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Thank you so much for the invitation and chance to speak, I'm not going to speak about the act.

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I'm here to speak about another programme that we we run.

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It's called Murtha, and the word Murtha in many Indian languages means empathy.

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And it's a programme that we've developed over the last five to six years with

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a lot of formative work that went on before what I'm going to present to you,

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which which appears like a fully formed programme.

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But there's a whole host of work in terms of formative work in designing it that went on many years prior to that.

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Before I start, I just want to thank our funders,

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which was the Grand Challenges Canada and Marijuana Health Initiative, which continue to fund our programme.

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The purpose behind me really is is multiple.

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One is to move away and shift the paradigm of mental health, you know, to what we call what we like to call as democratising mental health.

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We want to get away from a notion of mental health as being a health and an illness condition,

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but much more something that affects all parts of your life and which needs to be integrated into an entire whole,

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as opposed to be seen as something to be dealt by professionals alone.

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The second thing that we wanted to do is we realise, as L.A. docs showed you,

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that there's a lot of social capital in our communities and we want to tap into that social capital.

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You know, there's always this notion that government should provide things or where will the money come from?

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But there's actually a lot of social capital which we could tap in very easily.

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We don't use any mental health metaphors in our in our programmes, as you will see, actually, I mean,

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although I've said community led mental health initiative, that's the description we use when talking to professionals.

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What we call it is something about promoting wellness and reducing distress on our programme

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does not actually have anywhere in the entire thing on mental health that talks about distress.

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It talks about stress. We use a lot of local metaphors, so people use metaphors like tension.

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So we say, Look, we here, the programme will help you deal with tension. It will help you deal with stress.

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It helps you deal with day-to-day issues. It's not a mental health programme.

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And you know, the most important thing is that this whole programme has a certain degree of community ownership.

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So we work with Village Council to juggle budgets. We get into a village, we talk to the village franchise, we get them involved,

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and we use their help in identifying volunteers within the programme within how we start work.

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So. So who? Who delivers what we do? This is what we call them champions.

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And this is one of our champions. McSwain, who lives in a village in Maisano district, is as many of our champions are not very highly educated.

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She I think she was educated about eight standard and her husband supports her work.

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What she does. All of our champions are volunteers. So nobody gets paid for doing the work.

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They they they work about roughly two hours a day,

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and that's about the work they do for the programme and the rest of the time they do other things in their lives,

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which is what might be farming their rural communities.

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So there's a lot of farming activity, people out, household work to do, and they do all of that.

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And in addition, they'll probably do eight to 10 hours of work for the programme.

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And McSwain always says that it's given her a chance to help her village and made her a very confident woman.

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This is very interesting because when we first tried to talk to McSwain, she wouldn't talk to us like us.

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I'd be photographs. She wouldn't even allow us to talk to us without kind of looking away from us.

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And then over a period of time, she's now become confident enough to stand there and be photographed for this particular picture.

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So what do we cover? We cover about we cover our district called Manzanar, which is in in Gujarat,

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very close to the border, then Gandhinagar, which is way the state capital is.

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It's a district with about two million population, of which about one and a half million is rural population.

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And in that one and a half million, it's a one to one million adult population.

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So that's the population we cover. There are four hundred and fifty two villages and our programme is being scaled up.

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So at the moment we reach about 450 villages.

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By the end of the year, we will probably have covered every single village, so we will have some service that we provide in every single village.

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We currently have about six hundred and fifteen champions and the number will go up to about 800 to 900 by the end of the year.

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So this is a programme which runs at scale to answer, perhaps question what happens when you try to run programmes at scale?

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Are they sustainable? Can they continue and do they actually deliver what they promise to deliver?

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So what? What champions do? We don't see them as non-specialist health workers.

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As I said, we try to get out of this health worker health domain.

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So one of the things they do is if they identify people who have a common mental health problem,

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which is our which is me trying to explain to you a common mental disorder.

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That's not how they see it. They see it as a certain set of symptoms.

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They will provide them with four to six sessions of counselling if they saw somebody who had what is called as a very severe mental health problem,

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which would be something like psychosis or bipolar disorder.

