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

(August 2015 to February 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 second half-yearly report of the Community Mental Health project. A lot has happened since our last half yearly report in July 2015, not the least of which included an additional change to the project’s name. The full name of the project is now “Project ‘Shifa’, the Community Mental Health project at Padhar hospital. “Shifa”, meaning “healing” in Hindi and Urdu, was chosen as many felt the project needed a more attractive and provocative name rather than merely the mundane (though usefully self-explanatory) “Community Mental Health project”. However, as all our previous reports and our project accounts were under the “CMH” label, it was decided to continue to use both names together for the time being.

It is impossible to mention the names of all the people we need to thank, and who helped make this project a reality. First of all, all the readers of these lengthy and sometimes idiosyncratic reports! We are overwhelmed by the flurry of supportive mails and pep talks we have received from all of you; your encouragement has been the most important factor for our growth. Thanks especially to all the psychiatrists, neurologists 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 our entire project team (field workers, Mr. Bappa and Mr. Achal, drivers and all our nursing students). We also thank Dr. Rajiv Choudhrie (our medical superintendent) and Mr. Vikas Sonwani (our administrative officer) for allowing and encouraging all our project activities. A very special mention must also go to three people from Padhar who have always been encouraging and supporting our work, but never get acknowledged: Dr. Lisa Choudhrie (our pathologist at Padhar who never fails to encourage me after every single outreach visit and who has greatly helped our efforts at looking for financial sources), my dear wife Dr. Ramya (our anesthetist at Padhar and who really is also my own private psychotherapist) and our lively little daughter Saphira (who ensures I am on my toes at all times).

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. This is our second half-yearly report. The purpose of the half-yearly report is primarily to highlight major milestones and challenges only, as well as to talk about a few selected success stories of individual patients and their families.

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 approximately 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 and none of whom exclusively work for this project alone):

1) One consultant psychiatrist (Dr. Johann Ebenezer)

2) Project Office Coordinator (at present no specific coordinator, but 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)

We finally managed to get a picture with the whole team below (of course the nursing students keep changing though)!

Major milestones and challenges over the past 6 months:

These past 6 months have largely been a period of consolidation and enhancement of existing activities. The total number of patients registered under the project has increased to 472, of which nearly 200 were provided medications in the field and are being followed up regularly at their homes by the field workers twice a month. Many of the others were referred to the Psychiatry OPD for further interventions and have become regular outpatients. In contrast to the first six months of 2015 in which 410 new patients were registered, the number of new cases added this half of the year was only 72. This was partly due to an intentional limiting of new patients screened each visit, as the number of follow up patients in each visit had grown significantly, and was starting to stretch our limited human resources to the limit (we still have only one trained mental health professional!) We also believe that limiting the numbers seen each visit vastly improves the quality of service we can provide, both in terms of the support and time we can give each family, as well as in the quality of follow up by the field workers.

We had some major changes in our team composition over the past few months. Mr. Moris, one of our initial project coordinators, left Padhar in September 2015. Mr. Achal, another of our initial project coordinators, has been allotted other tasks at Padhar, though he continues to

help us when he can. The void created was ably filled by Mr. Bappa Mukherjee, who has taken over responsibility of coordinating all field activities in all projects run by Padhar Hospital. He has contributed some important and very useful structural changes in the project. The field workers are no longer in-charge of particular clusters, but rotate through all clusters in a schedule monitored by Mr. Bappa. He has also organized their follow up so that every single patient receiving long-term medications in the field is visited at their homes for follow up every fifteen days by a field worker. This has greatly improved the efficiency and quality of follow up, and his supervisory work has taken a great load of my shoulders, and has enabled me to finally start paying more attention to other aspects of the project like the awareness, educational and research related activities.

Every February, the Christian Medical Association of India (CMAI) celebrates its “Healing Ministry Week”. This year’s theme focus was on “Compassionate care towards mental health”. It provided us with an opportunity once again to raise awareness on mental health issues for a week from 14th to 20th February. It began with a talk by me in the Sunday Church service on 14th, followed by daily morning devotions in the hospital conducted by different sections of staff (chaplaincy, doctors, nursing staff, allied health professionals, administrators and students) through the week focusing on different mental health topics. There was a good response from the staff and students, and the entire week was meaningful with skits, songs, testimonies and devotional talks related to the theme. In addition, on the CMH Wednesday outreach visit that week (17th Feb), we invited any interested staff from all departments to come with our team to the Desawadi cluster, just to give them a chance to be a part of our mental health outreach work. Ten staff from various other departments attended.

