May 2006, Volume 56, Issue 5

Editorial

Mental Health in Pakistan: Where do we stand?

Amin A. Muhammad Gadit  ( Department of Psychiatry, Memorial University of Newfoundland, St. John's, NL A1B 2A3, Canada. )

Mental health in Pakistan has remained a subject of debate since the last few years. The incidence and prevalence have both increased tremendously in the background of growing insecurity, terrorism, economical problems, political uncertainty, unemployment and disruption of the social fabric. 1 Sinking below poverty line by almost 39% of the individuals is an alarming factor worth noting. Many people are now presenting to psychiatrists probably because of the growing awareness through the good work of media. Though there are many things which can be done to improve the mental health of the people in the areas of social environment, economic improvement and political harmony etc. but the important subject for debate is that, how far we are in the areas of education, service and research related to mental health having direct impact on the patient population. From 1947 to 2005, almost 58 years have passed since the independence of the country and many countries with this age have done wonders in overall upkeep of health care and specially the mental health. The scenario though is improving, but is it at the required pace? If we first take the area of education by virtue of which we train our future doctors who in turn can become navigators helping us in sailing smoothly through the heavy storm of up surging mental illnesses, we find lacunas which are evident when it comes to ultimate care of patients. With the exception of very few institutions, the subject of behavioral sciences which has been introduced by the PMDC in the early years of medical teaching is not being taken serious enough, low number of behavioral scientists cannot alone be blamed for this, there are no structured rotation programmes for senior medical students which means a calendar indicating topics, patient sessions, log book and evaluation strategy with weightage in the final year marking system. Low interest by students in the subject of psychiatry despite few institutions' model teaching/training programme is understandable in view of no separate paper in psychiatry and very low representation in the paper and clinico-orals of the subject of General Medicine. Regarding the departments, are we fulfilling the international requirements of a good department of psychiatry with full-fledged faculty in all hierarchies? The answer is simply 'no'. Regarding the postgraduate education, how many recognized centers follow structured programmes emphasizing adequate patient exposure, ongoing continuing medical education programmes, research, exposure to subspecialties like, child, geriatric, forensic and rehabilitation psychiatry etc., is there a rural exposure, is there training in cultural issues, is there emphasis on liaison service and multidisciplinary team approach, is there a standard methodology for continuous monitoring and evaluation with resultant weightage in postgraduate exit examinations, is there training in audit and psychiatric administration, the answers to most of these questions will remain unanswered nationally. It is precautionary not to say a word about the selection criteria of evaluators and examiners lest it is not politically biased and motivated. It is also worth noting that during postgraduate training how many of the prospective specialists are monitored and assessed for culturally relevant mental state examination, adequate case note management, observation of prescribing practices and its justification, communication skills, ethical behavior and understanding.

Once certified, there is no provision of higher specialist training for a period of at least three years on the pattern of UK with evaluation of practice-based efficiency, infact, the UK model is worth adopting. 2 There is no trend for CME credit maintenance and hence no programme specifically designed for psychiatrists though there are many such programmes for the general practitioners of course with no condition of maintaining credit certification, this is mostly prompted by the pharmaceutical companies with a view of improving sale as evidence has shown that the knowledge of even the most common disorder depression was not adequate among general practitioners. 3

When we come to service, though the major teaching hospitals have established separate departments of psychiatry but in most of the cases they are not well equipped specially in terms of psychiatric manpower both skill and number wise. Still Pakistan has very low number of psychiatrists and these too are continuously being drained by the developed countries especially by the western world where they are being offered an attractive package and lifestyle that the question remains as to who comes back and serves the nation. 4 It is not surprising that there are a large number of Pakistani psychiatrists in United Kingdom, United States, Canada, Australia and New Zealand apart from those in Middle East, Africa and South East Asia. It seems that soon we shall become a psychiatrists exporting region like our neighbour India thus causing further deepening of the problem related to the already existing scarcity of psychiatrists. 5 Also, at the same time it is vitally important to abolish the feudal psychiatry which fortunately is being eroded by young generation of psychiatrists. There is also acute shortage of allied mental health professionals. In view of poverty, low health budget, high cost of medicines there is huge economic burden on the patients. 6 The hospitals also don't follow the intake/admission criteria, no separate unit for subspecialties, no appropriate long stay units, no exit/discharge criteria, no rehabilitation services, no exchange of information between psychiatrists and family practitioners, no proper advertisement of available services, no concept of day centers, day hospitals, ill developed community services, no central registry of patients and set policy for management systems in the psychiatric set ups and finally no internal referral system.

As far as research is concerned, there is still low representation in local accredited journals and very low in international journals. 7 Though there has been an increase in lay and scientific write-ups recently but it is still far from satisfactory state. Papers are produced for promotions and that too are for the sake of papers, matter of keeping up standards are ignored. The Journal of Clinical Psychiatry published regularly from Lahore once upon a time disappeared eventually. The first journal of Pakistan Psychiatric Society called JPPS was published in the year 2003, which was blocked politically and was not reproduced again.

It appears that still we are far behind in achieving the standards and in order to improve the existing scenario some steps are essential. In order to bring improvement in psychiatric education, it is important to pay emphasis on the subject of behavioral sciences, design an appropriate undergraduate training program in line with one of the international modules, inculcation of research interest among medical students, either introduction of a separate paper of psychiatry or at least 25% of weightage in the paper of medicine, at postgraduate level more structured training program with exposure to subspecialties, designing a postgraduate curriculum and module, introduction of audit of training and performance, provision of higher specialist training at the level of specialist registrar, private-public partnership in provision of services, mobilization of more resources for mental health and maintaining of records. There is a need for development of research culture especially in the areas of need assessment is also necessary. Along with these efforts the medical fraternity can force the government to allocate a higher budget, reduce poverty, bring social justice and harmony, improving political scenario.

It is also advisable to create better incentives for the mental health professionals in order to avert brain drain. Efforts for providing a conducive environment to the public to help in promoting sound mental as well as physical health is imperative.

References

1. Gadit, A., Vahidy, A. Mental Health Morbidity pattern in Pakistan. Jour Coll Physicians Surg Pak, 1999;9:362-5.

2. Royal College of Psychiatrists. Higher Specialist Training Handbook 1998, review 2001.

3. Gadit, A., Vahidy, A., Knowledge of depression among general practitioners, J Coll Physicians Surg Pak 1997;7:249-51.

4. Khan MM. The NHS International Fellowship Scheme in Psychiatry: robbing the poor to pay the rich? Psychiatr Bull 2004;28:435-7.

5. Khan MM. The International Fellowship Scheme. Letter to Editor. Psychiatr Bull 2004;28:433-4.

6. Gadit AA Out of pocket of expenditure for depression among patients attending private community psychiatric clinics in Pakistan. J Med Health Pol Econ 2004;7:23-8.

7. Patel V, Sumanthipala, A. International representation in psychiatric literature and survey of six leading journals. Br J Psychiatr 2001;178:406-9.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: