A few years ago, I noticed a young man in a pharmacy asking for a strong anxiolytic without a prescription. A ten-tablet strip was handed over to him without a question. I asked the salesman, who was not a pharmacist, how this medication was provided without a prescription. His response still echoes in memory: “Sir log yeh dawain chanay ki tarha phanktay hain; logon ko tensions hi itni hain.” (People swallow these medications like grams; because they are so stressed.) We can easily infer some dire facts. First, the selling of these drugs is unrestricted and unregulated. Second, the incidence of mental health issues is higher than what most studies and publications suggest, since a majority of the people using psychotropic medications are not diagnosed and are therefore not part of any database. Third, there is evidence of the medicalisation of some non-medical issues. The common stress, emanating from day-to-day stressors, is being taken as a medical problem hence being treated with medicine.

Over the years, eminent mental health specialists have written and reported about Pakistan’s deficient and almost paralyzed mental health facilities. As has been said time and time again, the lack of skilled professionals is having a detrimental effect on the performance of the health sector, particularly the mental health sector. The situation is substantially worse in rural areas. We hear about this deteriorating condition every year. Should the same elegy be repeated at the end of 2023?

The primary cause of the increase in mental health-related problems in Pakistani - or any other society - lies in the country’s socioeconomic and psycho-political circumstances. However, many mental health professionals and researchers overlook these. It is worth noting that this is not exclusive to Pakistan; it is a global phenomenon. Every time a pharmaceutical company releases a new psychotropic, attractive literature is released with a claim of greater efficacy. The National Health Service of the United Kingdom has spent millions on so-called evidence-based forms of psychotherapy and studies are consistently published on its effectiveness. On the other hand, suicide rates in the country are rising concurrently. So, why, in a nation where everyone has access to the best care at their doorstep, is the prevalence of mental health issues increasing rather than decreasing?

The answer is not difficult to comprehend. The suggested course of treatment, which includes medication and psychotherapy, does not address the root causes of mental health problems. Psychosocial conditions are the major contributing factors. They differ depending on the society. If so, the question that has to be answered is whether a worldwide system of diagnosis and treatment will produce the desired outcome. Obviously it will not. Accordingly, each society must determine what, in its unique set of circumstances, is producing mental health issues and what kind of treatment is necessary to address those social triggers.

For almost forty years, Pakistani society has endured turbulent socio-political circumstances. It is among the areas most severely affected by the ongoing acts of terrorism. Within the course of ten years, almost 80,000 individuals died. Many people who died before and after that time are not included in this figure. All we were interested in was how many people the society lost. There were, as far as I could find, very few studies done on the trauma this violence caused to the entire society. Pakistani society was distinct, notwithstanding the challenges posed by terrorism. In this society, the culprits and motivations behind the gory events that have occurred over forty years are still unknown. It is more difficult to recover from post-traumatic consequences when the causes of the trauma are unclear, as they are in this instance. Then, in the name of toheen (blasphemy), there was yet another wave of violence, hatred and division. In the name of religion, the most heinous kind of mob lynching was both glorified and justified.

It was hoped that the end of martial law and the transition to democracy in 1988 would bring about people’s rule and an end to the feeling of uncertainty and powerlessness. Instead, the rifts in the society widened and political instability inflamed the hatred. Over the past twenty years, political differences have caused a major rift in the society that will likely take years to heal. A serious economic collapse has resulted from the political unrest sparked by radical politics. The misery of living is increasing due to unprecedented inflation.

While there was relatively less violence in 2023, there was an unprecedented level of political unrest and economic collapse. It is unrealistic to expect the degree and kind of hopelessness and helplessness experienced this year to end without severely affecting society’s mental health. How can one expect imported therapies or psychotropic medicines to treat mental health concerns and address such massive social triggers of mental health problems?

All of these experiences are accumulated by the human mind. They continue to influence the physiology and thinking of those who are affected. It becomes impossible for someone who experiences such painful things to maintain good physical and mental health. The future of mental health in Pakistan, thus, lies in answering the following questions: Do experts attempt to suggest an indigenous strategy to liberate society from the grip of these traumatic experiences? Do the people in control of the nation intend to stop the society from going through similar horrors in the future? Are the political elite aware of the psychological impact of their actions, including the language they employ during political rallies, on the general public? Have the religious leaders considered the size of the chasm and schism they are creating with their sermons? Did the nation’s intelligentsia evaluate their worst failure in identifying the social problems and suggesting a way out to the masses? In a similar vein, have mental health practitioners considered how they are treating only the symptoms of a mass pathology while ignoring the underlying cause? In 2023, the botched performance of all the stakeholders only got worse. Nothing good is in store for the suffering society in the near future.

It wouldn’t be incorrect to state that mental health of the masses is nowhere on their priority list of those who are at the helm of affairs in Pakistan.

The writer is a clinical psychologist. He lives and works in Ireland and can be contacted at akhtaralisyed@gmail.com