MANAshanti Sudhar Shodh (MANAS) means “project to promote mental health” in Konkani. The intervention was developed through extensive consultation with local stakeholders, formative research and piloting.1-2 Two models of care were developed and tested against one another at public primary health centers and private general practitioner facilities in Goa.
In both models, a health assistant was enlisted to screen clients at the clinic or facility for depression and/or anxiety. Clients were then randomized to either enhanced usual care or collaborative stepped care, as described further below. Low-cost generic antidepressant medication was made available by the MANAS project in the public primary health care facilities, in order to ensure that drug supply and affordability issues did not impact the utilization of drug treatment in the two arms. Drugs were not provided in either arm of the private sector facilities. These differences between the public and private sector facilities are consistent with drug prescription practice in these facilities.
Enhanced Usual Care
In enhanced usual care, the results of the screening were communicated to the clinician, who had been provided with a booklet of basic information on diagnosis and medical treatment of anxiety and depression. The clinician then chose how to proceed.
Collaborative Stepped Care
Case management formed the back bone of the collaborative stepped care intervention. A non-specialist health worker was recruited and trained to deliver psychosocial interventions alongside the enhanced usual care interventions. Psychosocial interventions included psychoeducation, yoga, interpersonal therapy, and proactive monitoring of adherence. Specialist support was also provided to the clinicians. These intervention components were delivered in a stepped care fashion. A stepped care model initially offers service users the lowest treatment tier deemed appropriate to meet their clinical needs, only ‘stepping up’ to more intensive or specialist services if initial treatment is unsuccessful.