"If only my anguish could be weighed and all my misery be placed on scales….it would outweigh the sand of the seas" Job 6:2

A vivacious young art student leaps to her death from the 4^th floor of her university.

A distraught medical student takes an overdose and dies after failing a class.

A young model is found dead, hanging from the ceiling fan in her room at home.

These are not figments of my imagination. These are real people whose tragic deaths made headlines within the last year. I see patients struggling with suicidal ideation every day in my hospital or clinic.

Pakistan is not a good place to be depressed. Help is hard to find and stigma is everywhere. Despite a flurry of activity on the topic of mental health and suicide in the last couple of years, the facts speak for themselves. According to WHO estimates, the rate of completed suicide in Pakistan is around 7.5 people for every 100,000. In any given year, that translates to around 13,000 people a year who die by their own hand, often due to lack of available mental health care. ‘Attempted suicides’, where a person tries to kill him or herself but does not succeed, number much higher.

It is perhaps fitting then that World Mental Health Day, observed every year on October 10, bears as its theme for 2019 Focus on Suicide Prevention. WHO’s website says the overall objective of World Mental Health Day is "raising awareness of mental health issues around the world and mobilizing efforts in support of mental health": Which sounds great until you realise that talking to a destitute mother of four about mental health is an obscenity because how exactly is she supposed to improve her mental health when her daily wage labourer husband hasn’t worked for a month and she barely feeds her children by cleaning people’s houses?

In short, talking about mental health in a country like Pakistan is, well, complicated.

Research indicates that suicide is a leading cause of death in young people, invariably the 2^nd or the 3^rd leading cause, depending on the country and the research you are talking about. Whether it is 2^nd or 3^rd is, of course, immaterial since a single suicide is one too many, and Pakistan, with it’s demographic ‘youth bulge’ is at special risk. A lot of attention has been focused in the last two years on young people, especially on college and university campuses, attempting or committing suicide. This has been driven in part on cases like the ones outlined above. A single student suicide can traumatise dozens of other people: friends, onlookers, first responders, teachers, parents and many others. But there is another insidious epidemic of suicide that stays hidden. Young people are dying but no one is noticing because they are poor and, like poor people everywhere, largely voiceless.

Suicide attempts regularly present to the emergency department of Pakistan’s biggest and oldest hospital, Mayo Hospital, in Lahore (where I work). These individuals are often young, unmarried girls, mostly from poor families in rural areas who present after ingestion of various substances. Two common substances are the highly toxic aluminum phosphide known colloquially as ‘wheat pill’ since it is commonly used as a fumigant for stored cereal grains, and various household chemicals which have corrosive properties.

‘Wheat pill’ poisoning can be rapidly fatal due to profound shock and multi-organ failure while corrosive ingestion can result in severe chemical burns in the mouth, esophagus, and GI tract which can lead to permanent disability. Despite the seriousness, such patients, if they survive, are discharged with no psychiatric referral or assessment. I have first-hand experience of multiple cases of corrosive ingestion being treated as outpatients for long-term GI complications without a psychiatric evaluation. In one instance, a young woman who overdosed and was intubated received psychiatric treatment only because her sister was a trainee at the same hospital and called the psychiatry team. The patient went on to make a full recovery.

Resource-starved countries like Pakistan spend miniscule portions of their national budget on health, of which an even smaller proportion is spent on mental health. Psychiatrists, psychologists, mental health nurses and counselors, substance abuse therapists are all in critically short supply.

When I gave up a lucrative psychiatric career in the USA to come back to Lahore, many people thought I was crazy. I still get regular calls and emails from the USA to come work there since psychiatric practitioners are needed everywhere in the world.

Also read: "In Pakistan, mental health has never enjoyed parity with physical health"

So, what is the solution?

One possible remedy for students is peer counseling which the students of our university have experimented with quite successfully. The Zain Haq Counseling Program (ZHCP) set up to commemorate one of our former students who died young is now in its 3^rd year and going strong. The programme is student-led and run, and provides a platform for students who have an interest in mental health to reach out to their peers who may be struggling through open mike sessions, poetry slams, art competitions and various other activities. Our students have given presentations and talks about the programme at many educational institutions all over Lahore and also, by invitation at the Aga Khan University in Karachi. The beauty of a peer counseling program is the minimal resources required to run it and the fact that many students will often talk more willingly to their friends and class fellows than to a mental health professional.

For cases like ‘Wheat pill’ poisoning, a simple ban on its sale without the appropriate licence or authorisation would help greatly. India, Bangladesh and Korea, among others, have drastically cut their suicide rates by enacting bans or restrictions on the sale of agricultural chemicals.

Those of us in academia are working hard to educate and train the next generation of mental health professionals of course but even here, resource constraints are a continual problem. Faculty is difficult to find and retain and support staff is non-existent. We have taken steps to overcome this problem by engaging community mental health professionals, those not in academics full-time to serve as part-time and adjunct faculty. Tele-mental health is another service that is woefully underutilised in the public sector although most therapists and some psychiatrists (including me) offer online services that allow us to expand our reach.

We have a long way to go, both to help those with mental health issues and also, as a corollary to work on creating a more just and equitable society but every time October rolls around, we are reminded both of the progress we have made and the road still to be travelled.

The writer is a psychiatrist and a faculty member at King Edward Medical University, Lahore. He taught and practiced psychiatry in the United States for 12 years.

He tweets @Ali_Madeeh