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| REVIEW |
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| Year : 2020 | Volume
: 34
| Issue : 1 | Page : 6-14 |
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Mental healthcare in Pakistan
Afzal Javed M.B.B.S., F.R.C.Psych., M.Phil 1, Muhammad Nasar Sayeed Khan M.B.B.S., F.C.P.s. (Psychiatry) 2, Amina Nasar F.C.P.s. (Psychiatry) 3, Alina Rasheed M.Sc 4
1 Pakistan Psychiatric Research Centre, Fountain House, Lahore, Pakistan, Pakista
2 Pakistan Psychiatric Research Centre, Fountain House, Lahore, Pakistan, Pakistan
3 Services Hospital, Lahore, Pakistan
4 Shaukat Khanum Research Centre, Lahore, Pakistan
| Date of Submission | 17-Jan-2020 |
| Date of Decision | 21-Jan-2020 |
| Date of Acceptance | 23-Jan-2020 |
| Date of Web Publication | 20-Mar-2020 |
Correspondence Address:
Afzal Javed
Fountain House, 37-Lower Mall, Lahore
Pakista
 Source of Support: None, Conflict of Interest: None  | 10 |
DOI: 10.4103/TPSY.TPSY_8_20
Background: According to the latest report, over 15 million people in Pakistan are suffering from some form of mental illness. But for a population of 220 million, only 400 trained psychiatrists exist with few state-run psychiatric hospitals and a small number of psychiatric units in teaching and general hospitals. In a traditionalist society, there is frequently a social disgrace together with discussing dysfunctional or abnormal behaviors as mental health problems and is generally described as a “shortcoming of character.” Methods: We carried out comprehensive literature review to collect data on the current mental health picture in Pakistan, and we also compared and formulated the recommendations from the literature of the related countries in the region and developed countries whenever possible. Results: Mental healthcare is still not a priority in the health system in Pakistan. A dire need still exists for a recognition from both public and private sectors for improving mental health planning and services in the country. Government must actualize social strategies that should be simple, equitable, and practical, as well as being able to address the issues of the regular needs. Asset allotment for emotional wellness is horrifyingly low and wasted away by defilement and fumble. A requirement exists for expanded spending on mental healthcare and psychological and emotional well-being just as appropriate usage of accessible assets. Conclusion: In this review, we suggest that a progressive change is required in the current state of psychiatry in Pakistan and that a need exists for a continuing review about existing strategies with a focus on setting sustainable priorities in the field of mental health, especially in policymaking, capacity building, awareness among public, and the use of media to minimize stigma.
Keywords: mental health system, psychiatrist's education, psychiatry, stigma
How to cite this article:
Javed A, Khan MN, Nasar A, Rasheed A. Mental healthcare in Pakistan. Taiwan J Psychiatry 2020;34:6-14 |
| Demographic Data of Pakistan | |  |
Pakistan is the world's sixth most populous country with its 2017 estimated population of around 220 million (Bureau of Statistics, Government of Pakistan, at www.pbs.gov.pk). From 1950 to 2012, Pakistan's urban population was expanded over sevenfold, while the total population was increased by over fourfold (www.indexmundi.com/pakistan/#Introduction). In the past, the country's population had a relatively high growth rate, and it has now changed with having moderate birth rates to an average growth rate of 2.40%[1]. Being a low-income country, it positions 34th among the 37 low-salary nations[2]. Gross domestic product (GDP) ranges around US$1,375 per capita, and infant mortality rate ranking comes as number 155 worldwide with 69 deaths for every 1,000 live births[3].
