, citing that they weren’t looking for sympathy, or knew that no one would understand them even though they were shouldering an immense burden daily. The underlying cause of this self-isolation within student bodies is imperative to understand in order to tackle the issue effectively, and according to our counsellor, has to do with how students are treating each other. She spoke about how it’s become far easier for people to make distasteful remarks about each other due to the fact that social media has depersonalised our society in general. But according to her, the university system itself has the biggest role of all to play in this.
“In an environment where one student’s loss is inevitably another’s victory, how can we possibly expect young minds to stay sane?” she stated.
Many of the best private universities in Pakistan evaluate student performance through a relative grading system, where one student is scored according to how they have done compared to the rest of the class. The atmosphere automatically becomes claustrophobic and isolating, as students are conditioned to look out for themselves, and healthy activities, such as group studying are discouraged.
[box type="shadow" align="alignright" class="red_lines" ]The dismissive and apathetic attitude that university managements have towards their students and their needs is highly alarming, and it is a common sentiment amongst students.[/box]
Add to this the consistent pressure that families put on their children to exceed in all academic aspects and the lofty and often ridiculous expectations instructors have of their students’ capabilities, you are bound to get a melting pot of severe distress. Considering just these academic factors, it is not difficult to understand why there has been a rise in the occurrences of such unfortunate tragedies within university walls in recent times.
Of course, the system needs to change drastically in order to avoid these incidents from happening, but the way administrations have reacted to the aftermath of deaths — particularly suicides — of their students, has been harrowing. Last year, an alleged suicide of a student at an elite private university was ignored until close friends of the victim raised the alarm. Even after this was accompanied with mass uproar from the student community, the administration was extremely hesitant to investigate the death; instead they attempted to sweep the entire incident promptly under the carpet.
According to a faculty member at another private university where the unpleasant incident of a student jumping from the fourth floor took place about two weeks ago, the events currently transpiring on campus are unfortunately following the same formula. “The administration has been completely dumbfounded with what has happened, and are constantly trying to pretend that everything is normal. Students who had witnessed the suicide firsthand were expected to continue their classes in the same building on the very next day,” she revealed.
The faculty member also disclosed what reasons administrations may have to suppress these issues. “There is a bureaucratic mindset that permeates our institutions, and it makes the people in charge want to downplay issues of mental health for the sake of their reputation,” she revealed, “but in my opinion, the way they are alienating the students at the moment is far worse.”
The dismissive and apathetic attitude that university managements have towards their students and their needs is highly alarming, and it is a common sentiment amongst students, faculty members, and counsellors of these universities that there need to be systematic changes from the grassroots level up, and these changes need to be taken seriously.
“It’s been extremely stressful for me. More students are accepted into the university each year and there are only two counsellors on campus to handle every case,” the counsellor stated, in a university that houses 5,000 students per year. Many universities don’t even have a counsellor, and if they do they are often not qualified enough to handle the diversity and quantity of cases.
Simply put, however, merely increasing the number of counsellors is not enough; there are mental health departments in every university that create systems to bring tangible solutions to these problems. For example, the way instructors belittle and treat students in classrooms is a pertinent issue. A way to solve this would be to introduce sensitivity training for all faculty members before they are inducted. The counsellor continued to state that despite her consistent efforts to try and introduce a measure such as this, she has been ignored and demonised, “I’m too young for them [faculty] and they decide that I am not as qualified as them, so none of them pays attention. The administration never helps either.”
Also read: “A complex issue that requires complex solutions”
When asked how we can go forward from here, it is apparent that better systems and policies need to be created on campuses as soon as possible. These include faculty and staff training, more educational classes on mental health stigmas, and an academic system that is more cooperation based rather than competitive. There need to be solidified policies to tackle major traumatic events to proactively avoid them, to deal with them while they happen, and to react to them after they take place. At the moment however, administrations are refusing to even accept that there is a problem. If this sort of attitude continues, the problem is going to exacerbate, and students are going to continue to suffer in isolation with no respite.
