Global Mental Health

Community Psychiatry in Rural Southern India

1Presented by: Geetha Jayaram M.D.,M.B.A.

Disclosures: none

Objectives:

To identify global concerns in community psychiatry in mental health care provision

To design and develop culturally congruent interventions for depressed women

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Definition of mental health

The World Health Organization describes it as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”

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WHO initiativesWHO initiatives

Global burden of mental disorders

• The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions

• Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis

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Global burden of mental disorders-2

• Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved

• Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programs and activities

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Global burden of mental disorders -3

• Millennium Development Goals such as promotion of gender equality and empowerment of women must be addressed

• Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care.

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Global burden of mental health-4

• Disturbances of mental health remain not only neglected but also deeply stigmatized across our societies

• Strong links between psychiatrists, community leaders and patients and families that are based on negotiation and respect, are vital for progress

• When strong partnerships exist, they can contribute to community understanding and advancement of psychiatry.

Promotion of mental health in poorly resourced countriesHelen Herrman,Leslie Swartz. The Lancet - 6 October 2007 ( Vol. 370, Issue 9594, Pages 1195-1197 )

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Global burden of mental health-5

They suggest that successful strategies can be adopted to overcome barriers to scaling up, such as the low priority accorded to mental health, scarcity of human and financial resources, and difficulties in changing poorly organized services

However, there is a lack of well documented examples of services that have been taken to scale that could guide how to replicate successful scaling up in other settings

Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet. 2011;378:1592–603.

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Maanasi project objectivesMaanasi project objectives

• To bring mental health care to villages in rural Southern India

• In phases- provide transportation, manpower, training and assessments- provide medical and psychiatric evaluations and treatment- sustain psychiatric care/ evaluate outcomes

Cooperative work byCooperative work by

• Rotary Club of Howard West, Maryland, USA• Rotary Club of Bangalore Midtown, India• St. John’s Medical College, Bangalore, India,

Departments of Community Medicine and Psychiatry

How was this accomplished?How was this accomplished?

• Raising funds through creative means• Establishing a local link• Identifying an academic center that was

willing to assess needs, was able to treat psychiatric patients and provide emergency/ inpatient care and medications

• Finally, sustaining a collaborative academic/ humanitarian partnership between 2 entities to complete tasks

Work done Work done

• Epidemiological survey

• Evaluation of integrated model of care • Stepwise goals to accomplish tasks:

liaison work and collaborative efforts among 3 entities; training and supervision of 4 caseworkers; cross training to support identification of local medical problems; supervision by psychiatrist once a month or more

• Means of delivering care through culturally congruent means

Surveys conducted across the world Surveys conducted across the world

• Lifetime prevalence of depression may be around 25%

• Depression more in women and alcoholism in men• In India prevalence estimates vary between urban

and rural areas, possibly due to differences in methodology

• A meta analysis yielded a rate of 70-73/ 1000 persons

• Previous models at providing mental health care have not been successful

Phase 1 and 2Phase 1 and 2

• Identifying and training HS educated community health workers

• A door to door survey of a population of 17,000 using the ‘symptoms in others’ questionnaire derived from the Indian Psychiatric Survey Schedule by Kapur and Carstairs (subsequently over a million households)

• Referral of patients to the clinic, screening by internist and evaluation by psychiatrist

Global burden of mental disorders

Rank

Worldwide High-income countries† Low- and middle-income countries

Cause DALYs‡ (millions)

Cause DALYs (millions)

Cause DALYs (millions)

1 Unipolar depressive disorders

65.5 Unipolar depressive disorders

10.0 Unipolar depressive disorders

55.5

2 Alcohol-use disorders

23.7 Alzheimer's and other dementias

4.4 Alcohol-use disorders

19.5

3 Schizophrenia 16.8 Alcohol-use disorders

4.2 Schizophrenia

15.2

4 Bipolar affective disorder

14.4 Drug-use disorders

1.9 Bipolar affective disorder

12.9

No health without mental healthProf Martin Prince MD,Prof Vikram Patel PhD,Shekhar Saxena MD,Prof Mario Maj PhD,Joanna Maselko ScD,Prof Michael R Phillips MD,Atif Rahman PhDThe Lancet - 8 September 2007 ( Vol. 370, Issue 9590, Pages 859-877 ) DOI: 10.1016/S0140-6736(07)61238-0

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Table 1: Global burden of mental, neurological and substance-use (MNS) disorders

Results of the Maanasi projectResults of the Maanasi project

• Majority of patients were between the ages of 21 and 50 (21 villages)

