We neither listen to our patients nor try to understand them but give them prescription-Prof. Imran Ijaz Haider


 Symposium Proceedings: Suffering in Silence-Patient with mental illness

We neither listen to our patients nor try
to understand them but give them
prescription-Prof. Imran Ijaz Haider

Suicide is the second leading cause of death in people
aged 16-24 Years while 60%of all suicides are in Asia
and West Africa - Farid Aslam Minhas

Psychiatry is a discipline in which all sciences
come into play - Prof. Nasar Sayeed Khan

LAHORE: Prof. Nasar Sayeed Khan Prof. of Psychiatry at Service Institute of Medical Sciences was the first speaker at the symposium on Suffering in Silence- Patients with Mental Illness organized by Academic Dept. of Psychiatry and Behavioral Sciences at Fatima Memorial Hospital at Lahore on May 13th 2016. Sponsored by a multinational pharmaceutical company Eli Lilly this academic activity was participated by a large number of mental healthcare professionals including psychiatrists and clinical psychologists. Making use of the revolution in information technology, the organizers had linked a number of Dept. of Psychiatry in the country besides taking guest speakers from Canada and UK who not only made presentations but also actively participated in the interactive discussion. Prof. Nasar Sayeed Khan who is currently in Canada made his presentation from there.

Speaking on Perception of patient with psychiatric morbidity Prof. Nasar Sayeed said that things are different in case of patients suffering from schizophrenia and other problems. Psychiatrists and psychologists still have to go a long way to find a cure for the mind disorders. Treatment strategies are all mixed up.  There are no hard and fast rules which we are practicing. Categorization of disorders and issues are complicated.  We lack in indigenous data. Patients are in physical, emotional, psychological pain. Psychiatry is a discipline in which all sciences come into play. Philosophy of mind is a complex science. In psychiatry it takes more time to understand pain than to relieve pain.  Schizophrenia, Bipolar Disorders’, Autism, Depression, OCD, ADHD, Cortical Blindness and Alzheimer’s Disease etc., is a plethora of mental illnesses and it was extremely difficult to find out which circuit in this scenario needs to be fixed up.

Prof. I. A. K. Tareen chairing the first session during a seminar “Suffering
in Silence” organized by Dept. Of Behavioural Sciences of FMH Lahore
recently. Sitting on the dais are members of the experts panel
Prof. Khalid Gill, Dr. Rubina Aslam, Prof. Farid Aslam Minhas and others.

Continuing Prof. Nasar Sayeed said psychoanalysis was a specialty. We do not agree with many of its theories but it did shed light on many important issues. He then referred to the impact of schizophrenia on overall functioning and the patient continues to suffer throughout the  life. Our role, he further stated, was to correct most of the problems whether it is related to psychiatry, social, physical or emotional. Duration of untreated psychosis makes lot of difference.  Just imagine the future of a child if he/she has some mental illness. Anxiety and Depression are symptoms; these problems are seen early in life in patients who suffer from psychosis. If it goes beyond, everything is compromised. If schizophrenia is not treated appropriately, it will become complicated and become worse. We need to adopt holistic approach. We must know what to start; when to start and when to change to the other antipsychotic if one does not work. We have to go slow, try one drug at a time till we get remission.

These patients do not think there is anything wrong with them but we see their miseries. The best drug is to which a patient responds. Everybody has some experience with every drug.  Our objective should be that the patient gets well. Earlier the patients are identified, diagnosed and intervention started, best are the prognosis, he remarked.

