“She was half-conscious when she was brought to me,” our psychiatry professor said, “and this is what she had been prescribed.” He showed us an image of a local psychiatrist’s prescription. The prescription included a total of eight medications, two of which were injections, for a 16-year-old girl who had presented with a two-day history of vague physical symptoms following a stressful event. By all professional standards, she did not even require a single medication; yet here she was, disoriented by eight drugs.
This was unquestionably an unethical practice. However, as I endeavor to demonstrate in this article, this episode is but an exaggerated display of issues deeply ingrained in the mental health profession itself. Precisely because the issues are usually not as exaggerated as in this case, they are far more pernicious. Before delving further, a few disclaimers are in order:
I am not an outsider critiquing these problems to wholly condemn the profession. Rather, I am a practicing psychiatrist, committed to my professional community, who views it as my responsibility to shed light on these issues. My aim is to encourage fellow practitioners to address these challenges and to alert service users to be more cautious. I understand that in a field lacking resources and battling stigma, such a critical stance further complicates matters. However, I believe that critical reflection is as vital for the growth of a discipline as it is for individual development. Additionally, as a rather costly private practitioner by Pakistani standards, it’s important that I openly declare a conflict of interest: the more my views are heeded, the more clientele my associates and I may attract. Nonetheless, I am hopeful that any potential benefit will be counterbalanced by the critical scrutiny that my views and practices will inevitably undergo. I invite my critics to hold me accountable, ensuring that my deconstructive analysis is followed by reconstructive efforts.
Illicit ties with pharmaceutical industry
Prescribing more medications than are justified is the number-one crime of which a shamefully large number of psychiatrists are guilty. If psychopharmacology is all there is to psychiatric practice, should we not at least get that right? Most people with mild-to-moderate symptoms who present to psychiatrists do not need a prescription. Unfortunately, many of my colleagues, despite recognizing this, rationalize by saying that if they don’t prescribe, the patient will think they are not good psychiatrists. If the ludicrous standard of “more medications equals a better doctor” has become popularized, why do we feel compelled to conform to it?
The answer is simple: it is also the standard that pharmaceutical companies hold us to. This is where the kickbacks come from. From international tours (for the entire family, mind you) to “scientific conferences” (my son learns more science from YouTube Kids than most of these conferences ever teach anyone), to tissue paper boxes, pharmaceutical companies cover it all. They only ask you to prescribe their specific brand. The more you prescribe, the more you get.
Even the more severe conditions usually do not warrant more than two medications. I can see the justification for three at times. Four medications are reserved only for really severe and resistant cases. Unfortunately, however, prescribing 4-5 medications has become the criminal norm even for mild-to-moderate cases.
Over-Diagnosis: Medicalization and Marginalization
Life is hard. Suffering is an indispensable part of life. Fear and sadness are normal responses to difficult life situations. Not everyone who walks into a clinic presenting with life challenges needs a DSM/ICD diagnostic category attached to them. Google searches already provide such self-diagnosis checklists; professionals are not needed to exacerbate the situation.
The labels we attach become an indelible part of people’s identities and significantly alter how other physicians, their families, and their employers will interact with them. The patients themselves will see themselves in a different light and behave accordingly. This treatment, for the most part, has significantly negative consequences. The diagnostic guidelines we follow are not scripture, and they are definitely not based on unquestionable science. They are useful and can be significantly helpful in a number of cases, but they need to be employed with extreme caution.
10-minutes per patient?
When your prescription practices are dictated by pharmaceutical companies and diagnostic practices focus on checking off specific catch-phrases from a list, 10 minutes is far too much time. Our patients tell us about experiences in which they received only a couple of minutes of attention. If you are the only doctor on duty in a public hospital with over a hundred patients to be seen in less than 3 hours, the time constraint is understandable. It is not excusable at an administrative level, but it is understandable at the level of the junior doctor. But it does not apply to private practice!
People bring very personal and deeply disturbing problems from their lives to us with really high expectations. Part of the reason they come to us, unfortunately, is that the rapid spread of individualism in our society means they don’t have people to talk to. And end up making them feel unworthy of being heard.
Public hospitals are, in many ways, comparable to garbage dumps, while private practices could easily be mistaken for five-star hotels. Consultants in public hospitals routinely arrive late and leave early. Why? They need to get to their private practices, of course. Public hospitals are tolerated by these superstar consultants because they enhance their image; private practice is where the real money lies.
Neglecting Psychosocial and Cultural Context
Despite touting the “biopsychosocial” model to our non-psychiatry colleagues, and despite this being another reason why less than ten minutes might suffice, we often exhibit a complete disregard for psychosocial aspects in diagnosis and treatment. If mastering three major classes of diagnoses and four categories of medications is our primary skill set, then why do we need an elaborate four-year training program and a series of grueling examinations? If we cannot develop the basic psychological expertise to address existential concerns, do we even deserve the title of “doctors of the mind”? Or should it be “doctors of the brain”? Then how are we different from neurologists?
And this will be a sore point for most of us: aren’t there alternatives within our cultural context to which people can turn for better mental health? Do we have any acknowledgment, let alone a relationship, with those indigenous resources?
The Colonial Mindset: The Core of the Crisis
All these issues converge at a singular point: the colonial mindset that continues to pervade psychiatric practice in Pakistan. This trap prevents us from examining alternative frameworks that could offer more comprehensive, just, and culturally appropriate mental health solutions. There is far more to this malady, but I will limit myself to just a few ways in which the problems I enlisted above relate with a colonial mentality.
Why do we over-prescribe, over-diagnose, and ignore psychosocial and cultural aspects? It is because we are intent on reducing everything psychic to the body/brain. In technical terms, this is biomedical reductionism. What is that? It is an archaic, essentially Western model that believes reality is mechanical and is best understood by breaking it down into its most fundamental parts. As promising as this model was for early developments in science, it is no longer tenable, even in the West. Mere lip-service to a biopsychosocial model, which has failed in its own country of origin, rather than being a remedy, only worsens the problem.
Why are money and long life central to all our concerns? Of course, these are basic human yearnings, but they are yearnings that have found exclusive priority and focus in Western lifestyles. The much-envied Western healthcare system, with capitalism running through its veins, epitomizes this prioritization. Despite its magnificent and jaw-dropping achievements, the glaring shortcomings and unsustainability of these models have become patently obvious. In the UK, NHS employees are almost routinely on strike due to low pay, and the public complains of egregiously delayed access to specialist care. In the US, people drive to Canada or fly to their home countries to undergo surgeries. If the Western economy can’t sustain these models, how in the world are we expected to?
Conclusion and Future Directions
To decolonize psychiatry in Pakistan is not just a deconstructive act—it is also a reconstructive one. It offers us an opportunity to redefine the philosophical foundations upon which our psychiatric institutions stand. It is linked with a similar process in other institutions, but our scope is limited to mental health profession. As we acknowledge our colonial past, we must simultaneously imagine and work toward a future that is more reasonable, relational, and culturally resonant. This was part of Allama Iqbal’s dream for our role in the world. We identify him as a founding father and a national poet-philosopher. However, his warnings against getting deceived by the “dazzling exterior of Western civilization” have fallen on deaf ears. His was a nuanced relationship with Western intellectual resources, one in which appreciating and contributing to scientific developments did not necessitate forsaking our own traditions. This was the reconstructive task for Pakistan.
It is beyond the scope of one article to detail what that reconstructive task entails for the field of mental health in Pakistan. The first step in that direction would be a deeper appreciation of these and other problems. Following that appreciation, we will be in a position to articulate meaningful alternatives. It is our hope to articulate that in a series of articles on Mad in South Asia.