THIRD HALF-YEARLY REPORT OF PROJECT “SHIFA”, THE COMMUNITY MENTAL HEALTH PROJECT AT PADHAR HOSPITAL

(March 2016 to October 2016):

Dear colleagues, financial supporters and well-wishers of the CMH project, Padhar

It gives me immense joy and pleasure to be able to write the third half-yearly report of Project Shifa, the Community Mental Health (CMH) project at Padhar hospital. The past few months since our previous half year report in February 2016 have been very eventful, and we are thankful to God for the considerable local, national and international attention and support we have been receiving since then. This report will provide a synopsis of these developments, and also discuss the “outcome evaluation data” for this period.

So many people from so many places need to be thanked for their help, that I would not know where to begin, and apologies for the many people who will inevitably be left out in such lists. As always, all the readers of our reports, we are grateful for your support, encouragement and suggestions. Thanks especially to all the mental health professionals, neurologists, family physicians and community health professionals from various national and international institutes and organizations that we have regularly corresponded with for their valuable suggestions and inputs. Thanks to the project team (field workers, Mr. Bappa Mukherjee, drivers and all our nursing and elective students) for their untiring efforts and their inspiring dedication, despite hectic schedules and lots of multi-tasking. We also thank Dr. Rajiv Choudhrie (our medical superintendent) and Mr. Vikas Sonwani (our administrative officer) for permitting us to go ahead with all our activities and plans. The Friends of Padhar, UK, has been giving us an annual donation last two years, for which we are grateful; they are the first organization to do so (all our other donations were from individuals). I also specially must mention Dr. Robert Drake from Dartmouth, USA, who has been a real support and inspiration. Not only did he co-author our paper describing our model of mental health care (for the British Journal of Psychiatry International), but he also arranged a donation through the Foundation for Excellence in Mental Health.

A special mention needs to be made of Mr. Bappa Mukherjee’s tremendous impact on the various projects at Padhar Hospital since he took over the coordination of all the community projects in the hospital, including Project Shifa. In the past few months, he has galvanized the team of ten field workers into a truly formidable force within the hospital, and this has had a major impact on the outputs of all the hospital’s many community projects. For the first time, a dedicated community department, “the Maranatha Community Initiatives Department” (consisting of Mr. Bappa and the ten field workers) has been formed in the hospital, and is responsible for coordinating all field activities. Project Shifa too has benefited significantly from this, and I continue to be amazed at how this small group of people multitasks and manages so many activities so efficiently. It is humbling for me personally, as a doctor and a human being, to learn so much about team work from them. I am indeed proud to be associated with them, and to have them as my team for Project Shifa.

We bring out monthly and half yearly reports regarding the progress of this project; in case any of you has not read those, or would like some more information, we would be happy to mail these to you at request.

Scope of the project:

Padhar Hospital is a rural Lutheran multi-specialty mission hospital located in Betul District of Madhya Pradesh, roughly equidistant from Bhopal and Nagpur. Project ‘Shifa’, the Community Mental Health (CMH) project at Padhar Hospital is a project designed to screen, identify and facilitate treatment and community re-integration of patients with mental illnesses and epilepsy in a specified target area of 75 poverty-stricken villages within a radius of less than 30 km around Padhar Hospital. It is currently running on a limited budget financed entirely by personal donations from well-wishers. The project activities include building awareness of mental health issues and epilepsy in the target community, door-to-door screening by field workers using a specially designed screening tool, weekly outreach clinics (on Wednesdays) by the team including the consultant psychiatrist in selected village settings, provision of free medications on site for patients with severe mental illnesses and epilepsy, referral of patients with less severe mental health issues to Padhar hospital for more pharmacological and/or psychotherapeutic interventions or consultations with other departments, fostering community re-integration of patients and their families in the field, facilitating practical community-based research to improve methodology of rural mental health service provision, and a mechanism to follow up patients receiving medications in the field on a regular basis.