• Patients were predominantly females• At least a third of patients had multiple

illnesses

Results of the Maanasi project-2

• Major Depression and Dysthymia were the predominant diagnoses

• Majority of patients were women between 15 and 40 years of age

• Among Anxiety disorders, GAD was most often diagnosed (6.47%), followed by Social Phobia (1.94%), Panic Disorder (1.29%), and Agoraphobia (0.65%)

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Aspects of care in villagesAspects of care in villages

• A sliding fee scale is offered or care is free• Care is accessible• The caregiver is trusted• Walk in care is permitted• Support systems are in place• Outside informants are available• Medications are free or a nominal amount is charged;

payment may be in kind

Outcomes are influenced byOutcomes are influenced by

• Cultural identity of the providers

• The environment in which they practice

• Cultural perceptions of mental illness and its treatment

• Economic environment in which care is rendered

What Are The Costs Of Not What Are The Costs Of Not Treating Depression?Treating Depression?

Treatment• Direct medical costs• Costs of medications used and discarded as

ineffective

Non-treatment Functional disability Medical morbidity Mortality• Decreased work capacity and economic

decline

Panzarino. J Clin Psychiatry. 1998;59 (suppl 20):11.

Outcomes- phase 1Outcomes- phase 1

• Initial screening by trained health care workers who administered the ‘symptoms in others’ checklist derived from the instrument devised by Kapur etal. -‘caseness’ was identified

• Potential patients underwent a medical screening and psychiatric evaluation

• Community health workers are women who live in the villages, have a HS education, and are trusted by the villagers

Outcomes -2Outcomes -2

• A cohort of 300 patients treated at the clinic for Major Depression were consecutively selected to be evaluated for outcomes

• A trained research investigator went to the patients’ homes to interview them using the

-SCID to generate a DSM IV diagnosis

-outcome of treatment was measured using the HAM-D and the WHO quality of life scale

Preliminary results -1Preliminary results -1

• Of the 300 patients interviewed, 99 did not meet criteria for MDD either current or lifetime, and had no other psychiatric diagnosis

• Of the remaining 201, 90% of the sample were women. Mean age was 38.7±12.7

• Among the 201, with the HAM-D, 129 subjects were noted to have significant depression after 6 months. Depression had remitted in 72 subjects

Preliminary results-2Preliminary results-2

• The two groups were compared across a host of clinical and socio-demographic factors

• Analysis indicates that co-morbid anxiety disorders results in the persistence of depression

• The quality of life as measured by the WHO scale is poorer in the group with depression at 6 months

Other goals reachedOther goals reached

– Services have been offered through outreach to 187 villages

– Dedicated female caseworkers have educated women in ‘Mahila Mandals’ and networked among them

– Clinic services have expanded to include screening and treatment for hearing and vision loss, geriatric care, treatment of epilepsy for children

Key drivers for successKey drivers for success

• Culturally congruent care with local caseworkers who have intimate knowledge of the villages

• Outreach to those who cannot access care• Dedication and consistent support &

leadership of 3 teams: US team, Bangalore Midtown Team and St. John’s Departments of Community Medicine and Psychiatrymedicine and psychiatry

Where do we go from here?Where do we go from here?

• We must sustain care that is being provided• We must emphasize the instrumental role that Rotary

played in the development of the project• We must demonstrate the unique model of care for

psychiatric patients, spread the word, replicate efforts; the local authorities will provide means, personnel, and sustain funding

• The vision is to begin with a village, to a district, to a state, and perhaps all states and low income countries

Future goalsFuture goals

Use IT support for efficiency and better outcomes as follows:

1. Cell phone appointment and medication adherence reminders

2. Completion of the computerized database of all registered patients, with accurate contact and cell phone information

3. Use of Skype technology to seek supervision by psychiatric specialists on a regular basis during clinic hours

4. Use of TV and computer stations for mass educationducatio

Discrimination studyDiscrimination study

Depression is the third leading contributor to the worldwide burden of disease. We assessed the nature and severity of experienced and anticipated discrimination reported by adults with major depressive disorder worldwide. Moreover, we investigated whether experienced discrimination is related to clinical history, provision of health care, and disclosure of diagnosis;

Also, we investigated whether anticipated discrimination is associated with disclosure and previous experiences of discrimination.