Prof. Farooq Naeem from Canada was the next speaker who called for more patient participation in such programmes.  He was of the view that we are not experts on patient’s perspective. In fact we are not so experts as we think we are. To promote culture adopted ideas of stress, we should understand to connect with the patient. At present there is dis-connect between patients and psychiatrists. There is a need for comprehensive explanation of anxiety. Patient may be suffering from some GIT problems and they also complain of depression and anxiety. We use lot of spicy food and it has a lot to do with much abdominal upset, pressure on chest, feelings of gas going to the brain and thus causing some mental illnesses as explained by the patients. It is all anxiety and we need to listen to the patient but at times we the psychiatrists are arrogant. We do not try to listen to the patients. We should try to learn from our patients and try to understand impact of culture. Young people between the ages of 18-40 years have enormous stress. In Pakistan information technology is quite cheap, more people have smart phones in Pakistan and they have access to lot of information through the internet. We should try to use this information technology for accessibility of the patients. We can develop websites for online therapy. It is easy to do things there and we living overseas will try to help you as much as we can. At this it was pointed out that if the Pakistan Psychiatry Society recommends this, then we will discuss how information technology can be used to contact the patients and also use it for therapeutic interventions.

Inaugural Session

These two presentations were followed by a formal inauguration of the symposium.  In his welcome address Prof. Imran Ijaz Haider, Chief Organizer and Prof. of Psychiatry at Fatima Memorial Hospital described the case of a young female who had some abdominal surgery and the surgeon put some plastic mesh there.  Later the patient developed rashes all over his body. She consulted many specialists to seek relief. Some  said she was having delusions, others said she wanted to seek attention but one of  the surgeons decided to listen to her then took  out the mesh from her abdomen and her condition  improved within days. There are so many patients like this who continue to suffer but we  the mental healthcare professionals see patients with  usual signs and symptoms of pain, tiredness, sleep problems, and try to   label them  in diseases such anxiety, depression. Any symptoms we do not understand is labeled as anxiety and depression and keep on adding some more drugs with a promise that the patient will get better. We do not listen to the patient, do not try to understand and give them a prescription. In fact we should be focusing more on psychosocial aspects. We should try to know the patient’s perspective, how they feel. We should be able to understand these people to whom nobody listens in the society.


Prof. Farid Aslam Minhas along with Prof. I.A. Tareen presenting a mementoe
to Prof. Aftab Asif at the seminar “Suffering in Silence” held at Lahore recently.

Dr. Ali Madeeh Hashmi Associate Prof. of Psychiatry at King Edward Medical University was the next speaker and topic of his presentation was “No Body Understands Me”. He was of the view that we the mental healthcare professionals concentrate too much on drugs and symptoms. We do not try to understand what the patient wants to tell us. Our whole focus is on symptoms and diagnosis. While practicing in the West, there are certain problems because unless you fit the patient in some disease, the insurance companies will not pay you, hence there are the economic pressures in USA. But in Pakistan we have another problem of progressing from pre-scientific to scientific era.  Scientific basis of psychiatry are still being formed in Paksitan and things are still evolving. Guidelines, he opined, are useful but remember we are all patients but they  suffer more as compared to us. His advice to his professional colleagues was that do not fit every patient in a box. We are in the process of developing forensic psychiatry at KEMU. At times we do come across violent patients. He then referred to a book “In the land of Pain: authored by Alfbonse Daudet  a French who suffered from mental illness and he has described his own feelings in this book.  He referred to yet another book “Use your Third Ear” by Reik which also makes an interesting reading. Famous short story writer Saadat Hassan Manto, we all know was suffering from mental illness and was also hospitalized for some time in a mental hospital in Lahore. His book “Toba Tek Singh” is a delight to read. His suggestion was that  let us ignore  DSM, ICD, symptoms and everything, slow down, do not rush, give some time to the patient. Everybody gives them prescription. Broaden our reading as literature has a lot to teach to the healthcare professionals.

