Global Mental Health

The Maanasi Story October 2016

2

Geetha Jayaram M.D.,M.B.A.

Demographics for women

Two thirds of India's households are in rural areas. More than one-third of India's population (35%) is under age 15. Twenty eight percent of the rural population is in the lowest wealth quintile Forty one percent of women aged 15–49 have never been schooled. Thirty five percent of women have experienced physical or sexual violence, including married women. Of 43% of married women who were employed, a quarter received no payment for their work and 12% were paid only in kind (International Institute for Population Sciences and Macro International, 2007)

Common Mental Disorders • CMD, which are neurotic disorders presenting with anxiety and

depressive symptoms, are widespread and are known to cause significant disability worldwide. In India, prevalence rates of CMD range from 2% to 57%

• Majority of patients with CMD present at primary care centers but end up receiving symptomatic treatments like painkillers and vitamins because they are not recognized by primary care physicians as being mental illnesses

N. Isaacs , K. Srinivasan , I. Neerakkal , G. Jayaram. Indian J of Comm Med. Vol. 31, No. 2, April - June, 2006 This study was funded by the rotary foundation through a matching grant programme

(M.G#20594)

Global burden of mental illness

Mental disorders are highly prevalent, have greater effects on role functioning than other chronic physical illnesses Across the world, such disorders have a substantial role in disability. Seventy six and 0.3–85.4% of serious cases in less developed countries received no treatment often due to structural barriers The reallocation of treatment resources is recommended by the World Health Organization to substantially decrease the problem of unmet needs for treatment (WHO, 2004)

Global Burden 2

A study from four low income countries points toward a significant association of common mental disorders with female gender, low education, poverty, lack of access to running water in the home, experiencing hunger, and difficulties making ends meet Gynecological complaints are associated with an increased risk and this association remains evident after adjustment for socio-economic factors

Cooperative 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

Mugalur

• Is 30 km from an urban center- Bangalore • It serves as a center for all community related activities of the

medical school • Services include a general health clinic, antenatal and

postnatal care, childcare, services for the elderly, and for the blind and deaf

• The center serves more than 206 villages • Other medical care is 10 km away

Background

• Started as a humanitarian project • Collaboration between service and humanitarian

organizations, academic institutions and local village leadership

• Involved 25 villages at first and has spread over 10 years to 206 villages with care for 1700 active patients on a shoestring budget; population reach of 6 million households

Maanasi 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

Phase 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

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

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

Surveys conducted across the world show that

• 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

Background

Common mental disorders that refer to anxiety and depression syndromes are important cause of psychiatric morbidity in primary health centers. Studies evaluating outcomes of common mental disorders (CMD) from India are few

Background 2

• Women suffer from depression at 2-2.5 times that of men. When women are affected, it impacts the whole family

• While depression is the leading cause of disability for both males and females, the burden of depression is 50% higher for females than males (WHO, 2008). In fact, depression is the leading cause of disease burden for women in both high-income and low- and middle-income countries (WHO, 2008)

Obstacles to care delivery

• Cultural • Geographic • Economical • Structural • Lack of knowledge, low literacy, lack of

training, lack of resources

Background 3

• Started as a humanitarian project • Collaboration between service and

humanitarian organizations, academic institutions and local village leadership

• Involved 25 villages at first and has spread over 17 years to 206 villages with care for 1800 active patients on a shoestring budget

Background 4

• Research in developing countries suggests that maternal depression may be a risk factor for poor growth in young children (Rahman et al, 2008)

• This risk factor could mean that maternal mental health in low-income countries may have a substantial influence on growth during childhood, with the effects of depression affecting not only this generation but also the next

(Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. Rahman, Atif et al. The Lancet , Volume 372 , Issue 9642 , 902 – 909)

Maanasi Project Phase 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

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

0

10

20

30

40

50

60

70

80

percent

MaleFemale

Gender Distribution

Females between ages 21-50 years

Demographics

Age distribution : Assessed in 2000

Age group Frequency Percent

0 – 15 years 25 3.1

16 – 30 216 27.0

31 – 45 263 32.8

46 – 60 134 16.7

>60 84 10.5

Total 722 100

Mean Age = 40.27 +/0 - 16.55

Standard of Living Index

SLI Frequency Valid Percent

Low 188 26.0

Middle 313 43.4

High 221 30.6

Total 722 100.0

Standard of living index (SLI) based on household ownership of assets and possessions; the index can be

used to measure socioeconomic disadvantage or poverty. The SLI was created by assigning scores to a

range of 30 household goods and assets, including the type of house and toilet facilities, fuel used for

cooking, and ownership of durable goods*. (International Institute for Population Sciences and ORCMacro. National Family

Health Survey (NFHS—2) 1998-99: India. Mumbai: IIPS; 2000.)

