Reimagining Psychiatry in Rural India
By bridging physical and cultural divides to meet the needs of drastically underserved populations in India, advocates may end up creating a model for the rest of the world.
Sathya, a 25-year-old woman from a rural village outside Chennai, India, was 18 when she started throwing stones at worshippers going to pray at the temple next door to her home. She grew angry, refused to help her mother with chores, and would often wander away.
Earlier that year, Sathya had been raped by a classmate.
After years of angry behavior, Sathya's mother sought treatment from a Hindu healer for 10,000 rupees (roughly $180). When that yielded no real improvement, she brought her daughter to a psychiatrist 25 miles and three bus rides away in the small city of Pudukottai. The medicines he prescribed cost them the rest of their savings, still to no noticeable effect.
Last year, treatment came to them. A lime green RV parked in the dirt lot directly in front of the neighboring temple; inside, Sathya was able to Skype with a psychiatrist over 240 miles away in urban Chennai. The doctor diagnosed her with schizophrenia and prescribed psychiatric medication that Sathya collected for free from a window in the back of the bus.
The RV was a mobile telepsychiatry clinic, a project of the Chennai-based nonprofit Schizophrenia Research Foundation (SCARF). SCARF now reaches 800 villages like Sathya's through telepsychiatry, connecting hard-to-reach patients with psychiatrists and prescriptions.
It's an oft-cited statistic in the discussion on mental health in India: it is estimated there is only one licensed psychiatrist for every 400,000 people. (The United States has roughly 58 per 400,000, in comparison, and Argentina leads the world with an estimated 580.) And with many of the nation's psychiatrists in cities, the numbers are even lower in rural areas.
But Indian mental health advocates say simply training more psychiatrists isn't the answer. As researcher and psychiatrist Dr. Vikram Patel, founder of mental health NGO Sangath, wrote:
Mental health services in developing nations imitate those in the West, where specialists in clinics or hospitals treat patients. This works well when there are enough specialists, and importantly, enough hospitals. When both are in short supply, more innovative thinking is needed.
Through rural outreach programs, organizations like SCARF, Sangath and other Indian NGO's are reimagining the Western specialization model for mental health. They're filling the Indian "treatment gap" in psychiatry not with more doctors, but with new technology and community training.
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On paper, the Indian government has taken significant steps toward providing mental health care for its 1.2 billion citizens. The National Mental Health Programme, launched in 1982, mandating that basic psychiatric care be provided in every government-run primary health center. The government provides basic training for all primary health center doctors, and pays for psychiatric medication to be stocked and available to patients.
"At the central level, there seems to be good progress," says David Nash, CEO of Indian mental health non-profit the Banyan. "At the implementation level, it's a disaster." Out of 626 districts across India, 125 have some mental health programming in place, Nash says.
Even among those 125 districts, many still aren't providing psychiatric care. Mental health training for primary health doctors amounts to six days of instruction. "Doctors are reluctant to make any significant decisions. Much of the money gets returned at the end of the year unspent," Nash says.
The mobile clinic, which started in 2011, is just one method being used to treat rural patients who lack access to adequate government care. "Directly seeing someone is the best way, but something is better than nothing," says Kotteshwara Rao, the program coordinator for SCARF's community mental health programs.
The clinic serves five villages weekly, and sees up to 40 patients in a day. In the end, each person has only 20 minutes or less with the psychiatrist. For returning patients, most of the session revolves around their prescription; only the SCARF center in Chennai is able to provide in-depth counseling for patients who need it, Rao says.
Given how few specialists are available, many organizations are increasingly relying on community health workers. SCARF trains local women to do a broad survey of mental health issues in the community, and refer those that need treatment to the clinic. Their outreach workers also conduct home visits for distant, long-term patients. Sangath completed a similar training in Goa, where women were given six weeks of training on how to recognize and help issues such as depression and alcohol abuse.
According to Vandana Gopikumar, founder of the Banyan and member of the Indian Mental Health Policy Group, low-level health workers could drive the expansion of mental health services in India. "The non-specialized workforce is the workforce that needs to be built up," Gopikumar says. "What is therapy? Therapy is really a kind person who is speaking sweetly with you and trying to solve your problems."
SCARF outreach worker Kruba Gunasekaran is from a village eight hours from Pudukottai. After completing a month-long training, she now has a roster of patients in the surrounding villages she visits every other week. "I try to spread some awareness and get the patient to the clinic," she says.