The United Nations Development Programme's Human Development report of 2019 determines Pakistan's human development index (HDI) value for 2018 as 0.560, which puts the country in the medium human development category – positioning it at 152 out of 189 countries and territories[4]. Pakistan's HDI value was increased from 0.404 to 0.560, an increase of 38.6% during 1990–2018. Detailed reviews of Pakistan's progress in each of the HDI indicators between those years showed a visible improvement. Pakistan's life expectancy at birth was increased by 7.0 years, with mean years of schooling increased by 2.9 years and expected years of schooling increased by 3.8 years. Pakistan's GNI per capita (the dollar value of a country's final income in a year divided by its population) was increased by about 62.4% between 1990 and 2018, and literacy rate is reported as 60% for total populations (male 69% and female 45%). Pakistan, a developing country and one of the next groups of 11 countries, along with the emerging national economies (BRICs), has high potentials to be among the world's largest economies, according to the data from the World Bank (www.data.worldbank.org).
Pakistan is a democratic parliamentary federal republic, with Islam as the state religion[5]. Freedom of religion is an important part of the Constitution of Pakistan (www.pakistani.org/pakistan/constitution) which provides all its citizens the rights to profess, practice, and propagate their religion subject to law, public order, and morality. Pakistan has a rich cultural background, and the country's diversity is more visible along cultural and linguistic differences, emphasizing local cultural etiquette and traditional Islamic values that govern personal and political life[6]. The basic family unit is the extended family although for socio-economic reasons, there has been a growing trend toward nuclear families.
The Indus Valley civilization, one of the oldest in the world and dating back at least 5,000 years, included much of what is present-day Pakistan (by L. Ziring and S. H. Burki, in Encyclopedia Britannica at www.britannica.com/place/Pakistan). Remnants of this culture fused with the migrating Indo-Aryan people during the second millennium B. C. The area underwent successive invasions in subsequent centuries from the Persians, Greeks, Scythians, Arabs (who brought Islam), Afghans, and Turks. The Mughal Empire flourished during the 16th and 17th centuries (www.thoughtco.com/the-mughal-empire-in-india-195498)[7] and the British came to dominate the region in the 18th century. At the end of British rule in 1947, India was divided to two countries: India and Pakistan (with two provinces in Pakistan – East and West Pakistan)[8]. But East Pakistan became a separate nation of Bangladesh in 1971. Currently, Pakistan has four (Sindh, Balochistan, Northwest Frontier, and Punjab) provinces [Figure 1]. | Figure 1: Map of Pakistan (Courtesy of Encyclopedia Britannica, Inc., copyright 2005; used with permission)
Click here to view |
| Mental Health in Pakistan | | |
Like many developing countries, Pakistan is struggling in several health and social spheres, which have substantial impact on the health system of the country. Healthcare delivery system in the country includes both state and nonstate and profit and not-for-profit (voluntary sector) service provisions[9] (www.apps.who.int/nha/database/Regional_Averages/Index/en). The country's health sector is equally marked by urban–rural disparities in healthcare delivery and an imbalance in the health workforce, with insufficient health professionals, nurses, paramedics, and skilled health workers, especially in the peripheral areas (apps.who.int/nha/database/Regional_Averages/Index/en).
In terms of mental health, Pakistan is no exception for its low priority for mental health when compared to many other developing countries[10]. It is true that needs for the care of patients with mental illness have been recorded in this region over many centuries, and local healthcare systems including Ayurveda and Unani treatment models had a significant influence on healthcare over the centuries. Cultural and religious beliefs on indigenous and traditional healthcare were always apparent in the local systems and had an important influence on perception, awareness, and choices for various health-related treatment modalities[11]. Healthcare systems and particularly mental health systems had a major shift following colonization by the British. Influenced by British systems and custodial nature of care, treatment and management of the mentally ill were mostly by establishing mental hospitals in the Indian subcontinent[12]. Lahore Mental Hospital was an example of this type of service that continues serving large part of the country even after its independence in 1947.
Following British traditions, during 19th and 20th centuries, people with psychiatric illnesses were mainly treated and managed in big institutions[13]. The initial aim of institutionalization of those with mental illness was to segregate them from the community. But with time, it became evident that those patients required care and management in the community. This movement certainly witnessed a well-deserved recognition in Pakistan during the 20th century[14].
