The women walk for hours over dusty roads and under the hot sun to a clinic in the village of Mugalur, some 30 miles outside of Bangalore, India. One of them has been beaten severely and abandoned by her husband and has been identified as having dysthymia. She struggles with thoughts of suicide. Another acted out violently against several members of her family and wandered the fields aimlessly with little concept of herself or others, showing evidence of psychosis. Yet another spent six hours a day washing herself and her clothes compulsively by hand and so would miss her school bus. Her washing rituals routinely disrupted her studies.
These women and hundreds more like them benefit from mental health services offered at no cost through the Maanasi Project.
Psychiatrist Geetha Jayaram, M.D., established the project in 2002 (“maanasi” means “of sound mind” in Kannada, the local language) with funds raised through the Rotary Club of Howard West, Md., and the personal contributions of family, friends, and others. The funds are administrated by and supplemented through the Rotary Club of Midtown, Bangalore. Jayaram, a longtime Rotarian, is a faculty member in the Johns Hopkins University departments of Psychiatry and of Health Policy and Management and the Armstrong Institute of Patient Safety. Through a partnership with the departments of Psychiatry and Community Health at St. John’s Medical College in Bangalore, Jayaram launched the project, beginning with an assessment of the extent of the need for mental health services among the area’s women.
“India has a mere 4,500 psychiatrists,” Jayaram told Psychiatric News. “Yet it has a population of more than 1.2 billion people, so there is a huge shortage of psychiatric care. What we are doing is really just a drop in the bucket.”
The project began with a survey of 12,000 households in 25 villages regarding the prevalence of common mental disorders to determine the need for psychiatric care, said Jayaram, who supervises the project from abroad and during annual visits. To conduct the surveys, her team obtained permission of the “panchayat,” a local council with authority over villagers. The team consisted of four trained women caseworkers with a high school education who were fluent in the local languages and had good standing in the community.
Jayaram and her team established a psychiatric clinic that dovetailed with the primary care health clinic in Mugalur, which was already familiar to villagers. Women who screened positive for symptoms of mental illness with various standardized instruments translated into the local languages, including the Structured Clinical Interview for DSM-IV-TR, were encouraged to come to the clinic on Friday afternoons, when the psychiatrist sees patients.
The psychiatrist works with an internal medicine or family medicine clinician who assesses patients for symptoms of mental illness and refers them to the psychiatrist when necessary. “In this culture, many symptoms of mental illness are expressed somatically anyway, so it makes sense that they are examined by the internist first,” Jayaram said. The psychiatrist and primary care physicians are affiliated with St. John’s Medical College, and Jayaram supervises the care provided at the clinic.
Maanasi Project caseworkers (from left) Shantha, Usha, Anjum, and Gowramma traverse hundreds of miles on motorbikes to provide mental health services and medications to women in villages in southern India. Over the years, they have also helped educate many of the villagers about mental illness and treatment.
Since many of the women are agricultural workers and cannot afford to take a day off from working in the fields to make the trip to and from the clinic, caseworkers travel to the villages, Jayaram said. Each caseworker received a moped to traverse miles of unpaved roads between 187 villages where the women most at risk for relapse live. During home visits, caseworkers evaluate the women for symptoms; track patients’ behaviors, thoughts, and feelings; dispense medications with the community medicine physicians; and provide supportive therapy. Doctors and social workers may provide behavioral therapy onsite when indicated.
They also educate women and families at monthly women’s cooperatives about symptoms of mental illness and treatments that will help them. The clinic doctors, including Jayaram, also conduct home visits for patients who need specialized attention. The Maanasi clinic now serves approximately 1,600 patients. “Many have been successfully treated and are well,” said Jayaram, and the success of the venture has resulted in services being provided to women from 187 villages.
She recalled being asked to speak on an Indian TV program about the topic of depression. “As a result of that segment, the community medicine program at St. John’s Medical College was besieged with calls, emphasizing the great unmet need for depression treatment,” she noted.
The clinic continues to be a site for research and teaching, in addition to patient care.
The project was not always greeted enthusiastically at the start. Jayaram initially encountered resistance from villagers. For instance, a myth spread among villagers that antidepressant medications would lead to blindness, causing some of the women to resist the treatment. Members of the village mafia threatened some patients who had been encouraged to stop drinking as part of their treatment because they could no longer sell liquor at inflated prices, Jayaram said.
In addition, some women skipped clinic visits, telling caseworkers that they felt shame in accepting free medications.
In one unexpected obstacle, the caseworkers had to be convinced to wear protective helmets when riding their motorized bikes, “because they didn’t think the helmets went with Indian apparel,” Jayaram explained. “But I told them I didn’t want to lose them in an accident, and they complied.”
To educate women in the villages about mental health concerns, the caseworkers attend street festivals in the different villages and act in plays that portray the manifestation of different mental illnesses and how they may affect the villagers in everyday life. Over the years, the villagers have come to “embrace the caseworkers with love and respect,” Jayaram noted.
Jayaram and her husband, Jayaram Kumar, a fellow Rotarian, received an invitation to attend the 2013 forum of mhGAP (Mental Health Gap Action Program), a project of the World Health Organization (WHO) from Shekhar Saxena, M.D., director of the WHO Department of Mental Health and Substance Abuse. The goal of the forum was to discuss how to improve the delivery of mental health services in low-income countries around the world. Jayaram presented information about the Maanasi Project. “Dr. Saxena felt strongly that this was a project that could be replicated in other parts of the world,” Jayaram said.
Even certain areas in the United States, she remarked, could benefit from a model of integrated care like the one used by the clinic in Mugalur. “For so many of our low-income patients, care is fragmented. Someone with acute schizophrenia cannot negotiate the burden that we place on them and be expected to show up at five different appointments in five different places” for varying health care needs.
The Maanasi Project not only embodies the model of integrated care and collaboration between providers, Jayaram pointed out, it “applies transatlantic innovation to community psychiatry,” she said. ■