Summary
• As the “silent pandemic”, mental health issues have aggravated because of the Covid-19 pandemic, causing more stress, anxiety, and depression.
• Lack of understanding, stigma around mental health, low capacity and constrained resources in the healthcare system, and inadequate attention from policymakers allows the problem to grow in Pakistan.
• It is crucial for the government to respond to the emerging mental
health crisis to avoid long-term impact on economic productivity, public health and societal dynamics in Pakistan.
• A national response to mental health will have to be multi-pronged with due focus on assessing the current situation, allocation of funding, institutional alignment, awareness and behavior change communication, and increasing professionals who can engage in tackling challenges.
Identifying the Problem
Addressing issues of mental health have often taken a back seat in the policy debate around personal and public well-being. An increasing emphasis by international organizations such as The World Bank, World Economic Forum, and World Health Organization, has raised alarms of an ‘epidemic of poor mental health’ and is shifting the narrative. Mental health is the largest burden on illness globally, more than all cancers and heart disease combined, and it will cost the global economy around USD 16 trillion by 2030 [i].
For Pakistan, mental health is increasingly becoming a public health crisis and called by experts as the “silent pandemic” [ii]. WHO defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” [iii] At the moment, there are more than 15 million people in Pakistan suffering from a mental health issue [iv], with 75% of them not receiving any treatment, and more than 50% are suffering from severe to moderate stress [v].
The debate around mental health has gained special emphasis in context of the Covid-19 pandemic. Earlier, outbreak of SARS in Hong Kong was identified as a “mental health catastrophe” as it led to a rapid increase in psychiatric health issues such as PTSD and depression [vi]. Given that Covid-19 is a global pandemic, its repercussions on mental health are considerably damaging. Experts have highlighted that the negative impact of this pandemic is felt through economic factors, social isolation and bereavement, which has led to anxiety and depression. The mental health implication of Covid-19 can be understood through analysing multiple factors that have increased stress, anxiety and depression among the general population which leads to decrease in productivity and overall well-being [vii].
What Contributes to the Problem?
Absence of evidence and facts about Covid-19 in early days combined with mis and disinformation that spread through traditional and digital media led to an increased amount of paranoia and anxiety. The uncertainty around Covid-19, its origin, symptoms, causes and remedies caused an information frenzy leading to all sorts of claims; unvalidated opinions, and conspiracy theories circulated through social and personal networks. This caused a strain on the mental composure of families, households, communities and societies [viii].
It became necessary to rely on preventative and containment measures to curb the spread of this highly contagious virus. While the importance of self-isolation, social distancing, and quarantine cannot be undermined, its impact on psychological health was not taken under consideration [ix]. The uncertainty of the virus, along with the loneliness and lack of social interactions due to isolation have led to anger, confusion and posttraumatic disorder among the population [x]. These feelings can often translate into violent social settings for instance domestic abuse. When the lockdown was initiated in the UK, the domestic abuse helpline saw an increase of 700% in just a single day [xi]. One can only imagine how dire those numbers would be for Pakistan, a country ranked as the sixth most dangerous country in the world for women [xii].
The fear of getting infected or infecting others has led to more caution when it comes to cleanliness and hygiene, causing excessive anxiety, and may lead to anxiety disorder among people with pre-existing psychiatric conditions such as OCD [xiii]. With diminishing mental health, the pandemic also disrupted everyday routines of general population, and a lack of healthy diet and habits can have a negative impact on health and may turn into emergent health problems [xiv].
Mental health resilience of frontline healthcare workers (HCWs) has been challenged during the Covid-19 pandemic. With SARS, it was reported that between 18-57% of the healthcare professionals reported severe mental health problems and psychiatric symptoms both during and after the breakout. A small recent study of Pakistani HCW shows that all of them suffered from a mental health condition; 72.3% suffered from depression, 85.7% had anxiety, and 90.1% had stress [xv]. A more thorough research of three major cities; Multan, Lahore, and Faisalabad has shown that HCWs suffer from mild to moderate symptoms of depression, anxiety and stress. The main cause of these symptoms is related to “improper infrastructure for patient care, lack of awareness among the masses, and poor compliance with safety measures”. The major cause of stress for HCWs is exposure in the line of service and being a potential threat for infecting their loved ones [xvi].
