Mutuality as a method: advancing a social paradigm for global mental health through mutual learning.

PURPOSE: Calls for "mutuality" in global mental health (GMH) aim to produce knowledge more equitably across epistemic and power differences. With funding, convening, and publishing power still concentrated in institutions in the global North, efforts to decolonize GMH emphasize the need for mutual learning instead of unidirectional knowledge transfers. This article reflects on mutuality as a concept and practice that engenders sustainable relations, conceptual innovation, and queries how epistemic power can be shared. METHODS: We draw on insights from an online mutual learning process over 8 months between 39 community-based and academic collaborators working in 24 countries. They came together to advance the shift towards a social paradigm in GMH. RESULTS: Our theorization of mutuality emphasizes that the processes and outcomes of knowledge production are inextricable. Mutual learning required an open-ended, iterative, and slower paced process that prioritized trust and remained responsive to all collaborators' needs and critiques. This resulted in a social paradigm that calls for GMH to (1) move from a deficit to a strength-based view of community mental health, (2) include local and experiential knowledge in scaling processes, (3) direct funding to community organizations, and (4) challenge concepts, such as trauma and resilience, through the lens of lived experience of communities in the global South. CONCLUSION: Under the current institutional arrangements in GMH, mutuality can only be imperfectly achieved. We present key ingredients of our partial success at mutual learning and conclude that challenging existing structural constraints is crucial to prevent a tokenistic use of the concept.

Feasibility and acceptability of a novel community-based mental health intervention delivered by community volunteers in Maharashtra, India: the Atmiyata programme.

BACKGROUND: Many community-based intervention models for mental health and wellbeing have undergone robust experimental evaluation; however, there are limited accounts of the implementation of these evidence-based interventions in practice. Atmiyata piloted the implementation of a community-led intervention to identify and understand the challenges of delivering such an intervention. The goal of the pilot evaluation is to identify factors important for larger-scale implementation across an entire district in India. This paper presents the results of a feasibility and acceptability study of the Atmiyata intervention piloted in Nashik district, Maharashtra, India between 2013 and 2015. METHODS: A mixed methods approach was used to evaluate the Atmiyata intervention. First, a pre-post survey conducted with 215 cases identified with a GHQ cut-off 6 using a 3-month interval. Cases enrolled into the study in one randomly selected month (May-June 2015). Secondly, a quasi-experimental, pre-post design was used to conduct a population-based survey in the intervention and control areas. A randomly selected sample (panel) of 827 women and 843 men age between 18 to 65 years were interviewed to assess the impact of the Atmiyata intervention on common mental disorders. Finally, using qualitative methods, 16 Champions interviewed to understand an implementation processes, barriers and facilitators. RESULTS: Of the 215 participants identified by the Champions as being distressed or having a common mental disorder (CMD), n = 202 (94.4%) had a GHQ score at either sub-threshold level for CMD or above at baseline. Champions accurately identified people with emotional distress and in need of psychological support. After a 6-session counselling provided by the Champions, the percentage of participants with a case-level GHQ score dropped from 63.8 to 36.8%. The second sub-intervention consisted of showing films on Champions' mobile phones to raise community awareness regarding mental health. Films consisted of short scenario-based depictions of problems commonly experienced in villages (alcohol use and domestic violence). Champions facilitated access to social benefits for people with disability. Retention of Atmiyata Champions was high; 90.7% of the initial selected champions continued to work till the end of the project. Champions stated that they enjoyed their work and found it fulfilling to help others. This made them willing to work voluntarily, without pay. The semi-structured interviews with champions indicated that persons in the community experienced reduced symptoms and improved social, occupational and family functioning for problems such as depression, domestic violence, alcohol use, and severe mental illness. CONCLUSIONS: This study shows that community-led interventions using volunteers from rural neighbourhoods can serve as a locally feasible and acceptable approach to facilitating access social welfare benefits, as well as reducing distress and symptoms of depression and anxiety in a low and middle-income country context. The intervention draws upon social capital in a community to engage and empower community members to address mental health problems. A robust evaluation methodology is needed to test the efficacy of such a model when it is implemented at scale.

Perceptions regarding the Indian Mental Healthcare Act 2017 among psychiatrists: Review and critical appraisal in the light of CRPD guidelines.

