Common mental disorders (depression and anxiety) in Afghanistan are responsible for 0.7m disability-adjusted life years lost. In Pakistan, common mental disorders are responsible for 3.1m disability-adjusted life years lost. Yet more than 90% of cases go untreated.
The aim of this Research Theme in general is to focus on the prevalence of common mental disorders (CMDs) in post-conflict settings and chronic physical disease populations, where implementation of effective interventions, delivered by non-specialist workers, has huge potential to alleviate distress, improve health and save costs.
Our Mental Health projects aim to bridge the mental health care gap, and improve access to care in Pakistan and Afghanistan through three impactful projects: Problem Management Plus (PM+), Collaborative Care (SPiRiT-D), and the META-SMI trial.
SPiRiT-DThe SPiRiT-D arm of the Centre for IMPACT aims to evaluate the effectiveness, cost-effectiveness, and implementation of the Collaborative Care model for treating depression in primary care clinics in Pakistan, where access to mental health services is limited.
Working with the SINA healthcare network in Karachi, the project has adapted the model to the local context, and is currently testing it through a hybrid type-II effectiveness implementation cluster randomised controlled trial.
Vitally, the project will explore strategies for its long-term scale-up and sustainability.
The trial is being conducted in 24 SINA primary care clinics and has achieved its recruitment target. The 725 participants recruited are being followed up at 3, 6 and 12 months follow-up to assess effectiveness outcomes (such as depression severity, caseness), and implemention outcomes (such as treatment reach, implementation).
Collaborative care is a model of care delivery that provides patient-centred, cost-efficient care without relying on having many mental health specialists, and has been shown to be effective for treating depression in patients with noncommunicable diseases.
Principles of Collaborative Care
- Care is provided by a Team based in a health service setting.
- The Team systematically identifies people who have depression, through routine screening with a simple questionnaire Patient Health Questionnaire-9 (PHQ-9).
- The Team provides treatments for depression (medicines and/or brief psychological treatment) according to a protocol.
- The Team monitors response to treatment using a treatment tracking tool.
- Team members are non-specialists who are trained to screen and treat depression. We train them in Behavioural Activation therapy because it works for depression, and it is relatively easy to learn.
- Non-specialists are supervised remotely by a mental health specialist only for the few cases where there are complications.
Implementation of collaborative care for depression in physical health programmes is widely recommended.
PM+The PM+ project is an implementation evaluation study spanning Pakistan and Afghanistan, designed to scale up the World Health Organization’s Problem Management Plus (PM+) intervention. By leveraging a task-shifting model—delegating key psychological support strategies to trained community members—the project builds local capacity to make mental health care accessible while reducing the structural burden on specialized healthcare systems.
Country-Specific Strategies
Pakistan
The project aims to train 300 mental health specialists across 6 regions and at least 30 mental health institutes. Operating as master trainers, these specialists will cascade their knowledge to frontline workers, establishing a robust framework to roll out PM+ at scale.
Afghanistan
Capacity is being built directly within the community layout. The project is training 717 Community Health Workers (CHWs) and 75 Community Health Supervisors (CHSs) across 5 provinces to deliver essential, frontline psychological support.
The META-SMI TrialDoes metformin reduce weight gain in people with severe mental illness?
This study is looking at a medicine called Metformin. Metformin is a safe, low-cost medicine that is already widely used to treat diabetes. Research suggests it might also be used in people without diabetes to help reduce the weight gain caused by antipsychotic medicines.
The goal of this trial is to see if giving Metformin to people who are just starting antipsychotic treatment can stop them from gaining too much weight.
Why is this research important?
People with severe mental illnesses (SMI), such as schizophrenia or bipolar disorder, often need to take strong medicines called antipsychotics to stay well. While these medicines are very helpful for mental health, they have a major downside: they often cause patients to gain a lot of weight quickly.
This weight gain is dangerous because it increases the risk of other serious health problems, such as heart disease and diabetes. It can also be discouraging for patients, sometimes leading them to stop taking the medication they need for their mental health.
If Metformin works, it could provide a cheap and simple way to protect the physical health of people with severe mental illness. This would help patients stay on their necessary mental health treatments while lowering their risk of developing diabetes or heart problems in the future, and help them to live longer healthier lives.
Where is the study being conducted?
The study is taking place in Pakistan, specifically at outpatient clinics in Rawalpindi and Peshawar. This setting is important because most previous research on this topic has been done in wealthy countries. This study aims to find a solution that works well and is affordable for people in low- and middle-income countries.
The SPiRiT-D arm of the Centre for IMPACT aims to evaluate the effectiveness, cost-effectiveness, and implementation of the Collaborative Care model for treating depression in primary care clinics in Pakistan, where access to mental health services is limited.
