Preventive mental health

The core of our conscious being centers on our mental state. The way we feel and think determines how we behave and act. And still when we use the word ‘health’ we basically mean physical health.

In 1948, however, when the World Health Organisation adopted its constitution, in the preamble, health was defined as a “state of complete physical, mental and social wellbeing and not merely the absence of disease and infirmity”.

Mental health is not just absence of mental disorder. Like physical health, mental health also needs to be protected from risks and threats and it needs to be nourished and nurtured. There is now ample evidence through credible research that the foundations of mental health problems are laid during early childhood; that the mother’s own mental health is a very major determinant of child’s physical and mental development; and that simple proven interventions at this stage are most effective.

More than 65 percent of adult mental disorders have their roots in early childhood. It would not be too much of an exaggeration to say that if we care for mental health in the early phase of life, the rest of our life course will take care of itself.

The eyes do not see what mind does not know. Because of low mental health literacy we do not recognise mental health issues that are prevalent in our society, among our families and within us. We are blind to them or choose to ignore them due to perceived stigma, or we mislabel and mismanage them. For example, a synthesis of 44 studies about the existence of perinatal depression (depression among mothers around the time of child birth) among Pakistani mothers has yielded a pooled prevalence of 32.4 percent. Simply put, a very large number of mothers are depressed immediately before or after the childbirth in Pakistan.

Because of a predominant rural population and high levels of poverty and illiteracy, most times these depressed mothers remain unrecognised and continue to suffer in silence. How a depressed mother can take care for her new born and the lasting affects that might leave on the child are no less than preventable tragedies. This issue is never even mentioned when we talk about key health issues in the country. The WHO estimates a 95 percent treatment gap in perinatal depression in the Eastern Mediterranean Region of which Pakistan is also a part.

Depression, anxiety, drug abuse, suicide and various other severe conditions such as psychosis are much more prevalent than we think. Depressive disorders are ranked fifth and anxiety disorders eight among the top ten reasons due to which healthy years were being lost among Pakistanis according to the 2017 Global Burden of Disease study. The spectrum of mental problems is very broad and many more people reside on the milder end of the spectrum than those on the severe end with full blown mental disorders.

Silent and unattended suffering is way more common than frank clinical depression and schizophrenia. Underlying psychosocial stress and associated physical illness play a critical role in mental illness. What is much more important is to understand the value of preventive and promotive mental health. The old adage that prevention is better than cure is as much applicable in the case of mental health as much for physical health.

These were the concerns which led me to help establish the President’s Programme to Promote Mental Health of Pakistanis on Oct 10, 2019 on the occasion of World Mental Health Day. The programme was launched by President of Pakistan Dr Arif Alvi who is a very keen advocate of health and development issues. This was the first time that mental health had been picked up at such a high level in the country, a testament to the president’s interest and the government’s commitment in this area.

The programme emphasises the role of early-life interventions that promote mental health and prevent mental illness, and calls for a phased implementation of two evidence-based interventions. The first is the WHO ‘Thinking Healthy Programme’ for mothers, a psychosocial intervention delivered by community health workers and peers to high-risk mothers in low-resourced settings. The second intervention is the WHO School Mental Health Programme adapted for Pakistan. This programme includes training teachers in skills and strategies to promote mental health in their schools and the early recognition and management of mental health problems.

A five year implementation plan has been envisaged for rolling out this across all four provinces and two areas of Pakistan after piloting in Islamabad Capital Territory. The most important aspect of this program is a vision to deliver these interventions in an integrated manner as part of the prioritised package of essential health services at primary health care level. Sustainability of most development initiatives is a perennial problem in Pakistan. Integration of essential mental health interventions in official package would be the key to sustainability. The idea of this evidence-based programme is also fully aligned with the 2018 report and recommendations of the Lancet Commission on Global Mental Health and Sustainable Development.

What also motivated me towards facilitating the establishment of a president’s programme was the knowledge that most of the internationally credible research for proving effectiveness of simple early life preventive and promotive mental health interventions was actually undertaken in Pakistan. The Human Development Research Foundation (HDRF), a not-for-profit Islamabad-based research organisation has spearheaded this work in rural areas of twin cities and their research has been widely published and acclaimed. Their work is so important and credible that the WHO has based global initiatives on the work.

In a context where a country of 220 million people has only 600 psychiatrists and less than 1000 clinical psychologists, mental healthcare, especially preventive and promotive, cannot rely entirely on specialists. The WHO advocates ‘Task-shifting’, a strategy where tasks traditionally delivered by specialists are delivered by non-specialists after appropriate simplification and under supervision.

Community health workers, community volunteers, teachers and primary health are staff in Basic Health Units, Rural Health Centres and General Practitioners, all need to be oriented towards public mental health. The president’s programme proposes just that by actively involving families, communities, schools and primary healthcare staff in mental health of women and children. Interestingly, as opposed to 600 psychiatrists in the country there are around 1500 Pakistani psychiatrists based in the UK and US!

Mental health which sits at the core of all human activity and endeavour needs to be mainstreamed in our healthcare planning. Societal attitudes towards mentally suffering people needs to be changed and much more attention needs to be paid on preventive and promotive mental health.

The writer is former special assistant to the PM for health.

Email: zfrmrza@yahoo.com