Background: Informed by the UN Convention on the Rights of Persons with Disabilities, the Indian government replaced the 1987 Mental Health Act with the transformative "Indian Mental Healthcare Act, 2017" (IMHCA 2017), which gained presidential approval on April 7, 2017. While the new act aligns with CRPD guidelines, emphasizing the promotion, protection and realization of complete and equitable human rights, legal capacity, equality and dignity for persons with mental illness, it has faced diverse criticism from various stakeholders, particularly psychiatrists. This study systematically explores the critiques and apprehensions expressed by psychiatrists regarding the IMHCA 2017 using available published resources and assesses these criticisms within the context of CRPD guidelines. Methodology: We conducted a scoping review of the literature, using two search engines like PubMed and Scopus. The review covered academic publications, reports and documents from both national and international sources, authored by psychiatrists and psychiatric organizations, related to the IMHCA 2017. The primary search term "IMHCA 2017" was used without temporal restrictions. Publications authored by mental health professionals from India and around the world were included in the final analysis. Through qualitative analysis, key themes reflecting psychiatrists' viewpoints were identified. These themes, marked by substantial criticism, were then assessed in accordance with the guiding principles of the CRPD, including its optional protocol and general comments. Results: The study analyzed 33 manuscripts discussing criticisms and concerns about IMHCA 2017. Manuscript types included opinion papers (60.6%), original research articles (21.21%), review articles (9.09%), editorials (6.06%) and comments (3.03%). All but one article were authored by psychiatrists, with five by non-Indian authors and the rest by Indian psychiatrists. Most articles were published in the Indian Journal of Psychiatry (75.76%), with some in other journals. About 54.55% critically scrutinized act provisions, while 45.45% highlighted positive aspects. The analysis identified seven prominent criticism themes: clinical apprehensions, lack of clarity and comprehensiveness, feasibility challenges, neglect of caregivers, mistrust toward psychiatrists, crises in general hospital psychiatry units and ideological reservations. Conclusions: Each theme was critically assessed in the context of CRPD guidelines, and corresponding recommendations were formulated.

Inverting the deficit model in global mental health: An examination of strengths and assets of community mental health care in Ghana, India, Occupied Palestinian territories, and South Africa.

Global mental health [GMH] scholarship and practice has typically focused on the unmet needs and barriers to mental health in communities, developing biomedical and psychosocial interventions for integration into formal health care platforms in response. In this article, we analyse four diverse settings to disrupt the emphasises on health system weaknesses, treatment gaps and barriers which can perpetuate harmful hierarchies and colonial and medical assumptions, or a 'deficit model'. We draw on the experiential knowledge of community mental health practitioners and researchers working in Ghana, India, the Occupied Palestinian Territory and South Africa to describe key assets existing in 'informal' community mental health care systems and how these are shaped by socio-political contexts. These qualitative case studies emerged from an online mutual learning process convened between 39 academic and community-based collaborators working in 24 countries who interrogated key tenets to inform a social paradigm for global mental health. Bringing together diverse expertise gained from professional practice and research, our sub-group explored the role of Community Mental Health Systems in GMH through comparative country case studies describing the features of community care beyond the health and social care system. We found that the socio-political health determinants of global economic structures in all four countries exert significant influence on local community health systems. We identified that key assets across sites included: family and community care, and support from non-profit organisations and religious and faith-based organisations. Strengthening community assets may promote reciprocal relationships between the formal and informal sectors, providing resources for support and training for communities while communities collaborate in the design and delivery of interventions rooted in localised expertise. This paper highlights the value of informal care, the unique social structures of each local context, and resources within local communities as key existing assets for mental health.

Atmiyata, a community champion led psychosocial intervention for common mental disorders: A stepped wedge cluster randomized controlled trial in rural Gujarat, India.

BACKGROUND: While effective lay-health worker models for mental health care have been demonstrated through efficacy trials, there is limited evidence of the effectiveness of these models implemented in rural LMIC settings. AIM: To evaluate the impact of a volunteer community-led intervention on reduction in depression and anxiety symptoms and improvement in functioning, and social participation among people living in rural Gujarat, India. METHODS: Stepped-wedge cluster randomized controlled trial was used to assess the effectiveness of delivery of psychosocial intervention across 645 villages in Mehsana district of Gujarat, India between April 2017 and August 2019. The primary outcome was an improvement in depression and/or anxiety symptoms assessed using GHQ-12 at 3-month follow-up. Secondary outcomes were improvement in (a) depression and anxiety (Patient Health Questionnaire, (PHQ-9), Generalized Anxiety Disorder (GAD-7) & Self-Reporting Questionnaire-20 (SRQ-20); b) quality of life (EQ- 5D); c) functioning (WHO-DAS-12), and social participation (Social Participation Scale SPS). Generalized linear mixed-effects models were used to assess the independent effect of the intervention. RESULTS: Out of a total of 1191 trial participants (608- intervention & 583-control), 1014 (85%) completed 3-month follow-up. In an adjusted analysis, participants in the intervention condition showed significant recovery from symptoms of depression or anxiety (OR 2.2; 95% CI 1.2 to 4.6; p<0.05) at the end of 3-months, with effects sustained at 8-month follow-up (OR 3.0; 95% CI 1.6 to 5.9). Intervention participants had improved scores on the PHQ-9 (Adjusted mean difference (AMD) -1.8; 95%CI -3.0 to -0.6), and SRQ-20 (AMD -1.7; 95%CI -2.7 to -0.6), at 3-months and PHQ-9, GAD-7, SRQ-20, EQ-5D and WHO-DAS at 8 months follow-up. CONCLUSION: Findings suggest that Atmiyata had a significant effect on recovery from symptoms of depression and anxiety with sustained effects at 8-month follow-up. TRIAL REGISTRATION: Trial registration details. The trial was registered prospectively with the "Clinical Trial Registry in India" (registry number: CTRI/2017/03/008139).

