GIVEN the shrinking space for freedom of expression, what should be the subject of the first column in the new year? A frivolous question perhaps but it has to be asked. A look at the mountains of words used over the past few days to describe the anxieties of the state and society shows that the decline in the Pakistani people`s mental health is one of the issues left unattended. The subject thus chooses itself for today`s discussion.

It is quite a serious matter. Our guide is the Pakistan Association for Mental Health (PAMH), which celebrated the golden jubilee of its existence last year, quite an achievement for a civil society organisation in a state that likes to keep the entire civil society on the chopping block.

According to PAMH, more than 34 per cent of the country`s population is at present suffering from one form of mental disorder or another. The figure probably does not include a large number of people who have never seen a psychiatrist and who hotly deny the need for doing so. As a test we have in mind not merely freedom from mental illness but the WHO-defined right to the enjoyment of physical and mental health.

Further, according to a PAMH survey of mental health between the 2007 and 2009, every second house in Karachi had one or more persons taking tranquillisers; every fourth house had a psychosomatic/psychiatric problem and masked depressive disorder; every tenth house had a patient needing psychiatric care for depression, psychosis, psychosomatic disorder, obsession, intellectual disability, epilepsy or drug dependence. Overall in Karachi there were two million people suffering from mental, emotional, intellectual or social adjustment disorders, of which at least 0.3m needed urgent psychiatric/psychological attention; in the whole of Pakistan 20m people (10 pc of the population according to WHO) were then reported to be mentally ill.

In Karachi of course there are multiple reasons for the decline in mental health such as threats to life, fear of gangsters, mafias, extortionists and security forces that have not assumed epidemic proportions in other parts of the country. But in other areas too, unemployment, increased lossessustained by small farmers, rising cost of living and police excesses pose formidable challenges for the citizens` mental health. And the anxieties of the rich and the privileged are too well known to nee d retelling.

According to PAMH, escape from anxiety/insecurity takes three routes drug addiction, religiosity and/or politics of nihilism. Given that a surge in these symptoms, especially religiosity and politics of nihilism, is visible even to a layman`s eyes, the population of Pakistanis with mental disorders may well be more than what is reported by any organisation.

As against this fairly high incidence of mental illness, facilities in the public sector for the treatment of patients are grossly inadequate. While institutions in the private sector have tried to fill the gaps in the mental health cover, the cost of treatment is beyond the capacity of a majority of the population. However, PAMH, as stated in a publication to commemorate its golden jubilee, has been able to prove, after running a clinic for free treatment of persons with mental illness, that `with as little as 13 medicines, 90pc of the patients can be treated (WHO-proposed formulary)` Further it says, it is the high cost of consultation that drives the less affluent to seek help from quacks and faith healers.

At the same time, PAMH has shown that Serious Mental Illness (SMI) `needs only general care of patients including attention to diet, proper hygiene, and regularity in taking the prescribed me dicines`. In order for the regimen to be successful, a member of the patient`s family must be inducted as part of the treatment plan and he or she must be able to access a community mental health worker that the association or some other organisation has trained.

Fortunately, awareness of the need to pay due attention to matters related to mental health and facilities for the teaching and training of psychiatrists and psychologists have grown considerably over the years. A notable feature of this phenomenon is the leading role played in it by eminent psychiatrists and psychologists.These mental health professionals also spearheaded the campaign to have the old Lunacy Act replaced with the Mental Health Ordinance in 2001. Their role was even greater in persuading the Sindh government to adopt the Sindh Mental Act in 2013, which was followed by similar enactments in Punjab and Khyber Pakhtunkhwa about two years later.

In 2015, the Sindh Mental Health Act was amended to explore the nexus between the attempt to commit suicide and the offence of blasphemy and mental disorder. The amendment, which deserves to be better known and more widely adopted, goes as follows: `A person who attempts suicide including (...a person) accused of blasphemy shall be assessed by an approved psychiatrist and if found to be suffering from a mental disorder shall be treated appropriately under the provisions of this Act.

The journey of public-spirited practitioners of psychiatry has not ended. For quite some time they have been demanding the following: • Aboliting `mental hospitals` and setting up small hostel-like accommodations in every district and even down to the tehsil level.

• Linking psychiatry departments of teaching hospitals to such hostels and giving institutional advice to the community.

• Training a new breed of mental health workers and community mental health promoters to take up the major burden of care after diagnosis is made; and • Strengthening undergraduate teaching of psychiatry and behavioral science.

While these demands need to be seriously examined, the sharp decline in the people`s mental health calls for a study by a high-powered commission into the causes of this worrying trend. This body should also suggest measures the state must take, not only to upgrade facilities for the care of people with mental disorders as well as those with serious mental illness, but also to review employment and wage policies, strengthen medicare and social security cover, and revamp the justice and law and order regimes. •