This week You! speaks to Amna Asif, an entrepreneur who is making efforts to help people struggling with mental illnesses and fight the stigma surrounding it through her start-up...

Mental health in Pakistan has remained a subject of debate since the last few years. The incidence and prevalence have both increased tremendously in the background of growing insecurity, terrorism, economical problems, political uncertainty, unemployment and disruption of the social fabric. People with mental illness are often labelled as ‘crazy’, ‘lunatics’ or being possessed by an evil spirit. The rampant increase in the stigmatisation of mental illness is the reason why people so easily vilify a person instead of showing concern, care and compassion. A lack of understanding and awareness about mental illness causes people to rely on herbal and spiritual cures and exorcising evil spirits instead of seeking medical help and therapy.

In Pakistan, the scenario is even worse. Every year approximately 0.2 per cent of the healthcare budget is allocated to mental health which is not enough. However, this cannot remain the case anymore since UN addresses this as a serious issue. Since then, a wave of advocacy and awareness is spreading, and many hard questions are being asked. Keeping this in mind, this week You! talks to Amna Asif, who is a mental health advocate. She is determined to free the society from the mental health stigma through her start-up project ‘Relivenow’ started in January 2018. It is an online platform that will provide a mobile connection between psychologists and people looking for counselling and therapy.

You! What is the mental health scenario in Pakistan?

Amna Asif: There are many other platforms that have just now started, one is a Lahore-based hotline which is free of cost but they lack credibility. Sadly, the mental healthcare is the most neglected area, and we do not have updated data since 2009. The last recorded data found that there are almost 400 psychiatrists in the country. The count of mental health professionals in 2018 is not officially available. One of the issues is that ethics are not being followed in this regard; a third year student of psychology claims to provide counselling - just to earn money.

Another pressing problem that prevails is that our physicians fail to advise their patients to seek help. Most gynaecologists do not even warn women of post partum.

You! What inspired you to start a business in this field and become a mental health advocate?

AA: After I had completed my BBA in HR, I immediately started working at Zepcom as an HR executive, and then started my MBA. During one of my courses, which was about technology innovation, we had to come up with a start-up and that is when I came up with this idea. I chose this as a start-up for several reasons. Firstly, I had history of anxiety and still at times battle with it. So, I know how important it is to get support, which is why I am also aware of the fact that this area of healthcare is the most neglected. Secondly, these platforms do not exist in Pakistan. There are NGOs that are working for mental well being, psychologists are privately giving sessions, but proper organisations don’t exist. Thirdly, international organisations such as ‘BetterHelp’, ‘Unsuicide’ and ‘Psych Central’ are doing a great job in providing assistance to patients; and I myself have used them to overcome my problem.

It was during this period that I came across Nest I/O incubator - a company that helps new and start-up companies to develop by providing services such as management training or office space. It was taking its seventh batch, and that’s when I thought of pursuing this fulltime. This is more of a social entrepreneurial project than a money making initiative.

You! How do you tend to reach out to the audience?

AA: Digital media is our main source of marketing. We post on Instagram and Facebook daily, and receive a response through direct messages and Facebook inbox. Moreover, we hosted an event in February by the name of ‘Reachout’, where we invited two psychiatrists and had an open panel discussion. This was just a month after we went live as an online forum. It was a free public event to discuss what mental health is and the stigmas associated with it. Around 150 people signed up for the event but only 50 showed up, which clearly proves the point about the stigma that is widely attached.

You! How many clients are you catering to currently?

AA: Right now we have clients from Pakistan, France, Germany and Dubai. We have six psychiatrists and 12 on-board, overall. The criteria of our psychiatrist are very strict we only bring those professionals in who have 800 counselling hours and minimum three years of experience.

You! How does the stigma related to mental disorders acts as a hindrance for your work?

AA: Our work is twofold. You would know that you need water in your life, so you’ll just go and get it. You don’t need anyone to convince you to buy water and present a whole argument. My job requires me to convince people of its importance. I have to explain to them that they may be suffering from a mental disorder, then tell them that they may need help and lastly convince them to seek help. This is how the stigma has made the process difficult and slow.

You! Do you believe that women are prone to mental illness in Pakistan than men?

AA: I think both genders are prone to mental illness, because it does not discriminate between men and women. The reason why statistics are up is that women can show their emotions, but for men the issue is their concept of toxic masculinity. The statistics for men is lower because their masculinity is on the line and they don’t want to appear weak. Postpartum depression is that one category that single-handedly affects women and that too at a high rate - 8 out of 10 women suffer from postpartum at some point and other problems such as domestic violence, sexual and emotional harassment. Pertaining to these factors, the rates of mental disorder in women can be higher.