What exacerbates the problem
Recognition and awareness
In dealing with mental health, the most pressing issue is the stigma/taboo around it which hinders recognition and awareness of it as a ‘real problem’. The stigma exists at multiple levels. First of all, the major issue is linked with awareness regarding mental health. Studies have suggested that Pakistanis have a very vague understanding of their own mental health or illness, and people struggle with contextualizing mental health issues they experience, despite the fact that they had all the symptoms present [xvii].
Furthermore, religion and culture play a critical role in how Pakistanis perceive or associate themselves with mental health problems, and the taboo attached with it especially impacts females more than males. Varied religious or cultural interpretations may reinforce the taboo around mental health as something evil or unnatural. For instance, people with depression are often judged to be depressive either because they are not practicing their religion, or because their psychological issues are seen as a weakness, especially among women [xviii]. People facing mental health issues are not just struggling with their condition but also dealing with stress of judgement that is caused by the stigma around mental health [xix].
Capacity of the Healthcare system
At the moment, there are around 400 qualified psychiatrists in Pakistan, and most of them are working in urban parts of the country [xx]. There is only one psychiatrist for every 100,000 Pakistanis. In comparison, the average among OECD countries is 16:100,000, and in a country like Turkey which is somewhat similar to Pakistan when it comes to religious and cultural norms, the ratio is 5:100,000 [xxi]. This lack of human resources also has deeper roots; out of 114 medical colleges in Pakistan, very few require expertise in mental health to graduate [xxii]. There is no separate assessment required for medical students in psychiatry as part of their final general medicine examination, and nothing but few lectures on behavioural sciences and psychiatry. These structural gaps prepare a corp of medical graduates who choose family practice, but unfortunately are unaware or not competent enough to deal with mental health related issues [xxiii].
Because of lack of awareness around mental health, capacity of the health sector, and peer-influence around religion and culture; people in Pakistan often resort to seeking help from traditional healers like a Hakim, spiritual healers (Maulvi, Peer, Fakir), or faith healers (Amil, Sanyasi). A research showed that around 86% people with excessive mental health issues visited a traditional healer before reaching out to a mental health specialist [xxiv].
State Response
Even before eruption of Covid-19, Pakistan lacked a coherent national mental health plan, which is described as a shortsightedness of leaders in healthcare, non-seriousness of the issue at hand [xxv], and limited political will and priority given to mental health [xxvi]. Experts, however, have identified that the reason behind this is competing public health priorities, and given that Pakistan is a lower-middle income country with budgetary constraints, it is difficult to allocate considerable resources to deal with mental health issues. Current spending on mental health is focused on developing specialist services at the tertiary level, which is not adequate to deal with the extent of this issue. At the same time, there is no mechanism for quality assurance or accountability, which leads to sub-optimal treatments [xxvii]. Health information systems do not cover indicators that would help gauge the severity of mental health problems in the country, and potentially support evidence-based solutions [xxviii].
The National Action Plan for Covid-19, developed by the government, focuses on containing and responding to Covid-19 outbreaks, and emphasizes collaboration among different government sectors [xix]. Unfortunately, the 136-page long document does not have a single mention of “mental health” or associated reference, which reflects the ignorance of policymakers to one of the major fallouts from the pandemic.
However, it is important to highlight an important step by the Federal Government towards addressing mental health. The Ministry of Planning, Development and Special Initiatives, supported by UNICEF, is initiating a pilot project in Islamabad called Mental Health and Psychosocial Support (MHPSS) as a response to Covid-19. As a digital initiative, users will be able to self-diagnose and understand their symptoms by using a mobile app, and will then be directed to a healthcare facility, or a specialist based on the severity of their condition. Even though digital access is a challenge, the pilot can yield important insights and is a step in the right direction. If successful, it will be presented to provincial governments with the aim of scaling it up [xxx].
