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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 low- and middle-income countries (LMICs). For many people in the far west, the nearest psychiatrist is thirty hours away by road. Patients in the far west sometimes travel to India to receive specialist care— a commute that is long, expensive, and compromises the continuity of care. Like other chronic health conditions, mental illness requires regular follow-up.

Furthermore, doctors in LMICs often receive little mental health training-— resulting in patients getting treated for their physical symptoms, while their psychological state often gets unrecognized or misdiagnosed.

To bridge this treatment gap, 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: Primary Care Providers (PCS) identify mental health conditions, and counselors use therapy rather than unwarranted medications.Patients who do not follow up regularly are supported by community health workers (CHWs) who make home visits and encourage patients to visit the hospital on a regular basis and adhere to medication. Every week PSCs consult with the psychiatrist and ensure every case and treatment plan receives appropriate care. This task-sharing response was developed to account for the staffing and infrastructure available.

There also an investment in adequate on-site training: PCPs are trained by a psychiatrist who visits the hospital every 3 months. 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. Our pro-active panel review looks at every patient’s care to make sure that the psychiatrist agrees with the diagnosis and treatment.
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.

In comparison, most other programs use on-demand consultation, but such systems do not address errors that are unknown to the PCP or PSC.

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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