Kashmir Workshop Report16.9.2013 to 27.9.2013

Facilitated by Director of Health services, Royal College of Psychiatry, supported by WHO

Led by Dr. Sayed Aqeel Hussain-Kashmir and Dr. Peter Hughes-UK

Week 1 Dr. Peter Hughes FRCPsychDr. Sayed Aqeel Hussain MRCPsychDr. Sophia Thomson MRCPsychDr. Sally Browning MRCPsychDr. Jane Mounty MRCPsychDr. Sajad Yousuf MRCPsychDr. Eleni Palazidou MRCPsychWeek 2 Dr. Henrike Klasen MRCPsych PhdDr. Lucy Potter MRCPsychDr. Mina Bobdey MRCPsychDr. Sajad Yousuf MRCPsychDr.Sayed Aqeel Hussain MRCPsych

Contact details Dr. Peter Hughes e-mail: dppmh@hotmail.comDr. Sayed Aqeel hussain : sayedaqeel@gmail.comList of abbreviations and acronyms

IG Intervention GuidemhGAP Mental Health Gap Action Programme mhGAP-IG Mental Health GAP Action Programme - Intervention GuideMNS Mental, Neurological and SubstanceNGO Non governmental organisation

PHC Primary Health CareWHO World Health Organisation Golden questions adapted from Vikram Patel’s “Where there is noPsychiatrist”J and K Jammu and Kashmir state

mhGAP Modules Abbreviations

GPC General Principles of CareDEP DepressionPSY PsychosisEPI EpilepsyDEV Developmental DisordersBEH Behavioural DisordersDEM DementiaALC Alcohol Use and Alcohol Use DisordersDRU Drug Use and Drug Use DisordersSUI Suicide and Self-HarmBPD Bipolar DisorderOTH Other Significant Emotional or Medically Unexplained ComplaintsSTR Stress module

Acknowledgements

First and foremost, we would like to thank the Dr Sayed Aqeel Hussain, Dr. Muzaffar Khan and Director of Health Services, Dr. Saleem-Ul-Rehman, Kashmir for making this training happen. We thank the Royal College of Psychiatrists, World Health Organisation and all those who have made this training a success. We thank Dr. Arshid Hussain Assistant professor at Government psychiatric hospital, Srinagar

We would like to thank all those who have been involved in the preparations and support for this programme both in India and UK.

We thank support of J & K Police, J and K Bank, HELP foundation and Action AID India and TCI cements

We thank all the UK volunteers, President Sue Bailey and Elen Cook at the Royal College of Psychiatry.

Introduction and objectives of the project

This report describes the mhGAP workshop conducted in Dhobiwan, Tangmarg, and Kashmir on 16.9.2013 to 27.9.2013. The workshop was co-facilitated by Dr. Peter Hughes, Dr. Sajad Yousuf, Dr.Sophia Thomson, Dr. Sally Browning, Dr. Jane Mounty, Dr. Eleni Palizadou, Dr. Henrike Klasen, Dr. Lucy Potter and Dr. Mina Bobdey.

Introduction and Context

mhGAP is a WHO programme initiated in 2008 designed to scale up care for mental, neurological and substance use disorders among non-specialist providers, including primary health care. The objective is to scale up mental health care in resource poor settings to address the gap in mental health care unmet needs of persons suffering from MNS disorders.

Kashmir, India Context

Kashmir is a region in the north of India, which has been affected significantly by conflict for over 20 years. It is a Muslim dominant region. There is a clear gap in mental health provision at primary care level.

There is a currently centralised psychiatry service.

There is one psychiatric hospital in Kashmir.

This is a 150-bed hospital Institute of Mental Health and Neurosciences, Srinagar. There is 1 professor of Psychiatry, 1 associate professor, 2 assistant professors, 3 lecturers (including Dr. Sayed Aqeel Hussain), 8 registrars, 9 postgraduates, and other doctors including house physicians, assistant surgeons (staff grade) and interns- (variable number). There is adequate medical input at hospital. This reflects a currently centralised psychiatry service.

