The “Project Maanasi” is a mission to deliver mental health and primary care services to poor rural women and children in southern India. The goal of the program has been to provide low cost or free care to villagers, sustained outreach to those who cannot access the clinic, and educate patients and others about seeking care to improve their lives.
2. April 27, 2015 2
Disclosures: none
Objectives:
To identify commonalities in community
psychiatry in Baltimore and rural India
To design and develop culturally
congruent interventions for depressed
women
6. 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
7. 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
8. 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
9. 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
• Means of delivering care through
culturally congruent means
10. Surveys conducted across the world
• Lifetime prevalence 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
11. 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 (subsequently over a million households)
• Referral of patients to the clinic, screening by internist
and evaluation by psychiatrist
12. April 27, 2015 12
Global burden of mental disorders
Rank
Worldwide High-income countries†
Low- and middle-income
countries
Cause DALYs‡
(millions)
Cause DALYs
(millions)
Cause DALYs
(millions)
*
Data from ref. 1. Examples of MNS disorders under the purview of the Grand Challenges in
Global Mental Health initiative.
†
World Bank criteria for income (2009 gross national income (GNI) per capita): low income is
US$995 equivalent or less; middle income is $996–12,195; high income is $12,196 or more.
‡
A disability-adjusted life year (DALY) is a unit for measuring the amount of health lost because of
a disease or injury. It is calculated as the present value of the future years of disability-free life
that are lost as a result of the premature deaths or disability occurring in a particular year.
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 Schizophreni
a
15.2
4 Bipolar affective
disorder
14.4 Drug-use
disorders
1.9 Bipolar
affective
disorder
12.9
Table 1: Global burden of mental, neurological and substance-use (MNS) disorders
13. 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
14. April 27, 2015 14
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%)
15. 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
16. 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
17. What Are The Costs Of Not
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.
18. 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
19. 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
20. 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. Depression had remitted in 72
subjects
21. 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
22. Other 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
23. Key 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 psychiatry
24. 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
25. Future 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
education at Mahila Mandals
26. Discrimination 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 and whether anticipated
discrimination is associated with disclosure and
previous experiences of discrimination.
27. Methods
• Methods 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
28. Findings
• 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
29. Higher levels of discrimination
• 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)
30. Interpretation
• 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 treatmentff
• This finding suggests that new and sustained
approaches are needed to prevent
stigmatization of people with depression and to
reduce the e ects of stigma when it is alreadyff
established
31. Future 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, and
the Rotarian
32. Papers 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
33.
34. 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
35. 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
36. 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
37. 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
38. 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
39. 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)
40. 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
41. 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
42. 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
43. 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.
44. 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)
45. 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 stigmatizing
Most 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
46.
47.
48.
49. 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
