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Community-based care improved outcomes for patients with schizophrenia

A trial that provided community-based interventions to patients seeking care for schizophrenia showed that community-based care, when added to facility-based treatment, helped decrease disability and reduce symptoms of psychosis.

Findings from the trial, which was localized to three sites in India, led researchers to suggest that community-based interventions are most effective in settings where facility-based services are scarce, such as rural areas in lower- and middle-income countries.

Study author Graham Thornicroft, PhD, of King’s College London, and colleagues at Sangath, a community health services nonprofit organization in Goa, India, conducted the COmmunity Care for People with Schizophrenia in India (COPSI) study to quantify how community-provided services enhanced traditional, facility-provided services.

Graham Thornicroft

“The absence of accessible services for people with schizophrenia in low-income and middle-income countries contributes to the substantial public health burden of schizophrenia; poor health and social outcomes, including poverty; social exclusion attributable to stigma and discrimination; and human rights violations in these settings,” the researchers wrote.

The randomized, parallel-group COPSI trial included 282 adult participants from three states in India — Tamil Nadu, Goa and Maharashtra — who were already receiving care for schizophrenia from a clinical practice, or were seeking care for the first time.

Patients were randomly assigned to community care in addition to facility-based care (n=187) or to facility-based care only (n= 95).

The community-based intervention included home visits by community health workers who created personalized, flexible treatment plans that were designed to prompt collaboration between the study participant, caregivers and the specialty facility. Community health workers were supervised by psychiatric social workers to ensure consistency of care, according to the study.

Patients receiving facility-based care sought inpatient services from private psychiatric clinics and practices, which researchers said is the precedent for patients who seek care for schizophrenia in India.

Findings showed that, after 12 months of treatment, patients from both groups saw a decrease in symptoms and disabilities, as measured by the Positive and Negative Syndrome Scale (PANSS) and the Indian Disability Evaluation and Assessment Scale (IDEAS). However, patients in the community-based intervention group had moderately lower scores than those receiving facility-based care (PANSS adjusted mean difference: –3.75; 95% CI −7·92 to 0.42; IDEAS –0.95; 95% CI, −1.68 to −0.23).

There was no difference in the proportion of patients who saw more than a 20% reduction of overall schizophrenia symptoms (PANSS: 85 in the intervention group vs. 44 in the control group; IDEAS: 75 vs. 28).

Data also showed that, at the rural Tamil Nadu site, community-based care was associated with a significant decrease in symptoms and disabilities according to PANSS (P=.003) and IDEAS (P=.01).

Researchers noted that 18 (73%) patients, 17 of whom were in the intervention group, were admitted to hospital care over the course of the trial, though some of those admissions were related to accidents, physical illness or preexisting conditions.

“In the global mental health context, the results strengthen the case for consideration of the adoption of community-based plus facility-based care as an initial step in the provision of services to where they are needed and scarce (as is the case in many low-income and

middle-income countries),” researchers wrote. “This provision might need to be progressively supplemented by intensive or specialist services for patients who are difficult to treat, as is common in high-income countries.”

Because the treatment of schizophrenia is a gradual and long-term process, research efforts would benefit from a longer follow-up period, they wrote.

Disclosure: The researchers report no relevant financial disclosures.