It is the main referral centre for all patients suffering from mental illness. It provides referral services for the other associated hospitals of Government Medical College (GMC), Srinagar. The hospital provides teaching programs to Post graduate and undergraduate students of GMC Srinagar and also provides a rotatory training programme to medical interns affiliated with it.

Private system – all of Psychiatrists work in private sector as well. They also go to different districts at weekend to review patients. This is an ad hoc arrangement including Srinagar. The attendance at different districts is informal and variable.

Overall there are several districts in Kashmir with no psychiatry hospital except srinagar including private psychiatry.

There are several psychiatrist employed by the director of health services as B grade Psychiatrists –currently 4. They are appointed by the director to a particular district . They see patients in that district.

These district hospitals have opd but no inpatients.

There is a J and K chapter of Indian Psychiatrist Association, which includes psychiatrists from both Jammu and Kashmir. There is support from this organization for the mhGAP programme.

The District Mental Health Programme is part of the national mental health programme and aims to address this gap of mental health capacity at Primary Care level.

This is the flagship mental health intervention in India.

Primary care is provided in Kashmir in each district led by Chief medical officer of district.

In Kashmir there are 12 districts. The District Mental Health Programme has not been launched in Kashmir yet. It is planned to be launched in 2013. The aim is for every district (12) of Kashmir to have trained personnel, trained at nodal centres and to put in practice that knowledge and skills within the 12 districts.

Objectives of the Project

The objectives of the Project was to provide an mhGAP based standard training for prescribers and separate base training for non prescribers, develop supervisory strategy for follow up and Medical Student educational matching programme Kashmir –St. George’s Medical school, UK

The objectives of the training were to ensure that participants:

Become familiar with the mhGAP programme and mhGAP-IG Acquire skills found within mhGAP on assessment, diagnosis and

management of priority conditions in mhGAP Master various models of training methodology and training

techniques, facilitator skills and supervision skills Identify a pool of potential champions of mhGAP in Kashmir. Develop a strategy for supervision A secondary project of establishing a medical student matching link

between UK and Kashmir

Background of project

Dr. Sayed Aqeel Hussain is a Kashmiri Psychiatrist who has trained in UK. His idea of bringing mhGAP to Kashmir originated out of London conference in early 2008. He led the development of this project in Kashmir through tireless endeavor. (see Appendix i-background concept)

In UK Dr. Peter Hughes led in coordinating from UK. Dr. Peter Hughes has an extensive record of mhGAP training throughout the world. This represented an opportunity to utlise the Royal College of Psychiatrists volunteering programme.

Volunteers for the programme were recruited by Dr. Peter Hughes through volunteering database, special interest group meetings and direct contacts.

Selectionwas made,based on those who had delivered mhGAP training,

attended an orientation, and had significant internationalmental health teaching experience. Originally there were psychiatrists and psychologists. However eventually the group was made of Psychiatrists and a Kashmiri Psychologist.

The preparationprocess was by e-mail and Internet contact predominately.

All facilitators were enabled to access EZ collab website to access mhGAP facilitator guides and PowerPoint presentations.

Some of lecturers were able to attend an mhGAP orientation in Manchester in September 2013 led by Dr. Peter Hughes and Dr. Sophie Thomson in London in March 2013. Practical difficulties in getting visas meant some people were unable to travel.

Facilitators were matched with the more experienced partnering with less experienced. There was an attempt at gender balance but the majority of lecturers were female.

There were some with no mhGAP experience but were matched with skilled people. There was an effort to get those to be fully briefed on mhGAP teaching methodology.

In Kashmir the programme was overseen by Dr. Sayed Aqeel Hussain and Dr. Muzzafar Khan (psychologist).

Another portion of the programme was getting a matching with UK St. George’smedical school and medical school Kashmir.

