Title: Can Mobile Health Improve Depression Treatment Access and Adherence Among Rural Indian Women? A Qualitative Study Authors: Bhat A 1, Goud BR 2, Pradeep JR3, Jayaram G 4, Radhakrishnan R*5,6, Srinivasan K*3,7 1. Department of Psychiatry, University of Washington, USA 2. Department of Community Health , St John's Medical College, India 3. Department of Psychiatry, St John's Medical College Hospital, India 4. Department of Psychiatry, Johns Hopkins University School of Medicine, USA 5. Department of Psychiatry, Yale University School of Medicine, USA 6. Yale Institute for Global Health, Yale University, USA. 7. Division of Mental Health and Neurosciences, St Johns Research Institute, India *Shared last-authorship Correspondence: Rajiv Radhakrishnan MBBS, MD Email: [email protected] Word count: 2988 Abstract: 247 words Tables: 2 1 Funding Source: The study was supported by the Yale Global Mental Health program (RR). Maanasi project is supported by grants from the Rotary Clubs of Bangalore, Midtown and Howard West, USA. Conflicts of Interest: None declared. 2 Abstract: Introduction: Low rates of follow up with mental health treatments, and medication non- adherence are common among patients with Major Depressive Disorder (MDD), more so in low- middle income countries (LMIC). While mobile mental health has the potential to address this problem in resource-poor settings, the feasibility and acceptability of its use in rural women is unknown. We aimed to explore barriers to access and adherence to mental health treatment, and the feasibility of using mobile health to address these barriers among women with MDD in rural south India. Methods: Six focus groups were conducted among women with MDD (n=69) seeking care at a rural community health center in South India. Discussion centered on barriers to mental health treatment access and adherence and attitudes toward use of technology in addressing these barriers. We transcribed the discussions and analyzed them using qualitative analysis software. Results: Reasons for non-adherence were: transcultural explanatory model of illness; structural, financial and social barriers to access, and medication side-effects. Women were unenthusiastic about mobile health solutions due to illiteracy, lack of family support, unfamiliarity with use of mobile devices, lack of access to mobile phones and preference for in-person clinical consultation. Conclusions: This qualitative study examines the acceptability of mobile-mental health as a strategy to address barriers to depression treatment access and adherence among women in a rural setting. There are several barriers to adoption of mobile mental health technology in LMIC. It is important to address these barriers before implementing mobile health based solutions. 3 Keywords: mobile mental health; depression; non-adherence; global mental health; qualitative study 4 1. Introduction Depressive disorders account for a significant proportion of the global burden of disease (Global Burden of Disease Study 2010) (Ferrari et al., 2013; Whiteford & Baxter, 2013). In 2010, depressive disorders were the second-leading cause of disability worldwide and accounted for an additional burden attributable to mortality associated with suicide and cardiovascular disease (Ferrari et al., 2013). About three quarters of the global burden of neuropsychiatric disorders is in countries with low and middle incomes (LMIC), yet the vast majority of patients (76-85%) in these countries receive no treatment (World Health Organization, 2010). In India, according to the National Mental Health Survey (Gururaj et al., 2016) the treatment gap for mental health problems ranges from 70.4% to 86.3% and contributes to the high rates of suicide (Radhakrishnan & Andrade, 2012). Factors that contribute to this treatment gap include workforce deficits (with one psychiatrist for a population of 400000 (Koshy, 2015) with a majority of psychiatrists practicing in urban areas although 2/3rd of the population lives in rural regions), systemic barriers such as poor transportation infrastructure, and patients’ unwillingness or inability to seek mental health treatment (Gururaj et al., 2016). With the goal of bridging the treatment gap and scaling up services, the Disease Control Priorities Network (DCP-3) has recommended packaging interventions across a range of delivery platforms to make care accessible in resource - poor settings in LMICs (V. Patel et al., 2016). This includes information and communication technology packages via mobile phone and the internet to improve outreach and delivery of personalized interventions. Good clinical outcomes require access to and initiation of treatment (access), and adherence to follow up and treatment (adherence). Mobile mental health technology