Kashmir Workshop Report

16.9.2013 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 FRCPsych
Dr. Sayed Aqeel Hussain MRCPsych
Dr. Sophia Thomson MRCPsych
Dr. Sally Browning MRCPsych
Dr. Jane Mounty MRCPsych
Dr. Sajad Yousuf MRCPsych
Dr. Eleni Palazidou MRCPsych
Week 2
Dr. Henrike Klasen MRCPsych Phd
Dr. Lucy Potter MRCPsych
Dr. Mina Bobdey MRCPsych
Dr. Sajad Yousuf MRCPsych
Dr.Sayed Aqeel Hussain MRCPsych

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

IG Intervention Guide
mhGAP Mental Health Gap Action Programme
mhGAP-IG Mental Health GAP Action Programme - Intervention Guide
MNS Mental, Neurological and Substance
NGO Non governmental organisation
PHC Primary Health Care
WHO 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 Care

DEP Depression
PSY Psychosis
EPI Epilepsy
DEV Developmental Disorders
BEH Behavioural Disorders
DEM Dementia
ALC Alcohol Use and Alcohol Use Disorders
DRU Drug Use and Drug Use Disorders
SUI Suicide and Self-Harm
BPD Bipolar Disorder
OTH Other Significant Emotional or Medically Unexplained Complaints
STR 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 Psychiatrist

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

Lead for Group -

Dr. Sayed Aqeel Hussain

Dr. Muzaffar Khan

Week 2

Dr Sayad Yousuf, MRCPsych – Consultant general adult psychiatrist

Dr Henrikje Klasen, MRCPsych, PhD – consultant child- and adolescent
psychiatrist, associate professor
Dr Mina Bobdey, MRCPsych, CSBM, DPM - Consultant Old age and Adult
psychiatrist
Dr 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 Yes
Dr. Sophie Thomson Adult Psychiatrist-UK 1 F Yes
Dr. Eleni Palazidou Adult Psychiatrist-UK 1 F
Dr. Jane Mounty Adult Psychiatrist-UK 1 F Yes
Dr. Henrike Klasen Child Psychiatrist-NL 2 F Yes
Dr. Sally Browning Adult Psychiatrist-UK 1 F Yes
Dr. Lucy Potter Adult Psychiatrist-UK 2 F Yes
Dr. Sajad Yousuf Adult Psychiatrist-UK 1,2 M Yes
Dr. Mina Bobdey Adult Psychiatrist-UK 2 F
Dr. 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 DOCTO STUDE PSYCHO SOCIAL OTHER

RS NTS LOGIST WORKER
64 42 41 4 9 4 SPEECH
participa MALE THERAPIST -1
nts 66% COUNSELLOR
22 -1
FEMALE HOMEOPATHY
34% CONSULTANT
-1

Week 2 Gender DOCTO TEACHE PSYCHO NURSE OTHER

RS RS LOGIST
46 13 9 7 2 19 LAWYER -1
participa MALE
nts 28%
33FEMA
LE
72%

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
components
4) Pre/Post test and Evaluation
5) Introduction to mhGAP
6) General Principles of Care
7) DEP
8) SUI
9) DEM
10) OTH
11) DRU
12) EPI
13) PSY
14) BEH/DEV
15) STR
 16) 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 1

Estimate 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 reported
PSY drugs 8 62%
EPI Drugs 5 38%
Other drugs 7 54%
No meds available 3 23%
Total commenting on drugs available at 13 13
PHC

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 MEAN PRE TEST POST TEST RANGE RANGE MEAN DIFF PRE
1 SCORE SCORE PRE POST AND POST
68% 84% 44-92% 68-96% + 16
WEEK
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 Excellen Good Satisfactor Poo Unsatisfactor Types of

t y r y teaching
Clinical 46% 44% 10% 0 0 x
relevanc
e
Structur 21% 75% 4% 0 0 X
e
Clarity of 77% 20% 0 0 0 x
Teaching
and
language
Overall 63% 32% 2% 0 0 X
score
Types of 88% Role-
teaching play
preferred 64% Group
work
62% Case
discussion
50%
Lecture
46% case
presentatio
n
Week 2
Clinical 40% 55% 5% 0 0 X
relevanc
e
Structur 45% 45% 9% 0 0 X
e
Clarity of 50% 43% 7% 0 0 x
Teaching
and
language
Overall 48% 52% 0 0 0 x
score
Types of 86% Role-
teaching play
preferred 60% Group
work
50%
Lecture
45% case
discussion
31% Case
presentatio
n
Overall
week 1
and
week 2
Clinical 43% 47.5 7.5% 0 0 X
relevanc %
e
Structur 33% 60% 6.5% 0 0 X
e
Clarity of 63.5% 31.5 3.5% 0 0 x
Teaching %
and
language
Overall 0 0 0 x
score
Types of 86% Role-
teaching play
preferred 60% Group
work
50%
Lecture
45% case
discussion
31% Case
presentatio
n

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 1
Group work 2
Case discussion 3
Lecture 4
Case 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 Hussain
October 2013