The 21st century has witnessed mental health initiatives that have highlighted the crucial nature of mental health in a well-functioning society. Mental disorders as defined by the latest edition of the Diagnostic Statistical Manual (DSM V), are characterized by disruptions in emotion, cognition, or behavior that are reflective of psychological, developmental, or biological disturbances.
Pakistan, as a Nation, has ineffectively attempted to grapple with the categorisation and holistic treatment of those who suffer from disorders. There is a definite stigma associated with suffering from a mental disorder. Pakistan will only progress when it begins to recognize those that suffer from mental issues.
In order to tackle the evident stigma, there needs to be a basic understanding of what mental illness is. Raising awareness is the primary step in setting Pakistan on the path to providing its citizens better care and treatment.
Types of Mental Disorders
A common misconception about Bipolar Disorder is that those that suffer from it experience great bouts of excitement and happiness that subside into depression and melancholia. In actuality, bipolar disorder, depending on which type it is (I, or II), is characterized by periods of mania that can last weeks or months. During this period, an individual is more excitable and has increasing amounts of energy. This manic period is often associated with a lot of activity. Often people can become very creative during these periods, and also very productive. However, the dangers of those who are suffering from manic episodes is that they may engage in risky behavior without considering the consequences. Eventually, the manic episode ends, and a more difficult period of depression arises. This period can last for months depending on the individual.
When considering treatment for such an individual, one needs to be trained and aware that this individual is not just depressed. A depressed individual, or someone suffering from unipolar depression, ranges in severity. Some people can battle depression in their day-to-day lives while there are those whose pain may reach a point where they begin to have suicidal thoughts. The worst thing society as a whole can do is ignore the plight of these people. Majority of the time, those suffering from depression do not reveal that they are suffering due to fear of how their families and society would treat them. The anxiety of hiding their suffering often exacerbates the situation.
Probably one of the most devastating disorders is schizophrenia. This illness typically rears itself in early adulthood and its root causes are unknown. However, there seems to be a palpable genetic component, and this illness may manifest if an individual experiences great amounts of stress.
Schizophrenia is characterized by varying degrees of positive symptoms (symptoms that are active in nature), such as hallucinations and delusions. It is also marked by negative symptoms (absence of qualities), like anhedonia, catatonia, and a general blunted nature. Schizophrenia is representative of the state of psychosis in that a very clear disruption of reality can occur.
Often those who suffer from schizophrenia are assumed to be cursed/a victim of ‘kala jadoo’ (black magic). A lack of education about the treatment for schizophrenia as well as the lack of funds for those who seek treatment, is a fundamental problem. Schizophrenia often requires medications as well as social support in order for the illness to be better treated.
In addition to the aforementioned disorders there are several other disorders, such as, obsessive compulsive disorder, social anxiety, post traumatic stress disorder, and autism. There is no single way of treating these disorders. They vary in their degrees of intensity and the types of treatments that are required.
There first needs to be a basic awareness of the existence of mental health and the types of disorders. Secondly, those in official positions must address the overwhelming stigma towards those who suffer from such ailments. Finally, specialised treatments and programs need to implemented that cater to a patient’s needs and the nature of the illness.
A Biopsychosocial understanding of living with Mental Illnesses
In order to understand the onset of mental illness, it is necessary to understand how stress can be a trigger. Social pressures and demands can increase stress on individuals. This stress causes the release of cortisol, a hormone, that increases the fight or flight response resulting in agitation. Chronic stress, especially as a result of incomplete psychological needs such as love or security, can result in psychological or physical problems/illnesses.
Just like increased stress can cause medical problems , such as an increase in blood pressure and thyroid problems, it can also cause the onset of mental disorders. Biology and the environment both have a dynamic and interactive approach in shaping the external and internal aspects of an individual.
Awareness and education programs need to teach a biopsychosocial approach to dealing with mental illness. Living in the middle or lower class in Pakistan can often mean being exposed to many stressors, and therefore treatment and education about dealing with stress is paramount.
The few acts as revealed by figure 1.1 show the discrepancy in addressing mental health reform in Pakistan. From the 1912 Lunacy Act in British India to the 2001 Mental Health Act, there was little legal action taken to address the need for proper procedure and treatment of the mentally ill.
The Mental Health Ordinance of 2001 finally took some strides in addressing mental health reform in a modern society. It focused more on providing treatment and management of illness than the previous statute. In addition, the 2001 ordinance sought to reduce stigma by referring to people as ‘mentally ill’ as opposed to ‘lunatics’.
Another reformation within the 2001 ordinance was the inclusion of ‘informed consent’. This type of consent occurs when an individual or their family is debriefed about the risks and advantage of seeking a particular treatment. This option was not necessarily given to individual’s prior to the 2001 ordinance.
