The lifetime prevalence of mental disorders among adults in India is around 15% with an estimated 150 million Indians affected. Common Mental Disorders (CMDs) which include depression, anxiety, stress and associated suicide risk comprise the bulk of this disease burden. The vast majority of Indians with CMDs receive no care and experience stigma-related marginalisation from their communities. To address these gaps in care, we have developed a multifaceted intervention comprising: (1) a village-based anti-stigma intervention to improve community attitudes and behaviours toward people with CMDs; (2) capacity strengthening of primary health care centre doctors and frontline, village-based, non-physician health workers; (3) a mobile technologyenabled clinical decision support system for use by these healthcare providers; and (4) integrated care within the existing public primary healthcare system.
SMART Mental Health, led by CI Maulik, builds on this work and was conceived as an implementation platform for India’s national strategies and policies to improve mental health services.7, 15, 25 It is underpinned by the WHO’s Mental Health Gap Action Programme (mhGAP) whose guidelines were developed under the leadership of AI Saxena and CI Thornicroft.26 We have regularly consulted with WHO throughout the project. Our goal is to develop a system that could be implemented with minimal additional resources within the existing Indian government healthcare infrastructure and improve the delivery of evidence-based management and prevention of CMDs. The key elements of SMART Mental Health are: 1. Increasing community awareness of CMDs and reducing stigma related to mental health: An anti-stigma campaign was developed and implemented in 42 villages covering around 40,000 people over a three-month period.25 It used pamphlets and brochures; multi-media resources (e.g videos of people with mental disorders talking about their illnesses); and a drama on mental disorders and the benefits of getting treated which was either staged live or shown as a video recording. The research team used these resources to generate discussions with households in each village. A before-after evaluation was completed in two villages to assess changes in mental health knowledge and stigma. The attitudes and behaviour related to mental disorders improved, and stigma perceptions related to help-seeking reduced significantly (Table 1). Qualitative evaluation found that the ‘social contact’ elements were highly beneficial. The literature suggests that these elements are particularly important in influencing social norms related to CMDs.13 2. Task sharing and strengthening skills of existing primary health care workers: India’s rural public health system has a tiered structure. Sub-centres service about 3,000 – 5,000 individuals, and primary healthcare centres (PHCs) service about six sub-centres. Each PHC has one or two doctors per 30,000 people. Accredited Social Health Activists (ASHAs) are female residents of the villages, appointed by the village administration (Panchayat) who serve as non-physician health workers. ASHAs have around 10 years of formal education and receive three weeks of training per year. Currently ASHAs primarily focus on maternal and child health and conduct village-based services in each household. Remuneration is performance-based. Although a similar structure is present across India, numbers and efficiency levels vary greatly.
David Pereis – Head Primary Health Care Research, Office of Chief Scientist ,The George Institute.
Palab Maulik – Deputy Director George Institute for Global Health, India
- National Health and Medical Research Council, Australia