We have been able to progress on our academic and research front as well these months. In October 2015 we had our first publication in an Indian journal Current Medical Issues (a quarterly publication by the department of Continuing Medical Education at Christian Medical College, Vellore). This article was published as a human interest piece, and described the development of the project since its inception. We have also accumulated considerable data from our screening tool, and are now planning to write up our current data to publicize it as a locally relevant instrument. We have also completed a very detailed outcome evaluation of our project by applying our newly-designed outcome evaluation tool on all patients registered till mid-November 2015 (ie 452 patients) based on our field records. I was ably assisted in this task by Dr. Vivek, a junior doctor currently working in the medicine department at Padhar who will very soon be joining a postgraduate program in psychiatry. He has been accompanying us on our Wednesday outreach visits this month, and has put in many late night hours helping me compile our outcome data. We thank him for his help and interest. We will discuss this data and its implications below under the heading “Outcome evaluation data” below. We hope to write this also up to promote our outcome evaluation tool as well, as it appears to be a useful method to evaluate the effectiveness of mental health related field work in resource poor settings like ours. More on these and other research-related activities under the heading “Research and Correspondence” below...

Of course, major challenges still remain. Paramount among these is the question of sustainability. Finances are still an area of great concern – we are still entirely reliant on

personal donations of a few interested people, and our efforts at governmental and non-governmental financial support have still not come through. However, God has richly blessed and provided for our needs, and the donations have thus far been sufficient to meet our basic medication and transport needs. Since we have designed the project to be as low-budget as possible, our basic transport and medication expenses are very minimal, and all team members are existing employees or students of Padhar hospital (so salary of team members is at present not a problem). We have, since our last half-yearly report in July 2015, spent only Rs. 84,730/- 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). I am reminded endlessly of St. Paul’s confident assertion, “Thy grace is sufficient for me!” We have also received some promises of further individual donations, and hopefully these should help sustain us in the coming months.

Another challenge involves the patients being referred to the hospital for further interventions. As our outcome evaluation report below shows, we have had trouble in getting a number of those with milder mental health issues (anxiety disorder, milder depression, neurotic conditions, substance abuse, migraines etc) to come to the hospital. Our data suggest that those who do come do well, but a large number of them just do not come to the hospital. This contrasts starkly with our severe mental disorder patients (schizophrenia, other psychoses, epilepsy and bipolar disorder), most of whom we provide medications and group therapy in the field and seem to be overwhelmingly benefitting from the interventions. Future strategies for enhancement of the project would probably have to include working out new community-based strategies to serve the milder mental disorders better.

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. Of the 75 villages in our target area, only 28 remain to be screened. Most of these are smaller villages, as most of the big and central villages in each cluster have already been covered. We have therefore already covered the bulk of the population in the target area.

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 to provide positive and negative feedback to the field workers on the progress of work in their clusters, and to share success stories and challenging cases.

3) Record keeping: We keep case notes for individual patients screened in the field and data sheets where details of diagnosis etc are recorded. Although we had planned to print separate record sheets for the project, these have not yet materialized (due to budget restrictions)...so we are still using the hospital's OPD sheets for now. 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 second.

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) and this year’s CMAI healing ministry week in February (with its theme focus on mental health) as opportunities to build awareness in and around our area and beyond by organizing talks, publicity pamphlets, and even a radio talk (in October 2016 for World Mental Health day.). As mentioned in our recent monthly reports, community awareness of mental health issues in the target area has noticeably improved over the past few months. It appears as though stigma has been reduced to some extent as well; many patients and relatives from the target area now approach us directly at the outreach visits or in the hospital even before their areas are screened.

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, 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 across 4 continents, including Germany, Switzerland, Sweden, the UK, the USA, Singapore, Australia, Spain, Portugal and many parts of India. All guests are given an orientation to the subject of psychiatry and the Community Mental Health project prior to the visits, as well as on-site clinical teaching.