Facilitators:

Overall there were 9 overseas lecturers/facilitators

8 of the 9 were UK based AdultPsychiatrists and 1 Netherlands based Child Psychiatrist. Two of international facilitators were male and rest were female. Kashmir counterparts were male. Three of facilitators had led mhGAP training before. Another 3 had attended an mhGAP orientation in UK

Week 1

Dr. Peter Hughes –Consultant Adult PsychiatristDr. Sajad Yousuf- Consultant Adult PsychiatristDr. Sophie Thomson –Retired Consultant Psychiatrist Dr. Sally Browning –Retired Consultant PsychiatristDr. Jane Mounty- Retired Consultant PsychiatristDr. Eleni Palazidou –Retired Consultant Psychiatrist

Lead for Group -

Dr. Sayed Aqeel Hussain Dr. Muzaffar Khan

Week 2

Dr Sayad Yousuf, MRCPsych – Consultant general adult psychiatristDr Henrikje Klasen, MRCPsych, PhD – consultant child- and adolescent psychiatrist, associate professorDr Mina Bobdey, MRCPsych, CSBM, DPM - Consultant Old age and Adult psychiatristDr Lucy Potter - trainee psychiatrist

Lead Week 2

Dr. Sayed Aqeel Hussain Dr. Muzaffar Khan Dr. Sajad Yousuf

Table 1 –list of facilitators –UK-Kashmir

Name of Facilitators Profession Week

Gender

mhGAP experience

Dr. Peter Hughes Adult Psychiatrist-UK 1 M YesDr. Sophie Thomson Adult Psychiatrist-UK 1 F YesDr. Eleni Palazidou Adult Psychiatrist-UK 1 FDr. Jane Mounty Adult Psychiatrist-UK 1 F YesDr. Henrike Klasen Child Psychiatrist-NL 2 F YesDr. Sally Browning Adult Psychiatrist-UK 1 F YesDr. Lucy Potter Adult Psychiatrist-UK 2 F YesDr. Sajad Yousuf Adult Psychiatrist-UK 1,2 M YesDr. Mina Bobdey Adult Psychiatrist-UK 2 FDr. Aqeel Hussain Psychiatrist -Kashmir 1,2 M Yes Dr. Muzaffar Khan Psychologist-Kashmir 1,2 M

Description of the mhGAP Training Workshop

Preparation

The trainings were based on the draft mhGAP Base Course that has been developed by WHO in Geneva.It is pertinent to mention that mhGAP is a Human Rights based intervention. The mhGAP Base Course was based on a set of PowerPoint presentations and mhGAP IG.

For prescribers the Base course was covered with a treatment including

medication as well as psychosocial management. For non-prescribers the emphasis was on case identification and psychosocial management.

Participants were given a folder with copy of mhGAP for each.

Training Venue and Participants

The training was held in Regional Health and Family Welfare Institute, Dhobiwan, Tangmarg, Kashmir. This is a trainings centre outside of Srinagar.

Three rooms were used. Certain sessions were for whole group such as introduction, general principles of care.

Selection of Participants

(see Appendix xii for list of participants)Selection was made by Dr. Aqeel Sayed. Method of selection involved

Advertisement in newspapers for all those interested with registration fee

Personal contacts Director of health organized 4 active working doctors from each district

and 2 nurses from each district –overall 40 doctors and 18 nurses were allocated to come.

Selection criteria for participants included the following:

–Experience in PHC –Geographical distribution -Evidence of motivation

There was a registration charge to ensure motivation. The target group was those delivering primary health care.

For the non-prescribers there were groups of counselors, psychologists, social workers, police personnel, teachers and NGO representatives.

All those who applied by registration fee had to submit CV for review and consideration ofsuitability –Dr. Sayed Aqeel Hussain and Dr. Muzaffar Khan selected based on these.

Summary of week 1 and week 2 participants

Week 1

The professions covered included doctors, professor physician, ConsultantHomoeopathist, psychologists, social workers, teachers, counselors, and speechtherapist. There were representatives from NGOs such as HELP. There were 64 attendees.

Two groups were for prescribers and one group for non-prescribers. There were joint sessions for General principles of care, introduction, Drug use and Stress module.

The non –prescriber group focused on the base course with some description of medication while the other groups were the standard courses for prescribers. There was a strong base line of knowledge amongst all participants.

Week 2

Week 2 had 50 participants, who attended some of the time with 42 completing the whole course and taking part in both pre- and posttest evaluations. Some participants were absent for personal or professional reasons some of the time and usually gave their apologies in advance. Four teachers did not return after the first day of training.

