An Interview with Global Mental Health Delivery Fellow Swapna Moorthy

What is your professional background?

After completing my psychiatry residency, I began the Dr. Mario Pagenel Fellowship in Global Mental Health Delivery at Harvard Medical School, which combines clinical care, training and education with research and advocacy.

Photo of Swapna MoortyAs a global mental health Fellow, part of my role has been to facilitate and support the scale-up of the mental health program in Rwanda with Partners in Health (PIH), known locally as Inshuti Mu Buzima (IMB). We work with the Rwandan Ministry of Health to support local structures for mental health care delivery.

The mental health program was first implemented in 2011 in the northern province of Rwanda, in Burera District. It is a community-based mental health program that aims to decentralize mental healthcare and make it more accessible. The mental health team works in the community with community health workers, in health centers with nurses, and at the hospital level with non-specialist providers, doing capacity building and training to improve the quality of mental health care delivery at different levels.

A vital part of the work is to increase awareness about mental health and illness and to reduce stigma and discrimination. With the lessons learned in Burera, the mental health program was scaled up to the eastern province in 2019. 

What are the challenges you face in the work? What does your daily work look like?

Mental health in Rwanda has been deeply impacted by the 1994 Rwandan Genocide. The government has made great strides in creating a robust and inclusive healthcare system; however, there are still several challenges in delivering mental health care. There are very few trained psychiatrists and mental health specialists in Rwanda, relative to the population. As is the case in most parts of the world, mental health is not prioritized the way physical health is. Therefore, creating awareness that mental health and physical health are intimately connected, and that there is no health without mental health, is a significant and challenging part of the work.

Since mental health care services are concentrated in urban areas, patients in remote and rural communities have to travel for miles to receive treatment and often do not receive treatment at all. The mental health program’s goal is to use task-shifting and train non-mental health providers in essential mental health care competencies, so they can provide treatment for mentally ill patients closer to their homes. 

When the mental health program was scaled up last year to two additional PIH-supported hospitals in the eastern province, there were many lessons to be applied from the work in Butaro, and also a unique set of challenges. The mental health team started by training community health workers and engaged people in the community to create awareness and destigmatize mental health and illness. Next came the training and supervision of health center nurses. At first, we tried to address the low-hanging fruit like the medication supply chain and clinical care practices at the health center and hospital level. I work with a team of psychiatric nurses and psychologists and provide clinical supervision and training. It is encouraging to see the positive changes that are slowly happening, but there is still a lot of work to be done, which will take time and continued advocacy. 

In the context of the COVID-19 pandemic, people living with severe mental illness are particularly vulnerable. We have tried to take it one day at a time and one challenge at a time to find ways to adapt our strategies so that we can continue to provide mental health care to those in need during these uncertain times. In the last six months, we have seen the world experiencing collective anxiety of an unprecedented nature, and this is true in Rwanda as well. There is a rapidly growing need for mental health support, and the long-term impacts of this pandemic remain to be seen.

Understandably, current efforts emphasize the containment of the virus. Still, we cannot be myopic about the fact that as the pandemic eventually wanes and “normal life” resumes, the psychological sequelae will have long outlived this virus. As a mental health provider, this COVID-19 era is a call-to-action, to prepare for these waves of psychological distress that have already begun and will continue for years to come, in Rwanda and worldwide. 

How did you first learn about UpToDate and the Better Evidence Program?

UpToDate has been a helpful on-the-go resource for as long as I can remember, since medical school days. It is easily accessible when you’re rounding on patients in the ward or seeing patients in the clinic – a quick reference tool when there is no time to open up a textbook. Everyone I know in the medical community uses UpToDate. The previous global mental health fellow introduced me to the Better Evidence Donation Program.

How have you used UpToDate in your work?

As a psychiatrist working to integrate mental health into primary care, UpToDate is really helpful when I encounter mentally ill patients with medical conditions or vice versa. We aim to integrate inpatient mental health services with general medical care. As a result, I work with general practitioners frequently and have to understand co-morbid conditions.

Our philosophy is for providers to consider the intersection between mental and physical illness and not view them as compartmentalized problems. For instance, a patient admitted with severe silicosis was on oxygen and had been hospitalized for several months when he developed symptoms of depression. In such a case, we really try to tie the two issues together and work collaboratively so that we can provide more holistic care to the distressed patient. 

Psychiatry isn’t widely covered in UpToDate. However, neurology and neurological illnesses fall under the mental health umbrella in terms of care delivery in Rwanda, and UpToDate has been a handy tool for me to brush up on the latest treatment recommendations and their rationale, and then provide training to others on the team. 

What makes UpToDate a unique tool for healthcare delivery?

UpToDate is uniquely helpful because it’s so accessible in any situation. I like having reliable and updated content right there on my phone, in an app. It’s a helpful resource for reading, research, and clinical practice.