“There are wounds that never show on the body…” — Laurell K. Hamilton
Asim Jamil, a young man in his 30s, killed himself some days ago. A huge tragedy. May Allah bless his soul. My heartfelt condolences to the grieving family. He was the second son of the famous Maulana Tariq Jamil, a renowned religious scholar and a household name in Pakistan.
To quell rumours, the bereft older brother recorded and released a video message on social media, explaining the circumstances of his death. Tired of the chronic depression he had been suffering from since the age of 13, Asim took his security guard’s gun and shot himself in the chest.
The brother explained that for the last six months his depression had become severe and he was undergoing ‘electric shock treatment’. This was the will of God and we are satisfied with His will, he said.
What is the depression the late Asim Jamil was suffering from?
We all feel low from time to time for various reasons. Usually, it is due to some loss or sense of failure — for example, the loss of a loved one. Sometimes one feels low without any understandable reason. But most often, the sadness goes away in a few days or weeks and we are back to normal. However, if it persists beyond two weeks and increases in severity, then a point comes when it becomes a disability — a depressive illness or a depressive disorder — and requires therapeutic intervention, like any other physical health condition.
Globally, an estimated 5pc of adults suffer from depression.
It is just like having a common cold which generally stays for a few days and then goes away, but then, sometimes, turns into a respiratory tract infection requiring antimicrobial treatment. Rarely, it may even turn into life-threatening pneumonia.
In the manner of a physical health condition, depression is a mental health condition. Human health, according to the WHO definition, is a state of complete physical and mental well-being, together. So, the physical and mental dimensions are inextricably woven in the word ‘health’. They coexist within us, influence each other and require equal attention.
According to WHO, a depressive disorder involves a depressed mood or loss of pleasure or interest in activities for long periods of time. It can affect all aspects of life, including relationships with family, friends and community. Other symptoms may include poor concentration, feelings of excessive guilt or low self-esteem, hopelessness about the future, thoughts about dying or suicide, loss of or disrupted sleep, changes in appetite or weight, and feeling very tired or having low energy. A person suffering from depression prefers isolation.
A depressive episode can be categorised as mild, moderate, or severe, depending on the number and severity of symptoms, as well as the impact on an individual’s functioning. There can be a single episode of depressive disorder or there can be recurrent episodes. Depression can be a part of bipolar disorder, in which depressive episodes alternate with periods of manic symptoms, which include euphoria or irritability and increased activity or energy. Sometimes depressive illness runs in families.
Depression is on the rise. Globally, an estimated five per cent of adults suffer from depression. In Pakistan, in 1990 depressive disorders ranked 22nd among the leading 25 causes of Disability Adjusted Life Years, a metric calculated by adding years of life lost due to premature death and years of life lived with disability. By 2019, depressive disorders had jumped to the 16th position. Depression is about 50pc more common in women than men. Globally, one in four women suffers from pregnancy- or childbirth-related depression (perinatal/postnatal depression), the prevalence of which would be even higher in Pakistan.
Depressive illness or depressive disorder is a treatable condition. For mild depression, cognitive behaviour therapy, a form of talking therapy or psychotherapy by a trained person is helpful. Moderate to severe depression requires high-intensity psychological intervention or antidepressant medication or both. Antidepressant medication must be taken only under continued medical supervision.
The treatment is long-term — six months or more — and the medicines have side effects (dependence is not one of them). They are usually quite effective but must be taken under professional supervision. In a few cases of severe depressive illness, psychotherapy or medication don’t work.
In such cases, sometimes electroconvulsive therapy (ECT) is also administered but it is a very specialised treatment and has to be administered at the advice and under the supervision of a psychiatrist. In common parlance, ECT is referred to as ‘electric shocks’, as Asim Jamil’s brother mentioned in his message.
There is a general lack of awareness and understanding about mental disorders, including depression, even among educated people. Commenting on Asim Jamil’s unfortunate death by suicide due to depressive illness, a senior and popular media anchor described depression in his vlog as a special kind of madness and a contagious condition! Because of such ignorance, people suffering from mental illnesses are stigmatised, called mad, mocked and mistreated.
Our medical training also lacks the required attention to mental health. In our country, mental health issues are increasing and so common that they cannot be left to psychiatrists or psychologists alone. In any case, we have only less than 1,000 psychiatrists and less than 3,000 psychologists in the country. Globally, it is estimated that around 60pc of patients with depression lack treatment, one can well imagine the situation in an income-poor country like Pakistan.