Educational Status:

Education Frequency Valid Percent

Illiterate 444 61.49

Primary 29 4.0

Middle 88 1.1

High 97 13.43

PUC 34 4.7

Degree 16 2.2

Results 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 • Major Depression and Dysthymia were the

predominant diagnoses • Among Anxiety disorders, GAD was most often

diagnosed (6.47%), followed by Social Phobia (1.94%), Panic Disorder (1.29%), and Agoraphobia (0.65%)

Aspects 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 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

Aim of this study

The aim of the present study was to examine the outcomes of the broad category of CMD and specifically major depression in individuals resident in a rural community following naturalistic treatment with antidepressants

Outcomes- 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

Methods

Individuals with a diagnosis of CMD using a 2 stage diagnostic process were invited to seek treatment from a primary health center Outcome was assessed in 144 patients diagnosed with major depression using a structured interview schedule (SCID) at 6 months Outcome was measured using 17-item Hamilton Depression Rating Scale (HAMD) and WHO QOL (Brev) version. Individuals with a score of ≥ 7 on HAMD were deemed to have incomplete remission (Williams JW. A Structured Interview Guide for the Hamilton Depression Rating Scale.Arch Gen Psychiatry. 1988;45(8):742-747. doi:10.1001/archpsyc.1988.01800320058007) The WHOQOL Assessment. The WHOQOL group. Soc. Sci. Med. Vol. 41, No. 10, pp. 1403 1409, 1995)

Outcomes -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 (Structured Clinical Interview for DSM 4)

Preliminary 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 (HAM –D score = or >10). Depression had remitted in 72 subjects

Outcomes were poor in those

• That had co morbid anxiety, had interpersonal difficulties, such as those with spouse or mother in law, financial problems, alcoholism in spouse, and bereavement, severe poverty

• In our second outcome study, lack of transportation, financial

problems, inability to take time off work were associated with poorer outcomes

Other causes for failure of treatment

Logistic regression analyses showed comorbid medical conditions and life stressors were significant variables predicting a poor outcome, while past psychiatric illness predicted a better outcome

Preliminary 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

Results

114 (79%) individuals with CMD continued to be symptomatic at 6 months. Co-morbid psychiatric conditions, especially anxiety was associated with poor outcome. Individuals with higher score on HAMD had poorer quality of life as measured by WHO QOL. Treatment with antidepressant medication did not significantly influence the outcome.

Conclusions from the first outcome study

A significant majority of individuals diagnosed with major depression resident in a rural community had a poor outcome However, many patients either did not seek treatment or prematurely discontinued treatment Implications for public health approaches to the treatment of CMD are highlighted Further work entailed actively addressing these issues

How do you remedy the problem?

• Education • Outreach • Teaching in women’s cooperatives • Focus groups at schools • Data gathering • Enrolling the help of community leaders

Study of Caregiver Burden 73 caregivers consented to participate in the study, 48 (65.7%) were females. The average score for caregiver wellbeing was 6.00 ± 1.81, for marital relationships was 6.53 ± 1.37, appreciation for care giving was 6.07 ± 1.40, for perceived severity of disease was 5.99 ± 1.90, and for relations with others was 5.64 ± 1.59, the last of which was significantly associated with type of mental illness (p<0.05) The burden among caregivers in general was lower than expected, probably due to the interventions made in the community based program (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. Vol 1., Issue 2. Pg 25-34)

Cultural aspects of care

Delhi psychiatrists saw more patients daily (24.3 vs. 11, P < 0.001), and spent less time on new evaluations (33.3 vs. 69 min, P < 0.001) Both groups had similar approaches to major disorders. But, Delhi psychiatrists were less likely to combine medication treatment with psychotherapy (P < 0.05), and more likely to advise families to secretly administer medications in treatment refusal, such as in acute schizophrenia (P < 0.001) or major depression (P < 0.01)

Cultural aspects of care 2 • These differences highlight the salience of local cultural

context in the practice of psychiatry and in the treatment of Indian patients

• Delhi psychiatrists are overwhelmed by the epidemic levels of untreated illness, spend less time with patients, and rely more heavily on medication treatment

• Delhi psychiatrists employ unique approaches to handling difficult treatment issues, such as treatment refusal, intensive involvement of the family, and recommendations to the family about suitability for marriage for a patient

(Practice patterns and treatment choices among psychiatrists in New Delhi, India. AD Wasan, K Neufeld, G Jayaram - Social psychiatry and psychiatric epidemiology, 2009. Vol.44. Issue 2. Pg 109-119)