Week 2 was much more diverse than week one, both in terms of professional background as well as in terms of prior knowledge of mental health issues. The largest groups of participants were nurses, who formed nearly half group (24 participants). Within this group there were teaching staff from the nursing college (including the principal of the college, readers and assistant professors), specialist mental health nurses, working at the specialist mental hospital, nurses participating in an MSc course on mental health nursing as well as ordinary staff nurses working in district hospitals or community health centers). There were also 11 teachers, many of them working in special education or at a teaching college. There were 9 doctors including the CMO of Kupwara district, which has been chosen to be the site for the Kashmir pilot mhGAP. Finally there were 3 health workers, one lawyer and two psychologists.

In order to deal with the diversity of the group there were 2 groups. One consisted of all the doctors as well as the more academically trained nurses, the psychologists and some of the staff of the teachers training college

The second group mainly consisted of the more junior nurses and teachers

In-groupone-medication issues were discussed in great detail while the second class focused on psychosocial interventions as well as case recognition. Both classes had a native speaker to make sure there were no communication problems.

Another significant difference between week one and week two was that quite a large number of participants of week two came from Kupwara district and had been directed to participate in the course. The reason for this was that only two days before the start of week two it was decided that Kupwara should become the pilot site for the implementation of the complete mhGAP programme within Kashmir. This decision was taken partially due to the great success of week one of training.(appendix xiii & appendix xiv)

Participant Background

Table 2-Partcipant background (appendix xii)

Week 1 Gender DOCTORS

STUDENTS

PSYCHOLOGIST

SOCIAL WORKER

OTHER

64 participants

42 MALE66%22 FEMALE34%

41 4 9 4 SPEECH THERAPIST -1 COUNSELLOR -1HOMEOPATHY CONSULTANT -1

Week 2 Gender DOCTORS

TEACHERS

PSYCHOLOGIST

NURSE OTHER

46 participants

13 MALE28%33FEMALE 72%

9 7 2 19 LAWYER -1

Cultural/Political Considerations

There were no particular issues affecting the participants attending.

During the training in week 1 there was a problem of demonstration and travel restrictions. (hartal) However this did not have any effect onattendees.

Training Workshop

Training Agenda

The agenda was finalised at the beginning of the training. (See appendix ii). The agenda was adjusted each day and week 1 to week 2.

All chapters were selected apart from Alcohol ALC and Dementia DEM.

After further discussion during week 1 it was fell that Dem should be covered but to a minor extent.

Some chapters were emphasised

DEP PSY BEH and DEV OTH

DRU

Also seen as important but less so were

EPI

Overwhelmingly in the primary care context the most important chapter was considered to be OTH and after this DEP. Drug use DRU was seen as an important problem in Kashmir.

Main components in the schedule included:

1) Formal opening 2) Ground rules 3) Introduction of the mhGAP Programme and its various

components4) Pre/Post test and Evaluation5) Introduction to mhGAP 6) General Principles of Care 7) DEP8) SUI9) DEM10) OTH11) DRU12) EPI13) PSY14) BEH/DEV15) STR16) Post evaluation and feedback 17) Revision session 18) Formal closing and certificate ceremony

Formal opening of workshop

Workshop was launched on Day 1 with speeches by Dr. Muzzaffar Khan, Dr. Sayed Aqeel Hussain, Prof Yousuf- (former head of department of medicine Government Medical College Srinagar), Dr. Peter Hughes, Dr. Sophia Thomson, Dr. Eleni Palazidou, Dr. Sally Browning, Dr. Sajad Yousuf (UK based Kashmiri origin Psychiatrist) and Dr. Jane Mounty.

Training Methodology

The training methodology was designed to build capacity within participants with the following outcomes:

Demonstration and practice by facilitating sessions in front of the group; and

Integrate knowledge from mhGAP and teach primary care providers using a variety of training techniques.

Main types emphasized include:

Lecture, Group Discussion, Brainstorming, Case Study, Role Playing, Small group and Large Group Exercises.

Techniques taught and modelled during the course of the session included:

Establishing ground rules, Energizing exercises, Engaging audience to produce case examples from their own Kashmiri

experience, and Modelling.

