Building mental health capacity in rural communities

Katherine Schiavoni, MD, MPP

Resident in Medicine and Pediatrics

PGY-4

May 11, 2019. 

I am nearing the end of my one-month rotation with Compañeros en Salud / Partners in Health in Chiapas, Mexico. As mentioned in my last post, I am working a resident mentor in several rural community clinics in the Sierra Madre region of Chiapas state.

During my month in Chiapas, I have had the opportunity to learn more about the mental health program developed here by Compañeros en Salud (CES). Mental illness, particularly depression, is increasingly recognized as an equal concern in poorer areas as it is in well-resourced settings. The World Health Organization estimates that depression will be the leading cause of disability worldwide by 2030. CES trains its social service year physicians (pasantes) to deliver mental health care in the rural primary care setting. The pasantes receive training by the mental health team, including a psychiatrist and psychologist, to deliver brief structured interventions in the clinic using motivational interviewing and cognitive behavioral therapy techniques. They also receive training in pharmacotherapy and are able to initiate medications when needed.

This month, I witnessed several beautifully conducted visits for depression. In one consult, a woman in her mid-30s presented for headaches and pain in her neck and arms. The pasante, Alex, asked thorough questions about her physical symptoms and listened to the ways in which the pain impacted her. After about 10 minutes, he gently asked, "and how is your mood? Is there anything difficult going on in your life right now?". She began to cry and discuss how her husband's alcohol use is impacting her children, and how she feels guilty about what they have experienced and hopeless about the future. Alex provided psychoeducation about depression, and about the effects that trauma can have on children's behavior. They engaged in brief motivational interviewing about problem solving strategies and agreed to meet again, including with her children, next week. He also prescribed an NSAID for the headaches. Upon leaving, the patient looked visibly relieved.

Letrero Community

In collaboration with the mental health team, pasantes also treat patients with schizophrenia. Before CES began working in Chiapas, many patients with psychosis were confined to small rooms, or chained in their homes because families had no other options. The clinicians on the mental health team can now visit these patients in their homes and pasantes can provide oral and injectable antipsychotics. In one of our consults, woman in her late 20s with schizophrenia presented with her mother for a follow up visit. The patient wore dark sunglasses and spoke at length about her concern that there was a microchip implanted in her brain. Despite her delusions, she has been functioning at home and able to sell foods with her mother as part of their business. Her mother displayed a high level of understanding about the nature of her daughter's disease. The patient was moderately controlled on risperidone, and we made plans to coordinate with the mental health team’s psychiatrist for further titration of her medication. Many challenges remain, but the quality of life for patients with psychosis is generally improving.

Compañeros en Salud is now in the process of training mental health community health workers, called acompañantes, similar to their existing programs in chronic disease and maternal health. The acompañantes will receive a training course in recognizing mental health conditions, providing psychoeducation and talk therapy. They will also follow patients longitudinally who are being treated with pharmacotherapy by other members of the team. A large part of their role will be to help reduce stigma and increase education about mental illness in the community.

The process of building mental health capacity is ongoing, but there have been tremendous gains already. It has been a privilege to see the amazing work happening and to be part of the care of patients at the community clinics.