Team members:

The project team currently consists of the following members (all of whom are hospital employees/students and none of whom exclusively work for this project alone):

1) One consultant psychiatrist (Dr. Johann Ebenezer)

2) One Coordinator (Mr. Bappa Mukherjee organizes field staff coordination and supervision)

3) Ten field workers

4) Nursing Students posted in the department of psychiatry (on rotation.). Apart from this, elective students from India and abroad (whenever they are present)

Major milestones and challenges over the past 6 months:

These past 6 months have largely been a period of networking and expansion, as well as consolidation of gains made in the field. The total number of patients registered under the project has increased to 523 (up from 472 in the last half-yearly report). Of these, a core of about 170 patients with mostly severe mental health issues and epilepsy are regularly receiving medications in the field and are being followed up by field workers at their homes twice a month. Many of the others were referred to the Psychiatry OPD for further interventions and have become regular outpatients. Maintaining rigorous follow up and home-based and community-based care and rehabilitation of this core group actively involving and empowering families has been our primary focus.

We took the liberty of sharing our previous half-yearly report (Feb 2016), with its detailed outcome evaluation and interpretations, with a wide variety of professionals and organizations both nationally and internationally, and we were thrilled by the encouragement and suggestions for improvement which we received. A full list of these new contacts is included under the “Research and Correspondence” section below.

In May 2016, I was invited to attend two meetings organized by the Indian Council of Medical Research (ICMR). The first of these was a training session for medical officers about mental health at Bhopal organized by the ICMR’s sister institute the National Institute of Research in Environment and Health (NIREH), at which I was invited to give a presentation of our work. The second was a brainstorming session on the future of mental health research in India, to which I was invited as a member of the expert panel that included prominent mental health professionals involved in community mental health work from all over the country. It was truly humbling to be the junior-most person seated in a room full of renowned professionals, a real honour for our project and our hospital.

In April 2016, we received a commission from the editor of the British Journal of Psychiatry International to write a special paper on our work. Dr. Robert Drake, psychiatrist at Dartmouth School of Medicine, USA, kindly agreed to co-author this paper. The completed paper describing the “Shifa” model of rural mental health care was accepted for publication in September 2016 – a major milestone. Another paper describing suicide patterns presenting to Padhar Hospital was also accepted for publication in the Indian Journal of Psychological Medicine in August 2016, and is due to come out in the special edition on suicide planned for November 2016. We are continuing to work on other research work as well, including a pilot evaluation of our screening tool as well as a descriptive paper on post-encephalitic syndromes. More on these under the “Research and Correspondence” heading.

An attempt to expand and generalize at least some aspects of the model is being undertaken, though very cautiously at the moment. The District Collectorate has granted us permission to train Government Health Workers (ASHAs and Anganwadis) from villages beyond our current target area. At present we have conducted two training sessions for workers from more than 120 villages in the use of our screening tool, and they have started screening in their villages. I am happy to report that some of them have already started referring some patients to us for treatment (and personally accompanying them as well), so it appears that they are able to screen fairly easily – an encouraging sign. They have been given a deadline to complete their screening by November 30th 2016, after which we will have to plan phase 2 in which I will have to evaluate the screened patients. We have not yet finalized exactly what model of care we will offer them keeping in mind our extremely limited financial and human resources. We still have only one mental health professional, and Mr. Bappa insists that he and his team already have their hands full with all the projects at Padhar. As of now, it appears I will just evaluate and refer them to Padhar for treatment, and those who come will have to pay for the interventions they receive. In the process, we will be able to generate more data for our tool, and also hopefully demonstrate its reliability when used by workers who are not part of the team. This could potentially be a great step in propagating variations of this model in other parts of the country and beyond.

We were pleasantly surprised and encouraged that Project Shifa was selected as one of three finalists for the BMJ Awards South Asia in the category “excellence in delivery of primary care”. It was quite an honour to be selected and to have progressed this far among the more than 1500 nominations that were received this year. The final round will be an oral presentation at Delhi on November 18-19th 2016.