Implications
The implications of not addressing mental health issues in Pakistan, especially during the pandemic, can have long-term repercussions for the country. In 2006, the economic burden of mental illness in Pakistan was estimated at PKR 250 million; current estimates are much higher with a multiplier effect over 15 years. At the same time, mental health issues can have a longstanding impact on economic productivity, public health and society. Research has shown that at workplaces, mental health problems are often overlooked or undermined, and it damages the individual’s health and career, and also decreases their productivity and creativity at work [xxxi]. Failure to address mental health problem like depression increase the risk of cardiovascular disease, diabetes, and stroke [xxxii]. In other words, untreated mental health issues compound into chronic diseases causing a strain on the country’s fragile healthcare system. At the same time, there is a clear relationship between mental health and perpetration of domestic abuse. With an increase in it since the pandemic started, victims of domestic abuse are further pushed towards PTSD and other mental health related issues without receiving any treatment or support [xxxiii].
Another major issue is that when individuals are not able to afford or access mental health services or support due to societal pressure, they tend to find other ways to endure their stress and depression, often leading to various forms of addiction [xxxiv]. Data shows that in Pakistan, especially among the youth, depression and disappointment is the leading cause for drug addiction along with other mental health issues like stress and anxiety. Pakistan has a total of 7.6 million drug addicts, and this number is “increasing at the rate of 40,000 per year making Pakistan one of the most drug affected countries in the world” [xxxv].
The Global Risks Report 2021 by World Economic Forum has identified that the young generation that is coming of age during the pandemic are under massive stress and anxiety, especially those who are currently entering the workforce. Due to the economic recession caused by the pandemic, the young generation is ever more uncertain about their future prospects, and more than 80% have said that their mental health has deteriorated [xxxvi]. This can have a long-term impact in the form of youth unemployment, and more students dropping out of education streams.
Addressing mental health is critical for Pakistan’s national development. It is not just a public health issue, but it also falls under the umbrella of developmental and human rights issue [xxxvii]. For LICs, increasing their minimum spending on mental health to USD 2 per person per annum (pppa) can lead to a USD 4.26 million per million population returns to the economy [xxxviii]. Right now, Pakistan is spending less than USD 1, and there is a potential for a USD 5 return on every USD 1 invested in scaling up treatment for depression and anxiety. There indeed is potential in investing in mental health in Pakistan, which is unfortunately being sidelined or ignored by the policymakers because the returns from such investments take considerable time to reach fruition.
Recommendations
It is important to realise that there is no silver bullet that will resolve all mental health problems. A multi-pronged approach will be required to understand and respond to mental health challenges in Pakistan.
1
Nationwide Assessment
Instead of embarking on ad-hoc policy interventions, a comprehensive and robust national diagnostic on mental health is required. A nationwide survey can help identify the scale and extent of problems across provinces and regions. The baseline survey should help formulate an informed response strategy and can be complemented by regular administrative data on mental health.
2
Allocation of Budget
Instead of embarking on ad-hoc policy interventions, a comprehensive and robust national diagnostic on mental health is required. A nationwide survey can help identify the scale and extent of problems across provinces and regions. The baseline survey should help formulate an informed response strategy and can be complemented by regular administrative data on mental health.
3
Focal Unit at MoNHSRC and Provincial Departments
A focal unit specifically mandated to understanding, promoting awareness and coordinating a response to mental health should be established at the Ministry of National Health Services, Regulation and Coordination. Once this unit is functional, a strategic dialogue with provincial counterparts should lead to creation of provincial units.
