The prevalence of chronic non-communicable diseases, including cardiovascular disease (CVD), type-2 diabetes, and common mental disorders (CMD, which include depression and anxiety) are increasing worldwide, including in India. Patients with CMD are often underserved, especially in rural areas, due to both mental health stigma and lack of trained providers. The treatment of patients with dual diagnoses involves special challenges and, if left untreated, depression and anxiety can contribute to non-adherence and worsened disease outcomes. Similarly, lack of staff training in India's Primary Health Centers (PHC) can result in missed diagnoses, inappropriate treatment, and increased patient morbidity and suffering. A growing body of research suggests that some of these challenges can be overcome by integrating treatment of individuals with multiple diagnoses, addressing common risk factors and using stepped or collaborative clinical care models that take advantage of shared resources. This may also help reduce the stigma of seeking mental health services. During the past decade, our Indo-US collaborative research team has studied mental health, CVD, adherence to medical regimen, and AIDS stigma in South India. We have developed interventions to target these behaviors in randomized controlled trials (RCT) and have trained lay health outreach workers (ASHA) to deliver services to individuals with both communicable and non-communicable diseases. We now plan to build on this work by implementing a multi-level integrated intervention in collaboration with 50 PHC in rural South India and evaluate it in a cluster RCT. We will also assess whether community-based risk factor screening can increase the number of patients diagnosed with co-morbid conditions in the PHC. The proposed intervention is informed by a Social Ecological model, using behavior change strategies guided by Cognitive Social Theory. Patients in intervention PHCs will receive integrated care by their physicians and PHC staff, based on a collaborative, stepped care model. They will also participate in community-based Healthy Living groups, co- facilitated by ASHA to increase sustainability. The groups will use both cognitive and behavioral strategies to target health promoting behaviors such as physical activity, nutrition, adherence to medical regimen, as well as problem-solving skills, coping skills, and social support, which are risk factors for both CVD and CMD. Patients in control PHCs will receive an enhanced standard non-integrated care model, which includes providing referrals for mental health needs plus prescriptions for antidepressant medication. If effective, the proposed study will contribute to th field in several important ways by 1) combining low-cost, evidence-based strategies that will impact multiple chronic diseases; 2) building capacity of PHC staff with respect to diagnoses and treatment; 3) helping link community members to primary care; 4) increasing health awareness in the community and reduce the stigma associated with seeking care for mental illness; and 5) enhancing integration and linkages between existing government programs, such as PHC and India's National Rural Health Mission.
People who are diagnosed with both mental and chronic physical illnesses present special challenges for the health care system, and nowhere is this truer than in resource-limited settings, such as rural India, where people with depression and anxiety are often underserved, due to both mental health stigma and lack of trained providers. These challenges can lead to complications, both in the management of the chronic physical disease as well as increased suffering for the patients, their families and their communities. In this application we build on previous research, conducted both in the West and in India, by proposing to integrate the treatment of patients with depression or anxiety and either cardiovascular disease or type-2 diabetes, in primary health care settings using a collaborative care model to improve the mental and physical health of primary care patients in rural India in a culturally appropriate and sustainable fashion.
