Mental health: Pakistan’s Achilles heel during Covid-19

Today, as we stand at the floodgates, waiting for the deluge of Covid-19's mental health related aftermath, we are not prepared. Pakistan’s healthcare sector has historically not invested in mental health. Stigma, lack of human resource, minimally nuanced understanding of needs, lack of disciplined efforts for advocacy, and the shortsightedness of leaders in healthcare, have led to a general apathy, under recognition, and a nonchalance towards the public's mental health needs. This will now be our undoing.

Mental health disparities exist world over; even in well-developed health systems, services are scarce, insurance reimbursement remains a constant battle, and trained mental health workforce remains under pervasive shortage. The World Economic Forum, the World Bank, and the World Health Organisation have all raised alarms about an epidemic of poor mental health. And indeed, mental illness is now responsible for the largest burden of illness globally, surpassing that of all cancers combined or heart disease. Before Covid-19, the crisis was projected to cost the global economy $16 trillion by 2030. And while these projections will change in light of the havoc the pandemic is wreaking, optimal mental health plans in most parts of the globe have largely remained a moving target.

Pakistan is in a much more dire state; and now with Covid-19 upon us, we stand on the precipice of a disaster that is sadly of our own making.

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Let’s explore some statistics. Out of 114 medical colleges in Pakistan, only a handful require competency in the subject to graduate. In most colleges, there is only one optional psychiatry question you may attempt in your final professional examination. This means that out of the approximately 14,000 doctors graduating each year, only an insignificant percentage have any meaningful knowledge or skills in screening for or managing these patients, even at a primary care level.

It is important to understand the downstream effects of this. No competency in psychiatry means that most doctors who start their small GP practices spread around the country are unequipped to see patients with mental health needs; often they fall prey to the many pharmaceutical agents who become their primary knowledge bearers. This leads to pill pushing, polypharmacy and frank malpractice. Minimal teaching also communicates a covert message that mental health is not important or simply obsolete, adding to a widely prevalent stigma of the mental health profession amongst the medicine fraternity. This stigma is a well-established phenomenon, and perpetuates shortage when it comes to the mental health workforce.

At a systems level, mental health is under-resourced and under-researched. Conservative estimates show that around 50 million people in Pakistan suffer from a mental health disorder. With only 500 psychiatrists, we are looking at a ratio of 1:100,000 patients. The state of child and adolescent mental health is starker — currently we have 5-6 trained pediatric psychiatrists, only one training programme, and over 20 million children that require trained help. If this doesn’t give us pause, try projecting these numbers in multiples, as the mental health needs of the population accelerate exponentially fuelled by the Covid-caused ubiquitous blanket of anxiety.

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Reports from all over are documenting dramatic increases in depressive and anxiety symptoms. A UK based charity focused on abuse and mental health concerns, has reported a 700% rise in calls to its helpline in one day. How do we propose to reconcile with such surges in Pakistan? The economic burden of mental illnesses in Pakistan was PKR250,483 million in 2006, which has likely already accelerated. Now, with the global economy in free fall, how are we proposing to afford this?

Studies of past epidemics have found that those on low incomes showed significantly higher amounts of post-traumatic stress and depressive symptoms, because a temporary loss of income had a greater impact. At least 38% of Pakistanis live under multidimensional poverty and more than a third below the poverty line, lending that demographic especially vulnerable to mental health trauma. With no structures and processes to carry out data tracing in a timely manner and an impending calamity upon us, it is time for swift but correct and efficient decision making to salvage the situation as much as possible as opposed to continuing to bury our heads in the sand.

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The hard hitting reality here is that a small percentage of us will catch the virus, but everyone will be psychologically impacted by it. From the uncertainty of lost jobs, furloughs, home schooling of children, isolation, loneliness, to changed work routines, increase in domestic violence and substance abuse, everything is a recipe for a differently nuanced traumatic experience. Healthcare workers are fighting an enemy that has already killed more than 200,000 people around the world, and as with any war, this fight, in addition to direct casualties, will take a toll on the minds of many who survive. Like healthcare and other frontline workers, leaders of small and large organisations are also at risk, as they make tough calls of closing down shop with implications on a number of workers and families. The emotional burden of making difficult decisions, whether to choose who gets a ventilator, or who loses their job, and having to do that again and again, has downstream repercussions on mental health. So those we would look to heal, reinvent, and reimagine our world in the post pandemic era would also have gone through emotional exhaustion, with little support available to them.

It is clear that the social, economic, and political impact of the pandemic will depend on the pre-existing cracks and vulnerabilities of a given system. With a stark dearth of trained workforce, a mushrooming increase in semi-trained professionals filling large gaps, no structured disaster response system, and an absence of a coherent national mental health plan, we have a whole canyon to reckon with. It is imperative that as we build on our capacities in research and clinical needs related to the pandemic, we do not ignore a rising peril with consequences far and beyond the rise and fall of coronavirus. We must urgently invest in short, immediate and long term action items that span across policy, training, research, and service delivery. If there was ever writing on the wall for Pakistan, this is it.