MethodsMethods

In a cross-sectional survey, people with a diagnosis of Major Depressive Disorder were interviewed in 39 sites (35 countries) worldwide with the discrimination and stigma scale (version 12; DISC-12). Other inclusion criteria were ability to understand and speak the main local language and age 18 years or older. The DISC-12 sub-scores assessed were reported discrimination and anticipated discrimination. Multivariable regression was used to analyze the data

FindingsFindings

• 1082 people with depression completed the DISC-12. Of these, 855 (79%) reported experiencing discrimination in at least one life domain. 405 (37%) participants had stopped themselves from initiating a close personal relationship, 271 (25%) from applying for work, and 218 (20%) from applying for education or training.

• We noted that higher levels of experienced discrimination were associated with several lifetime depressive episodes (negative binomial regression coe cient 0·20 [95% CI 0·09–0·32], p=0·001)ffi

Higher levels of discrimination were Higher levels of discrimination were found found

• With poorer levels of social functioning (widowed, separated, or divorced 0·10 [0·01–0·19], p=0·032; unpaid employed 0·34 [0·09–0·60], p=0·007; looking for a job 0·26 [0·09–0·43], p=0·002; and unemployed 0·22 [0·03–0·41], p=0·022).

• Experienced discrimination was also associated with lower willingness to disclose a diagnosis of depression (mean discrimination score 4·18 [SD 3·68] for concealing depression vs 2·25 [2·65] for disclosing depression; p<0·0001)

InterpretationInterpretation

• Discrimination related to depression acts as a barrier to social participation and successful vocational integration. Non-disclosure of depression is itself a further barrier to seeking help and to receiving e ective treatment ff

• This finding suggests that new and sustained approaches are needed to prevent stigmatization of people with depression and to reduce the e ects of ffstigma when it is already established

Future Goals-2Future Goals-2

• Develop a corpus fund to continue the project• Develop employment opportunities for treated women

(tailoring, gardening, meal preparation in schools, etc.)

• Partner with the local government for subsidies• Recognize key personnel who play a role annually • Replicate efforts in other villages • Publish efforts in local and national media

Papers publishedPapers published

• Isaacs AN, Srinivasan K, Neerakkal I, Jayaram G. Initiating a community Mental Health programme in rural Karnataka. Indian J Community Med (2006) 31:86- 87.

• Srinivasan K, Isaacs A, Thomas T, Jayaram G. Outcomes of Common Mental Disorders in Southern Rural India. Indian J Soc Psychiat (2006) 22:110-115.

• Wasan AJ, Neufeld K, Jayaram G. Practice Patterns and Treatment Choices Among Psychiatrists in New Delhi, India: A Qualitative and Quantitative Study. Soc Psych Psych Epid (2009) 44:109-119.

• Byrisetty S, Goud BR, Pradeep J, Jayaram G. Designing and Implementing an Electronic Health Record System for a Rural Mental Health Program at the Primary Health Care Centre in Mugalur. Paper presentation at the E-Governance conference in Bangalore, India, June 2010. Proceedings published.

• Rao V, Goga J, Inscore A, Khushalani S, Rastogi P, Subramaniam G, Jayaram G. Attitudes towards Mental Illness and Help-Seeking Behaviors among South Asian Americans: Results of a Pilot Study. Asian J of Psych (2011) 4(1):76.

• Jayaram G, Goud R, Srinivasan K. Overcoming cultural barriers to deliver comprehensive rural community mental health care in Southern India. Asian J of Psych (2011) 4(4):261-265.

• Swaroop N., Shilpa Ravi., B. Ramakrishna Goud., Maria Archana., Tony M Pius., Anjali Pal., Vimal John., Twinkle Agrawal., Jayaram G., Burden among caregivers of Mentally Ill patients: A rural community based study. International Journal of Research and Development of Health; April 2013. Vol. 1(2). Pg 29-34.

• Ethnicity, Culture, and Mental Illness. Psych CME. Broadcast August (2004), CME Article.• Jayaram G. MAANASI: Rural mental health in Southern India. Association of Women Psychiatrists Newsletter (2006) 24:11-12.

(Invited Article)• CME TV- A Surgeon General’s Perspective on the Impact of Race, Ethnicity and Culture on Mental Illness. February 16, 2005, Co-

presenter• http://www.cmeoutfitters.com/email/2005/020105.htm• Cultural aspects of anxiety- National Symposium. Presented at the American Psychiatric Association Meeting. May 2004. Slide sets

made, Co-presenter• Cultural aspects of anxiety- National Symposium. Presented at the American Psychiatric Association Meeting. May 2004. Slide sets

made, Co-presenter• Rural mental health in Southern India. TV Channel 9, Bangalore, presented January 2011• Montgomery County TV – Interview on Global Mental Health. 2013.• Invited international collaborations• World Congress of Psychiatry. Chair, Global Mental Health of women in 4 countries, Bucharest, Romania, 2013.• World Health Organization Mental Health Initiative –October 2013, Geneva, Switzerland. • Jayaram G, Venkatesh P. Where have all the girls gone? Female Feticide in India: a cultural genocide. Edited by Leah Dickstein.