has the potential to address both access and 5 adherence because of the extent of its reach and availability even in resource-poor settings (DeSouza, Rashmi, Vasanthi, Joseph, & Rodrigues, 2014; Yellowlees & Chan, 2015). Our previous work in a rural mental health clinic in South India (The Maanasi project at the Community Health Training Center, Mugalur), examined the delivery of comprehensive psychiatric care by trained community health workers (CHWs) in collaboration with primary care providers (PCP) and psychiatrists (K. Srinivasan, Isaacs, Villanueva, Lucas, & Raghunath, 2010). In this model, following a monthly visit with a physician at the Primary Health Center (PHC), the CHWs conducted home visits for patients with depression. The CHWs educated the patient and her family about depression and its treatment and encouraged them to visit the rural mental health clinic (co located in the PHC) for further assessment and treatment. Despite this attempt to improve access and care delivery, we found that up to 53% of patients were non- adherent to treatment (Pradeep, Isaacs, Shanbag, Selvan, & Srinivasan, 2014; K. Srinivasan, Isaacs, A.N., Thomas, T., Jayaram, G., 2006). These high rates of non-adherence present a significant hurdle to mental health care delivery and to remission of symptoms. While there is evidence that mobile phone messaging reminders can reduce non-adherence to appointments and treatments (Gurol‐Urganci, de Jongh, Vodopivec‐Jamsek, Atun, & Car, 2013), the feasibility and acceptability of use of technology to improve adherence among women with Major Depressive Disorder (MDD) in rural areas has not been evaluated. There is a need to understand barriers to access and adherence, and assess the feasibility of using technology such as text-messaging, phone calls and appointment reminder devices to address identified barriers. In particular, we wanted to assess these issues in women, given the higher prevalence of major depression among women (Gururaj et al., 2016) and the fact that factors indicative of gender disadvantage (low 6 decision making autonomy, reproductive health factors) are risk factors for depression (Vikram Patel et al., 2006). The aims of the present qualitative study were a) To explore barriers to accessing mental health treatment and evaluate reasons for poor adherence to follow up and medication among women with MDD in the population covered by the Maanasi Project in Mugalur, a rural area of Anekal taluk, Bangalore district, India (b) To assess attitudes towards use of mobile technology to improve mental health treatment access and adherence. 2. Methods 2.1 Setting We conducted this study among patients enrolled in Maanasi - The Community Rural Mental Health Program of St. John’s Medical College and Hospital (SJMCH), Bangalore, India. The Maanasi project, is an ongoing program which has been in operation since 2002. It is coordinated by the Departments of Community Health and Psychiatry at SJMCH, is located in Mugalur, a village situated 30 km from Bangalore city, and is supported by funds provided by the Rotary Foundation. Patients from about 50 villages in this area utilize the services of the project. At the time of the study, psychiatric consultation was available once a month. A PCP is present at the clinic every day, and provides continuing medication management. CHWs conduct home visits for follow up and education. 7 2.2 Study design This was a cross sectional, exploratory qualitative study using focus group discussions to collect information on barriers to mental health treatment access and adherence, and attitudes to use of mobile health to address identified barriers. The study was conceived as a process evaluation of the Maanasi project. 2.3 Study participants Community Health Workers (CHWs) of the clinic approached women (ages 18 – 85 years) who were diagnosed with MDD at the Maanasi clinic for consent to participate in a focus group discussion. We included newly-diagnosed women currently undergoing treatment, those who completed treatment and those who were non-adherent to treatment, to obtain a broad range of perspectives. All participants who expressed interest and were able to provide verbal informed consent were allowed to attend the discussion. We obtained study approval from the Institution Ethics committees of St John’s Medical College, India and the Yale University School of Medicine, USA. 2.4 Focus Group Discusssion procedures We developed a FGD guideline for the focus group discussions that included open ended probes specific to the following topic areas: barriers to accessing mental health treatment, reasons for poor treatment adherence, and attitudes towards the use of technology such as text-messaging, phone calls, and appointment reminder devices to