The enactment of the Sindh Mental Health Bill in 2012 was to reiterate the points mentioned in the 2001 ordinance. However, there were special clauses to address when its appropriate to enforce treatment on individuals and when it is necessary to respect individual rights.
Fortunately for Pakistan, there is an existing mental health policy first formulated in 1997. This policy aims to offer counseling services, rehabilitation, and teaching modules to educate people. The policy also trains individuals seeking to help those suffering from mental illness by being trained in crisis intervention. In addition, there are also special programs for those engaged in substance abuse.
The enactment of the policy program involved two phases. The first phase included general information units and training personnel to be better educated about mental illness and intervention. It also involved the establishment of institutions and models of rehabilitation. The second phase focused on legislative features and indicators like crime rates and statistical and demographic data. It also emphasised an increase in research and a focus on how to better existing models of care.
Problems with Existing Policy
It may seem like there are already structures in place that address issues associated with mental health. However, there are key improvements that need to take place to increase rehabilitation and decrease the plight of those suffering from mental ailments.
In order to better understand how to allocate resources and attention there needs to be better collection of information.
The existing data and statistics on mental illness are lacking. Consequently, there needs to be better collection of census data to see which disorders are prevalent amongst specific populations and groups within Pakistan.
Policy development needs involvement from local and international parties on effective implementation of programs. Research on successful international mental health programs may prove fruitful when modified with existing structures.
Future Focus & Goals
1) Stigma reduction
The concept of seeking help and admitting to having a mental ailment is severely looked down upon in Pakistani society. Admitting to having a mental illness is not only seen as a weakness but as a fundamental flaw in one’s character. Pakistani individuals often view those suffering from mental illness as a reflection of their upbringing. In addition, those with mental illness are treated as if the manifestation of their illness is proof of their weakness and bad character.
In order to better provide treatment and begin more open discourse about how to better help those with mental illness, Pakistani society needs to take an inward glance upon itself.
Policy makers and media companies need programs to address how mental health is just as paramount as physical health. There also needs to be an open discourse about the taboo of admitting to having mental illness in society.
Stigma reduction needs to be a primary focus of future programs. This can be achieved through public awareness programs about specific disorders. This can occur through placement of stalls at universities and schools. Alternatively, it can also be achieved through distribution of pamphlets or posters.
Stigma reduction will occur through public discourse on the acceptability of seeking treatment. Those who are living with a disorder in modern Pakistani society need to know that they are publically supported.
2) School wide Education
Education in Pakistan is something that needs further investment. When looking at education through the mental health lens, it only makes sense that schools should be the first place to enact change.
Many disorders such as bipolar disorder and schizophrenia manifest themselves during and post adolescence. It could be beneficial to include a section on brain disorders and mental health in existing school curriculums.
This will allow future generations to become more aware of the symptoms associated with mental illness. Implementation of such programs in a school setting will enhance the likelihood of seeking treatment or recognising the need to help someone else.
3) Research Funding
The field of mental health is constantly updating and unfolding upon itself. Research across the world is shedding light on the root causes and treatments for disorders, such as schizophrenia and autism.
In order for Pakistan to make strides in mental health reform there needs to be support for Clinical Psychologists and Neuroscientists. With funding and financial backing these researchers can seek to uncover more about mental illness in the context of Pakistani society. Pakistani universities and hospitals should be recognised and considered when offering funding for medical programs. As essential as physical health funding is, so should psychological and neurological concerns.
4) Special Programs
Offering treatment to those with mental disorders is often more complex than it seems. Those with specific disorders vary in and amongst themselves. Symptoms that may be present in one individual may be absent or uncommon in another.
In reference to the biopsychosocial model, an individual varies in terms of different social pressures and environmental backgrounds. When offering treatment in terms of long term rehabilitation, it may make sense to consider a holistic treatment catered to individuals.
Pharmacological and behavioral therapy works best when it is specific to an a specific person’s physiology and personality.
If for example, an individual with bipolar disorder seeks treatment, some medications may react better than others. Consequently, it may be beneficial to have more specialised practices and centers based on specific mental illnesses. The specialisation of the subfields within mental health will create greater focus and improve quality of treatment.
Though much has yet to be achieved, Pakistan does have an existing policy that can be altered and enforced to create change. There is progress taking place in Pakistan and NGOs that work towards supporting those that suffer from mental health issues. Some of these institutions include, Pakistan Association for Mental Health, Karwan-e- Hayat, and Edhi Destitute Home Habitats for the Mentally Ill.
However, in light of daily stressors, political instability, and civil inequality, there is a palpable effect on the mental health of the Pakistani nation. Awareness campaigns and specialised treatments cannot be limited to the major cities.
Mental health will become more paramount to Pakistani society when education and social change is given precedence over other civil concerns.
By: Rozemun Khan