Ayesha Mian is one of Pakistan’s leading psychiatrists specializing in child, adolescent, and adult psychiatry. She is just one of 7 specialists in this field, and with a population of 60% youth, her 20 years of experience is highly sought.
She returned from the US in 2013 and was one of only 2 child psychiatrists in Karachi.
She founded Synapse, one of Pakistan’s leading mental health institutes, and was the former Chair and Associate Professor, Department of Psychiatry at AKU. She has also been a trailblazer and a leader in many spheres of gender diversity. According to her, mental illness is like any other disorder. When the brain goes into stress, anxiety, and depression follow.
In the 8th episode of LEADHers, Farhat Kapadia Mehboob, founder, and editor-in-chief, WOW360pk, asks Dr. Ayesha how COVID has impacted people’s mental health. The episode explores the impact of social media, how eating disorders have become more prevalent, and how parenting needs to evolve in the current scenario with a shift to nuclear family units.
1) What drew you to Psychology as your choice of career?
I realized the only thing I really could do with a passion was psychiatry because it allows you to work with humans at a very deep level. It is such a privilege to work with people this close; they share with you, they trust you. They reveal their deepest, darkest parts of who they are and how they think, what they think about, how they live their lives. So I think that piece, and also it gives you lots of space to be very creative because each person’s story is so different. It might be the same depression and anxiety, but a life story comes with it, which makes each person and each patient unique.
2) Mental health is as important as physical health, and people are slowly becoming more aware and speaking about it – do you feel the taboo still exists in Pakistan?
Of course, it does. And the taboos they’re everywhere. When a patient comes to me, my first explanation to them really is that the brain is like any other organ of the body. If your pancreas is stressed, you will get diabetes. If blood vessels are stressed, then you’ll get high blood pressure. Same as when the brain goes into stress, you get anxiety and depression. It’s like the piece of meat, it’s like that organ, and that’s how it’s important to see it as an illness like any other medical disorder. It is part of your whole physical being, which helps reduce the stigma a little bit sometimes.
3) In your experience, how has COVID impacted the mental health of people?
We see more women struggling with anxiety and depression. The other cohort that mental illness has affected is the young people. A recent article came out in The Lancet, they looked at the data from 222 countries, and they found that there’s a 25% increase in anxiety and depression. The most vulnerable population was the young people under 30 and women. So those are the two cohorts that have suffered greatly.
For women, domestic violence is another aspect for women as it has increased. Moreover, child abuse has increased. In our culture, when men get depressed and when they get anxious, they are not trained to talk about it or express their anxiety. It comes out as anger; it comes out as violence because men won’t sit down and express that they are really feeling low, and unemployment, of course, has gone up. Financial hits have happened, people have lost jobs. Unfortunately, their anxiety and depression come out on the family more than in other aspects.
4) Gen Z or young adolescents feel they have been impacted the most by the pandemic – is that your experience too?
My sub-specialization is in child adolescent psychiatry. Right now, there are just about seven of us in the whole country. 60% of the population is under 30 so we have a very young population. There’s a significant prevalence of anxiety depression for a lot of social-cultural factors, not just because of genetics, but a lot of reasons.
We just don’t have trained people that are working with these kids. So the gap between a child showing any symptoms of mental health-related issues, whether it’s stress or anxiety or ADHD or whatever it might be to the point that they get care, not even proper care, but care that they are seeing some doctor is about 10 years. So you’ve got a pathology that has started and is growing and becoming worse over 10 years.
So until they get help, and on top, there are only 7 people in the entire country, so they get mismanaged because they are not getting to the right people.
The middle school and high school stage is when we see an increase in eating disorders. We see an increase in anxiety disorders, depressive disorders, bipolar disorder. So, those things kind of go up at that time – PTSD, trauma-related issues.
5 – Many parents feel their children are being ‘dramatic’ or are too sensitive – when should parents see the red flags and take notice of them?
I have grown up listening to this that if kids are born, they are taken care of, regardless, but that’s not how it happens. There might have been a time when that happened because a whole village was raising a child. There would be older siblings, younger siblings, khala, phopo, nani, chachi, people from the neighborhood in the house. So, there was always someone who had their eyes on the kids. So in case children are not receiving support or moral support – either the father is too busy, or the mother is too busy, there was always somebody to cater to that gap and mentor, advice, help them. That is all gone; you’ve got nuclear families. Children have a lot of knowledge these days cognitively, but they are growing emotionally the same way, so that is creating this rift where parents need to understand that they need to be present to answer children’s questions a lot more – and they will have questions. These kids are very open. They’ll come ask you questions, and you can’t dismiss them because if you don’t answer, they will go to the net, they won’t go to another adult.
