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When a Psychiatrist is 30 Hours Away: An Integrated Approach to Mental Healthcare

Imagine having a family member with a severe mental illness that goes untreated because a psychiatrist or medications are not accessible, or their condition goes undiagnosed.

More than 75 % of people with severe mental illness do not receive treatment for their conditions in LMICs. In far west Nepal, the nearest psychiatrist is 30 hours away by road. This means patients may travel to India to receive specialist care— a commute that is long, expensive, and compromises the continuity of care. Like any other chronic health condition, mental illness requires timely follow up and medical adherence.

Furthermore, doctors in low- and middle-income countries often receive little mental health training— and patients get treated for their physical symptoms, while their psychological state often gets unrecognized or misdiagnosed.

To bridge this treatment gap, an appropriate response must be customized to the staffing and infrastructure available. This means task-sharing. We have piloted an integrated mental healthcare program that includes primary care providers, on-site psycho-social counselors (PSC) and a remote psychiatrist, with the following roles: PCPs identify mental health problems, counselors use therapy rather than unwarranted medications, and a psychiatrist reviews all treatment plans to ensure high quality care.

To meaningfully equip staff at every level to provide quality care, PCPs are trained by a psychiatrist who visits the hospital every 3 months for additional on-site training. PCPs evaluate patients and send them to PSCs who conduct a full psycho-social evaluation and provide psychotherapy. After thorough evaluation, patients are sent back to the PCP and medications are prescribed by PCP only if it is necessary. To ensure high- quality services, every week PSCs consult with the psychiatrist and ensure every case receives appropriate care.

Most programs use on-demand consultation, but such systems do not address errors that are unknown to the PCP or PSC. Our pro-active panel review looks at every patient’s care to make sure that the psychiatrist agrees with the diagnosis and treatment. Because remote training is not enough, we also provide regular supervision via panel reviews and on-site training from the psychiatrist. Patients who are not following-up regularly are supported by community health workers (CHWs) who do home visits and encourage patients to visit the hospital on a regular basis and adhere to medication. In Achham, we started this integration in 2016 and has been well received by the clinicians. We measure the impact at the patient level and the outcomes have been positive too.

Patient outcomes are measured via validated tools like PHQ-9. We assessed changes in PHQ-9 scores for patients with moderate to severe depression, from our catchment area between September 1, 2016 to August 31, 2018 and 52% patients’ demonstrated clinical response. These rates are similar to what is seen in well-funded, closely monitored clinical studies conducted by world-class research universities in high-income countries.

Overall, we see a significant change in attitude and treatment among healthcare providers. With our experience in Achham and the impact and acceptability of the integrated model, in August 2017, we expanded our mental health services to our second hub in Dolakha, where we have been receiving similar reactions from the care providers and encouraging results from patients’ scores.

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