The project incorporates multiple components:
Weekly outreach visits and screening (PaCoMSI)
Outreach visits are performed weekly, picking one ‘cluster’ of villages a week. The 75 target villages are divided into 11 clusters, so that each cluster gets re-visited approximately once in 3 months. Home visits are available for selected patients who are too sick or too far to come to the location. We have recently attempted 'clubbing of clusters' (covering more than one cluster on a single outreach visit) to adjust for lost visits due to difficult weather conditions or other reasons.
In preparation for the visits, field workers screen selected areas using our new family-level screening tool, the Padhar Community Mental Health Screening Instrument (PaCoMSI), to detect mental illnesses and epilepsy. The tool is short, incorporates local terms and concepts, and can screen entire villages one family at a time (rather than one person at a time). Pilot data emerging on sensitivity and specificity are very encouraging.
Those with positive PaCoMSI screens are evaluated by the psychiatrist, and managed as needed according to the following strategies:
- Severe mental disorders & epilepsy: Medication provided in community setting; patient/family psycho-education through Group Therapy; home-based rehabilitation strategies
- Common mental disorders: Mostly referred to base hospital for relevant tests and interventions; some medication on a case-by-case basis
- Developmental Disorders: Intensive screening for treatable co-morbidities (which are treated in the community); parent/family psycho-education through Group Therapy; some referred to base hospital for more intensive interventions (if willing and able)
- Alcohol use disorders: Mostly referred to base hospital; as of June 2016: community-based ‘detoxification camps’ using self-help groups (2 camps held so far)
Medication: Field workers follow up all patients receiving medications in the field twice a month in their homes
Group Therapy: Group Therapy sessions have a psycho-education focus and are held in one cluster each month (alongside the Outreach Clinic) for selected patients with severe mental illnesses, epilepsy and developmental disorders. These sessions focus on the nature and management of the disorders, family burden, stigma, and re-integration into the family and community. Sessions for alcohol treatment further focus on motivational counselling and triggers of alcohol use.
Community re-integration: The primary strategy for severe mental illnesses has been to encourage families to get patients back to work in the field or house (e.g., agricultural work, manual labour, household chores) as soon as their symptoms remit sufficiently. Psycho-education of family members further empowers families to take charge of treatment rather than depending on health professionals.
Education, capacity-building, and stakeholder engagement
Weekly team meetings bring together all field workers, coordinating staff, psychiatry nursing students, and the consultant psychiatrist. In addition to reviewing problems and planning strategies for the coming weeks, these are an important opportunity for learning and training. We also regularly host visiting and prospective medical students, theology & sociology students, nursing students and others, who receive an orientation to psychiatry and the Project and on-site clinical teaching. These past months have seen students and visitors from Germany, Sweden, Singapore, Australia, Italy, and various parts of India.
The field workers and success stories of individual patients help increase awareness of mental health issues in the community, and we raise awareness of events like World Mental Health Day by organizing talks, publicity pamphlets, radio talks, etc.
Finally, 3 tiers of reports are generated regularly: Weekly outreach census reports (circulated internally within Padhar hospital), Monthly reports (wider circulation to team members, donors, and well-wishers), and half-yearly reports (wider circulation and publicity, often including individual case stories as examples and plans for the future).