Letter to the Editor

The COVID-19 pandemic outbreak impacted several countries worldwide, yet each community experienced distinct circumstances, challenges, and difficulties. COVID-19 has exposed disorderly governance, untrained human resources, incoherent information systems, and suboptimal health service delivery systems in many countries including Pakistan. The country’s adopted lockdown caused most outpatient departments in hospitals and private practitioners/ rehabilitation centers to remain closed and the consequences are still prevalent post-COVID. ^{Reference Rana, Mukhtar and Mukhtar1} During the lockdown, existing mental-health patients faced difficulty in receiving treatment, which precipitated relapse, and uncontrollable behaviors, as well as self-harm, and further mental health problems. During that period, 33%, 40%, and 27% of Pakistanis experienced depression, anxiety, and stress respectively. ^{Reference Riaz, Abid and Bano2} Furthermore, 36.2% of Pakistanis showed noticeable symptoms of depression and 50.4% showed substantial anxiety symptoms post-COVID-19 pandemic. ^{Reference Ullah, Khan and Ali3} This paper presents preventive and corrective disaster preparedness measures to manage the public mental health crisis in the Pakistani population.

According to the World Health Organization, over 24 million people in Pakistan are suffering from some form of mental health-related issues. Despite being a major contributor (8.9% to the overall disease burden), mental health remains neglected at large. ⁴ In LMICs (low-and-middle-income countries), which are more vulnerable to natural disasters, poor socioeconomic statuses, and mental health crises, allocation of resources remained disproportionate. For instance, only a fraction of the Pakistani budget (Table 1) is allocated to mental health which is 2.4 billion (0.4%) from the total health budget of 617.2 billion PKR. ^{Reference Gadit5} Since Pakistan’s public health sector has yet to fully recognize psychology as a profession, the number of mental healthcare professionals is limited. Furthermore, Pakistan has no comprehensive mental health law, consequently making it a complicated issue in terms of institutional infrastructure and legislation as well. ⁴

Table 1. Country-wise date from Pakistan for the year 2020 (peak of COVID-19)

Despite the 10 – 16% prevalence of mental illnesses in Pakistan’s population, mental health remains a neglected national priority in terms of disaster preparedness, efficient healthcare systems, and public health management. ^{Reference Ansari6,Reference Mukhtar7} According to the INFORM disaster risk index Pakistan is ranked 18^th out of 191 countries indicating high risk in terms of hazard and exposure, vulnerability, and lack of coping capacity (DRMKC – INFORM). ⁸ The COVID-19 pandemic, coupled with the monsoon flood of 2022 which displaced more than 33 million people, has contributed to psychological distress, and mental health issues. ⁹

COVID-19 has reportedly precipitated and perpetuated mental health consequences including anxiety, depression, and stress. Quarantine and lockdown precipitated a fear of death, panic, hoarding, and economic distress/poverty, as well as domestic/intimate partner violence against women. ^{Reference Mukhtar10} Country-specific literature has reported aggravated xenophobia, anxiety, PTSD, and disease-associated stigma on the rise, even towards medical healthcare practitioners. ^{Reference Rana, Mukhtar and Mukhtar11} Despite the high rate of mental illnesses in the country, help-seeking is drastically low due to the prevailing stigma regarding mental health, lack of awareness/ education, and low literacy rate, as well as the taboo around psychiatric patients, and religious fanaticism. There is only 1 psychiatrist available for 500 000 people, which is 1 of the lowest in the world. ^{Reference Torjesen12}

Primary care facilitators and community health workers appeared less trained for raising awareness, prevention, care, and psychoeducation, as well as mental health repercussions. The following are a few recommendations in terms of assessment, management, intervention, and prevention towards public mental health care:

Cost-effective and Sustainable Psychological Interventions

Pakistan needs robust mental health research on effective prevention of mental challenges, capacity building, and sustainable mental health interventions to attain the United Nation’s Sustainable Development Goals (SDGs) for 2030. ¹⁴ Psychological Crisis-Intervention (Risk-Resilience- Recovery) should operate through certified and trained mental health practitioners to provide standardized psychological assistance for emotional-mental well-being, as well as cognitive-behavioral and psychosocial impacts, effective immediately (Figure 1). Frontline healthcare response teams at provincial, district, and sub-district levels should implement advanced training on COVID/disaster preparedness, and management/control for future pandemics/epidemics.

Figure 1. Precipitating, perpetuating, predisposing, and protective factors of mental health in Pakistan.