The following tools were utilized and demonstrated as techniques during the training:

PowerPoint Projectors

General Observations and Comments

The group was divided in first week into prescribers (2 groups) and 1 non-prescriber group. (See appendix xii)

There were several joint sessions such as on Day 1, Drugs, supervision and stress module.

All 3 groups reported a highly interactive group who were engaging well and had a good basic theoreticalknowledge. There were a significant number of primary health care workers present in each group.

They did need some reminding of ground rules from time to time, as the participants could get very engaged in discussions.

The theme of conflict and economy came up frequently for Kashmir amongst the participants. The lecturers were informed of the stress of the conflict in Kashmir over 20 years and how this they feel has led to many psychiatric problems.

The group identified the chapter OTH as key to their primary care work and also depression. Epilepsy was seen as less important as they can refer to neurologists relatively easily.

Primary care clinics can have up to 70 to 100 people per day. Many of these are repeat attenders with about 5 minutes to see each person. It is difficult to organise for follow up with the same doctor.

Priority areas that the participants identified were DEP, OTH and DRU.

There were some specialists from drug services who may have biasedsome of the observations. There were teachers, which also may have led to emphasis on children.

Ground rules were set, however, punctuality was sometimes an issue.

Results

The participants were invited to complete the template page 43/44 from WHO monitoring and evaluation framework. (appendix iii and iv) Prescribers were able to document the MNS patients they had seen in the previous month on their PHC. This was an estimate. It gave us a baseline of MNS activity at PHC level. The section Other MNS conditions was ambiguous, as this should capture somatisation bit was interpreted as a more general other by some. Of those that offered cases at PHC 60% were new cases and 36% follow up. 19% of new cases were refereed on. There was an equal gender distribution. 45% of cases were DEP whereas 13% OTH which is contrary to what was the verbal feedback of participants. Other chapters were representedreasonablyevenly at low level with OTH as the only other peak.

Participants were asked to describe if they had medications available. There were 22 PHC representatives were covered. 13 of these commented on the questions about drugs for DEP, PSY, EPI and other. 62% had drugs for PSY. Next was 54%, which was for other medications. This meant benzodiazepines predominately. Next was EPI where there were drugs available in 38%.

Table 3- Facility monthly monitoring and evaluation 1 month before training

SURVEY OF PHC WEEK 1Estimate of cases MNS from previous Month NO OF CASES 1071 100%New cases 628 60%Follow-up 387 36%Referred on 117 19%Male 377 50%Female 382 50%Under 18 179 17%Over 60 100 16%DEP 453 45% of mns PSY 45 5%BIPOLAR 8 1%EPI 46 5%

DEV 48 5%BEH 42 5%DEM 63 6%ALC 60 6%DRU 72 7%SUI 29 3%OTH 131 13%DRUGS for DEP 4 31% of sites reportedPSY drugs 8 62%EPI Drugs 5 38%Other drugs 7 54%No meds available 3 23%Total commenting on drugs available at PHC

13 13

The participants were all actively involved in the training. By active repetition, small and large group work there was an experiential evidence of improvement of skills and knowledge.

Assessment of Knowledge Based on Pre and Post-Test(appendix v for test and xii for results)

Table 4- Pre-Post test results

WEEK 1

MEAN PRE TEST SCORE

POST TEST SCORE

RANGE PRE

RANGE POST

MEAN DIFF PRE AND POST

68% 84% 44-92% 68-96% + 16WEEK 2

64% 82% 28-84% 56-96% +18%

The results of pre and posttest show that there was an increase of pre and posttest of +17 between the two weeks.

There were a negligible number with negative change, which can be understood by chance, or language.

The great range of prior knowledge was apparent in the results of the pre-test, which although not differing significantly from that of week one (mean 64% as opposed to 68% in week one) showed a much greater range of scores ranging from 28% to 84% pre-test (week one 44% to 92%).

Attitude analysis

(appendix vi-attitude form-pre and post and xii for results)

There was a small change of 3.5 between pre and post attitude test representing a negligible change.

During the training there was much discussion of issues such as stigma, religion, gender, conflict and pressures of primary health care work. These indicated a sophisticated attitudinal approach from the beginning.