7) Group Therapy: Group Therapy sessions in the field for selected patients with severe mental illnesses, epilepsy and developmental disorders and their family members have been held in many clusters these past few months – Sillot, Desawadi, Dholildhana and Chiklimal. 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 sessions, which are usually held at central school or government buildings in the main villages (and on one occasion even held in an open-air setting), have so far have been very interactive and participatory, and I am happy with the reception and response of the patients/relatives who have participated.

8) Community re-integration of patients with severe mental illnesses: As discussed in our previous half-yearly report, one of the greatest challenges in any community-based mental health program will always be the re-integration of individuals who have been shunned by family and society for so long, and many of whom have, as part of their symptoms, lost their social and communication skills. Most of our community re-integration strategies have so far focused on working with the families of the severely ill patients in the outreach clinics, during field worker follow ups and Group Therapy sessions. 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.

These strategies seem to have worked well. As seen in our “outcome evaluation data” section below, approximately 80% of our schizophrenic/psychotic and epileptic patients have become more integrated back into their community, and our data seems to indicate that functional or occupational recovery was more strongly related to community re-integration than symptom improvement per se. So our emphasis on quickly getting patients back to some kind of simple occupational tasks appears to have facilitated greater community re-integration even in cases which have not attained full symptom remission (see “Outcome evaluation data” section below.).

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. We think it is another simple but useful tool for similar rural based mental health programs to utilize periodically to evaluate their progress, and we plan to write up our evaluation process as an example.

c) A few other interesting findings have been thrown up by our outcome evaluation data. Probably most interesting has been the considerable number of post-encephalitic syndromes with varied neuropsychiatric sequelae ranging from cognitive deficits to psychosis, seizures, behavioural problems and various movement disorders. As this group, though heterogeneous, clearly represents a large group of potentially preventable neuropsychiatric morbidity, it is worthwhile considering what are the practical strategies for primary prevention. We are working with Ms Hepsiba (our microbiologist at Padhar) on a write up about this as well.

d) We continue to maintain our contacts established over the past few months, and 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 corresponding with include the Psychiatry and Neurology 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.

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 patients registered before mid-November 2015 (as the ones registered after that are yet to have their first follow up by me in the next round of outreach visits to each cluster.). Thus although we now have 472 registered patients, we included 452 in our evaluation. Of these, 13 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 439 patients was ultimately included in our outcome evaluation data below.

Severe mental disorders:

A total of 83 patients 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, 61 were diagnosed with schizophrenia, 15 with other psychotic spectrum disorders and 7 with bipolar disorder. 71 of these patients in all (87%) received medication in the field, and 16 (19.2%) were referred to the hospital for various purposes. A total of 9 patients (11%) were lost to follow up and could not subsequently be traced.

Among our 61 patients with schizophrenia, 56 (92%) were prescribed medications in the field. Of these, 47 (nearly 80%) could be described as taking medicines daily (24) or on most days (23). Regarding improvement in major psychotic symptoms (like delusions and hallucinations), 34 patients (56%) had complete remission, and another 19 more (31%) showed at least some improvement (in other words, nearly 90% of our schizophrenia patients showed at least some

symptom improvement). 50 of these patients (80%) showed improvement in functional or occupational status, with 26 (43%) 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 – 47 (78%) showed at least some degree of reintegration, of which 24 (40%) could be regarded as completely reintegrated.

Trends among patients with other psychotic spectrum disorders were broadly similar to those with schizophrenia. Of 15 patients with these disorders, 9 (60%) were prescribed medication in the field. 8 of these 9 patients (89%) had good compliance, taking medicines either daily or on most days. Of these the total of 15 patients, 10 (67%) had improvement in psychotic symptoms, of which 8 (53%) had complete remission. These 10 patients also displayed good occupational/functional improvement and community reintegration.

Among the 7 patients with bipolar disorder, 6 (nearly 90%) were prescribed medications in the field and 3 (about 40%) were referred to the hospital for interventions. 5 (70%) 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.