Another exciting development in these past months has been the community detoxification camps for alcohol dependent patients. Although not part of the core work of project Shifa, it is the same team that is involved, and it is an intimately related activity. One of our concerns expressed in the last half-yearly report was that our model was not able at that time to cater to the needs of common mental health issues including substance use in the field (though we were referring such patients to the hospital.). Thanks to the enthusiasm and organizational skills of Mr. Bappa, we have been able to start working on this very important area. We have so far had 2 such camps, each of one week duration, with the patients continuing to meet in self-help groups similar to Alcoholics Anonymous groups since then. The first camp was in June 2016 and the second was in September 2016, targeting the Dholidhana and Khari areas respectively. Ten patients were enrolled in each of these. As of this month, 8 out of 10 of each group are well and still meeting in their respective groups regularly. Thus, as an acute intervention, it seems to be an exciting success. Long-term follow up will be required to see how the groups progress though. The next is being planned for the Chiklimal area probably in December or January.

Regarding our follow up patients in the field, we have adopted a rights-based approach to their long-term care. To ensure accessibility of care, we have adopted this community-based approach and home-based rehabilitation model (with free medications) for those with severe illnesses, and treatment at minimum cost in the hospital for those with milder common mental health issues. But once the severely ill patients are better, we offer them and their families the option of whether to continue care or not. Most of them do indeed continue. Those who do not want to continue once they are better are allowed to make informed decisions, and are educated about the risks of relapse. We do not follow up those who opt to discontinue treatment in the field as part of the project, but inform them that they can avail treatment at the hospital if required in case they relapse. The exact figures of these are included in the “Outcome evaluation data” section below.

Of course, major challenges still remain. Paramount among these is the question of sustainability. We are in a better position financially this year due to the personal donations we received. However, no system that runs purely on donations is sustainable in the long run. Expenses have been shown to be very minimal in this model. As we expand, we may have to start charging minimally (at least to cover medication costs). Another option is to look for small-scale donations from the villagers themselves – a model that has helped to partially finance the detox camps we have held. We have, since our last half-yearly report in Feb 2016, spent only Rs. 91,090/- on field medications ordered – an incredibly small amount considering the large number of patients who have benefited and the very encouraging outcomes being achieved (see “Outcome evaluation data” section below). To illustrate just how economical this is, it translates into an average of about Rs. 90/- per month per patient (considering that about 170 patients currently receive medications in the field) – or about Rs. 3/- per day! Of course, this does not factor in transport and miscellaneous expenses such as stationary. However, even if these are factored in, it amounts to less than Rs. 10/- per patient per day with the current model of care. In addition to this, a small contribution of about Rs. 2,000/- was given towards

the second detox camp in September, as part of the hospital’s contribution towards this (most of the remaining expenses were covered from donations from interested villagers).

The other major challenge ahead is sustainability in terms of manpower. As has often been pointed out, the major structural weakness in this project and its model is the reliance on a single mental health professional to head it. It is the one weak link in an otherwise well-oiled machine. It is very unlikely we will get another mental health professional anywhere in the near future. Perhaps the solution is to try and get another team member who can be trained to run things in my absence as well, under my supervision. This could potentially be anyone from an interested nurse to an interested medical officer, to an occupational therapist (if available). As work grows and expands, this appears to be an essential missing link in the structure that we desperately need to work on.

Current Activities of the project:

1) Weekly outreach visits on Wednesdays We continue to have weekly outreach visits, picking one cluster of villages a week. As the 75 target villages are divided into eleven clusters, each cluster gets re-visited approximately once in 3 months. We often do a few house visits as well, for selected patients who are either too sick or too far to come to the selected locations. In these past 6 months, we have often attempted clubbing of clusters in order to adjust for lost visits due to difficult weather conditions or other reasons such as festivals, leaves etc. Field workers follow up all patients receiving treatment in the field twice a month in their homes.

2) Weekly meeting on Saturday These continue to be held every week, and are attended by all field workers, coordinating staff, nursing students posted in psychiatry, and myself. Apart from reviewing problems encountered and planning strategies for the coming weeks, they are also an important opportunity for learning and training. They also provide ample opportunity for feedback and encouraging one another, and are a great help in fostering team work and spirit.

