A doctor commits to community psychiatry — at home and worldwide
Eashwaramma had not left her home in two years. She missed her daughter’s wedding and couldn’t help her husband with his agricultural work. People said prayers for her, consulted a priest, and visited the temple. When I met her 25 years ago, she told me the devil was sitting on her chest.
A psychiatrist, I was visiting the villages near where I grew up in southern India through a Rotary mental health project I initiated. Eashwaramma was my first patient. She was in the midst of a severe depressive episode. Our care team gave her medications and explained the diagnosis to her and her family.
I have treated both princes and paupers. Their sense of shame about mental illness is identical. The wife of a Saudi prince was successfully treated for bipolar illness at the Johns Hopkins Hospital in Baltimore, where I work as a professor. Her family had kept her hidden at home, not reaching out for care until she was brought to the U.S. Like Eashwaramma, she had suffered unnecessarily for years.
The World Health Organization estimates that close to 1 billion people around the world have a mental health disorder. To draw attention to the problem, the United Nations recognizes World Mental Health Day every year on 10 October.
Across the world, mental health disorders often go unaddressed and are a major cause of disability. My home country, India, has fewer than one psychiatrist for every 100,000 people, and psychiatric care is not available in rural areas. This fact haunted me when I interviewed for my residency at Johns Hopkins. The department chair asked me what would happen if more doctors like me left the country. That bothered me a great deal and stuck in the back of my mind.
A condition and its complications
When I became chief resident in my department, I chose to train further in community psychiatry, which focuses on people with severe mental illness and those whose situations are made worse by poverty, illiteracy, lack of transportation, limited access to medical treatment, and other circumstances.
During my first 18 years, I treated people experiencing poverty in Baltimore. I remember Shameka, who witnessed the shooting of a neighbor’s 5-year-old child. Another time, her house was broken into and she was attacked. She suffered from post-traumatic stress, but with medication and therapy, Shameka is doing well, serving as a spokesperson for the National Alliance on Mental Illness. She is proud of her job and is teaching others how to care for themselves.
Image credit: Vartika Sharma
But I never forgot my roots. I launched Project Maanasi to provide community mental health care in India’s Karnataka state. It has become a joint initiative of the Rotary Club of Bangalore Midtown and my undergraduate alma mater there, St. John’s Medical College. Maanasi means “of sound mind.” Villagers of Mugalur, where I met Eashwaramma, chose the name. With support from a Rotary Foundation grant, we opened the project’s first clinic in the village in 2002.
In establishing an integrated care model, we focused first on women. They have depression and anxiety at about twofold the rate of men globally. When we treat women, we essentially take care of the entire family, as women are primary caregivers and drivers of health care.
With help from St. John’s medical students, residents, and nurses, we started with a door-to-door survey of 17,000 households to assess their mental health needs. We integrated psychiatric care into an existing primary care clinic. That way people receive care where they already go for routine health needs, eliminating obstacles to treatment and reducing stigma.
Today we treat people from 212 villages and several million households. Medications are offered at low or no cost. Female caseworkers with a high school education who live in the villages and speak the local languages perform outreach. Community health workers share information in village cooperatives, at village festivals, and elsewhere. Supervising physicians accompany caseworkers to see patients in their homes or evaluate them at the clinic.
One of those patients was Radha, a Mugalur resident, who was married in her teens to a stranger. After her first child, her husband disappeared with their infant while she was going through severe postpartum depression. With outreach by the village caseworkers and clinical care, Radha recovered. Educated by our clinic workers, her neighbors serve as Radha’s support network. They have saved her life on more than one occasion.
Clinic doctors also screen village residents for hearing and vision loss. Other projects have included blanket distribution and the donation of an electrocardiogram machine, computers, cabinets, and so on. With the help of my husband, Jay Kumar, an engineer and a past district governor, we got four scooters for caseworkers. We have started a tailoring school run by a patient, who has helped other women in the village become seamstresses. Rotarians donated the sewing machines.
We’ve introduced advanced technology, working with community medicine specialists to develop a cloud-based database for patient records and training caseworkers to enter data in the field on tablets. They’ve gathered data on more than 2,500 patients that can be analyzed for research and teaching.
Replicating results around the world
Today, Project Maanasi has produced a model that we’ve been able to replicate, including in Kenya, where we established an integrated care clinic that the Ministry of Health has taken over, serving a population of half a million people. In Guatemala, we are setting up a similar care center for girls who endured child marriages, domestic violence, rape, and illiteracy.
In Lithuania, Jay and I worked with Rotary members to address an alarmingly high rate of youth suicide. With help from a Rotary Foundation global grant, and with the partnership of Past District Governor Vygintas Grinis and Vilnius University, we provided crisis hotlines and a workable system for treatment. This effort contributed to a significant decrease in suicide rates in 14 districts and helped save thousands of lives in just two years.
As part of this effort to improve mental health everywhere, I co-founded the Rotary Action Group on Mental Health Initiatives, which is now represented in about 50 countries across the globe.
Perhaps my proudest moment was when I met Eashwaramma again last year, more than two decades after she connected with Project Maanasi. I was happy to see that she is staying with
her son in a spacious two-story house, no longer depressed. She has been weaned off medications for years. She welcomed us into their home with a smile and offered us tea. She was full of life.
A professor of psychiatry at Johns Hopkins University School of Medicine, Dr. Geetha Jayaram is a member of the Rotary Club of Howard West in Ellicott City, Maryland, and co-founder of the Rotary Action Group on Mental Health Initiatives.
This story originally appeared in the September 2024 issue of Rotary magazine.