IN my last column on the physical health of those with mental illness, I talked about evidence that showed people with mental illness had higher physical morbidity and early mortality as compared to the general population. I provided some global figures, but now, we also have evidence of this from South Asian countries, including Pakistan.

A cross-sectional study was published online by the British Journal of Psychiatry in February this year by Gerardo A. Zavala, Asiful HaiderChowdhury et al, involving 3,989 patients 1,314 of them from Pakistan with severe mental illness (conditions such as schizophrenia, bipolar disorder and psychotic depression) and going to mental hospitals in Bangladesh, India and Pakistan. Eleven per cent of these patients had diabetes, 23.3pc had hypertension or high blood pressure and 46.3pc were overweight. Of these mental health patients, 70.8pc had not been previously diagnosed for these physical conditions and only half of those diagnosed were receiving any treatment. The prevalence of all these physical conditions in those with severe mental illness was found to be considerably higher than the general population in these countries. Pakistani patients in this study were particularly found to be smoking more than the general population.

Covid-19 brought to attention mental health issues during the pandemic like never before.

The combination of multifactorial psychosocial stresses and isolation highlighted mental health issues not only among Covid patients but also the people at large and among healthcare providers.

It also brought into focus existing unattended and widespread mental health problems.

However, less attention has been paid to how people already suffering from severe mental illness survived the pandemic. Some useful crosscountry work has taken place in this direction, which has shed light on this dark corner of the global pandemic.

Before dwelling further on this part, it is important to give readers an idea of the scale of mental health issues and access to mental health care in Pakistan. A comprehensive study for Pakistan has been led by the US-based Institutefor Health Metrics and Evaluation, which has looked at `The state of health in Pakistan and its provinces and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019`. Published recently in the Lancet, the study has meticulously analysed the diseases weighing down on Pakistan the most, the risk factorsfor286causes ofdeathand369eauses of non-fatalhealthloss.Thisworkended justbefore the Covid-19 sweep.

In this detailed analysis, depressive disorders ranked second among leading causes due to which the people of Pakistan live with disability over the years (on top was dietary iron deficiency). This work has also shown that among the top 25 leading causes of disability-adjusted life years (DALYs) in Pakistan, depressive disorders have climbed up from the 22nd position in 1990 to 16th in 2019. DA LY is an interesting metric calculated by adding years of life lost due to premature death and years of life lived with disability.

According to WHO, globally, one in every eight people lives with a mental disorder; only 29pc of people with psychosis and only one-third of people with depression receive formal mental health care. This situation in lowand middleincome countries is much worse. According to one estimate, there are only around 600 psychiatrists in Pakistan and almost all of them are located in the big cities. Mental health is stigmatised, severely underfunded and underresearched. Mental health issues are growing fast and are largely not prevented and remain untreated. In a local study, it has been found that 32.4pc of mothers in Pakistan suffer from perinatal depression, ie, depression among mothers around the time of childbirth; 95pc of them remain untreated. Thirty-five per cent of schoolaged childrenin the countryhave been assessed to have emotional and behavioural problems.

The IMPACT research team, which studied the higher prevalence of physical illnesses among people with severe mental illness in South Asia just before Covid hit the world, also decided to study the impact of the pandemic on people with severe mental illness. It is obvious that because of pre-existing disabling mentalconditions, these people would be disproportionally affected during any emergency situation, more so during a global pandemic due to an infectious disease.

Under the project IMPASS, they have studied the impact of the Covid-19 pandemic on people with severe mental illness and on mental health service provision in Bangladesh and Pakistan.

The Institute of Psychiatry, Rawalpindi Medical University led this work in Pakistan. They reviewed the relevant literature, surveyed 1,299 people with severe mental illness, surveyed 31 mental health facilities, spoke to families of the patients and healthcare workers and organised stakeholder meetings. The team could only speak to those people with mental illness who had reported to a mental health facility a huge limitation for their work as most patients with severe mental illness in Pakistan lack institutional care.

The researchers found that these people suffered economic hardship and food insecurity during the course of the pandemic. A considerable proportion of the people with severe mental illness reported difficulty in obtaining medicines and seeing healthcare professionals during this time. Government restrictions had a huge impact on employment and caused further social isolation. Since only those people were interviewed who had access to mental health facilities, and since there was a necessary condition for vaccination for these people to be seen by health workers, higher than expected vaccination was observed among them 77pc were found to be vaccinated which was even more than the general population at the time of this study.

This work has concluded that people with severe mental illness are more vulnerable and at risk from the effects of pandemic. The findings of this work must indeed guide the formulation of the future mental health policy in the country. • The wnter is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University and WHO adviser on UHC.

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