The Effectiveness of a Multi-Pronged Psycho-Social Intervention Among People With Mental Health and Epilepsy Problems - A Pre-Post Prospective Cohort Study Set in North India

Document Type : Original Article


1 Herbertpur Christian Hospital, Emmanuel Hospital Association, Uttarakhand, India

2 Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden

3 Northland District Health Board, Whangarei, New Zealand

4 Dr. RML Hospital and Post Graduate Institute of Medical Education & Research (PGIMER), New Delhi, India


In low- and middle-income settings, many people with mental health problems cannot or do not access psychiatric services. Few studies of people with epilepsy and mental problems have evaluated the effectiveness of a predominantly psycho-social intervention, delivered by lay community workers. The aim of this study was to assess the effectiveness of a community-based complex mental health intervention within informal urban communities while simultaneously addressing social determinants of mental health among disadvantaged people with severe and common mental disorders (CMDs), and epilepsy.
In this observational, prospective cohort study set in Uttarakhand, India, the lay-worker led intervention included psychoeducation, behavioural activation, facilitation of access to care, and facilitated psycho-social support groups. Participants were categorised as having a severe or CMD or epilepsy and assessed 5 times over 24 months using primary outcome measures, including the Patient Health Questionnaire (PHQ9) (severity of depression), the World Health Organization Disability Assessment Schedule (WHODAS 2.0), the Recovery Star, and scoring of a bespoke Engagement Index. Analysis included descriptive statistics as well as hierarchical linear regression models to report fixed effects as regression coefficients.
Among the 297 (baseline) participants only 96 people (31%) regularly used psychotropic medication (at least 4 weeks) and over 60% could not or did not consult a psychiatrist at all in the study period. Nonetheless, people with CMDs showed a significant reduction in their depression severity (PHQ9: B = -6.94, 95% CI -7.37 to -6.51), while people with severe mental disorders (SMDs) showed a significant reduction in their disability score (WHODAS 2.0: B = -4.86, 95% CI - 7.14 to- 2.57). People with epilepsy also reduced their disability score (WHODAS 2.0: B = -5.22, 95% CI -7.29 to -3.15).
This study shows significant improvements in mental health, depression, recovery, disability and social engagement for people with common and SMDs, and epilepsy, through a community-based intervention that was nonpharmaceutical. It provides preliminary evidence of the value of predominantly psycho-social interventions implemented by lay health workers among people with limited or no access to psychiatric services.