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They will then make a referral to them to the psychiatric services of this district, and they normally make that effort to actually accompany them.

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They go with them, they help them navigate the health system. They will ensure the follow up happens with them.

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The third thing that they do is they they try to increase awareness in the community around stress and mental health issues by showing films.

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We give these champions a mobile phone, which is like a, you know, a smartphone like this, which has four films loaded on it.

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And these films are not about mental illnesses. They are about what we call antecedents of mental illnesses.

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So they are friends on unemployment. They are a film on marital discord.

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There's a film on interpersonal violence, and there is a film on alcohol use and its effects on the family.

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And these are 10 minute films.

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We designed them using a director from Bollywood, and so they are designed and are going to Bollywood style, song and dance.

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They're not documentaries. They don't try to preach to you. They tell you a story.

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They're meant to be interesting. They're meant to be fun. And these films are only 10 minutes long.

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I mean, you can go on Google and check them up. They're they're on YouTube.

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The films are loaded on YouTube. They are. They've also been.

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Subtitled in English for you to understand if you wish, but we use them, and they were developed after a lot of field testing,

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piloting and informative work that went into it and they tell a story, and the films are meant to be shown to small groups of four or five people.

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So you know what? A champion will collect four or five people, and we call it, we don't call it broadcasting.

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We call it narrowcasting. So we're not trying to broadcast. We won't actually do narrowcasting, have four or five people sit there.

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Every film will stop it. Every two minutes, it'll pause at two minutes automatically.

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The champions will ask questions, will raise a discussion and the idea is to be not a passive observer of a film,

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but to get actively involved in understanding what happens.

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And and that actually provides a lot of help to our champions to identify people in the village who might need help.

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Somebody says, Well, you know, my neighbour, she's got the same problem as this film is showing, and then they kind of approach that person.

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The other important thing that our champion does is that they enable access to social benefits.

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So the whole bunch of social benefits that the Indian government offers widows, pensions, disability, pensions,

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all sorts of things which are impossible to access because getting access to those pensions are getting access to those benefits requires paperwork,

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which is very difficult to navigate. I mean, if you ever go down there, you realise how hard it is to actually get the paperwork ready.

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Champions have an app which is on their mobile phone, which if they enter some details about you into it,

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the app will tell them which benefits you might be entitled to.

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And they are trained in how to fill up the forms so that for all these benefits,

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they'll take the forms and get you to fill up and they'll go and submit the collector's office.

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Most of the time,

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you need to submit something in the collector's office and then chase it up with the collector's office to ensure that that benefit is delivered.

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So they do a lot of social care, not just health care.

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And finally, they use a smartphone to document their work.

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So, you know, they kind of put in how many people they've seen when they've seen, who they've seen, who they worked with.

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And what are these sessions, these sessions, largely the six sessions of counselling that they do, are largely based on three techniques.

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They're based on active listening problem-solving techniques and behavioural activation, again,

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stuff that has been shown to be effective in research studies and that there's a structure of these sessions.

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It's important to understand that these sessions are not delivered in a clinical setting.

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They are delivered in the community very often at the person's home,

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sometimes in public areas like I remember this champion telling us which I thought a very fascinating.

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She said that she delivered one of the session to this woman while women, while they were both at the, well, getting some water.

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And she said, I sat her down and we had a 20 25 minute session and it worked very well.

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So, you know, they're delivered at different places that deliver what people want.

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People say I would rather come to a place, not be at home than fine. That's equally OK.

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And they deliver five to six such sessions, it doesn't stop them from doing more, but we tell them to try and keep it time limited.

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And these champions receive about seven days of training. It's around thirty five hours of training that they receive.

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The training again again has been developed with a lot of formative work which went in.

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So our training is called animation training. We don't have any lectures.

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We don't have any PowerPoints, and everything is done in the form of the entire.

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Training is done in the form of a rule play because many of our champions are not literate, you know, and they're not sat in the classroom.

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So if you did a forty five minute lecture for them, there's no way we're going to get their attention. So a lot of it is role play.

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A lot of it is about working out scenarios and how will you deal with them?

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What will you do? There's a lot of observational learning that happens, and usually the training is divided over two days at a time.