Physical and mental illnesses often coexist. Preventive, promotive, curative and rehabilitative mental health services should be an integral component of quality primary healthcare, and all members of the PHC team and the people themselves must be trained to deal with mental health issues.
Asim Jamil’s tragic death was highlighted because of his famous father. It is, however, a stark reminder of the vast amount of silent and unaddressed mental health suffering all around us.
The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University, WHO adviser on UHC, and member of the Pakistan Mental Health Coalition.
zedefar@gmail.com
Published in Dawn, November 3rd, 2023
Understanding suicide
Zafar Mirza
“No one commits suicide because they want to die”… “Because they want to stop the pain”.
Tiffanie DeBartolo
WHILE late Asim Jamil’s tragic suicide is fresh in minds, it is important to talk about the phenomenon by way of demystifying and destigmatising it.
I know three people in my life who took their own lives. One had been visibly in a low mood for some time before he hanged himself. Another, an adolescent, had a fight at home on some sticky matter and in the evening his body was found on a nearby railway track.
The third one was burnt in his house; there is speculation that the arson was deliberate, as he was living alone following a separation. Now that I have sat down to write on the subject, the faces of all three dear ones are coming to my mind, two cheerful, one sad. May Allah bless them all.
Suicide, “the deliberate act of killing oneself”, indeed can happen as a premeditated act or on an impulse. It can happen due to a stressful life situation or because of mental illness.
Sometimes people kill themselves when they reach a dead end in a crisis situation, e.g. Hitler, and sometimes it runs in the family, for example, the famous writer Earnest Hemingway had seven members over four generations who took their own lives. There are also instances of mass suicides. Suicide, hence, is a diverse phenomenon in terms of its occurrence, reasons and methods.
Mental disorders and suicide are closely related. Systematic reviews inform that up to 70 to 80 per cent of suicide deaths are attributed to a mental or substance use disorder. Relative risk of suicide in people with depressive disorders is highest followed by bipolar disorder and schizophrenia.
Psychological autopsy studies have shown that 40pc of suicides in China, 35pc in India, and 37pc in Sri Lanka are linked with the diagnosis of depression. However, an important study published from Pakistan in 2008 by Murad Moosa Khan et al found even stronger association between mental disorders, especially depression and suicide.
Of the 100 suicides the team studied, 96 were established as having psychiatric disorder through psychological autopsy and 79 out of these had depression as a principal diagnosis.
The most common methods of suicide were hanging, followed by poisoning. Firearms were used in 15pc of these suicides. And only three of these 96 victims were undergoing treatment, one from a psychiatrist and two from family physicians. These numbers speak for themselves and reflect the mental health care situation in the country.
Regardless of the causation, the incidence of suicide is increasing the world over. Globally, around 800,000 people take their own lives every year. Seventy-seven per cent of these suicides take place in low- and middle-income countries.
Globally, among young people between 15 and 29 years, suicide is now the fourth leading cause of death, according to WHO. Of all suicide deaths, 58pc occur between the ages of 15-49.
They are patients, not sinners.
There is a generally accepted rule of thumb that for every suicide there are 10 unsuccessful suicidal attempts and for every such attempt there are 100 people who harbour suicidal thoughts.
According to the estimate of Mental, Neurological and Substance Use Disorders, Burden of Disease study in Pakistan in 2019, there are 9.77 suicides per 100,000 population, which comes to around 20,000 suicides per year in the country. Going by the above, there would be 200,000 attempts and two million people with ideas of suicide.
These are high numbers. In the WHO Eastern Mediterranean Region, among 22 member states, Pakistan has the third highest rate of annual suicides after Djibouti and Somalia.
Lately, there have been reports about high rate of suicides from northern areas, especially in Gilgit-Baltistan and especially among young women. Some researchers have been probing the causes but until now there is no conclusive inference.
More women are educated than men in the main cities and nearby areas in GB, there are limited job opportunities and there are strong local traditions for not allowing young people to exercise their life choices. These and others may be the causes, and it may be simply that suicides are being reported more in the media from these areas because similar causes are not less prevalent in many other areas of Pakistan.
