Community-based care linked to reduction of disability in schizophrenic patients [COPSI study]

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1. In low-income countries, supplementary community-based care was modestly effective in reducing symptoms and disability for schizophrenic individuals. 

2. Community-based care may lead to improved treatment adherence in individuals with schizophrenia. 

Evidence Rating Level: 2 (Good) 

Study Rundown: Access to quality mental health care remains difficult in many low-income countries. The lack of mental health specialists presents a challenge for patients with schizophrenia and their caregivers. In the current study, investigators trained lay health workers to provide care that supplements facility-based care. During follow-up at one year, there was greater reduction in positive and negative symptoms for patients that had received this supplementary care. Additionally, there was also greater reduction in overall disability and improved treatment adherence among recipients of community-based care. Of note is that the most significant positive changes were seen in those the Tamil Nadu site, the most rural and isolated of the communities in the study. The results suggest that care delivered by trained lay health workers may be a useful addition to the traditional facility-based system, especially in health care systems with strained resources. The study was limited by the relatively small number of participants (N=282), with low power to detect difference in adherence.

The study was funded by Wellcome Trust.

Click to read the study, published today in The Lancet

Relevant Reading: Poverty and mental disorders: breaking the cycle in low-income and middle-income countries

In-Depth [randomized controlled trial]: This study assessed the efficacy of supplementary community-based care on managing individuals with schizophrenia in low-income areas of India. A total of 282 participants were randomly placed in a 2:1 ratio to either received both community-based and facility-based care (combined intervention), or facility-based care alone. The primary endpoint was a change in symptoms and disabilities over the course of one year as measured using the positive and negative syndrome scale (PANSS), and the Indian disability evaluation and assessment scale (IDEAS). The secondary endpoint measured treatment adherence.

Both groups saw reduction (improvement) in PANSS scores at 12 months, although the reduction was greater (P=0.08) in the combined intervention group, with adjusted mean difference of -3.75 (95% confidence interval [CI], -7.92 to 0.42). In a post-hoc analysis, a greater proportion of patients in the combined intervention group had improved by 20% or more on the IDEAS total score compared to the facility-based care group, with borderline statistical significance (75 [48%] vs. 28 [35%], adjusted odds ratio = 1.84, 95% CI, 0.97 to 3.46, P=0.06). Finally, adherence was improved in those who received the community-based intervention, although the study had low power to discern this difference.

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