Taking mental health care to rural areas of India
THE FIRST EPISODE of #TheScanPodcast
The first episode of #TheScanpodcast talks about the need for mental health care in rural areas. As per the National Mental Health Survey 2015-16, common mental disorders such as depression, anxiety and substance use disorders affect nearly 10 per cent of the Indian population. However, facilities to treat such disorders are mostly found in the district hospitals or a private practitioner in the nearest urban hub or medical college.
Also, the treatment gap for mental disorders in the country ranges from 70 to 92 per cent for different disorders. This means that only 10 to 30 per cent of those with mental illnesses surveyed got the required treatment.
Challenges & On-field Experiences in addressing Mental Health Care
In September 2014, a team from The George institute visited the tribal belt of the West Godavari district of Andhra Pradesh. The team -- including Dr Pallab Maulik, who is the deputy director of the Institute along with researchers Sudha Kallakuri and Siddhardh Devarapalli --were visiting a hamlet in an area called Koyyalagudem.
Dr Maulik’s team wanted to start a research project aimed at improving mental health care access in tribal villages. A local contact led them to the village. It was a good 5 to 6 km from the main road. People had to walk up the main road to find any public transport. The houses were all scattered.
The team was trying to understand the various problems in the area, particularly mental health problems. For people living in this area, the nearest healthcare facility, which is a primary health care centre was very far. Foremost on their mind were their own physical health problems.
Talking about mental health in most contexts is a challenge. However, this task becomes even more difficult in hard to reach villages such as Koyyalguddam. In the first episode of our new podcast series called “The Scan”, researchers talk about the difficulty in establishing a mental health program in rural areas of the country.
The eventful journey in September 2014 was the start of a process which the researchers undertook to establish a pilot project called SMART Mental health in Andhra Pradesh’s West Godavari district to help increase access to mental health. The results of the pilot project were very encouraging, and a similar project is now underway in Palwal and Faridabad districts of Haryana.
The most basic care available at the primary health care level focuses on treating simple ailments in people, and reproductive and child health or RCH. Reproductive health involves looking after pregnant women, delivery of baby, and post-natal care. With relation to children, the focus is mostly on preventive care such as monitoring baby growth, immunisation, deworming, among others. Mental health care facilities are not usually available at the village level.
Contrary to the notion that mostly city dwellers suffer from mental illness, there is a significant burden of mental illness in rural and tribal belts. It must be understood that mental illness is closely linked to socio-economic and demographic factors. It strikes the marginalised sections of society, especially women and those who do not identify with heteronormative genders, those who are poor and those from lower caste. Particularly common disorders such as depression and anxiety are linked to environmental factors such as these.
Role & Importance of ASHA’s & PHC’s in delivering Mental Health Care
In India, every village in the country has a Accredited Social Health Activist or ASHA. An ASHA worker is a community health worker who acts as a bridge between the community and the public health system in the country. She is involved in nearly all the health programmes, be it immunisation, or surveillance for malaria control or simply communicating messages that help prevent diseases. She knows everyone in her village and can reach out to the community in a way that makes them comfortable.
In the podcast, TGI researchers describe how the SMART mental health project involved extensive training of ASHA workers on mental health issues. One of the key components of this training was just using a mobile tablet. The tablet helped the ASHA worker screen patients who needed further mental health care. In Andhra Pradesh’s tribal villages ASHA workers were not as exposed to technology and were apprehensive about it. The training helped them screen record data related to the given population in select villages and identify high risk patients who can be referred for treatment.
During the screening process, ASHA workers are encouraged to counsel the people who were obviously in distress. People who are at a higher risk of having a mental disorder are then referred to doctors at the primary health care level. Asha workers also do preliminary counselling for those in distress.
Doctors at the primary health care level are usually not trained in treating mental health diseases. Doctors were trained extensively by the George Institute to handle common mental disorders at the PHC level. The treatment for most common mental disorders does not need medications. If required, doctors could prescribe some antidepressants.
Since the PHC was far away for many villages, the project supervisor often arranged for medical camps in the villages. To maintain anonymity of the patients, often patients would be sent one by one to go see the doctor. If the patient suffered from a severe mental disorder, he or she could be referred to a psychiatrist at the nearest district hospital.
In fact, during COVID-19, ASHA workers from the Haryana project site could help people in distress and counsel them. The ASHA workers also helped those with acute mental distress, especially those with addictions by connecting them with the doctor psychiatrist.
While screening villagers and interacting with them, ASHA workers were also able to handle emergency situations, especially averting suicide.
The project helped build capacity of the existing resources - that is the ASHA and the government doctors in PHC- to deliver mental health care.
Click below to listen to the entire podcast: