Pakistan Reader# 216, 28 September 2021
Socio-economic pressures, limitations of healthcare sector, and lack of institutional mechanisms fuel the mental health crisis in PakistanApoorva Sudhakar
On 10 September, Pakistan observed the World Suicide Prevention Day and the National Centre of Research on Suicide Prevention was established in Rawalpindi. This was reportedly the first organisation to be established in Pakistan, aiming to contribute to policy-making and preventing suicidal tendencies, through research-based information.
The debate around suicides and mental health has gained importance over the year, especially during the pandemic and after the rise in cases of abuse and sexual assault in different parts of Pakistan. According to the report, State of Human Rights in 2018, by the Human Rights Commission of Pakistan (HRCP), the country witnessed 1,338 suicides in 2018, of which 786 victims were men and 552 women. The report cited the Pakistan Association for Mental Health (PAMH) which said that Pakistan was turning into an increasingly depressed country, with every fourth household having a problem relating to mental health. The PAMH said of the total number of people who suffered from mental health problems (unspecified in the report), 25 per cent suffered from depression and the number of women suffering from depression was double that of men.
Mental health in Pakistan: A brief background
Suicide is likely to be one of the larger and visible expressions and indicators of a mental health crisis within a person and the society. However, suicides are linked to disorders like psychosis, depression, psychiatric disease, and substance use disorders. Other psychotic disorders which come within the purview of mental health include schizophrenia and sexual disorders. The News International cites estimates which say that around 50 million people in Pakistan undergo some form of mental disorder and that 36 per cent of the population suffers from anxiety and depression.
The HRCP report suggests that poverty, injustice, crime, socio-economic issues, family pressure, and crime are some of the reasons driving the mental health crisis in Pakistan. Similarly in the case of suicides, in a recent survey conducted by Dawn, on the drivers behind suicides in the country, respondents believed financial troubles and mental health were most likely to lead a person to take their own life.
The case study of Sindh
A study conducted by the Sindh Mental Health Authority, paints a larger picture wherein between 2016 to 2020, the province witnessed 767 suicides; of this, 462 were men and 301 women. Moreover, 6.1 per cent of the suicides were recorded in the 10-15 age group, and 13.9 per cent in the 16-20 age group.
The highest number of cases recorded in Tharparkar district; here, 79 people died by suicide, 60 per cent of them teenagers. Tharparkar also accounted for highest number of female suicides with 48 cases while 31 cases of suicide by men was recorded; of this, 60 per cent of the females were housewives and 40 per cent of the victims belonged to low-income groups, mostly engaging in unskilled labour, and worked as peasants, daily wagers and owners of small-scale businesses. The study was criticised and termed unrealistic, and experts believed the figures were largely underreported.
In a follow-up study in 2021 in Tharparkar, it was revealed that most suicides were linked to poverty, low incomes and untreated mental illness. In Tharparkar, 24 per cent of the 79 victims were undergoing some mental illness; nine per cent were indebted; 60 per cent of the victims belonged to the 10-20 age group; 36 per cent in 21-30 age group; nine per cent in the 31-40 age group; and five per cent were aged 41 and above. The study observed that 60 per cent females were housewives and 40 per cent of the victims belonged to low-income groups, mostly engaging in unskilled labour, and worked as peasants, daily wagers and owners of small-scale businesses.
This brought forth the larger socio-economic divisions within the country and its impact on mental health. In the Dawn survey mentioned previously, 28.9 per cent of the 5157 respondents said seeking remedies for mental health problems is not affordable by all.
Driving the mental health crisis: Institutional issues
Apart from the social stigma and economic drivers of mental health, Pakistan witnesses a lack of understanding of the issue from the government and other healthcare sector limitations.
First, the apathy from the authorities. In May, the Punjab Police initiated an online campaign reportedly aimed at building awareness about mental health and suicide prevention. However, the poster shared by the Punjab Police read that if a person survived their attempt to die by suicide, they would be imprisoned for up to one year. The Twitter audience reacted to the campaign and many claimed that the police were implying that instead of offering support to a person in need, the initiative implied that if they attempt to take their life, they better succeed, thereby reflecting an apathy from the police and concerned authorities.