Epilepsy:

We had 44 patients with epilepsy (excluding those with mental retardation who also had seizures which were evaluated under the developmental disorders). Of these, 8 had co-morbid severe psychiatric disorders such as psychosis or mood symptoms as well. 35 of our epileptic patients (80%) had fairly good compliance with medications given in the field. Complete seizure control was achieved in 27 (61%) of the total patients, and another 11 (25%) had more than 50% reduction of seizures. Among the 8 who had psychotic or mood symptoms, 6 (75%) experienced symptom reduction, and 4 (50%) had complete control. Approximately 80% of our epileptics had good functional/occupational recovery as well as community re-integration.

Common mental disorders:

We had a total of 154 patients diagnosed with various common mental disorders (65 patients with depressive disorders, 70 with anxiety & other neurotic conditions, and 19 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 (118, or 77%), of which only 20 (less than 18%) attended the psychiatric OPD. 51 (33%) were prescribed medications in the field, of which 23 (45%) could be described as having fairly good compliance. Overall, 45 (30%) patients with

common mental disorders were documented to have experienced improvement in their symptoms, and these tended to be those who attended the OPD or were compliant with their medications. 97 of the other patients (63%) were lost to follow up, almost entirely because they did not attend OPD when referred, and our field workers are expected currently to follow up only those patients who receive medications in the field regularly. We have, while screening for anxiety disorders, managed to pick up some patients with underlying medical conditions that caused their anxiety symptoms like thyroid problems, diabetes, hypertension, anemia and one very interesting case of a lady with Rheumatic heart disease (who received treatment from the medicine department at Padhar and is better on follow up in the field).

Developmental disorders:

We identified 112 patients with various developmental disorders including Mental Retardation of various causes (which formed the bulk), Autistic spectrum disorders and Cerebral palsy. Of these 41 (37%) had some co-existing neuropsychiatric conditions that could be treated with medications or specific behavioural/psychological strategies such as 10 patients with psychosis (of which 90% improved), 15 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, 64% had fairly good compliance. In all, 26 patients (23%) were lost to follow up. However among the 86 patients followed up, we had 35% who showed at least some improvement in functional status and community re-integration – a very encouraging statistic that far exceeded our expectations for these very challenging disorders. This was probably the single most exciting achievement of the project that could be documented from the outcome evaluation. (See the Conclusions of outcome evaluation section below for an analysis of why we think our strategies for this group were so successful given the limited resources).

Migraines and other headache syndromes:

37 patients were diagnosed with migraines or other headache syndromes. Another 23 patients with headache syndromes were also diagnosed with depression or anxiety and were thus included under the “common mental disorders” in the evaluation. Among the 37 “pure” headache syndromes, 18 (nearly 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 (nearly 20%) 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. 8 of these were referred to the hospital, but only 2 actually came. One of these was a case of Huntington’s disease, an inherited progressive neurological disorder which nearly always leads to eventual death. She had severe (and progressively worsening) unsteadiness, involuntary movements, behavioural problems and psychosis. She was evaluated and treated with medication in the field, and has experienced considerable improvements in her psychotic symptoms, behavioural problems and involuntary movements, though she still has severe unsteadiness while walking. We are happy that we were able to identify her and help make her remaining days more bearable and fulfilling.

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).

Schizo

phrenia

other psyc

hoses

bipolar diso

rder

epilep

sy

depres

sion/an

xiety/

substa

nce

Headach

e syn

dromes

develo

pmental

disorders

0102030405060708090

100

Good Compliance

Schizo

phrenia

other psyc

hoses

bipolar diso

rder

epilep

sy

depres

sion/an

xiety/

substa

nce

Headach

e syn

dromes

devel d

is (tre

atable

comorbidities)0

20

40

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symptom improvement

Schizophrenia other psychoses bipolar disorder epilepsy developmental disorders

0

10

20

30

40

50

60

70

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90

positive change in functional status

Schizophrenia other psychoses bipolar disorder epilepsy developmental disorders

0

10

20

30

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80

90

positive change in community re-integration

CONCLUSIONS OF OUTCOME EVALUATION AND FUTURE DIRECTIONS:

The outcome evaluation data described above generates many interesting observations. First, it appears that the great emphasis we have given to the more severe conditions has paid off and about 80% of our patients with debilitating conditions like schizophrenia, epilepsy and bipolar disorder are doing well and have achieved a better level of occupational and social functioning since we made contact. We think this very encouraging trend is because of the fact that the intervention was taken to their homes and surroundings. Evaluation, medications, family education, group therapy and rehabilitation strategies were all conducted in the field, and families were entrusted with and empowered to care for these patients. Intensive follow up of these patients is being carried out by a field worker visiting each of their homes twice a month, perhaps the reason why we have managed to achieve an unexpectedly good compliance rate of between 80 to 90% for these disorders.