Anxiety and depression among patients with axial spondyloarthritis.

OBJECTIVE: The axial spondyloarthritis (axSpA) mainly affects young population and often leads to reduced mobility, but less is known about the impact it has on mental health. The objective of this study was to determine the prevalence of symptoms of anxiety and depression among axSpA patients and explore the underlying associated factors. METHODS: A cross sectional survey-based study was conducted from a single center. A convenient sampling was done to include 100 patients. We included questions about disease activity, sleep, fatigue, quality of life (QoL), and work productivity. All patients were asked to fill the patient health questionnaire-9 (PHQ) for depression and general anxiety disorder-7 (GAD) for anxiety. A multivariate binomial logistic regression analysis was performed to determine associations between PHQ-9 and GAD-7 scores with various socio-demographic factors, disease activity scores, and other variables. RESULTS: Clinically significant symptoms of anxiety and depression were present in 38% and 36% patients, respectively. Both were significantly associated with younger age at disease onset (P < .05), high disease activity, sleep disturbances, fatigue, poor QoL, and high impact on work productivity. Misbeliefs that "doctors hide side-effects of medicines" and "all modern medicine used in treatment of axSpA causes side-effects" were also related to higher anxiety and depression scores. Depression was also found to be associated with female patients. CONCLUSION: Anxiety and depression are common in axSpA. They are associated with high disease activity and reduced work productivity. Patients should be regularly screened for these symptoms.

Atmiyata, a community-led intervention to address common mental disorders: Study protocol for a stepped wedge cluster randomized controlled trial in rural Gujarat, India.

BACKGROUND: While lay-health worker models for mental health care have proven to be effective in controlled trials, there is limited evidence on the effectiveness and scalability of these models in rural communities in low- and middle-income countries (LMICs). Atmiyata is a rural community-led intervention using local community volunteers, called Champions, to identify and provide a package of community-based interventions for mental health, including evidence-based counseling for persons with common mental disorders (CMD). METHODS: The impact of the Atmiyata intervention is evaluated through a stepped wedge cluster randomized controlled trial (SW-CRCT) with a nested economic evaluation. The trial is implemented across 10 sub-blocks (645 villages) in Mehsana district in the state of Gujarat, with a catchment area of 1.52 million rural adults. There are 56 primary health centers (PHCs) in Mehsana district and villages covered under these PHCs are equally divided into four groups of clusters of 14 PHCs each. The intervention is rolled out in a staggered manner in these groups of villages at an interval of 5 months. The primary outcome is symptomatic improvement measured through the GHQ-12 at a 3-month follow-up. Secondary outcomes include: quality of life using the EURO-QoL (EQ- 5D), symptom improvement measured by the Self-Reporting Questionnaire-20 (SRQ-20), functioning using the World Health Organization's Disability Assessment Scale (WHO-DAS-12), depression symptoms using the Patient Health Questionnaire (PHQ-9), anxiety symptoms using Generalized Anxiety Disorder Questionnaire (GAD-7), and social participation using the Social Participation Scale (SPS). Generalized linear mixed effects model is employed for binary outcomes and linear mixed effects model for continuous outcomes. A Return on Investment (ROI) analysis of the intervention will be conducted to understand whether the intervention generates any return on financial investments made into the project. DISCUSSION: Stepped wedge designs are increasingly used a design to evaluate the real-life effectiveness of interventions. To the best of our knowledge, this is the first SW-CRCT in a low- and middle-income country evaluating the impact of the implementation of a community mental health intervention. The results of this study will contribute to the evidence on scaling-up lay health worker models for mental health interventions and contribute to the SW-CRCT literature in low- and middle-income countries. TRIAL REGISTRATION: The trial is registered prospectively with the Clinical Trial Registry in India and the Clinical Trial Registry number- CTRI/2017/03/008139. URL http://ctri.nic.in/Clinicaltrials/regtrial.php?modid=1&compid=19&EncHid=70845.17209. Date of registration- 20/03/2017.

