“In three words, I can sum up everything I’ve learned about life.
It goes on”
— Robert Frost
ecently my mother asked me to find time to see someone. It was late at night and I was trying to unwind after a long day of work. I irritably responded that I had no time to take on new patients. She pleaded, however, that this person was very unwell and possibly suicidal. The next morning, I looked at my clinic schedule, which was booked out, to see where I could squeeze in another distressed person who may be at risk of killing themselves.
As we mark another World Suicide Prevention Day on September 10, we will do well to remind ourselves of what we are facing in Pakistan. As our economy continues to deteriorate and more and more families begin to feel the pinch of destitution and desperation, the prevalence of mental illness, already very high in countries like Pakistan, will rise further. Along with increasing crime and terrorism, we will also face a ‘perfect storm’ of mental illness including suicide and other violent acts.
In 2003, the International Association of Suicide Prevention established September 10 as the World Suicide Prevention Day in conjunction with the World Health Organisation. This year’s theme, Creating Hope through Action, carries over from 2021 and points to the need to do more in several areas: more research to find the true incidence of suicide and deliberate self harm which can be a precursor to suicide attempts; more advocacy to make sure medical professionals as well as the general public take suicide attempts seriously; and better access to care for those who have contemplated or attempted suicide.
In all the bad news engulfing us, a radiant silver lining is the abolition last year of a colonial era law criminalising suicide. This law, which dated back to the mid-1800s was finally repealed after years of lobbying and advocacy by mental health organisations and the public at the end of 2022. This cleared the way for a number of positive changes. Accurate research on the prevalence of suicide can now be carried out. This was impossible in the past since patients and families would not report it for fear of being prosecuted. As suicide can now be talked about more openly, we can demand better access to care for those in distress.The numbers in Pakistan about suicides are scary (this was before the law was repealed and probably are significant underestimates): 2,300 suicides were reported by Pakistani newspapers in 2019-2020. Most of the victims were under the age of 30. The Global Burden of Diseases study reports an incidence of 2.7 suicides in Pakistan for every 100,000 people. Even though that is a significant underestimate, it is still a frightening number.
People from all segments of life are at risk. The highly public suicides on college and university campuses all across the country over the last few years should be a wakeup call to all of us about the enormity of what confronts us.
No one should be under any illusion that only the poor and the destitute are at risk. The highly public suicides on college and university campuses across the country over the last few years should be a wakeup call for all of us about the enormity of what confronts us.
As medical teachers, our worries also centre on another fact: the absolute and critical dearth of qualified mental health professionals in Pakistan (and other low income countries). The statistics have been repeated often enough to be familiar to most. Qualified psychiatrists in Pakistan number less than 1,000 for our burgeoning population. We cannot train people fast enough to meet the needs of our people. As quickly as we can train and certify them, they are snapped up by richer countries (since the shortage is global). Training for psychologists who provide ‘talk therapy’ is uneven and unregulated resulting in a huge number of inadequately trained, unlicensed people flooding the market.
Following the Covid-19 pandemic, this has resulted in thousands of minimally trained people offering ‘mental health’ services online. These can do more harm than good. Those of us who are trying to hold back the rising tide of mental illness are being overwhelmed, sometimes to the point of mental illness and suicide ourselves. So what can be done?
Awareness and advocacy is first and foremost thing. It is indeed a welcome sign that the subject of mental health, including serious issues like suicide, is now being openly talked about. Contrary to popular opinion, talking about suicide does not increase its risk, quite the opposite. Now that young people are talking to one another all over the globe via social media, the time to brush things under the carpet is gone. Remember that young people, our most precious and valuable resource, are the ones most at risk for mental health problems especially given the current economic climate.
Any expression of self-harming behaviour should be treated with the utmost seriousness. Even with the shortage of mental health professionals, an emergency consultation can be obtained within a week or two. Most college and university campuses now have counselors on-site and while their expertise varies widely, they can at least initiate the process of help. Teachers and parents need greater awareness and education about mental health issues in the young. It is important to know how to respond. In many cases, it is even more important to know what not to do. Invoking parental authority, denying the problem or verbal or physical abuse will almost always make the problem worse. Listening and empathising is a good start. The good news is that a visit to a mental health professional does not automatically mean a prescription for medicines or a life-long stigmatising label but do choose carefully who you go and see.
Suicide is the last step in a long chain of actions which in retrospect can be traced back to many things. We cannot save everyone but every life lost to suicide is a tragedy and almost always a preventable one.
The writer is a psychiatrist and faculty member at King Edward Medical University. He tweets Ali_Madeeh