Book Chapter (In press), 2011.• https://vimeo.com/76316516

Anti Stigma Program European Network (ASPEN)

• The INDIGO (International Study of Discrimination and Stigma for Depression) research network included 19 European funded countries and 17 non funded research network including our site in India; local IRBs approved the study

• A minimum of 25 participants with Major Depressive Disorder aged 18 to >65, able to speak and understand the main local language, assessed face to face by an independent examiner were administered the DISC 12

DISC 12

• Is a structured interview containing 32 questions about aspects of everyday life including work, marriage, parenting, housing, and leisure and religious activities

• Qs such as “have you been treated unfairly in making or keeping friends?” or anticipated discrimination, such as “have you stopped yourself from applying for work?”, and Qs on coping strategies such as “have you been able to use your personal skills or abilities to cope with stigma and discrimination?” are asked

DISC- 12 (2)

• Participants responses were rated with a 4 point Likert scale (0= no difference, 1= a little difference, 2= moderately different, and 3= a lot different)

• The DISC items were divided into 4 subscales of experienced discrimination, anticipated discrimination, overcome discrimination, and positive treatment

Discrimination and depression

• 79% of people with depression reported experienced discrimination in at least one domain of their lives

• The most commonly affected domains were discrimination by family members (40%), making or keeping friends (33%), marriage or divorce (23%), and keeping a job (21%)

• 71% wished to conceal their depression from others• 37% anticipated discrimination while initiating a close

personal relationship; 25% did not apply for work

Cross-national variations in reported discrimination among people with major depression

Participating countries were classified according the Human Development Index (HDI) in ‘very high, ‘high’, ‘medium’ and ‘low’ human development. Multivariable regression was used to analyze the data

Findings on cross cultural differences

• Both levels of experienced and anticipated discrimination widely differed across countries

• For experienced discrimination, no significant differences were found between developed vs. developing countries (India is a medium HDI country as ranked by the World Bank in 2010)

Findings on cross cultural differences-2

• People living in developed countries however reported higher levels of anticipated discrimination than those in developing ones

• A sort of ‘dose-effect’ relationship with levels of human development was found, with differences remaining significant despite taking into account confounding factors

The HDI report 2013

Notes that by 2020, Brazil, China and India—will surpass the aggregate production of Canada, France, Germany, Italy, the United Kingdom and the United States. Much of this expansion is being driven by new trade and technology partnerships within the South itself

The 2013 HDI

Identifies 4 specific areas for sustaining development momentum:

1.Enhancing equity, including with regard to gender

2.Enabling greater voice and participation of citizens, including youth

3.Confronting environmental pressures

4.Managing demographic change

Interpretation

Anticipated discrimination is less likely to be the case for patients returning to traditional communal settings, since their work roles are more integrated with other aspects of their lives and are less likely to be taken away simply because of questions about their performance. Moreover, they are more likely to work with friends or relatives in a more permissive and protective setting.

Interpretation-2

• Another possible reason for lower levels of discrimination in less developed countries is the nature of family and community support in these countries

• There is some evidence to suggest that people with mental health problems are less likely to be shunned within their families and neighborhoods because the whole extended family and community see the person’s condition as their responsibility, which is often related to family structure (Quinn 2007)

Interpretation-3

The broader social context may also make the difference for people with depression to perceive the ‘others’ as more or less supportive and/or stigmatizingMost developing societies are "socio-centric," with a primary emphasis on social relations and a range of conventions, rules, and roles that tend to sustain long-term relationships, and make isolation difficult to maintain

Work enabled byWork enabled by

• Carl P. Miller Discovery Grant

• RI Matching Grant 20954

• Rotary University Teachers’ Grant

• Support from the Rotary Clubs of Howard West and Bangalore Midtown

• Matching Grant 58871

Presentation of the Maanasi project

https://vimeo.com/76316516

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Work enabled by

• Carl P. Miller Discovery Grant• RI Matching Grant 20954 • Rotary University Teachers’ Grant• Support from the Rotary Clubs of Columbia

and Koremangala• Matching Grant 58871