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[post_content] => Dr. Murad Moosa Khan is a member of the Royal College of Psychiatrists and has a PhD in suicide epidemiology from the University of London, UK. At present, he is Professor and Chair, Department of Psychiatry at the Aga Khan University. His clinical and research interests include suicide and attempted suicide, mental health of women, and medical ethics. He is the first president of the International Association for Suicide Prevention, the first Asian as well as the first Pakistani in the 60-year history of the Association.
The News on Sunday: How many therapists and how many psychiatrists does Pakistan have?
Dr. Murad Moosa Khan: There are approximately 350-400 qualified psychiatrists in the country. Psychologists — probably about the same number, but not sure. There are no credentialed courses for training of therapists in Pakistan, though I am aware a number of organisations offer such courses and a number of individual advertise themselves as “therapists”.
The issue here is that psychologists and ‘therapists’ are not licensed in Pakistan, as there is no licensing or credentialing body for these people. Doctors are licensed by the PMDC to practice in Pakistan but psychologists and all other forms of therapists are not. It’s a free-for-all for these people in Pakistan.
TNS: Is suicide a serious epidemic in Pakistan?
MMK: It is not an epidemic but it is a serious public health issue. We do not have good data on suicide and self-harm in Pakistan to give us a national picture, though we do have data for some cities.
TNS: How many suicide hotlines does Pakistan have?
MMK: Probably not more than a couple. Hotlines on their own are of little value. They can be useful if they are part of a comprehensive suicide prevention initiative. For example, what would a hotline counsellor do if he/she receives a call from an individual who is threatening to kill themselves? Who would they alert? Would the police respond to such a request? In other cases, if the person needs to be referred to an emergency mental health facility, where would this be — if the person lives in an area where there are no such facilities. As it is, even in the cities, emergency psychiatric care is very poor. There are many other ethical issues around such hotlines. So, without a comprehensive plan hotlines are of little value.
TNS: Is there a gender or class angle to it?
MMK: Globally, more women attempt suicide (but survive) but more men die by suicide and the ratio is approximately 1:3. In some countries, such as China and Bangladesh, the ratio is reversed (more women than men die by suicide). In Pakistan, the ratio is narrower — perhaps 1:2. The majority of suicides are in middle and lower socioeconomic classes.
TNS: What measures do you suggest for the prevention of suicide in the country?
MMK: Suicide is a very complex issue and requires complex, multilevel solutions. There is need for more investment in mental health in Pakistan. As of now, mental health does not have a separate budget. There is need for training of doctors, particularly primary healthcare doctors and nurses, and psychiatry needs to be taught and examined in the undergraduate medical curriculum in Pakistan. Currently, very few of the more than 100 medical colleges teach psychiatry properly in undergrad and only one college (Aga Khan University) conducts a certifying exam in Psychiatry. The PMDC does not require a separate exam in Psychiatry.
The diagnosis and registration of suicides need to be improved and there should be a detailed forensic investigation of every case to determine whether the death was suicide, homicide or accident.
Suicide is still criminalised in Pakistan and there is urgent need to revisit this law as most other countries of the world have decriminalised suicide. The religious edicts against suicide should not be applied to attempted suicide. There are two different phenomena. Currently, the law states that people who attempt suicide and survive can be given a jail sentence and heavy financial penalty. For an already mentally disturbed person, this further adds to his/her problems and stops people from seeking help. Many private hospitals collude with families of victims to hide such cases by mislabeling them as accidents or identifying them as some medical condition. This leads to serious undercounting of attempted suicide cases.
There also needs to be responsible media reporting of suicides, following the guidelines of the World Health Organisation (WHO) and we need more good, robust data through high quality research.
The problem of suicide may be global but solutions always have to be local, based on local research findings.
Also read: A brave act or cowardice?TNS: As President of the International Association for Suicide Prevention, what sort of issues have you managed to tackle in Pakistan?
