Given the limited fiscal space available to the governments for mental health, it should at least sensitise the people that mental disorders are just like physical disorders
Suicide by a senior police officer in Rawalpindi, self-immolation by an unemployed man in Karachi, suicide by a man in Rawalpindi only two days after his marriage, and suicide by a girl in Badin as a result of alleged social media blackmailing show that the vulnerability cuts through gender, social group and age cohorts in Pakistan.
According to one estimate, around 13,000 people committed suicide in Pakistan in 2012. The number might be an underestimation. According to the Pakistan Penal Code, suicide is a criminal act, and all suicides have to be reported to the police and evaluated at a medico-legal centre. However, the families cover up many incidents of suicide by reporting those as accidental deaths because they fear harassment by the police or want to avoid complicated legal procedures, or to avoid the social stigma after the loss of their loved one.
The suicide rate among men is two to three times higher than among women. It is believed that mental illness will be among the leading causes of death by 2030.
Suicide is significantly associated with certain mental disorders. Most suicides are related to psychiatric disease, depression, substance use disorders, and psychosis. However, anxiety, personality-disorders, eating-disorders, and trauma-related disorders, as well as organic mental disorders, also contribute to suicide. According to one estimate, nearly 90 percent of the people who have died by suicide suffered from mental disorders.
Psychological disorders come in many shades and hues and may show a wide range of symptoms. Some of the better known mental disorders are mood disorders such as depression, personality disorders such as antisocial personality disorder, psychotic disorders such as schizophrenia, sexual disorders such as sexual dysfunction, and eating disorders such as anorexia nervosa.
Some of the common symptoms of mental disorders are agitation, hostility or aggression, alcohol or drug abuse, changes in energy levels, anxiety, confusion or disconnectedness, erratic behaviour, irritability and mood changes, perception or thought process disturbances (psychoses), such as hallucinations and delusions, persistent or abrupt mood changes that can interfere with day-to-day life, problem denial, and social withdrawal.
While poverty is a leading cause of suicide, it is routinely associated with factors unrelated to economic circumstances. An online survey in Pakistan about various dimensions of suicide showed that over half of respondents considered a mental illness and financial troubles as the primary reasons for suicide, followed by the experience of being abused or bullied and strained family relationships. Divorce was seen as being a low risk factor of suicide.
Some of the personal narratives showed that forced marriages, relationship breakups, parental abuse of children, body shaming, sexual abuse, psychological disorders, and poor academic performance were major causes of suicides in Pakistan. Some widely accepted social expectations, like a girl should be married off at an early age and should have children early in her marriage, should put up with her spouse and adjust with her in-laws and should make all the compromises in adverse circumstances significantly contribute to female suicides.
Psychological problems in Pakistan are widespread. According to one estimate, around 50 million people in Pakistan suffer from mental disorders. A range of psychiatric disorders have been reported, such as depression, substance and alcohol misuse, schizophrenia, bipolar disorder, and post-traumatic stress disorder. According to one estimate, 36 percent of Pakistanis suffer from anxiety and depression, which is often caused by strained family and friend relations, the feeling of not fitting in the society, the unstable economic and political conditions of the country giving rise to unemployment and poverty.
Bipolar disorder is a mental disorder that causes extreme and unusual shifts in mood, energy, and activity levels. About 2.4 percent of the global population suffers from this disorder. According to a study conducted in various institutions in Lahore, Karachi, and Islamabad, it was found out that 14 percent of young students have bipolar disorders. Post-traumatic stress disorder develops in an individual who has experienced a traumatic, shocking, or scary event in his or her life. A study showed that physical assault is the most common reason behind the PTSD.
Substance misuse and addiction are widespread in Pakistan. According to one estimate, around 6.7 million adults are using drugs. Among them, the majority fall between the ages of 25 and 39. Schizophrenia is a severe mental disorder that affects the way a person thinks, feels, and behaves. Its symptoms include hallucinations, delusions, and a reduced interest in daily life and reduced speaking. It usually occurs between the ages of 16-30.
While it is socially acceptable to seek help from a health professional for physical disorders, seeking help for psychological disorders is problematic in Pakistan. Mental illness is often associated with supernatural forces such as witchcraft, possession, and black magic. Families often hide mental illness to prevent the patient from adverse stereotyping. With nearly one-third of Pakistani population suffering from some form of mental disorder, and depression being considered to responsible for 90 per cent of suicide cases, complacency in this regard could spell disaster for the public health system.
There are many myths regarding the mentally ill. People who have psychosis are shunned as violent. Secondly, it is believed that mental disorders are communicable, that is, the evil spirit of the patient can afflict the persons interacting with the patient. Thirdly, many people feel that shrines offer the best chance of recovery from the affliction. It is frequently reported that patients are physically harmed as part of their treatment. Mass media also stigmatizes mental illness. Disturbing revelations about the spiritual healers in live telecasts exaggerate the problems in the treatment of mental disorders.
The psychological health care system is woefully deficient in Pakistan, and the way it is mainly managed explains why accessing psychological help is a taboo subject. At the time of independence in 1947, there were three asylum-like hospitals, one each at Hyderabad, Lahore, and Peshawar, with a total of 2000 beds. These were in a miserable shape with no psychiatrists and managed by medical officers only. These hospitals were called mad-houses or “pagal khanay,” and patients were often brought there in chains.
Before the Mental Health Ordinance (MHO) of 2001, the law related to mental health provision was the Lunacy Act of 1912. After the 18th Amendment, health became a provincial subject in Pakistan. The Sindh Provincial Assembly took the lead and passed the Mental Health Act in 2013. The Punjab government enacted the Punjab Mental Health Act in 2014.
Seven decades after independence, the health care system is still not adequate. Whereas the median number of mental health beds per 100,000 population is above 50 in high-income countries, and 11.3 in the more developed countries of the Eastern Mediterranean Region, this figure is around 1.7 for Pakistan. A recent survey showed that nearly a third of the respondents believed that people fail to access mental health services because mental health professionals are not accessible.
In the absence of a formal functioning health system that is adequate for the needs of the population, traditional spiritual healers call the shots in Pakistan. Popularly known as baba, pir, or Sufi, the spiritual healers are well respected in the community. They practice at their residences, clinics, shrines or mosques and explain mental illness in terms of possession by an evil spirit, or by magical influences cast by enemies.
The treatment includes amulets, spiritually treated water, burning incense, or reciting mantras. Much to the chagrin and resentment of mental health professionals, the spiritual healers enjoy the acceptance of large masses of people who approach them for their mental health problems.
Though collaboration between spiritual healers and psychiatrists, as is often suggested, under some formal institutional arrangement has some appeal, there could be no denying the fact that public investment is the key to overcoming the challenge. Given the limited fiscal space available to the governments for significantly increasing investment in mental health, how and when investment in mental health will take place is an open question. At least, the government should try its best to sensitize the population that mental disorders are just like physical disorders.
The writer is an Assistant Professor in the Department of Economics at COMSATS University Islamabad, Lahore Campus