Initiating a Community Mental Health Programme in Rural Karnataka

This paper describes the development of a community mental health programme which is integrated with other services rendered at a primary care institution in a rural area and that addresses CMD alongside psychotic disorders and epilepsy. This initiative was a collaborative effort between the Departments of Community Medicine and Psychiatry of St. John’s Medical College, Bangalore. The programme was based at the Community Health and Training Centre at a village called Mugalur, which is 30 km from Bangalore city. This centre serves as the hub for all community-based activities of the Department of Community Health. Services include a 24-hour general health clinic, antenatal, intranaal and postnatal care, child care, care of the elderly and specialised services for those with visual and hearing impairments. The other health care facilities available in the area are a government Primary Health Centre and a few private clinics, all of which are located about 10 km away from the centre. Material and methods Four motivated women were chosen from the local women’s groups called Mahila Mandals. All steps were taken to ensure that the four workers were married women with good social standing in the community, who had demonstrated a keen interest in community activities and an ability and eagerness to learn about the proposed project. They also enjoyed family support and encouragement to participate in this programme. The women chosen to be Community Health Workers were then trained in identification and referral of patients with mental illnesses, the common myths and misconceptions prevalent in the area and in conducting community surveys. The training lasted 3 days and included lectures, role plays and observation of patient interviews at the psychiatry out patient department at St. John’s Medical College Hospital. The CHWs then commenced a survey of twenty five villages around Mugalur. The survey included administration of a field tested questionnaire [“Symptoms in Others Questionnaire” 4 to identify patients with epilepsy and severe mental illnesses like psychosis, and an enquiry as to whether any one in the household suffered from long standing headaches and other bodily complaints. The latter enquiry was made to identify persons who could be suffering from CMD since primary care attenders with CMD frequently present with somatic symptoms 5 . CHWs interviewed one adult member of every household in the intervention area. Persons suspected as having an illness described above were requested to visit a weekly clinic at the Mugalur Centre for a “check-up”. The CHWs also followed up such persons in their homes to encourage them to visit the clinic. The survey commenced in March 2003 and was completed in July of the same year. Patients who visited the clinic initially underwent a physical examination conducted by interns posted at the centre, to rule out any obvious physical illness. They were then clinically evaluated on the basis of the ICD 10 criteria, by a psychiatrist from St. John’s Medical College Hospital. The CHWs facilitated the initial interviews by being present while the patient was being interviewed. Treatment mainly consisted of pharmacotherapy. Concurrently, to increase awareness of mental illness in the community, a street play was developed. It included messages on CMD and epilepsy, the need for accessing treatment and continuation of care as well as the need to treat mentally ill patients without stigma. The play also advocated tolerance and compassion for such patients. The play depicted real life situations of patients with CMD and epilepsy and was enacted in different villages. These street plays were preceded by song and dance programmes of the local school children in order to increase viewership. In addition to these plays, the CHWs also disseminated