MMK: We are trying to raise the issue at different forums to raise awareness and get the government’s attention. On Saturday December 15 we have convened a round table conference in Islamabad to come up with recommendations for suicide prevention in Pakistan. We will be sending these recommendations to the government. We hope the government takes some action. I continue to supervise a number of research projects on suicide and attempted suicide in Pakistan while collaborating with researchers in other countries.
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[post_content] => At the current rate, 800,000 people commit suicide across the globe annually. This means, every 40 seconds, somebody somewhere in the world ends their life with their own hands. While this figure compiled by World Health Organisation is already a horrendously high figure, it is increasing annually. It is expected, that by 2020, the figure will have jumped to 1.53 million people: every 20 seconds.
However, little is known about suicides in Pakistan. Deaths by suicide are not included in the national annual mortality statistics and national suicide rates are neither known nor reported to the World Health Organization (WHO).
There are two major causes for this lack of reporting and by extension, acceptance of suicide. Under Pakistani law (which in turn is based on Islamic law), suicide is illegal, and punishable with a jail term and fine. As bizarre as it sounds, section 325 of the archaic Pakistan Penal Code reads: “Whoever attempts to commit suicide and does any act towards the commission of such offence shall be punished with simple imprisonment for a term which may extend to one year, or with fine, or with both.” While there is currently an on-going attempt in the Senate to decriminalise suicide, this point clearly highlights how the state looks at suicide.
Recently, there has been a spate of deaths via suicide in a certain section of our society, due to which there is a greater conversation on the topic than before. The operative phrase being: if a poor man who is riddled with debt and mouths to feed, and is unable to find a way out of the rut, takes his life, it is not as big a matter as it is when somebody from a middle-class background takes his or her own life.
Who’s to know what finally pushes people over the edge to commit the act of taking their own life. Is it a brave act or cowardice? Is it the ultimate act of selfishness? These conversations are best left to psychologists and philosophers. However, one thing is clear, there is a path of suicide, strewn with signs for those who want to see.
But can we see? Do we want to see? Do we have the time to see? Would we even understand what we have seen?
The simple answer is no. We cannot see, because that’s how we’ve been brought up. To bottle up our frustrations, our fears and our failures. The way the family is set up, a son or daughter cannot go up to their parents and speak their heart out. And even if they do, the parent is most likely to nonchalantly brush it under the table, with “you don’t know what I went through” statement. And its not that one suddenly decides that the only way forward is six feet under. There is a small trickle of helplessness which eventually swells into a river. With most middle-class families fighting an eternal battle to defeat inflation, most don’t have the time or the relationship to see subtle changes in their offspring; in the way they talk, in the way they behave, and how their patterns change as they sink ever so slowly into quicksand.
With the family unavailable, who can one turn to? Friends? The fear of being laughed at, mocked and ridiculed, for being weak, is immense. And so the stream swells.
Personally, pop culture has also played a severely detrimental role in the subject of suicide, although of late, there have been a few examples of a change in tone. But that is mostly outside Pakistan. Like crime shows on news channels, TV serials and dramatisations make an impressionable mind believe that suicide is a way out.
Khurrum Qureshi, a mental health practitioner based in Islamabad, told me of a three step spiral which may eventually lead to the final act. The first is, “I don’t matter”, followed by “the world and everyone around me will be better off without me”, and the final stage is, “I will be able to commit suicide by doing this”.
While the third point has more to do with access — to pills or handgun — the first two are critical. “There is a huge stigma in reaching out for help as it shows weakness,” he says,“ he added. And when these people try and have a conversation with their parents or elders, instead of hearing them out, the kneejerk reaction is, to shut down the conversation entirely. This is primarily because to the religious belief of suicide being haram. However, this shutting the door on the conversation furthers the belief that ‘I don’t matter’.