3) Record keeping: We keep case notes for individual patients screened in the field and data sheets where details of diagnosis etc are recorded. All patients are assigned a unique CMH project card with their CMH project registration number. This will not only help us to identify them easily in the field, but will also make their visits to Padhar hospital easier, as they can be easily directed to the psychiatry department or project office.

4) Reporting: As planned, 3 tiers of reports are being regularly generated: a) Weekly outreach census reports (circulated by e-mail internally within Padhar

hospital to those directly involved in the project)b) Monthly reports (intended for wider circulation by e-mail to all team members as

well as donors, well-wishers and anyone else) c) Half-yearly reports (intended for wider circulation and publicity, and also including

some individual case stories as examples, as well as broader plans for future etc) – of which this current report is the third.

5) Building awareness in the community of mental health issues: The field workers, while screening, also help to increase awareness of mental health issues in the community, and the success stories of individual patients also greatly help in increasing awareness of the effectiveness of treatment. We also regularly make use of events like World Mental Health Day (October 10th) for awareness building by organizing talks, publicity pamphlets, radio talks etc. This year, for World Mental Health Day, we organized awareness talks for the police in Betul and for some school children. We also recorded a radio talk, but it was unfortunately not broadcast due to some technical failures in the radio station (their computers crashed), and we have not been able to re-record it as yet.

6) Education: Apart from the nursing students and field workers who are regular participants in the project's work, we have also been fortunate to regularly have a number of guests from a variety of nationalities and backgrounds...including elective medical students, masters in family medicine students, students entertaining prospects of future medical careers, theology & sociology students, elective nursing students and others. These past months have seen elective students and visitors from several countries, including Germany, Sweden, Singapore, Australia, Italy, and from various parts of India. All guests are given an orientation to the subject of psychiatry and Project Shifa to the visits, as well as on-site clinical teaching.

7) Group Therapy: Group Therapy sessions with a psycho-educational focus for selected patients with severe mental illnesses, epilepsy and developmental disorders and their family members are being held in various clusters. We attempt to pick one cluster each month and have the sessions along with the Wednesday Outreach Clinic that week. These

sessions focus on educating about the nature of the disorders and management issues, as well as addressing family burden and issues of stigma and re-integration into the family and community. Group therapy also forms an integral part of our detoxification camps for alcohol dependent patients, with sessions focusing on motivational counseling, strategies to deal with triggers of alcohol use, family issues and other group discussions.

8) Community re-integration of patients with severe mental illnesses: The primary strategy has been to educate and encourage the families to get the recovering men back to work in the fields or locally-available manual labour jobs as soon as their symptoms remit sufficiently to allow some degree of work. For the recovering women, our strategy has been to encourage house work primarily, or when possible helping with agricultural work. Other strategies involved educating family members about the illnesses and their treatment, and empowering the families themselves to take charge of treatment rather than depending on health professionals.

9) Research & Correspondence: a) As mentioned earlier, our primary research focus is on evaluating our new screening

tool to pick up mental illnesses and epilepsy called the Padhar Community Mental Health Screening Instrument (PaCoMSI) that incorporates local terms and concepts. Pilot data emerging on sensitivity and specificity is very encouraging. So far as we know, it is the only such short tool available for rural third world settings to screen entire villages one family at a time that can pick up a broad range of neuropsychiatric syndromes. Although we have not yet completed screening the entire target area, we plan to write up our data compiled so far as a pilot evaluation study soon.

b) Our outcome evaluation tool has also generated some very informative data that is useful for evaluating our progress, and also provides much food for thought on weaknesses and potential areas for improvement.

c) Post-encephalitic neuropsychiatric syndromes: We are continuing to work along with Hepsiba (our microbiologist at Padhar) and Dr. Stephen Mathew (microbiologist from PIMS, Pondicherry) on a descriptive paper regarding the considerable number of post-encephalitic neuropsychiatric syndromes we are encountering.

