Dec 19, 2016

Digital initiatives are helping improve rural India's mental health

Video conferencing, mobile apps may be the answer to rural India’s mental health care problem. They are low cost, can be scaled and are location agnostic.


For many years, Palani Selvakumar had trouble eating and sleeping. He couldn’t work and would stay in bed all day. He would imagine and hear things — he suspected his wife of having an affair, abused her verbally, and even hit her on that premise. He had no real relationship with his children as he hardly ever spoke to them.
Finally, help came in the form of a local health worker (LHW) who visited Selvakumar’s home in 2010, spoke to him about his mental health and referred him to Schizophrenia Research India’s (SCARF) mobile bus clinic.

Rural India is a dark place for those with mental health problems. Awareness is low and there is hardly any psychiatric help available  

He was diagnosed with paranoid schizophrenia by a SCARF psychiatrist, who conducted the consultancy remotely from Chennai, using a flatscreen TV, a high-resolution camera and WiFi. He was given free medicine from the pharmacy on the bus. Later, he was visited periodically by an LHW, who advised him on the importance of medication and follow-ups.
Selvakumar’s is much better now — he has started working as a contractual painter with BHEL, sleeps at night and has regular meals. “If the health worker hadn’t come to my place, I would have continued to suffer and also made my family suffer with me,” he says.
SCARF has been leveraging technology to provide mental health care to people since 2005, when it started counselling Tsunami victims through video conferencing. In 2010, it launched a mobile tele-psychiatry project called STEP (SCARF Telepsychiatry in Pudukottai). The project used in-bus clinics to provide free mental health care in Pudukottai, a backward district in Tamil Nadu. It covers 156 villages with a population of about 300,000 and has helped 1,500 people till date.

Not in the pink of mental health

Rural India is a dark place for those with mental health problems. Awareness is low and there is hardly any psychiatric help available. Because of this, mental illnesses remain undiagnosed and patients don’t receive treatment for years. Shockingly, 75% of India’s 3,800 psychiatrists work in urban areas where just 31% of the country’s population lives.

The SCARF telepsychiatry in Pudukottai (Tamil Nadu) project covers 156 villages and has helped 1,500 people till date

Jammu and Kashmir has only two mental health hospitals. India’s northeast, which comprises seven states, has only one mental health hospital. A recent survey conducted by Medecins Sans Frontieres (MSF or Doctors Without Borders) found that nearly 1.8 million adults (45% of the population) in the Kashmir Valley show symptoms of significant mental distress.
The National Mental Health Programme (NMHP) and the District Mental Health Programme (DMHP) were launched in 1982 and 1996 respectively to provide mental health services. “The government implemented the DMHP in 250 districts, but it wasn’t successful in even one district due to lack of trained psychiatrists, psychiatric workers and nurses,” says Dr G Prasad Rao, president of the Indian Psychiatric Society and Director, Schizophrenia and Psychopharmacology Division, Asha Hospital.

Technology to deliver mental health care

The new National Mental Health Care Bill, 2013, which was passed in the Rajya Sabha recently, promises universal access to mental healthcare to all by 2020. This may very well be impossible because India lacks the necessary personnel, infrastructure and investments needed to achieve this.
One of the main ways to strengthen this mandate is by harnessing technology to supplement, or in some cases, supplant conventional methods of delivering mental health services. The new mental health care bill, recognises this, and talks of the need to leverage “…use of appropriate technology” to provide appropriate mental health care to the people of India.

“We see great potential in harnessing technology to reach out to the millions of unreached in underserved communities”
– Dr N Manjunatha, NIMHANS  

“We see great potential in harnessing technology to reach out to the millions of unreached in underserved communities,” says Dr N Manjunatha, assistant professor of psychiatry, National Institute of Mental Health and Neuroscience (NIMHANS).
The hospital has tied up the Karnataka state government to ride on its digital infrastructure and provide mental health care services through video conferencing to all district hospitals, four taluk hospitals and two central prisons hospitals in the state. Till date, they have provided around 2,500 tele-consultations, 75% of which were psychiatric consultations.
NIMHANS director Dr B N Gangadhar says that 80-90% of their patients come from outside Bangalore. “They receive follow-up treatment from NIMHANS via video conferencing at their local primary health centres (PHCs). Psychiatrists use telemedicine facilities to diagnose the problem and prescribe medicines,” says Dr Gangadhar.

Mobile apps could be the way forward

The timing is ripe to expand the use of technology — low-cost mobile phones, smartphones and handheld devices — to diagnose mental illnesses and deliver health care. According to a paper titled “Mobile mental health care — an opportunity for India” by Peter Yellowlees and Steven Chan, published in the Indian Journal of Medical Research, mobile applications may be a viable solution to rural India’s mental health care problem. They are low cost, enable real-time collection of data and feedback, can be scaled and are location agnostic.

SCARF psychiatrists conduct consultancies remotely, using a flatscreen TV, a high-resolution camera and WiFi

The George Institute for Global Health, a private non-profit, launched a pilot initiative called the SMART Mental Health programme in 2014 to test the effectiveness of digital mental health applications using tablets to gauge depression, stress and suicidal risk in rural patients.
They have screened 28,000 people in 42 villages in West Godavari district of Andhra Pradesh for common mental health disorders and found that about 5% of the population needs clinical intervention. These people have been referred to local PHCs for treatment. Those suffering from severe mental health disorders were referred to the closest district hospital with a psychiatrist.

Mobile apps may be a viable solution to rural India’s mental health care problem. They are low cost, enable real-time collection of data and feedback, can be scaled and are location agnostic  

“Initially, we thought ASHAs (LHWs), who are lay village health workers with little education, may have difficulty in using tablets and navigating the clinical decision support system,” says Dr Pallab Maulik, deputy director and head of research and development, The George Institute. But, they picked up the technology easily.
Initiatives by Grand Challenges Canada — a Government of Canada-funded initiative fostering innovation to solve key global health problems — are also leveraging technology to deliver mental health care. One of the projects is being implemented in Ganderbal district of Kashmir and Nashik district of Maharashtra by nonprofit SAWAB. It aims to test a low-cost model for improving mental health services by training local health care workers to improve identification and treatment of mental disorders in youth.
A telemedicine bus screens a mental health awareness film in a rural area in south India

Another project, being actioned by nonprofit Atmiyata, will use mobile phones to provide guidance to community mobilisers — self-help groups and farmers clubs — on how to promote wellbeing and diagnose common mental health disorders.
But, the challenges of providing mental health care in rural India go beyond lack of initiatives and psychiatrists. “Availability of psychiatric medicine is major challenge at both PHCs and district hospitals. Continuity of treatment is affected because doctors come and go and local hospitals have no doctors for long periods of time,” says Dr Pallab Maulik of the George Institute.
Challenges such as these need to be addressed and awareness has to be spread in order to ensure those with mental disorders come out and seek the help that is now at hand.
(Names of patients changed as per request)

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Nelson is a writer of FactorDaily.