People are more receptive to Gunasekaran than they might be to a licensed doctor from the city, especially when discussing sensitive subjects. "In some families, we get really attached," she says. "People share a lot of personal stories with me. They talk to me like family."
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Despite rejecting a specialist-based system, some worry the mental health movement in India still imitates the West in other ways, to a fault: by using Western definitions to diagnose disorders, and psychiatric drugs to treat them. These definitions and treatments may not be universally applicable for the unique population and conditions on the other side of the world.
"[Medication] is an easy option. Who wants to solve the psychological problems and the cultural issues?" says Dr. K.S. Jacob of Christian Medical College in Vellore. Jacob has written extensively on the "medicalization" of public health in India, the result, he says, of pharmaceutical interests and Western influence.
Much of the treatment given through rural outreach programs now is the prescribing and supplying of medicine. Check-ups with outreach workers or specialists are often a conversation about whether that medicine is working. "Home visits are important to explain why taking medication is important," says Kavitha, a community outreach worker with the Banyan.
Many programs aim to provide more counseling and other services, the way some urban-based programs do. But time is limited for both outreach workers and the patients they serve. "We should be more like a wellbeing center," Gopikumar says of the rural Banyan clinic. "But our [rural patients] don't have time for yoga and meditation... They don't have the luxury to take time to get well."
Rather than resisting Western medicine, many rural families are eager for a seemingly silver bullet solution that doesn't make them travel long distances or lose a day's wage.
In the fishing village of Kovalam north of Chennai, even the local Muslim faith healer, Allauden, has begun referring his clients to the Banyan clinic. "The Banyan does it through beds, injections and tablets. We do it through it through wind," he says, explaining the difference between their methods. "I can see in the patients' face whether I should treat them or send them to the Banyan. I only see small cases now."
Patients seem less concerned with what kind of treatment they are receiving than they are with what works. After trying religious healing or alternative therapies, patients coming to the Banyan's rural clinic are often seeking a quick medical fix.
"Most of them have this misunderstanding that doctors who administer shots are better," Kavitha says. After taking the time to reach the Banyan clinic, families would be "unhappy" if they were prescribed counseling and alternative therapies, such as yoga, rather than a pill. "The only thing they will think is, 'we've come so far, and they won't even give me a tablet?'"
Rao has seen similar reactions among SCARF patients. People often approach him asking for medication to treat issues ranging from menstrual problems to alcoholism. "People are thinking that if they go to a psychiatrist, they are getting a solution to everything in the world," he says.
Outside the clinic in Sathya's village, a woman approached Rao asking for pills to deal with her headaches. "In a vegetable shop, you can't get chicken or mutton," Rao explained, despite her repeated requests. "We don't have medicine for those kinds of problems here."
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The Indian Mental Health Policy Group hopes to redirect the psychiatric focus of the mental health movement toward more holistic healing. In late June, the group released a set of policy proposals for the District Mental Health Program. The Group advised a national "focus on improved quality of life of the client vs. mere symptom reduction... [including] the need for social protection and effective poverty reduction policies."
"The whole country is moving toward this paradigm shift, where we're looking at mental health from a well-being, development lens, and less from an illness sort of lens," Gopikumar says. "As far as possible, have treatment available locally. And treatment doesn't just mean popping pills."
For patients like Sathya, simply treating symptoms of schizophrenia with medication isn't enough. Because of her illness, her mother is having a hard time finding her a husband. "No one will marry a mentally ill girl," Rao says of the strong stigma against those with mental health problems. After her rape, Sathya refuses to let men look at her, including her own brothers.
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But a marriage could give her widowed mother one less mouth to feed. Sathya's prescription leaves her hungry and asking for more, so her mother often spaces out the daily dose to one pill every couple of days. Sathya's family may decide to marry her to her 40-year-old uncle. "Whatever the family decides, I will agree to that," Sathya says. She is no longer angry and throwing stones. But she is far from being healed.
"Things are not as simple in India. There is so much interplay between poverty, stress, gender insensitivity and discrimination, and mental health," Gopikumar says. Those on both sides of the psychiatry debate agree India needs to take a broader view. By reimagining what it means to provide mental health care in rural India, advocates may end up creating a model for the rest of the world to follow.