Mental healthcare is provided mostly by public health sector although there have been some recent developments in the private sector as well. Psychiatric care offered by different sectors generally highlights the influence of the British allopathic system on psychiatric care. It also reflects rapid upward shift in the development of traditional services, training of personnel in allied disciplines, education of public, and provision of community mental healthcare. Those trends are encouraging despite having limited resources and low-resource allocation for mental health and psychiatric services with a limited number of trained personnel in the mental health field[15].
In Pakistani culture, it is commonplace to approach spiritual or traditional healers in cases of physical or mental illnesses[16]. Faith healing is the traditional way of treatment for mental ailments in this culture, as people usually perceive mental illness to be the result of supernatural influences. Use of faith healers is irrespective of socio-economic factors as it usually depends on the person's belief toward spiritual healing[17]. Faith healers are a major source of care for people with mental health problems in Pakistan, particularly for women and those with little education. Commonly used faith-healing techniques involve repetition of Quranic verses, “dum,” and use of “taweez” or ropes on the body. Apart from those, several fake faith healers use various other methods, some of which can be dangerous[18]. People who consume traditional healer services or their resources are usually considered deprived or uneducated. But several factors determine the help-seeking behavior from faith healers. Strong beliefs play a significant rôle in directing people toward traditional healers, especially in rural areas of the country, where people habitually believe in the evil eye and black magic.
| Problems of Mental Health in Pakistan | | |
People are more reluctant to reveal that they have a mental illness, and mental health problem is a taboo subject that is not even discussed about. People in society have been silencing the mental health talk for one reason or another since time immemorial. When recognizing mental health issues as a concern, the greater part of the community always seems to be in the denial mode[19]. It is a pity that Pakistan has limited political will and priorities for mental health. This unfavorably influences the quality of care provided for people suffering with mental illnesses. Societal circumstances, sadly, cause a person to fall more victim to his/her dilapidated mental condition, and the outcome seems almost inevitable after a few failed attempts to solve the issue through faith and spiritual healing. Consultation with the medical specialist has never viewed as a need or even a choice. People, especially the women, who suffer from mental health problems, feel humiliated to discuss their visit to a therapist because of the dread of being judged or thought as an insane person[20]. The consequence is often tragic, with lives being devastated and even lost due to this.
Mental health disorders in Pakistani occur in various forms, and symptoms can overlap with physical complaints and mask each other, especially when seen in primary care[21]. What should be done in a culture where drug addiction is seen as a simple getaway for individuals enduring stress or depression? Issues identified with emotional and mental well-being escalate the cases of suicide, particularly among the adolescents aged 25 years and younger. The unprecedented rise in psychological well-being among young population is an alarming situation. Tragically enough, it is the adolescents in the society who get much less sympathy from our social segments. This is also expressed in the limited research conducted at a national level in the field of mental disorders among young people.
Mental issues are among the important factors for increasing the vulnerability for further difficulties[22]. Disgrace about mental issues and prejudice against patients and families prevent individuals from seeking psychological help and mental healthcare. They can likewise add to accidental and deliberate damage to their physical well-being. Simultaneously, some physical health conditions have been associated with significant rise in anxiety and increase the risks of mental disorders, such as cardiac problems, diabetes, and obesity. Pakistan like many other countries has a higher prevalence of depression due to current social adversities[23]. The common mental illnesses are highly prevalent with reported prevalence of depression (6%), schizophrenia (1.5%), and epilepsy (1%–2%) in Pakistan[24].
| Mental Health Services in Pakistan | | |
There are around 400 qualified psychiatrists working in Pakistan. Most of the psychiatrists are working in urban cities although the posts of district psychiatrists have also been created throughout the country[25]. Psychiatrists, in general, are working single handed, although major centers in the country are developing multidisciplinary services[26]. It is admirable that the new generation of trained psychiatrists advocates for a multidisciplinary team approach in their clinical practice, and they conduct outreach clinics, provide leadership to develop community services, and train other mental health professionals with organization of programs to improve mental health literacy in remote areas of the country[27].
