Draped in a red plaid scarf worn loosely around her head, 21-year-old Aasia* has just been shifted to the ward after five days in intensive care. Her skin looks pale and her legs are flexed. Even at 21, Aasia seems to have carried the weight of the world on her tender shoulders. And perhaps, this burden was all too much for her to bear: Aasia is in hospital after ingesting rat poison in an attempt to end her life.
Standing beside her is an elderly man, her father, while her mother is sitting on a vacant bed next to her. “Aasia doesn’t have any mental health issues,” her father avows.
The family has been lodged at the National Poison Control Centre (NPCC) at the Jinnah Postgraduate Medical and Dental Centre (JPMC) in Karachi ever since Aasia was brought in. The father simply doesn’t understand how matters came to such a head. Being the only daughter remaining in the house after the marriage of her six elder sisters, he claims she is loved unconditionally.
“She tried to end her life because her mother had taken her to task for cooking the food too spicy,” he narrates. “She was making mistakes for the past few days while preparing meals for the family and was being criticised over that.”
Little did the parents know the toll such taunts were taking on Aasia. Fed up with the bickering, Aasia consumed poison. It took the family three hours to take Aasia to the NPCC, but luckily, they reached in time.
Although figures for suicide and suicide attempts are notoriously sketchy in the country, doctors agree that they are seeing an increase in the number of such cases. What they indicate, however, is that aside from increasing stressors, there is a mental health emergency that remains unaddressed
On the extreme right to Aasia lies another young woman named Khizra* who attempted suicide by consuming insecticide. The 20-year-old was admitted to the hospital a few hours ago and is now stable after receiving the treatment.
A small quarrel with her younger brother over ironing of clothes had made her feel worthless and convinced her to take her own life. Khizra ran and took an insecticide soon after the quarrel was over, giving no time to the family to comprehend the situation. Her mother laments that children don’t think about their parents when they resort to such extreme decisions.
Aasia and Khizra are only two of the patients admitted at Ward 5 of JPMC. There are many other patients of both genders who have either intentionally ingested poison or are victims of venomous insect bites or stings.
Dr Muhammad Junaid Mahboob, a resident doctor at the NPCC, tells Eos that approximately 15-20 patients are admitted daily at the NPCC, many of whom consume poison deliberately in order to kill themselves. The number of patients brought in is surprisingly higher on weekends.
While 98% of the patients of intentional poisoning survive, Dr Mahboob states that the survival chances depend on the type of poison, the amount taken, and the time it takes to reach the hospital.
While poisoning is one of the three leading modes of suicide in Pakistan besides hanging and firearms, Dr Mahboob specifies insecticide and rat poison as the most-opted poisonous substances by people who attempt suicide. The other less-reported poisonous substances are phenyl and acids. Explaining the reasons for poisoning, he says, the most common problems reported by patients are loneliness, family quarrels, domestic violence, and interpersonal relationship issues.
The NPCC, established in 1989 with the help of the World Health Organisation (WHO), treats patients of intentional and accidental poisoning. As a routine practice, doctors at the centre recommend all suicide survivors to see a psychiatrist at Ward 20, Department of Psychiatry and Behavioural Science, when they are being discharged.
Despite doctors’ recommendation and the psychiatry ward being only a few metres away from the NPCC, Dr Mahboob believes that not many patients see a psychiatrist because they never accept they need professional help.
“[Underlying] causes when left untreated increases the vulnerability to suicide risk after attempted suicide,” he says.
“Within the first six to 12 months following a suicide attempt, people are at increased risk of another attempt,” corroborates Dr Murad Moosa Khan, president of the International Association for Suicide Prevention (IASP) and professor at the Department of Psychiatry, Aga Khan University.
“Since these people have already experienced death closely, they are not afraid of dying anymore,” he elaborates. “This persuades them to attempt suicide more aggressively.”
Trust and betrayal
Most loved ones respond to suicide as something out of the blue. In reality, those thinking about suicide have been doing so for long. And in many cases, it’s a pressure cooker inside those people’s minds — in terms of helplessness and feeling overwhelmed — that has exploded and manifested as suicide or suicide ideation.
That said, there is no single cause for suicide, states the American Foundation for Suicide Prevention. It occurs when stressors and health issues converge to create an experience of hopelessness and despair.
