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

Published in Dawn, January 26th, 2024