Cultural aspects of care 3 • Cross-sectional multisite international survey (34

countries worldwide) of 1082 people with MDD. Experienced and anticipated discrimination were assessed by the Discrimination and Stigma Scale (DISC)

• Countries were classified according to their rating on the Human Development Index (HDI composite statistic of life expectancy, education, and income per capita indicators). Multilevel negative binomial and Poisson models were used for analyses

(Antonio Lasalvia, Tine Van Bortel, Chiara Bonetto, Geetha Jayaram, Jaap van Weeghel, Silvia Zoppei, Lee Knifton, Neil Quinn,Kristian Wahlbeck, Doriana Cristofalo, Mariangela Lanfredi, Norman Sartorius, Graham Thornicroft, the ASPEN/INDIGO Study Group. BJP. Dec 2015, 207 (6) 507-514)

Cultural aspects of care 4

• People living in ‘very high HDI’ countries reported higher discrimination than those in ‘medium/low HDI’ countries

• Variation in reported discrimination across countries was only partially explained by individual-level variables

• The contribution of country-level variables was significant for anticipated discrimination only

• Contextual factors play an important role in anticipated discrimination

• Country-specific interventions should be implemented to prevent discrimination towards people with MDD

Cultural aspects of care

Resistance from care givers and care obtainers: • Incorporating psychiatric care into community

medicine concepts and ‘total health care’ • Involving village leadership • Appointing women case workers and using

women’s cooperatives/ schoolrooms for teaching • Addressing myths and misconceptions about

medication and injections • Overcoming geographic and access barriers

Partnerships • Local and International

• Academic and philanthropic; ministries and government entities

• Sustaining funding sources

• Sharing experiences and quality with a Global network

• Developing common teaching and training videos • Public health/ service announcements, advertising and articles

detailing the work

(G Jayaram, R Goud, K Srinivasan - Asian journal of psychiatry, 2011;Overcoming cultural barriers to deliver comprehensive rural community mental health care in Southern India. Vol 4, Issue 4. Pg 261-65)

Total # of households served Bangalore Urban

Anekal Taluk, Bangalore East, North and South

2,139,413

Bangalore Rural

Devanahalli, Dodballapur, Hoskote and Nelamangala

850,968

Kolar District

Bangarapet, Kolar, Malur, Mulbagal, Srinivasapur

1, 387,062

Tumkur District

Chinayakanhalli, Gubbi, Koratagere, Kunigal, Madugiri, Pavagada, Sira, Tiptur, Tumkur, Turuvekere

2,584,711

Total

Over 6 million households until 2014

6,962,154

Patient data- 1600 as of Jan 2015

≤ 19 (children and adolescent), 193, 13%

20 - 59 (Adults), 1138, 74%

≥60 ( Elderly), 208, 13%

AGE

≤ 19 (children and adolescent)

20 - 59 (Adults)

≥60 ( Elderly)

Gender distribution

Female, 1155, 75%

Male, 384, 25%

Gender Distribution

Female

Male

Literacy levels

1137

120

228

33 21 0

200

400

600

800

1000

1200

Illiterate Primary school High school Higher secondary Graduates

Educational status

Educational status

Standard of Living Index

High , 231, 15%

Medium, 885, 59%

Low, 392, 26%

socio ecconomic status

High

Medium

Low

Standard of Living Index

• Composite of life expectancy, education and income • Highest 5 countries are Finland, Norway, Sweden,

Germany, Australia / USA

Patient visits Number of visits: • Average no of visits by each patient to the clinic=6.5 times

(minimum of 1, maximum of 198) • About 1209 (About 80%) out of 1539 patients visited the

clinic five or less times. Or in other words, about 20% of our patients have visited our clinic six or more times.

Distance from clinic: • Average distance from where the patient is coming is about

25 Km. (Maximum of 300 Km, Minimum of 0 Km)

Results today

Today the “Maanasi Clinic" at Mugalur village is serving mainly poor women and children with varying degrees of mental illness by providing medical care to patients from 206 villages, 8 districts around Bangalore with a reach of 6 million households

Further steps • Construction of an interactive database • Development of simple teaching modules and training

videos • Duplication of efforts in other districts, and countries • Formation of a Rotary world wide Action Group • Better outcomes through the use of information technology • Social and economic development through rehabilitation • Networking with Global and Academic partners (JHH and

INDIGO group) • Safety studies

Ongoing needs

• Maintenance costs • Vehicles to be replaced • Duplication of efforts locally and globally • Ongoing funding for studies • Costs of infrastructure, both physical and IT

related such as databases • Teaching videos for patients and staff