Millions of women in Pakistan, for example, are constantly being told, by their spouses, by their in-laws, and even by parents, that they are good-for-nothing; they are neither beautiful nor intelligent so much so that it kills their self-esteem and they gradually start doubting themselves.
“This is called conditioning,” explains Adeel Hijazi Chaudhry, CEO of psychiatric helpline Talk2Me. “We receive numerous calls from women plagued by self-doubt asking us whether they are really not good enough.”
Such situations tend to hurt a person’s ego. If loved ones are questioning their existence, who does one find love and validation from? Such existential questions can, and often do, lead to an abyss, out of which there is no return.
“More than the chemical changes in the brain, suicide is linked with the thoughts running in the brain. When a person is unable to find solutions to the problems and has lost the ability to control their thoughts, they resort to suicide,” says Dr Khan.
More than 90% of people who die by suicide have some form of mental illness at the time of their death. Dr Iqbal Afridi, dean of JPMC’s Psychiatry and Behavioural Sciences department, argues that depression is one of the leading risk factors of suicide but other medical conditions, such as bipolar disorder and schizophrenia, can also contribute to it.
Dr Khan implies that any change in behaviour or the presence of new behaviour is a warning sign that should never be ignored. For instance, if a person stops receiving calls, starts avoiding people or going to gatherings, he should be reached out to understand what triggered this change.
Warning signs indicate a person is in crises and needs immediate attention, whereas risk factors suggest someone is at increased risk of suicide, but not necessarily in crisis. Risk factors classified by the American Foundation for Suicide Prevention into health, environmental and historical factors, are conditions that increase the chances of a person attempting suicide. Establishing and identifying risk factors can improve the prevention and treatment of suicidal thoughts and behaviours.
“According to a conservative estimate, nearly 15-20% adults and 10% children in Pakistan have some form of mental disorders. Some studies quote an even alarming number of 34%,” says Dr Khan. The most common mental illnesses are depression and anxiety, but they either remain undiagnosed or untreated and therefore, increase the risk for suicide.
The uncertainty of numbers
The WHO estimates that nearly 800,000 people die by suicide every year, making it a global phenomenon. Suicide, an act of killing oneself voluntarily and intentionally, is quite prevalent in low- and middle-income countries and is the second leading cause of death among young people (15-29 years of age).
Although Pakistan is said to have lower suicide rates than other countries, the absence of official statistics makes these rates hard to determine. Suicide rates are described as the number of self-initiated, intentional deaths. Accurate collection of data on suicide is affected by a number of reasons, including whether a suicide is reported in the first place, how a person’s intention of killing himself or herself is determined, who is responsible for completing the death certificate, whether a forensic investigation is carried out, and the confidentiality of the cause of death.
Existing data [for official purposes] relies on reported cases. “There are indications that for each adult who died by suicide there may have been 25 others attempting suicide and 100 others with suicide ideation,” says Dr Afridi.
It follows, then, that existing data relies largely on reported cases, the number of unreported cases goes misrepresented and is not part of the official count.
“There are indications that for each adult who died by suicide there may have been 25 others attempting suicide and 100 others with suicide ideation,” says Dr Afridi.
If ever there was any doubt about the growing scale of this phenomenon in Pakistan, the numbers show it is slowly becoming an epidemic.
“More than 13,000 people died by suicide in Pakistan since 2012, according to a WHO report on suicide prevention,” states Dr Khan. “These are the latest statistics we know,” he adds.
Data generated by the Human Rights Commission of Pakistan (HRCP), an independent non-government organisation, also presents a grim picture. Based on the monitoring of leading newspapers and reports from volunteers, the HRCP estimates that more than 3,500 cases of suicide and attempted suicide were reported in 2017, over 2,300 cases were registered in 2016, while more than 1,900 cases were recorded in 2015.
The WHO has also researched the extent of known suicide, suicide attempts and self-harm cases (reported to hospitals) and declared reported cases to be only the tip of the iceberg. The organisation claims that a majority of cases remain “hidden” under the surface and are never reported to healthcare services.
The crude suicide rate in Pakistan, according to WHO Global Health Estimates 2016, was 2.9 per 100,000 population in 2015 and 2016. Although the WHO Global Health Estimates provides a comprehensive assessment of mortality for countries, these figures underestimate the actual magnitude of the issue, taking the legal, sociocultural and religious stigma, and poor reporting of cases in consideration.