WHO's Mental Health Atlas More Details 2017[14] reported that there were only four big psychiatric (mental) hospitals in the country, with 344 residential care facilities and 654 psychiatric units in general hospitals. The quantity of mental health beds in the population was 2.1/100,000. The prevalence of child psychiatric disorders is reported to be high in Pakistan, but engaging children and families in treatment remains challenging. As per the WHO's report, there are 3,729 outpatient mental health facilities in the country, of which 1% are for children and adolescents only. These facilities treat 343.34 users per 100,000 persons in general population. The average number of contacts per user is 9.31. Forty-six percent of outpatient facilities provide follow-up care in the community, while 1% has mental health mobile teams. In terms of available interventions, 1%–20% of users have received one or more psychosocial interventions in the past year. Totally, 624 community-based psychiatric inpatient units are available in the country for 1.926 beds per 100,000 population. Only 1% of those beds in community-based inpatient units is reserved for children and adolescents.
Big hospitals in the country are integrated with mental health outpatient facilities and out-reach programs linking with primary care. In the last few years, the number of beds in psychiatric hospitals has been decreased, and more emphasis is now placed on small units in general hospitals and community-based units along with general health facilities. In addition to beds in mental health facilities, there are also 0.02 beds for people with mental disorders in forensic inpatient units and 1,620 in other residential facilities, such as homes for people with mental retardation (learning disability), detoxification inpatient facilities, and homes for the destitute[26].
| Development of Psychiatric Subspecialties in Pakistan | | |
Pakistan is still struggling for establishing subspecialties in the field of psychiatry. General psychiatrists provide most of the services with limited facilities for child and adolescent psychiatry[28], forensic psychiatry[29], rehabilitation psychiatry[30], and old age psychiatry[31]. Services for the treatment of drug addiction are provided in both private and public sectors, despite limited number of experts in this field. Forensic services are generally limited to mental hospitals, although some specific forensic services have started in a few teaching institutions. But there are some recent developments for establishing psychiatric subspecialties, especially in major academic departments and hospitals in the country in both public and private sectors.
There has been a promising interest for the child and adolescent psychiatric services to meet the vast needs of an increasing number of children with mental health problems [28, 32, 33]. There are a handful of child and adolescent psychiatrists in the country, but new child and adolescent psychiatry units are opening in many medical colleges. The College of Physicians and Surgeons of Pakistan (CPSP) is starting a fellowship in this subspecialty that will attract more trainees in this growing specialty.
Similarly, psychiatric rehabilitation is witnessing rapid developments in various areas of psychosocial rehabilitation[34]. Lahore Mental Health Association (LMHA) was started in 1962 to mobilize efforts and resources for the uplift and promotion of mental health in the country. Late Prof. Rashid Chaudhry, a founding member of the association, worked out a plan for establishing thefirst rehabilitation center for the mentally ill in Lahore. A formal proposal entitled, “Establishment of a half-way house and day-night rehabilitation unit for persons with mental illness” was submitted to the Government of Pakistan in 1965. In 1971, Mr. John H. Beard, Executive Director of Fountain House in New York, visited the rehabilitation unit of LMHA. The close relationship that developed because of the technical collaboration between the two houses led to the adoption of the name of Fountain House to the newly established facility at that time (www.fountainhouse.com.pk).
The concept of agro therapy, which is based on the philosophy of supporting patients with structured agricultural-based activities, has been found as a promising innovation for rehabilitating chronic mentally ill from rural areas[35].
