Every year, on October 10, we celebrate World Mental Health Day. This year’s theme declares mental health as a basic human right. The World Health Organization (WHO) describes this by stating that, “….everyone, whoever and wherever they are, has a right to the highest attainable standard of mental health. This includes the right to be protected from mental health risks, the right to available, accessible, acceptable, and good quality care, and the right to liberty, independence and inclusion in the community.”
Globally about one in eight people live with a mental health condition. Without access to quality care, this affects their living conditions, their physical health, their opportunity to form meaningful connections as well as their ability to contribute to society to their full potential. People with mental health conditions are also often deprived of their right to autonomy, safety and security, educational opportunities and health decision making. They may also be more vulnerable to abuse, personal violations and discrimination. Another important factoid to consider here is that 90 per cent of the people suffering from mental health disorders live in the lower and middle income countries.
What does this mean for a country like Pakistan where only 3.0 percent of our GDP is allocated to health and 0.4 per cent of that to mental health interventions; a country where health literacy level remains abysmally low, and mental health in particular is strikingly stigmatized. One can break down WHO’s definition to comprehensively analyze this predicament, thereby leading to more pragmatic solutions.
Right to highest attainable standard of mental health: Mental health is not just an absence of disease but a state of wellness which allows people to cope well with stressors, learn and work optimally and therefore contribute to their community to their potential. It allows for development of executive functioning skills like decision making, resilience, agility, and emotional intelligence. However, in a country reeling under one of the highest numbers of out of school children, an archaic education system with little to no focus on social-emotional learning (SEL), poverty, minimal employment opportunities and a fractured socio political and economic structure, mental health and wellness is a hard sell.
Right to be protected from mental health risks: Generations of stigmatized and therefore untreated mental health disorders and historical trauma have left our population particularly vulnerable to disorders like anxiety, depression and PTSD. Risks are particularly damaging during earlier years through biological drivers like antepartum and postpartum depression, parental substance abuse or other untreated disease; and through psychological drivers like harsh parenting, verbal and physical abuse, and punitive discipline at home and at school. Similarly, environmental factors like violence, political instability, uncertainty and deprivation and natural disasters all place mental wellness at considerable risk. From individual to contextual and societal determinants, Pakistan stands as a breeding ground for mental health distress and disorders.
Right to available, accessible, acceptable, and good quality care: Most of the medical schools in Pakistan don’t have a primary level mental healthcare curriculum; this leaves most graduating doctors who form the vast majority of general physicians disseminating care in Pakistan bereft of even basic training of screening and management. Specialist care is limited to around 400 adult psychiatrists, and less than 10 child and adolescent psychiatrists; most of these focus on biological treatment modalities and nuanced psycho social interventions are largely missing.
There are no licensure requirements for clinical psychologists, these are also few and far in between with practice that goes largely unmonitored and unsupervised. Counselling training programmes have sprung up across the country; so have tele mental health programmes, with little to no attention to quality assessment, which may be causing more harm than good.
Right to liberty, independence and inclusion in the community: Mental health disorders, despite their high community prevalence of 16-20 per cent, remain highly stigmatized. Pathways to care are riddled with charlatans, unethical practices, dangerous ‘totkas’, polypharmacy and well-meaning home remedies and faith healing. By the time a patient reaches a trained healthcare worker, the disease is often advanced; a likely scenario thus is of an individual who is not given autonomy of care, is ostracized and may not be included in decision-making of consequential matters. Psychiatric illness is perceived as different from other diseases, the neurobiological component misunderstood, and associations with other physical disorders go largely unrecognized.
On a canvas such as above, it isn’t a stretch to declare that we are far from exercising mental health as a basic human right in Pakistan. There is a pressing need for strategic advocacy and thoughtful and well-researched awareness campaigns, especially those focused on children and youth. Creative measures and innovative methodologies that use social media channels to reach a wider audience are critical to start a meaningful discourse.
A national mental health policy is essential – one that takes a broad and bold perspective and incorporates mental health and wellness as a core element in social, developmental, education, health as well as economic and corporate sectors. With the significant economic, health, social and humanistic burden at stake, a contextual and considered response is the need of the hour.
The writer is an adult, child and adolescent psychiatrist. She is the founder and CEO of Synapse, Pakistan Neuroscience Institute.