d) Other research work being considered: Discussions are ongoing with Dr. Robert Drake (Dartmouth, USA) regarding possible collaboration in two particular areas:

research into the holding of religious/superstitious beliefs by patients alongside their treatment, and models of Group sessions to educate families of our field patients about relevant mental health issues. We are also continuing to discuss with Medic Mobile, a company that facilitates field research through mobile phones, on possible future collaboration. Apart from this, Teresa Kreusch, a German public health student at Karolinska institute in Sweden with a neuroscience background, had expressed interest in doing her PhD Thesis in collaboration with us. We are awaiting her final decisions on this, and continue to look forward to this possibility.

e) Correspondence and networking: We continue to maintain our contacts established over the past few months. We continue to look forward to further encouragement and suggestions for improvement from experts in psychiatry, neurology and community health from both India and abroad. Some of the institutes we have been regularly corresponding with in the past include the Psychiatry, Neurology and Distance Education departments at Christian Medical College Vellore, the Neurology and Community Medicine departments at Christian Medical Colleges Ludhiana, the Psychiatry department at Dr SMCSI Medical College Karakonam, the Public Health department at NIMHANS (National Institute of Mental Health and Neurosciences, Bangalore), the MAANASI project based at Bangalore, the Centre for International Health at Ludwig Maximilian University, Munich, Germany and CHGN (Community Health Global Network), a non-profit organization based primarily in the United Kingdom and Kenya.

Some of the newer contacts include the Indian Council of Medical Research (ICMR) and its subdivision the National Institute for Research in Environmental Health (at Bhopal), the National Health Mission (headquartered at Delhi), the London Institute of Hygiene and Tropical Medicine, the psychiatry department at Dartmouth university in the United States, the Maudsley Institute of Psychiatry, Psychology and neurosciences at London, the World Mental Health Federation, the World Association for Social psychiatry, the World Psychiatric Association, the Indian Association of Social Psychiatry, the department of Mental health and substance abuse at the World Health Organization (WHO), the psychiatry department at the office of the United Nations High Commissioner for Refugees (UNHCR), Medic Mobile and a number of renowned non-profit organizations in India involved in community mental health work (including the Banyan in Tamil Nadu, MEHAC in Kerala and the Bapu trust primarily in West Bengal).

A new group “Christians in Psychiatry”, consisting of more than 60 Christian Mental

Health professionals from across India, has recently been formed. The first National Conference of Christians in Mental Health is being planned for January 2017, and I have been requested to speak as one of the resource persons.

OUTCOME EVALUATION DATA:

Using our outcome evaluation tool, we were able to generate data on our patients under four broad domains – symptom improvement, compliance with treatment, occupational/functional recovery and level of community re-integration. Using our field records, we evaluated all 523 patients registered in the project so far. 26 were excluded as definite diagnoses could not be established (because they were referred to OPD for more detailed evaluation and did not come). Thus data from 497 patients was ultimately included in our outcome evaluation data below.

Severe mental disorders:

A total of 98 patients (up from 83 in the last half-yearly report in February) were diagnosed with severe mental disorders (excluding those who also had co-existing epilepsy or developmental disorders like mental retardation; such patients were included under those respective headings). Among these, 66 were diagnosed with schizophrenia, 23 with other psychotic spectrum disorders and 9 with bipolar disorder. 78 of these patients in all (80%) received medication in the field, and 23 (23%) were referred to the hospital for various purposes. A total of 19 patients (19%) were lost to follow up and could not subsequently be traced. One patient died, and 13 old recovering patients dropped out by choice.

Among our 66 patients with schizophrenia, 60 (91%) were prescribed medications in the field. Of these, 50 (nearly 80%) could be described as taking medicines daily (25) or on most days (25) initially. Regarding improvement in major psychotic symptoms (like delusions and hallucinations), 36 patients (55%) had complete remission, and another 22 more (33%) showed at least some improvement (in other words, nearly 90% of our schizophrenia patients showed at least some symptom improvement). 55 of these patients (83%) showed improvement in functional or occupational status, with 28 (42%) fully back at work and functioning at the same level as before their illness began. Level of re-integration into their community tended to reflect occupational/functional status – 52 (79%) showed at least some degree of reintegration, of which 26 (39%) could be regarded as completely reintegrated. Among these recovering patients, 11 patients dropped out by their own choice, and one died.

