A combination of community- and facility-based treatment for schizophrenia is modestly more effective than facility-based care alone, according to new research published in The Lancet.
The study reports the results of the first randomized trial to test community-based care for people with schizophrenia in a low-income country - in this case, India.
In low- and middle-income countries, there is an absence of the clinical and social services for schizophrenia patients that - in high-income countries - are coordinated by specialist community-based multidisciplinary teams.
Severe financial and human resource constraints in lower-income countries make developing new methods for accessible schizophrenia services very difficult.
"In many low-income countries, fewer than 10% of people with mental health problems receive any treatment," says 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.
"There may be just a handful of psychiatrists, and in some countries, there are no mental health specialist doctors at all," he adds.
But observational evidence has shown that community-based rehabilitation services in low- and middle-income countries could improve the clinical and social outcomes of people with schizophrenia.
Standard facility-based care versus community-based care
The most deprived of the three study sites, Tamil Nadu, was reported as having the most significant symptom and disability reduction among schizophrenia patients.
The new trial compared the clinical effectiveness of two different service delivery methods.
Patients with moderate to severe schizophrenia were randomly assigned to receive either collaborative community-based care alongside facility-based care or facility-based care alone.
The community-based care consisted of training lay health workers over 6 weeks to deliver "a package of personal, evidence-based treatments to the patient at home" to support family members, with supervision from psychiatric social workers.
Symptoms and disabilities of the patients were measured using two scales - the Positive and Negative Syndrome Scale (PANSS) and the Indian Disability Evaluation and Assessment Scale (IDEAS). In these scales, the lower the rating is, the better the level of function in the patient is.
After 1 year, the patients in the community intervention group had lower scores on both the PANSS and IDEAS scales than the patients in the standard care group. The patients in the community intervention group were also three times more likely to continue taking their antipsychotic medication than those in the standard care group.
In particular, the most rural and deprived of the three study sites in India, Tamil Nadu, was reported as having the most significant symptom and disability reduction among schizophrenia patients.
Community care improves symptoms and disabilities but has some drawbacks
But the community-based care was no more effective than standard facility-based care for increasing knowledge of schizophrenia among family members, lessening the burden of caregivers, or reducing stigma and discrimination around schizophrenia. High levels of stigma and discrimination toward people with schizophrenia are reported in low-income countries.
Also, the costs of the community-based interventions were more expensive than standard care. Community-based care costs roughly an extra $153 for each patient.
Despite this, the authors of the study think that their results strengthen the case for community-based care to be provided alongside facility-based care in areas where services for schizophrenia are scarce.
Prof. Thornicroft says:
"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."
The study also notes that both the World Health Organization (WHO) and the Expert Policy Group of the Ministry of Health in India have recommended using non-specialist health workers to supplement psychosocial services in low- and middle-income countries.
Written by David McNamee