  1. Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet. 2013;382(9904):1575-1586. doi:10.1016/s0140-6736(13)61611-6
  2. Charlson FJ, Baxter AJ, Dua T, Degenhardt L, Whiteford HA, Vos T. Excess mortality from mental, neurological and substance use disorders in the Global Burden of Disease Study 2010. In: Patel V, Chisholm D, Dua T, Laxminarayan R, Medina-Mora ME, eds. Mental, Neurological, and Substance Use Disorders: Disease Control Priorities. 3rd ed. Volume 4. Washington, DC: The International Bank for Reconstruction and Development/The World Bank; 2016.
  3. Gururaj G, Varghese M, Benegal V, et al. National Mental Health Survey of India, 2015-16: Summary. Bengaluru: National Institute of Mental Health and Neurosciences; 2016.
  4. Singh MB. 'Untreated epilepsy' - A conspiracy of silence? Epilepsy Behav. 2016;60:202-203. doi:10.1016/j.yebeh.2016.04.032
  5. World Health Organisation (WHO). Mental Health Atlas 2011. Geneva: WHO; 2011.
  6. Patel V, Parikh R, Nandraj S, et al. Assuring health coverage for all in India. Lancet. 2015;386(10011):2422-2435. doi:10.1016/s0140-6736(15)00955-1
  7. Patel V, Saxena S, Lund C, et al. The Lancet Commission on global mental health and sustainable development. Lancet. 2018;392(10157):1553-1598. doi:10.1016/s0140-6736(18)31612-x
  8. Kirmayer LJ, Pedersen D. Toward a new architecture for global mental health. Transcult Psychiatry. 2014;51(6):759-776. doi:10.1177/1363461514557202
  9. DeSilva M, Samele C, Saxena S, Patel V, Darzi A. Policy actions to achieve integrated community-based mental health services. Health Aff (Millwood). 2014;33(9):1595-1602. doi:10.1377/hlthaff.2014.0365
  10. Atif N, Lovell K, Husain N, Sikander S, Patel V, Rahman A. Barefoot therapists: barriers and facilitators to delivering maternal mental health care through peer volunteers in Pakistan: a qualitative study. Int J Ment Health Syst. 2016;10:24. doi:10.1186/s13033-016-0055-9
  11. Patel V, Weobong B, Weiss HA, et al. The Healthy Activity Program (HAP), a lay counsellor-delivered brief psychological treatment for severe depression, in primary care in India: a randomised controlled trial. Lancet. 2017;389(10065):176-185. doi:10.1016/s0140-6736(16)31589-6
  12. Mental Health Policy Group. XIIth Plan - District Mental Health Programme. New Delhi: National Mental Health Policy Group; 2012.
  13. Jain S, Jadhav S. Pills that swallow policy: clinical ethnography of a community mental health program in northern India. Transcult Psychiatry. 2009;46(1):60-85. doi:10.1177/1363461509102287
  14. Sarin A, Jain S. The 300 Ramayanas and the District Mental Health Programme. Econ Polit Wkly. 2013;48(25):77-81.
  15. Ebenezer JA, Drake RE. Community mental health in rural India: the Shifa project in Padhar Hospital, Madhya Pradesh. BJPsych Int. 2018;15(2):38-40. doi:10.1192/bji.2017.8
  16. Shields-Zeeman L, Pathare S, Walters BH, Kapadia-Kundu N, Joag K. Promoting wellbeing and improving access to mental health care through community champions in rural India: the Atmiyata intervention approach. Int J Ment Health Syst. 2017;11:6. doi:10.1186/s13033-016-0113-3
  17. Ameh S, Klipstein-Grobusch K, D’Ambruoso L, Kahn K, Tollman SM, Gomez-Olive FX. Quality of integrated chronic disease care in rural South Africa: user and provider perspectives. Health Policy Plan. 2017;32(2):257-266. doi:10.1093/heapol/czw118
  18. The Lancet Psychiatry. Task sharing: stopgap or end goal? Lancet Psychiatry. 2019;6(2):81. doi:10.1016/s2215-0366(19)30006-9
  19. Fuhr DC, Salisbury TT, De Silva MJ, et al. Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2014;49(11):1691-1702. doi:10.1007/s00127-014-0857-5
  20. De Silva MJ. Impact evaluations of mental health programmes: the missing piece in global mental health. J Epidemiol Community Health. 2015;69(5):405-407. doi:10.1136/jech-2014-203866
  21. Mathias K, Goicolea I, Kermode M, Singh L, Shidhaye R, Sebastian MS. Cross-sectional study of depression and help-seeking in Uttarakhand, North India. BMJ Open. 20;5(11):e008992. doi:10.1136/bmjopen-2015-008992
  22. Government of India. National Mental Health Programme for India. New Delhi: Department of Health and Family Welfare; 1982.