An associated matter in the Pakistani context is the issue of death certificates.
Since a death certificate is mandatory to make funeral arrangements in urban areas, suicide cases are often reported to police and hospitals, but many family members don’t opt for autopsy or forensic investigation due to religious and legal issues, hence the manner of death remains unknown, says Dr Khan. While in rural areas, where a death certificate is not a requirement for burial, he suspects that many suicide cases are hushed up.
“Ending the stigma associated with suicide, making forensic investigation compulsory to determine the manner of death and decriminalising suicide and suicide bid can improve the reporting of such cases,” proposes Dr Khan. He adds that Pakistan is among the few countries of the world where attempting suicide is a criminal offence with an imprisonment of up to one year or with fine or with both, according to Section 325 of the Pakistan Penal Code.
The legal status of suicide in a country has a massive impact on the reporting of such cases. Although decriminalising suicide and suicide attempt may not lead to its prevention, it can improve the reporting and access to medical treatment.
The dearth of psychiatrists and cost of treatment
With a significant number of the population having some form of mental illnesses, there are less than 500 qualified psychiatrists in the country.
This small pool of skilled doctors is distributed largely in urban areas. The dearth of psychiatrists and their inaccessibility, especially in far-flung rural areas, is one of the many reasons people don’t opt for any professional help. The cost of treatment together with travel expenses rises if a patient travels to the city to see a psychiatrist.
“If a person comes from Umerkot to get a treatment in Karachi, the cost of his treatment along with travel and accommodation expenses adds up to nearly 15,000 rupees, which is quite a lot for an ordinary person,” says Dr Khan. “If there is a chronic illness which requires long-term continuous treatment, consisting of consultation, medication and travelling costs, the treatment becomes difficult to afford.”
This means that it is critical to establish crises centres in each city with qualified and trained professionals who can provide services within the physical and financial reach of patients.
“Also, all the crises centres should be connected through a network database so if a person, attempting suicide from the top of the building, calls a psychiatrist in Karachi to inform about his situation, the doctor is able to contact his nearest crisis centre to ensure appropriate help,” urges Dr Khan.
Another problem that prevents people from seeking psychiatric treatment is the cost. The fee of a psychiatrist on an average ranges from 500 rupees to 3,000 rupees for a single session. This, combined with medicines, make the cost of treatment unaffordable for an average person. Although public hospitals provide psychiatric treatment with nominal or no charges, many people prefer private treatment due to the disparity between public and private hospitals.
But why is there such a dearth of psychiatrists?
Although there are over 100 medical colleges in the country, Dr Khan and Dr Afridi are unanimous that only a few of them are actually functional and providing state-of-the-art education in psychiatry. The rest are either not functional at all or lack competent staff and need facilities. Hence, the turnout of psychiatrists is affected badly.
Dr Khan claims that psychiatry is not a popular specialty among students because it offers a lower income compared to other specialties of medicine.
“An eye specialist can earn thousands of rupees in a few minutes by performing a cataract surgery,” he says. “On the other hand, a psychiatrist only earns 2,000 rupees for a one or two-hour-long session.” Psychiatry is a time- and energy-consuming undertaking, but it is also a low-paying medical speciality. Moreover, the written examination of psychiatry is not mandatory; this is another reason why this subject is neglected by students. Dr Khan advises the PMDC to give special emphasis to this specialty and make its examination compulsory in MBBS courses in all public and private medical universities.
Ending the stigma associated with suicide, making forensic investigation compulsory to determine the manner of death and decriminalising suicide and suicide bid can improve the reporting of such cases.”
Sadly, the mental illness stigma is not only confined to common people; it is also found among medical professionals but never talked about. Adam Brenner, associate professor of psychiatry at the UT Southwestern Medical Center, argues that since mental illnesses are not considered “real” diseases due to stigmatisation, medical students fear that they won’t be considered “real” doctors if they choose to be psychiatrists.
Some also believe that mental illnesses are distressing, and can have a dangerous effect on those who work with them. Brenner advises that, if students get to meet more patients who are reclaiming their best selves after recovery from mental illness, and work with psychiatrists who are proud to work with such patients, this stigmatisation can be tackled.
