Pakistan is home to about 200 million people, but has one of the poorest mental health indicators and less than 500 psychiatrists for this population size. This paucity of mental health professionals in Pakistan creates a massive treatment gap, leaving more than 90% of people with common mental disorders untreated. Early in my career as a psychiatrist, I understood that more is needed from mental health professionals to help make some meaningful contributions at the population level. As a clinician, I see patients with a whole spectrum of disorders at my clinic; of course, the more common being depression and anxiety. With passing years, I have noticed many changes. For example, more people now seem to be aware about mental health issues, but the stigma surrounding mental health still remains. I've also seen a rise in comorbidity of depression and anxiety with other non-communicable diseases, like diabetes. One of the recent cases I saw was that of a 28-year-old woman who has been having recurrent bouts of depression for the last 6–7 years. She has had four children after being married at 20 years of age. On top of the poor social determinants, such as poverty, she faces ongoing difficult life circumstances including experiencing intimate partner violence. The main reasons for her recurrent bouts of depression are certainly driven by her psychosocial circumstances. As her psychiatrist, I have linked her up with social and welfare services as well as poverty alleviation programmes in her vicinity. It is exceedingly difficult for women to talk about and seek help, especially for intimate partner violence, in Pakistan owing to our social and cultural norms. She has expressed suicidal ideas during her bouts of depression but has resisted these thoughts on account of her children and religious beliefs. She bravely faces her struggles and continues to cope with her life circumstances and raises her four children.
In my other role as a public mental health professional, I conduct research around maternal mental health and early childhood development. Being a public mental health professional, I interface with the Ministry of National Health Services and the policy making environment. Developing and testing task-shifted maternal psychosocial interventions delivered through existing health systems remains my main focus of work. This remains my focus for two main reasons: (1) women are a vulnerable and neglected group in Pakistan; and (2) there remains a huge treatment gap for women's mental health—ie, there are very few psychiatrists to treat a huge burden of mental health issues in Pakistan. Having psychosocial interventions that can be delivered by non-specialists or peers ensures that this gap is reduced to some extent. And working to promote women's mental health also addresses the wellbeing of their children. Besides these reasons, psychosocial interventions are less costly to invest in, thus more likely to be scaled up.
For the longer term, having more trained human resources is needed for Pakistan. I contribute to this workforce as a public mental health academician. I train, teach, supervise, and mentor individuals at various stages of their careers to take up mental health research and service delivery. My teaching and mentoring responsibilities are embedded within my ongoing research programmes. I have both masters and doctoral students who I mentor and supervise, with the sole intent that these are the needed human resources for public mental health. As an example, one of my public mental health doctoral students is looking into the implementation challenges of using lay peers (ie, other mothers) to deliver maternal mental health psychosocial interventions within community settings. Another student is working on how to use lay peers to detect maternal depression, its recurrence, and associated social determinants, such as poverty, at the community level. This detection is one of the components of a collaborative care model for maternal depression that I am endeavoring to develop and test at the primary health care level in Pakistan.
With the recent pandemic of COVID-19, like other countries, Pakistan has been responding at all fronts, including the public health front. As one of the very few public mental health professionals in Pakistan, I serve as a member on a technical steering committee established to promote the mental health and psychosocial wellbeing of students by the Higher Education Commission of Pakistan. Through this committee, I am contributing to ensure mental health and psychosocial services for adolescents and young students are available at their colleges and universities. This committee is a rare example of having two sectors—ie, health and education—working together to address the mental health needs of Pakistan's youth in a very sustainable way.
Being a Pakistani psychiatrist turned public mental health professional puts many demands on me to contribute, as much as possible, for the wellbeing of populations and communities I work with.
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