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 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 percent 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 a 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 percent adults and 10 percent children in Pakistan have some form of mental disorders. Some studies quote an even alarming number of 34 percent,” 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.
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