A disaster/emergency preparedness plan for mental health was started after a major earthquake in 2005[36]. Establishment of the National Disaster Management Authority (NDMA), a federal authority (www.ndma.gov.pk/ndmc.phpis) was a step forward in dealing with disasters in the country. The Parliament of Pakistan passed National Disaster Management Act 2010. This Act created a National Disaster Management Commission (NDMC) who was responsible for laying down the policies, plans, and guidelines for disaster management. The NDMA is the lead agency at the federal level to deal with the whole spectrum of disaster management activities. It is the executive arm of the NDMC, which has been established under the chairmanship of the prime minister as the apex policymaking body in the field of disaster management.
| Psychiatric Education in Pakistan | | |
Undergraduate psychiatric education
The Pakistan Medical and Dental Council (PMDC) is the administrative regulatory organization for the medical profession and has recently been dissolved and given a new name – Pakistan Medical Commission. This is a regulatory body for all healthcare professionals that recognizes and registers all undergraduate medical and dental colleges and postgraduate medical institutions in Pakistan.
Psychiatry is now considered as a mandatory field for undergraduate medical education in the country, with teaching of cognitive and behavioral sciences as a subject right from the 1st year of the local bachelor's degree program, i.e., Bachelor of Medicine and Bachelor of Surgery (MBBS)[37]. This subject is included in the community health sciences curriculum and taught from year 1 to 4 in undergraduate medical colleges. The subject of psychiatry is included for teaching in the 4th or the 5th year of the medical colleges, with clinical placements for a period of 3–6 weeks along with a combination of theoretical lectures. There is no separate examination in psychiatry for medical students, and this is included as a part of the general medicine paper in the final-year examination.
It is a positive step taken by the PMDC in introducing behavioral sciences during the early academia years; however, to teach this subject, there is still a lack of qualified behavioral specialists. Although the acknowledgment for the subject of psychiatry by the medical regulatory body is convincing evidence for every single medical school to give due respect to the curriculum of psychiatry, the absence of psychiatry as an essential subject in the final examinations of MBBS has made little progress for the teaching of psychiatry at undergraduate level in medical education. In this manner, only a couple of lectures on behavioral sciences during the preclinical year in the medical college and a few more in psychiatry during the clinical years along with 8–10 demonstrations with in the psychiatry unit are all together performed and taken into consideration to be practically enough to meet the PMDC criterion. Consequently, psychiatry not being an examination subject in the final assessments provides no motivation to the undergraduate medical students to study this key discipline more thoroughly. The requirement of a different formal and clinical test for psychiatry is felt intensely, and certain institutes from the private sector are advocating the essentialness of appropriate-structured training and separate assessment in psychiatry on the undergraduate level.
Psychiatric undergraduate education in Pakistan contrasts sharply with the complexity to the circumstances in the developed world in which a significant portion of the syllabus is dedicated to behavioral sciences, psychology, and mental health problems during undergraduate training. Furthermore, an ever-increasing interest for tests such as the U.K. The Professional and Linguistic Assessments Board test and the United States Medical Licensing Examination for U.S.A, which give a lot of weight to assessment of knowledge about psychiatry, limits medical students for perusing their careers in these countries.
Many medical graduates choose family practice as their future career. But it is a pity that many of them are not completely equipped with the requisite learning of psychiatry with the present state. The need for extensive undergraduate education is thus important in the field of mental health.
Postgraduate education in psychiatry
The CPSP regulates the postgraduate teaching and training in all medical specialties. This is a self-governing body with close liaison between the Government of Pakistan and Pakistan Medical Commission. The CPSP is likewise accountable for certifying clinical and academic organizations for postgraduate preparation and training across the country in the different fields of medicine. The College offers membership Member of College of Physicians and Surgeons (MCPS) and fellowship Fellow of College of Physicians and Surgeons (FCPS) qualifications in various medical fields, which includes psychiatry. The CPSP with the assistance of subject specialists recommends a standardized, skill-based, and time-encircled leaning program for each faculty. It additionally places a direction for postgraduate research and proceeds with training for experts through preparing workshops and classes.
The duration of the FCPS training varies from 4 to 5 years, depending upon the specialties chosen. Competency-based curricula have been developed for each discipline by the relevant faculties. The college at present is offering FCPS in psychiatry[38]. This qualification is comparable with many other national postgraduate programs offered in other Asia countries[39].
