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Enhancing capacities of primary care physicians to tackle the rising burden of common mental disorders in India
Correspondence to RAKESH MEHRA; rakeshmehra13@gmail.com
[To cite: Mehra R, Vats S, Kumar A, Bhalla S. Enhancing capacities of primary care physicians to tackle the rising burden of common mental disorders in India. Natl Med J India 2025;38:181–6. DOI: 10.25259/NMJI_481_2022]
Abstract
Background
The scarcity of specialists to treat mental disorders in highly populated low and middle-income countries like India has always remained an important public health problem. Recently, a collaborative training model was developed to train primary care physicians (PCPs) for the management of mental disorders in India. We document the effectiveness of capacity building in enhancing PCPs knowledge, behaviour, and practice in managing common mental disorders.
Methods
We did a cross-sectional study across India from June to November 2020, utilizing both quantitative and qualitative data collection methods. The study tools and programme were designed and developed based on the Kirkpatrick model and Andragogy theory, respectively. A total of 143 enrolled PCPs were included in the study. The baseline-end of study, pre and post-intervention assessments, and the overall programme evaluation were done for knowledge, attitude, and practice (KAP). A paired sample t-test with p values was done to test the differences between baseline-end of study and pre and post-test values. In addition, the mean and standard deviation of the responses were calculated. Qualitative data and open-ended responses were analyzed using an inductive content analysis technique.
Results
The study showed a significant improvement in the KAP of trained physicians as measured by the post-intervention survey (p<0.05). This collaborative training intervention has a high potential for scaling up while optimally addressing the scarcity of trained mental health professionals in similar settings, such as India.
Conclusion
The collaborative training model showed notable improvements in the knowledge, attitude, and practices of primary care physicians when managing common mental disorders. These results emphasize the effectiveness and practicality of structured, theory-based training in enhancing mental health services at the primary care level. The model’s success suggests that it could be expanded and scaled up in other low-resource settings that face comparable workforce issues in mental health care.
INTRODUCTION
Mental health is a state of well-being in which an individual realizes their abilities, can cope with the normal stresses of life, can work productively, and are able to contribute to their community.1,2 However, in the past decade, there has been a 13% rise in mental health conditions and substance use disorders due to rapid sociodemographic changes.3 This poses a serious challenge to health systems, particularly in low-income and middle-income countries where 76%–85% of people with severe mental disorders are unable to receive treatment for their disorder.4
The burden of mental health problems in India is 2443 disability-adjusted life years/100 000 population.5 Although India launched the National Mental Health Programme in 1982,6 developed the Mental Health Policy in 20147 and replaced the Mental Health Act of 1987 with the rights-based Mental Healthcare Act in 2017,8 the contribution of mental disorders to the total disease burden almost doubled in India from 1990 to 2017.9 Poor implementation of mental health services, lack of evidence-based treatment, socioeconomic differentials and stigma are documented as major reasons for the rising burden of mental disorders in India.9,10
In addition, India faces a shortage of mental health personnel to deliver quality mental healthcare services. The Indian mental health workforce comprises 0.29 psychiatrists, 0.78 nurses, and 0.07 psychologists and social workers per 100 000 population, which is significantly lower than the global average.11 Therefore, an integrated approach is of paramount importance to manage patients with mental disorders in India.12–15 Task shifting and sharing with non-specialist primary care physicians (PCPs) can improve mental health services.16 However, even after providing training to PCPs, the quality of services provided by them remains suboptimal due to the perceived lack of competency in mental healthcare.16,17
Hence, it becomes imperative to train PCPs to scale up quality interventions for individuals with mental health conditions.18 We evaluated the usefulness of capacity building in improving PCPs’ knowledge, behaviour and practice for the management of common mental disorders.
METHODS
Description of programme
The Certificate Course in Common Mental Disorders (CCCMDs) was based on adult learning theory and aimed to enhance the knowledge, skills and core competencies of PCPs in the management of common mental disorders. The duration of the programme was 5 months, with one online contact session per month of an average duration of 5 hours. The pedagogy involved a mix of case studies, interim assignments, group discussions, and role-plays to accommodate participants’ queries. The programme was open to Indian nationals practicing in the healthcare setting, with a minimum qualification of MBBS and 3 years of clinical experience, or who had a recommendation from the centre faculty (where they would be enrolling for the course). The call for applications from eligible self-sponsored physicians, irrespective of their organizational affiliations and influences, was circulated through the social media platforms of Public Health Foundation of India (PHFI) without any incentive being paid to the participants. However, a fee of ₹10 000 was sought from each enrolling participant to ensure their adherence to the online sessions. The funding partner funded the operational and functional costs of rolling out the programme.
