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. 2014 Sep 19;17(4):124. doi: 10.1136/eb-2014-101893

Community-based intervention for people with schizophrenia successfully provided by supervised community health workers in a low-resource setting

Harry Minas 1
PMCID: PMC13404021  PMID: 25239250

What is already known on this topic?

There is a critical global shortage of specialist human resources for mental health, particularly in low-income and middle-income countries (LMICs). In settings with inadequate numbers of mental health professionals, evidence suggests that task shifting is an effective human resources strategy and that minimally trained community health workers can increase access to mental health services while maintaining or improving the quality of clinical and social outcomes.1

What does this paper add?

  • While previous studies have focused on community health treatments for people with common mental disorders, this trial focuses on the public health problem of services for people with schizophrenia in low-resource settings.

  • The study demonstrates the impact of the intervention, particularly on disability, and assesses the additional cost of community-based care.

  • Significant outcomes from the intervention occurred only in the site with the most limited resources, with no significant additional benefit in the better-resourced sites.

Limitations

  • The findings are limited to a subgroup with long-standing schizophrenia, with median duration of illness of 7 years.

  • Longer follow-up is needed for an intervention focusing on people with moderate or severe schizophrenia with persistent symptoms and disability.

  • While the additional costs of the intervention were examined, the economic benefits of reduced disability were not estimated.

What next in research

  • Examine whether the impact of the intervention is greater in people with recent onset of schizophrenia, and whether persistent disability can be prevented by incorporating the intervention in early intervention programmes that are being established in LMICs.

  • Apply well-developed methods for estimating the economic benefits of reducing severity of disability as well as additional economic costs of the approach.2 Such estimates are important in LMICs with limited capacity for investment in mental health. Evidence of return on investment will strengthen mental health advocacy.

  • Different outcomes across sites suggest the need for more reliable data on the health systems and the economic and social contexts within which the model is being applied and evaluated.

Could these results change your practices and why?

This study will change my mental health system development practice in LMICs by presenting further evidence for the positive impact of community health workers. It will change the practice of psychiatrists and other specialist mental health professionals in LMICs, who currently spend a great deal of their time in direct assessment and treatment, by demonstrating the value of a stronger focus on training and supervision of community health workers. Even the modest improvements in clinical and disability outcomes demonstrated in this study strengthen the case for task shifting as a viable human resources strategy.

Footnotes

Competing interests: None.

References

  • 1.Kakuma R, Minas H, van Ginneken N, et al. Human resources for mental health care: current situation and strategies for action. Lancet 2011;378: 1654–63. [DOI] [PubMed] [Google Scholar]
  • 2.Mihalopoulos C, Vos T, Pirkis J, et al. The economic analysis of prevention in mental health programs. Annu Rev Clin Psychol 2011;7:169–201. [DOI] [PubMed] [Google Scholar]
Evid Based Ment Health. 2014 Sep 19;17(4):124.

Commentary

ABSTRACT FROM: Chatterjee S, Naik S, John S, et al. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial. Lancet 2014;383:1385–94.

Patients/participants Two hundred and eighty-two outpatients aged 16–60 years with a primary diagnosis of schizophrenia (ICD-10) and illness duration of at least 12 months. Participants were recruited by screening existing caseloads. Informed consent procedures were adapted to enable informed consent from illiterate individuals.

Setting Three sites in India; January 2009 to December 2011.

Intervention Collaborative community care, involving a community care programme plus facility-based care (n=187). The community care programme aimed to promote collaboration between the person with schizophrenia, their caregivers and their treatment team. It was a flexible programme with an initial needs assessment to ensure components were individualised. Components included psychoeducational information for participants and caregivers; rehabilitation strategies to improve personal, social and work functioning; providing links to self-help groups; strategies for dealing with stigma and networking with community agencies to assist with practical issues such as access to benefits and employment opportunities.

Comparison Facility-based care alone (n=95).

Patient follow-up Eighty-nine per cent of the intervention group and 91% of the control group were available for follow-up at 12 months.

Allocation Concealed.

Blinding Single-blind (assessors).

Outcomes

Symptoms (Positive and Negative Syndrome Scale) Both groups demonstrated a reduction in symptoms, but the marginally greater symptom reduction in the collaborative community care, fell short of statistical significance (mean difference (MD) −3.75, 95% CI −7.92 to 0.42. There was also no decrease in the proportion of participants at all sites showing more than 20% reduction in overall symptoms (51% in both groups).

Disability (IDEAS) Collaborative community care was significantly more effective at reducing disability (adjusted MD=−0.95, 95% CI −1.68 to −0.23).

Experiences of stigma and discrimination Both groups demonstrated a similar reduction in overall experience of negative discrimination (OR=1.02, 95% CI 0.54 to 1.92). However, those in the intervention group were less willing to disclose their illness (2.77, 1.65 to 4.67).

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