Ethical issues in the design and conduct of stepped-wedge cluster randomized trials in low-resource settings.

BACKGROUND: Stepped-wedge cluster randomized trials (SW-CRTs) are increasingly popular in health-related research in both high- and low-resource settings. There may be specific ethical issues that researchers face when designing and conducting SW-CRTs in low-resource settings. Knowledge of these issues can help to improve the ethical conduct of SW-CRTs in a global health context. METHODS: We performed an ethical analysis of two studies using SW-CRT designs in low-resource settings: the Que Vivan Las Madres study conducted from 2014 to 2017 in Guatemala and the Atmiyata study conducted from 2017 to 2018 in rural parts of India. For both case studies, we identified and evaluated the classification of the study as research or nonresearch and the ethical issues regarding the justification of the design, including the delayed rollout of an intervention that had a promising effect. RESULTS: In our case studies, some minor ethical issues surfaced about the registration and stakeholder pressure on the order of randomization, but both included good justification for the design and delayed rollout. Our analysis did, however, demonstrate that careful consideration of the role of randomization and registration of the trials is important. DISCUSSION: SW-CRTs can provide an opportunity for rigorous evaluation of interventions destined to be rolled out on the basis of limited evidence. Furthermore, in SW-CRTs, the underlying objective is often to provide a robust evaluation of the effectiveness for generalized dissemination, and this makes the SW-CRT no less a research study than any other form of cluster randomized trial. CONCLUSION: The design and conduct of stepped-wedge cluster randomized trials raises at least two ethical issues that need special consideration in both high- and low-resource settings: the justification for using the design, specifically the delayed rollout of the intervention to the control group, and the classification of the study as research or nonresearch. In our case studies, these issues did not seem to raise special ethical scrutiny in low-resource settings. Further ethical evaluation will hopefully result in specific ethical guidelines for the use of SW-CRTs in both high- and low-resource settings to contribute to responsible functioning of these trials and adequate protection of participants.

Promoting wellbeing and improving access to mental health care through community champions in rural India: the Atmiyata intervention approach.

BACKGROUND: There are limited accounts of community-based interventions for reducing distress or providing support for people with common mental disorders (CMDs) in low and middle-income countries. The recently implemented Atmiyata programme is one such community-based mental health intervention focused on promoting wellness and reducing distress through community volunteers in a rural area in the state of Maharashtra, India. CASE PRESENTATION: This case study describes the content and the process of implementation of Atmiyata and how community volunteers were trained to become Atmiyata champions and mitras (friends). The Atmiyata programme trained Atmiyata champions to provide support and basic counselling to community members with common mental health disorders, facilitate access to mental health care and social benefits, improve community awareness of mental health issues, and to promote well-being. Challenges to implementation included logistical challenges (difficult terrain and weather conditions at the implementation site), content-related challenges (securing social welfare benefits for people with CMDs), and partnership challenges (turnover of public health workers involved in referral chain, resistance from public sector mental health specialists). CONCLUSIONS: The case study serves as an example for how such a model can be sustained over time at low cost. The next steps of the programme include evaluation of the impact of the Atmiyata intervention through a pre-post study and adapting the intervention for further scale-up in other settings in India.

Community beliefs about causes and risks for mental disorders: a mental health literacy survey in a rural area of Maharashtra, India.

BACKGROUND: Explanations for mental disorders in India can be influenced by biomedicine, systems of traditional medicine and supernatural beliefs. Community beliefs about causes of mental distress influence help-seeking behaviours. This study aimed to assess local knowledge and understanding of causes and risks for mental disorders in a rural area of Maharashtra, and to assess the prevalence of possible common mental disorders. METHODS: A cross-sectional mental health literacy survey was undertaken in late 2007. A questionnaire was administered to 240 systematically sampled community members and 60 village health workers (VHWs). Participants were presented with two vignettes describing people experiencing symptoms of mental disorders (depression, psychosis); they were asked about the causes of the problems and the vulnerabilities of community sub-groups. Additionally, the General Health Questionnaire (GHQ12) was administered to assess prevalence of possible common mental disorders. RESULTS: The most commonly acknowledged causes of the problems were a range of socioeconomic factors. Supernatural and biological explanations were not widely endorsed. Women, the unemployed and the poor were judged as more likely to develop mental disorders, while both young and older people were perceived to be less vulnerable. Results of the GHQ12 indicated that 27% had a possible common mental disorder and that the elderly were at increased risk, contrary to community perceptions. CONCLUSION: Enhancing mental health literacy of both VHWs and community members using approaches that are sensitive to local conceptualizations of mental health and illness will contribute to improved treatment and care for people with mental disorders. Further investigation of mental health among the elderly in this community is indicated.