Prof. Aftab Asif, Head of the Dept. of Psychiatry at KEMU talked about Bipolar Disorders. These patients, he said, do not accept the fact that they have some positive illness. Each patient is a different one. These patients may be suffering from severe bipolar disorders or become manic.  In hypo manic state, they are the happiest person and may dispose of property worth millions of rupees just like that. Sometimes the disease becomes so severe that the family thinks it is difficult to keep them at home and it is better to get them hospitalized. Severe aggression in these patients is another problem. Bipolar patients should not be prescribed anti-depressants as it will make them worse. Manic aggression becomes a real problem. Remember manic patients can also think of suicide. His advice to his colleagues was not to confront with these manic patients but give them sometime and listen to them.

Mr. Imtiaz Lalika a farmer who was suffering from a mental illness described his perspective. He pointed out that we are suffering from all social evils.  Now old fashioned treatment modalities will not work. Doctors will have to give time to the patients so that patients should improve.  It was also important that patients do not indulge in self medication and remain in constant touch with their physician. I have been suffering from bipolar disorder. I became too much ambitious and thought that I have been left behind by other family members who have progressed a lot. There are some personality disorders. One of my brothers who is a doctor but did not practice, once felt that I need to consult a doctor, hence brought me to a psychiatrist. I have just started treatment. His advice to the audience was to be contented as contentment was a blessing. One should also remain in touch with the religion and offer prayers, it helps a lot. Finally one has to have belief in oneself only then one will get better.

Prof. Farid Aslam Minhas from Institute of Psychiatry Rawalpindi talked about suicide. He stated that we tend to ignore this topic and do not know the facts. We should try to know the magnitude of the problem. Majority of the people suffering from some mental illness do not get treatment, hence what policy and planning we can have. According to WHO 1.5% of all deaths are due to suicide. In patients between the age of 16-24, suicide is the second leading cause of death. It accounts for 1.8% of global burden of diseases and by 2020 it will increase to 2.4%.  About 20 times more people indulge in self harm than those who complete suicide. What is more frightening is the fact that 60% of all suicides are in Asia and West Africa. Prof. Murad Musa from AKUH Karachi has done lot of work on Suicide. Hanging and poisoning is the common modes of suicide and agro phosphate is used more as compared to overdose of psychotropics and other substances. In the West almost 96% of those who commit suicide have a diagnosed psychiatric illness while in Pakistan they do not come to the psychiatrist or doctors to discuss it. Murad Musa study also highlighted another fact that 62% of those who committed suicide used to live in joint family or in extended family set up which is our pride but we need to find out what happens and what are the problems between in-laws and other family members which lead them to commit suicide. Anesthetists and psychiatrists are more prone to commit suicide hence there is a need to have some coping abilities. When you feel that we should talk to the patients, those who are going to listen to them must be trained how to deal with it and they must be supervised. There is lot of emotions and we need to time ourselves while listening to the patients. We should think of culturally adaptable therapy. He also talked about stigma attached to psychiatry and research. People who suffer from mental illness try to hide it as they think it is a sin. In our country suicide is criminalized and penalized. He then referred to the Mental Health Gap Programme initiated by WHO in 2008 and suicide is one of the issues included in this.  It is estimated that 75% of patients suffering from mental illness have no care and four out of five do not get drugs. All these years nothing has changed, all of us talk but do not deliver. We should try to know what is happening in the society in the rural areas and try to educate the patient, teachers, community leaders. Family physicians  and even paramedics.

This session was moderated by Dr. Usman and members of the expert’s panel included Prof Farid Aslam Minhas, Prof. Khalid Gill, Dr. Rubina Aslam, Dr. Ayesha Rasheed and Dr. Saqib. Participating in the discussion Prof. Gill said that let us look at different aspects. It is important that our medical students should be able to recognize the mental illnesses and there was a need to build bridges between religious scholars and mental healthcare professionals to help these patients. Prof. Khalid Mufti from Peshawar commended this initiative to discuss about the patient’s perspective and said time has come that we all must change our strategies in the light of emerging scientific evidence.

