The first randomised trial to rigorously test community-based care for people with schizophrenia in a low-income country shows that treatment in the community led by lay health workers is more effective than standard facility-based care at reducing disability and psychotic symptoms, and ensuring that individuals continue their antipsychotic medication.
"Our findings from India show even more positive outcomes than similar trials of collaborative community-based care carried out in high-income countries. They show that this approach of using community health workers, under proper supervision, who make home visits could play a major part in improving outcomes for people with schizophrenia in low-income countries using the locally available, human resources", explains Graham Thornicroft, a professor of community psychiatry from the Centre for Global Mental Health, King's College London, Institute of Psychiatry, who led the research.
"In many low-income countries, fewer than 10% of people with mental health problems receive any treatment. There may be just a handful of psychiatrists, and in some countries, there are no mental health specialist doctor at all."
The COmmunity care for People with Schizophrenia in India (COPSI) Trial, published in The Lancet, randomly assigned individuals with moderate to severe schizophrenia aged 16 to 60 years to receive either collaborative community-base care plus facility-based care (187 patients) or facility-based care alone (95) at three sites in India.
For the community intervention, lay health workers were trained to deliver a package of personal, evidence-based treatments to the patient at home, under close supervision from psychiatric social workers (intervention coordinators), and also to support family members.
The study's main measures of success were changes in symptoms and disabilities over 12 months rated on the Positive and Negative Syndrome Scale (PANSS) and the Indian Disability Evaluation and Assessment Scale (IDEAS). The lower the rating, the better the level of function.
After 1 year, total PANSS and IDEAS scores were lower in the community intervention group than in the usual care group. In particular, a significant symptom and disability reduction was noted at the site of Tamil Nadu, the most rural and deprived of the study sites. Additionally, patients receiving the community intervention were almost three times more likely to continue taking their antipsychotic medication than those given usual care.
However, community-based care was no more effective for reducing stigma and discrimination, lessening caregiver's burden, or increasing knowledge about the disorder amongst family members.
The authors note that costs in the intervention group were higher than in the usual care group, saying that, "The average greater cost for participants in the intervention group over the study period was almost INR 9500 [roughly US$153 / £92]; therefore, a judgment should be taken as to the value in terms of the clinical and social improvements identified for a group of highly vulnerable people."
According to Thornicroft, "By recruiting patients from real-world clinical settings across three diverse sites our findings establish that people with schizophrenia can be treated successfully using mobile community teams in a resource-poor country. By moving treatment into the community, it is possible to scale up services where they are needed and scarce, as is the case in many low-income and middle-income countries."
Commenting on the research, Derrick Silove and Philip Ward from the University of New South Wales in Sydney, Australia point out that despite this being a milestone study, several issues need further consideration such as ensuring that the physical health of patients is safeguarded and that services take into account the local context and culture. They conclude, "Sustaining of mental health initiatives, particularly in low-resource settings, needs a comprehensive, multisectoral approach based on genuine engagement with the community…The active involvement of local leadership and stakeholder groups is crucial to sustain and develop programmes; mental health for all means all need to play a part. Therefore, as services are rolled out across low-income and middle-income countries, the global must engage with the local to forge an equal partnership to improve the lives of people with schizophrenia and their families."
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