Massachusetts General Hospital Vincent Program in Global OB/GYN
Perinatal anxiety and depression are more common among women living in low- and middle-income countries (LMICs) than among women in high-income countries, and untreated perinatal depression has particularly high public health impact in LMICs. Perinatal depression increases the risk of obstetric complications, morbidity, and mortality; in infants, perinatal depression is associated with low birth weight and poor growth outcomes during the first year of life. Treating depression among pregnant and postpartum women in LMICs is complicated by a number of factors, which may include a shortage of clinicians, lack of specialized mental health training for those clinicians, and high levels of societal stigma around mental health conditions. In this issue of our Global OB-GYN newsletter, Dr. Paudel, a psychiatrist and global health expert, describes his experience providing maternal mental health services in Nepal, where maternal suicide rates are high and access to mental health care is limited. Here, he offers the case of a 19-year-old pregnant women with severe depression and no access to prenatal care or mental health services. As co-founder and director of the Health Nepal Foundation, Dr. Paudel continuously confronts the challenges of community-based mental health treatment in a resource-limited setting, highlighting his commitment to serve vulnerable women in this region.
- Amelia M. Stanton, Ph.D., Clinical Research Fellow
-Christina Psaros, Ph.D., Associate Director
Behavioral Medicine Program, MGH Department of Psychiatry
Notes from the Field
Addressing Maternal Mental Illness in Rural Nepal by Shreedhar Paudel, MD, MPH
Pic: Community-level mental health education to pregnant and postpartum mothers, Dang, Nepal
Pic: Home visit by a psychosocial counselor, Dang, Nepal
Mental health is a neglected field of medicine with limited financial, technical and human resources in Nepal, where more than 90% of people with mental illnesses either do not seek or have access to much needed mental health services. National mental health data is limited but according to the World Health Organization, Nepal has one of the most alarming suicide rates in the world. Recognizing the severity of mental health challenges in Nepal, Health Foundation Nepal (HFN), a non-profit organization based in the United States and Nepal, has been implementing an innovative maternal mental health program in rural Nepal since February 2019. As co-founder and founding executive director of HFN and a practicing psychiatrist at Massachusetts General Hospital (MGH), mental health in Nepal was one of my top priority projects. I currently direct mental health projects in Nepal on behalf of both HFN and MGH Global Psychiatry. HFN mental health team is comprised of psychosocial counselors (PSC) working in the field; a medical officer to PSCs; and volunteer psychologists and psychiatrists from Kathmandu and the United States to supervise and monitor the program. PSCs coordinate with local stakeholders to identify pregnant and postpartum mothers in each community, covering a population of about 35,000 in the Dang district of Nepal. We organize maternal outreach clinics and evaluate and treat pregnant and postpartum mothers with depression and anxiety. We use the Nepali version of PHQ-9 and GAD-7 screening tools to screen and follow up for depression and anxiety.
Our PSCs conduct home visits to provide services to mothers who are unable to come to the outreach clinic for various reasons. All HFN staffs follow a standard treatment protocol. High-risk mothers with suicidal tendencies are referred to a nearby teaching hospital in Nepalgunj, about four hours bus ride from our project site. Mothers with severe depression or anxiety are followed at home on a weekly basis and are referred to medical officers trained in mental health. Similarly, those with moderate and mild depression or anxiety are followed by PSCs at home on a biweekly and monthly basis respectively. During the follow-up home visits, PSCs provide tailored psychosocial counseling to mothers. Additionally, HFN organizes mental health awareness programs in communities, targeting the general population and school children, to minimize stigmas associated with mental illness. As of March 2020, we have screened 671 mothers (539 post-partum and 132 pregnant cases) and have been treating and following all mothers with any form of mental illness.