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We do it over three weeks. It's only seven days, but it's not seven days in a row.

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We find that our champions will not take that in if we try to do it all at seven days and then they get a refresher training every six months.

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So they come back in for a day and we do some refresher training on what they are up to and how they can address specific issues.

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And this is how the whole structure of the programme is organised.

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So there's a project manager for a district who is up, who is an employed professional.

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So we pay for them. They are on a salary. There are community facilitators and the community facilitators tend to be young people from within the

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district who might have a social work background or a bachelor's in social work or a psychology bachelor's.

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But people who live within that community. And again, they are paid a salary.

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So these are the two paid kind of people in the programme.

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The champions are the ones who actually deliver the programme and they are volunteers.

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And there's also some another level called Mitra. And I'll explain to you what Mithras mean in the context in Gujarat.

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But they don't do. They don't do a lot other than help the champions identify people who might be in need of treatment.

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The reason why we did this innovation in Gujarat is because we found that in places like in Gujarat,

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in the villages, the villages are divided by cost and religion very actively so that in a village of two thousand,

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if I champion came from a particular caste, they would have actually never visited the other part of the village where some other caste,

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which is amazing, but it's only a village of two thousand people. And so these metros tend to be from other parts of the village where they may

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not have access to and so they can do a full coverage of the entire village.

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So that's how the whole thing is organised and we do kind of track our champions progress.

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So what I forgot to tell you is that the community facilitators meet with the champions every hour,

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every fortnight, and they provide them with mentoring and supervision.

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So they will actually say, OK, what are you? What are you working with? What are you doing?

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Are you stuck somewhere? Where are the issues? OK, you have a problem. Maybe I'll come with you and see how we can solve it.

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So sometimes this was a modelling of treatment that is done by the facilitators.

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And obviously, this is how it will go as we we find that it takes our champions at least three to four

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months before they feel confident enough to start dealing with things on their own.

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So they get training. Then they have a bit of a hand-holding phase when the facilitators work with them to get them ready to work with other people.

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And then we kind of monitor how well they are doing.

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There are times when we ask people to leave, when we say, Look, we don't think are really suited for this,

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and maybe you should not continue work and we actually ask them to go because we don't think they're doing the kind of stuff we would want them to do.

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You would ask me what the attrition, because I think this is a volunteer driven programme, what's your attrition rate?

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Our attrition rate across the last 12 months is about 20 percent, and the largest chunk of the attrition actually happens after phase one.

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When the training is over, many people take the training and then they decide this is not actually what I wanted to do.

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So you get the biggest chunk of attrition there.

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You don't get much attrition afterwards and then you get an attrition towards the end after a year when people say, Look,

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I've done my bit for society, I want to do something different or many of them have even gone on to do other things.

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So like one of our champions at the end of the year, stood for elections to the local Punjab and became the Punjab chief and said,

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Now I can't do this, I've got more important things to do and so quit doing our work.

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But interestingly, then allocated twenty thousand rupees in her village for this work because she

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was now the person who was in control of the finances at the at the Punjab.

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So people do all sorts of interesting stuff. In the last hour, this is nine months of data which I've got here for you.

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We reached out to about 9000 beneficiaries who have received counselling sessions, so that's and we expect to end the year with around 12000.

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Hopefully by next year will be reaching around 15 to 20000 people.

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That's about on an average of five sessions, so that's close to about 50000 sessions that have been delivered in the last one year.

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Around 2000 people with severe mental disorders have been linked in with the psychiatric

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service and maintained in the psychiatric service for follow up for treatment.

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About 4000 people have received various kinds of social benefits, and around 45000 people have viewed these films that we have.

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And this is again, this is like an ongoing thing.

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So if I meet you after three months, these numbers will change because we continue to roll out and scale it up.

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So you're going to see all of this is wonderful and nice, but where is the evidence that any of this works?

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I mean, that's usually the thing. This is all wonderful. Nice thing.

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Everyone feels good. Touchy feely stuff. Where is the evidence at work?

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So I'm we actually. We actually did do. And this is something that we are interested in.

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So we actually did do a proper control evaluation of what we were doing.

