Sometimes we hear about a death -- a result of a suicide -- making news headlines in Pakistan. But not all suicides make news. Lack of proper care facilities, along with social, legal and religious stigmas create an invisible barrier in the reportage of these cases. Like this barrier, mental health problems are also invisible and so are the national official statistics of suicides committed in Pakistan.

Add to it negligence of mental health on a governmental level and we are left with absence of any official data on suicides in Pakistan. Lack of official data creates an impediment for research and policy creation which also affects the treatment of the issue.

Dr. Habib Ullah Chaudhry, a senior psychiatrist based in Lahore and ex-president of Pakistan Psychiatric Society explains that hospitals have their own data for patients admitted due to mental illnesses or suicidal tendencies. Yet, he says, data is not adequate because most suicides aren’t reported as suicides, but as accidents due to the stigmas attached. This leaves a hole in data gathering. World Health Organization (WHO) collects data from governments around the world to create a database of the numbers. "It is also hard to find exact suicide numbers in Pakistan because when suicide cases occur in rural areas, they don’t even make it to the hospitals," he says.

According to a recent review titled, Suicide and Its Legal Implications in Pakistan, suicide deaths are not included in the national annual mortality statistics that are provided to the WHO. National rates are neither known nor reported, the review states.

Dr Iftikhar Minhas, a Lahore-based psychiatrist and the Public Relations Secretary of Pakistan Psychiatric Society elaborates that another reason why hospitals have a difficult time in recording suicide cases is because if a suicidal patient undergoes screening, chances are that they will refuse to be admitted or deny treatment because of their belief systems.

Sualeha Siddiq Shekhani, lecturer at Center of Biomedical ethics and culture, Sindh Institute of Urology and Transplantation (SIUT) in Karachi has done extensive research on mental health issues. She explains that one of the major reasons why Pakistan lacks official data is because, "mental health is not a priority on a governmental level, neither is suicide. Secondly, the stigma associated with suicide plays a major role," she points out. To avoid an encounter with medico-legal centers and police cases, as suicide is a criminal offence in Pakistan, the families resort to private hospitals where these cases are not reported, Shekhani explains.

Dr. Murad Moosa Khan, President of International Association for Suicide Prevention (IASP) and Professor of Psychiatry at the Aga Khan University in Karachi, says that focus of the government when it comes to catering towards health is mostly towards communicable diseases. Maternal and child health are another top priority, and most of the donor funding also goes towards efforts catering to maternal mortality rate, child mortality rate, and infant mortality rate. "Mental health is at a low priority, which has a close link with suicide, which has an even lower priority," he says.

Dr Khan has done extensive work in gathering statistics on suicide in Pakistan. According to a research paper that he wrote, "While official rates of suicide are lacking, it has been possible to calculate rates of suicide in at least six different cities of Pakistan. Crude rates vary from a low of 0.43/100,000 per year (average for 1991-2000) in Peshawar to a high of 2.86/100,000 for Rawalpindi (in 2006), with other cities falling in between: Karachi, 2.1/100,000 (1995- 2001); Lahore, 1.08/100,000 (1993-95); Faisalabad, 1.12/100,000 (1998-2001) and Larkana, 2.6/100,000 (2003- 2004)."

It is also important to note that according to Pakistan’s Federal Budget (2017-2018) report, the total revised budget for healthcare is Rs12. 379 billion, out of which 418 million is reserved for public health services. While 0.255 percent of the total budget goes towards health, out of that only 3.37 percent is given to mental health. This shows that mental health is at the very bottom of the pyramid when it comes to budget allocation by the government and explains the lack of research and the absence of statistics on suicide.

Dr Yasir Abbasi, a UK-based consultant psychiatrist and clinical director who works with Mersey Care NHS Foundation Trust explains that "in order to tackle the problem of suicides in Pakistan, it is essential to have a prevalence rate. When there is a prevalence rate, you can determine the enormity of the problem." Dr. Abbasi quoted WHO data, according to which, Pakistan has only 0.19 psychiatrists per 100,000 inhabitants. It is one of the lowest numbers in WHO Eastern Mediterranean Region, and in the whole world.

In addition to lack of government expenditure, the social, religious and legal stigmas push the problem deeper into the pits. Dr Khan recommends a multi-pronged approach which can tackle the issue. "The government needs to establish a task force of experts and make them come up with recommendations on how to address mental illness," he says. Dr Khan also recommends decriminalisation of suicide and for religious scholars to address that self-harm inflicting people have a mental illness and they need to be given medical attention and forgiven.

Most of the data available online on suicide rates and mental illness in Pakistan is outdated. A few individual doctors or a handful of NGOs are working on estimates they gather through their own findings and methodologies. No standardised methodology for collection of data exists at the moment.

According to a WHO mental health report, the last time Pakistan’s mental health policy was revised was fifteen years ago in 2003 and the disaster/emergency preparedness plan for mental health was last revised twelve years ago in 2006. The mental health legislation was enacted in 2001 after it replaced the colonial Lunacy Act of 1912.

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In 2015, suicide mortality rate (per 100,000 population) in Pakistan was reported at 2.1, according to the World Bank collection of development indicators, compiled from officially recognised sources. WHO estimates that 24 million people in Pakistan are in need of psychiatric assistance, which makes roughly 13 percent of the total population. But according to Dr Khan’s report, almost 34 percent of Pakistani population suffers from common mental disorders and depression is implicated in more than 90 percent of suicides.

Pakistan is listed among the world’s top ten most depressed countries and it is hard to estimate if this national depression will subside if a policy is not created to deal with the issue at hand and for that, numbers are needed.