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.

1. Global Mental Health
Community Psychiatry in Rural Southern
India
1
Presented by: Geetha Jayaram M.D.,M.B.A.

2. Disclosures: none
Objectives:
To identify global concerns in community
psychiatry in mental health care provision
To design and develop culturally
congruent interventions for depressed
women
May 13, 2015 2

5. Definition of mental health
The World Health Organization describes
it as “a state of well-being in which the
individual realizes his or her own abilities,
can cope with the normal stresses of life,
can work productively and fruitfully, and is
able to make a contribution to his or her
community”
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6. WHO initiativesWHO initiatives

7. Global burden of mental disorders
• The burden of mental disorders is likely to
have been underestimated because of
inadequate appreciation of the
connectedness between mental illness and
other health conditions
• Conversely, many health conditions increase
the risk for mental disorder, and comorbidity
complicates help-seeking, diagnosis, and
treatment, and influences prognosis
May 13, 2015 7

8. Global burden of mental disorders-2
• Health services are not provided equitably to
people with mental disorders, and the quality
of care for both mental and physical health
conditions for these people could be
improved
• Health-care systems should be strengthened
to improve delivery of mental health care, by
focusing on existing programs and activities
May 13, 2015 8

9. Global burden of mental disorders -3
• Millennium Development Goals such as
promotion of gender equality and
empowerment of women must be addressed
• Mental health awareness needs to be
integrated into all aspects of health and social
policy, health-system planning, and delivery
of primary and secondary general health
care.
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10. Global burden of mental health-4
• Disturbances of mental health remain not only
neglected but also deeply stigmatized across our
societies
• Strong links between psychiatrists, community
leaders and patients and families that are based on
negotiation and respect, are vital for progress
• When strong partnerships exist, they can contribute
to community understanding and advancement of
psychiatry.
Promotion of mental health in poorly resourced countries
Helen Herrman,Leslie Swartz. The Lancet - 6 October 2007 ( Vol. 370, Issue 9594, Pages
1195-1197 )
May 13, 2015 10

11. Global burden of mental health-5
They suggest that successful strategies can be adopted
to overcome barriers to scaling up, such as the low
priority accorded to mental health, scarcity of human
and financial resources, and difficulties in changing
poorly organized services
However, there is a lack of well documented examples
of services that have been taken to scale that could
guide how to replicate successful scaling up in other
settings
May 13, 2015 11

12. Maanasi project objectivesMaanasi 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

13. Cooperative work byCooperative 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

14. How was this accomplished?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

15. Work doneWork 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 or
more
• Means of delivering care through
culturally congruent means

16. Surveys conducted across the worldSurveys conducted across the world
• 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

17. Phase 1 and 2Phase 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

18. Global burden of mental disorders
Rank
Worldwide High-income countries†
Low- and middle-
income countries
Cause DALYs‡
(millions)
Cause DALYs
(millions)
Cause DALYs
(millions)
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 Schizophre
nia
15.2
4 Bipolar
affective
disorder
14.4 Drug-use
disorders
1.9 Bipolar
affective
disorder
12.9
No health without mental health
Prof Martin Prince MD,Prof Vikram Patel PhD,Shekhar Saxena MD,Prof Mario Maj PhD,Joanna Maselko ScD,Prof Michael R Phillips MD,Atif
Rahman PhD
The Lancet - 8 September 2007 ( Vol. 370, Issue 9590, Pages 859-877 )
DOI: 10.1016/S0140-6736(07)61238-0
May 13, 2015 18
Table 1: Global burden of mental, neurological and substance-use (MNS) disorders

19. Results of the Maanasi projectResults 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

20. 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%)
May 13, 2015 20

21. Aspects of care in villagesAspects 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

22. Outcomes are influenced byOutcomes 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

23. What Are The Costs Of NotWhat Are The Costs Of Not
Treating Depression?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.

24. Outcomes- phase 1Outcomes- 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

25. Outcomes -2Outcomes -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

26. Preliminary results -1Preliminary 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

27. Preliminary results-2Preliminary 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

28. Other goals reachedOther 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

29. Key drivers for successKey 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
Psychiatrymedicine and psychiatry

30. Where do we go from here?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

31. Future goalsFuture 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
educationducatio

32. Discrimination studyDiscrimination 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;
Also, we investigated whether anticipated discrimination
is associated with disclosure and previous experiences
of discrimination.

33. MethodsMethods
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

34. FindingsFindings
• 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

35. Higher levels of discrimination wereHigher levels of discrimination were
foundfound
• 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)

36. InterpretationInterpretation
• 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 offf
stigma when it is already established

37. Future Goals-2Future 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

38. Papers publishedPapers 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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)

45. 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

46. 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

47. 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

48. 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.

49. 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)

50. 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

51. Work enabled byWork enabled by
• Carl P. Miller Discovery Grant
• RI Matching Grant 20954
• Rotary University Teachers’ Grant
• Support from the Rotary Clubs of
Howard West and Bangalore Midtown
• Matching Grant 58871

52. Presentation of the Maanasi
project
https://vimeo.com/76316516
May 13, 2015 52

53. 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