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Interpersonal conflicts are there. Unemployment. Alcoholism is a major problem

March 11, 2008
Cases Without Borders

Psychotherapy for All: An Experiment

SIOLIM, India — At the faded one-story medical clinic in this fishing and farming village, people with depression and anxiety typically got little or no attention. Busy doctors and nurses focused on physical ailments — children with diarrhea, laborers with injuries, old people with heart trouble. Patients, fearful of the stigma connected to mental illness, were reluctant to bring up emotional problems.

Last year, two new workers arrived. Their sole task was to identify and treat patients suffering depression and anxiety. The workers found themselves busy. Almost every day, several new patients appeared. Depressed and anxious people now make up “a sizable crowd” at the clinic, said the doctor in charge, Anil Umraskar.

The patients talk about all sorts of troubles. “Financial difficulties are there,” said one of the new counselors, Medha Upadhye, 29. “Interpersonal conflicts are there. Unemployment. Alcoholism is a major problem.”

The clinic is at the forefront of a program that has the potential to transform mental health treatment in the developing world. Instead of doctors, the program trains laypeople to identify and treat depression and anxiety and sends them to six community health clinics in Goa, in western India.

Depression and anxiety have long been seen as Western afflictions, diseases of the affluent. But new studies find that they are just as common in poor countries, with rates up to 20 percent in a given year.

Researchers say that even in places with very poor people, the ailments require urgent attention. Severe depression can be as disabling as physical diseases like malaria, the researchers say, and can have serious economic effects. If a subsistence farmer is so depressed that he cannot get out of bed, neither he nor his children are likely to eat.

In India, as in much of the developing world, depression and anxiety are rarely diagnosed or treated. With a population of more than one billion, India has fewer than 4,000 psychiatrists, one-tenth the United States total. Because most psychiatrists are clustered in a few urban areas, the problem is much worse elsewhere.

As a result, most Indians with mental illness go untreated, especially in poor and rural areas. “There is a huge treatment gap for people with depression,” said Dr. Vikram Patel of the London School of Hygiene and Tropical Medicine, the psychiatrist who began the Siolim project. “In most places in the developing world, 80 percent to 90 percent of people with severe depression don’t receive adequate treatment.”

For India, adding thousands of psychiatrists would take large sums of money and years of effort, resources unavailable to a developing country with many other health problems besides mental illness. By contrast, Dr. Patel’s strategy costs relatively little and does not require legions of doctors.

“It’s a really interesting, exciting thing he’s doing,” said Dr. Greg E. Simon, a researcher at the Center for Health Studies in Seattle.

Dr. Simon, a psychiatrist who studies mental health in the developing world, said the Goa strategy grew from a crucial idea. Unlike, say, heart disease and stroke, which can require expensive interventions, depression is relatively simple to diagnose and treat. Many studies have shown that talk therapy and antidepressants lead to significant improvement in most patients.

“The fundamentals of helping people with depression are pretty low tech,” Dr. Simon said. “The core resource is humans,” people who can identify patients and offer treatments.

The Goa program, financed by the Wellcome Trust, is not the first using nonmedical workers to treat mental illness, but it is the largest. Almost 2,000 patients have been treated. Dr. Patel is conducting a randomized clinical trial to see whether the strategy works, the first time such a careful study has been run in the developing world.

If the research, which will finish in 2010, reports positive results, donors and governments are more likely to try it elsewhere in India and the world, Dr. Patel said, adding: “This is the most important question in psychiatry. How do we scale up treatments to a population in a low-resource setting?”

“If you rolled this program out across India,” Dr. Simon said, “you’d be doing some good for a fifth of the world’s population.”

Dr. Patel, 43, grew up in Bombay, now Mumbai, and wanted to be a caterer. His middle-class parents insisted on a more respectable career. He went to medical school.

After completing training, he spent two years in Zimbabwe as a researcher. He hoped to prove that Western concepts of mental illness did not apply in the developing world. Instead, he came to the opposite conclusion, that the ailments were in fact just as common and just as treatable as in the West.