The course content was delivered by faculty from premier institutes in India, including the All India Institute of Medical Sciences, New Delhi; St. John’s Medical College, Bengaluru; R.G. Kar Medical College, Kolkata; and B.Y.L. Nair Ch. Hospital and T.N. Medical College, Mumbai. The participants were required to attend all 5 online contact sessions, submit the interim written assignments, and pass the exit examination with a minimum of 50% marks to receive the certificate of completion.
Evaluation model
The Kirkpatrick model is one of the widely used models to evaluate training programmes.19 The distinctive 4 levels of the model measure participants’ reaction to training, knowledge improvement, change in behaviour and outcome of the training. Hence, the Kirkpatrick model was used.
Study design
A repeated cross-sectional design is one of the most efficient methods for evaluating interventions.20 It provided an opportunity to collect responses at multiple points in time to assess the effectiveness of the intervention.
Study population
It consisted of 143 PCPs enrolled in CCCMD, Cycle I (from June to October 2020) and consisted of a mix of medical graduates (MBBS) and postgraduates from across the country.
The data were collected at different points in time using Google Forms after sharing the participant information sheet and receiving informed consent to participate in the study.
The data related to reaction, behaviour, and results were collected at the end of the training programme from 50% of the participants who successfully completed the programme. Simple random sampling was used to select the required sample. Subjects who participated in all 5 online sessions (including the pre-test and post-test of each module), appeared and cleared the final examination of CCCMD at the end of the course after Module 5 (minimum 50% score required to clear the examination) and submitted two interim assignments to the respective regional faculty were considered to have completed the programme.
Data collection tools
Data collection tools, comprising both open-ended and closed-ended questions, were developed by the programme implementation team under the guidance and supervision of experienced psychiatrists. The following tools were used for the data collection.
Baseline and end-of-study questionnaire.
These were developed to assess the participant’s knowledge regarding common mental disorders before and after the training programme. These consisted of 30 multiple-choice questions with only one correct answer. The baseline questionnaire was administered one month before the learning sessions and the sharing of reading materials in May 2020. The end-of-study questionnaire was administered after the completion of all learning sessions in November 2020.
This study tool captured the self-reported/self-perceived change in the practice (based on a 5-point Likert scale ranging from increased knowledge from 1 very low, 2 low, 3 neutral, 4 high and 5 very high) of participants before and after the training in terms of newly acquired knowledge when applied to their daily practice. This captured their improved knowledge and its application while managing depression and anxiety disorders, psychosomatic disorders and psychosis, alcohol and substance abuse, childhood mental and behaviour disorders, suicide and referrals.
Pre-test and post-test questionnaires. These were developed to assess the improvement in participants’ knowledge before and after every learning session. There were 5 sets of modules, each consisting of specific pre-test and post-test questionnaires, with 10 questions in each set. These were used just before and after every learning session from June to October 2020.
Participant exit interview questionnaire. This tool was developed to collect the participant’s responses to the overall programme and administered at the end of the training programme. It consisted of the following 5 parts: (i) participant information; (ii) reaction to a training programme; (iii) learning from the training programme; (iv) behaviour change due to training programme; and (v) result of training.
Data analysis
The data were stored and managed in Microsoft Excel 2013 and analyzed using the Statistical Package for the Social Sciences version 21. Cronbach’s alpha showed internal consistency and reliability of the Likert scales used in the tools (>0.86). Quantitative data were presented as summaries, including means and standard deviations for variables that are approximately normally distributed or medians and interquartile for skewed variables. Descriptive analysis was done with frequencies and percentages (mean and standard deviations), and for comparative tests, a t-test was used for data analysis. p value of 0.005 was considered of significance.
