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Treating the mind as well as the body

Yale Medicine Magazine, 2013 - Winter


Since 2004, Yale psychiatrists have offered mental health care to patients in a city high in the Peruvian Andes.

Mark Rego, M.D., HS ’89, and James Phillips, M.D., HS ’74, traveled to Peru for the first time in 2004 as members of a Peruvian American Medical Society (PAMS) mission to Ayacucho, a city of 150,000 high in the Andes. Each year PAMS brings a team of more than 100 physicians, nurses, and medical students to Peru to provide medical services. The PAMS team wanted to add a psychiatric component to its medical mission, and in Ayacucho Rego and Phillips found a population still traumatized by a long-running civil war between the Peruvian army and the Shining Path rebellion that ended in 1992. The region also has a poverty rate of about 70 percent and many cases of untreated mental illness.

“There is a sense we run into in fundraising conversations that mental health shouldn’t be a priority in impoverished areas—poor people don’t have time to be depressed,” Rego said. “A mountain of data shows just the opposite. There is plenty of psychiatric illness and psychological distress, and pretty much all of it is unaddressed.”

Rego and Phillips found a lack of interest among local health care providers in meeting that need. “I was hoping to get a sense of what happens to people with mental disorders,” said Rego, a clinical assistant professor in psychiatry at the School of Medicine. “I had a list of contacts—NGOs, human rights people, medical people. My main question to everybody was, ‘What happens if you become mentally ill here?’ The answer was a resounding, ‘Nothing.’ ”

Finally, they reached the last name on the list.

Sister Anne Carbon, originally from the Philippines and a member of an Irish order, the Missionary Sisters of St. Columban, had arrived in Peru two and a half years earlier. A former psychiatric nurse, Carbon spent six months at a convent in Lima learning Spanish, then another two years in a teaching psychiatric hospital in Lima. She came to Ayacucho in 2003.

“She started with couple of boxes of donated medicines and a table and chair,” said Phillips, associate clinical professor of psychiatry. “There is plenty of trauma from the war of the 80s. It is also simply the case that any area of the world is going to have its incidence of psychiatric illness, and Ayacucho certainly does, independent of the war. Poverty is a big component. We see a lot of psychotic depression. There’s a very high incidence of alcoholism. That certainly is poverty-connected. Domestic violence is a reaction. It is an area that had never had psychiatric services. Sister Anne picked Ayacucho because of that history to start her own clinic.”

Over the next few years Rego and Phillips, working with the local group of professionals in Peru, would address that failure to tackle mental health issues. Since 2004 they have collaborated with a clinic in Ayacucho run by Catholic missionaries, and have brought several Yale students to Peru for clinical rotations. A recent agreement with the Universidad Peruana Cayetano Heredia in Lima has expanded the venues for those rotations. And through their efforts, psychiatric treatment has become more accessible to the local population.

The Yale professors started by providing furniture for the clinic and helping it relocate from Ayacucho’s outskirts to a more central location. They then asked colleagues and friends for donations to pay the nurses’ salaries, and found NGOs that provided medicines.

Carbon announced the clinic’s opening at its new location on a local radio station in 2005. “Once the word got out, patients started flooding in,” Phillips said. In the course of the following years the two Yale psychiatrists gathered a core of clinicians including psychiatrists Galen Stahle, M.D., Stephen Bittner, M.D., Antonio Bullon, M.D., and Roberto Blanco, M.D., and clinical psychologists Lorenzo Puertas, Ph.D., and Luis Bedregal, Ph.D. who have joined them on the semi-annual trips. Bullon, Puertas, and Bedregal trained in the United States and continue to practice in this country. In addition, Alfredo Massa, M.D., FW ’09, a Peruvian psychiatrist who did an addictions fellowship in the Department of Psychiatry, joined their group and participates in the supervision of Yale medical students in their Peru rotations. Massa was also instrumental in developing the medical student exchange program with the Universidad Peruana Cayetano Heredia.

“At six in the morning there would be these long lines of patients waiting outside the clinic,” said Xin He, a medical student who joined the American psychiatric group in a PAMS mission in Peru during the summer of 2011. Although she was there to do research on rural medical service programs, she spent a few days shadowing and interpreting for doctors and clinic staff in Ayacucho. Among the patients she met were a man in his 40s who had developed a fear of leaving his house; a 13-year-old girl who had been raped and impregnated by her stepfather; and a middle-aged woman who defied her husband to seek a prescription to treat her depression. “There were a lot of heart-wrenching issues,” she said.

The clinic, whose directorship was turned over in 2011 to a Belgium religious congregation that specializes in mental health, The Brothers of Charity, is open weekdays and has a staff of eight nurses, two psychologists, a social worker, a physical therapist, and a pharmacist. The order is led by Brother Jimi Hyata, a clinical psychologist. Although the clinic is run by a Roman Catholic religious order, treatment is nonsectarian. The nurses are bilingual, speaking both Spanish and Quechua, the indigenous language.

Once a month psychiatrists from a teaching hospital in Lima make the 12-hour bus ride from Lima on their own time to do inpatient evaluations and medication follow-ups. “We pay their transportation and lodging,” Phillips said. “There have been a couple of Lima psychiatrists who have been very loyal through the years.”

Yale psychiatrists visit the clinic twice a year, once in the summer as part of a larger PAMS team, and once in January as a team of about eight people. Those winter trips last a week and are coordinated to meet with the psychiatrists from Lima. “We work with them on the Saturday and Sunday,” Phillips said. “The rest of the time we see patients, we do home visits with the staff, we do case presentations, and we do other kinds of training exercises.”

The clinic, Phillips said, offers a full-scale schizophrenia program. For other patients there are active therapy programs that try to involve families and psychosocial rehabilitation. “Those are always a work in progress,” Phillips said. “The treatment is not just you come and see the psychiatrist once a month; there’s an effort to do a full range of psychiatric care.”