He now splits his time between London and Goa, where he runs a social welfare organization, Sangath, which means partnership in Hindi.

Known in the West for its beautiful beaches, Goa is relatively wealthy by Indian standards. But most of its three million residents earn a few dollars a day, not enough to afford much medical care. Public health officials say that poverty can lead to alcoholism, domestic abuse and stress, all contributors to depression and anxiety.

At government clinics like the one here, overworked doctors lack time and inclination to ask patients about mental health. Even clinicians who look for depression may miss it. For reasons that no one fully understands, depressed patients in the developing world often complain of physical symptoms like fatigue, headache and insomnia rather than emotional problems like sadness or regret.

As a result, Dr. Patel said, depressed patients in Goa may receive unnecessary and expensive treatments that fail to address the underlying problem. For all those reasons, he said, most depression and anxiety remains undiagnosed. But they are common. A survey by Dr. Patel found that one in three adults seeking care at public health clinics in Goa were depressed or anxious. Dr. Neerja Chowdhury, a psychiatrist at Sangath who is helping manage the project, said, “That might be an underrepresentation.”

The program began in 2005, hiring 12 recent high school or college graduates who lacked medical backgrounds. Six “health assistants” received a week of training, and six “health counselors” had three months of training. The workers — paid the equivalent of $100 to $200 a month, significantly less than Indian psychiatrists — were sent to the six clinics.

Five days a week, the assistants screen almost every patient who arrives at the door. Pregnant women, minors and emergency cases are excluded. The screening is created for the program. It includes questions about physical symptoms, as well as emotional problems.

A patient meeting the criteria for mental illness is immediately sent to the health counselor, who provides a straightforward explanation of depression and anxiety and offers a range of treatments like talk therapy, yoga and, in conjunction with a doctor, antidepressant medication. Patients return every few weeks for follow-ups.

The screening and first consultation typically take a half-hour. In the old system, the few patients with diagnoses of depression were referred to a psychiatrist at one of two state mental hospitals. Dr. Patel said many patients failed to show up for appointments because they could not afford to take time from work or pay for transportation.

Most are also apparently wary of visiting a mental hospital. In India, the stigma of mental illness remains strong. To minimize the problem, health workers avoid using the words “mental illness,” “depression” or “anxiety” with patients, relying on more commonly used words like “strain” and “tension.”

The patients “are happy to talk,” Dr. Sudipto Chatterjee, a psychiatrist at Sangath, said, “as long as you stay away from the idea of mental illness.”

Dr. Chatterjee helped draw up the program and oversees the screeners and counselors. He said they not only diagnosed as well as doctors but were generally better listeners, partly because they have more time.

Psychiatrists usually “have five minutes to see a patient,” Dr. Chatterjee said.

In a society where many people have no place to share their worries, the effects of therapy can be striking. On a recent Saturday morning at the Siolim clinic, Ms. Upadhye, the health counselor, sat in her closet-size plywood-wall office, trying to stay cool under a negligible breeze from a tiny plastic fan, when a psychiatric patient arrived for a return visit.

A housemaid in her 50s who wore large glasses, bright bangles on her wrists and a light blue sari, the patient had originally reported physical problems like headache, insomnia and pains but had been given a diagnosis of depression. As Ms. Upadhye listened, the woman let loose a flood of words.

Speaking in Konkani, the predominant Goan language, she told the counselor that she was not getting along with her four children, especially her son, who had recently beaten her up in a drunken rage. She said she had no one to talk to. Holding tightly to her handkerchief, she began to cry.

Within minutes, she began to relax. Her expression loosened.

“I feel better when I tell my problems to somebody else,” she said.

Ms. Upadhye ended by reminding the woman to keep taking her antidepressant medicine and to check in regularly.

After the session, Ms. Upadhye reflected that just listening to her patients made a big difference.

“I feel like I’m doing something, just giving them time to ventilate,” she said. “They can tell their problems, they can share their feelings.”

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