Mental Health

[ghazi52]

Mental healthcare is too important to be left to psychiatrists or psychologists alone​

The WHO Thinking Healthy manual is based upon research conducted in Pakistan.

MENTAL healthcare is too important to be left to psychiatrists or psychologists alone. In low-resource settings like ours, unaddressed mental health issues are growing at an alarmingly high rate and there are just not enough specialised mental health experts.

Around 1,000 psychiatrists and 3,000 psychologists in a country of 240 million-plus people cannot possibly deal with this burden of disease. Specialist mental health care, by both psychiatrists and psychologists, is too expensive, inaccessible, and inefficient. Psychology practice is not even regulated. Sadly, a somewhat similar situation exists in most low- and middle-income countries (L&MICs).

For an acute depressive episode, for example, either antidepressant medicines are prescribed or psychological therapy is provided. There is growing evidence now that psychological treatments outperform medication on the important outcome of keeping people well in the longer term following an initial episode. But how many people can access psychotherapy? The majority are irrationally prescribed anti-depressants, which are also used irrationally.

Due to an extreme dearth of specialists, mental health researchers have developed a number of evidence-based psychological interventions for non-specialised settings employing a task-shifting approach. A former colleague at the World Health Organisation (WHO), Dr Shekhar Saxena, spent years studying, analysing and selecting such interventions with mental health researchers around the world.

Then, with the help of a large and diverse group of experts, Dr Saxena managed to put together a mental health gap intervention guide (mhGAP) in 2010. The second version of the WHO mhGAP Intervention Guide was published in 2016. It spanned interventions for depression, psychosis, epilepsy, child and adolescent mental and behavioural disorders, dementia, disorders due to substance use, self-harm, suicide, and other significant mental health complaints. This work serves as an important milestone in mental health care in L&MICs.

The WHO Thinking Healthy manual is based upon research conducted in Pakistan.

The mhGAP Intervention Guide refers to Thinking Healthy: A Manual for Psychosocial Management of Perinatal Depression, which was produced by WHO in 2015 as the first of a series of manuals created as an extension of mhGAP. It describes evidence-based, effective psychological interventions to address perinatal depression.

Depression is about 50 per cent more common in women. Globally, one in four to five women suffer from pregnancy-related depression — perinatal and postnatal depression, the prevalence of which would be even higher in Pakistan. A depressed mother has serious consequences for child care and development. Sixty-five per cent of adult mental disorders have their origins in childhood and adolescence.

The WHO’s Thinking Healthy manual is based upon research conducted in Pakistan, led by Dr Atif Rahman and his team under the auspices of the Human Development Research Foundation located in a rural setting close to Mandra, a small town on GT Road near Rawalpindi.

The foundation was set up by Dr Rahman, an accomplished psychiatrist and mental health expert who divides his time between Pakistan and the UK. As a professor of Child Psychiatry & Global Mental Health at the University of Liverpool, he has quietly made significant contributions to the field of mother and child mental health in L&MICs.

The Thinking Healthy Programme is based upon psychological intervention — cognitive behaviour therapy (CBT) — which was tested in one of the largest randomised controlled trials to be conducted in the developing world. This research was undertaken in 40 union council clusters in rural Rawalpindi.

Nine hundred depressed pregnant women in their third trimester, and living in poor communities, were identified and THP was administered to 463 of them. From pregnancy to one year postnatal, these mothers received eight to 16 sessions of psychological treatment. They were followed up, evaluated, and compared to 440 depressed pregnant women in the control group.

The results were astounding. In a poor rural community with hardly any access to mental health care, the integration of CBT into the routine work of trained community health workers more than halved the rates of perinatal depression among the women compared to the control group, and these positive effects were sustained later in life.

THP includes simple CBT strategies aimed at identifying and modifying maladaptive styles of thinking and behaving that lead to poor self-esteem, inability to care for infants, and disengagement from social networks.

These are substituted with more adaptive ways of thinking and behaving. Behavioural activation is employed to rehearse more adaptive behaviours, such as self-care, attention to diet, and positive interactions with the infant between sessions. Women are also guided in problem-solving to overcome barriers to practising such strategies.

The research also showed positive results in the infants of these mothers through higher rates of immunisation and fewer episodes of diarrhoea. They were also likely to use contraception and both parents reported spending more time playing with their infants.