Second, the criminalisation of suicides. There is a larger debate in Pakistan on the need to decriminalise suicide. Section 325 of the Pakistan Penal Code classifies suicide as a criminal offence. Therefore, an attempt to die by suicide is punishable with “simple imprisonment for a term which may extend to one year, (or with fine, or with both).” This, however, does not act as a deterrent, rather hinders people from seeking out help when required.
Third, the under-equipped healthcare system. The healthcare system in Pakistan is limited with regard to mental health services. According to the World Health Organisation (WHO), Pakistan has one of the least number of psychiatrists at a mere 0.19 psychiatrists per 100,000 inhabitants, which is less than 500 mental health professionals in the entire country. Further, the average number of beds for mental health patients in Pakistan is only 1.7 per 100,000 population. Asma Humayun, a consultant psychiatrist, says that 75 per cent of Pakistanis who suffer from mental disorders are not receiving treatment.
Fourth, the lack of regulation. Adding to the above issue is the rise of unregulated mental healthcare and the lack of regulation to quality of services provided by independent practitioners in the public as well as private sectors. After the Noor Mukadam murder and reports surfaced that the accused had reportedly worked as a counselor, the Pakistan Psychiatric Society (PPS) called on the government to address the mushrooming of unregulated mental health services.
Fifth, the role of religion and faith. A large section of the population relies on religion and faith as a solution to mental disorders. Anxiety, schizophrenia and other disorders are perceived as possession by a supernatural being. In these cases, people resort to seeking advice from faith healers, thereby depriving the person from actual treatment.
Responding to the crisis: The State strategy
First, the delay in decriminalising Section 325. In 2017, the Senate and the Council of Islamic Ideology unanimously adopted a bill to decriminalise Section 325; the bill could not be passed in the National Assembly as it lapsed with the end of the previous government’s term.
Second, slow progress in implementing Mental Health Acts. Pakistan is also signatory to the WHO’s Mental Health Action Plan 2013-2030; however, as is evident, progress has been slow and limited. Mental health is seldom seen as an immediate concern. For example, Sindh, Punjab and Khyber Pakhtunkhwa passed their own Mental Health Acts in 2013, 2014 and 2017 respectively. However, in Sindh, the Mental Health Authority was formed only in October 2017. This was the case in Punjab and Khyber Pakhtunkhwa as well.
Despite the challenges and hindrances, the expansion and frequency of the discussion on mental health serves as an opportunity for Pakistan to gear up and bring a holistic change to address its mental health crisis.
Afshan S Khan, “Centre for research on suicide prevention established in Rawalpindi,” The News International, 13 September 2021
Zahra Khalid, “Peanuts for mental health,” The News International, 22 August 2021
“Mental healthcare,” The News International, 26 July 2021
Atika Rehman, “Pakistan’s silent suicide problem,” Dawn, 31 December 2020
“The Punjab Police teach us a lesson on how not to discuss suicide prevention,” Dawn Images, 22 May 2021
Rabeea Saleem, “Decriminalisation will lead to suicide prevention. It's high time Pakistan repealed Section 325, a British Raj remnant,” Dawn, 4 September 2021
Dr Rafi Amir-Ud-Din, “Dispelling myths about mental health,” The News International, 16 February 2020
Shahina Maqbool, “Pakistan Psychiatric Society: Crackdown on unregulated mental health centres demanded,” The News International, 26 July 2021
Asma Humayun, “Time to invest in mental health,” Dawn, 29 July 2021
Rafia Zakaria, “Mental illness and possession,” Dawn, 3 February 2021
“State of Human Rights in 2018,” Human Rights Commission of Pakistan, Government of Pakistan, March 2019
Faiza Ilyas, "Thar tops in suicide cases, moot told," Dawn, 26 March 2021
Imtiaz Dharani, "New study reveals 60pc suicide victims in Thar were teenagers," Dawn, 24 August 2021