Neuropsychiatric diseases like unipolar depressive disorders, addictions, bipolar disorder and schizophrenia make up 28% of the global burden of disease among noncommunicable diseases and are economically more disabling than cardiovascular disease or cancer. When you add infectious diseases, neuropsychiatric disorders make up 14% of the entire global burden of disease. While access to mental health is essential to improving quality of life among people and economies of the world, there is a dearth of resources. How do we address the need? Vikram Patel MD, a psychiatrist at the London School of Hygiene and Tropical Medicine is doing fascinating research in task shifting, the idea of training community health workers to handle psychiatric interventions with supervision, as an answer to the need. I was lucky to get a chance to visit his clinical trial center in Goa, India.
With India's population of over 1 billion people, they require at least 150,000 psychiatrists. Currently, they have around 3000 psychiatrists meeting about 2% of the country's need. The idea of task shifting is to train community health workers to carry out psychosocial interventions. Chosen community health workers are those who are dedicated to their community's psychological health and understand the cultural contexts within which mental illness exists in their society. I got a chance to meet these wonderful women at Sangath, Goa. They go out to primary care centers to do prescribed therapies that have shown to be helpful in addiction and depression.
For the trial Sangath recently did (MANAS trial), the community health workers use depression and addiction scales to screen and triage patients in primary care centers who are having trouble with depression and alcohol abuse. Those who screened positive would either be assigned to the control group or see a community health worker for 6-8 cognitive behavioral therapy sessions to treat depression or addiction. In the picture below, you will see the packets the community health workers use to do the therapy and assess improvement behind them.
The community health workers get supervision weekly with more senior counselors on difficult cases and meet with a psychiatrists at least once a month. They are connected to referral services for urgent and more medically complicated cases. These trials have shown a significant impact to improving depression and addiction in this community.
It was a wonderful experience for me to see people trying creative solutions to major problems to accessing mental health care. It's a great way to involve the community, to help create sustainable resources, build capacity in a health system, and reduce the stigma of mental health.
Jhilam Biswas, MD
