Evidence from Vidarbha: Psychological first aid prevents suicide among farmers

A suicide prevention programme in Maharashtra’s Vidarbha region involving community health workers has reduced the prevalence of depression and suicidal tendencies in the area covered, said a study published in Lancet Psychiatry on Thursday.

The Vidarbha Stress and Health Programme or VISHRAM, which was implemented over 18 months from September 2014 to October 2015, used community health workers for the first line of treatment, instead of trained psychiatrists and counsellors. The researchers then interviewed 1,887 subjects on mental health indices. They found that the prevalence of depression fell by 22% in the one year and prevalence of suicidal thoughts fell by 51%. People with suicidal thoughts are at a higher risk of committing suicide.

Maharashtra’s Vidarbha and Marathwada regions have been wracked by an agrarian crisis, leading to several farmer suicides over the past decade. In 2015, for instance, 1,328 farmers committed suicide in Vidarbha, according to government figures.

The recently released National Mental Health Survey of 12 states showed that 2.7% of the people surveyed had depressive disorders, 4.6% had alcohol use disorders and 0.9% were at a high risk of committing suicide.

The grassroots community mental health programme addressed the risk factors associated with suicide- depression and alcohol use disorders. It was carried out in 30 villages in Amravati district, which has recorded a large number of farmer suicides.

The programme was carried out with the assistance of a non-governmental organisation called Prakriti that was working in the area, and then deployed trained community mental health workers to make people more aware about depression, and offer counselling services. Some cases were referred to government psychiatrists or government doctors.

Lack of mental health facilities in the area

A 2013-14 study conducted by VISHRAM published in 2015 found that 5.2% of the 1,456 people interviewed had thought of taking their life in the last 12 months. Nearly half of the population (45.3%) also had depression. Old people (above 55 years), women, less-educated people, people below the poverty line and those in debt were more likely to be depressed.

As part of the programme, community health workers in villages were trained to raise mental health awareness and provide “psychological first aid” to patients. This involved door-to-door visits with a mental first aid kit that helped identify people suffering from depression, suicidal thoughts and other mental health problems. Workers would ask whether villagers were are getting enough sleep, for instance, or if they had “tension” (a word which many of them used to signal mental stress).

The counselling mostly focused on listening, said Suvarna Damle, the executive director of Prakriti, who works in Akola and Amravati districts with the widows of farmers who have committed suicide. “For many male farmers, ventilating their thoughts itself was relief.”

She added, “In a patriarchal set up, the men felt that they have to bear the economic burden. In fact, the wives were always unaware about the family’s economic problems and felt that they could contribute.”

The counselling included talking of options available to farmers. These included letting wives help solve the family’s economic problems, getting children to participate in community marriage ceremonies instead of having grand weddings, and not giving dowries to daughters getting married, said Damle.

The counsellors also referred patients who need further professional help to psychiatrists under the District Mental Health Programme.

Scaling up

The study showed that the prevalence of depression in the population had fallen from 14·6% in the baseline study of 2013-14 to 11·3% in 2014-15. The prevalence of suicidal thoughts in the past 12 months fell from 5·2% to 2·5%.

In addition, there was a six-fold rise in the percentage of people who sought care from 4.3% in the baseline study to 27.2%, said Dr Rahul Siddhaye, associate professor at the Public Health Foundation of India. He added that they found no significant difference in the access to treatment across different caste, gender and social class.

Compared to deploying psychiatrists to deal with the problem, there is a huge saving in using lay counsellors based in villages to treat psychological problems. “Intervention had to be grounded in community views, in the local language and metaphors to address mental health,” said Dr Vikram Patel, from Public Health Foundation of India, who led the research.

Before the programme began, the cost of treatment was approximately Rs 85,000 per patient. By contrast, the community programme costs Rs 2,800 per patient.

The recent National Mental Health Survey in India in showed that about 90% of the people with depression have not received any care in the previous 12 months. VISHRAM shows how the massive treatment gap might be reduced, the researchers said.

Last year, the state government started a programme called Prakalp Prerana in Vidarbha and Marathwada to address the mental health problems. The programme is run with existing front line workers, such as Accredited Social Health Activist workers, government doctors and paramedic staff who are trained to treat the farmers detected with depression.

“While they are also reaching out to people, they are using the existing machinery of ASHA workers, who are already burdened,” said Damle. VISHRAM, on the other hand, used people from the community trained in addressing mental health, and only a few ASHA workers.

The National Mental Health Programme also works in Akola and Amravati. However, to avail of its services, patients have go to district hospitals at specific times, or visit the few blocks where the government psychiatrist consults once a week, said Damle. There are very few private psychiatrists in the area.

While a report have shown that the number of suicides in both Vidarbha and Marathwada has come down, it cannot be attributed to VISHRAM or any programme in particular yet, as there is not yet enough data on the matter.

However, what is known from this research is that the programme has recduced suicidal behavior. “Suicides are a tip of a pyramid,” said Patel. “If you reduce suicidal thoughts, it ultimately reduces the number of suicides.”

He added, “This model of rural community health care should be seen as a model to ultimately reduce suicide in the country and should be scaled up in the country.”