This FCPS course takes place in three stages (Part 1, Intermediate module, and Part 2). The qualification for FCPS-I is a one-year position after graduation (with or without an introduction in psychiatry) and is largely founded on appraisal of clinical uses of fundamental science learning applicable to psychiatry. Those who pass FCPS-I go on to further four-year training in the specialty at CPSP-approved departments under the supervision of CPSP-appointed supervisors. Candidates submit a dissertation before sitting for FCPS-II examination. The dissertation is written under the supervisor's supervision. Instead of a thesis, the College has recently offered applicants an option to write two research papers as afirst or second author in the Journal of the College of Physicists and Surgeons, Pakistan, or in other indexed journals on MEDLINE. The FCPS-II assessment comprises two composed papers, objective structured clinical examination and a clinical appraisal of the competitor in the field of psychiatry by a board of inspectors selected by CPSP. The composed papers evaluate the critical-thinking and basic thoroughly considering capacities of the examinee issue-situated inquiries.
Exception from FCPS-I is offered to those with qualifications such as Diplomat American Board of Psychiatry and FCPS-I Bangladesh.
The CPSP also offers membership (MCPS) training in 22 disciplines including psychiatry. The duration of the MCPS training is two years. Competency-based curriculum is developed for each discipline by the relevant faculties. The CPSP has arrangements of accreditation for MCPS and FCPS that depends on measures and criteria created by the specialists. Since not many hospitals have the required framework, skill, and caseload, henceforth the college does not recognize such hospitals for postgraduate training in psychiatry. Most of the approved hospitals are in public institutions with only a few in military and the private sectors.
Furthermore, other institutions have also started opportunities for postgraduate training. In the public sector, one such attempt is the Diploma in Psychological Medicine and Diploma in Psychiatric Practice that was started at Fountain House, Lahore, in collaboration with universities in Egypt and London.
Additional postgraduate training qualification offered by numerous public sector universities is Doctor of Medicine in Psychiatry (MD). It is a five-year program, offered under the supervision of qualified and experienced supervisors, who offer broad assessments in clinical, academia, and research areas (www.uhs.edu.pk/).
| Research in Mental Health in Pakistan | | |
Research in the field of mental health is extremely limited, despite an increasing rate of psychological problems in the general population[40]. There are not many epidemiological studies in the field of mental health as research has not been a significant and a preferred incentive among local professionals. There are not many national studies on the prevalence or incidence of mental disorders; the available data are inadequate and there is no incentive for doing research[41]. The Advanced Education Commission of Pakistan has now created enthusiasm for advancing research at all levels, and it is trusted that improvement will be observed in different areas of research in coming years.
As of now, there are just a few books compiled by local authors with the dependence still being on the Western literature. Under the current conditions, it is fundamental that Pakistani authors produce bona fide work as reading materials and reference books, which emphasize the local issues, and recognize the therapeutic techniques relevant to local populations.
Despite a general decline in research, many centers in the country promote psychiatric research as a promising aspect of professional career. Pakistan Psychiatric Research Centre (www.pprcpakistan.org.pk) is one of such facilities in the field of psychiatric research in Pakistan. Established as a research and educational component of Fountain House at Lahore, it has initiated and participated in several original research studies in the country. Since its inception from the early 1980s, it has assumed paramount importance in the field of research in the country and has published more than 250 publications based on many national and international studies conducted in the country. It has also emerged as a center of excellence for organizing educational activities, conferences, symposia, and academic activities in different fields of mental health.
Recent contribution of Pakistani psychiatrists (through Pakistan Psychiatric Research Centre) for research on antipsychotic prescription studies highlights the current interest of local professionals in collaborative studies.
| Legislation on Mental Health in Pakistan | | |
After the independence of Pakistan, most of the laws practiced in the British ruled the Subcontinent continued in the country[42]. The mental health legislation did not lag behind and the Lunacy Act 1912 was in use for psychiatric patients. This law was taken from the British legislation mainly based on the historic development of a legal framework to detain psychiatric patients in Britain[43]. The Government of Pakistan revoked the 1912 Lunacy Act (which was enacted in 1912 for British India) with the new Pakistan Mental Health Ordinance (MHO) that came into effect in 2001 (MHO for Pakistan on February 20, 2001, www.emro.who.int/MNH/WHD/Pakistan Ordinance.pdf.).