Feedback

(For full feedback see Appendix vii and viii)

The feedback was conducted on last day. There were 4 main questions on clinical relevance, structure of training, clairity of language and teaching and overall score. Types of teaching method were analysed. Further areas were questions on what was good about training and what was not good. Areas of imrpvoement and general comments were also included. Results as below in Table

Week 1 –specific feedback

Feedback was very positive.

Clinical relevance. 46% scored excellence for this. 44% Good and 10% satisfactory. Overall this means 90% scored good and excellent for this category.

Structure of training – 21% scored excellent. 75% scored good and 4 % satisfactory. Overall this score shows 96% good and excellent.

Clarity of language and teaching – 77% excellent, 20% good, 3.5%.Overall this is 97% good and excellent.

Overall Score 63% excellent, 32% good, and 2% satisfactory. Overall this means an overall score of 95% good and excellent

Week 2 –specific feedback

Participant feedback from week 2 was very positive, with over 90% rating course structure, and 95% rating clinical relevance as either good or excellent.

Week 1 and 2 combined scores

Clinical relevance. 43% scored excellence for this. 47.5% Good and 7.5% satisfactory. Overall this means 90.5% scored good and excellent for this category.

Structure of training – 21% scored excellent. 60% scored good and 6.5 % satisfactory. Overall this score shows 93% good and excellent.

Clarity of language and teaching – 63.5% excellent, 31.5% good, 3.5% satisfactory.Overall this is 95% good and excellent.

Overall Score 55.5% excellent, 42% good, and 1% satisfactory. Overall this means an overall score of 97.5% good and excellent

Table 5 Feedback results     

Week 1 Excellent

Good Satisfactory

Poor

Unsatisfactory

Types of teaching

Clinical relevance

46% 44% 10% 0 0 x

Structure 21% 75% 4% 0 0 XClarity of Teaching and language

77% 20% 0 0 0 x

Overall score

63% 32% 2% 0 0 X

Types of teaching preferred

88% Role-play64% Group work62% Case discussion50% Lecture46% case presentation

Week 2 Clinical relevance

40% 55% 5% 0 0 X

Structure 45% 45% 9% 0 0 XClarity of Teaching and language

50% 43% 7% 0 0 x

Overall score

48% 52% 0 0 0 x

Types of teaching preferred

86% Role-play60% Group work50% Lecture45% case

discussion31% Case presentation

Overall week 1 and week 2 Clinical relevance

43% 47.5% 7.5% 0 0 X

Structure 33% 60% 6.5% 0 0 XClarity of Teaching and language

63.5% 31.5% 3.5% 0 0 x

Overall score

0 0 0 x

Types of teaching preferred

86% Role-play60% Group work50% Lecture45% case discussion31% Case presentation

Types of teaching – each feedback form indicated preference for type to training method. 87% had preference for Role –play. 62% had preference for Group work. 53.5% Case discussion. 50% choose Lecture method. 38% Case presentation. The majority of participants choose at least 2 types of teaching

Table 6 preferred training methods

Rank of teaching methods

Rank

Role play 1Group work 2Case discussion 3Lecture 4Case presentation 5

What was best about the course? This was another feedback question.

There was a theme of the type of teaching methods and appreciation of facilitators.

What was the worst thing about the course? Main theme was

too short need to cover stress more OCD and anxiety states conflict

What ways to improve course?

More time repeat yearly supervision systems in place Kashmiri psychiatrists to be involved.

Other comments – there was a very positive appreciation of the training

Week 1

Verbal feedback was very positive. The comments echoed the feedback above. Participantsfelt they could use these skills. They were energised by the Supervision workshop session. It was felt difficult by some to use mhGAP IG in front of patient without losing credibility. Other contentious issue was the issue of not prescribing vitamins or placebo for treatment for MNS conditions.

Week 2

Both groups particularly enjoyed role-plays and small group work, with one participant stating, “the best thing was that participants were not only passive listeners but were also involved in role plays and discussions”. Another described the structure as “easy and to the point”, stating that it “will surely help GP’s and health care workers in primary health care”. Several commented on how the course had changed their attitude to mental health and cleared misconceptions, believing that they would be better placed to help their communities. Overall the participants felt that having a combination of both international and local trainers worked well. Although there were some comments that at times, the language was not grasped by everyone, the majority felt it provided an insight into other cultures and what is happening in other parts of the world. There were very few suggestions for development, but the most common theme was that participants would have liked more time to cover topics in further detail, and possibly a longer training period.