Qualitative data or open-ended responses were analyzed using the inductive content analysis technique. The transcripts were reviewed by two authors (RM and SV) multiple times to identify themes and categories. A coding framework was developed, and both authors coded the transcripts. The transcripts were reviewed again to identify any new codes that may have emerged and to update the coding frame. This process was used to develop categories, which were then conceptualized into broad themes after further discussion. The themes were categorized into four categories: actual implementation of new learnings, behaviour, practice, and sustainability of new learnings.
| Question | Correct response (%) | |
|---|---|---|
| Baseline (n=143) | End-of-study (n=122) | |
| Which of the following behaviour should the physician feel, warrant a mental health evaluation? | 72.0 | 82.8 |
| Mental Health necessarily consists of all except | 84.6 | 89.3 |
| People who are having severe depression are at most risk for which of the following? | 94.4 | 95.1 |
| Which of these is a common symptom of schizophrenia? | 74.8 | 88.5 |
| Which of the following is a common symptom of obsessive–compulsive disorder? | 79.7 | 81.1 |
| Men who have anxiety disorder have high risk of developing? | 48.3 | 56.6 |
| Delirium and seizures may occur during withdrawal from heavy, long-term use of which of the following substances? | 72.0 | 87.7 |
| Which of the following is the most common long-term course of dementia? | 86.0 | 88.5 |
| NDPS Act stands for | 93.7 | 98.4 |
| A man at a railway station is talking and laughing very loudly, donating money to many workers there and telling people he has been sent by God by special powers to heal everyone. He likely has which of the following? | 81.8 | 86.9 |
| People with severe mental health problems can fully recover | 59.4 | 72.1 |
| True about intellectual disability is | 49.7 | 74.6 |
| Common mental disorders include one of the following | 86.0 | 93.4 |
| Which of the following is not an antidepressant drug? | 88.1 | 95.1 |
| Psychosomatic disorders are | 31.5 | 54.9 |
| What disease arises due to the effects of chronic alcohol abuse and the damage that this causes to neurons and glia? | 81.1 | 95.9 |
| Parenting advice should avoid | 86.0 | 95.1 |
| Which of the following is a feature of all developmental disabilities? | 65.7 | 63.9 |
| Which of the following is a common reason why a woman with schizophrenia might not regularly take her medicine? | 90.2 | 91.0 |
| Which of the following are risk factors for childhood psychiatric disorders? | 96.5 | 97.5 |
| Cognitive triad for depression does not include | 83.9 | 95.1 |
| Comorbidity means | 92.3 | 97.5 |
| The role of primary care physicians in the treatment of mental illnesses in the community is | 95.8 | 94.3 |
| According to Global Burden of Diseases 2017 report, the third leading cause of disability globally is | 76.9 | 74.6 |
| False about primary health care is | 64.3 | 73.0 |
| False about prescribing anti-depressants is | 79.7 | 90.2 |
| True about post-partum depression is | 72.0 | 89.3 |
| False about the management of psychosomatic disorders is | 84.6 | 91.8 |
| True about substance-induced psychotic disorder is | 64.3 | 68.9 |
| True about autism is | 88.1 | 92.6 |
Ethics
The study received ethical clearance from the Institutional Ethical Committee of Public Health Foundation of India, New Delhi.
RESULTS
A total of 143 participants (male 76%) enrolled in the programme; however, only 132 attended the online contact sessions from June to October 2020. The average age of the participants was 44.5 years, with a median clinical experience of 16 years. A majority (65%) of the participants were graduates, while the remaining 35% held postgraduate qualifications. Around four-fifths of the participants were practicing in urban areas, while the remaining practiced in rural areas. The participants were affiliated with all types of sectors, i.e. private (70.6%), state government (17.6%), central government (4.6%), and others (7.2%). The median overall patient load was 300 patients per month, of which only 28 were patients suffering from any common mental disorder. The programme was completed by 131 participants who met all three eligibility criteria.
Baseline and end-of-study
The baseline and end-of-study responses were received from 143 and 122 participants, respectively. There were 30 questions in the baseline and end-of-study questionnaires. For every correct answer, 1 score was provided. Analysis showed that participants obtained an average baseline and end-of-study score of 23.2 and 25.6, respectively (Table 1).