Red flags, of course, can be many, but if I were to pick up some small ones, is that and if there is a personality change. Somebody who is happy go lucky, and chill is now suddenly quiet, is snapping at you a little bit more or they are isolating, for example, they don’t want to sit together, or want to eat alone in the room, sudden academic decline such as a student who would get A normally now gets Bs. If they participated in sports and other co-curricular and have discontinued. So whenever there’s a change happening.
That doesn’t necessarily mean that there is a mental health disorder but it just means there’s something going on. So it’s good to ask them, it’s good to talk to them, it’s good to reach out to a therapist or psychiatrist.
It’s important to know that psychiatrists are not scary looking and that is why I maintain a presence on social media. About good 40-50% of the time, I’m actually deep pathologizing children. I’m telling parents that come to me, there is no problem with that. A lot of people are scared that psychiatrists will prescribe medicines and give a label which is not the case.
6 – There is a misconception that mental health can only be cured with medication, can therapy help, and to what extent?
I always give the analogy of another illness, for example, if someone comes in with a blood pressure issue, we suggest them to decrease their sodium intake, start exercising, decrease their stress, start doing yoga, start going to kickboxing, or some kind of meditation. You have a lot of stress in your life, see a counselor, see a therapist, talk to somebody, talk to a mentor because the stress is causing all of that. If that doesn’t work, then we say do all of these, but perhaps you also need to start medication.
This is exactly how anxiety, depression, stress in children, adolescents, and adults is. The first response or reaction that we have is, depends on how severe the illness is, whether it is mild or moderate. The first thing I write on top of my prescription is exercise equipment, mindfulness apps, meditation, videos available on YouTube for yoga. For children, I tell them to join co-curricular activities. Suggest parents to not focus too much on grades, it’s not that important. Put them in music, music is fantastic, sports is fantastic. So, if those things don’t work or if there is a pathology that severe, there is a strong family history, for example, then sometimes, you need to do all of those, but also add medication because you know, genetics is not on this child’s side or adult side but that’s what I would do with any other illness too.
7 – There are many reports that show that social media especially Instagram has led to mental health issues and eating disorders in young girls. Do you feel that’s true?
We’ve seen that in COVID quite a bit. So I think what happened during COVID is that all the other distractions in your life – from school to tuition, to co-curricular, etc. You did those and now that went away. The only sort of outlet that children and adolescents had was the TV or the screen, or the social media and honestly, even us, all of the mental health experts globally were telling parents to ease up. This is a very, very hard time for children so it’s okay if they are sitting for an hour and two watching because what else can they do when they were restricted.
There was a sort of an obsession that we’ve seen with Snapchat and I have never seen. Every time I would go on Snapchat, even before COVID all I saw were videos of food, cooking recipes, so there were that and there were, of course, videos and TikTok of people kind of dressing up, using filters looking a certain way.
So here you are kind of watching videos of food and watching videos of people where they are saying how many calories are in what and this is how you have to reduce or this is how you have to prepare it. Even adults were talking about weight gain so that conversation then has led again, globally to the rise in anxiety, depression, and eating disorders. Eating disorders have actually been shot off the roof.
8 – You introduced Pakistan’s first child and adolescent mental health training program. Can you elaborate?
When I decided to move back from the US in 2013, it was in my mind, I wanted to influence the space of mental health in Pakistan – give it a different look, make it attractive, make it appealing, make it accessible. And the big piece, because I had sub-specialty training in children and adolescents. I feel very passionately about the youth, that’s just my thing, I love teenagers, I love working with them, it’s a lot of fun. That is what I wanted to introduce because, at the time, there was nothing here. In 2013, when I was coming here, I was the second child psychiatrist in Karachi and perhaps the third or the fourth in Pakistan. There was really nothing there. We need training and so a training program. There were no training programs. There are programs for psychiatry residency programs in different university hospitals, but there’s nothing for child and adolescent psychiatry.
So it took us two years – it takes a while – it’s a two-year-long program. There is a curriculum, and you have to get it credited. We have signed MoU in a couple of places in the US. It is a very robust training program that has been created with my mentors at Yale University, Stanford, and, a lot of places – so very cutting edge. There is a very big leadership component in it as well because I feel like whoever is taking the training in 2 years should have leadership capacities to be able to start programs in the community and at large. It is at Aga Khan University and at this point, it is still the only one that exists. Our fellow trainees have to do a leadership program.
The idea is to build the capacity of schools, school teachers, parents. One of the reasons to start Synapse really was to create a space where we could get everyone who is interested and should be talking about mental health.
9 – In Pakistan, do we have any mental health support system for people who play highly competitive sports?
So at this point, no but the conversation has started. So it’s been nice. Recently, the T20 world cup happened, in every match #OnMyMind was advertised, which is a mental health initiative – to take care of your mental health. It has become a very, very big thing now. There are tennis players, gymnasts, cricket players – Ben Stokes is a player who said I’m going to take a year off.
