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By Rupa Chinai In the first such major experiment of its kind in the country, the Manas project trains local people in Goa to deal with common mental health disorders, including depression, within the primary health setting
Despite its remarkable achievements of an over 82% literacy rate, and the second highest per capita income in the country, Goa has a dark side to its success story. Prosperity has seen an increase in depression and stress-related problems among Goa's young adults and women in the reproductive age-group. This situation has prompted the start of an innovative programme to treat common mental disorders within the primary health setting. Representing the first such major experiment of its kind to be carried out in a low-income country, Sangath Society, a CSO working with mental health issues in Goa, has initiated the Manas (Mana Shanti Sudhar Shodh or Search for Mental Peace) project. Sangath uses low-cost, locally available resources in a 'stepped care' approach first advocated by the World Health Organisation (WHO). Collaborating on this project are the Goa government's Directorate of Health Services and the London School of Hygiene and Tropical Medicine. Data from Goa on common mental health disorders conforms to the international evidence on predicted trends. A recent study estimates that depression will be the second leading cause of disability by 2030, after AIDS and before heart disease and traffic accidents. This was highlighted by the 'Global burden of disease study' conducted by researchers at Harvard University and the WHO. Dr Vikram Patel, a psychiatrist and leader of the Manas programme, says the project effectively integrates care for common mental health disorders within the primary healthcare setting. It draws on the strengths of the NGO movement to train and motivate local graduates in health counselling, and places them within the existing primary health system to improve the range of curative and preventive services. This approach is expected to drastically cut down on irrational and expensive treatment, which makes up a large chunk of out-of-pocket expenditure on healthcare by patients, Patel says. Compared to studies in other countries, the rate of 'frank depression' amongst very young adolescents (12-14 years) was found to be relatively low in Goa, although one in five young people are affected by mental 'distress'. The study found that strong family support was a critical protective factor, whilst the risk factors associated with mental illness among adolescents include social change and adoption of a non-traditional lifestyle, violence (including sexual violence), tobacco use, living in an unsafe neighbourhood, and educational stress. Sangath's studies show that the rate of common mental disorders dramatically rises in young adulthood. In a community setting, around 6% of women in the reproductive age-group (19-50 years) suffer from depression. Based on population data this would translate to about 20,000 depressed women in this age-group in Goa at any given point of time, according to the study. The state has a population of around 14 lakh.
Sangath's research further reveals that one in five adults attending primary health centres (PHCs), and one in four mothers attending antenatal clinics, suffer from depression. The symptoms were typically expressed through physical complaints like fatigue, aches and pains, and gynaecological problems such as abnormal vaginal discharge. The birth of a girl-child, marital violence and poverty contribute towards depression after childbirth. Postnatal depression, in turn, is a major risk factor for infant malnutrition. Economic difficulties, violence and gynaecological ill-health are also risk factors. Thus, women who are socially or economically disadvantaged -- because they are poor or live with violent husbands -- are especially vulnerable. Treatment for depression results in high out-of-pocket expenditure. Research evidence shows that depressed women are three times more likely than non-depressed women to spend 50% or more of their household income on out-of-pocket healthcare in a month (this is independent of their other physical health problems). Depression in women is strongly linked to their husbands' alcoholism; it affects their economic, physical and mental wellbeing. Sangath's training of locally-based counsellors through the Manas project meets an important need for psychological support and effective treatment of Goa's depressed. The standard practice by doctors is to prescribe unnecessary and expensive drugs based on the patient's physical symptoms, without consideration of their mental anxieties. Depression is usually treated inappropriately with sleeping pills and/or vitamins. The Manas project's health assistants screen all patients attending the primary health centre for depression. A health assistant provides the first patient interface with the project. She uses a standardised questionnaire that's internationally tested and found to be a valid tool in identifying patients suffering from anxiety, stress or depression, says Sudipto Chatterjee, a psychiatrist with Manas and the project's intervention team leader. While the doctor is in overall supervisory charge, his role is limited to confirming the initial diagnosis of the health assistant and exercising his judgement on the use of anti-depressants. Usually avoided in cases of mild depression, severe cases are prescribed a standardised, low-cost course of medication, enabling patients to reach a level of equilibrium where they can better