The treatment gap

January 19, 2020

A conversation is needed on access to mental health services but considering the scarcity of data on mental illnesses in Pakistan, it is a difficult one to start

A small pharmacy in Charar Pind close to DHA in Lahore is frequented by maids, drivers, and cooks who work in the area. They come in to see Afzal Doctor, complaining of issues like fatigue, brain fog, mood swings and loss of appetite. Often there seems to be no obvious cause for their complaints besides the nature of manual labour.

“I have been coming here for more than two years now. Whenever I feel that my blood pressure is low, I come here to get a taaqat ka teeqa (energy boost),” says Tahira (not her real name), a 36-year old who works full-time as a maid at a house in DHA, and earns Rs20,000. She is a single parent and looks after four children. Her husband abandoned her a few years ago, leaving her to take care of the household, and her children’s school fees. The injection that she is referring to comprises supplements that contain a combination of B vitamins (like B1, B6, B12), which help support the health of the nervous system and improve immunity.

She adds that the injection makes her feel better and helps her get rid of brain fog.

“My friend, Parveen referred me to Afzal Doctor. She makes chapatis for a family that lives in DHA and washes their dishes on weekends. Parveen’s husband has a temper and beats her; often afterwards, she comes to get this injection. There is a noticeable difference in energy levels and she has enough to show up to work the next day,” she explains, adding that she can’t stop working, “he will beat her even more if she doesn’t bring in money”.

“Mental health problems will not show up in a blood test. People’s pathways towards seeking help for mental health are different and often meandering,” concedes Dr Sameera Alam, the head of psychiatry at Services Hospital, a public hospital in Lahore. She highlights the importance of increasing mental health awareness to reduce stigma and improve access. In her view, ensuring that more psychiatrists and psychologists are available in district hospitals will facilitate people in seeking help as they are the first point of contact.

“People come from far-flung areas to get treated, they get referred to us. Most often, they go to faith healers first. Sometimes mental health problems come with obvious symptoms but there are also mental health problems that do not have symptoms that can be caught at first glance. General tests may put you in the clear but people may still struggle and find themselves unable to lead stable lives. And, on average, we see between 80 and 100 patients on a daily basis,” she explains.

She underscores the importance of being affiliated with a public regulatory college. “There is oversight and the training is rigorous if you go through this system. There is 18 years of formal training to get an MS in Clinical psychology. Couple that with the diversity in experience that comes with working in a public hospital – there is no match for it,” she adds.

But,“200 million people are currently provided health cover by less than 500 psychiatrists mainly confined to five major cities,” says Alia Ali, the course-cordinator for Therapy Works, a counselling and psychotherapy centre affiliated with the Counselling and Psychotherapy Central Awarding Body (CPCAB) in the United Kingdom and is a member of the British Association for Counselling and Psychotherapy (BACP). The organisation also provides training to aspirants who want careers in psychology and counselling.

“There is a year-long training process for a certificate course in human counselling which works as an initiation. There is further training going all the way up to Level 7. Therapists who work here have been trained by us. Client work is only allowed when you reach a certain level of competence. You also have to do 50 hours of self-work so it is a rigorous process,” she explains.

She explains that the current public mental health paradigm focuses on conventional psychiatry and clinical psychology, and the private sector can promise innovation. She stresses the importance of providing people support in an environment where violence, unemployment, extremism and terrorism can result in severe anxiety, frustration, anger and fear.

However, even though concessions can be made in cases where people are unable to pay the full price of a session, each session costs Rs 2,000. For a more experienced therapist, the rate is higher – it is still left to the therapist’s discretion; if they wish they can revise it downwards. By and large, people who are more likely to avail private mental health services belong to the higher income tiers of the society.

“I twice took my mother for psychiatric treatment at a public hospital. This was two years ago, when the token used to cost around Rs100. My mother is okay but she has episodes of extreme restlessness and depression. She also struggles to get a full night’s sleep. But after those two appointments, it was hard to convince her to go again. Besides, I heard that the token cost is soaring now – it’s four times the amount,” says 23-year-old Anila (not her real name), who works as a receptionist in a salon and makes Rs 25,000 a month. Doctors had referred Anila’s mother to the psychiatrist when she was at the hospital for an appendix operation.

“My mother was prescribed medicines. She takes them now, whenever she is struggling with sleep and anxiety. The problems are not going away. She’s now recovering from an eye surgery. My brother is unemployed. But we try to make things easier for her and not to give her too much stress,” she says.

Anila’s comments underline the need for more effective dissemination of information and thinking about access in a more holistic way. The price for a token in a public hospital is Rs150. However, if one gets prescribed medicines and tests, that adds to the bill, making access to wellness difficult for those belonging to the lower tiers of society.

“I did not have a job that paid regularly and I was depressed because of multiple issues in my private life. The biggest barrier was not stigma but not having money to spend on therapy,” says a 24-year-old content creator Ali (not his real name) who used to do freelance work.

“Ultimately, I realised that work which was also helping me pay for rent and utilities and therapy ultimately was work that was depressing me so I shifted my focus and got another job. The therapy gave me the tools to take a bold decision. It also helped me plan for this change, but finding the right therapist is a whole journey,” he adds.

A conversation on access to mental health services needs to be had but considering the scarcity of data on mental illnesses in Pakistan, it is a difficult one. Problems relating to access do not revolve solely around the stigmatisation of mental illnesses. With merely 0.4 percent of the health budget devoted to mental health, public institutions are under-financed, overworked and stretched too thin. The private sector is coming up with solutions, simply moving to fulfil a demand, but it looks to cater to a certain market.

Then there are community-based responses, which sometimes might not take a formal shape. Word-of-mouth referrals are important when it comes to seeking therapy. There are groups and collectives that help those who want to find the right therapist for themselves.

In a conservative society riddled with economic and political problems, where the conversation is only shaping up, such initiatives can provide great respite.

The writer is a staff member

Mental health in Pakistan: Gap between psychologists and patients