The effect of VISHRAM, a grass-roots community-based mental health programme, on the treatment gap for depression in rural communities in India: a population-based study

Background VISHRAM was a community-based mental health programme with the goal of addressing the mental health risk factors for suicide in people from 30 villages in the Amravati district in Vidarbha, central India. We aimed to assess whether implementation of VISHRAM was associated with an increase in the proportion of people with depression who sought treatment (contact coverage).

Methods A core strategy of VISHRAM was to increase the demand for care by enhancing mental health literacy and to improve the supply of evidence-based interventions for depression and alcohol-use disorders. Intervention for depression was led by community-based workers and non-specialist counsellors and done in collaboration with facility-based general physicians and psychiatrists. From Dec 25, 2013, to March 10, 2014, before VISHRAM was introduced, we did a baseline cross-sectional survey of adults randomly selected from the electoral roll (baseline survey population). The structured interview was administered by field researchers independent of the VISHRAM intervention and included questions about sociodemographic characteristics, health-care service use, depression (measured using the Patient Health Questionnaire [PHQ]-9), and mental health literacy. 18 months after VISHRAM was enacted, we repeated sampling methods to select a separate population of adults (18 month survey population) and administered the same survey. The primary outcome was change in contact coverage with VISHRAM, defined as the difference in the proportion of individuals with depression (PHQ-9 score >9) who sought treatment for symptoms of depression between the baseline and the 18 month survey population. Secondary outcomes were whether the distribution of coverage was equitable, the type of services sought, and mental health literacy.

Findings 1887 participants completed the 18 month survey interview between Sept 18, and Oct 8, 2015. The contact coverage for current depression was six-times higher in the 18 month survey population (27.2%, 95% CI 21.4-33.7) than in the baseline survey population (4.3%, 1.5-7.1). Contact coverage was equitably distributed across sex, education, income, religion, and caste. Most providers consulted for care were general physicians. We 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.

Interpretation A grass-roots community-based programme in rural India was associated with substantial increase in equitable contact coverage for depression and improved mental health literacy. It is now crucially important to translate this knowledge into real-world practice by scaling-up this programme through the National Mental Health Programme in India.