Until this point in the article, I have avoided using the word ‘commit’ with ‘suicide’ as ‘commit’ connotes a crime or a sin. There is a history of how suicide has been considered a crime in different countries. This was the case in Britain until 1961. P
akistan continued with it until Section 325 of the Pakistan Penal Code, a law from 1860 and a colonial legacy, was repealed in May 2022 by the Senate and in October 2022 by the National Assembly. It was a result of a successful national advocacy and lobbying campaign, ‘Mujrim Naheen Mareez’ launched by Taskeen Health Initiative, a Karachi-based not-for-profit working on increasing mental health awareness, providing free-of-cost mental health support and advocating for mental health policy change in Pakistan. Taskeen is also an active part of Pakistan Mental Health Coalition, an alliance of more than 100 members and organisations working to promote mental health.
Under Section 325, suicide was an offence. A person attempting suicide could be imprisoned for up to one year and could also be fined. The state could take over the assets of those that committed suicide. This would result in non-reporting, stigmatising and lack of treatment. The law has changed now and needs to be fully implemented.
Patients with mental disorders, with previous suicidal attempts and suicidal ideation need special attention. Suicide prevention is critical and complicated and professional help must be sought at the right time.
Suicide is also a taboo. Enlightened religious scholars especially need to play an important role in destigmatising suicide as more than 90pc of people taking their own lives are actually suffering from mental illnesses. They are patients, not sinners.
The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University, WHO adviser on UHC, and member of the Pakistan Mental Health Coalition.
Zedefar@gmail.com
Published in Dawn, November 17th, 2023
Peer-Reviewed Publication
Zafar Mirza
“No one commits suicide because they want to die”… “Because they want to stop the pain”.
Tiffanie DeBartolo
WHILE late Asim Jamil’s tragic suicide is fresh in minds, it is important to talk about the phenomenon by way of demystifying and destigmatising it.
I know three people in my life who took their own lives. One had been visibly in a low mood for some time before he hanged himself. Another, an adolescent, had a fight at home on some sticky matter and in the evening his body was found on a nearby railway track.
The third one was burnt in his house; there is speculation that the arson was deliberate, as he was living alone following a separation. Now that I have sat down to write on the subject, the faces of all three dear ones are coming to my mind, two cheerful, one sad. May Allah bless them all.
Suicide, “the deliberate act of killing oneself”, indeed can happen as a premeditated act or on an impulse. It can happen due to a stressful life situation or because of mental illness.
Sometimes people kill themselves when they reach a dead end in a crisis situation, e.g. Hitler, and sometimes it runs in the family, for example, the famous writer Earnest Hemingway had seven members over four generations who took their own lives. There are also instances of mass suicides. Suicide, hence, is a diverse phenomenon in terms of its occurrence, reasons and methods.
Mental disorders and suicide are closely related. Systematic reviews inform that up to 70 to 80 per cent of suicide deaths are attributed to a mental or substance use disorder. Relative risk of suicide in people with depressive disorders is highest followed by bipolar disorder and schizophrenia.
Psychological autopsy studies have shown that 40pc of suicides in China, 35pc in India, and 37pc in Sri Lanka are linked with the diagnosis of depression. However, an important study published from Pakistan in 2008 by Murad Moosa Khan et al found even stronger association between mental disorders, especially depression and suicide.
Of the 100 suicides the team studied, 96 were established as having psychiatric disorder through psychological autopsy and 79 out of these had depression as a principal diagnosis.
The most common methods of suicide were hanging, followed by poisoning. Firearms were used in 15pc of these suicides. And only three of these 96 victims were undergoing treatment, one from a psychiatrist and two from family physicians. These numbers speak for themselves and reflect the mental health care situation in the country.
Regardless of the causation, the incidence of suicide is increasing the world over. Globally, around 800,000 people take their own lives every year. Seventy-seven per cent of these suicides take place in low- and middle-income countries.
Globally, among young people between 15 and 29 years, suicide is now the fourth leading cause of death, according to WHO. Of all suicide deaths, 58pc occur between the ages of 15-49.
They are patients, not sinners.
There is a generally accepted rule of thumb that for every suicide there are 10 unsuccessful suicidal attempts and for every such attempt there are 100 people who harbour suicidal thoughts.
According to the estimate of Mental, Neurological and Substance Use Disorders, Burden of Disease study in Pakistan in 2019, there are 9.77 suicides per 100,000 population, which comes to around 20,000 suicides per year in the country. Going by the above, there would be 200,000 attempts and two million people with ideas of suicide.
These are high numbers. In the WHO Eastern Mediterranean Region, among 22 member states, Pakistan has the third highest rate of annual suicides after Djibouti and Somalia.
Lately, there have been reports about high rate of suicides from northern areas, especially in Gilgit-Baltistan and especially among young women. Some researchers have been probing the causes but until now there is no conclusive inference.