Trends among patients with other psychotic spectrum disorders were broadly similar to those with schizophrenia. Of 23 patients with these disorders, 11 (48%) were prescribed medication in the field. 10 of these 11 patients (91%) had good compliance, taking medicines either daily or on most days. Of the 23 patients with these disorders, 12 (52%) had improvement in psychotic

symptoms, of which 10 (43%) had complete remission. These 12 patients also displayed good occupational/functional improvement and community reintegration. Of these recovering patients, however, one was lost to follow up.

Among the 9 patients with bipolar disorder, 7 (nearly 80%) were prescribed medications in the field and 4 (44%) were referred to the hospital for interventions. 6 (67%) could be said to have had fairly good compliance, all of whom had complete remission of symptoms, good functional/occupational recovery and were completely re-integrated into their communities. However, one patient eventually dropped out by choice.

Epilepsy:

We had 58 patients (up from 44) with epilepsy (excluding those with mental retardation who also had seizures which were evaluated under the developmental disorders). Of these, 9 (up from 8) had co-morbid severe psychiatric disorders such as psychosis or mood symptoms as well. Among our 44 old patients, 3 dropped out by choice and 2 died. In all, 40 of our epileptic patients (70%) had fairly good compliance with medications given in the field. Complete seizure control was achieved in 30 (54%) of the total patients, and another 18 (32%) had more than 50% reduction of seizures. Among the 9 who had psychotic or mood symptoms, 7 (77%) experienced symptom reduction, and 4 (44%) had complete control. More than 80% of our epileptics had good functional/occupational recovery as well as community re-integration.

Common mental disorders:

We had a total of 168 patients (up from 154) diagnosed with various common mental disorders (66 patients with depressive disorders, 79 with anxiety & other neurotic conditions, and 23 with substance use disorders predominantly alcohol and nicotine). As mentioned in earlier reports, we were not actively screening for substance use disorders in our screening tool under this project, and most of those who got picked up had co-existing neuropsychiatric conditions that were picked up in our screening. In contrast to epilepsy and the severe psychiatric disorders, most of our patients with common mental disorders were referred to the hospital for evaluations or more intensive interventions including psychotherapy (132, or 79%), of which only 23 (less than 18%) attended the psychiatric OPD. In the previous report from February, 51 (30%) were prescribed medications in the field, of which 23 (45%) could be described as having fairly good compliance. Overall, 45 (about 30%) of those old patients with common mental disorders were documented to have experienced improvement in their symptoms in that report, and these tended to be those who attended the OPD or were compliant with their medications. Among the 14 new patients in this evaluation, none were prescribed medications in the field (i.e. all were referred, of which only 3 came to the hospital).

Developmental disorders:

We identified 123 patients (up from 112) with various developmental disorders including Mental Retardation of various causes (which formed the bulk), Autistic spectrum disorders and Cerebral palsy. Of these 45 (37%) had some co-existing neuropsychiatric conditions that could be treated with medications or specific behavioural/psychological strategies such as 13 patients with psychosis (of which 90% improved), 17 with seizures (of which 80% had some reduction of seizures), 17 with involuntary movements or self-injurious behavior (of which 77% showed some improvement), 22 with hyperactivity (of which 60% showed some improvement) and 34 with excessive aggression (of which 75% showed improvement). Of the patients given medication in the field, about 60% had fairly good compliance. In all, 34 patients (28%) were lost to follow up, and 6 dropped out of treatment. However among the 83 patients followed up, we continued to have approximately 35% who showed at least some improvement in functional status and community re-integration.

Migraines and other headache syndromes:

41 patients (up from 37) were diagnosed with migraines or other headache syndromes. Another 26 patients (up from 23) with headache syndromes were also diagnosed with depression or anxiety and were thus included under the “common mental disorders” in the evaluation. Among the 41 “pure” headache syndromes, 18 (less than 50%) received medication in the field but only 6 of these (33%) had fairly good compliance with these medications. Although 23 patients were referred to the hospital for further evaluations of their headaches, only 1 of these actually came. Overall, 7 patients (about 17%) experienced improvement in their symptoms, and these were the ones who were compliant with their medications.