Pre-test and post-test
The mean (SD) pre-test and post-test scores were 7.70 (1.79) and 8.54 (1.64), respectively. There was a significant (p<0.005) improvement in participants’ knowledge after individual training sessions (Table 2).
| Module | Mean (SD) | Percentage change | p value | |
|---|---|---|---|---|
| Pre-test score | Post-test score | |||
| Introduction to common mental disorders (n=140) | 8.1 (1.67) | 8.6 (1.66) | 6.2 | <0.001 |
| Depression, anxiety disorders and suicide (n=136) | 7.9 (2.12) | 8.9 (1.36) | 12.7 | <0.001 |
| Psychosomatic disorders, neurocognitive disorders and psychosis (n=132) | 8.00 (1.48) | 8.5 (1.62) | 6.3 | <0.001 |
| Alcohol and other substance use disorders (n=132) | 6.8 (1.72) | 8.00 (1.81) | 17.6 | <0.001 |
| Childhood mental and behavioural disorders, national policies and programmes and long-term mental health care (n=132) | 7.7 (1.58) | 8.8 (1.62) | 14.3 | <0.001 |
Participants exit interview
The exit interview questionnaire was shared with 50% (66) of participants who had completed the training programme; 60 participants (male 71%) responded to the exit interview.
Reaction. More than 83% and 85% of the participants responded that the training content and quality, respectively met their expectations (Fig 1). Eighty-eight per cent (88%) of the participants found the teaching methodology in the training programme useful (Fig 2). The majority of participants rated the faculty as very good (Fig 3).
- Participants’ reaction to training: whether they found the training relevant to their current role and practice, whether it met their expectation from the course, whether the trainer’s expertise met their expectation, whether there was quality delivery of the programme or not
- Participants’ reaction to curriculum of training: Towards the teaching methodology adopted in imparting the training, the content of the training such as PowerPoint presentations used, case studies and role-plays
- Participants’ reaction to trainer: whether the trainer’s knowledge and teaching methodology was effective and efficient as per their expectation
Learning. The average perceived knowledge score before and after the training was 2.3 and 3.8, respectively (p<0.005; Table 3). In addition, the average perceived practice score before and after the training was 2.1 and 3.6, respectively. A significant improvement (p<0.005) was recorded in all common mental disorders, namely depression, anxiety disorders, psycho-somatic disorders, psychosis, alcohol, and substance use disorders, childhood mental/behaviour disorders, and suicides (Table 4).
| Knowledge | Before | After | Difference | p value |
|---|---|---|---|---|
| Epidemiology of common mental disorders | 2.5 | 3.9 | 1.4 | <0.001 |
| Diagnosis and investigations of common mental disorders | 2.3 | 3.7 | 1.5 | <0.001 |
| Programme and policies of common mental disorders | 2.1 | 3.7 | 1.6 | <0.001 |
| Practice | Before | After | Difference | p value |
|---|---|---|---|---|
| Management of depression and anxiety disorders | 2.2 | 3.7 | 1.5 | <0.001 |
| Management of psycho-somatic disorder and psychosis | 2.1 | 3.6 | 1.5 | <0.001 |
| Management of alcohol and substance abuse | 2.2 | 3.6 | 1.4 | <0.001 |
| Management of childhood mental/behaviour disorders | 1.9 | 3.5 | 1.6 | <0.001 |
| Management of suicide | 2.0 | 3.5 | 1.5 | <0.001 |
| Referral of cases | 2.4 | 3.5 | 1.1 | <0.001 |
In response to a question, participants were asked to share one case they had managed because of this training programme. A total of 78.3% shared their experiences about how this programme helped them to manage common mental disorders in their daily practice. Following were some of the verbatim statements depicting a positive impact of training on a majority of participants’ practice
‘I (participant no 9) managed a case of somatoform disorder., when patient, a young female fell down suddenly and became nonresponsive. Her vitals and glucose were normal and on giving a painful stimulus she opened her eyes and gradually came back to normal’
‘(Participant no 15) Managed a 60-year-old female patient who was diagnosed to have generalized anxiety disorder. There was a definite improvement on the next visit within a week and follow up will continue for next 6 months’
While most of the participants shared that they were able to counsel and treat patients suffering from common mental disorders, some participants opined that now, they were able to do initial diagnosis and investigations of such patients and refer them for proper care. On the other hand, few stated that it is too early to notice any change in their practice.