More women are educated than men in the main cities and nearby areas in GB, there are limited job opportunities and there are strong local traditions for not allowing young people to exercise their life choices. These and others may be the causes, and it may be simply that suicides are being reported more in the media from these areas because similar causes are not less prevalent in many other areas of Pakistan.
Until this point in the article, I have avoided using the word ‘commit’ with ‘suicide’ as ‘commit’ connotes a crime or a sin. There is a history of how suicide has been considered a crime in different countries. This was the case in Britain until 1961. P
akistan continued with it until Section 325 of the Pakistan Penal Code, a law from 1860 and a colonial legacy, was repealed in May 2022 by the Senate and in October 2022 by the National Assembly. It was a result of a successful national advocacy and lobbying campaign, ‘Mujrim Naheen Mareez’ launched by Taskeen Health Initiative, a Karachi-based not-for-profit working on increasing mental health awareness, providing free-of-cost mental health support and advocating for mental health policy change in Pakistan. Taskeen is also an active part of Pakistan Mental Health Coalition, an alliance of more than 100 members and organisations working to promote mental health.
Under Section 325, suicide was an offence. A person attempting suicide could be imprisoned for up to one year and could also be fined. The state could take over the assets of those that committed suicide. This would result in non-reporting, stigmatising and lack of treatment. The law has changed now and needs to be fully implemented.
Patients with mental disorders, with previous suicidal attempts and suicidal ideation need special attention. Suicide prevention is critical and complicated and professional help must be sought at the right time.
Suicide is also a taboo. Enlightened religious scholars especially need to play an important role in destigmatising suicide as more than 90pc of people taking their own lives are actually suffering from mental illnesses. They are patients, not sinners.
The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University, WHO adviser on UHC, and member of the Pakistan Mental Health Coalition.
Zedefar@gmail.com
Published in Dawn, November 17th, 2023
More than 1 in 10 pediatric ambulance runs are for mental health emergencies
A new study offers a novel look at the scope of the youth mental health crisis across the United States – in 2019-2020, more than 1 in 10 kids who were brought to the hospital by ambulance had a behavioral health emergency. Out of these behavioral health emergencies, 85 percent were in 12-17-year-olds. Findings were published in the journal Academic Emergency Medicine.
“Our study found that pediatric behavioral health emergencies requiring an ambulance were much too frequent,” said senior author Jennifer Hoffmann, MD, MS, emergency medicine physician at Ann & Robert H. Lurie Children’s Hospital of Chicago and Assistant Professor of Pediatrics at Northwestern University Feinberg School of Medicine. “And yet, there are no national guidelines for EMS personnel to manage these patients. We found considerable variation in the use of sedative medications and restraints across different parts of the country. There is a great need for standardized EMS protocols for pediatric behavioral health emergencies. Currently only four states have these available.”
In addition to regional variation, the study found increased odds of restraint use among patients 6-11 years old. Children with developmental, communication and physical disabilities were three times more likely to be restrained than children without these disabilities.
“EMS personnel are likely less comfortable with weight-based dosing of sedative medications and EMS agencies in most states don’t have pediatric-specific sedative protocols, which might contribute to the increased use of physical restraints for younger children while in the ambulance,” said Julia Wnorowska, medical student at Northwestern University Feinberg School of Medicine and first author on the study. “Also, protocols for EMS personnel are needed to help manage children with autism spectrum disorders and other neurodevelopmental disabilities. Specific interventions could be developed to prevent and reduce agitation in this population, such as personalized emergency information forms that delineate patient-specific triggers and de-escalation techniques.”
“Future research should determine whether the use of restrictive interventions can be reduced, while simultaneously promoting staff safety, through strategies such as education and adoption of pediatric-specific protocols,” said Dr. Hoffmann, who also is the Children's Research Fund Junior Board Research Scholar.
Research at Ann & Robert H. Lurie Children’s Hospital of Chicago is conducted through Stanley Manne Children’s Research Institute. The Manne Research Institute is focused on improving child health, transforming pediatric medicine and ensuring healthier futures through the relentless pursuit of knowledge. Lurie Children’s is a nonprofit organization committed to providing access to exceptional care for every child. It is ranked as one of the nation’s top children’s hospitals by U.S. News & World Report. Lurie Children’s is the pediatric training ground for Northwestern University Feinberg School of Medicine. Emergency medicine-focused research at Lurie Children’s is conducted through the Grainger Research Program in Pediatric Emergency Medicine.
JOURNAL
Academic Emergency Medicine
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