ne in four individuals will experience a mental disorder at some point in their lifetime. This statistic is recognised globally as mental health problems overtake physical health problems as a leading cause of illness worldwide. According to the World Health Organisation, there are about 700 qualified psychiatrists for a population of almost 240 million in Pakistan. This roughly comes to a psychiatrist for 350,000 people, far below the Western average of 14-20 psychiatrists per 100,000. Pakistan has, to its credit, made notable strides in addressing mental health issues, updating its mental health legislation and shedding light on a previously neglected aspect of healthcare. Our urban society seems to be gradually becoming more sensitised to the issues around mental health in general, frequently reflected in the content of our television plays.

One of the major challenges in Pakistan’s forensic mental health system is the inadequate number of mental health professionals, including psychiatrists and clinical psychologists, who can assess and provide appropriate treatment to individuals within the criminal justice system. The shortage of mental health professionals is particularly alarming in rural areas, leading to disparities in access to mental healthcare for those involved in criminal cases.

Unfortunately, many individuals in a state of mental disorder commit crimes they would not have done had they been mentally well. Chapter 34 of the Code of Criminal Procedure 1898, titled Lunatics, provides guidance for the judiciary on how to process the mentally ill offender in a court. However, due to lack of awareness, this is rarely actioned upon and such individuals are unjustly processed through the criminal justice system, like any other person.

One such case concerns Imdad Ali, who in 2001 killed a person while in a state of mental disorder. While he was on death row, his and two other cases (Ghulam Abbas and Kaneezan Bibi) were taken up by lawyers from the Justice Project Pakistan in the Supreme Court of Pakistan supported by amicus curae Brig Prof Mowadat Hussain Rana (retired), professor of psychiatry; and Barrister Haider Rasul Mirza, ASC.

The resulting landmark judgment in February, 2021, was positively recognised in news media around the world as a step forward to support the mentally ill in Pakistan’s courts. Death sentences of Imdad Ali, Kaneezan Bibi and Ghulam Abbas were commuted. The judgment laid the foundation of how the courts should ensure that the rights of the mentally ill offender. It directed: “The Federal Government (for Islamabad Capital Territory) and all the Provincial Governments shall immediately launch training programmes and short certificate courses on forensic mental health assessment for psychiatrists, clinical psychologists, social workers, police and prison personnel.” In addition, it directed: “The Federal Judicial Academy, Islamabad, and all the Provincial Judicial Academies shall also arrange courses for trial court judges, prosecutors, lawyers and court staff on mental illness including forensic mental health assessment.”

I have published and presented internationally on this topic for over a decade. A major concern raised is about malingering on part of the offender (faking mental disorder) or dishonest forensic psychiatric reports, or both. A comprehensive assessment of an offender combined with collateral information from family and friends, past records and validated psychological rating scales can weed out the malingerer from a genuine case. A forensic psychiatric report should be a comprehensive document that answers a legal question. Therefore, having training in this field is critical so that when such reports are submitted to the courts, the information is credible and valid. The forensic report aims to guide the court on factual historical data on the mental disorder of the accused and how it intersects with the alleged crime. There are standardised psychological assessment tools to help with diagnosis and assessing levels of risk of violence that can be incorporated into a forensic report.

The Supreme Court judgment mentioned above states that: “The report/ opinion of the Medical Board must not be a mere diagnosis of a mental illness or absence thereof. It must be a detailed and structured report with specific reference to psychopathology (if any) in the mental functions of consciousness, intellect, thinking, mood, emotions, perceptions, cognition, judgment and insight.”

High profile crimes in Pakistan, like in most countries, often captures the ire of the public. Often, these cases fuel public anger with demands of dire consequences for the accused. Though every citizen has the right to a fair trial, it can become daunting for mental health professionals in such an environment to ignore public opinion for fear of repercussions. This is especially relevant in cases of blasphemy; crimes against children and women; or by children and women.

In Islamic jurisprudence, forensic psychiatry was summarised by the following hadith. Our beloved Prophet Muhammad (peace be upon him) said: “The pen has been lifted from three: from the sleeper until he awakens; from the child until he reaches puberty; and from the insane person until he comes to his senses.” Abu Dawood (4403) and at-Tirmidhi (1423).

It will take time for our society to appreciate fully that those with mental illness when they commit crimes, should be treated and rehabilitated rather than punished.

Last year, I began a project creating the first certificate course on forensic mental health in Pakistan accredited by Queen’s University in Kingston, Ontario, Canada. The objective of this three-month twelve-module certificate course is to sensitise professionals to the topics of law, psychiatry, psychology and key forensic mental health principles. These professionals can come from all the disciplines whose work involves the mentally ill offender and/ or sentenced individuals including and not limited to psychiatrists, psychologists, social workers, police, prison officials, lawyers and judges.

The Pakistan Psychiatric Society has welcomed this initiative and some of its key officers graduated from the inaugural course in 2022. The Punjab Institute of Mental Health (PIMH) in Lahore frequently receives requests to assess mentally ill offenders who are presented before a medical board. Prof Ali Madeeh Hashmi at the Department of Psychiatry, King Edward Medical University, has supported his consultant psychiatrists at PIMH to attend the certification course. In Sindh, Dr Jamil Junejo is active in this field, working from the Sir Cowasjee Jehangir Institute of Psychiatry.

The advancement of forensic mental health in Pakistan is an urgent and essential task. By addressing the current challenges and implementing evidence-based practices, Pakistan can ensure that individuals with mental illnesses receive fair treatment within the criminal justice system while also fostering a more compassionate, understanding society. This year’s World Mental Health Day theme – mental health is a universal human right – is especially apt for mentally ill offenders and sentenced persons.

The writer is an associate professor specialising in forensic psychiatry at Queen’s University, Canada