Dr. Sudipto Chatterjee, psychiatrist, and Namrata Pagi, a health worker, who is trained to identify and treat depression.

PHOTOGRAPHS BY DAVID KOHN India has only 4,000 psychiatrists. Depression and anxiety are rarely diagnosed and treated, especially among the millions of rural poor.

By DAVID KOHN

SIOLIM, India - At the faded one-story medical clinic in this fishing and farming village, people with depression and anxiety typically got little or no attention.
Busy doctors and nurses focused on physical ailments - children with diarrhea, laborers with injuries, old people with heart trouble.
Patients, fearful of the stigma connected to mental illness, were reluctant to bring up emotional problems.
Last year, two new workers arrived.
Their sole task was to identify and treat patients suffering depression and anxiety.
The workers found themselves busy.
Almost every day, several new patients appeared.
Depressed and anxious people now make up “a sizable crowd” at the clinic, said the doctor in charge, Anil Umraskar.
The patients talk about all sorts of troubles.
“Financial difficulties are there,” said one of the new counselors, Medha Upadhye, 29. “Interpersonal conflicts are there. Unemployment. Alcoholism is a major problem.” The clinic is at the forefront of a program that has the potential to transform mental health treatment in the developing world.
Instead of doctors, the program trains laypeople to identify and treat depression and anxiety and sends them to six community health clinics in Goa, in western India.
Depression and anxiety have long been seen as Western afflictions, diseases of the affluent.
But new studies find that they are just as common in poor countries, with rates up to 20 percent in a given year.
Researchers say that even in places with very poor people, the ailments require urgent attention.
Severe depression can be as disabling as physical diseases .
If a subsistence farmer is so depressed that he cannot get out of bed, neither he nor his children are likely to eat.
In India, as in much of the developing world, depression and anxiety are rarely diagnosed or treated.
With a population of more than one billion, India has fewer than 4,000 psychiatrists, one-tenth the United States total, which has a population of 300 million.
Because most psychiatrists are clustered in a few urban areas, the problem is much worse elsewhere.
As a result, most Indians with mental illness go untreated, especially in poor and rural areas.
“There is a huge treatment gap for people with depression,” said Dr. Vikram Patel of the London School of Hygiene and Tropical Medicine, the psychiatrist who began the Siolim project.
“In most places in the developing world, 80 percent to 90 percent of people with severe depression don’t receive adequate treatment.
” For India, adding thousands of psychiatrists would take large sums of money and years of effort, resources unavailable to a developing country with many other health problems besides mental illness.
By contrast, Dr. Patel’s strategy costs relatively little and does not require legions of doctors.
Dr. Greg E. Simon, a researcher at the Center for Health Studies in Seattle, and a psychiatrist who studies mental health in the developing world, said the Goa strategy grew from a crucial idea.
Unlike, say, heart disease and stroke, which can require expensive interventions, depression is relatively simple to diagnose and treat.
Many studies have shown that talk therapy and antidepressants lead to significant improvement in most patients.
“The fundamentals of helping people with depression are pretty low tech,” Dr. Simon said.
“The core resource is humans,” people who can identify patients and offer treatments.
Almost 2,000 patients have been treated through the Goa program.
Dr. Patel is conducting a randomized clinical trial to see whether the strategy works .
If the research, which will finish in 2010, reports positive results, donors and governments are more likely to try it elsewhere in India and the world, Dr. Patel said, adding: “This is the most important question in psychiatry.
How do we scale up treatments to a population in a low-resource setting-” Dr. Sudipto Chatterjee, a psychiatrist at Sangath, helped draw up the program and oversees the screeners and counselors, who are paid $100 to $200 a month.
He said they not only diagnosed as well as doctors but were generally better listeners, partly because they have more time.
In a society where many people have no place to share their worries, the effects of therapy can be striking.
On a recent Saturday morning at the Siolim clinic, Ms. Upadhye, the health counselor, sat in her office , when a psychiatric patient arrived for a return visit.
A housemaid in her 50s , the patient had originally reported physical problems like headache, insomnia and pains but had been given a diagnosis of depression.
As Ms. Upadhye listened, the woman let loose a flood of words.
Speaking in Konkani, the predominant Goan language, she told the counselor that she was not getting along with her four children, especially her son, who had recently beaten her up in a drunken rage.
She said she had no one to talk to.
She began to cry.
But within minutes, she began to relax.
Her expression loosened.
“I feel better when I tell my problems to somebody else,” she said.