A viable solution to address this glaring shortage of psychiatrists and improving mental healthcare in the country is task-shifting. Task-shifting, as defined by the WHO, is a process of delegation whereby tasks are passed on to less specialised health workers. By reorganising the workforce in this way, task-shifting can utilise the available human resources effectively.
For instance, when there is a shortage of specialised doctors, general physicians can be trained to perform some of their specific roles. Furthermore, qualified nurses can lessen the burden of general physicians while lady health workers or community workers can also deliver some services after being trained. This way the human resource pool expands quickly, bridging the gap between healthcare facilities and the community.
In line with this, Dr Iqbal Afridi and his team were set to leave for Thar to train 150 general physicians a day after our meeting. There was hustle and bustle in his office and doctors were constituting teams to execute the training. Thar, a large, barren region known for its droughts and alarming suicide rates, makes an ideal place for the training, says Dr Afridi. He was hopeful that the training will help general physicians control the situation of the region.
“Our aim is to train general physicians in the first phase, nurses in the second, lady health workers in the third phase and teachers in the fourth phase,” he shares. He also stresses the need to establish mental healthcare centres in tertiary hospitals, schools, workplaces and all the important places within a region.
As much as task-shifting is important to deal with workforce crisis, it alone cannot address the crisis in the long run. The WHO recommends task-shifting to be implemented with the strategies to increase the numbers of health workers in all cadres.
Helplines at your beck and call
Among the horde of difficulties to access free, quality and timely mental healthcare, mental health helplines are a ray of hope for people who can pour their heart out with their confidentiality intact. Talk2Me is one such helpline that conducts 75-90 counselling sessions weekly and has touched more than 19,000 lives through its free-of-cost service.
“With a team of 110 members, of whom 48 are clinical psychologists with a Masters Degree and valuable experience, we assist people to deal with their problems and live a normal life,” says the CEO of Talk2Me. Claiming to be the first 24×7 free mental healthcare service in Pakistan, he says, millions of dollars have been invested in the Talk2Me to keep it free of cost.
Despite running Talk2Me successfully, Hijazi says that suicide prevention helplines cannot be a success in Pakistan because we don’t have an interim social service system that can provide immediate intervention to the patients if the information is provided by the helpline.
Mapping the magnitude of problem, Hiijazi states that nearly 55 million Pakistanis suffer from some form mental disorders, in contrast to 3.2 million Pakistani reported in 1992.
“The suicide rate has gone up by 30 percent during the last quarter,” he says. Hijazi discusses the various factors that can lead to suicide. “Unmonitored internet usage and lack of communication between parents and children are the leading causes of suicide among young people,” he shares. He questions how anti-anxiety tablets are easily accessible to teens and pre-teens without prescription from drugs stores.
Being a survivor of depression himself, Hijazi says the word suicide is now been abused and is becoming a common thing now. People talk about being suicidal as a joke.
Although President Arif Alvi announced a 24/7 mental health helpline after the suicide of model Anam Tanoli in September 2018, no progress has been to materialise the project, he claims. “Initially it was announced that Talk2Me will be funded to roll out the helpline. After putting in a lot of hard work, when the framework was presented that can be implemented in less than half of the budget allocated for the helpline, the project was awarded to someone else based on their political affiliations ,and till date the government has shown no interest in materialising the helpline,” Hijazi adds.
Another online initiative Baat Karo — Talk Because We Listen is also helping people deal with their mental illnesses. “Having 40 members on board including 20 psychologists and psychiatrists, Baat Karo — Talk Because We Listen has reached 1200 people directly, and helped them through their depression,” says Fahad Malik, founder of Baat Karo. The free-of-cost service focuses on suicide intervention, prevention, awareness and education and also provides help and hope through online chat, college campus and high school events and other educational programmes. Having lost a close friend to suicide, Malik initiated this Baat Karo helpline to help people with their depression and other illnesses. The project has moved to a web-based model after the success of its WhatsApp chatline.
Umang, a newly launched start-up daily receives 10 calls on an average, mostly from people with suicidal ideation who fall in the age bracket of 18-26 years. “With a team of 60 people, comprising 30 clinical psychologists and 10 senior doctors, we assist people through 30-45 minutes free counselling sessions, followed by 3-5 therapy sessions,” says Dr Kinza Naeem, CEO and founder of Umang.