4
Creation of Support Groups
Establishment of a psychosocial support group that is led and managed by experts and specialists, and overseen by health bodies and regulatory agencies, can be used as a tool to help frontline healthcare workers better deal with mental health conditions, especially during the pandemic. The model can be tweaked and adapted for scaling up to other contexts once it has been thoroughly tested and evaluated.
5
Whole-of-Government Approach
Addressing mental health will require the coordination and collaboration of multiple agencies and tiers across the administrative structure. Ministries/Departments/Divisions of Health, Education, Information Technology & Telecommunication, Broadcasting, Social Protection etc, will have to work in sync to design and execute a holistic response with each agency exploring avenues to promote mental health awareness and contributing to preventive and curative responses.
6
Updating Health
Studies Curricula
There is an urgent need to introduce mental health as an important part of health education. By educating the upcoming cohorts of doctors and health sciences professionals, there will be an increased and better qualified workforce who can contribute to tackling this growing issue. In addition to medical degree programmes, short courses and certification programmes can also be initiated to help develop a qualified workforce to tackle some components of the response.
7
Strategic Communication & Engagement
A strategic communication campaign that is jointly executed by the public and private sector to create awareness of mental health, challenge the stigma and taboos around it and identify avenues of seeking professional help will need to be executed. This should be a national effort with local and regional language, culture and context tailored messaging and mix of media. In addition to behaviour change communication, helplines staffed with experts can be set up to support people in immediate need with guidance and direction.
This material has been developed by Tabadlab in partnership with DRI. It has been funded by UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government’s official policies.
End Notes
[i] Mian, A., (2020, May 27), Mental health: Pakistan’s Achilles heel during Covid-19, DAWN. Retrieved from DAWN: https://
www.dawn.com/news/1553941
[ii] In conversation with Dr. Asma Humayun
[iii] WHO, (2013). Investing in Mental Health: Evidence for Action. WHO. Retrieved from WHO: https://apps.who.int/iris/bitstream/
handle/10665/87232/9789241564618_eng.pdf;jsessionid=2449597423D95617ECB80CB295B46A96?sequence=1
[iv] Javed A, Khan MN, Nasar A, Rasheed A. (2020). Mental healthcare in Pakistan. Taiwan J Psychiatry 34. DOI: 10.4103/TPSY.TPSY_8_20
[v] Humayun, A. (2020, October 11). Time to invest in mental health. Dawn. Retrieved from Dawn: https://www.dawn.com/news/1584443/time-to-invest-in-mental-health
[vi] Haider II., Tiwana F., and Tahir SM. (2020). Impact of the COVID-19 Pandemic on Adult Mental Health. Pak J Med Sci 36. DOI: https://doi.org/10.12669/pjms.36.COVID19-S4.2756
[vii] Arshad et al, (2020), Assessing the Impact of COVID-19 on the Mental Health of Healthcare Workers in Three Metropolitan Cities of Pakistan, Psychology Research and Behavior Management 13, http://doi.org/10.2147/PRBM.S282069
[viii] Mukhtar, S., (2020), Psychological health during the coronavirus disease 2019 pandemic outbreak, International Journal of Social Psychiatry 66(5). https://doi.org/10.1177/0020764020925835 DOI: 10.1177/0020764020925835
[ix] Ibid.
[x] Mukhtar, S. (2020, April). Pakistanis’ mental health during the COVID-19. Asian Journal of Psychiatry 51. https://doi.org/10.1016/j.ajp.2020.102127
[xi] Townsend, M. (2020, April 12). Revealed: surge in domestic violence during Covid-19 crisis. The Guardian. Retrieved from The Guardian: https://www.theguardian.com/society/2020/apr/12/domestic-violence-surges-seven-hundred-per-cent-uk-coronavirus
[xii] Khan, S. (2019, September 23). Violence against women on the rise in Pakistan. DW. Retrieved from DW: https://www.dw.com/en/violence-against-women-on-the-rise-in-pakistan/a-50550672
[xiii] Haider II., Tiwana F., and Tahir SM. (2020)
[xiv] Mukhtar, S., (2020), Psychological health during the coronavirus disease 2019 pandemic outbreak Mukhtar, S., (2020), Psychological health during the coronavirus disease 2019 pandemic outbreak
[xv] Sandesh R., et al. (2020, July 02). Impact of COVID-19 on the Mental Health of Healthcare Professionals in Pakistan. Cureus 12(7): e8974. doi:10.7759/cureus.8974
[xvi] Arshad et al, (2020).