‘I (participant no 16) was able to diagnose and refer a case of depression to the psychiatrist early’
‘It’s early to say but very useful in clinical practice (participant no 42)’
Behaviour. In response to questions related to the assessment of change in behaviour, 80% of participants agreed that after attending the programme, they are able and confident in sharing the new knowledge and skill with other people and colleagues. In addition, 5% stated that they have not yet started sharing the new learning and others did not respond to the question.
‘Now I (participant no 17) can let other Primary Health Carers to [know] a basic understanding of diagnosis and management of common mental disorders’
‘I (participant no 31) discussed my acquired knowledge with my fellow doctors and they also find it very interesting. We had very healthy discussion’
‘By gaining additional knowledge we (participant no 32) can counsel better with our patients and discuss better with our colleagues’
Furthermore, the majority of participants (85%) opined that the new knowledge gained during training was sustainable and/or can be made sustainable with some continuous learning efforts. However, 1 of 60 participants opined that the knowledge gained from the training programme could not be sustainable and others (8) did not respond to the question. ‘I (participant no 9) hope it will help if put into regular practice because now a days a majority of population are suffering from the common mental disorders the course covered. Specially the adolescent mental health’
‘I (participant no 18) got a good insight into mental disorders, may not start treating them but this knowledge would help me in early diagnosis and referral to the psychiatrist’
Nearly 50% of participants stated that they noticed an increase in the number of patients suffering from common mental disorders in their daily clinical practice, while others opined that it is too early to notice any change in their practice related to common mental disorders.
‘Due to gained knowledge about MH disorders I (participant no 15) am able to recognize more cases’
‘As I (participant no 59) started discussing, counselling and started treating the mental disorders which I was not doing before there is a mild increase in the patients with mental disorders. Hoping for a further more increase’
Moreover, participants provided an overall rating of 8.4 out of 10 for the whole training programme. In addition, 90% of participants agreed that they would like to undergo a similar training programme in the future, whereas 0.7% were unsure and 0.3% clearly did not wish to attending any such programme in the future.
DISCUSSION
This is a unique evaluation that meticulously recorded the changes in knowledge, behaviour, and practices of the participants before, during, and after the programme. It revealed that the pre-training knowledge and behaviour of participants toward common mental disorders were relatively low. It supports the finding that local health professionals need to be trained for early detection and management of common mental disorders,21 in resource and expert constrained settings.
The participants showed significant improvement in the baseline and end of study evaluations, as well as in the pre- and post-test evaluations, after each training session. There was a self-perceived change in the practice of enrolled participants after the training, with a significantly improved average perceived practice score (p<0.05) before and after the training. Similarly, the greatest improvement was observed in participants’ perceived knowledge of common mental disorders before and after training (p<0.005). These findings are in line with other similar studies done in Nigeria,22 Ethiopia23 and other countries.24,25
The result indicates a significant improvement in knowledge of trained physicians in most common mental disorders such as depression, anxiety disorders, psycho-somatic disorders, psychosis, alcohol and substance use disorders, childhood mental/behaviour disorders, and suicides, where the most prominent improvement was recorded in management of childhood mental disorders and behavioural disorders.
We also found that the knowledge gained from the training programme is sustainable and/or can be made sustainable with some ongoing learning efforts. Consistent with the findings, this evaluation study indicates that training has a significant impact and is vital for training practicing PCPs with continued medical education to achieve the success of integrated treatment and management of common mental disorders within existing general healthcare services.26
Conclusion
The learning from this training programme can be used in the development and implementation of similar programmes in other low-income and middle-income countries that face an alarming burden of common mental disorders and a shortage of trained physicians. This collaborative training intervention has a high potential for scaling up while optimally addressing the scarcity of trained mental health professionals in high population density settings such as India. This can prove to be a sustainable model while strengthening the linkages between the community and existing government programmes.
ACKNOWLEDGEMENTS
We wish to acknowledge the help and support extended by the other partner organizations in this training initiative, Association of Healthcare Providers-India, for being the strategic partner and The Live Love Laugh Foundation, for being the funding and the knowledge partner.
Conflicts of interest
None declared
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