Comment was made those international facilitators needed to understand local culture better.

GPs commented that they at times were pressurized to prescribe medication in case of conversion so we should have visited clinics and had first hand experience, Nursing Tutors felt modules were pitched at primary health care level initially but they seemed to agree later that it was helpful in there work. A teacher in-group 2 felt at time including extended family as we did in role-play could have counter effect and stated we should have visited some family’s to understand the culture.

(Full Feedback is in appendix viii)

Observations on mhGAP, mhGAP-IG and Facilitator Guides

Paper Facilitator guides were not used in this training. However the PowerPoint guides were used extensively.

There was some difficulty in marrying up the mhGAP IG and the PowerPoint. The slides were seen as very good although could not be covered in the time allocated and it was necessary to edit the PowerPoint before the training. Overall the best use was to start with the PowerPoint for a mini-lecture then to have a practical case based discussion using mhGAP IG. All participants had a copy of mhGAP IG.

The chapters that were felt were important by participants were DEP, DRU, OTH, STR. It was mentioned many times that Kashmir has had conflict for over 20 years. Some of participants worked with stress cases and spoke of PTSD frequently.

Screening questions first were on physical health problems as a screen before entering mhGAP. Next in process was use of golden questions adapted from Vikram Patel’s “where there is no Psychiatrist” These were questions on Sleep. Fear, energy, substance use and money spent on substance use. These were well received.

General Principles of care were discussed and reinforced every day using acronym CATMAP.

DRU –this was one of the most important chapters covered, as abuse of prescription drugs and benzodiazepines is a very common problem in Kashmir. This session was led by Dr. Muzzaffar who led a training based on local practice and indicated to all the services available in Kashmir. Some trainingin motivational interviewing approach.

DEP. This was covered extensively over 2 days. It served as a template for other modules. Problem solving skills were highlighted and demonstrated. They were seen as possible to be put in 5-minute consultations. In Kashmir the majority of patients who might present with depression are likely to be somatising. This caused some difficulties, as there was some confusion as to the link to the chapter OTH. Patients were described with probable dysthymia, whichdid not quite land in either DEP or OTH.

STR. This module was discussedin a large group. PTSD was emphasised amongst the participants but the lecturer emphasised need for careful and objective diagnosis. It was seen as a very useful chapter and important for psychosocial interventions. Here was an opportunityto demonstrate breathing and relaxation exercises.

PSY-this was readily understood in Kashmir.

DEV and BEH. These cases seem to be missed at PHC level. Parenting skills was emphasised. These were repeated again and again.

EPI- this seemed straightforward and in Kashmir mostly people can be refereed easily to neurologists.

BIPOLAR- this is seen as an important topic but emphasis was on early referral on to secondary care.

SUI- this is a significant problem and most of participants had come across cases

DEM –initially this was left out but was discussed following discussions from participantsabout cases they hadseen and carer strain was emphasised

Emphatic Theme of the training was the psychosocial. Medications were discussed at prescribers group.

There was a heated discussion about using a manual in front of the patient. It was felt that this would instil a lack of confidence in the attendee at a clinic. There was some work on developing strategiesaround using the book in a way that wouldn’t be too obtrusive.

Another issue that was discussed was prescribing and using placebo. We used the term “human placebo” where the placebo is the positive therapeutic value of the health professional rather than a vitamin injection or other type medication.

Day-by-Day feedback

(See appendixix for full details)

The structure of the training was similar in week 1 and week 2.

Training was given in groups each led by two trainers. The teaching was very interactive and included group discussions, role-play, mini lectures and demonstrations.

Each day the trainers reviewed the progress of their groups including any arising issues and tried to address them the next day.

