New Delhi: A study published in The Lancet Psychiatry reports on the evaluation of VISHRAM (the Vidarbha Stress and Health ProgRAM), a grass-root community mental health program designed to address the mental health risk factors for suicide (ie, depression and alcohol use disorders) in a predominantly rural population of 100,555 people in 30 villages in the Amravati district of Vidarbha, a region which has been at the epicentre of farmer suicides in India. The program, implemented over 18 months, was delivered by two NGOs (Prakriti, with technical support by Sangath), was evaluated by the Public Health Foundation of India, and was funded by the Tata Trusts.
The program was evaluated through a survey done at the start and end of the program. At the end of the program:
- The prevalence of depression fell from 14·6% to 11·3%
- The proportion of people with depression who sought care rose from just 4.3% to 27·2%, a six fold increase
- Treatment access was equitably increased across caste, gender and social class
- The prevalence of suicidal thoughts in the past 12 months fell from 5·2% to 2·5%
- A range of mental health literacy indicators showed significant improvement
VISHRAM involved three sectors: at the community level, existing front-line workers such as ASHA workers, worked with community to raise mental health literacy and provide psychological first-aid; the next sector comprised lay counsellors who provided psychological treatments (for e.g. the Healthy Activity Program for depression) in the community and primary health care centres; and the third sector had psychiatrists from the government’s District Mental Health Program and private sector, providing medication for serious mental disorders at the primary health care centres and rural hospital.
The Vidarbha region of Maharashtra has reported a high prevalence of suicides in agricultural communities. A 2015 study conducted by VISHRAM found that 5.2% of the population interviewed had thought of taking their life in the last 12 months. Out of these, nearly half (45.3%) also had depression.
VISHRAM is the first program in the region to have shown an impact not only on the increasing demand for care for depression but also a concomitant reduction in suicidal behaviour. One third of the global burden of mental illness falls on India and China, more than all high-income countries combined. Yet in both countries less than 1% of the national healthcare budget is allocated to mental health care3. The recent National Mental Health Survey in India shows that about 90% of people with depression have not received any care in the previous 12 months; VISHRAM shows the first evidence on how this massive treatment gap might be reduced. The findings observed significant improvements in a range of mental health literacy indicators, for example, conceptualisation of depression as a mental health problem and the intention to seek care for depression.
VISHRAM is led by Indian psychiatrist Professor Vikram Patel. Professor Patel, winner of the Pardes Humanitarian Prize, and recognized by the UK Government with an OBE in 2016, is an advocate of low-cost interventions delivered by front-line workers to tackle the vast unmet needs for care for people with mental health problems in India. He said, “VISHRAM offers a model for the scaling up of community mental health care in India, through a partnership between communities with front-line workers, lay counsellors and the mental health practitioners from the private and government sectors. In particular, it also offers a template for reducing suicide in Vidarbha”.
The lead author of the study, Dr Rahul Shidhaye, Associate Professor, Public Health Foundation of India concludes that, “it is now critically important to translate this knowledge into real-world practice by scaling-up VISHRAM intervention through National Mental Health Program across the country”.
