The evolving crisis in Pakistani mental healthcare

The Pakistani healthcare system is no stranger to challenges. A dearth of infrastructure, constant cuts to a meagre health budget, overpopulated hospitals and overwhelmed physicians – by and large, the system in its entirety is either a marvel of medicine based on sheer human effort or a pariah exemplifying poor policy-making on the part of unconcerned politicians. Yet even in these less than ideal circumstances, there is a proverbial black sheep in the fields of medical care – mental illness is still a concept at best foreign to most and at worst challenged for its very existence.

To provide a brief insight, the World Health Organization's Mental Health Atlas Project gathers country-specific data in order to analyse progress towards achievement of objectives listed in the WHO Comprehensive Mental Health Action Plan for 2013–2020. According to the 2017 atlas,¹ no mental health data had been compiled in a report for policy, planning or management purposes in the previous 2 years in Pakistan. The inadequacy of organised efforts at the level of institutions means that a lot of information cannot be reliably reported, but the few statistics we do have are alarming. The government's expenditure on mental health is 0.40% of the total health expenditure. Disability-adjusted life years due to mental illness work out at 2430.27/100 000 population. The suicide mortality rate is 2.9/100 000. There is neither a specific policy with implementable targets that can be monitored for progress, nor a dedicated authority to ensure its implementation.¹ The 2009 WHO-AIMS report on Pakistan's mental health system estimated the numbers of psychiatrists and psychologists to be 342 and 478 respectively.² Some more recent unofficial reports project the number of psychiatrists to be 500 serving a population of around 200 million. Given these figures, it is not surprising that mental health policy faces a crisis in practical implementation.

History of mental health legislation in Pakistan

The Mental Health Ordinance 2001 was the last legislation passed for mental health policy, replacing the Lunacy Act 1912, which set out the provisions for admission, care and some legal rights of the ‘lunatic’.^{Reference Somasundaram3} Under the ordinance, a mental health authority was to be established, comprising psychiatrists, psychologists and the Secretary of Health. This authority was not only to oversee the training and review of existing personnel and facilities, but also to formulate new policy for awareness and national standards of care. Much of the admission protocol from the Lunacy Act was retained and most of the guidelines for basic human rights of the mentally ill, including but not limited to their right to confidentiality, consent and appropriate treatment in case of attempted suicide. It also stipulated provisions for the examination of prisoners with mental diseases. Most of the amendments made to the act thereafter have only delineated the jurisdiction of the provincial governments and have not focused on any improvement in implementation or the adoption of a standard of care. No provincial act even exists for Baluchistan or Azad Jammu and Kashmir to date.^{Reference Tareen and Tareen4}

The legal framework and sample cases

Although ground rules of the approach to mental illness exist, the biggest challenge is the translation of these principles in the civil and criminal justice system. Civil courts have to deal with numerous cases related to ownership of assets/property, financial contracts and guardianship of people with mental illness.

In criminal law, chapter XXXIV, sections 464–475 of the Code of Criminal Procedures discuss the rights and exemptions for individuals without a ‘sound mind’. Ali & Saleem have described a series of cases in which the court had to adjudicate over an insanity plea from the accused. For example, there is a precedent of diagnosed mental illness such as schizophrenia leading to acquittal of the accused from charges of Qatl-E-Amd or intentional homicide. In another case, the absence of permanent infirmity in hypomania led to the dismissal of the accused's plea, on grounds of insanity, to postpone his trial for intentional homicide. In a third case, the accused entered an insanity plea after an initial confession of homicide. It was rejected on the grounds that there was no concrete evidence of mental illness.^{Reference Ali and Saleem5}

However, there are cases that have raised debates on fundamental human rights. In a controversial case, 50-year-old Imdad Ali was given the death penalty by a three-judge bench of the Supreme Court for murder of a cleric, despite confirmation of his paranoid schizophrenia by government psychiatrists who had treated him for the previous 8 years. The court stated that schizophrenia is ‘not a permanent mental disorder’, in direct contradiction to the ICD-10 and DSM-5 classifications of mental illnesses. The British Pakistani Psychiatrists Association (BPPA) wrote a letter to the Chief Justice of Pakistan bringing to light the inaccuracies of the procedure and requesting a panel of psychiatrists for an expert opinion.^{Reference Qadir, Fatima, Hussain and Menezes6} As of 2018, Imdad Ali was still on death row despite multiple appeals in his case, which were all rejected.

In another oversight, suicide and attempted suicide are deemed criminal offences under section 309 of the Pakistan Penal Code. The latter is punishable by incarceration of up to 1 year, or a fine or both. Owing to prevalence of Islamic beliefs that condemn suicidal behaviour and the fact that all attempted suicide cases must be registered by medico-legal centres (MLCs) before treatment, there is widespread hesitancy in disclosing such behaviour or seeking help for it. Pakistan provided no suicide mortality data to the WHO and did not count suicides among its annual mortality data until as recently as 2017.^{Reference Naveed, Qadir, Afzaal and Waqas7} In February 2018, an amendment to the Mental Health Ordinance 2001 decriminalised attempted suicide and proposed the right to appropriate treatment, although the practical implementation remains to be seen.^{Reference Majeed, Amir Sherazi and Afzal8}

Perhaps the most sensitive application of mental health laws in Pakistani society comes in conjunction with the application of the blasphemy laws. The Pakistan Penal Code recognises a number of punishments for various degrees of the offence, the harshest one being death under section 295-C. In 2005, Saifullah Khan, who suffered from severe psychosis and delusions, was accused of blasphemy for alleged desecration of the Holy Quran. His appeal for bail was rejected by a Sessions Court despite the Standing Medical Board's confirmation that the accused was ‘unfit to plead’. The decision was later reversed by a High Court in 2006.^{Reference Siddique and Hayat9} In Shahbaz Masih v State in 2007 Masih was acquitted by Lahore High Court on account of having an ‘unsound mind’, but such success stories are few and far in between.^{Reference Husain10} Numerous times the victims have been extracted from police custody by mobs and beaten or burnt to death despite clear evidence of mental illness. In some cases, the blasphemy laws have even been used to frame or persecute minorities or individuals with disabilities such as Down's syndrome.^{Reference Husain10}