When you arise in the morning, think of what a precious privilege it is to be alive - to breathe, to think, to enjoy, to love — Marcus Aurelius, Roman emperor and stoic philosopher

A few weeks ago, my student doctors and I discussed the case of a young man admitted to our large public hospital for ‘psychosis,’ the dreaded illness most akin to ‘madness.’ He was in his early twenties and, like most of our patients, desperately poor. Also, like most of them, he had received a semblance of early education and then dropped out to work and help his family. He worked 12 hours a day, 6 or 7 days a week at a local ‘factory’ making matchsticks and had been working night shifts for several months. My students were shocked to hear that he made the equivalent of perhaps Rs 25,000 a month for this back-breaking work (by contrast, a doctor employed at our hospital makes around Rs 100,000 per month immediately after graduation). In addition, since the young man in our care worked nights, his sleep cycle had been irregular for several months. He had also been indulging in the illicit drugs on offer at his workplace, a common occurrence to both feel calmer and to stay awake during long hours of repetitive, boring work. Eventually, his mind cracked, and he began hearing voices and became violent, which is how he ended up in our hospital.

As another tumultuous year draws to a close, we would do well to examine what the year has brought us. Over the past five years, Pakistan has witnessed a notable shift in attitudes, awareness and initiatives regarding mental health. While challenges persist, things have changed a lot.

For one, awareness campaigns and educational initiatives have gained momentum. Efforts by governmental bodies, non-governmental organisations and grassroots movements have significantly contributed to breaking the silence surrounding mental health issues. Through media campaigns, workshops and community outreach programmes, there has been a deliberate attempt to educate the public, reduce stigma and encourage seeking professional help.

Additionally, increased dialogue and discussion around mental health in mainstream media have played a pivotal role. Television programmes, radio shows and social media platforms have begun featuring discussions, stories, and expert opinions on mental health, fostering a more open environment for conversations previously deemed taboo.

Pakistan’s youth demographic has emerged as a driving force behind the transformation of mental health perceptions. With 40 per cent of Pakistan’s population under the age of 15, we have one of the youngest populations in the world and they have been actively engaging in advocacy, organising events and utilising social media platforms to raise awareness and challenge societal norms regarding mental health. Their advocacy efforts have been instrumental in pushing for change and garnering support for mental health-related causes.

Importantly, the government’s acknowledgement of mental health as a priority has seen a shift in policies and resource allocation. There has been increased funding for mental health programmes and an emphasis on integrating mental health services into primary healthcare systems. Government-led initiatives aimed at expanding mental health infrastructure and training more professionals signify a crucial step towards better accessibility and quality of care.

The Covid-19 pandemic, while a challenging period, has also catalysed changes in mental health approaches. The pandemic highlighted the importance of mental well-being and prompted the adoptation of tele-health services, online counselling and remote therapy sessions. This shift towards technology-enabled mental health services has helped reach individuals in remote areas or those facing mobility constraints.

Despite these positive strides, significant challenges persist. The biggest challenge for the young man in our care and millions more like him is poverty. It stymies our efforts everywhere we turn: people cannot afford high-quality mental healthcare when and where they need it; poverty worsens every mental health indicator, restricting access to education, employment and healthcare and exacerbating other factors like domestic violence. A country like Pakistan, trapped in a vicious international system of debt bondage, can never afford to spend what is needed on social services, including mental health.

The shortage of mental health professionals remains a critical issue, especially in rural areas but other challenges also exist, including regulation and oversight of mental health professionals, accountability mechanisms for those practicing sub-par care and the like.

The mental health genie, though, is out of the bottle and it is not going back in. My two young sons, both now in college, faced their own share of challenges in school, with the younger one suffering more since he is the sensitive, artistic type. Bullying on their school campus and trying to grapple with Pakistan’s antiquated education system with its emphasis on rote learning and authoritarian teacher attitudes did not help with their mental health in their teen years. My youngest one has, after learning from the experience of her brothers, become an outspoken advocate for many issues, including mental health. And it is young people like her who are driving the change in Pakistan’s mental health landscape.

While a change in social conditions will need to await a different kind of revolution, a mental health revolution is already under way in our country, led, as always, by Pakistan’s energetic and dynamic young people who are interacting with the world outside Pakistan in all kinds of new and inventive ways.

A few weeks ago, I met two young women in my clinic, both college students who work online for US companies at night and make a decent wage, although working nights was beginning to affect their mental health. Hopefully, they can recover and continue their work to lift their families and communities to be on par with the rest of the world.

And the young man in our hospital? He is beginning to recover gradually and will, we hope, be able to return home fully healed. His family is glad to have their son back. We know he has to go back to a life of poverty and deprivation, but perhaps in his next try, he can find a way to hold on to health and hope as he moves along in his life journey.

The writer is a psychiatrist and faculty member at King Edward Medical University. He is the author of Faiz Ahmed Faiz: A Biography, Sang-e Meel Publications, 2022.

His X handle: @Ali_Madeeh