Even when people do reach out, there is the desire for a quick fix. But mental health is not a 100-metre dash. Unlike an appendix operation or a course of antibiotics, which are tangible, mental help is not seen by many as being of any use. And besides, reaching out for help, is proof that one is sick and weak. And hence, there is a huge degree to shame involved. It furthers their low sense of self.
Also read: No time to sensationalise
And this shame is not just for the suffering individual. In most cases, the parents see their child’s problem as their own failure. And suddenly the conversation becomes about them, and not the person suffering. This is another reason why families chose to brush it under the carpet, as they fear it being perceived as their own weakness.
According to Qureshi, this is why those who suffer from suicidal thoughts and/or depression, usually reach out to strangers. And in today’s social media age, this is usually online.
As we all know, the internet is a big bad place, and the chances of finding a shoulder to cry on are equal to being led further down the rabbit hole.
‘Hanging on in quiet desperation is the English way, the time is gone, the song is over, thought I’d something more to say’: Pink Floyd - Time.
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[post_content] => Death induced by suicide is a life cut short by self-directed violence. It finds its way in the newspapers and news TV channel segments readily. Often mediapersons reporting it do not know what an important part of the equation they are: With every suicide, there is an unfortunate but important duty laid on the shoulders of the mediaperson working on that news story. Will this opportunity be used to raise awareness, and perhaps help save lives from a similar fate? Or will it be just another sensationalised bit of news?
The choice is ours. We, the journalists, have important work to do in society as relayers of information. This must be done carefully, consciously, and sincerely.
But when it comes to mental health issues, particularly suicide, is it really the fault of the journalist, when he or she has never been trained in the subject?
Journalists have “beats” to report on; health is an important beat — public health, sexual and reproductive health, maternal and child health, and other sub-specialties under the health beat.
However, there has been no formal training of Pakistani journalists to date on how to have mental health as a beat, and how to report on it. If a journalist has organically acquired a certain sensitivity to report on delicate issues, then he or she will apply it when reporting on suicide as well. Yet journalists may often get lost in the quagmire of details when reporting on a suicide. Details like the where, when and how. The opportunity of raising awareness on the issue is often lost in such reporting.
This year in June, fashion designer Kate Spade and celebrity chef Anthony Bourdain died by suicide just days apart. There have been relatively well known Pakistanis who died after committing suicide. This has shed media light on the subject. A study on ‘Newspaper Coverage of Suicide‘ done at Sindh University by Mahesar RA states that “One person, after every 16 minutes, dies not merely because of accident or any other disease but intentionally because of suicide [sic]”.
However, the journalists reporting on it in Pakistan are not really trained to do so. They are learning as they go along by trial and error. The subject of “suicide” — and mental health on the macro level — is staring at us in the face as an unavoidable news beat. But the lack of training leaves means we are making mistakes.
[box type="shadow" align="alignright" class="red_lines" ]Reporting on suicide, and mental health issues, is a huge responsibility, as well as an opportunity to make a difference. These are not stories to be sensationalised. These are not lifestyle or entertainment stories.[/box]
One of the most common mistakes is extreme positions taken by the media when reporting on suicide. One extreme is stigmatising and re-stigmatising both the person who committed suicide as well as the family. The sad music while reporting on suicide on tv, the hackneyed jargon, the nuanced but audible judgment in the news report — it all shows a lack of objectivity.
However, the other dangerous extreme is romanticising the act of suicide — of glorifying it, and instead of presenting facts about this act of extreme self-directed violence, perpetuating myths about it and calling it a “choice.” With the suicides of the aforementioned celebrities (Spade and Bourdain) experts began talking about the risk of triggering what is called the “Suicide Contagion.”
Experts of mental health affirm that suicide (of one or multiple well-known people), can lead to an increase in suicidal behaviour among people who are already at a risk of it. Thus, it is important that these news reports do not just mull over details and allude to it as a heroic act, but present the fact, which is that suicide is, in a majority of cases, linked to mental health issues.