After its adoption by the WHO, THP has been implemented in more than 30 diverse countries including China, Vietnam, India, and Peru. The programme is extremely cost-effective. Community health workers require a brief training period of only five days. The programme has even trained peer counsellors such as women selected from the same community.

The challenge, however, is scaling it up to a national level whilst maintaining its quality. Dr Atif Rahman and his team are continuing this work on these lines through innovative uses of technology. A school mental health programme has also been developed and tested for its effectiveness.

I was motivated to write this article when recently in a mental health meeting one participant referred to the WHO Thinking Healthy Programme. When asked if she knew that this WHO programme was developed on the basis of research conducted in Pakistan by Pakistanis, she said she didn’t know!

Readers who want to know more about the THP can google the above-mentioned resources and can also download an interesting article recently published by Vikram Patel and Atif Rahman in the Journal of the American Academy of Arts and Sciences, entitled ‘Empowering the (Extra)Ordinary’.

The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University, WHO adviser on UHC, and member of the Pakistan Mental Health Coalition.

[email protected]

Published in Dawn, December 15th, 2023

 

[RescueRanger]

Great article, I have worked with an excellent NGO called ROZAN in Pakistan on this aspect for what is called "PsychoSocial First Aid" or "Mental Health First Aid".

You can learn more of ROZAN's work here:

What We Do - Rozan

Rozan’s approach is holistic, and interventions are framed from a prevention (awareness-raising, mobilization, skills-building), protection (law enforcement, service delivery, and… more

rozan.org

I wrote a detailed article on the original PDF which I will re-post here:

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There is no health without mental health​

Continuing from my series of articles on First Aid, today's article is going to be focusing on mental health and simple first aid tips you can use for yourself or to help others, as always, feedback is really appreciated. Thank you.

About mental health
We all see friends and loved ones going through rough times, but sometimes what we’re witnessing is a developing mental health problem, or a mental health crisis. In preparation for these times, we can learn to provide what’s known as ‘mental health first aid’.

What is mental health first aid?
Mental health first aid is the help you give to someone developing a mental health problem, experiencing a worsening of a mental health problem or in a mental health crisis.

You can give this first aid until the person has received appropriate professional treatment or the crisis is resolved.

Mental health first aid can help people experiencing:

• depression
• anxiety problems
• psychosis
• substance use problems
• eating disorders
• gambling problems.

It can also help if a person is experiencing a mental health crisis, such as:

• suicidal thoughts and behaviours
• non-suicidal self-injury (sometimes called deliberate self-harm)
• panic attacks
• traumatic events
• severe psychotic states
• severe effects from alcohol or other drug use
• aggressive behaviours.

More than 20 million Pakistanis (10% of the country’s population) suffer from some form of mental health condition. That means every person is likely to know someone who is experiencing a mental health problem, whether it is a family member, a friend or colleague.[1]

Know the signs:

The first step in providing mental health first aid is understanding the signs and symptoms of an emerging or worsening mental health problem. Only a trained professional can diagnose someone with a mental illness, but you can be aware of changes in a person’s mood, behavior, energy, habits, or personality. These changes may be the sign of a mental health problem.

Some symptoms that may indicate a serious problem include:

• bizarre or unusual thinking
• hallucinations, such as hearing or seeing things that aren’t there
• extreme mood changes
• restless, agitated and disorganized behavior
• marked decrease in activity
• difficulty concentrating
• significant drop in performance at work or school
• significant withdrawal from friends and family
• neglecting self-care (such as neglecting personal appearance and hygiene, and eating poorly)
• suicidal thoughts or behaviors
• non-suicidal self-injury (deliberate self-harm)
• destructive or high-risk behavior
• confusion and disorientation
• emotional outbursts
• sleep problems
• weight or appetite changes
• being quiet or withdrawn
• substance use problems
• feelings of guilt or worthlessness
• changes in behavior or feelings that have lasted for longer than 2 weeks.

Having one or 2 of these symptoms usually doesn’t indicate a mental illness, but if a person is exhibiting several symptoms, they may need professional help (particularly if the symptoms have lasted for some weeks or they’re impacting their usual activities, such as work, school or relationships). Don’t ignore signs or symptoms that you notice in others, and don’t assume they will go away. And remember not everyone will show the same signs and symptoms.

