Shank’s mare

Missing a bus could be a wonderful experience, provided you utilize this time to ponder over your life’s curve. These small pockets of time could come handy if one is given to introspection. Other day, I missed a bus and I decided to tred back home by shank’s mare.

On the way back, I saw a swan sitting in the middle of the road, by the lake side, calm and cozy with her beak buried deep in her feathers. Instantly my mind went to the good Lord in the blue canopy above and around us, to whom we all belong, who is watching over us all the time. One’s heart and soul find peace and comfort in His reassuring presence. There are the situations when you could feel that God is around, in cool breeze ruffling the feathers of the swan, moments like these bring you closer to Him. We have to believe in His presence, only then we can actualize such moments. In the words of Lawrence, ‘if in this life we would know the serene peace of Paradise, we must school ourselves in familiar, humble, and loving converse with God”.

Some would argue that belongingness is a basic need for all human beings. It is a basic need like eating and sleeping, which we all need to have before we can move on to higher order needs on Maslow’s hierarchy. Fulfillment of this would encourage the search for higher order attainments – self actualization can only come once this is formidably consolidated.

One way to find real peace of mind is to follow one’s dreams and work towards actualizing the cherished goals in life. Any time management technique which doesn’t put a person in touch with his inner self is a marketing gimmick. Question to ask is why have we cramped our lives and time with clutter of activities – from absolute nonsense to things that we actually don’t enjoy doing? Happiness, we are told lies in pursuing worthy goals and actualizing our true potential. However before we can have it, we have to confront our fears of saying ‘no’. Only then we can redirect the course of our lives- individually and collectively. It takes courage to say no to an old routine, which has become a familiar way of life. The hound of disapproval might come back to haunt us. However saying yes to our dreams brings a new stride in our feet, an attitude with which we can actualize every possibility. With such small decisions we could redirect the course of our lives.

So on next working day, miss a bus or take a walk back home. Think about the course of your life. What needs to be shed – like an old cloth? This will make room for more challenges and happiness. You might also see a spectacle of joy and presence, telling you that you were created to be happy, to enjoy the serenity of days in your life. An everlasting presence might dawn upon you, fulfilling you days with peace and joy.

Suicide Prevention day!

It is estimated that one million people commit suicide every year; one death after every two minutes. Rates of suicide vary over the course of life span. Among all the suicide related death 60% are happen in Asia. Concerning fact is that it is the highest cause of mortality in the age group of less than 30 years. Another grave statistics is the high estimates in married females. Suicide leaves a grave scar on the psyche of the family, which struggle with the remorse of this tragic event for all the days to come. While the relative may be alive physically, they lose the will to live. Most of them end up with depression. All efforts should be made in order to prevent this dreaded cause of death. Looking at its consequences, one death is too many, in case of suicide.
Suicide is on the rise in Pakistan, so informs research carried out over the course of decade at Aga Khan University. The various social and religious factors which use to protect people from the suicide are changing. The fine balance between the will to live and impulse to harm oneself is being disturbed. What are the factors which cause this: literature informs us that there are some immediate factors while other are long term contextual difficulties which makes people vulnerable to deliberate self harm. Social and economic deprivation makes people vulnerable to self harming behavior. World Health Organization (WHO) estimates that for every suicide there are at least 10 to 20 cases of deliberate self harm. Delayed dispensation of justice, social inequity, economic deprivation and sustained stress push people towards hopelessness. In desperation individuals resort to self harm. Once they cross this threshold than it becomes difficult to get back to the baseline mental health.
It is encouraging that there is an international recognition on the burden of this issue. A concerted effort on parts of International Association of Suicide Prevention (IASP) and WHO has made it possible to organize a World Suicide Prevention day on September 10th , 2009. This was organized initially in 2003, catching momentum in subsequent years. This year a conference is being organized at Aga Khan University on September 30th, 2009, with a theme ‘Suicide – Hidden realities in Pakistan.
This task is too important to be dealt by mental health care professionals, alone. Media along with the civil society has to play its role in propagating the message that suicide is preventable. This needs to be done in cultural context. One of the biggest impediments in reducing the stigma attached with this mental health problem is its legal status in the context of Pakistan. According to Pakistani law, suicide is a crime, punishable by jail term and financial penalty. Though conviction rates are low, it impairs help-seeking, limiting it to handful of centers with medico-legal cell. Most victims seek care in the emergency care departments of general hospitals, which are ill equipped, in terms of training and expertise related to psychological management of such cases. This slipshod approach leaves many hanging. Easy, over the counter accessibility of drugs is another menace which feeds this problem. Perhaps the most troublesome predicament is the availability of Organophosphates in the rural and semi-urban settings. It is not surprising that these factors contribute to the rising suicide rates.
Relatives and family members have to deal with the issues of Suicide. It is ironic when they get blamed for the death of the relative. However burden of this grief can be heavy; mind goes back to things which could have been done differently, the micro-expression of relief which, in hindsight, are dreaded way of saying a farewell to long period of misery. Therefore it is equally important to address the grief and guilt inculcated in the relatives of the deceased. Media when employed constructively can reduce the burden of this mental, social and public health problem.