Dr Naeem finds bullying, study stress, competition among youngsters, excessive use of social media and lack of communication between parents and children the leading causes of suicide among youngsters. She adds that Umang counsels people but doesn’t deal with actively suicidal patients and recommends people to see a psychiatrist based on their conditions.
Dr Naeem aims to establish a proper call centre that can cater to numerous calls, crisis centres in every region and free referral centres, so if a patient calls from Sheikhupura he can be referred to a psychiatrist close to his vicinity who provides free-of-cost service.
Taskeen, another NGO, helps connect patients with healthcare providers. “We have a portal of nearly 100 service providers — both individual and institutions — all verified by Taskeen itself. A person can choose from any of them as per his convenience,” says Dr Taha Sabri, co-founder of Taskeen. The organisation conducts workshops and awareness sessions about mental healthcare in communities too.
Besides them, Aman Foundation is also playing an active role in promotion of mental health and has catered more than 1200 calls on mental health through Aman TeleHealth (ATH) from March 2018 to March 2019. The total number of calls landed in ATH during this tenure were 66,581, making it an average of around 182 calls per day.
Do we have a national suicide prevention policy?
While suicide prevention must be a fundamental element of the national mental health plan, mental well-being receives little to no attention in the country. Although Pakistan is a signatory to WHO Mental Health Action Plan 2013-2020, and the year 2020 is just around the corner, no progress has been made in the mental healthcare sector, says Dr Asma Humayun, Consultant Psychiatrist at Meditrina Healthcare, Rawalpindi.
The current per capita health spending of Pakistan is US $ 36.2 which is below the WHO’s low income countries’ benchmark of US$ 86, according to the World Bank’s report, while nothing is separately specified for the mental health. “There is no budget for mental health!,” Dr Humayun adds.
When asked whether Pakistan has a well-devised and implemented national mental health plan, a national suicide prevention plan in particular, and has the 18th Amendment made anything better in terms of mental healthcare, Dr Humayun responds in the negative.
Within the meagre health budget announced by the government, mental health receives an even tinier share.
“Not only must the government increase the health budget, it should allocate a separate budget for mental health,” suggests Dr Khan.
Dr Afridi describes health as a combination of physical, mental and social well-being. Just like the three sides of a triangle, he explains, the three components of health are connected with each other, each having its own importance for a healthy balanced life.
While health is based on three components, he adds, mental health is based on four characteristics: when a person realises his potential, can handle the regular stresses of life, can work productively, and can make a contribution to community.
“If a person lacks any of the aforementioned characteristics, he does not have a healthy mind,” he states. “Having said that, people who mock patients with mental illnesses but never contribute to the society themselves need to evaluate their own mental well-being again.”
Hijazi also claims that no counsellors have been appointed in the schools despite the Prime Minister’s orders of appointing at least one counsellor in every school across Pakistan. He emphasises the need for all educational institutes to have counsellors on campus and that these professionals should conduct mental health awareness workshops on a regular basis.
“Pakistan’s leading university in Lahore has the highest suicide rates among all the higher educational institutions,” he claims. “Thankfully the management has started to take it seriously now,” he says. He bemoans that people may prefer to die of their undiagnosed and untreated mental illnesses than to be seen standing outside the psychiatrist’s clinic.
While suicide is a complex global phenomenon, it can be prevented with timely and effective evidence-based interventions.
The first step in this regard is the collection of accurate data in order to devise effective strategies. The WHO has laid great emphasis on the improvement of data on suicides and suicide attempts in its report Preventing suicide: a global imperative.
In the absence of a well-organised surveillance system and national data registry in Pakistan, the number of suicide and suicide bid cases bite the dust, providing zero opportunity to gauge the magnitude of the problem, establish national health priorities and improve research and prevention.
Because believe it or not, young Pakistanis are being foisted with multiple pressures in this age of recession. Not everyone is coping. Before the epidemic becomes endemic to the country, the government needs to act.
*Names changed to maintain privacy and anonymity.
If you know someone – friend or family member – at risk of suicide, please reach out to them. The Suicide Prevention India Foundation maintains a list of telephone numbers (www.spif.in/seek-help/) they can call to speak in confidence. You could also accompany them to the nearest hospital.