Taj Nabi Khan
The mental illnesses, despite being the most common disabling condition in the developing countries including Pakistan, have been ignored over the years. The alarming situation in the rise of mental disorders on one hand encourages the irrational use of psychotropic drugs and on the other hand, “quacks” practices.
Around 50 million people suffer from common mental disorders for whom there are only 400 trained psychiatrists in the country, which means there is only one psychiatrist available per half-million people. The illness afflicts 15 to 35 million adults, which is approximately 10-20% of the population and about 20 million children, which is approximately 10% of the population, who need immediate attention of the policy makers and mental health practitioners.
Pakistan –one of the ninth most populous countries of the world has been experiencing both general health problems and mental health issues. The country is far behind from the developed countries in terms of trained mental health professionals, available psychiatric beds, provision of supportive healthcare, resourcing, infrastructure and, above all, coordination between different disciplines and effective leadership to run the services efficiently in order to meet the current challenges.
The country is not keeping pace with the mounting prevalence of psychiatric disorders caused due to organised violence, disruption in the social structure and natural calamities. Mental illness, evidenced in suicide rates and deliberate self-harm has reached to an alarming situation.
Common mental health problems have been identified in both rural and urban populations associated with socio-economic adversity, relationship problems and lack of social support. Depressive and anxiety disorders are high, followed by bipolar, schizophrenia, psychosomatic disorders, obsessive compulsive disorder and post-traumatic stress disorder. Alongside these is the high prevalence of depression and the serious drug problems with a growing number of inject-able drug users in the urban population creating a public health predicament. Mental health issues among children and the adolescent population is as common as in adults, but their incidence is under reported due to the associated social stigma.
The mental health services are still under resourced in terms of qualified health professionals and patients care at the level of other models of community psychiatry in the developed countries. Financial resources are meagre and mostly limited to the cities even though majority of the population is rural. Facilities are underutilised due to the social stigma attached to psychiatric labelling and a popular misconception in the community that mental illnesses are due to the possession of “Jin” or evil eyes or “Jadho” magic. People consult traditional healers whose caseloads are often dominated by mental disorders. The number of psychiatric beds is much smaller compared to the population with no waiting list in place and progress in the mental health care is not compatible with that in other medical disciplines and also undermined at the policy level.
The behavioural sciences are not being taken seriously in the medical schools with no structured rotation programme for senior medical students having low interest in the subject of psychiatry. Postgraduate training and education in psychiatry is available in certain teaching hospitals, but with no recognised sub-specialties such as child, forensic, geriatric and rehabilitation psychiatry and little exposure to the rural population. Some clinical psychology training centres/departments are providing clinical services and offering one or two years courses, but the majority emphasise teaching rather clinical supervision with no formalised clinical placement schedule in multidisciplinary settings.
Adequate training in psychiatry for general medical practitioners are needed in the primary care units in terms of early diagnosis for eliminating referrals of people with schizophrenia to harmful practice and reducing referrals to specialist psychiatric service. At the DHQ/Teaching Hospitals the availability of clinical psychology services is of paramount importance to reduce the irrational use of psychotropic drugs and to resolve psychological issues through talk therapy.
The universities need to introduce postgraduate courses embedded in inter-professional learning principles to train mental health professionals to facilitate the extension of specialist services to the district head quarter hospitals linked to BHUs/RHCs.
Each district specialist psychiatric unit at district level or in teaching hospitals would have to adhere to the true principle of community psychiatry including multidisciplinary teams comprising a consultant psychiatrist, a clinical psychologist, medical social worker, occupational therapists and community psychiatrist nurse (male and female). That would reduce the social stigma and provide cost effective psychiatric service at the door step for a significant population utilising the existing infrastructure.
— Tahir Khalily is Professor of Psychology at IIUI while Taj Nabi is freelance columnist based in Islamabad.