WITH the world becoming increasingly aware of the snowballing mental health (MH) crisis, there has been a corresponding rise in digital-based solutions designed to respond and scale the delivery of care. A recent WHO report shows that one in eight people worldwide suffers from mental health disorders; this prevalence is almost double that of diabetes and more than that of cardiovascular disease. In addition, people with chronic illnesses and co-morbid anxiety, and/or depression not only have a lower quality of life than those without concomitant MHDs, they are also likely to die five to 10 years earlier.

In a recent op-ed, former SAPM Zafar Mirza detailed the morbidity cost and DALY (disability-adjusted life years) specifics for MHDs in Pakistan. Reports of deaths by suicide feature almost daily in news reports, and there has been an increase in opinion and analysis pieces on the topic. The magnitude of MHDs in Pakistan is accentuated by multiple social drivers including poverty, unemployment, political instability, lack of education, violence, etc. MH-specific reasons span from the absence of uniform policy, to the dearth of basic health literacy and a trained workforce. Most people with MH problems don’t seek professional help due to the inability to recognise symptoms, lack of evidence-based services and referral systems, cost implications, prior experiences of unsatisfactory care, etc.

By necessity, the period spanning Covid-19 saw the increased use of digital support services in healthcare delivery. Resultantly, a potential proof of concept was provided that would make MH services more accessible to the people, by lowering costs, eliminating travel, increasing outreach, and improving schedule flexibility. Pakistan saw a rise in tech-based interventions in the MH space. These include, but are not limited to, helplines established during Covid, mental health apps connecting end users to health professionals, and GPs providing telehealth services, using a hub and spoke model. Recently, the government proposed a similar intervention to provide free consultation services. The MH app Humraz pledges to improve the quality of life for those with MHDs.

This recent initiative, as others before it, is welcome. New interventions mean that there is increasing awareness; knowledge and edification almost always push the needle in the right direction. This also opens the door to a collaborative discourse on policy, strategic directions, resource mapping, priority setting and defining the values and guiding principles for interacting with technology.

Any digital intervention must include provider education and training in its use.

However, as with any other new tool entering the utility space, we recommend caution and a deep understanding of the contextual macro and microcosm before we tout it as a solution for all problems.

The mental health context: As things stand, Pakistan has around 600 trained psychiatrists and fewer than 500 psychologists, mostly concentrated in urban centres. This amounts to one psychiatrist for every 10,000 adult patients and less than eight child and adolescent psychiatrists for about four million children suffering from MHDs. There are a few counselling training programmes, some accredited by international bodies, with varying levels of supervisory oversight. There is no central credentialling body for therapists. There are over 100 medical schools but most provide very little quality training in MHDs. This means that often the graduating generalists (GPs) and other specialists, who are the gateway to MH referrals, have limited knowledge of MHDs. Quality trained professionals are spread thin between the responsibilities of providing clinical care, teaching, training, advocating and conducting research. Direly needed public health interventions also often fall by the wayside due to lack of policy, collaborative action and a unified strategic response. Faith healers and other traditional health providers often fill the gap and provide ‘care’ to patients.

Digital solutions in healthcare: Using digital solutions for the provision of health services necessitates due diligence and oversight in ethical, evidence-based and high-quality care. Globally, frameworks and guidelines in healthcare delivery models have been developed to ensure relevant and applicable engagement with AI and digital technology. New programmes, using digital interfaces, must follow these principles to ensure quality of care, minimise harm to patients and respect values and priorities. Any digital intervention must also include provider education and training in the use of the new modality; in-person and online clinical care are different beasts and often require differing skill sets and ethical foundations.

Digital MH services in Pakistan: In the complex backdrop described above, digital solutions for mental health care delivery in Pakistan must be well-researched. Adding new-age services to a scarcity landscape, without buffering and buttressing the system, may prove more catastrophic than beneficial. When there is such stark trained workforce shortage, is there transparency on end providers? What are the processes being used to measure and ensure ongoing quality? Are we measuring patient usage, satisfaction and outcomes? As we create demand for mental health care, do we have a trained and credentialled supply of quality management? These are just a few questions.

Pakistan’s MH landscape requires a comprehensive and strategic approach that includes, amongst other priorities, a legal and policy framework, innovative training and regulation structures, and health literacy and advocacy interventions.

Digital technology is a tool that can be used to scale and accelerate the efforts described above. It is not the solution and should not be used to take attention away from a system already mired in challenges. We must take our time with digital solutions and ensure that all such programmes are vetted in needs assessment, take a contextual approach, stay relevant to community awareness and digital comfort and are informed by a systems and programme evaluation approach.

We are appreciative that there is a robust discourse around mental health. The effective response must be measured and steady.

The writers are consultant child, adolescent, and adult psychiatrists at the Synapse Pakistan Neuroscience Institute.

Twitter: @ayesha_mian1

Twitter: @AishaSChachar

Published in Dawn, April 27th, 2023