The conflict-ridden Kashmir valley of the state of Jammu & Kashmir, India (District of Ganderbal) is the main site where this innovation takes place. This area of focus has been selected primarily because of the tremendous existing mental health service gap as well as the increased burden of psychiatric disorders. Studies conducted in the region have revealed a 30-fold increase between 1996 and 2006 in the prevalence of major mental illnesses as well as a lifetime prevalence of 15.19% for the post-traumatic stress disorder. [1-2, 6]
This two-year innovative intervention in the rural and post-conflict region of Jammu and Kashmir, India, aimed to improve mental health services provided to youth. The main obstacle in providing basic mental health services and reducing the treatment gap in LMIC countries are lack of access and resources. To circumvent this and to meet the project’s overarching objective, effective and affordable community-based care and rehabilitation was provided, effective treatments for use by non-specialists, including Lay Health Workers was developed with focused but brief training, and mobile and IT technologies was developed to increase access to evidence-based care.
Collaboration with an already well-established and reputable voluntary organization, SAWAB (in Kashmiri this term refers to doing a good deed for the benefit of others) representing the only mental health service provider in the region greatly facilitated the integration with existing medical and pastoral systems (imams, local self-government leaders, etc.) and improved early detection and the timely delivery of mental health services to an underserved population.
Key features of the Lay Health Workers (LHWs) role included:
- Identify major mental disorders focusing on three WHO-identified major disorders: psychotic, bipolar and depressive disorders, as well as trauma-related presentations
- Appropriately refer patients to the voluntary organization, SAWAB, for consultation and supervision of care by LHWs
- Request supervision from mental health professionals when deemed necessary.
- Provide psychosocial support to patients and families including psychoeducation, stress and adherence management as well as relapse prevention
- Communicate on a weekly basis with patients using cell phones
- Complete patient/family member assessments and LHW questionnaires using netbooks
Once LHWs identified potential patients with the help of a stakeholder in the community, they arranged for consultation with a psychiatrist within 15 days. If needed, medication was provided free-of-charge and prescribed by psychiatrists along established guidelines. Pathways to care and time from onset of illness to referral were recorded for all patients. Patients functioning and symptoms were assessed throughout the project using three published scales. Quality of life, satisfaction with services and engagement of patients as well as their family members in treatment were also recorded.
The project was enabled by the use of technology and media. Key characteristics of mobile, informational technology and electric media use included:
- Cell phone use by LHWs ensured that contact was maintained with 100% of patients
- Netbooks enabled LHWs to complete questionnaires in real-time and to request online supervision as well as communicate electronically with supervisors
- Netbook allowed patients and their families to complete electronic questionnaires assessing symptom and functioning progression
- Media (TV, newspapers) was commissioned to increase awareness of mental health issues and the availability of services offered by the project
- Tele-psychiatry offered consultations to patients in remote areas
Watch the video with Dr Ashok Malla on Mental Health in rural Kashmir.