Suicide almost always is not something that happens suddenly out of the blue. It has been considered by the person earlier. There may have been warning signs which people close to the person may have missed. An article published by International Journalists Network titled, Guidelines for Reporting about Suicide, aptly suggests to journalists that they must not suggest that a suicide was caused by a single event. “Suicide is complex, and is often the outcome of different causes, including mental illness — whether recognised and treated or not,” says the article.
Giving details of the method employed for the suicide may also contribute to the suicide contagion. Graphic details and photographs are not only disrespectful and insensitive to the deceased and the bereaved family, but also end up giving ideas to those who may be thinking on the same lines.
Care must be exercised even when writing an obituary for the person who left this world — whether as a journalist on a news platform or as a friend or peer on the many social media platforms. Be careful of the language you use. And most importantly, focus objectively on that person’s life instead of the methodology of death.
Pakistan Tehreek-e-Insaf’s then presidential nominee, Arif Alvi, had publicly suggested a readily available 24/7 psychiatric helpline in September 2018. In November 2018, the President, while addressing the 22nd International Psychiatric Conference organised by Pakistan Psychiatric Society (PPS) said that everyone should play his role for establishing a healthier society in the country. The government can and must play its role too in this regard, and the media can play its role by reminding policymakers and those in positions of power to recognise that mental health must be put on the forefront of the list of priorities when it comes to public health.
WHO’s 2014 report, “Preventing suicide: a global imperative” estimates that for every suicide there are at least 10–20 acts of Deliberate Self Harm (DSH). By this estimate, there may be between 130,000 to 270,000 acts of DSH in Pakistan annually. This means that there are signs before the actual act of suicide is completed. Journalists must include then, after consulting a mental health doctor or therapist, some points about how to recognise the signs that a person may be inching towards suicide, and what can be done to help such a person. The reader can also be directed towards Suicide Prevention Helplines.
Also read: A phone call away?
Reporting on suicide, and mental health issues, is a huge responsibility, as well as an opportunity to make a difference. These are not stories to be sensationalised. These are not lifestyle or entertainment stories. These are stories that come under the beat of “health”. Once journalists recognise this, the reporting will become more responsible. Most importantly, out of these dark and seemingly hopeless news stories, there can emerge a ray of hope — the hope that if reporting is done intelligently and carefully, it may help spread much needed awareness. It may help someone out there. It may help save a life.
[post_title] => No time to sensationalise
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[post_content] => If you google, “suicide hotline Pakistan” not a single phone number will appear. Unlike many Western countries, Pakistan government does not provide a national suicide prevention hotline where people can call and seek confidential support regarding their mental health issues which may lead to suicide.
“A suicide hotline is a sudden cry of help; it is like going to the ER (emergency room) if you are hurt,” says Sualeha Siddiq Shekhani, lecturer at Center of Biomedical Ethics and Culture, Sindh Institute of Urology and Transplantation (SIUT) in Karachi.
Lack of a governmental hotline facility has opened room for non-profit and other civil society organisations to step up and create this facility.
Fazal Wahid, Islamabad-based Chief Executive Officer of Lifeline Pakistan, an addiction and psychiatric treatment center that provides rehabilitation services and psychiatric help, has given his personal number on the website as a helpline facility. “Suicide is becoming a national threat, it is a blind spot in Pakistan, that is why I have given my personal number here,” he says.
Aman TeleHealth, an initiative of Aman Foundation based in Karachi, also has a helpline which caters to people with mental health issues. “We receive around 5000 calls annually from people that are seeking some sort of counselling related to mental health issues,” says Dr Kiran Asif, Manager of Operations at Aman TeleHealth.
Also read: Editorial
The question arises that if the government provides a suicide hotline for people, will it help the issue? Dr Murad Moosa Khan, President of International Association for Suicide Prevention (IASP) and Professor of Psychiatry at the Aga Khan University in Karachi, explains that providing the public with a suicide hotline number is highly unlikely to solve the suicide issue. He emphasised on the need of a holistic programme, which includes risk assessment which is linked to a proper treatment facility along with the hotline facility to fully tackle the issue of suicide.