Approach the person

• Give the person a chance to talk to you. If they don’t open up to you themselves, and you are concerned about them, initiate the conversation. Be open and honest about your concerns about their mental health.
• Make sure you approach the person in a comfortable space and at a time when you won’t be interrupted.
• Speak from your own perspective. Use ‘I’ statements, such as ‘I have noticed…’ and ‘I feel concerned about…’ rather than ‘you’ statements, such as ‘You seem to be withdrawn…’ or ‘You’re not eating and sleeping…’.
• Say you’re concerned and you’re here to help.
• Respect the person’s own interpretation of their symptoms.
• If the person doesn’t want to talk to you, encourage them to talk to someone else they trust.

Be supportive

• Use phrases that will help the person feel listened to, understood and hopeful. Some examples are ‘I’m here for you’, ‘I can see this is a really hard time for you’, and ‘What can I do to help? Just tell me how’.
• Show the person dignity and respect.
• Don’t blame.
• Be consistent in your emotional support and understanding.
• Encourage the person to talk to you or someone else.
• Listen well.
• Give the person hope for their recovery.
• Find accurate and appropriate resources for more information if the person wants it.

Know what’s not helpful
Sometimes even with the best intentions, we can make matters worse. When reaching out to someone you suspect might have a mental health problem, avoid:

• telling them to ‘snap out of it’ or ‘get over it’
• being hostile or sarcastic
• getting over-involved or over-protective
• nagging
• trivializing their experience (for example, don’t tell them to smile or get their act together)
• belittling or dismissing their feelings
• being patronizing
• trying to cure them or solve their problems.

Encourage someone to seek help for a mental health problem
Ask the person if they need help to manage how they’re feeling. If they want help, a good place to start is a visit to their GP. You can also chat to them about their options, particularly local and online services. Encourage them to act on their options.

If the person doesn’t want help, try to find out why. They may have some mistaken beliefs about getting help or their options. Try to help them feel better about seeking help.

If the person still resists help, tell them they can contact you if they change their mind. Respect their right not to seek help unless you believe they are at risk of harming themselves or others.

Mental health first aid for someone who is suicidal
Suicide can be prevented. According to WHO estimates, there are around 130k to 270k cases of attempted suicide in Pakistan each year.

Always take suicidal thoughts and behaviors seriously.

Take these actions when helping a person who is suicidal:

• If you think someone may be suicidal, ask them directly.
• If they say yes, do not leave them alone.
• Link the person with professional help. Services such as Umang Pakistan offer free of cost counselling services, Umang can be accessed by dialing: Umang Hotline 03117786264 to speak to a counsellor free of cost 24/7. Rozan is another NGO that offers free of cost confidential counselling services which can be accessed by dialling 03355000407.
• In an emergency, call 911 or 15.

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If you would like to learn more here are some very good links:

Doing What Matters in Times of Stress​

An Illustrated Guide

www.who.int

A Guide to Psychological First Aid - Psychosocial Support IFRC​

pscentre.org

Disaster mental health information for psychologists​

Psychologists can help their communities prepare before disasters strikes, take steps to address emotional distress in the midst of tragedy, and build resilience skills to facilitate longer-term recovery.

www.apa.org

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References:
[1]Nisar M, Mohammad RM, Fatima S, Shaikh PR, Rehman M. Perceptions Pertaining to Clinical Depression in Karachi, Pakistan. Cureus. 2019 Jul 7;11(7):e5094. doi: 10.7759/cureus.5094. PMID: 31523527; PMCID: PMC6728784.

 

[ghazi52]

Pakistan’s struggle with mental health stigmatisation and human rights breaches requires a legal overhaul​

Unjustified stigma​

Ali Burhan Mustafa
December 26, 2023

PAKISTAN is grappling with the stigma surrounding mental health. A social fabric steeped in tradition often finds itself at odds with the critical need for progressive mental healthcare solutions.

This clash is exacerbated by misguided reliance on shamans and archaic spiritual rituals, propelled by misinterpreted religious doctrines, rather than scientific psychiatric intervention. This dependence on traditional healers, especially in impoverished areas, perpetuates the stigma.

Child sexual abuse in Pakistan, with its dismal conviction rates, casts a long shadow over our human rights record. Chilling statistics from organisations like Sahil, reveal thousands of cases with a conviction rate of less than two per cent.

Despite initiatives like the Zainab Alert Bill and national sex offender registries, the acute scarcity of child psychiatrists and underdevelopment of specialised branches, such as forensic and community psychiatry, are a glaring oversight in addressing mental health after abuse.