Second, we achieved results far better than we expected in the group of developmental disorders as a whole. Traditionally, this group of disorders is considered as having bleak prognosis with very little that can be done without heavy investments in money and time. Our results represent at least a modest challenge to that belief, and demonstrate that a low-resource minimally-staffed program can also have some impact on these very difficult disorders. We think our success here has been largely due to an intense effort to screen for co-existing conditions that can be treated with medications or specific behavioural/psychological strategies like psychosis, seizures, involuntary movements, self-injurious behavior, aggression, hyperactivity and significant behavioural problems. Where these co-existing conditions were picked up and treated, functional improvements were observed.

Third, we had far less impressive results in the group of common mental disorders like depression, anxiety and substance disorders as well as the headache syndromes. As our data reveals, the primary reason for this is that most of these patients referred to the hospital did not come and were therefore lost to follow up. These are conditions which, in general, need more intensive non-pharmacological strategies besides medications, and cannot be adequately managed in the community setting currently with our very limited staff. Hence, our strategy has thus far been to identify them, and in most cases to refer them to the hospital for management. Relatively few of them received medications in the field, and none of them attended group therapy sessions in the field as these have been designed primarily to cater to severe disorders. We probably need to work on strategies to encourage more of them to come to the hospital in the future. This is probably part of a wider problem facing Padhar hospital as a whole: that many patients in the surrounding rural areas are not able or willing to come to the hospital for treatment.

A SAMPLING OF SELECTED SUCCESS STORIES:

As with the previous half-yearly report, we have decided to include a few selected case stories as a conclusion to this report as well. As our outcome evaluation data reveal, there are, by God’s grace, simply too many “success” stories to include all of them. But these few are representative of the general picture, and have been written up by various field workers from their perspective. Outcome data and statistics on their own, however impressive they may be, can never match the effectiveness of even a single case story. Clinical stories like these can help give a “face” to the dry numbers from the statistical data, and that is the purpose of including a few in the half-yearly reports. Thanks to Mr. Achal for helping me with translation and editing of this section of the report.

Nisha Parte: a young girl’s strange journey back to reality

18-year-old Nisha Parte hails from Dholidhana, a picturesque little village less than 5 km away from Padhar. There are 5 members in her household, and the family’s financial situation is very difficult. Both her parents are manual labourers. They have a small piece of land on which they

grow grains for their own household consumption. She was studying in 10 th standard at a local school, and was otherwise leading a very normal and happy life. Suddenly, all that changed on one fateful day. She became very disturbed and agitated, and started becoming fearful and suspicious of people around her. She would yell and scream, and she stopped doing all her studies as well as well as all her household chores and agricultural work. She stopped looking after her personal hygiene, and even began soiling her clothes and the bed. Alarmed, the family took her to some magico-religious practitioners in accordance with local belief systems of supernatural causation, but she was not relieved.

She was identified by one of the community field workers and brought to Psychiatry outreach camp at Dholidhana about a few months ago under CMH Project, where she was evaluated and diagnosed to be suffering from an acute psychotic episode. She was prescribed Olanzapine under the project, and her family members were educated about the nature of the illness, management strategies and how to handle the situation during the acute phase of her illness. She improved dramatically, and no longer has any fearfulness or aggressive behaviour. Her self-care and cleanliness has improved back to normal, and she has again started engaging in her household and agricultural work, though she has not gone back to school as yet. We plan to discuss this issue as well with her parents subsequently, to smoothen out her future plans. What was most notable about her story was that she was picked up in the early stages of her illness itself by our field worker, and appropriate and effective treatment could be provided quickly thus limiting what might have developed into a much more disabling condition.

