Sangath’s PREMIUM project is community mental health in a nutshell. The project is one of the NGO's biggest and longest undertakings, and aims to detect depression and alcohol use disorders in primary health care centers. Once detected, patients will be referred to PREMIUM counselors, who are simply regular community members who have been trained to deliver mental healthcare interventions for depression and alcoholism.
Last week, the PREMIUM project team met for an update to discuss the logistical issues and results of the pilot program so far. I was given the opportunity to participate in these meetings as some of the world’s leading researchers in global mental health, depression and alcoholism sat in a room debating the most effective treatment delivery strategies, brainstorming how to reduce attrition, and how to maintain the quality of the intervention over time.
The discussion that interested me the most and that consumed most of the second day of the meetings, was that of social determinants of health. In rural India, where the PREMIUM trial is taking place, employment, education, food, shelter, and water are not always guarantees. Financial strain, a lack of education and job insecurity can negatively impact health, both directly through stress and indirectly through the impacts of poverty on health, such as the inability to afford medications for treatable diseases or a lack of knowledge of how to prevent such diseases. Many of the PREMIUM counselors have found that their patients want more than just a psychological intervention, as they report that their financial status and unemployment make it difficult to make changes in their lives. In the meetings, debates ensued as to the importance but potential confounding effects of incorporating job skills training into the counseling.
Another interesting issue that arose was peripheral issues discussed in treatment, such as domestic violence. In India, domestic violence is quite common, and, according to many in attendance in the meeting, accepted as normative in most communities. An ethical debate arose as to whether it would be appropriate to intervene in situations of violence in these communities when the victim does not express malcontent. Some expressed that even if a patient desired to escape his or her situation, the community would likely lack resources to respond. Furthermore, as most of the counselors are women and many of the substance use patients are men, counselors reported that gender roles and expectations often interfered with their ability to adequately address the issue. As much of my research in the United States focuses on domestic violence, I was invited to help edit the section of the counselor’s manual on the topic – an awesome opportunity!
In all their depth and breadth, the discussions at the PREMIUM pilot study overview meetings left me with one main impression: thoroughness. This intervention has been planned, vetted and gone through countless revisions. Counselors have gone through rigorous training, and are constantly supervised by highly qualified mental health professionals. PREMIUM puts quality above all.
When it comes to the developing world, I have felt that there is an incredible, life-or-death time crunch. People must be helped out of poverty, aided in their struggles for gender equality, and given all-encompassing healthcare – but it is an urgent task that must be done as fast as possible. In such a rush, it could be easy to neglect quality for the quantity of individuals helped or the speed with which help is delivered. Although I do certainly maintain that such issues are urgent global concerns, the PREMIUM trial is a testament for the benefits of taking it slow. Giving money and donations is certainly good, but throwing money at an issue is not a foolproof nor maintainable method of fixing a community’s problems. If there is any hope to create sustainable change in a community, you have to put in the time. Real change is created through the hard work of individuals and teams, working to truly understand the needs, desires, and problems of the community they serve. Despite our rush to develop the developing world, quality cannot be sacrificed for instant gratification.
