Community care helps schizophrenia patients in resource-poor settings

By Eleanor McDermid, Senior medwireNews Reporter

Collaborative care delivered by community health workers can improve outcomes among patients with schizophrenia receiving facility-based case in resource-poor settings, shows a study in The Lancet.

The COmmunity care for People with Schizophrenia in India (COPSI) trial involved patients with at least moderate schizophrenia symptoms recruited from three Indian sites and showed a “modest” improvement in outcomes, particularly among those in a rural site, which lacked locally accessible mental health services.

“Our findings from India show even more positive outcomes than similar trials of collaborative community-based care carried out in high-income countries,” said lead researcher Graham Thornicroft (Institute of Psychiatry, King’s College London, UK) in a press statement.

He noted that mental health specialists are scarce in many low-income countries, resulting in very low rates of treatment. “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.”

Overall, the 187 patients randomly assigned to receive the community intervention in addition to their usual care for 12 months had a significant reduction in overall disability, with an adjusted mean difference of –0.95 points on the Indian Disability Evaluation and Assessment Scale (IDEAS) relative to the 95 patients who continued to receive their usual facility-based care. There was also a –3.75 adjusted mean difference for symptoms scores on the Positive and Negative Syndrome Scale (PANSS), although this did not reach statistical significance.

The intervention was delivered by community health workers with at least 10 years of experience, and it included the provision of psychoeducational information, individualised rehabilitation strategies and adherence management strategies.

When analysed by recruitment site, the differences were most marked for patients from the one purely rural site, who achieved significant adjusted mean differences of –1.76 for IDEAS scores and –9.29 for PANSS scores. Neither of the other two sites, which were mixed urban/rural, showed significant differences for either measure.

The intervention had positive effects on medication adherence, but not on knowledge of schizophrenia or reported stigma. Four patients died during the study: one in each group from suicide and two others from causes not related to schizophrenia.

The total extra cost for the intervention over the whole study period was about 9500 Indian Rupees (€ 111.6, US$ 153.5), the team notes. “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.”

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