Review Mental Healthcare in Pakistan Afzal Javed, M.B.B.S., F.R.C.Psych., M.Phil.1*, Muhammad Nasar Sayeed Khan, M.B.B.S., F.C.P.s. (Psychiatry).1, Amina Nasar, F.C.P.s. (Psychiatry).2, Alina Rasheed, M.Sc.3 1Pakistan Psychiatric Research Centre, Fountain House, 2Services Hospital, 3Shaukat Khanum Research Centre, Lahore, Pakistan Abstract Background: According to the latest report, over 15 million people in Pakistan are suffering from some form of mental illness. But for a population of 220 million, only 400 trained psychiatrists exist with few state-run psychiatric hospitals and a small number of psychiatric units in teaching and general hospitals. In a traditionalist society, there is frequently a social disgrace together with discussing dysfunctional or abnormal behaviors as mental health problems and is generally described as a “shortcoming of character.” Methods: We carried out comprehensive literature review to collect data on the current mental health picture in Pakistan, and we also compared and formulated the recommendations from the literature of the related countries in the region and developed countries whenever possible. Results: Mental healthcare is still not a priority in the health system in Pakistan. A dire need still exists for a recognition from both public and private sectors for improving mental health planning and services in the country. Government must actualize social strategies that should be simple, equitable, and practical, as well as being able to address the issues of the regular needs. Asset allotment for emotional wellness is horrifyingly low and wasted away by defilement and fumble. A requirement exists for expanded spending on mental healthcare and psychological and emotional well-being just as appropriate usage of accessible assets. Conclusion: In this review, we suggest that a progressive change is required in the current state of psychiatry in Pakistan and that a need exists for a continuing review about existing strategies with a focus on setting sustainable priorities in the field of mental health, especially in policymaking, capacity building, awareness among public, and the use of media to minimize stigma. Key words: mental health system, psychiatrist’s education, psychiatry, stigma Taiwanese Journal of Psychiatry (Taipei) 2020; 34: 6-14 Demographic Data of Pakistan development index (HDI) value for 2018 as 0.560, which puts the country in the medium human development Pakistan is the world’s sixth most populous country with its category – positioning it at 152 out of 189 countries and 2017 estimated population of around 220 million (Bureau of territories [4]. Pakistan’s HDI value was increased from 0.404 Statistics, Government of Pakistan, at www.pbs.gov.pk). From 1950 to 2012, Pakistan’s urban population was expanded over to 0.560, an increase of 38.6% during 1990–2018. Detailed sevenfold, while the total population was increased by over reviews of Pakistan’s progress in each of the HDI indicators fourfold (www.indexmundi.com/pakistan/#Introduction). In between those years showed a visible improvement. Pakistan’s the past, the country’s population had a relatively high growth life expectancy at birth was increased by 7.0 years, with mean rate, and it has now changed with having moderate birth rates years of schooling increased by 2.9 years and expected years of to an average growth rate of 2.40% [1]. Being a low-income schooling increased by 3.8 years. Pakistan’s GNI per capita (the country, it positions 34th among the 37 low-salary nations [2]. dollar value of a country’s final income in a year divided by its Gross domestic product (GDP) ranges around US$1,375 per population) was increased by about 62.4% between 1990 and capita, and infant mortality rate ranking comes as number 2018, and literacy rate is reported as 60% for total populations 155 worldwide with 69 deaths for every 1,000 live births [3]. (male 69% and female 45%). Pakistan, a developing country The United Nations Development Programme’s Human Development report of 2019 determines Pakistan’s human 1*Corresponding author. Fountain House, 37-Lower Mall, Lahore, Pakistan. E-mail: Afzal Javed <[email protected]> Received: Jan. 17, 2020 revised: Jan. 21, 2020 accepted: Jan. 23, 2020 date published: Mar. 20, 2020 This is an open access journal, and articles are distributed under the terms of the Creative Access this article online Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to Quick Response Code: remix, tweak, and build upon the work non-commercially, as long as appropriate credit Website: is given and the new creations are licensed under the identical terms. www.e-tjp.org For reprints contact: [email protected] DOI: How to cite this article: Javed A, Khan MN, Nasar A, Rasheed A. Mental 10.4103/TPSY.TPSY_8_20 healthcare in Pakistan. Taiwan J Psychiatry 2020;34:6-14. © 2020 Taiwanese Journal of Psychiatry (Taipei) | Published by Wolters Kluwer - Medknow 6 © 2020 Taiwanese Journal of Psychiatry (Taipei) | Published by Wolters Kluwer - Medknow Javed, et al.: Mental healthcare in Pakistan and one of the next groups of 11 countries, along with