You! Are there any symptoms through which one can self assess if they need help?

AA: It is kind of a thin line, but there are certain symptoms that can easily help you to realise if you have a mental disorder. There is ‘behavioural change’ which is feeling lazy, not feeling like taking a shower, an extrovert suddenly becoming an introvert. Furthermore, there is an ‘eating disorder’ which is eating more than usual or having a loss of appetite. In addition, the ‘sleeping disorder’, which is becoming an insomniac or sleeping more than usual.

You! Could you name a few of mental disorders that are commonly seen but we are not familiar of.

AA: To name a few that are commonly seen are as follows:

Attention deficit hyperactivity disorder (ADHD): It’s when a child or a teenager is unable to pay attention, manage their time or set goals and achieve them. These children don’t tend to listen or perform tasks that are asked of them or tend to daydream a lot. ADHD is very common in children and parents should be at a lookout of this since early schooling. Here in Pakistan we just rule it out as bad behaviour instead of a serious problem.

Bipolar: It’s an extremely serious condition when a patient of depression goes to the point of becoming a maniac, they become suicidal, the victims have extreme mood swing from extremely happy to extremely sad and can be a risk to themselves or others.

Phobias: It’s a kind of an irrational feeling related to fear of something. You may feel like you’re having a panic attack when you are near the source of your fear. You may have fear for dogs which is Cynophobia, or fear of enclosed spaces i.e. claustrophobia or phobia of being in the dark.

Somatic disorder: It’s a condition where you feel a bodily pain although; it is triggered by something else.

Post traumatic disorder (PTSD): It’s a mental condition that is triggered by a horrifying event that they either were a part of or witnessed. If you’ve been in a serious accident (plane crash), in shooting or been sexually abused you may have chances of PTSD.

Obsessive compulsive disorder (OCD): It’s when you are trapped in the cycle of obsession and compulsion. Obsessions are the intrusive thoughts you have and compulsions are the behaviour you adopt to get rid of those thoughts. If someone is obsessed about cleaning to the point where they let go of their important events just to satisfy their urge of cleaning.

Gender Dysphoria: It’s the distress you may face as a result of your assigned gender. It’s when your assigned gender and gender identity don’t match.

What do the statistics say?

The deep-rooted bias related to mental disorder has always been prevalent in many societies. People with mental illnesses are often treated like outcasts & lunatics; and instead of being shown compassion, they are ostracised. Mental asylums are not a cure for such disorders and that too came as a late realisation worldwide.

• It was in 2009 when the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) was used to collect information on the mental health system in Pakistan. The goal of collecting this information was to improve the mental health system and to provide a baseline for monitoring the change. There were predictions being made on the basis of this report; but there hasn't been any extensive study done after it.
  
• In Pakistan, the government proposed a new mental health act in 1992 and circulated a draft among psychiatrists for their comments. However, it was not until 2001 that the 'Lunacy Act of 1912' was replaced by the Mental Health Ordinance of 2001. However, with the 18th amendment to the constitution and devolution of health responsibilities to the provincial governments, it became the task of the provinces to pass appropriate mental health legislation through their respective assemblies. Currently the mental health legislative scenario is fragmented and unsatisfactory. Only the provinces of Sindh and Punjab have a mental health act in place and there is an urgent need for similar legislative frameworks in other provinces to protect the rights of those with mental illness.
  
• For the first time, world leaders recognised the promotion of mental health and well-being, and the prevention and treatment of substance abuse, as health priorities within the global development agenda. The inclusion of mental health and substance abuse in the Sustainable Development Agenda was adopted at the United Nations General Assembly in September 2015. It was done in order to have a positive impact on communities and countries where millions of people would receive the much needed help.
  
• It was also in 2015 that a seminar was organised by the Pakistan Association for Mental Health (PAMH) in collaboration with the Human Rights Commission of Pakistan (HRCP) and Mental Health Forum (MHF). It revealed that Pakistan has only 380 trained psychiatrists.
  
• In 2016, Dr Ayesha Mian, Chairperson of Department of Psychiatry at the Aga Khan University (AKU) spoke about the harrowing issue of limited number of health professionals for mental disorders in Pakistan, "Around 50 million people are suffering from common mental disorders in Pakistan. The illness afflicts 15 to 35 million adults, which is about 10 to 20 per cent of the population."
  

Keeping this in mind, the ratio is grievously disproportionate. In light of the data available, there is roughly one psychiatrist available per half-million people. The result is that even when patients are fighting something as common as depression or anxiety recognise their symptoms, overcome the stigma, gain the support of their families and start looking for medical help, there simply isn't much help to be had.