The 2001 ordinance brought significant changes in mental health legislation. The new proposed law emphasizes mental illness promotion and prevention, developing local services demonstrating the protection of patient's fundamental rights. The new legislation focuses on:
- Access to mental healthcare including access to the least restrictive care
- Rights of mental health service consumers
- Family members and other caregivers
- Competency, capacity, and guardianship issues for people with mental illness
- Voluntary and involuntary treatment
- Accreditation of professionals and facilities
- Law enforcement and other judicial system issues for people with mental illness
- Mechanisms to oversee involuntary admission and treatment practices
- Mechanisms to implement the provisions of mental health legislation.
After the 18th amendment in the constitution of Pakistan, health became a provincial subject and all powers for legislation and service provisions in health sector became the responsibility of provincial governments. The province of Sindh took the lead and passed the Mental Health Act in 2013, with an aim to improve the delivery of mental healthcare and protect the rights of those diagnosed with mental health problems. The Punjab province enacted the Punjab Mental Health Act in 2014, without making any major changes in the Federal Ordinance. Other provinces have not replaced the ordinance with a mental health act to date, despite the growing pressure from legal and medical professions.
The current legislation is admirable because it has integrated human rights and care of the mentally ill[44]. Paradoxically, there is no description of specific rôle and effectiveness of public health intervention in this new mental health legislation. Although mental health policy, plan, and legislation do exist in the country, these are not implemented. Other missing components are justice, assets recognition, equal opportunities and efficient allocation of resources, sustainability and community engagement, and regular evaluation of the rights of mentally ill. Federal health authorities and perhaps even the regional health authorities are not established, and little training is given to the professionals in the new laws. The private sector, forming the main essence of the mental health services, is also ignored. Furthermore, it would not be possible to integrate the law with both the current health funding and resources. It is a pity that, until now, the laws have still not shown any efficacy and remain merely on paper[45].
| the Five-Year Plan and Vision 25 | | |
The country's future mental health policy seeks to move toward the implementation of the model based on the bio-psychosocial aspects and the advancement of psychological health into medical care at all scales. These policy trends provide directions for the next Five-Year Plan and the Vision 2025 that are based on the principles of creation of resources, community awareness, and establishing affordable and accessible services[46].
The government encourages economic support for both consumer and family associations. In addition to legislative and financial support, formal collaboration is recommended between the government departments responsible for mental health and the departments/agencies responsible for primary healthcare, child and adolescent health, and child protection. Similarly, the National Healthcare Program (Pakistan's national health strategy) also emphasizes on poverty reduction and restructuring of the healthcare industry to ensure care to patients with limited or no resources.
As per the Constitution of Pakistan, some public health laws deal with concerns of human rights, activism and reintegration, and cross-sectorial cooperation (www.pakistani.org/pakistan/constitution). It envisioned the training of general practitioners and the establishment of commodity facilities in community hospitals and psychiatric and rehabilitation institutes. Conflict management as well as mental health services, especially for disabled individuals, including up-gradation in major psychiatric institutions, is recommended in these laws. However, with very low allotted funding for health, public health is not a priority area for service provisions in the country.
| The Pakistan Psychiatric Society | | |
The Pakistan Psychiatric Society (PPS) is the professional organization that represents local psychiatrists and advocate for better mental health provisions in the country (www.ppspk.com/Web/Index). The PPS was founded in 1972 and is working under the mission of providing the highest level of compassionate, specialized, and effective care to psychiatric patients without discrimination and promulgation of mental health education at all levels. It aims to facilitate research activities and provides a strong base for multidisciplinary training based on the bio-psychosocial model. PPS is the largest scientific and professional psychiatric membership organization representing over 400 psychiatrists in Pakistan.