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And I'm going to show you some results now. They're hot off the press.

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The reason I say hot of the press, as in because are Sturbridge trial, which I'm going to talk to you or just ended in September.

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So I only got hold of the results now. So I would request you to not either put these results that I'm going to show you in the public domain

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because the paper is getting prepared and we'll be ready and published in the next month or two,

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hopefully. So what did we do?

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Most of the research that you've seen up to now were largely the research studies.

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So, you know, if you go back to any of those studies that I've showed you about,

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these programmes no longer exist, then our programmes, which continue to run, they were set up for a trial.

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When the trial ends, they finish.

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And as I've said, many of the things that were run by people who who are very motivated and it was about doing a trial.

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Whereas what you have here is a real life programme which continues to run,

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and the research has been kind of mounted on top of that real life programme.

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So it's kind of doing it in the reverse order. So you have a programme and you evaluate an existing programme and kind of tries to

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answer what Lakshmi was asking about what happens to programmes that you do run.

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And so we used a step wedge cluster, randomised controlled trial design.

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I won't get into the details of it, but this is a design which is well suited when you're trying to evaluate an implementation research design,

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when you're trying to evaluate at scale programmes in real life settings.

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And basically, what happens is that every cluster acts as its own control.

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And by the time you finish the entire trial, you actually provided the service to everybody.

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So ethically also, it tends to be good because the control also get the service that you're going to deliver.

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And you're not just walking out without delivering the service to the control, especially with an effective service.

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What we had was we looked for use GHQ 12, and the primary outcome was improvement on GHQ 12, and there's a whole host of secondary outcomes.

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In particular, we are interested in outcomes such as increased social participation, satisfaction reduction and disability.

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And that's a whole whole list of secondary outcomes of the trial.

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Had the trials been registered with the trial registry of India and the question of enhanced use.

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You know, the usual care, what is usual care.

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And we said in the control group, people would get enhanced, usually get an order, then horns usually cleared.

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Anyone who met our criteria for being what GHQ calls case, which is a terrible term.

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But that's how GHQ called it a case. They would explain the effects of stress and courage to seek help and provided handouts

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on how to access mental health services and also ask about utilisation of services.

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Again, because this is a real life trial, we were not interested in controlling usual care because if you do that,

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then you're back to the old research design. So I know I have five minutes.

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I'm going to quickly run you through this. I'm going to highlight a couple of points.

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The first is that although we use a GHQ cut-off of three, which is what is used to indicate common mental disorders in community settings,

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the average scores, as you can see, are above six both in the control and the intervention side, and six is usually a clinical score.

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OK, if you went to a clinic, people coming to a mental health clinic and if you did get scores on them,

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people about six are most likely to have a common mental disorder. So, you know, you're you're looking at people who, even by clinic standards,

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would have met a condition to be called as having a mental health condition.

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The GHQ score is interesting because the scores of 12 to 14 are in the range of what is called as moderate depression.

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So these are people who if you normally just saw them with a Q and rated them, they would have scored a moderate depression.

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The of the two standard treatment for moderate depression is therapy or antidepressant.

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So these are people who would have otherwise qualified to receive therapy or antidepressants.

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The G8 the G8 scores are also in the moderate anxiety score level.

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So what did we find at the end of three months? I'm not, I know I have a little time and I can talk about the trial in long detail.

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But what do you find at the end of three months is that people who have recovered in in are people who received the intervention.

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The likelihood of recovering the odds ratios are two point three at the end of three months.

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OK, so that 2.3 times more likely to have recovered from this common mental disorder.

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And at the end of eight months, which is very interesting because we did an eight month follow up to see four,

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we were looking for sustainability of improvement, but what we found is actually an even further increase.

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I know the kind of confidence intervals are large and all of that stuff, but there's actually an increase at the end of eight months.

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If nothing else, at least these improvements tend to be sustained.

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So if people get better, they not only get better, they remain better at the end of eight months.

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And all of our continuous measures assure improvement at both three months and eight months,

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and as you can see it, eight months, even the quality of life measures have started to improve,

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which you don't see that quite the social participation measures which are not so good at three months start to improve at the end of five months,

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eight months and even the disability scores have started to improve.

