How is the Aga Khan University’s Brain and Mind Institute (BMI) working to establish mental health care as a universal human right in cultures where mental ill health is not well recognised and resources are scant? On World Mental Health Day, Professor Zul Merali told us how attitudes towards, experience of and support for mental ill health vary across countries, requiring innovative responses.

With a background in psychology, biochemistry and neuroscience, Zul became interested in understanding how the brain responds to stressors, creating neurochemical change that increases vulnerability to mental ill health. “Mental illnesses cost more than all cancers put together, more than all communicable diseases put together, because they stay with you for a long period of time, affecting families and friends too,” explains Zul. “People can die 10 to 20 years sooner. We in the developing countries are particularly vulnerable because we get exposed to many more stressors – economic, for example, or from the instabilities arising from climate change – and we don't have the support systems.”

In 2020, Zul brought his 40 years of experience in research and leadership to the Aga Khan University (AKU), drawing together cross-agency expertise to establish the BMI. It is built on four pillars: research, innovation, education and partnerships.

Informing the future through research

“The brain is designed to scan the environment and the internal body for threats and make you take actions for your survival,” says Zul. “It's almost as if the brain is part of the environment itself. We're trying very hard to understand how these stressors influence brain circuits and chemistry, and what makes some people more resilient. We’re uncovering lots of very complex mechanisms in the brain, which is really a research frontier. But as we find interventions such as drugs and talking therapies that can be used clinically to change the brain’s responses, how do we apply them to practice, and get them taken up by communities?”

Putting evidence straight into practice with innovation

“We’re finding solutions that are very different, more realistic for our geographies and very exciting because we can make a difference very quickly,” says Zul.

The BMI takes a stepped approach to care, adapted from the World Health Organization’s pyramid framework. At the top are the relatively few acutely ill, requiring resource-intensive care. There are tiers below for the moderately ill and those at risk, with the well population at the base.

“A lot of the models of care that we adopted come from the Global North, where they have an abundance of psychiatrists and psychologists and systems of care. Developing countries, particularly in rural areas, don't have access to those.

“So we turn it upside down and put most of our resources at the bottom of the pyramid so that we can impact the largest numbers of people with minimal cost. Prevention, early detection and early intervention can be done in the community using the kinds of resources that are more readily available to us. We have a medical anthropologist and a social anthropologist on our team to make sure that the solutions we develop with and for the communities are culturally acceptable.”

In Sindh, Pakistan, the BMI worked with Lady Health Workers, giving them a tablet and training to screen people for mental health needs during their home visits. They refer those at severe risk to professionals, but work directly with those needing lower levels of care: listening to them, teaching them and problem-solving with them. The government has now approached the BMI to share the approach for wider use.

Educating faculty, students and the community

As well as developing academic programmes, the BMI is spreading knowledge of mental health issues more widely.

“If you have diabetes, you're going to understand that something happened with your pancreas and you'll get appropriate treatment to control your blood sugar levels,” says Zul. “Well, mental illness is no different. It's all to do with your brain. But because people don't understand that, they come up with ideas about why somebody's acting strangely.

“In Pakistan, people may think that evil spirits have possessed you, and community healers and shamans might have solutions, while in Kenya they'll go to their pastors and their imams. We've had many conversations with the religious leaders, who are looking for help in terms of recognising mental ill health and guiding people to the right pathways of care.”

The BMI has developed courses in mental health ambassadorship. Amongst the participants are non-experts within the university and at houses of worship, who learn to recognise the signs of mental ill health, provide mental health first aid and guide people to appropriate care.

Zul explains that where displaying signs of mental ill health is seen as a weakness, symptoms are often internalised, leading to head, stomach or back aches being more prominent in certain cultures. The BMI’s resilience workshops train participants in recognising how physical symptoms can reflect stress, and how to deal with daily stressors, building communities of care.

“We’re also working with the governments to develop policies that are more friendly to people with mental ill health,” says Zul. “We're not there to provide care. But we are there to change the models of care.”

Multiplying impact through partnerships

As former Head of Programmes and Research at Aga Khan Health Service (AKHS), Pakistan, Falak Madhani established close collaboration with the BMI and is now one of its implementation scientists. Her former and current organisations have been working with AKU’s BMI, its School of Nursing and Midwifery, and its Department of Psychiatry on a community-based programme in Gilgit-Baltistan and Chitral, Pakistan, that targets perinatal depression. This condition causes almost one in five women to experience a mental health condition during pregnancy or in the year after the birth. The programme illustrates how the Institute works through partnerships within and beyond AKDN.

The team adapted a WHO programme to establish peer-led support groups for mothers and fathers, initially working with a thousand participants. “We designed the manual and trained volunteers from within the community, where peer support is easily accepted,” says Falak. “Workshops covered information like breastfeeding and nutrition, as well as adopting positive behaviours which result in positive thoughts and positive feelings in the areas of self-care, looking after a young child and activating social support. We are seeing greatly improved depression and anxiety scores, even amongst those with severe depression.”

The programme itself is generating new partnerships. “I was in a training session in Ghizer District which included the government psychiatrist, the AKHS psychologist, a school counsellor and nurses. None knew of the others, and when they found that there were six other people working on the same problem in the same geography, it created the opportunity for a team approach to care and for referral pathways.”

Increasing acceptance?

“Just as I got the go ahead to set up the Institute, the COVID pandemic was declared. Confined to their homes, with things that were culturally and socially important to them taken away, people started to realise that we are all vulnerable. They started talking about mental ill health much more openly than they ever had. Conversations are a lot easier now,” concludes Zul.