Geetha Jayaram, M.D., Takes Global View of Mental Health

Mental illness is not just a first world problem. For example, the World Health Organization (WHO) recently projected that depression will be the leading cause of disease burden in the world by 2030, particularly among women, who suffer from depression at two to two-and-a-half times the rate of men.

Given such statistics, it is imperative to act on global mental health issues now, said Geetha Jayaram, M.D., an associate professor of psychiatry and behavioral sciences at the Johns Hopkins School of Medicine.

Jayaram was presented the 2016 Kun-Po Soo Award lecture at APA’s fall meeting, IPS: The Mental Health Services Conference, last month in Washington, D.C. She was honored for her efforts to improve mental health care in rural India, especially women and children.

Quoting the WHO statistics, Jayaram pointed out that depression in women impacts the whole family. It is typically the woman who prepares meals, cares for the children, gets them ready for school, and takes them to the doctor. Research now suggests that maternal depression may be a risk factor for poor growth in young children, affecting not only this generation but also the next.

Though less prevalent, disorders such as bipolar depression and schizophrenia also exert large tolls in developing nations, where mania and psychosis are still commonly interpreted as witchcraft or possession.

Jayaram discussed the wide range of social, economic, political, and environmental factors that may impact the mental health of people in developing nations, such as government instability, natural disasters, poor working and living conditions, and lack of natural resources. But perhaps the most critical factor is the lack of access to care. She said that about 70 percent of the people in low- and middle-income countries cannot get the mental health care they need. In some cases, there simply are no clinicians available or the staff in a nearby clinic do not have the necessary training or medications to treat mental illness. Other people are denied access to care for situational reasons—for example, living in a village whose sole road to a location with a clinic is wiped out by a monsoon.

Thus, Jayaram said, most people in developing nations with a debilitating mental disorder are left untreated and must live with functional impairment, exposure to stigma and discrimination, and the risk of premature death.

How can these problems be effectively addressed? While millions of dollars have been spent developing models of health care for low- and middle-income countries, Jayaram said that many do not adequately factor in characteristics such as large rural populations; the result is overcentralized and inefficient distribution of health services.

Jayaram used her own Maanasi Project—established in 2002 in the Indian village of Mugalur (Psychiatric News, March 17, 2006)—as an example of a successful “bottom-up” approach: that is, implementing a low-cost, culturally competent, sustainable, and scalable health clinic in an area of need.

Established through philanthropy, the clinic started small but has expanded by building relationships with both the communities and a regional medical center in the city of Bangalore. Getting support from village elders was important to get community engagement and understand cultural factors (for example, employing only case workers who are women, who can enter a home when the male head of household is away). A partnership with St. John’s Medical College in Bangalore provides the necessary resources for the clinic but also provides research and education opportunities for medical students and fellows.

Since its establishment, the Maanasi clinic has increased in reach; it now encompasses a region containing over six million people. The clinic also has a wider range of care; it now includes a rehabilitation center for patients to learn culturally relevant skills such as sewing.

But thinking globally does not exclude the United States, Jayaram pointed out.

“The same concerns exist in East Baltimore as in rural India—a lack of access to care, a lack of resources, and a lack of mental health training among care providers who normally serve these communities,” she said. “If we think we are too high and mighty to use a model that works in a developing nation, we risk wasting millions of dollars and countless patient lives.”

The Kun-Po Soo award, founded in 1987, recognizes an individual who has made significant contributions toward understanding the impact and importance of Asian cultural heritage in areas relevant to psychiatry. ■