Manashanti Sudhar Shodh

Integrating care for common mental disorders in primary care

To develop and evaluate the clinical and cost effectiveness of a primary care intervention strategy for the treatment of common mental disorders in Goa.

The philosophy of Manas is simple: first, that interventions for mental disorders must be based on evidence of which treatments are cost-effective; second, that these must be based on the reality that the vast majority of persons in India with mental disorders will not have affordable access to specialist services.

Thus, in Manas, we use two models of care. The first is Enhanced Usual Care (EUC), which will focus on improvement of recognition of mental health problems in primary health care. In this model a health assistant screens the patients attending the clinic for the presence of depression and provides the information to the doctor who may then wish to prescribe lowcost generic antidepressant medication (made available in the PHC by the Manas project).

The doctors in these clinics are provided with a booklet with the basic information on diagnoses and medical treatment of depression.

The second model is Collaborative Stepped Care (CSC). In this model, in addition to the Health Assistant, a Health Counsellor, who is recruited and trained to deliver the psychosocial treatment is provided in these clinics.

A range of psychosocial treatments, including psychoeducation, specific psychological treatments, yoga, proactive monitoring of adherence and specialist support to the practice is provided. Our primary research question is whether the addition of the Health Counsellor (who delivers all the psychosocial treatments) provides a cost-effective intervention in comparison to simply providing the PHC doctor with diagnostic information and access to antidepressants.

Soon after the initiation of the project in October 2005, we carried out extensive consultations with local stakeholders (PHC staff and private doctors) on the nature of the intervention. We held a number of workshops with local branches of the Indian Medical Association, with PHCs and with the Directorate of Health Services.
   We hosted a workshop of our collaborators (international and national) in January 2006. Formative research was carried out in 4 PHCs and in 4 GP clinics to assess the feasibility and acceptability of various components of the intervention. Piloting was then carried out in 4 PHCs from August 2006 onwards.
Findings of these studies have been published (see list of publications later in this report). The trial protocol was revised on the basis of the experience gained in the formative and piloting phases. Training for the intervention team was then conducted for 3 months, from December 2006. This included training in inter-personal therapy (led by Dr Helena Verdeli and Kathleen Clougherty from Columbia University, New York) and training on the use of yoga for stress related problems (led by Dr Shirley Teles, Swami Vivekananda Kendra, Bangalore and Dr Sitakant Ghanekar). Twelve PHCs were chosen for the trial’s first phase and randomly allocated to either of the two models of care.
    The running-in phase in 12 PHCs was started in February 2007. During this period, briefing meetings were conducted for PHC staff providing information on the project. This phase was useful in providing the intervention team with the actual experience of working in the PHC.
    The recruitment of patients in this first phase began on the 2nd April 2007 and was completed by 4th October 2007. Over 2,000 patients were detected to suffer from a common mental disorder and were offered treatment. A total of 1648 patients were enrolled into the study for evaluation. Outcome evaluations are being carried out by our partner NGO (VHAG) in order to ensure blinding. On the date of this report, the 2 and 6 month outcome evaluations have been completed with 87% and 86% follow up rates respectively.
    The intervention team continued to provide services in the PHCs until the end of February 2008. Closure meetings were conducted in 12 PHCs to provide feedback on the progress of the trial.
Recruitment for qualitative interviews began after completion of recruitment for the quantitative evaluation; 20 patients from EC clinics and 28 patients from CSC clinics were invited to participate in the interviews with the aim of obtaining narrative feedback from patients about their experiences about the quality of care. We also completed outcome interviews with 12 Health Assistants, 8 Health Counsellors, the 2 Clinical Specialists and 54 PHC staff, including doctors, who were involved in the trial.

Following advocacy by the Medical officers in the PHC’s, the Directorate of Health services has decided to provide Fluoxetine in PHC’s for the treatment of depression after completion of Phase 1. In addition, Sangath has been asked by the DHS to submit a proposal to run the District Mental Health Programme in North Goa.
GP Phase II was launched on 9th July’08 to 14th Feb’09 in all the 12 General Practitioners (GP’s) clinics all over Goa. The team recruited in total 1148 patients for evaluation. Evaluation at 2, 6 and 12 month has been successfully completed with 92%, 88% and 85 % follow up rate respectively. The team had a closure meeting of GP Phase on 31st October 2009 where in all the participating GP’s were presented with the certificate of Participation in the trial.

Phase II Qualitative interviews were successfully conducted with 62 patients. Besides this we are also conducting interviews with GP’s and GP staff to take feedback and their experiences on the MANAS Project. The team is working on the preliminary analysis.

Final Trial Steering Committee (TSC) and Data Monitoring & Ethical Committee (DMEC) meeting was conducted on 15th April’10. The 6 months preliminary results were presented during the meeting. The Committee members applauded the team for its work in conducting the trial and appreciated the team for conducting the trial with no significant protocol deviations.

As a part of dissemination activity the team organized Interpersonal Therapy (IPT) training from 19th July’10 to 30th July’10 which was attended by 25 participants from India and neighboring countries viz. Nepal, Bangladesh and Afghanistan.

On the eve of mental health day team conducted awareness meeting in the community.  Results of the study were shared with health officers and other senior officials of Directorate of health services, Goa by organizing a dissemination meeting on 7th December 2010 at DHS conference hall, Panaji Goa.

The first major paper from the MANAS study was published on 14th December 2010 in Lancet medical journal. Six members of Sangath are listed as authors. The story has been carried on the front page of the Indian Express and several other news outlets in India (e.g. The Telegraph) and abroad (e.g. NPR, BBC). It is a credit to the pioneering work that Sangath is carrying out in community focused mental health care. Click here for the Paper and the related press coverage.

The Manas manual for Health Counsellors
This manual is a resource for lay counsellors working in doctors’ clinics. It addresses the concept of stress and depression, the various treatments for depression and delivery of these treatments in the Manas program.
To download the manual, click here..
The Manas Manual for Family Physicians
This manual contains guidelines for the treatment of depression in patients attending family physicians’ clinics. It has been written for the use of doctors in the Manas program.
To download the manual, click here…
The Health Counsellor’s Trainer’s Manual
The Manual contains guidelines for delivering services to persons with Common Mental Disorders (CMDs) in primary care setting. It is prepared for training the Health Counsellors in the MANAS project.
To download the manual, click here..
Patient Material:
Click here to download Handouts for patients-English
Click here to download Stress and your health leaflet-English
Click here to download Stress and your health leaflet-Konkani

Training Material:

Doctors Material
Click here to download Doctor’s Manual
Health Counselor Material
Click here to download Qualitative Impact Evaluation
Click here to download Introduction to Manas Training kit
Click here to download Health counselor manual  
Click here to download Psychoeducation Flip chart-English
Click here to download Psychoeducation Flip chart-Konkani

Other Material:
Click here to download Brochure on study findings for Professionals
Click here to download Managing Stress Poster-Konkani
Click here to download Managing Stress Poster-English
Click here to download Study findings brochure for participant-English
Click here to download Study findings brochure for Participant-Konkani

Future Plans:
Once all the results of the trial are available, the team will widely disseminate the findings among various stakeholders. A video training package for health counselors has been developed. Besides, team has also developed health counselor and doctor’s manuals which will be useful guides in the treatment of Common Mental Disorders.