In week 2 it was decided to make optimal use of the available sub-specialties and therefore the mini-lectures on child-psychiatry and old-age psychiatry were delivered to the group as a whole. In the case of child psychiatry the subsequent practical exercises were then carried out in the separate classes. Teaching started at 10am and went through to 4.15pm with one 45-minute lunch break and two 15-minute tea breaks, leaving three hours pure teaching time in the mornings and two hours in the afternoon.

On the first Friday there was an afternoon session but not on second week.

The total teaching time was 23 to 25 hours and shorter than the recommended time of 35 hours

Feedback from facilitators

(For full feedback see Appendix x )

There was a very positive view of the training by externalfacilitators. Some themes were

High knowledge of participants from beginning and their engagement Importance of continuing this project Time limit Value of use of mhGAP IG

Media

There was a significant amount of Kashmiri press coverage on every day of the training in week 1. Some of the stories tended to focus on the conflict nature of mental health in Kashmir and were at risk of being politicised.

Overall the press coverage was positive and led to many requests for participation, which had to be declined because of capacity.

(See appendix xi)

Supervision

There was a group discussion around supervision at end of training to consider how supervision would take place in kashmir. There were many imaginative ideas such as an internet network as well as more formal supervision strategies.

A strategy meeting was held at end of training attended by director of Heath services and psychiatrists and others to develop a strategy for rolling out the programme in Kashmir. This meeting led to a plan for a roll out in 1 district and a suprervisionsystem.

Monitoring and evaluation

This is vital for the programme of mhGAP roll out. There is a WHO document which can be used in Kashmir. The participants were able to provide a list of cases they had seen of MNS conditions over the previous month and this can be monitored again.

Indicators of MNS conditions can be use of drugs, diagnostic recording, community awareness, surveys and formal interviews. This monitoring and evaluationstrategy is being developed.

The M and E strategy will be fleshed out at mhGAP meetings in Kashmir as follow up on rolling out in 1 district in Kashmir.

Medical school project

This project will be set up to link medical students in St. George’s Medical school and students of Kashmir. The project is led in UK by Dr. Roxanne Keynejard. It will involve matching students to have an Internet peer learning. This project will roll out over 2013-2014 and be evaluated in due course.

Conclusion and Suggestions

Suggestions arrising from dicsusions during the meeting - Integration of Mental Health into Primary Care in Kashmir:

To ensure that capacity is maintained, recommend a prompt follow-up of all participants with mhGAP refresher and monitoring of use in field .

Identification and selection of potential Kashmiri Master Trainers from this participant pool. Promptly communicate strategy, plan and expectations to this group.

For Master Trainers provide access to expert supervision.

Development of structured clinical and peer supervision for mhGAP trainees and implementation immediately following mhGAP Base Course at primary care level. Complex case dcisussion at peer meetings. Possibility of distance supervision by internet is possible to support programme. Internet network can be set up for mhGAP users.

Implementation of parallel programs such as Community Awareness (to promote uptake into the health care system), development of community-based psychosociaal interventions and training of other professionals such as midwives, traditional healers, community health workers to support mental health within primary care.

Enhance the capacity of secondary care to deal with increased demand of referrals and advice sought on MNS conditions.

Consider user groups to be developed and involved in creating access

to mental health care. Consider telepsychiatry and e-supervision for remote areas and areas

affected by insecurity to strengthen intergration of mental health into primary care. Ideally, e-supervisors could be from the Diaspora and supplement local supervision where not available.

For clinical supervision, this can be provided by experienced nurses or doctors who have completed a training in mhGAP and have competence in treating mental health patients.

mhGAP should ideally be piloted in one district

Integration of mental health indicators into the overall Kashmiri diagnostic recordng systems

Integration of this programme into the National health strategy Planning should take place upfront with a workforce development plan

and training strategy. Making mhGAP training as part of BSc general nursing course and

principal of SKIMS nursing college was going to discuss with Director of SKIMS institute. Director health services was also willing to support this initiative.

Anxiety disorders including OCD made into separate module. Recommend Dr Aqeel having some lead role in pilot project due to

start in Kupwara district. Training of trainers to implement mhGAP in Kupwara district. Local trainers trained. Local psychiatrists are key to the project and need to be familiarized

with PHC settings

Prepared by:Dr Peter Hughes Dr Sayed Aqeel HussainOctober 2013