the healthcare were always apparent in the local systems and had emerging national economies (BRICs), has high potentials to an important influence on perception, awareness, and choices be among the world’s largest economies, according to the data for various health-related treatment modalities [11]. Healthcare from the World Bank (www.data.worldbank.org). systems and particularly mental health systems had a major Pakistan is a democratic parliamentary federal republic, shift following colonization by the British. Influenced by with Islam as the state religion [5]. Freedom of religion is an British systems and custodial nature of care, treatment and important part of the Constitution of Pakistan (www.pakistani. management of the mentally ill were mostly by establishing org/pakistan/constitution) which provides all its citizens the mental hospitals in the Indian subcontinent [12]. Lahore Mental rights to profess, practice, and propagate their religion subject Hospital was an example of this type of service that continues to law, public order, and morality. Pakistan has a rich cultural serving large part of the country even after its independence background, and the country’s diversity is more visible along in 1947. cultural and linguistic differences, emphasizing local cultural Following British traditions, during 19th and 20th etiquette and traditional Islamic values that govern personal centuries, people with psychiatric illnesses were mainly and political life [6]. The basic family unit is the extended treated and managed in big institutions [13]. The initial aim family although for socio-economic reasons, there has been a of institutionalization of those with mental illness was to growing trend toward nuclear families. segregate them from the community. But with time, it became The Indus Valley civilization, one of the oldest in the evident that those patients required care and management world and dating back at least 5,000 years, included much of in the community. This movement certainly witnessed what is present-day Pakistan (by L. Ziring and S. H. Burki, a well-deserved recognition in Pakistan during the 20th in Encyclopedia Britannica at www.britannica.com/place/ century [14]. Pakistan). Remnants of this culture fused with the migrating Mental healthcare is provided mostly by public health Indo-Aryan people during the second millennium B. C. The sector although there have been some recent developments area underwent successive invasions in subsequent centuries in the private sector as well. Psychiatric care offered by from the Persians, Greeks, Scythians, Arabs (who brought different sectors generally highlights the influence of the Islam), Afghans, and Turks. The Mughal Empire flourished British allopathic system on psychiatric care. It also reflects during the 16th and 17th centuries (www.thoughtco.com/the- rapid upward shift in the development of traditional services, mughal-empire-in-india-195498) [7] and the British came to training of personnel in allied disciplines, education of public, dominate the region in the 18th century. At the end of British and provision of community mental healthcare. Those trends rule in 1947, India was divided to two countries: India and are encouraging despite having limited resources and low- Pakistan (with two provinces in Pakistan – East and West resource allocation for mental health and psychiatric services Pakistan) [8]. But East Pakistan became a separate nation with a limited number of trained personnel in the mental health of Bangladesh in 1971. Currently, Pakistan has four (Sindh, field [15]. Balochistan, Northwest Frontier, and Punjab) provinces In Pakistani culture, it is commonplace to approach (Figure 1). spiritual or traditional healers in cases of physical or mental illnesses [16]. Faith healing is the traditional way of treatment Mental Health in Pakistan for mental ailments in this culture, as people usually perceive Like many developing countries, Pakistan is struggling mental illness to be the result of supernatural influences. Use in several health and social spheres, which have substantial of faith healers is irrespective of socio-economic factors as impact on the health system of the country. Healthcare delivery it usually depends on the person’s belief toward spiritual system in the country includes both state and nonstate and profit healing [17]. Faith healers are a major source of care for people and not-for-profit (voluntary sector) service provisions [9] with mental health problems in Pakistan, particularly for women (www.apps.who.int/nha/database/Regional_Averages/Index/ and those with little education. Commonly used faith-healing en). The country’s health sector is equally marked by urban– techniques involve repetition of Quranic verses, “dum,” and rural disparities in healthcare delivery and an imbalance in use of “taweez” or ropes on the body. Apart from those, several the health workforce, with insufficient health professionals, fake faith healers use various other methods, some of which nurses, paramedics, and skilled health workers, especially in can be dangerous [18].