At the department of Psychiatry, School of Medicine at Makerere University in Mulago, Dr Etheldreda Nakimuli-Mpungu, popularly known as Dr Ethel, is a household name.
Firm in her speech with a touch of humour, a conversation with the medic reveals how enthusiastic she is about mental health, particularly among people living with HIV/Aids, a field she has extensively researched about for years.
Nakimuli has dedicated her life to taking care of patients in the mental health department at Mulago National Referral Hospital, for the last 20 years and no wonder BBC listed the senior lecturer, researcher, innovator as one of the most influential women of 2020.
Nakimuli says her earliest memory of her career path dates back to her childhood days. “We are two girls and four boys at home and growing up, my mother used to say her boys would be engineers and girls would be medical practioners,” she adds.
Whether her mother’s prophesy motivated her to focus on science subjects or she naturally excelled at them, Nakimuli can’t tell, but she eventually became a doctor.
She went to St Theresa Namagunga Primary School and Mt St Mary’s College, Namagunga for primary and secondary school, respectively. And in 1999, she was awarded a Bachelor of Medicine and Surgery from Makerere University.
Starting out her medical career as a young medical officer at Butabika Mental Hospital in 2001, Nakimuli says when she first entered the mental health facility, one of the things that made her uncomfortable was seeing HIV patients battling with mental disorders.
Her attempts to search for information on how to manage HIV patients with mental health issues at that time did not yield much, but this is an area she had picked interest in. But because she was not a psychiatrist, she needed to go back to school.
“I decided to carry out research on how to manage these kinds of patients. I went back for further studies and in 2006, I graduated with a Master’s degree in Psychiatry from Makerere University,” she adds.
Love for mental health field
As part of her master’s project, Nakimuli undertook research on severe mental health conditions of the HIV patients she had observed in Butabika hospital and her work was published in the American Journal of Psychiatry, earning her an award and scholarship at Johns Hopkins University for her doctoral degree in Psychiatric Epidemiology.
While at Johns Hopkins (2007-2011), she further did research on mental health challenges at different health centres in Uganda and found out that depression was the most common mental health issue that persons living with HIV suffered from.
According to Nakimuli, HIV-positive persons with depression could not consistently take their medication and consequently, efforts to suppress the virus were futile and most patients remained sick most of the time. But Nakimuli wanted to make the lives of persons living with HIV better and she would not settle until she came up with a solution.
“When I completed my research, I was asked what I was going to do about all these problems. The World Health Organisation recommendation was that the first line of treatment for depression is psychological treatment, but we didn’t have such treatments in our health centres then. That is when it dawned on me that I had to come up with the treatment,” says Nakimuli shares.
At the time, she was partly working for an American foundation to set up a monitoring and evaluation system for people receiving mental health treatment.
A year later, from the data collected, Nakimuli observed that the few people who received group counselling had a faster reduction in their symptoms than people who received other forms of treatment.
This signaled that group counselling was actually more effective. She, however, didn’t want it to remain an idea in her head but an innovation that she could actually prove that works. She wrote a proposal and started looking for funding in order to bring her concept to life.
Fortunately, her proposal was approved by Grand Challenges Canada in 2012 and she received a Shs331m grant for the pilot project. “We embarked on a project to develop the treatment. In 2014, we evaluated the effectiveness of the treatment in a randomised controlled trial whose results were published in the Lancet HIV in April 2015. I worked with a team of psychologists, social workers, psychiatrists, biostatisticians, physicians, and international HIV and mental health experts. At the end of the project, the results were positive,”she explains.
“The conditions for the grant were; if the pilot project worked, they would increase funding to undertake a bigger study and roll it out to other patients. We received more funding and extended our work in three districts of Kitgum, Gulu and Pader. In May 2016, we had a meeting with local government officials, collaborating partners from the Ministry of Health Mental Health Programme and TASO and kicked off the project,” she says.