Pakistan faces a dire human rights challenge, as detailed by the Human Rights Commission of Pakistan. A woman is raped every two hours — a statistic that is potentially more frequent, with claims of such incidents occurring every 20 minutes by groups such as Pakistan Men Against Rape.

The distressingly low rate of cases being reported and even fewer convictions exposes deep flaws within the justice system. A number of high-profile rape cases, including the Zainab Ansari incident and a mother abused sexually in front of her children, necessitates a demand for forensic psychiatric assessments in court proceedings.






Pakistani women are encumbered with a disproportionate share of mental health conditions compared to men. While attention has been drawn to many of the sociocultural practices responsible, including karo kari (‘honour’ killings often seen in Balochistan and Sindh), watta satta and child marriages, the struggles of women in less visible rural and urban slum areas remain largely unacknowledged.

Pakistan’s mental health framework is inadequate.

Despite Pakistan’s pledge to the WHO Comprehensive Mental Health Action Plan (2013-2030), women are brutally punished for perceived immorality. Such barbaric practices inflict fear and profound physical and psychological trauma, often leading to myriad mental health disorders.

This crisis is exacerbated by the lack of adequately trained healthcare providers who can recognise and assist victims and violence — a shortfall highlighted by the Unicef-initiated mental health and psychosocial support services programme in 2021. Medical studies corroborate this gap.

In Pakistan, the intersection of mental health and human rights is brought into sharp relief by the impact of blasphemy laws on the mentally ill. Between 1986 and 2010, an alarming surge in blasphemy accusations resulted in over 50 extrajudicial deaths.

The existing laws, increasingly stringent and far-reaching, ensnare individuals with mental health conditions such as schizophrenia and autism, often misused to conceal abuse against them. There is a critical need for legal reforms that provide robust protections for those with mental health challenges, ensuring that blasphemy laws are not weaponised against them.

Pakistan stands at a critical juncture, with recent legal reforms pointing towards progress in mental health care. The decriminalisation of attempted suicide was a commendable step away from punitive measures, signalling the emerging recognition of mental illness as a public health matter and not a criminal one.






However, the realities of mental health care in Pakistan, as evidenced by high suicide rates juxtaposed with an insufficient number of mental health professionals and facilities, particularly in the rural areas, highlight a landscape in desperate need of reform.

With a budget that fails to adequately address mental health and a medical community yet to fully acknowledge psychiatric subspecialties, Pakistan’s mental health framework is alarmingly inadequate.

Forensic psychiatry in Pakistan is at a pivotal juncture, facing the challenge of reconciling its colonial legacy with contemporary human rights and psychiatric practices. Our legal system, which often places an unreasonable onus on defendants to prove mental illness with insufficient support, calls for urgent modernisation.

Pioneering decisions like the Supreme Court’s ruling in the Safia Bano case are indicative of an increasing awareness of these critical issues and underscore the imperative for systemic legal reforms.

Pakistan’s struggle with mental health stigmatisation and human rights breaches requires a legal overhaul. The justice system, failing to shield vulnerable groups, particularly the mentally ill, highlights the need for incorporating psychiatric evaluation into judicial processes.

The writer is secretary, Pakistan Psychiatric Society, Punjab chapter.

Unjustified stigma

Pakistan’s mental health framework is inadequate.

www.dawn.com

 

[Amaa’n]

My favourite video on explaining empathy vs sympathy to those providing psychological care to those i need

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[ghazi52]

Mental health has to be identified as a priority public health issue in KP​

Asma Humayun
January 26, 2024

IN early November last year, a primary care physician from Chitral reported a case on the Mental Health and Psychosocial Support (MHPSS) web portal of the Ministry of Planning, Development and Special Initiatives (MoPD&SI).

The case pertained to a 30-year-old married woman who had been unwell for 16 months. The patient’s family had sought advice from a few aalims and pirs, spending Rs50,000 without any relief.

The patient had also made seven trips to Peshawar to consult a handful of psychiatrists and a neurologist, and even travelled to a major hospital in Karachi to seek help, incurring a total cost of Rs400,000, multiple psychiatric medications with associated side effects and a couple of misdiagnosed labels.