Prof. I. A.K. Tareen in his concluding remarks said that he was delighted to note that people were now joining hands to work together.  We should look at the person as a whole, may be they are suffering from many other diseases as well. Classification is important but we cannot pigeon hole people as each patient is unique. They may be having many things at the same time. I now see a bright future, things are improving and things were getting better with the every passing day. Let us all have love for the patient. My first book on psychiatry was dedicated to my patients who continue to suffer in silence and we all are responsible for this. Psychiatrist should have been the leader in telling what is right and we should stand for what is right. During the discussion it was pointed out that child psychiatry should be updated, we are going to train people. Psychological autopsies of those who commit suicide is a good suggestion worth looking into so as to know what drives them to commit suicide. Mental Health problems are on the rise in adults and adolescents while Hospitals are not prepared to face it.

 Second Session

Dr. Muhammad Mujtaba moderated the second session in which the panel of experts was Prof. Ijaz Haider, Dr. Nisar Hussain Khan, Dr. Sadaf Rashid and Dr. Shehryar Jovindah.

Prof. Riaz Bhatti was the first speaker who talked about people living with voices i.e. auditory hallucinations. He pointed out that it was difficult to find people who have empathy for them.  We also suffer from mental illnesses but we do not have the courage to admit it in public. According to reports the prevalence of hallucinations is between 5-28% and it may or may not be associated with mental illness. For bereaved people it is common to have grief reactions and they may hear voices from those who may be even dead. They hear voices as thoughts are entering from outside. He then displayed a video of auditory hallucinations and pointed out that the sound of unintended voices makes one upset. These people become shattered from inside. They are so frightening that at times the patients feel they would be better if they are dead.

Continuing Prof.Riaz Bhatti said that auditory hallucinations are most common in adults in schizophrenic’s spectrum of symptoms. They feel people are giving comments and remarks about them and they hear such voices till they go to bed. These people are schizophrenics and they wish to seclude themselves. It affects young adolescents between the age of 13-19 years and they suffer from nervous breakdown. Only 5-10% of these people who hear derogatory remarks, comments about themselves come to mental healthcare professionals. Some also experience vision hallucinations. Majority of these patients end up with traditional healers and patients suffer the most at their hands. They abuse them physically as well. People with manic depressive psychosis can also be diagnosed in time. If they seek treatment, they can lead a normal life so that they do not suffer in silence, he added.

Dr. Sobia Tameem Khan from UK talked about Patient at the heart of all we do. She pointed out that what cannot be cured must be endured.  He then referred to the Francis Report of 2013 and said that it has been noted that patient’s rights are not at the forefront. She then talked about patient empowerment and recovery. This report referred to the staff who was convicted for abuse of disabled individuals. This report also highlighted inadequacy of services, Patients died calling for nurses but they were not there. Public had no effective role and even the GPs did not help these patients. The patients as well as their relatives were also not involved in their care. We need strong patient centered leadership, compassion, committed care, looking at the cultural change and always putting the patient First.

She appreciated the start of CME in Pakistan and opined that professional bodies can do a lot.  She also talked about quality networking which ensures high quality care, communicate with the patients and monitor the services besides giving voice and effective participation in care to the patients.  Monitoring of services was essential. We can organize patient involvement workshops, Recovery Forums, recovery activities, look for transferable vocational skills. Carer’s Forum, Joint Cooking and sports sessions for patients and their families, community meetings could all be very useful. Patient centered leadership will also reduce hospitalization period, she remarked.

Prof. Altaf Qadir discussed Patient’s Perspective and pointed out that it is reported that Saadat Hassan Manto’s family used to complain about the use of ECT. They were of the view that it was not included in Lunacy Act of 1912. However, it may be mentioned here that first psychiatric treatment became available in 1952 and that is the time Manto was admitted into hospital. In those days all powers to admit and release patients were with the District Magistrate who was Deputy Commissioner. It was Mental Health Ordinance 2011 which was a revolution in the history of mental health care whereby these powers to admit was shifted to the families. However, this mental health legislation was not being implemented effectively and in its letter and spirit. He then referred to Punjab Mental Health Act 2014 which lays emphasis on community services, drug addiction and substance abuse is considered mental illness and not medial illness hence these patients are forcefully admitted against their consent.  The legislation says that those who commit suicide will be assessed by a psychiatrist. We often see mentally ill patients are being charged for blasphemy. He advocated strengthening the role of family in mental health legislation.

