The 2022 floods

Pakistan has experienced the worst national disaster in its history owing to the June 2022 floods, which have also been declared a major health emergency.³ The disaster has affected 33 million people, resulting in 15 million displaced people, 12 867 injuries and 1700 deaths.³ The destruction of over 2000 health facilities and disruption of healthcare services has left 8.2 million people in flood-affected areas without urgent healthcare services.³ Floods have a substantial mental health impact, mediated by physical trauma and economic insecurity, increased gender-based violence, domestic abuse and bereavement. The stressors resulting from financial insecurity intersect with direct flood impacts to increase the prevalence of mental health conditions such as anxiety, complicated grief, depression and substance misuse.^{Reference Asim, Mekkodathil, Sathian and N4} Consequences of disastrous climate events range from post-traumatic stress disorder due to the experience of flooding to the impacts of forced displacement on climate refugees.^{Reference Asim, Mekkodathil, Sathian and N4} Similar to previous natural disasters in Pakistan, such as the 2005 earthquakes in the northern areas, the absence of mental health and psychosocial support services (MHPSS) has been observed.^{Reference Baig, Rehman and Janjua5} The population has experienced a significant increase in mental health conditions, as evidenced by data indicating a surge in depression following flooding. In fact, clinical diagnoses of major depressive disorder were reported in 61% of the population studied.^{Reference Sazi, Alam, Piracha, Shahzad and Munir6} The Ministry of Planning Development & Special Initiatives (MoPDSI) reports that 1 in 5 people in flood-affected areas will need mental healthcare services.⁷ According to Global Burden of Disease data, in 2019 approximately 25 million (11%) of the country's population suffered from mental health conditions.⁸

In Pakistan, only 500 psychiatrists^{Reference Sikander9} serve the population of approximately 220 million, with almost all of them concentrated in urban areas. Thus, this shortage is particularly pronounced in rural areas, where most people affected by recent floods live. Research conducted by the UN and the MoPDSI found that among the 80 districts most severely affected by the disaster, approximately 83% of flood-affected districts in Balochistan, 56% in Sindh, 70% in Khyber Pakhtunkhwa, 66% in Punjab and 33% in Gilgit-Baltistan do not have a single psychiatrist.^{Reference Humayun10} In many cases, these communities are low-income and are unaware of or unwilling to address psychological impacts.^{Reference Humayun10} The baseline assessment of the initial mental health state in flood-affected regions of Pakistan indicates a surge in the prevalence of depression, anxiety and stress. Out of the individuals evaluated, 38%, 20% and 43% respectively were diagnosed with these mental health conditions directly attributed to the flood disaster.^{Reference Abid, Riaz and Husain11}

Our call to action

In the wake of the flood disaster in Pakistan, it is important for the government and mental health policymakers, along with academic coalitions and non-governmental organisations (NGOs), to develop and advocate for fit-for-purpose techniques and services provided by mental health professionals to deliver gender-sensitive mental healthcare. The use of ecotherapy and ecopsychology techniques in clinical work can be helpful in supporting patients and helping them gain insight during the therapeutic process. It is also important to strengthen the capacity of mental health professionals by adapting and changing their clinical training and approaches to adopt a non-pathologising approach in treating strong emotions experienced during interactions with affected communities.

Furthermore, indoor clinical rounds can be repurposed to provide integrated patient care and space to interview patients who come from flood-affected areas to better understand their emotions and help address acute feelings of hopelessness and anxiety. Based on the emergency MHPSS model^{Reference Humayun10} developed by the MoPDSI after the 2014 terrorist attack on the Army Public School in Peshawar, there has been increasing evidence of innovative digital models for MHPSS, focusing on providing culturally competent telemedicine services to patients.⁸ There is a dire need to establish community-based strategies to adopt task-shifting of MHPSS. The intervention may focus on integrating care at the primary healthcare level by increasing the capacity of non-specialists, including community representatives, primary healthcare providers, young mental health advocates, teachers, emergency responders and counsellors, to manage common mental health issues and recognise individuals who require professional support provided by district-level tertiary care specialists.

In this call to action, we urge mental health professionals and policymakers in Pakistan to align their efforts with established programmes that integrate MHPSS into disaster risk reduction strategies, as seen in low- and middle-income countries:

1. (a) initiate a multi-stakeholder dialogue on climate change and mental health by inviting national and international climate change advocates and experts to prioritise the provision of MHPSS with a gender-responsive approach

2. (b) develop and integrate climate change modules within the training curriculum for mental health professionals working in current and future climate change catastrophes

3. (c) include telepsychiatry in disaster relief packages along with essential health services delivery.