[post_title] => A phone call away?
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[post_content] => We at The News on Sunday have avoided attempting this Special Report for too long. It may have had to do with some ambiguity about this “truly serious philosophical problem” — suicide is definitely one subject that has tickled human imagination like none other. Yet it has many more dimensions in a society like ours that merit serious discussion.
It is the everyday reporting of suicide incidents in the media that draws attention to its prevalence. Beyond that, there is complete silence. There are no reliable statistics available on suicide; the picture is really blurry in rural Pakistan. But whatever little research we have done shows it is directly linked with mental health issues. There are of course very few impulsive suicides but that’s not what the general trend shows.
While all mental health problems are stigmatised in this country, the disgrace people feel about suicide is unmatched. It doesn’t help then that mental health is accorded such low priority in successive governments’ scheme of things, where the number of psychiatrists is abysmally low. There is a general lack of awareness about mental health issues, and suicide is particularly seen as a religious issue. Whatever the case, a suicide is almost always brushed under the carpet. Why are we as a society so uncomfortable discussing the issue?
With such a grim backdrop, Pakistan is fortunate to still have some experts who have dedicated their lives to solve this one issue. These experts very rightly suggest a holistic approach to tackle the problem but one aspect they do highlight is the need to decriminalise suicide which is only reinforcing the stigma attached to it.
Also read: Notes on suicide
The catalyst for this Special Report was the sad incident, a couple of weeks ago, in one of Lahore’s private sector universities where a student attempted suicide by jumping from a building and got killed. What is the situation like in educational institutions which host the most vulnerable age group? This is dealt with in detail, with some concrete suggestions about counsellors, faculty and students.
The role of media in understanding and reporting suicide in particular must be emphasised in the face of a general tendency to sensationalise. We hope to improve the understanding on this complicated subject in this Special Report and hope the country is better prepared to deal with its suicide problem.
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[post_content] => Sometimes we hear about a death — a result of a suicide — making news headlines in Pakistan. But not all suicides make news. Lack of proper care facilities, along with social, legal and religious stigmas create an invisible barrier in the reportage of these cases. Like this barrier, mental health problems are also invisible and so are the national official statistics of suicides committed in Pakistan.
Add to it negligence of mental health on a governmental level and we are left with absence of any official data on suicides in Pakistan. Lack of official data creates an impediment for research and policy creation which also affects the treatment of the issue.
Dr. Habib Ullah Chaudhry, a senior psychiatrist based in Lahore and ex-president of Pakistan Psychiatric Society explains that hospitals have their own data for patients admitted due to mental illnesses or suicidal tendencies. Yet, he says, data is not adequate because most suicides aren’t reported as suicides, but as accidents due to the stigmas attached. This leaves a hole in data gathering. World Health Organization (WHO) collects data from governments around the world to create a database of the numbers. “It is also hard to find exact suicide numbers in Pakistan because when suicide cases occur in rural areas, they don’t even make it to the hospitals,” he says.
According to a recent review titled, Suicide and Its Legal Implications in Pakistan, suicide deaths are not included in the national annual mortality statistics that are provided to the WHO. National rates are neither known nor reported, the review states.
Dr Iftikhar Minhas, a Lahore-based psychiatrist and the Public Relations Secretary of Pakistan Psychiatric Society elaborates that another reason why hospitals have a difficult time in recording suicide cases is because if a suicidal patient undergoes screening, chances are that they will refuse to be admitted or deny treatment because of their belief systems.
Sualeha Siddiq Shekhani, lecturer at Center of Biomedical ethics and culture, Sindh Institute of Urology and Transplantation (SIUT) in Karachi has done extensive research on mental health issues. She explains that one of the major reasons why Pakistan lacks official data is because, “mental health is not a priority on a governmental level, neither is suicide. Secondly, the stigma associated with suicide plays a major role,” she points out. To avoid an encounter with medico-legal centers and police cases, as suicide is a criminal offence in Pakistan, the families resort to private hospitals where these cases are not reported, Shekhani explains.