From Boston, I volunteer to provide mental health training and teleconsultation to the medical officer and PSCs on a regular basis. I also conduct weekly meetings with HFN mental health teams to supervise and ensure the appropriate implementation of projects. Our innovative mental health program has had a significant impact on the health of vulnerable mothers and their babies in rural Nepal. This community-based low-cost maternal mental health program has been well received by local communities and is universally available to all pregnant and postpartum mothers in our project sites.
A PSC from Saudiyar, Dang, one of our project sites in Nepal, presented a case to me in March 2019. During her home visit, a 19-year-old pregnant mother was found to be severely depressed. Her husband had been working in India, and she lived with her in-laws. She neither knew her expected date of delivery nor had had any antenatal visits. Due to the widespread stigma around mental illness, her in-laws concealed her mental health issues instead of seeking medical help. Her predicament was worsened by the fact that the entire district did not have a psychiatrist and the family lacked financial resources to consult a psychiatrist in a nearby mental health facility. After learning about her case, I requested a medical officer to visit the patient for further evaluation, where she was found nearly catatonic. With HFN’s financial support, we arranged for vital treatment to be provided at a teaching hospital in Kathmandu. However, because her in-laws could not accompany her for treatment and she was uncomfortable traveling to Kathmandu by herself, we arranged a supply of anti-depressants and weekly home visits by a PSC for her. After three months of home-based treatment, I received a field report on her recovery along with a smiling picture of her and a healthy baby. The report gave me a deep sense of fulfillment and joy.
Working in the realm of global health comes with all kinds of challenges and can sometimes be uncomfortable. The realization that our small efforts, collectively, can change the world of those in need maintains my motivation to continue this work. By engaging in global health work, we not only help vulnerable populations but also feed our own soul with a sense of gratification. For me, global health work is the social responsibility of every privileged global citizen.
Author's biography: Dr. Shreedhar Paudel is a psychiatrist and global health expert by training, a faculty at Harvard Medical School and works primarily at Massachusetts General Hospital (MGH) in Boston. He also serves as a Senior Advisor to the Chester M. Pierce, MD Division of Global Psychiatry and Director of the Division’s global mental health projects in Nepal. He is also a co-founder and the director of Health Foundation Nepal’s global mental health efforts.
Dr. Paudel is a medical graduate from Tribhuvan University, Nepal and completed his MPH in global health from Mount Sinai School of Medicine, New York. He served as a clinical instructor at Taishan Medical University, China and instructed clinical epidemiology at Mount Sinai School of Medicine before joining residency training in psychiatry at Berkshire Medical Center in Pittsfield, MA. His research and publications have been mostly on antipsychotic polypharmacy, shared decision making, quality of life and cognitive function among people with schizophrenia and community psychiatry. A graduate of MGH’s community and public psychiatry fellowship, Dr. Paudel joined the MGH Department of Psychiatry in 2018.
May 12, 2020: As violence against women and other vulnerable groups persists and escalates, we must remember, educate, and work to prevent future attacks. “They came to kill mothers” Gunmen murdered 15 mothers, 2 children, and one midwife at a Kabul Maternity Hospital." https://time.com/5838762/afghan-maternity-ward-attack-women/
George Floyd (October 14, 1973 – May 25, 2020):
"Law and order exist for the purpose of establishing justice and when they fail in this purpose they become the dangerously structured dams that block the flow of social progress." “Injustice anywhere is a threat to justice everywhere.” - Martin Luther King Jr.
The symposium for Gender-Based Violence in Disasters and Humanitarian Settings, initially planned to be held on June 9, 2020, has been postponed due to the ongoing COVID-19 pandemic. The new date for the event is to be determined.
Due to the ongoing COVID-19 pandemic, the International Gynecologic Oncology Observership offered at Massachusetts General Hospital has been suspended at least until December 31, 2020.
International Gynecologic Cancer Society holds monthly gynecologic oncology tumor board meetings including gynecologic oncologists and GYN-ONC trainees all over the globe. Interested fellows and residents, please email Thomas Randall (firstname.lastname@example.org) or Ak Goodman (email@example.com).