THE FIRST RANDOMISED trial testing 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.
The study found that it had better results in terms of reducing disability and psychotic symptoms and ensuring that individuals continue their antipsychotic medication.
The Community care for People with Schizophrenia in India (COPSI) Trial, published in The Lancet, reports that findings from India showed even more positive outcomes than similar trials of collaborative community-based care carried out in high-income countries.
Community care
The study randomly assigned 187 patients with moderate to severe schizophrenia aged 16 to 60 years to receive either collaborative community-base care plus facility-based care or facility-based care alone – 95 patients – 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 and also to support family members
The research showed 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,” said Graham Thornicroft, a professor of community psychiatry from the Centre for Global Mental Health, King’s College London, who led the research.
Psychiatrists
He explained that in many low-income countries, fewer than 10 per cent of people with mental health problems receive any treatment and that there may be just a handful of psychiatrist. In some countries, he said, there are no mental health specialist doctor at all.
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 one year, total PANSS and IDEAS scores were lower in the community intervention group than in the usual care group.
One rural setting, Tamil Nadu, one of the most deprived regions in the study, showed a significant symptom and disability reduction.
Additionally, patients receiving the community intervention were almost three times more likely to continue taking their antipsychotic medication than those given usual care.
However, the costs in the intervention group were higher than in the usual care group but approximately €110.
Low-income country
“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,” said Thornicroft.
However, researchers from the University of New South Wales in Sydney, Australia said 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.
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