n July 2024, a woman in Abbottabad allegedly attacked her three young children with a knife, killing one, before she attempted to take her own life. According to reports, the woman had been experiencing mental disturbance following childbirth a few months ago. She and her two surviving children were taken to a nearby hospital. The tragedy raises a question far more important than what had happened in those few terrible moments: who was there before the crisis unfolded?

If only someone could have noticed that she was unwell; maybe a family member, community health worker or primary-care professional could have identified the warning signs; maybe she could have been provided appropriate care. Had she reached a mental-health professional, would there have been a system around her to ensure follow-up and support?

We may never know the answers in this particular case; the uncertainty is precisely the point.

Mental health systems are often restricted to psychiatrists, hospitals and treatment numbers. People rarely enter these at a moment of crisis. They often become unwell at home, in their communities, schools and workplaces long before anyone reaches the right specialist.

Imran, a school teacher, once heard a fifteen-year-old say that his family would be better off without him. Imran had no training for such a moment. He told the boy to be strong and sent him back to his class. This is one of the many examples of ignorance regarding mental health issues.

Pakistan has just launched its first National Mental Health Policy (2026-2035), an important and overdue step. Recent estimates show that around 32.4 million people need mental healthcare. However, only about 5 percent have been able to access appropriate services. There is a scarcity of mental health professionals, with only 0.19 psychiatrists per 100,000 people. The Pakistan Psychiatric Society’s National Psychiatric Morbidity Survey, led by Professor Raza-ur Rahman, covering 17,773 adults, found that 32.28 percent had a current psychiatric disorder.

This figure represents families who may spend months or years not knowing that what they are witnessing has a name and can be treated. The obvious response is that Pakistan urgently needs more psychiatrists, clinical psychologists, psychiatric nurses and social workers. They must be properly educated, trained and supervised. Serious mental illness is a matter to be handled by qualified professionals.

Professional training takes time; meanwhile, distress does not wait.

Even if Pakistan can expand its specialist workforce, millions of people will still continue to encounter mental-health difficulties in places where no psychiatrist or psychologist is immediately available. This is why we also need to consider training people at the first point of contact: those at homes, schools, offices and basic health units.

This does not mean turning community workers into therapists. But scarcity of specialists does not have to mean scarcity of care. Zimbabwe offers a useful example. Faced with a severe shortage of mental-health professionals, it integrated the Friendship Bench into primary care, training community health workers to deliver brief, evidence-based psychological interventions under professional supervision.

This example shows the importance of the contribution of trained community members, which can lead to huge transformation. Imagine the woman from Abbottabad receiving necessary services on time; imagine Imran after receiving training in psychological first aid. He would have known what to notice, ask and to do next. It would have changed his response to the child.

That is the potential role of a trained community workforce.

The next question is: who can be trained for such community work?

The primary aim should be to integrate mental health into primary healthcare. Training lady health workers, midwives and medical officers at basic health units is the need of the hour. Community workers and volunteers can be taught mental health literacy, psychological first aid, recognition of warning signs, supportive communication, stigma reduction and appropriate referral. Their role is to notice, support and connect.

Pakistan already has traces of this integrative approach. The Hamdard Force initiative explored a community-based model in which trained members provided basic psychosocial support, identified mental health needs and connected people with services under specialist oversight. This initiative has shown that involvement of frontline workers can make mental health services and their outreach better.

Use of information technology can also strengthen these connections through digital training, supervision and tele-mental health services linking community work with mental health professionals.

One principle in this extension of services must remain non-negotiable: community workers should help and connect but never replace professional care.

What Pakistan needs is multiple layers of systemised care, including communities that are able to recognise distress; trained frontline workers offering appropriate first-line care; and accessible specialised mental health services for complex needs. These layers must be connected through functioning referral, supervision and follow-up systems.

A person who needs help may never reach a psychiatrist’s waiting room. They may first turn to a teacher, health worker, neighbour, relative or friend. We need those people to know what to say, when to act and where to open the door to help.

The writer is a professor of psychiatry at Ayub Medical Teaching Institute, Abbottabad. He can be reached at [email protected].