Pathways to Care: Experience from Pakistan

In order to recover from disease and improve health, patients choose different forms of treatment and care. A delay at any stage could be detrimental, leading to psychological, social or medical complications.

Research form the West has shown that general practitioners (GP) are the gatekeepers to specialised psychiatric services. This is similar to a model constructed by Goldberg and Huxley, proposing that patients have to pass through three filters in order to reach specialised mental health care (community-GP-psychiatric care).

In Pakistan, there are three main mental health service providers: the specialists in private sector, the government and traditional healers. Most of the government run mental health facilities are urban, mismanaged, poorly resourced and understaffed with irregular provision of medications. Generally, the poorest sections of the society visit these hospitals since they have no other options available. The rest prefer treatment from private medical specialists.

But even that has its own problems. It is unregulated while monetary exploitation and abuse of patients is not uncommon. This is particularly so in patients with schizophrenia, which leads to delay, thereby increasing the psychosocial morbidity and burden of illness. This is further compounded by the extreme dearth of psychiatrists and other mental health professionals in the country. For example, it is estimated that there are only 360 psychiatrists for a population of 160 million.

According to the World Health Organization (WHO), mental healthcare services should be integrated with general health services and provided in a decentralised manner. It is also beleived that trained health professionals are scarce in developing countries. If proper health care is to be brought within reach of the masses, primary healthcare physicians must work in collaboration with specialised personnel.

Research from the West and developing countries shows that about a quarter to half of the patients in primary care have mental health needs that have not been addressed. Due to poor awareness and resources, primary care staff has not been trained to treat and manage mental illness, thereby fulfilling the need-supply gap. This model was conceived by psychiatrists in the western countries with administrative convenience and well-established primary healthcare system.

In Pakistan, primary health is poorly developed with weak referral chain from primary to secondary to tertiary care services. Most patients by-pass the primary care services and access services at secondary and tertiary care centres directly. The main reason is the poor quality of services offered. Additionally, in the absence of any kind of health insurance, most patients pay out of their own pockets.

Studies on integration of mental health services in primary care centres in Pakistan are inconclusive. The issues involved are related to the perception of government-run primary health care services as well as the costs involved, knowledge of services, stigma, pathways to care and design issues.

A few years ago WHO and Pakistan medical and research council (PMRC) did a survey in order to study the reasons behind the poor utilisation of available BHU services. Low numbers and attendance rate of doctors (63.8 per cent), non-availability of medicines (22 per cent), geographic inaccessibility and low quality of services were some of the major factors. Public sector tertiary care hospitals (TCH) are a major recipient of government budgetary allocation, leaving little resources for improvement in the available primary health care infrastructure. Employees’ salary comprise 55 to 66 per cent of the budget, leaving little room for technological advancement, equipment and medicines.

Integration of mental healthcare in ailing primary care system is a difficult issue which may seem feasible for countries with well-established primary healthcare system. Nearly half a decade of research on pathways to psychiatric care in Pakistan has shown different, yet interesting trends.

For example, a pathway to psychiatric care study from a tertiary care hospital demonstrates that among 96 patients, only 2.8 pre cent were referred by primary care physician as opposed to 20 per cent referral from specialists in other fields of medicine. In this study 63 per cent cases were self/family referred. Only 17 per cent patients had a primary care physician. Clearly, the expected model of primary to tertiary referral care appears to be lacking at a practical level. In this study the principal referral path in Pakistan appeared to be word-of-mouth rather than primary care.

A substantial time period is lost before initiation of treatment in schizophrenia, which is labelled as duration of untreated psychosis (DUP). In the absence of a well-developed primary healthcare system, a majority of patients visit psychiatrists as their first contact. Time is lost due to non-recognition of prodromal symptoms and subsequently, inadequate treatment. Primary care system, which is competent and motivated, needs to be created while specialists must play their role in training and supervising this mass of generalists.

The prevalent apathy in public and private sector is primarily because of lack of awareness and the stigma related to mental illnesses; a perception which needs to be changed. An active public-private partnership could be a workable solution for mental health service provision. This requires a unified agenda and commitment from both tiers. Any lasting solution must address the deep rooted inequities, ethical misconducts and macroeconomic issues.