  23. Mathias K. Shadows and light - examining community mental health competence in North India. Umea, Sweden: Department of epidemiology and global health, Umea Universitet; 2016.
  24. Armstrong G, Kermode M, Raja S, Suja S, Chandra P, Jorm AF. A mental health training program for community health workers in India: impact on knowledge and attitudes. Int J Ment Health Syst. 2011;5(1):17. doi:10.1186/1752-4458-5-17
  25. Campbell C, Burgess R. The role of communities in advancing the goals of the Movement for Global Mental Health. Transcult Psychiatry. 2012;49(3-4):379-395. doi:10.1177/1363461512454643
  26. Mental Health Recovery Star: Organisational Guide. Mental Health Providers Forum, Hove, United Kingdom;  2010.
  27. Earl S, Carden F. Learning from complexity: the International Development Research Centre's experience with outcome mapping. Dev Pract. 2002;12(3-4):518-524. doi:10.1080/0961450220149852
  28. Poongothai S, Pradeepa R, Ganesan A, Mohan V. Prevalence of depression in a large urban South Indian population--the Chennai Urban Rural Epidemiology Study (CURES-70). PLoS One. 2009;4(9):e7185. doi:10.1371/journal.pone.0007185
  29. Patel V, Araya R, Chowdhary N, et al. Detecting common mental disorders in primary care in India: a comparison of five screening questionnaires. Psychol Med. 2008;38(2):221-228. doi:10.1017/s0033291707002334
  30. World Health Organisation (WHO). WHO Disability Assessment Schedule 2.0. Geneva: WHO; 2012.
  31. Ustün TB, Chatterji S, Kostanjsek N, et al. Developing the World Health Organization disability assessment schedule 2.0. Bull World Health Organ. 2010;88(11):815-823. doi:10.2471/blt.09.067231
  32. Government of India. Census of India 2011. New Delhi: Government of India; 2011.
  33. Hanlon C. Next steps for meeting the needs of people with severe mental illness in low- and middle-income countries. Epidemiol Psychiatr Sci. 2017;26(4):348-354. doi:10.1017/s2045796016001013
  34. Jordans MJD, Aldridge L, Luitel NP, Baingana F, Kohrt BA. Evaluation of outcomes for psychosis and epilepsy treatment delivered by primary health care workers in Nepal: a cohort study. Int J Ment Health Syst. 2017;11:70. doi:10.1186/s13033-017-0177-8
  35. Eaton J, McCay L, Semrau M, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet. 2011;378(9802):1592-1603. doi:10.1016/s0140-6736(11)60891-x
  36. Kohrt B, Griffith J. Global mental health praxis: perspectives from cultural psychiatry on research and interventions. In: Kirmayer LJ, Lemelson R, Cummings CA, eds. Re-Visioning Psychiatry: Cultural Phenomenology, Critical Neuroscience, and Global Mental Health. Cambridge University Press; 2015:575-612.
  37. Lund C, De Silva M, Plagerson S, et al. Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. Lancet. 2011;378(9801):1502-1514. doi:10.1016/s0140-6736(11)60754-x
  38. Gailits N, Mathias K, Nouvet E, Pillai P, Schwartz L. Women's freedom of movement and participation in psychosocial support groups: qualitative study in northern India. BMC Public Health. 2019;19(1):725. doi:10.1186/s12889-019-7019-3
  39. Burns JK. Poverty, inequality and a political economy of mental health. Epidemiol Psychiatr Sci. 2015;24(2):107-113. doi:10.1017/s2045796015000086
  40. De Silva M, Roland J. Mental Health for Sustainable Development: Prepared on behalf of the All-Party Parliamentary Group on Global Health; 2014.   
  41. Campbell C, Cornish F. Reimagining community health psychology: maps, journeys and new terrains. J Health Psychol. 2014;19(1):3-15. doi:10.1177/1359105313500263
  42. Mehrotra N. Disability, gender and caste: marginality, exclusion and opportunities in Indian economy. Women’s Link. 2012;18(2):5-8.
  43. Mathias K, Pillai P, Shelly K, Gaitonde R, Jain S. Co-production of a pictorial recovery tool for people with psycho-social disability informed by a participatory action research approach – a qualitative study set in India. Health Promot Int. 2019. pii: daz043. doi:10.1093/heapro/daz043
Volume 10, Issue 9
September 2021
Pages 546-553
  • Receive Date: 18 October 2019
  • Revise Date: 20 April 2020
  • Accept Date: 20 April 2020
  • First Publish Date: 01 September 2021