Three days after the case was reported, the lady was assessed (online) by a psychiatrist from the MoPD&SI team in Islamabad and a diagnosis of a dissociative disorder was confirmed. Following this, the reporting doctor from Chitral was supervised to manage the case to rationalise the patient’s medication, and to support her and counsel the family. This supervision continued over the next three months.

Today, the patient is symptom-free — for the past seven weeks — and has resumed all domestic responsibilities. The reporting doctor feels confident about his skills to identify and manage such cases.

In 2023, approximately 100 doctors from Chitral, Haripur, Kohat, Lower Dir, Mansehra, Mardan, Nowshera, Peshawar and Swabi were trained under this project. The doctors received a five-day training in mhGAP-HIG guidelines (recommended by the WHO and UNHCR) to help non-specialists manage common mental conditions.

These guidelines had been adapted for Pakistan’s cultural and healthcare context and published by the MoPD&SI. The trained doctors are now registered and thus connected to the web portal through a mobile application which systematically takes them through the assessment and management protocols described in the guide. Here, the doctors can share clinical information of the patients they manage and can also seek supervision when needed.

So far, 400 cases have been reported on the portal, including vital demographic and clinical information. Over 70 per cent of people presenting with mental health conditions were under the age of 40; two-thirds of the total cases were women. Over half of all cases were diagnosed to be suffering from depression, with another 30pc suffering from conditions related to stress and grief.

This pilot project in KP is a part of the MHPSS work initiated by the MoPD&SI after mental health was identified as a critical but neglected aspect of healthcare in the country in 2021. Noting a huge mental health burden and severe dearth of specialist services, the ministry developed a model for delivering evidence-driven, rights-based and scalable MHPSS services across the country.

This is a comprehensive multilayered model which aims to provide care in the community and at primary, secondary tertiary healthcare levels. The pilot was undertaken during the second half of 2023, in collaboration with the Directorate of Public Health in KP and supported by the International Medical Corps to build the capacity of primary care physicians in the selected districts.

At the provincial level, mental health has to be identified as a priority public health issue.

A situation analysis shows that KP has 37 districts with a population of over 40 million with at least 80pc living in rural areas. Only nine districts have psychiatric services, and some of these are limited to just one or two psychiatrists per district. There are no psychiatric services at the primary level.

In addition to the expected prevalence of mental disorders, the province has borne the brunt of conflict and terrorism, natural disasters, internal displacements and a huge refugee population. It is estimated that at least 20pc of those living in KP need MHPSS services. In addition, worrying suicide rates have been reported in some districts such as Chitral and Parachinar neither of which have any psychiatric services.

At the same time, consider that the average district has at least 100 doctors working at the primary care level who are potentially a huge resource for providing MHPSS services. This is because, according to the WHO, 70pc of common mental disorders can be effectively managed in the primary care.

This is where the MoPD&SI comes in. It has the technical expertise to develop, lead and scale up a system for integrating mental health into primary care services. This includes instituting a mechanism to register doctors, provide standardised training tools for training, provide supervision, evaluate and monitor the performance of trained doctors, develop a referral mechanism and collect vital data.

This is just the first step. At the provincial level, mental health has to be identified as a priority public health issue. A coordinating mechanism is needed between the health department, humanitarian agencies and development partners. At the moment, many projects are undertaken in silos with blurred and short-term outcomes. A clear direction needs to be set with focused objectives so that all resources can be pooled.

At the tertiary care level, a team of trainers need to be selected and trained for building the capacity of doctors in primary care. This is challenging because, one, specialists are already overwhelmed with teaching, clinical and administrative responsibilities; two, they are heavily invested in private work after official working hours; and three, there is no incentive for them to integrate mental health services into primary healthcare.






Ideally, mid-career specialists who are motivated and interested should be incentivised into a specifically designed career path.

At the district level, finally, three aspects will be vital. Firstly, doctors need to be carefully recruited for training. Unfortunately, not all doctors may be interested in continuing professional education, or in providing mental healthcare.

Younger, tech-savvy doctors interested in expanding their skills and likelier to have overcome stigmas associated with mental disorders will be suitable. It is crucial that women doctors too be targeted. Secondly, common mental disorders — particularly depression — must be included in the information management system.

Thirdly, basic psychiatric medication especially anti-depressants must be made available at primary healthcare facilities, if this plan is to work.

The writer is a consultant psychiatrist and the national technical adviser for the Ministry of Planning, Development & Special Initiatives.

X: Asma Humayun