Other neurological disorders:

A total of 9 other neurological cases were detected, including strokes and Parkinson’s, and at one case of suspected Huntington’s disease (who has been showing some improvement in psychotic symptoms on follow up, though her general condition is progressively deteriorating as expected). 8 of these were referred to the hospital, but only 2 actually came.

Below are some comparative charts showing the data for some of the diagnostic groups across the 4 domains of our outcome evaluation (showing percentages of patients). Data from the recent October 2016 evaluation is compared with the previous February 2016 evaluation data:

Schizo

phrenia

other psyc

hoses

bipolar diso

rder

epilep

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depres

sion/an

xiety/

substa

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0102030405060708090

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Good Compliance(Feb 2016)

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Good Compliance (Oct 2016)

Schizo

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bipolar diso

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epilep

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comorbidities)0

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symptom improvement (Feb 2016)

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comorbidities)0

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symptom improvement (Oct 2016)

Schizophrenia other psychoses bipolar disorder epilepsy developmental disorders

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positive change in functional status (Feb 2016)

Schizophrenia other psychoses bipolar disorder epilepsy developmental disorders

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positive change in functional status (Oct 2016)

Schizophrenia other psychoses bipolar disorder epilepsy developmental disorders

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positive change in community re-integration (Feb 2016)

Schizophrenia other psychoses bipolar disorder epilepsy developmental disorders

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positive change in community re-integration (Oct 2016)

CONCLUSIONS OF OUTCOME EVALUATION AND FUTURE DIRECTIONS:

Perhaps the most encouraging conclusion emerging from the above data and comparative charts is that, on the whole, we are maintaining the gains we made over this extended period of time. Of our patients with severe mental disorders (schizophrenia, other psychoses, bipolar disorder etc) and epilepsy receiving medications in the field and recovering, only 16 dropped out voluntarily by choice and 3 had died. The vast majority of these patients thus chose to continue treatment. Strong and regular follow up measures by the team as well as family support and family-assisted rehabilitation ensured that, on average, between 70 – 80 percent of our patients with severe mental disorders and epilepsy displayed improvement in functioning and community re-integration. This figure is similar to what was recorded in the February 2016 report (80%) – an indication that our community follow up strategies for this group of patients have remained effective over time.

For developmental disorders such as autism and the various mental retardation syndromes too, the overall picture has remained similar. Aggressive identification and treatment of co-morbid conditions along with family education has been the strategy in the field so far; it continues to ensure that about a third of these patients have attained some degree of functional improvement since we made contact.

The group of common mental disorders (depression, anxiety, substance disorders etc) remains a challenge. The strategy for these conditions has for the most part been limited to referring these patients to the Psychiatry OPD at Padhar for further interventions (both pharmacological and psychotherapeutic). Less than 20% of those referred actually came to the psychiatry OPD however, and less than half of those few prescribed medications in the field were compliant (in comparison to almost 80% good compliance rates among severe disorders). On the whole, the number of patients with these disorders who were documented to have improvement in symptoms remains constant at about 30%. At present, we have little more we can offer to the patients with depressive and anxiety disorders at a community-based level. However, Padhar Hospital has in this past 6 months begun the community detox camps for alcohol dependent patients; this has been a major new achievement.

Future directions would focus on maintaining follow up of our current patients, as well as continue to screen and evaluate parts of the target area that we have not yet screened. We also hope to see how our work with the government health workers (Anganwadis and ASHAs) that we have trained progresses. We will have to finalize what model of care we can offer for these new patients from outside the target area. We will also target to publish the pilot data from our screening tool, and our paper on post-encephalitic syndromes, as well as explore other areas of research. We look forward to the finals of the BMJ Awards South Asia on November 18th; it would certainly be a new experience! We also look forward to comments

and suggestions from our many readers both nationally and internationally on how we can improve and strengthen different aspects of this project.

Once again, thank you all for your prayers, support and encouragement. We hope that, God willing, our project will make continue to have a positive impact on the lives of people in these 75 poverty-stricken villages.

Thank you

Dr. Johann Ebenezer,

Psychiatrist, Padhar Hospital