Working with the SINA healthcare network in Karachi, the project has adapted the model to the local context, and is currently testing it through a hybrid type-II effectiveness implementation cluster randomised controlled trial.
Vitally, the project will explore strategies for its long-term scale-up and sustainability.
The trial is being conducted in 24 SINA primary care clinics and has achieved its recruitment target. The 725 participants recruited are being followed up at 3, 6 and 12 months follow-up to assess effectiveness outcomes (such as depression severity, caseness), and implemention outcomes (such as treatment reach, implementation).
Collaborative care is a model of care delivery that provides patient-centred, cost-efficient care without relying on having many mental health specialists, and has been shown to be effective for treating depression in patients with noncommunicable diseases.
Principles of Collaborative Care
- Care is provided by a Team based in a health service setting.
- The Team systematically identifies people who have depression, through routine screening with a simple questionnaire Patient Health Questionnaire-9 (PHQ-9).
- The Team provides treatments for depression (medicines and/or brief psychological treatment) according to a protocol.
- The Team monitors response to treatment using a treatment tracking tool.
- Team members are non-specialists who are trained to screen and treat depression. We train them in Behavioural Activation therapy because it works for depression, and it is relatively easy to learn.
- Non-specialists are supervised remotely by a mental health specialist only for the few cases where there are complications.
Implementation of collaborative care for depression in physical health programmes is widely recommended.
The PM+ project is an implementation evaluation study spanning Pakistan and Afghanistan, designed to scale up the World Health Organization’s Problem Management Plus (PM+) intervention. By leveraging a task-shifting model—delegating key psychological support strategies to trained community members—the project builds local capacity to make mental health care accessible while reducing the structural burden on specialized healthcare systems.
Country-Specific Strategies
Pakistan
The project aims to train 300 mental health specialists across 6 regions and at least 30 mental health institutes. Operating as master trainers, these specialists will cascade their knowledge to frontline workers, establishing a robust framework to roll out PM+ at scale.
Afghanistan
Capacity is being built directly within the community layout. The project is training 717 Community Health Workers (CHWs) and 75 Community Health Supervisors (CHSs) across 5 provinces to deliver essential, frontline psychological support.
Does metformin reduce weight gain in people with severe mental illness?
This study is looking at a medicine called Metformin. Metformin is a safe, low-cost medicine that is already widely used to treat diabetes. Research suggests it might also be used in people without diabetes to help reduce the weight gain caused by antipsychotic medicines.
The goal of this trial is to see if giving Metformin to people who are just starting antipsychotic treatment can stop them from gaining too much weight.
Why is this research important?
People with severe mental illnesses (SMI), such as schizophrenia or bipolar disorder, often need to take strong medicines called antipsychotics to stay well. While these medicines are very helpful for mental health, they have a major downside: they often cause patients to gain a lot of weight quickly.
This weight gain is dangerous because it increases the risk of other serious health problems, such as heart disease and diabetes. It can also be discouraging for patients, sometimes leading them to stop taking the medication they need for their mental health.
If Metformin works, it could provide a cheap and simple way to protect the physical health of people with severe mental illness. This would help patients stay on their necessary mental health treatments while lowering their risk of developing diabetes or heart problems in the future, and help them to live longer healthier lives.
Where is the study being conducted?
The study is taking place in Pakistan, specifically at outpatient clinics in Rawalpindi and Peshawar. This setting is important because most previous research on this topic has been done in wealthy countries. This study aims to find a solution that works well and is affordable for people in low- and middle-income countries.
If you want to know more about our Mental Health projects, check out our Latest News!
- Scaling Mental Health in the Mountains: Reflections on the PM+ Training of Trainers in Skardu
- EMCR Spotlight! Driving Meaningful Mental Health Research in Pakistan
- Experience Doesn’t Retire From Learning: Inside the 8th PM+ Training of Trainers in Abbottabad
- EMCR Spotlight! Scaling Support and Shaping Policy
Why is this research important?
The rising burden of multimorbid depression and noncommunicable diseases is a global challenge, largely neglected by healthcare services, particularly in Low- and Middle-income Countries.
Coexistence of depression and chronic physical diseases is highly prevalent and worsens outcomes for both the mental and physical disorder, affecting both quality of life and finances as healthcare costs increase.
Tackling depression alongside chronic diseases is therefore a high priority, made particularly urgent by the rising burden of mental disorders associated with the Covid-19 pandemic, and the unprecedented scale of floods in Pakistan, leading to loss of homes and livelihoods and multiple health problems.
People with noncommunicable diseases are 2-3 more times likely to have depression. The coexistence of noncommunicable diseases and common mental disorders contributes significantly to global deaths.
However, in Pakistan (as around the rest of the world!), mental health expertise and resources to respond to this high need are limited.
So innovative evidence-based solutions are urgently needed to address the widening mental health treatment gap.