[xvii] Shafiq, S. (2020). Perceptions of Pakistani community towards their mental health problems: a systematic review.
Global Psychiatry 3 (1). DOI: 10.2478/gp-2020-0001
[xviii] In conversation with Dr. Sonia Mukhtar.
[xix] Waheed, M., (2020, January 19). Mental health problems. The News on Sunday. Retrieved from TNS: https://www.thenews.com.pk/tns/detail/599993-shrouded-in-obscurity
[xx] Javed A, Khan MN, Nasar A, Rasheed A. (2020).
[xxi] OECD, (2014, July), Focus on Health: Making Mental Health Count. OECD. Retrieved from OECD: https://www.oecd.org/els/health-systems/Focus-on-Health-Making-Mental-Health-Count.pdf
[xxii] Mian, A., (2020, May 27).
[xxiii] Javed A, Khan MN, Nasar A, Rasheed A. (2020)
[xxiv] Shah et al. (2019). Impact of Conventional Beliefs and Social Stigma on Attitude Towards Access to Mental Health Services in Pakistan. Community mental health journal 55(3).
[xxv] Mian, A., (2020, May 27).
[xxvi] Javed A, Khan MN, Nasar A, Rasheed A. (2020)
[xxvii] Humayun, A. (2020, October 11).
[xxviii] In conversation with Dr. Asma Humayun
[xxix] National Action Plan for Corona virus disease (COVID-19) Pakistan. (2020). Ministry of National Health Services, Regulation and Coordination, Government of Pakistan. Retrieved from NIH: https://www.nih.org.pk/wp-content/uploads/2020/03/COVID-19-NAP-V2-13-March-2020.pdf?cf_chl_jschl_tk
[xxx] In conversation with Dr. Asma Humayun
[xxxi] HMHL. (2010). Mental health problems in the workplace. Harvard Mental Health Letter. Retrieved from Harvard: https://www.health.harvard.edu/newsletter_article/mental-health-problems-in-the-workplace
[xxxii] NIH. (2020). Chronic Illness & Mental Health. Retrieved from NIH: https://www.nimh.nih.gov/health/publications/%20chronic-illness-mental-health/index.shtml
[xxxiii] Bhavsar et al. (2020). Lockdown, domestic abuse perpetration, and mental health care: gaps in training, research, and policy. The Lancet. Retrieved from Lancet: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30397-%207/fulltext#articleInformation
[xxxiv] Javed A, Khan MN, Nasar A, Rasheed A. (2020)
[xxxv] Asghar, S. (2018). Drug abuse in Pakistan reaches alarming level. The Nation. Retrieved from The Nation: https://nation.com.pk/10-Feb-2018/drug-abuse-in-pakistan-reaches-alarming-level
[xxxvi] WEF. (2020). The Global Risks Report 2021: Insight Report. World Economic Forum.
[xxxvii] Humayun, A. (2020, October 11)
[xxxviii] Caddick, H., Horne, B., Mackenzie, J., and Tilley, H. (2016). Investing in mental health in low-income countries. ODI. Retrieved from ODI: https://odi.org/sites/odi.org.uk/files/resource-documents/11184.pdf
Muhammad Asad Rafi is a Research Analyst for Global Affairs and International Security at Tabadlab. He holds a M.A in International Security from Paris School of International Affairs at Sciences Po. His research interests lie in the fields of regional security, foreign policy and global affairs.
