Compañeros En Salud (CES)

Project type:	Program
Objectives:	To work with the Ministry of Health to integrate quality mental health care into primary care in rural communities.
Brief description:	Linking care between community and facility levels with the support of mental health community health workers.
Social:

Summary

Innovation summary

Within a few months of beginning operations in Mexican Chiapas’ rural areas in 2012, CES staff became aware of a (previously uninvestigated) high burden of mental health-related problems in the area. While working in only 6 communities of less than 2,000 inhabitants, 5 persons were found to live locked or chained because of chronic psychotic illness and almost 200 patients were diagnosed with depression.

In response, CES partnered with the Mexican Ministry of Health (MOH) to provide access to quality mental health care in primary care settings. The program provides accurate diagnoses and safe, effective, and culturally sound medical and non-pharmacologic treatments for mental health disorders based on the core principles of Service, Training, Advocacy, and Research.

Through the partnership with Partners In Health (PIH), best practices can be implemented across borders to PIH sister organizations such as CES, improving health care across the globe¹.

There is a high burden of mental health conditions in Chiapas but limited access to care. There is little funding allocated to mental health care and few practicing mental health professionals, especially at community and primary care levels where only 20% of mental health care spending is allocated.^1,2 Studies conducted in the areas where Compañeros En Salud (CES) works show that the average prevalence of depression among adults is 7.9%, and that 35.8% of adolescents suffer from depression or anxiety^3,4. Studies found that the lifetime prevalence of intimate partner violence (IPV) was 66.4% among women aged 15 years and older, and a significant association between IPV or sexual violence (SV) and the presence of moderate to severe depressive symptoms.⁵

CES’s goal is to improve staffing, supply, and services at the rural clinics by strengthening collaborations between the Ministry of Health and local public entities through a task-sharing and collaborative care models to diagnose and treat common and severe mental health conditions.

Impact summary

Between July 2021- June 2022:

CES treated more than 700 people living with mental health conditions at 11 facilities
Over 9,500 people were screened for depression and anxiety at the rural clinics or in their homes by the CES Mental Health Team. On average 67.7% of patients that receive care have improved their depression symptoms.1
More than 200 women were newly enrolled for mental health services for depression, anxiety, psychosis and epilepsy.
The CES programming has attended to more than 3000 patients, providing outreach and treatment services

“CES has helped me both physically and morally. I have changed a lot because beforehand I was someone who did not have any desire to continue living. Talking with Doctor Luis, Doctor Andrea, Doctor Azucena, and now with Doctor Mariana I am feeling much better. I feel as though I am actually doing something with my life thanks to CES. In addition, I was named one of the acompañantes for Laguna, which has helped tremendously and helped me to learn and understand more."

-Lupita, a patient from Laguna del Cofre

“Most importantly, the circle offers a space in the community where women’s voices matter. Or, as a participant put it: "For me, the women's circle means friendship, unity, and trust."”

A participant reflects on what the mental health women’s circles represent to her

Innovation

Innovation details

Compañeros En Salud (CES) began in Mexico in 2011 and now operates 10 rural public clinics in the Sierra Madre mountains of Chiapas—one of the most marginalized regions in the country. The team provides primary and specialized medical care in rural hospitals to improve quality and access to care. CES works with a range of staff, including Mexican physicians and nurses entering a required year of social service (pasantes), and community health workers (acompañantes) who visit patients with chronic illnesses. To meet communities' needs for specialized mental health care, CES trains physicians, nurses, and community health workers using a task-sharing model to properly diagnose and treat the most common mental health conditions, including depression, anxiety, trauma, and psychosis. Staff are overseen by professional mental health specialists to provide treatment consultations, through a mental health training and supervision curriculum.

The program is based on four principles:

Service

CES clinics are staffed by pasantes, young Ministry of Health (MOH) generalist physicians completing a year of service, who provide pharmacologic and non-pharmacologic treatments and are equipped with antidepressant and antipsychotic medications. Within the community, acompañantes (community health workers) provide basic psychoeducation and monitor treatment adherence, and refer patients to care. CES, in collaboration with Instituto Tecnologico de Estudios Superiores de Monterrey (ITESM) medical students, conducts active-case finding for patients with chronic diseases, including depression.

Training

In partnership with the ITESM, CES pasantes receive a diploma in Social Medicine and Global Health in Mexico. This involves monthly trainings on best clinical practices, how to diagnose and treat mental health problems, and social subjects. CES acompañantes complete a psychoeducation course focusing on working with patients with depression and that features expert patients describing what it is like to live with depression, so that acompañantes can give the most empathetic care possible.

Advocacy

As a private organization partnering with the government, CES is committed to advocating for mental health care throughout Mexico. The staff work to improve the reliability of the supply chain and encourage the MOH to increase the amount of mental health medication purchased. Aggregate patient data can also be used to demonstrate the burden of disease related to mental health to government officials.

Research

Like all Partners in Health (PIH) sister organizations, CES is committed to research informed by service delivery needs. A recent project assessed the validity of the PHQ-2¹ and the PHQ-9² for screening and diagnosis of depression in rural Chiapas. A second project determined the prevalence of depression in rural communities and primary care clinics in Chiapas.

Ongoing projects include: Chronic Psychosis Case Series – Treatment of Psychosis in Rural Primary Care Clinics^3-6.