The society is also committed to promoting excellence in the field of psychiatry, providing the best clinical practice based on recent advancements and recommended guidelines, to assist in the prevention of mental illness and to reduce the stigma associated with psychiatric illness. It seeks to advance the profession of psychiatry at both national and international levels.
The PPS regularly organizes public awareness programs, promotes research, and publishes scientific journals, bulletins, and magazines on mental health issues. It continues to work under its vision of promoting mental health, providing ethically sound care for patients and maintaining professionalism in the field of psychiatry.
Summary
It is true that mental health gets less prominence in Pakistan[47] and this is not an exception to the practice from many other developing countries. Millions of people suffer from common mental disorders, and unfortunately, mental health services in Pakistan are underdeveloped and poorly resourced. There are only 400 trained psychiatrists in the country –meaning that there is roughly one psychiatrist available per half-million people. These alarming statistics make immediate actions imperative to prevent further increase in mental illnesses.
Several factors contribute to the current state of mental health and mental health services in the country[26],[27]. There are many possible causes including inaccessibility to care facilities, limited healthcare resources, low number of professionals, and unreachable and nonaffordable medical facilities. Many a times, stigmatization and deeply rooted cultural belief link mental illness with supernatural forces and tag them as witchcraft, demonic possessions, and black magic. Furthermore, the standard of care varies among public and private sectors, and the increasing gap leads to further inequalities[19].
Psychological therapies are not readily available in Pakistan. Psychologists mostly provide counseling services. There is a growing need for training clinical psychologists in different psychotherapeutic modalities. Interactive work between clinical psychologists and psychiatrists can play a vital role in terms of improving access for psychotherapies and counseling. Placing more emphasis on training in psychotherapy will certainly improve care provided not only for psychologists but also by psychiatrists.
Training in psychiatry is still at early stages. Establishment of teaching departments of psychiatry in almost all medical colleges is a positive way forward, but including psychiatry as an examination subject in the curriculum is required for the medical graduates. Postgraduate programs in psychiatry are encouraging young doctors to choose psychiatry as a promising medical specialty for their future career. There is a need for more training in the fields of forensic psychiatry, psychotherapy, geriatric psychiatry, drug and alcohol abuse, child psychiatry, and learning disability. This will certainly help in training more experts in these subspecialties[48].
It is welcoming that some psychiatric centers and universities are starting courses for nurses and allied mental health professionals. It is also important that family physicians, general practitioners, nurses, and social workers are trained in recognizing mental health problems as well. Due to the increasing problems of drug abuse, it will make sense to include subjects of substance misuse and drug dependence as vital parts of the undergraduate and postgraduate training systems.
Families generally look after by their patients in their homes. It is thus important that training should focus on supporting families and carers with an emphasis on psychoeducation and community-based services. Drug abuse problem in Pakistan is on a rise, especially among the youth and nonmental health professionals who treat most patients. There may be several barriers that need to be explored for young people's views to accessing mental health services[49].
Despite many difficulties and problems, it is encouraging to note that mental health services are gaining more importance in country's health delivery system. Despite inadequate resource and limited infrastructure, notable developments are taking place in many areas of mental health care in Pakistan. However, such services need continuous and consistent reviews to develop accessible, affordable, equitable, and efficient service to all the citizens.
| Acknowledgments | | |
We would like to acknowledge PPS, senior psychiatrists, local institutions, academic departments of psychiatry, state-run hospitals, and voluntary organizations working in the field of mental health for the support given in data gathering.
Opinions expressed here are authors' personal opinion. They unnecessarily reflect on those opinions of any psychiatric societies, such as PPS or the World Psychiatric Association.
| Financial Support and Sponsorship | | |
None.
| Conflicts of Interest | | |
All authors declare no potential conflicts of interest in writing this review.
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