“Would you tell me,please, which way I ought to go from here?”

“That depends a good deal on where you want to get to,”

said the Cat.

“I don’t much care where —”

said Alice.

“Then it doesn’t matter

which way you go,”

said the Cat.

— (Lewis Carroll, Alice in

Wonderland)

arlier this week, I was asked to see a 52-year-old man in my hospital. He was suffering from anxiety and depression symptoms. He was an architect and bemoaned the fact that it was getting so hard to make an honest living in our country. He had been trying for long and had seen people he supposedly looked down upon become millionaires and billionaires, while he struggled to educate his children and maintain their respectable middle-class lifestyle. Of course, his illness of depression was ‘darkening his vision’, so to speak, and I am reasonably sure he will feel better once treated. But I did ask him, rhetorically, why he stayed on in Pakistan. He smiled ruefully and told me it was because of his elderly mother, even though his now grown-up children grumbled at him every day.

As our economy crumbles along with the rest of the world’s, stories like this are increasingly and painfully common. All of us increasingly feel like Alice: lost and confused. And with a downward economic slide comes its attendant mental health consequences: depression, anxiety, ‘stress’, substance abuse and sometimes, frank mental breakdowns and violence in various shapes and forms.

First, some background. It is true that there is a mental health emergency in Pakistan and people are, literally, dying for lack of appropriate care. This has been true for many years, if not decades. The good thing – if one can call it that – is that this sad fact is finally out in the open. The numbers are stark: for a population of almost a quarter of a billion people, we have a total of 600-700 psychiatrists in the country. The number of psychologists, those who provide non-medication related ‘talk therapy’ (and other services), is harder to estimate but is, at best, a few thousand, also grossly inadequate for our population. Other mental health disciplines, such as psychiatric nurses, social workers, substance abuse counsellors, occupational therapists etc do not yet exist in Pakistan. The quality of training in mental health interventions for non-specialist doctors (general practitioners and medical and surgical specialists) is poor. Most doctors and healthcare workers in Pakistan have no idea what to do with a person experiencing a mental health crisis. Our educational campuses with millions of students have next to no mental health services available on-site, and most teachers and administrators have no idea what mental health and mental illness are.

Add to that the circus that is Pakistani politics and the ever-present spectres of unemployment, poverty, crime and terrorism, and you have a perfect recipe for mental illness. Is it any wonder then that while the estimated global rate of depressive illness is around 15 percent, in Pakistan, studies have estimated that 1 in 3 Pakistani women and 1 in 4 men will experience an episode of depressive illness in their life (even that may be an underestimation). Rates of suicide have been rising as well. Attempting suicide is, thankfully, no longer a crime, thanks to years of efforts by the mental health community and its allies in various walks of life. People with acute mental health issues can now get the help they need. However, the number of reported suicide attempts and actual suicides will, no doubt, increase since accurate statistics can finally be collected.

The good thing is that mental health and mental illness are finally emerging from the shadows and being talked about: in homes, on the media and social media, on college campuses and in newspaper columns like this one. Awareness and advocacy are the first steps in tackling a crisis of these dimensions. But these are not enough. Pakistan spends a miniscule amount of its national budget on health, far below the amount recommended by institutions like the World Health Organisation; and mental health has no separate budget. This needs to change in line with the WHO’s declaration: “No health without mental health.” Efforts are under way to develop grassroots public mental health programmes for non-mental health specialists so that simple interventions can be delivered to the broad mass of people. Schools, colleges and universities are also being involved and encouraged to develop mental health interventions and staff for students and staff in need. Annual mental health events and days are marked across the country in major cities and more and more people are speaking up about their own struggles with mental health.

Meanwhile, the global economic crisis shows no signs of abating anytime soon. The mind is a reflection of the world around us. Chaos and uncertainty always promote mental illness. Our still rapidly growing population with its huge proportion of young people is one of our greatest assets, something that advanced industrialised countries can only dream of. But we need to nurture them, educate them, train them and yes, look after their mental health; to help them reach their full potential so they can lift us all up out of our doldrums.

If we can manage that, say in 20 years, the children of my architect patient will not have to apologise to their children for having let them down.

The writer is a psychiatrist and faculty member at King Edward Medical University, Lahore. He is the author of Faiz Ahmed Faiz: A Biography, Sang-e Meel Publications, 2022. He tweets @Ali_Madeeh