cope with their problems. They are counselled on how the medicine is to be taken, thereby minimising side-effects. After seeing the doctor, the patient is introduced to a health counsellor who explains how interaction between the body and mind creates physical symptoms linked to anxiety or depression. Psycho-education teaches patients how to deal with tiredness or sleeplessness through simple breathing techniques, as taught in yoga, along with advice on nutrition and lifestyle changes. Patients are then given an appointment for counselling after every three weeks until they feel better. Many patients improve with this simple intervention. Patients who remain symptomatic are offered interpersonal psychotherapy (IPT) delivered over an average of eight sessions. This attempts to draw the patient out through probing questions on issues of lifestyle, relationships and areas of conflict, so that they can begin to see the whole picture themselves, says Manas psychologist Gracy Andrews. It takes sensitivity and patience on the part of the health counsellor to deal with long, uncomfortable silences. Patients need time and space to think about their options so that they can make their own decisions and evolve their own solutions, she explains. Issues that have come up during these IPT sessions relate to conflict situations; dealing with grief and bereavement; role transition where a person adjusts to widowhood, retirement, divorce; or interpersonal deficits such as loneliness or social isolation, where a person does not have the skills to form other relationships, says Andrews. Another major aspect of the health counsellor's role is to refer patients to government and CSO schemes to help solve their economic and social problems. If, despite these treatments, patients still do not find relief they are referred to a psychiatrist associated with the project who offers them medication and intensive counselling. A panel of psychiatrists associated with Manas visits the health centre every two or three weeks and is available for phone consultations with the counsellor in between. Rare cases of patients who are contemplating suicide warrant immediate referral to a psychiatrist. . The Manas project underwent a formative phase between April and July 2006 when it was introduced in four primary health centres and four general practitioner clinics to identify hurdles before the main trial, and to see whether patients accepted the project. This was followed by a four-month-long pilot phase at four PHCs. When the trial is taken to scale, in March 2007, the first phase will see the participation of 12 government PHCs; 12 private family physician clinics will participate in the subsequent second phase. A special feature of the Manas-trained counsellors is that they are not health professionals but local women graduates who are trained over three months, including a month at the clinic. This is the first time in India that local people are being trained for placement in a primary health centre to treat common mental disorders. Fatima Gomes, a clinical psychologist associated with the Manas project, says their experience so far reveals a definite need for such services. The majority of patients they see are middle-aged women in the age-group 25 and above, from the lower socio-economic group. These women feel helpless about their problems and appreciate having someone they can talk to. Young people are not regular patients at the PHC. In many rural areas, young men migrate out for work and return only during festivals. Reaching this age-group continues to remain a challenge, Gomes says. Rural poverty and lack of public services impose restrictions on patients taking the full benefit of the counselling programme. For instance, many patients who come to the Sanquelim PHC in Bicholim district are from the neighbouring taluka of Satari, one of the least developed areas in the state. They are forced to travel long distances for help. Sadhna (not her real name), aged 45, from a village in Satari district, has to change three buses and travel two hours, paying Rs 10 for a ticket, before she can access the Sanquelim PHC. She complained of aches and pains but realised during counselling that they emanated from tension over the future of her two unemployed sons. It is difficult to convince Sadhna to return for further therapy sessions, given her anxiety to catch the last bus home and the effort involved in coming to the PHC. The counselling sessions also provided insights into the stresses faced by Goa 's industrial workforce. Ganesh (not his real name) is one of the few young men who has sought help from the Manas programme and has benefited from it. He works as a machine operator in one of the industries that have come up in the rural agricultural belt of Savoiverem in Ponda taluka. Families here own land but are severely cash-strapped. Among the lucky few to have a well-paying job, Ganesh, however, found he was bored and depressed at his work which was repetitive and required precision. He was unable to sleep and was very tense. Unused to the hire-and-fire work culture, he was paralysed with fear seeing colleagues being pulled up and petrified that he might do something wrong and invite a memo. The Manas programme helped him change his way of thinking. Ganesh's experience highlights the need for companies to support their workforce through regular training, motivation and counselling as they adjust to a new work culture. (Rupa Chinai is an independent journalist based in Mumbai) InfoChange News & Features, March 2007
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