On mental healthcare in Pakistan

An increased demand for professionals has resulted in more people opting for careers in the mental health sector. But, whether the quality of services show a parallel development is a question worth exploring

On mental healthcare in Pakistan

Everyone would be awed to know if someone was found opting for a career in psychology or psychiatry even until the 1990s. There was only one clinical psychologist in Lahore who was able to earn his living solely from the practice. Yes, there were a handful of psychiatrists in town. Some of them were foreign qualified and held key positions in public sector hospitals and had busy private practices as well. The referral pathway was quite complex and enigmatic at that time. Psychiatrists used to be the recipient of tertiary or quaternary referrals for psychotherapy and psychologists would receive referrals from them.

Thirty years down the road, the situation is very different. Not only has the number of psychiatrists increased but there are many psychologists and psychotherapists in practice now. Well-known psychiatrists and psychologists/ psychotherapists are consulted directly by a lay person suffering from the symptoms of mental health issues. Thanks to education, media, and awareness campaigns, the masses now know what the symptoms of depression or anxiety may be. This insight is far more prudent now than ever before. This increased demand for professionals understandably has resulted in more people opting for careers in this sector. The new generation of professionals are using more polished marketing strategies and are not reliant on their hospital jobs to establish a private practice. Indeed, the recognition of mental health issues is more apt now than before. Whether the quality of services show a parallel development is a question worth exploring.

There are only two disciplines active in Pakistan to help people with mental health problems; psychology and psychiatry, and that should be taken as a major inadequacy of the system. Other disciplines like, social care, occupational therapy, and community nursing are also needed. Secondly, mental health services in the public sector are being heavily directed by psychiatrists who practice a biological model. Consequently, the biological model of understanding and treatment of mental health problems is reigning to the extent of creating a huge imbalance in favour of pharmacological interventions. The practicing professionals, due to their approach and a high number of patients they have to see in the OPDs treat their patients as if they are suffering from a medical problem that needs only a prescription of medicine. The rest of the world has adopted a biopsychosocial for many decades. Barring a few exceptions, the psychiatrists in Pakistan do lip service to this holistic model without any evidence of it in their practice.

One can argue that the scant presence of allied health professionals may be the reason for this situation. It is quite unlikely that the situation can improve unless and until there are proper career pathways and related training and educational programmes for training professionals in community mental health nursing, occupational therapy and social care.

In such circumstances, the medicines need to be prescribed with more care and with robust ethical professionalism particularly when there is a huge risk of dependence and extenuation of functioning due to psychiatric medicines. Contrary to that, psychiatric medicines are prescribed with scant or no monitoring, starting with a cocktail of medicine without attempting monotherapy, and opting for second-generation antipsychotics even when first-generation antipsychotics are equally good in their effectiveness. Achieving sustained remission thus becomes impossible for most patients. A patient is switched to one medicine after the other that continues as a lifelong saga leading to disabilities especially in the domains of social functioning.

The over-the-counter availability of all the medicines in Pakistan is a complicating factor. It is not only illegal in most of the world but very dangerous for health in the long-term.

The over-the-counter availability of all medicines in Pakistan is a further complicating factor. It is not only illegal in most of the world but very dangerous for health in the long-term. The situation gets more deadly when it happens in relation to psychiatric medicine. The most harmful trend is self-medication. Also, patients may alter the doses as per their own judgment. The risk is aggravated when the use of such medicine is not monitored by a psychiatrist and/or the patient keeps switching psychiatrists frequently without showing their past prescriptions to the new doctor they consult. The absence of social care services and the review by a pharmacist at the dispensing pharmacy make such deviations potentially very harmful. Probably the commonest example of self-medication is anti-anxiety medicine that people take whenever they wish at whatever dose they fancy in total ignorance to their addiction risks.

Psychotherapy services are supposed to provide help to people with mental health problems in two conspicuous ways. First, psychotherapy may help in avoiding psychiatric medicine in the first place. The psychosocial issues can be addressed through psychotherapy without need to seek relief in medicines that inevitably give rise to side-effects and are difficult to stop for many patients. Second, psychotherapy helps the people come off psychiatric medicine by consolidating the improvement in their condition. However, this is possible if the therapist is properly trained and the model of therapy used is locally adapted. The recent mushroom growth of institutions for clinical psychology training and the number of practicing psychotherapists, unfortunately, make for services that lag on both these counts.

Psychotherapy has been considered a science like pharmacology. The evidence base for one form of psychotherapy was considered valid cross-culturally. The evidence for a particular form of psychotherapy was accepted in Pakistan without paying attention to the socio-cultural aspects of all forms of psychotherapy. There is a need to adapt them to fit the local culture and attitudes. Instead, they are being taught and practiced as given in the textbooks written in the West. The new generation of therapists is only taught, not trained. A new therapist comes into the market without being supervised for a prolonged period of time that is the norm in all well-developed healthcare systems in the world. Besides these semi-trained therapists, there are several untrained or inadequately trained therapists working without any licence. Some of them are known to prescribe medicines without any training or knowledge. Only in the last couple of years, the Pakistan Association of Clinical Psychologists (PACP) has succeeded in getting a bill passed by the parliament on the licensing of psychology practice.

The mental health services for people with treatment-refractory psychoses and intellectual disabilities is another area which is struggling to come out of primitive structures. Considering this dismal situation, an up-to-date and ethical provision of mental health services in Pakistan need a long distance to cover on teaching, training, legal monitoring and on procedural accounts.

Dr Akhtar Ali Syed is the principal clinical   psychologist at Brothers of Charity Services, Waterford, Ireland.

Dr Hashim Reza is a   consultant psychiatrist at Oxleas NHS Foundation Trust, London.

On mental healthcare in Pakistan