SUNDAR: mental health for all by all

SUNDAR describes the ingredients of Sangath’s approach to improve access to evidence based interventions for mental health problems through lay people as the front line mental health care providers.

What is the background? Describe what happened in the project
Even by the most conservative prevalence estimates, about 50 million people are affected by mental health problems in India. In contrast to this high burden, the country has approximately 5000 mental health professionals. It is clear that mental health care needs to be radically rethought if the country is likely to meet more than a tiny fraction of the needs of people affected by mental health problems. It is in this context that Sangath, an Indian NGO, began shaping its approach to using lay people to deliver evidence based psychosocial interventions for mental health problems. Inspired by similar approaches to ‘task-sharing’ interventions in other areas of health care in India, such as maternal and child health, Sangath adopted an approach which was replicated across a diverse range of mental health conditions. This approach is characterised by several principles: designing interventions based on global evidence of effectiveness and local evidence of cultural acceptability; systematically testing intervention delivery to ensure feasibility of its delivery by lay health workers and acceptability by patients and families; involving diverse stakeholders, in particular people affected by the target mental health problems, in shaping the content and delivery of the intervention; embedding the intervention in established health care platforms, most commonly those run by the government, to ensure scalability; evaluating the effectiveness and cost-effectiveness of the intervention in randomized controlled trials; disseminating the findings in a variety of methods, ranging from scientific papers to audio-video media; and working closely with federal and state ministries of health to scale up the innovations.

Several lessons emerged from these experiences, which have been coined into the acronym “SUNDAR” (which means ‘attractive’ in the Hindi language).

First, that we should Simplify the messages we use to convey mental health issues, for example avoiding using psychiatric labels which can cause shame or misunderstanding.
Second, that we should Unpack our interventions into components which are easier to deliver and incorporate culturally sensitive strategies.
Third, that these unpacked interventions should be Delivered as close as possible to people’s homes which typically translates to their actual homes, or the nearest primary health care centre or community facility.
Fourth, that we should recruit and train Available manpower from the local communities to deliver these interventions. This often refers to lay health workers, but could also include parents and teachers in the case of childhood disorders.
And finally, that we should judiciously Reallocate the scarce and expensive resource of mental health professionals to supervise and support these community health agents.
This approach is built around a collaborative care framework with four key human resources: the front-line lay health worker; the person with a mental health problem and his/her family; the primary or general health care physician; and the mental health professional. SUNDAR is attractive because it is improves access to care using available human resources in an efficient way and because it empowers ordinary people to provide mental health care for others-and, in so doing, promotes their own well-being. There are a number of NGOs in the developing world which are working to build skills in community based workers to deliver psychosocial treatments for mental health problems, but few who are using scientific methods to evaluate the effect of these approaches and working closely with ministries of health to take these innovations to scale. Sangath stands out as a rare example of an innovator committed to community empowerment, science and scaling up in low resource settings.

What was the impact and what can be learned?
We have completed randomized controlled trials of the SUNDAR approach for three conditions (dementia, schizophrenia, common mental disorders) and all have shown significant benefits on clinical and social outcomes. The dementia trial (“the Home Care Trial”) was the first such study from a developing country and won Alzheimer Disease International’s international prize for psychosocial interventions in 2010. The common mental disorders trial (the “MANAS” trial) was the largest trial in psychiatry from the developing world and the first to demonstrate the cost-effectiveness of task-sharing for mental health care. Results of our trials for alcohol use disorders, maternal depression, mental health in young people and autism will become available in the near future. This evidence has been used to scale up mental health care in rural communities in one of the poorest regions of the country through VISHRAM (Vidarbha Stress and Health Program), a partnership between Sangath, social development NGOs, the Ministry of Health and psychiatrists. Excitingly, the new National Mental Health Program of the Ministry of Health (Government of India) which finances the District Mental Health Program has, based on this evidence, mandated for the establishment of a new cadre of community mental health worker attached to primary health care centres throughout this vast country. This promising evidence has also led to a revolution in the field of global mental health research with task-sharing amongst the leading research priorities in the Grand Challenges for Global Mental Health which has leveraged more than 50MUS$ in the past two years to support more research and capacity building in this area. As a beneficiary of some of this new research funding, we have begun to experiment with the use of peers to deliver interventions, such as using mothers to deliver evidence based psychological treatments for depressed mothers in their community and the use of mHealth to empower parents of children with neurodevelopmental disabilities. What is truly SUNDAR about this innovation of task-sharing is its potential significance for developed countries. While it would come as no surprise to learn that there are astonishingly large gaps in access to evidence based care in developing countries, the real puzzle is that despite the apparent richness of resources, large proportions of people do not access such care even in developed countries. There are many explanations for this observation, at the heart of them all is the remoteness of mental health care from the communities it serves: the interventions are heavily medicalized, do not engage sufficiently with harnessing personal and community resources, are delivered in highly specialized and expensive settings, and use language and concepts which alienate ordinary people. In all these respects, the SUNDAR approach might be instructive to rethinking mental health care globally. At the core of this innovation is revisiting the questions of what constitutes mental health care, who provides mental health care and where mental health care is provided. By using appropriately trained and supervised lay workers, working in settings and at times convenient to the patient (even in their homes and outside regular working hours), offering a range of contextually appropriate interventions tailored to the needs of the individual and using familiar labels and concepts, SUNDAR is an approach with great relevance to rethinking mental health care in all countries. By acting on the axiom that mental health is too important to be left to mental health professionals alone, SUNDAR seeks to achieve a paradigm shift by reframing so called ‘under-resourced’ societies to being ‘richly-resourced’ for there is surely no society on earth which is not richly endowed with human beings who are capable of caring for those with mental health problems.