A CASE was recently reported from Mardan on the Ministry of Planning’s Mental Health and Psychosocial Support (MHPSS) portal. The case described a 65-year-old male citizen who had developed depressive symptoms after a spinal surgery in 1994.
Subsequently, he began taking an addictive sleeping tablet: clonazepam. In 2004, he had a relapse of his symptoms, this time after a prostate surgery. He consulted a psychiatrist who prescribed an anti-psychotic medication. He has been, unnecessarily, on these two medicines for the past two decades without further psychiatric review.
October 10 is World Mental Health Day, and the theme this year is ‘Mental health is a universal human right’. The occasion ought to compel us to consider the fact that not a single province in Pakistan has managed to form a comprehensive mental health policy or a strategic plan of action, or even implement existing mental health legislation.
The 2005 earthquake could have been an inflection point, as it was accompanied by an unprecedented humanitarian response for MHPPS from local and international organisations. However, these efforts were disorganised and lacked meaningful impact. At that point, the unpreparedness was perhaps to be expected; mental health services were almost nonexistent outside psychiatric units.
The sad part is that not much has changed since. The goal of reforming any mental health system is to respond to emerging needs and expectations. The on-ground reality is that the current system is neither able to respond to routine mental health needs nor to the additional burden that transpires due to the ongoing crises faced by the country.
World Mental Health Day, which will be celebrated tomorrow, is reminder that no province has formed a comprehensive mental health policy.
The World Mental Health Report (2022) identified major gaps in governance, services, resources and information in countries like Pakistan where mental health systems struggle.
Firstly, governance gaps are exacerbated in Pakistan by a deficiency in strategic planning, ambiguous goal-setting, and a significant absence of an evidence-based decision-making approach. There are plenty of examples of glorified national taskforces and technical working groups without clear objectives or terms of reference; and initiatives motivated by short-term ambitions, often only aiming at low-hanging fruit.
These processes always seem to lack transparency and accountability. Without thoughtful planning and careful monitoring, many well-intended opportunities to improve services are missed.
In 2017, the World Health Organisation (WHO) initiated a pilot implementation of the Mental Health Gap guidelines in pilot districts across each province in Pakistan. This programme is crucial for integrating mental health in primary healthcare, and is strongly recommended as a key strategy to address unmet mental healthcare needs in low- and middle-income countries. Except for its launch, no progress report is publicly available.
Despite the programme’s undeniable importance, and after six years, key interviews in relevant districts are not able to confirm much success outside a few ad-hoc training activities. Serious questions arise about the lack of a system’s approach, the contextualisation of these guidelines, processes of training and supervision, and, of course, monitoring and evaluation.
Recently, a much-promised mobile application was launched by the federal government as a solution to unmet mental healthcare needs in the country. The interest of the political leadership behind this initiative was most encouraging. Sadly, lack of scientific attention and planning led to its dissipation, which was as swift as its introduction.
Secondly, services gaps are evident from the fact that millions of Pakistanis lack access to equitable, rights-based mental healthcare. Specialist services in the public sector are limited to tertiary care hospitals and a handful of district hospitals where thousands of unwell citizens seek help on a daily basis. But each treatment is the result of a brief consultation and little-to-no psychological care. Private-sector services, meanwhile, are largely unaffordable and almost entirely unregulated.
Unfortunately, these gaps also exist in externally funded initiatives. As an example, Unicef launched a MHPSS project in Balochistan in 2021 and reported that 22,000 citizens benefited from psychosocial support, and that “one of the secrets to its success is that it builds on a cross-sectoral, multi-stakeholder collaboration”. Despite the report, there has been little evidence of the impact of these reported services.
Thirdly, a vital gap in the country’s resources exists because of a severe dearth of mental health specialists. Pakistan says it is committed to the global targets outlined by the WHO Comprehensive Mental Health Action Plan (2013-2030), which provides evidence-based guidance on community-based care and building capacity of a mental health workforce to overcome the resource gaps. Regrettably, we don’t seem to have an action-plan to get there.
Thus far, there has been little attention to strengthen training programmes for psychiatrists, psychologists, or psychiatric nurses. Despite fast-paced scientific advances, the curriculum for postgraduate training of psychiatrists at the College of Physicians & Surgeons was last published a decade ago.
As a result, the emerging public mental health challenges are overlooked in training programmes. For example, in spite of an alarming rise in the use of addictive substances across the country, neither specialists (psychiatrists, psychologists) nor non-specialist health workers (primary care physicians, nurses) receive training to provide evidence-based interventions.
Consider, on the other hand, that hundreds of Pakistani practitioners have been trained in the last decade to provide EMDR (Eye Movement Desensitisation and Reprocessing), which is a specific psychological therapy for post-traumatic stress, not prioritised in the WHO action plan.
Fourth, lack of focused mental health research widens the information gaps. There are instances where global researchers have invested in building the capacity of Pakistani health professionals to conduct their field work, and produce quality research. Since the primary objective of most of these projects was not to address the inherent gaps, we still lack vital information needed to develop mental healthcare scientifically.
In a system that lacks planning and accountability, and prioritises short-term gains, resources will continue to be drained on provisional endeavours without much progress towards the transformational change this country so desperately needs. The need to implement prompt mental health reforms has never been greater.
The writer is a consultant psychiatrist.
X (formerly Twitter): @AsmaHumayun
Published in Dawn, October 9th, 2023