[box type="shadow" align="alignright" class="red_lines" ]In 2015, suicide mortality rate per 100,000 population in Pakistan was reported at 2.1, where as the country’s psychiatrists per inhabitants number is one of the lowest in the world. [/box]
Dr. Murad Moosa Khan, President of International Association for Suicide Prevention (IASP) and Professor of Psychiatry at the Aga Khan University in Karachi, says that focus of the government when it comes to catering towards health is mostly towards communicable diseases. Maternal and child health are another top priority, and most of the donor funding also goes towards efforts catering to maternal mortality rate, child mortality rate, and infant mortality rate. “Mental health is at a low priority, which has a close link with suicide, which has an even lower priority,” he says.
Dr Khan has done extensive work in gathering statistics on suicide in Pakistan. According to a research paper that he wrote, “While official rates of suicide are lacking, it has been possible to calculate rates of suicide in at least six different cities of Pakistan. Crude rates vary from a low of 0.43/100,000 per year (average for 1991-2000) in Peshawar to a high of 2.86/100,000 for Rawalpindi (in 2006), with other cities falling in between: Karachi, 2.1/100,000 (1995- 2001); Lahore, 1.08/100,000 (1993-95); Faisalabad, 1.12/100,000 (1998-2001) and Larkana, 2.6/100,000 (2003- 2004).”
It is also important to note that according to Pakistan’s Federal Budget (2017-2018) report, the total revised budget for healthcare is Rs12. 379 billion, out of which 418 million is reserved for public health services. While 0.255 percent of the total budget goes towards health, out of that only 3.37 percent is given to mental health. This shows that mental health is at the very bottom of the pyramid when it comes to budget allocation by the government and explains the lack of research and the absence of statistics on suicide.
Dr Yasir Abbasi, a UK-based consultant psychiatrist and clinical director who works with Mersey Care NHS Foundation Trust explains that “in order to tackle the problem of suicides in Pakistan, it is essential to have a prevalence rate. When there is a prevalence rate, you can determine the enormity of the problem.” Dr. Abbasi quoted WHO data, according to which, Pakistan has only 0.19 psychiatrists per 100,000 inhabitants. It is one of the lowest numbers in WHO Eastern Mediterranean Region, and in the whole world.
In addition to lack of government expenditure, the social, religious and legal stigmas push the problem deeper into the pits. Dr Khan recommends a multi-pronged approach which can tackle the issue. “The government needs to establish a task force of experts and make them come up with recommendations on how to address mental illness,” he says. Dr Khan also recommends decriminalisation of suicide and for religious scholars to address that self-harm inflicting people have a mental illness and they need to be given medical attention and forgiven.
Most of the data available online on suicide rates and mental illness in Pakistan is outdated. A few individual doctors or a handful of NGOs are working on estimates they gather through their own findings and methodologies. No standardised methodology for collection of data exists at the moment.
According to a WHO mental health report, the last time Pakistan’s mental health policy was revised was fifteen years ago in 2003 and the disaster/emergency preparedness plan for mental health was last revised twelve years ago in 2006. The mental health legislation was enacted in 2001 after it replaced the colonial Lunacy Act of 1912.
Also read: Campus disorders
In 2015, suicide mortality rate (per 100,000 population) in Pakistan was reported at 2.1, according to the World Bank collection of development indicators, compiled from officially recognised sources. WHO estimates that 24 million people in Pakistan are in need of psychiatric assistance, which makes roughly 13 percent of the total population. But according to Dr Khan’s report, almost 34 percent of Pakistani population suffers from common mental disorders and depression is implicated in more than 90 percent of suicides.
Pakistan is listed among the world’s top ten most depressed countries and it is hard to estimate if this national depression will subside if a policy is not created to deal with the issue at hand and for that, numbers are needed.
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