Psychotherapy
CES has expanded community-level services to treat common and severe mental health conditions using Problem Management Plus (PM+), the Common Elements Treatment Approach (CETA), gender equity-focused psychoeducation groups, and women’s reflective circles. CES trains and supervises non-specialists in mental health care delivery, including training and supervising pasantes to diagnose and treat patients with pharmacologic treatment and brief psychological interventions. Moreover, the community mental health workers provide trauma-informed care sessions when providing PM+, especially to women that have lived or live with domestic violence.
Mental Health Integration
CES integrates mental health services into its existing effective, culturally-sound programs by collaborating with other clinical teams. Along with CES's Community Health team, the Mental Health team has recruited a cadre of community mental health workers (CMHWs) or cuidadoras who have been trained in PM+ to treat depression and anxiety in their communities.
Health equity
The rural communities of the Sierra Madre of Chiapas have limited mental health services that are culturally appropriate and that enable community cohesion from the sharing of knowledge. In this area there is a high prevalence of violence against women, which is related to a higher number of women with depression and anxiety than men. Women are rarely considered in community decisions, and although there are many women living in similar situations of inequity and violence, there are not enough spaces for them to connect and share knowledge in the absence of patriarchal structures. CES created Women’s Circles programs to promote mental health with a gender-based perspective. Furthermore, for the first time in the history of CES, a Cuidador has been facilitating reflective circles with adolescent men and men with substance use problems, focused on tackling substance use and mental health from a gender perspective.
From July 2021- June 2022: CES conducted 26 psychoeducation group sessions and 29 women's circle sessions. The team also co-designed the women's circles project along with cuidadoras via an advisory group and participatory feedback. The cuidadoras project grew from one community to nine.

Key drivers

Collaboration with the Ministry of Health: The team works closely with the Mexican Ministry of Health, local entities that support patients with substance use disorders, and the gender-based violence attention unit from the municipality.
The Community Health Workers: About 1.4 million people in Chiapas suffer from depression and other mental health conditions, there are simply not enough properly trained clinicians available to address the burden of mental health conditions in Chiapas. Community health workers play a pivotal role and are the bridge connecting their neighbors, friends, and family to local clinics across the 10 communities in which PIH works in rural Chiapas, Mexico. After patients have been diagnosed by a PIH-supported clinician in these rural communities, they are connected with a CMHW, who visits their home regularly to provide counselling and support.
Task sharing model with supervision structures: All the personnel that are non-specialists in mental health are supervised and continuously trained by specialists on-site or remotely, ensuring patient-centered treatments and quality care.

Challenges

Monitoring and evaluation adaptations: As the program continues to grow and develop, the team faces challenges in integrating and consolidating monitoring, evaluation, and quality improvement activities and ensuring that staff receive proper training on how to improve and adapt the way that the team collects and utilizes data.
Growing mental health care needs: There is a growing need and desire for expanded mental health care services throughout the area of Ángel Albino Corzo, as well as integrating additional care at facilities such as the birthing center and the local hospital.

Continuation

Continuous training of non-mental health specialists, including training acompañantes in brief psychological interventions, training staff in restorative justice and conflict resolution, expanding training and support in transdiagnostic approaches to support reflective circles with men to address masculinities, mental health and substance use.
Provision of care for substance use disorders via collaboration with local civil society and public organizations and participatory needs assessments.
Continuing to integrate mental health services to other clinical program areas in an effective, high quality and culturally-sound manner.
Strengthening the relationship with the Mexican Ministry of health by providing more hospital-level mental health care and expanding the catchment areas in which PIH works.

Funders

Many Voices Foundation
USAID
IMPACT Initiative

Impact

Evaluation methods

CES has validated the PHQ-9 and PHQ-2 in Chiapas, which are now used for routine depression screenings and care. Before 2016, the Patient Health Questionnaire (PHQ-9) was not validated in rural, Spanish-speaking Mexican communities. Through a study conducted by CES, the PHQ-9 was validated and found to have good psychometric properties for community-based depression screenings.
In 2021, CES established pathways to strengthen data monitoring and invest in mental health program evaluation using the electronic medical records (EMR) and the CommCare mobile app, resulting in improved and enhanced data information systems. Physicians, psychologists, and community health workers enter data into the EMR and CommCare at point of care, and review data for clinical care quality improvement and programmatic decision making.

Impact details

CES has now expanded to 10 clinics, and with 10 young clinicians and 64 community health workers, is treating over 350 patients with mental disorders.

CES treats patients with mental disorders including depression, schizophrenia, anxiety, post-traumatic stress and obsessive-compulsive disorder.

All 27 patients with schizophrenia have adequate treatment and the majority reintegrated into their family and community, five patients previously chained or locked in are now free.
Out of 106 patients with depression invited, 50% of patients attended at least one group psychoeducation session. Of this same cohort, 41% are in remission a year after starting treatment.
The acompañante program is currently running in eight of the ten clinics operated by CES.
- 61% of patients with depression receive home visits by an acompañante who helps with treatment adherence, medication adverse effects, and appointments to the clinic and provides psychoeducation.
CES has developed clinical algorithms for primary care management of depression, anxiety, psychosis and bipolar disorder.
CES has completed two research studies in the past year.

• 61% of people with depression receive home visits by an acompañante who helps with treatment adherence, medication adverse effects, and appointments to the clinic and provides psychoeducation.
• From July 2021 – June 2022, CES screened over 9,500 people for depression and treated 700+ people living with mental health conditions at 11 facilities. During this time 249 patients received at least one session of psychotherapy care using the WHO PM+ intervention by a cuidadora
• From July 2021 – June 2022, CES completed almost 2,000 mental health home visits, with an average of 160 visits per month.