Navalsha Karochi: light at the end of a family’s tunnel of despair

Navalsha is a 35 year old gentleman, also from Dholidhana. He comes from an unimaginably difficult family situation. Of the 5 people who live in his house, his wife and two of his children are mentally retarded from birth. He is the only earning member in his household, and even going through a regular day is extremely challenging given the sheer chaos of things at home. How he coped all these years is in itself remarkable; perhaps Navalsha must have thought it was just destiny or bad karma…who knows? But bad as it all seemed then, the worst was yet to come. All of a sudden one day, what was left of his world came crashing down when he came down with a severe mental disorder. He became agitated and fearful, and started roaming in the village and did not stay at his home. He stopped doing all his work. This had made the condition of his household more worst as he is the only earning member of his household. This state of affairs carried on for several years, with only brief periods of respite between severe episodes of his illness.

Navalsha and his family members were brought to one of the Psychiatry Camps at Dholidhana village under CMH Project. All four were evaluated and it was found that while his wife and two of the children were mentally retarded, Navalsha himself was suffering from an episodic form

of Schizophrenia. It was decided to focus attention on his treatment, as it was the best way to bring some level of normalcy back to the chaotic household. He was prescribed Olanzapine, and has been treated since the last one year. There is no one at home to supervise him, but the field workers have regularly been monitoring him at their follow ups, and Navalsha fortunately took medications regularly. He is now completely well, fully functional and has restarted his work and earning.

Today, looking at him, no one would imagine that Navalsha was once a “roaming lunatic” with nowhere to go. The intervention has restored him to health, and it has made his almost intolerable life just a little easier.

Shubham Shakya: cured of a terrifying malady

Shubham lives in the beautiful tribal village of Chiklimal, surrounded by vast swathes of green fields. He is just 12 years old, but has probably suffered more than many people do in a lifetime. He belongs to a poor family, and his father used to do hard labour work for their survival. For the last one year, young Shubham has been suffering from epilepsy. The condition steadily grew worse as the number of attacks has increased to up to 2-3 times a day. Shubham would barely recover his consciousness and orientation when it was time for the next fit. His family were terrified, and must have thought, like most do in these areas, that it was a curse from the gods and had no cure. It made the Shubham’s life miserable and he could not go anywhere alone. He dropped out of school too.

He was identified by a field worker and was brought to the CMH Outreach Camp at Chiklimal Village about 6 months ago. He was evaluated and prescribed Phenytoin under the project, and his parents were educated about the illness and the issues involved. He is now completely seizure-free and is happy and well again.

Meera: an unwanted wife finds love again

Meera is a 35-year-old lady from Sitaljiri, a scenic predominantly tribal village about 7 km away from Padhar. Her family lives in a very isolated house at the edge of their village, surrounded by fields on all sides. 10 years ago, after the birth of her 5 th child, she developed a post-partum psychosis which eventually became chronic schizophrenia. She became suspicious and fearful, talked and smiled to herself, became verbally abusive and aggressive at times, stopped doing housework and neglected her personal hygiene. Her husband meanwhile married again, and they all stayed together in the same small house. Meera was mostly neglected and confined to a corner of their plot, often spending days doing nothing but lying down under a tree in the open air. She was one of the earliest patients identified by our field workers way back in July 2014, when the CMH project was in its infancy. Since then, her family has been visited at their home multiple times by the CMH team including the psychiatrist, field workers and nursing

students during every outreach visit to their cluster, and many more times by individual field workers in between. But we always returned disappointed as the husband, his second wife and the family members in general were not happy to treat Meera fearing that her improvement would aggravate an already difficult social situation. There seemed to them to be more advantages of keeping her out of the picture.

Finally, after a year of persistent visits by the team, her family finally agreed to attempt treating her in July 2015. Several factors could have contributed to this change of heart. A number of similarly ill patients in surrounding area were getting better, and the family probably noticed this. When the time came for the marriage of one of their daughters, the family decided that it would be better and more socially acceptable to have Meera looking better. Or perhaps they were just tired of our persistence and decided to give it a go!

Anyhow, she has since been on Olanzapine and is compliant and is a completely different person now. Her psychotic symptoms have improved, she is no longer aggressive, her self-care is better and she helps out with household chores. Most remarkably, her family has been happy with her improvement and she has been completely accepted back into her home as a member of the family. Both wives co-exist peaceably, and the many children now have two mothers at home!

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.