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So. So not only is improvement getting sustained,

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but you're now seeing and this is something we anticipated that social participation and disability improvements will have a lag.

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People get better and it takes time before they get better, then start actually being more functional.

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And so after a lag of eight months, you start seeing people getting better like that.

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And I know you kind of going to say, OK, this sounds all very good, but look what it what does it say?

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As compared to other studies, Friendship Bench uses a very similar structure to ours and band uses badly health workers.

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We don't use paid health workers, and these are some of their findings from their study.

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Again, they did a very standard, randomised controlled trial with health workers who were trained and paid.

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But if you look at the kind of improvement and if we look at our improvements at the end of eight months,

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we have very similar kind of rates of improvement. These are adjusted mean differences at the end of eight months.

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And then this is the one which I like most, which is if you look at it,

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if you compare it to antidepressant studies because everyone thinks that antidepressants are the gold standard for treating depression.

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Well, the odds ratios for antidepressant studies range anywhere from one point three to two point one one three or two point two.

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We got an odds ratio of two point three. And if you think, Oh, this is carrying it too far,

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then I think you need to really question yourself about what your beliefs about mental illnesses and antidepressant treatments and all are.

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I think there's a lot of bias in our own minds about how we conceptualise depression and its treatment.

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You know, I mean, difference on IQ scores is about one point nine points, and B HQ nine has a smaller range.

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It's a zero to seven range. If you look at the antidepressant scores on the diet as the main differences are one point ninety seven,

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and that's a scale with a range of fifty seven points.

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So in a fifty seven point scale, you get a two point change on a twenty seven point scale, you get a two point change.

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I believe we're doing far better or our champions are doing far, far better than even antidepressants would do.

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And our effect sizes range from point three two point four, which is similar to what you get the effect sizes with antidepressants.

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So how good are people at identifying people with common mental disorders?

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And this is just a number to remember about 60 percent of the times they got it right.

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If you took a standard measure, 60 percent of the times the standard clinical measure versus the R ID turned out to be right.

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We I don't have a data on sensitivity because we didn't structure the trial for sensitivity.

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We were interested in specificity.

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Health care utilisation, as you can see, there's very little health care utilisation on the on our intervention group,

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whereas on the control group, what you see is that there's a lot of effort is being made, but people don't go for treatment.

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Got one minute and two more slides to get through these two slides are about what are health economics?

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She told me. So I'm not very knowledgeable, but basically what our health economics said was if you look at the total savings,

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which in savings to community savings, to individual savings to society and savings to government.

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If you add up the total savings, then it adds up to what, forty five thousand rupees?

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This is because of the less number of health care visits that you make, the the cost of OPD visits and all of that included together.

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And those are people that we are now getting ready on the economic impact.

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The other financial impact that we looked for in expenditure per household.

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And as you can see that there's a huge amount of borrowing that are people who are not receiving treatment were doing for health care costs.

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So people who are borrowing money to receive health care when they have some common mental disorder,

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then very often these people are not identified as having a common mental disorder.

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They go to a physician who orders lots of tests to give them some medicines, not necessarily receiving anti-depressants.

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So there's a lot of challenges in how you do this and how do you sustain it?

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We've now got funding from Marijuana Health Initiative to continue this for three more years, so we've got funding.

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We will cover the whole district in three years.

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We're now trying out our social franchising model, so we've tied up with the Maharashtra government agency, which is a neighbouring state,

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to make this into a social franchise, which they could then implement, and we would actually monitor and provide evaluation on.

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We are modifying it to use with young people. So we are working with two or large universities in Pune to try and modify this whole

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thing so that it would be used in the college for young people within their own settings.

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And finally, what we don't do very well is dealing with interpersonal violence or domestic violence,

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and that's something that we are now planning to build more work on and try and do better.

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We are also hoping we are also hoping to do a bit more graphic work on trying to understand the

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context of how these people actually are effective because their effective is still a black box.

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What we don't know is why is it effective and what is the stuff that works when people talk to other people?

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So that's something that we are hoping to do in the next couple of years, and I'm to stop your I hope I didn't run over time.

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Thank you so much.