Academic Dept. of Behavioural Sciences and Psychiatry at Fatima Memorial Hospital organized a
seminar on “Suffering in Silence” at Lahore recently. Photograph taken on the occasion
Prof. Imran Ijaz Haider, Dr. Ali Madeeh Hashmi, Dr. Nazish Imran,Dr. Sumaira Qamber
and others speaking on the occasion.

Prof. Ijaz Haider participating in the discussion pointed out that ECT is an effective modality of treatment and it was still valid in UK. There are centers which are governed and monitored. Drug addicts have no place to go; they are then admitted to psychiatric wards. What are the methods and who has to implement them has got to be clarified for which we need to have a committee. Trend in psychiatry, he further stated has changed, we see more violence and more and more patients are now being diagnosed, he added.

Prof. Khalid Mufti remarked that the symposium was very informative and commended Prof. Imran Ijaz Haider and his team. We are seeing a golden time in psychiatry. We are faced with abusive governance. It is high time that we do something for the community. Late Prof. Rashid Chaudhry did a lot for the community. Dr. Irfan from Peshawar said that the topic selected for the symposium was interesting and we must ensure dignity for those who suffer from mental health disorders.

Dr. Sumira Bokhari highlighted the role of females and talked about lack of acknowledgement for the services they render at home by the family and the society.  She goes through insecurity; there are high expectations from them. At times they have marital problems, conflicts; those who suffer from mental illness have problems in getting married. Women lack autonomy and at times they are humiliated by husbands and father. She urged that we must facilitate women to be active member of the society and build her lost esteem.

Dr. Nazish Imran in her presentation pointed out that child mental health often gets neglected. She showed two video clips with the consent of the patients wherein they described the sufferings of the children and their families under age 16-18 years. When the child suffers, the whole family suffers. About 35% of our population in Pakistan is under 14 years of age and almost 50% of adult mental health problems start at the age of fourteen years. We have limited mental health services available for children and we do not listen to their sufferings.  The Video she showed  described a child suffering from convulsive disorders and the other was suffering from OCD and ODD. She then pointed out that how one can treat such patients without the consent of the family and mother. They need to trust before we talk to them. Doctors lack understanding. Patients are not involved in treatment. Screening is not being done in schools to diagnose these children early in life. There is Lack of involvement in decisions which affect their life. She highlighted the importance of confidence in confidentiality and trust in person. She suggested that we must make psychiatric services child friendly, ensure professional competency and treat them with dignity and respect besides giving them say in development and delivery of mental health services.

Dr. Sabahat opined that it was a unique session which covered the patient perspective and we should continue such activities. Dr. Hamid Rashid Khawaja said that it was commendable. We must ensure to make the services available all over the country which at present was available in big cities only. Dr. Shaheryar said that in the West they are able to identify the problems and the patients are relieved of their sufferings. Female suffer more from stress and men do not know what women go through. Mental health issues should be highlighted through media. Teachers, parents should be educated and trained so that the patients are diagnosed early. Dr. Mariam Haroon opined that such get togethers provide us an opportunity to learn about latest advances. She also thanked all those who repeatedly referred to her late husband Prof. Haroon Rashid Chaudhry, commended his services and continue to give her respect which was a great support. Dr. Sadaf Rashid said that this academic activity gave a new touch, since there was no registration, my trainees could also attend it. Using information technology was commendable. Dr. Nazish Imran in her presentation highlighted that the voice of the younger generation should be heard. Dr. Nisar Hussain and Prof. Riaz Bhatti also commended the efforts of organizers.

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