We have a colleague in the UK, who’s a psychiatrist born and bred in the UK, but of Pakistani origin who worked specifically with cricket and mental health – elite cricketers mental health.
Sana Mir was really good. She started talking about mental health. Urooj, now who is the past captain had been talking about mental health. PCB had reached out to us at some point with British Asian trust as well and they’re talking about it. Hajra Khan is a football player, she’s a very big advocate of mental health. So the conversation has begun. We just recently did a webinar with Urooj and Dr. Hasan who is a psychiatrist in the UK and Dr. Saad Shafqat who is a cricket columnist and a professor of neurology at Aga Khan University to talk about how we can initiate a conversation about developing programs for mental wellness. It is still coming from women athletes and it will be lovely to have our male athletes also join the conversation as they are under a tremendous amount of stress.
10 – You have chaired the first conference on gender equality and women in leadership at AKUH. Please tell us more about that.
Once I came back to Pakistan, I came as the chair of the department of psychiatry. After three years, I had a chat with the president who said, I’d like you to develop an office of the student experience, which was an AKU global office so that put me very quickly in the top leadership space of AKU Global. That’s where you know, I started to move to see the problems or the microaggressions or the macroaggressions that women in leadership kind of feel and it is not something that happens consciously.
I think lots of unconscious biases happen when you are at the table and you’re talking, somebody will just cut you off and start a pattern of conversation that would never happen with a man. So tiny, tiny things like that, that I started picking up. Every time I had to do something it had to be justified and there was no room for failure. Anything that failed meant or looked like “you shouldn’t have given to a woman”.
AKU is fantastic because they have done a lot for women empowerment – after the first nursing school. Of course, my medical students who are 50 – 60% women at IED, that is the this Institute for Educational Development. 90% are still men in black suits, that’s when I went to the president again, I had gone for the Dean of students thing and I asked him can we do something and he has never said no to me. He said Ayesha create something focused on women in leadership because that’s where our gap is.
It is a fantastic conference, really enjoyed myself because we got a lot of people from outside, from the corporates, from Standard Chartered, from Unilever, so a lot of women leaders in those spaces or men leaders who will be given the mandate to increase women capacity in their organizations. We’ve got people, women like Roshaneh Zafar and Jehan Ara, women who are leading in their own spaces to Bina Shah who talks about feminism to sort of have this larger conversation of how you strategically take this forward so that it’s not just one other conference, but the conversation has started and then we can kind of plug it into the design of what AKU does.
10 – Can women have it all? Career, family, etc / How have you managed a work-life balance?
I’ve never been able to create a balance. What I did when the kids were younger was that I have a supportive husband. I think he’s kind of gender-neutral or gender blind – that was just not even a conversation. So I was sort of working in my space, and achieving all of this was never in the picture. I think there was a lot of passion for mental health in that space so it was automatically happening. There were no plans that I have to do this, or reach here but what I did very early on was to create a village. I was in Houston, I was in the US and my youngest sister was there. She was in college those days at the university of Houston. She and her friends would take my son to college with them. He was a good kid so he would attend classes with them. So there were a lot of khalas and mamus. What happened with that was in certain ways I think I needed to, but also the kids became one independent quickly and also they are very comfortable with meeting new people and connecting with them, and this also comes from a child psychiatrist perspective as well that it’s very important for children to learn from a lot of different people.
There’s insecurity that God knows what other people will teach your children. I don’t believe in that, ask for help and let other people engage in your children’s lives, so that helped, I think from that perspective. Also, more than work-life balance, I talk about work-life integration, so if it’s very, very important for your children to know the work that you do. So if our parents are disappearing for one week or two weeks or a day, what do you, what do they do? So as, as much as possible, I would take them to conferences they would come and see what’s happening at AKU. So it’s not like they’re having fun. They are the part of it, and they’re seeing the larger vision and mission of what you’re trying to do.
11 – A woman that inspires you?
I think there are things that women do that inspire me. So I feel that, for example, Rosa Parks went and sat in the bus where African-Americans could only sit behind. She went and sat in front and said, no, I’m going to sit in front. She talked about freedom of spaces and nudged a boundary.
In Pakistan, Yasmeen Lari, the first architect, nudged boundaries, and many other people that kind of do. Ismat Chughtai wrote what she wrote, Fahmida Riaz wrote feminist poetry – things that have not been done before and then nudged boundaries. I think that truly inspires me where I feel that things – Ruth Bader Ginsburg became the associate justice of the Supreme Court, Nigar Johar became the first Lieutenant-general. They’re putting themselves in spaces where other women have not stepped in yet.