Nakimuli says after tracking patients for two years from when they received their treatment, the team discovered progressive mental health stability. She completed the project in 2019 and her work was published in the Lancet Global Health Journal.
Group support psychotherapy
According to a global study published by the National Centre for Biotechnology Information (NCBI), 39 per cent of people living with HIV/Aids suffer from depression. Nakimuli’s goal was to target people who suffered from depression.
“We wanted a psychological treatment to administer to people as soon as they were diagnosed with depression at health centres, where they access their treatment. This would prevent depression from becoming severe with complications such as suicide because that is what used to happen. Depression can only be identified when the symptoms are severe,” she further says.
After discovering that group psychotherapy treatment was needed, and considering that she had funding, she then trained health workers in her pilot project on how to administer the treatment to their patients.
Depression and treatment
People suffering from depression get treatment as a group administered to them by health workers in health centres, where they get their HIV/Aids treatment. Each group, usually of 10 people, has activities that are structured into eight sessions, every session running for two hours and specifically handling a particular issue. The groups are also gender specific to cater for the different gender roles and challenges. Every group meets once a week for eight weeks, which is the duration of the treatment.
Beyond psychotherapy, group members also enjoy two sessions where they are taught income generating skills to financially empower them since poverty is a potential risk factor for depression.
Nakimuli says since the project was launched, about 5,000 people have been reached and treated.
“After 20 years, we have been able to produce significant research on patients with HIV/Aids and mental health. In fact, the big study we completed in 2019, is currently one of the most comprehensive on HIV/Aids and mental health,” she says.
Her work has been published in the American Journal of Psychiatry, Lancet HIV and Lancet Global Health, among other journals. Nakimuli says they have pulled out from two districts of Gulu and Pader and are only providing therapy to patients in Kitgum District. The project is currently being funded by CRI Foundation.
She is also currently training health workers to administer the therapy, as well as in talks with NGOs and the government through the Ministry of Health to have the therapy scaled up countrywide.
In 2011 when she published her research in the American Journal of Psychiatry, she received The International Fulbright Science and Technology Award to go for her PhD studies at Johns Hopkins University.
After doing the pilot project of her medical intervention- Group Support Psychotherapy, her work was recognised locally and on the international scene.
Internationally, she won the Elsevier Foundation Award for Early Career Women Scientists in developing countries. Nationally, she was among the recipients of the Presidential National Independence Medal of Honour in 2016.
Most recently, Dr Nakimuli was listed on BBC’s 100 Most inspiring and Influential women of 2020 for her work, which she refers to as the most comprehensive study in the field of mental health and HIV, currently. This was also published in the Lancet Global Health Journal.
Her other life
When Nakimuli is not attending to her patients, she is a wife and mother of four. She confesses that raising children, balancing her work and career have been made possible by the social support system.
“When I went to pursue my PhD, for example, I had three children and the third born was only four months. I travelled with the baby and left the two others with their father. It was difficult, but I managed,” she says.
Apart from undertaking research, Nakimuli teaches undergraduate and postgraduate students and takes part in the clinical care of patients with mental health challenges in Mulago National Referral Hospital.
After being in the mental health field for almost 20 years, the most important lesson Dr Nakimuli has learnt is that prevention of mental disorders is much easier and cheaper than the treatment of mental disorders. “Sitting in Butabika hospital and waiting to treat individuals with full blown severe mental disorders was painful,” she says.
While she considers science to be complex, Nakimuli believes collaborations, creativity, critical thinking skills and technology are key. Nakimuli says she draws inspiration from people who bring about positive change in society. Nelson Mandela and Barack Obama are some of her role models.Commenting on Uganda’s medical industry, Nakimuli believes that the industry is evolving and there is growth in both public and private sectors. But she is quick to admit that more needs to be done.
Knowing that there are people whose lives rely on my work energises me to get up in the morning to do what I do. Over the years, I have learnt that prevention of mental disorders is much easier and cheaper than the treatment of mental disorders.