Mental health helplines
MENTAL health helplines dedicated to support women and children against violence or advocate for reproductive health have been operating in the country for many years. Helplines gained renewed traction after the president advocated for a 24/7 helpline for mental health support following a high-profile suicide in 2018. The Covid-19 pandemic has further fuelled the trend of setting up mental health helplines, encouraged by the availability of humanitarian agency funds.
Recently, the Sindh Mental Health Authority inaugurated what was ostensibly its third helpline at Civil Hospital, Karachi. A news report claimed that two mental health counselling helplines were already functioning at the Sir Cowasjee Jehangir Institute of Psychiatry in Hyderabad and the Jinnah Postgraduate Medical Centre in Karachi. Although no official data is available, informal interviews suggest that the previous helplines were essentially just a landline number which was attended by the duty resident psychiatrist; that these were operational for short periods only; and that very few calls were, in fact, received. In essence, these helplines were an extension of hospital services.
The report from the launch of the third helpline cites high prevalence of psychiatric morbidity and alarming rates of suicides in Thar, but it remains unclear how this helpline links that community with mental health services at Civil Hospital. If it is designed for the citizens of Karachi, there are still many unaddressed questions. Given that over 10 per cent of the population is in need of some form of mental healthcare, how many lines are planned for this helpline? Mental health conditions are associated with many barriers to seeking help; so what is the strategy to engage the community? Is the objective of the service to provide information about mental disorders, to refer callers to appropriate specialists, to provide crisis intervention, or to offer treatment? Given that each caller may need up to half an hour of consultation time, does Civil Hospital have the capacity to sustain this kind of service?
There are other helplines, mostly supported by NGOs, which provide a range of heterogeneous services. There is considerable variation in the quality of service provided by these helplines, depending on their sources of funding and trained human resources. Although some have successfully sustained their services over years, examples abound of services lapsing within months because of time-limited funding. Even where services are still being provided, there are serious questions about the training and supervision of mental health professionals, implementation of scientific protocols and lack of appropriate referral pathways.
Any and all services for mental healthcare need to be rights-based.
Any and all services for mental healthcare need to be rights-based. They should be accessible, sustainable, confidential, must follow a standard of clinical care, have an inherent regulatory mechanism, and be consistently evaluated. It is both unclear and doubtful whether existing helplines have adequately qualified staff, collect required data whist protecting their callers, evaluate their services, or are in a position to share their training, risk management, treatment and referral protocols.
At the time of writing this op-ed, the website of a well-established 24/7 helpline brazenly claims to be recognised by the World Health Organisation and an international mental health network. However, neither one of these organisations accredit or endorse any service anywhere in the world. It is extremely misleading and unethical to promote services this way. Furthermore, the website claims that its service has provided “3,000 therapy sessions” since 2019. Were these one-off therapy sessions or were multiple sessions offered to each caller? And what is the nature of this therapy? What are users’ reviews? The website further claims to have 150 members in the team. Let us assume for a moment that the service is well meaning (as it is free of cost) and is backed by qualified specialists: why, then, are their names and qualifications not public? It is the basic right of a caller to know who will be treating them, and the kinds of interventions that will be available to them. Some NGOs agree to protect their staff by not revealing their identities, but they still have an ethical and scientific obligation to ensure that callers and subscribers are fully aware of their qualification and experience or lack of it.
To cite an example, last week, the National Suicide Prevention Lifeline in the United States announced a three-digit number for an emergency helpline (operational since 2005), which responded to 3.6 million calls and texts in 2021. It is funded by SAMHSA (Substance Abuse and Mental Health Services Administration), which is an agency within the department of health that leads public mental healthcare. “One of the goals of 988 is to ensure that people get the help that they need when they need it, where they need it. And so, when a person calls 988, they can expect to have a conversation with a trained, compassionate crisis counsellor who will talk with them about what they’re experiencing. If it’s the case that they need further intervention, then likely the crisis counsellor will connect with a local mobile crisis team”. Despite the fact that the service is part of an overall comprehensive mental health strategy and has invested $432m since 2021 to scale up crisis centre capacities, there are still concerns that demand might outstrip capacity very quickly.
In Pakistan, setting up mental health helplines has become a popular quick fix for inadequate physical mental healthcare. Unless we carefully formulate a policy followed by a plan to identify our priorities and develop services accordingly, unregulated, ad hoc helplines will fail to deliver. In the face of limited resources, it is also essential to consider the synergy between prevention and treatment helplines, which can be particularly helpful for remote regions that face a high burden of disease but a severe dearth of trained personnel. The MHPSS (mental health and psychosocial support) model developed by the Ministry of Planning, Development and Special Initiatives offers a solution to address the challenges identified above and to link existing helplines with a wider systematic strategy. A national guideline for regulating these helplines will certainly help.
The writer is a consultant psychiatrist.
Published in Dawn, July 21st, 2022