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Where There Is No Psychiatrist: Lay Health Workers Reduce Schizophrenia Disability in Rural India

March 18, 2014. Lay community health workers may help people with schizophrenia living in places short on psychiatrists, according to a study published online March 5 in The Lancet. Led by Graham Thornicroft at King’s College London, United Kingdom, and Vikram Patel of London School of Hygiene and Tropical Medicine, United Kingdom, the study tested the effectiveness of community health workers trained to deliver a schizophrenia-specific intervention in India.

People with schizophrenia who received home visits from the trained non-specialists, in addition to getting services from psychiatrists in specialized clinics, showed slightly greater functional improvements after a year compared to the control group who visited the specialist clinic only. When they looked more closely at the data, the researchers found that the improvements occurred in rural but not urban settings.

Though the gains were modest, the study supports the idea that existing health workers in developing countries can be recruited to help those with mental illness. Psychiatrists are usually scarce in these settings, and the vast majority of people with mental illness receive no care at all.

That the community health workers had a clearer impact in the rural site than in the urban ones suggests that any care model needs to be adapted to different settings within developing countries.

“The take-home is that there’s no one-size-fits-all plan for treatment services,” said Pamela Collins, director of the Office for Research on Disparities and Global Mental Health at the National Institute of Mental Health in Bethesda, Maryland. “People need to have a nuanced deployment of mental health human resources based on the context, even within a given country.”

Treatment gap
Collins, who was not involved in the study, oversees NIMH funding of research on how to implement mental health services in developing countries. “There's a tremendous need to provide high-quality care in contexts that simply do not have enough resources to meet the need,” she said. “Deploying less specialized workers with abbreviated training may be a more efficient way to do that, provided there’s adequate supervision.”

Global mental health advocates have proposed to fill this “treatment gap” with lay health workers already in the community, who, though they have not received specialized medical education, have some training in first aid, childbirth, or recognizing diseases and referring people to clinics. Although their skill sets vary, they are recognized as health experts by the community.

Previous studies have found that such community health workers can deliver effective care for depression and anxiety in developing countries (e.g., Patel et al., 2011), but the new study is the first to probe their outcomes for schizophrenia in a sizeable sample.

“There’s very little information in low-income countries about alternatives to hospital treatment for schizophrenia, and few data on the cost effectiveness of community health workers,” Thornicroft told SRF by email.

Previous work has found benefits to psychosocial interventions for schizophrenia customized for parts of the developing world, but these interventions have typically operated out of specialized clinics (e.g., Kulhara et al., 2009). In the new study, Thornicroft and colleagues tested how their India-specific intervention for schizophrenia, called COmmunity Care for People with Schizophrenia in India (COPSI) (Chatterjee et al., 2009), fared in the hands of community health workers making home visits in three different regions of India with a randomized, controlled design.

First author Sudipto Chatterjee and colleagues recruited 282 people with schizophrenia from the cities of Goa and Satara, and the Tamil Nadu region. People at the Goa and Satara sites came from either urban or rural environments and had access to specialized psychiatric care in nearby clinics. The Tamil Nadu site was entirely rural, however, and did not have mental health services nearby. The participants were 16-60 years old, were judged as moderately to severely ill by a psychiatrist, had been ill for an average of seven years, and took antipsychotic medication.

Over 12 months, the intervention group received on average of 18 visits from community health workers and went themselves to clinics to see a psychiatrist 10 times, whereas the control group on average visited a psychiatrist eight times.

At the end of the year, the intervention group showed slightly greater improvements than the control group in terms of disability, as measured by the Indian Disability Evaluation and Assessment Scale (IDEAS), which scores self-care, social skills, communication, and work. The researchers also reported a statistically non-significant 3.75-point difference in the Positive and Negative Syndrome Scale (PANSS) between the intervention and control groups (p = 0.08).

In an accompanying editorial, Derrick Silove and Phillip Ward of University of New South Wales, Australia, find it noteworthy "that findings from COPSI were broadly the same as those from similar trials of collaborative community-based care done in high-income countries."

When broken down by region, those at the rural Tamil Nadu site receiving the supplemental home visits showed significantly greater improvements in both symptoms and disability than the control group. No significant differences emerged at the other two locations, however, suggesting that home visits offered little benefit to those receiving care in nearby clinics.

With supervision
The results, however, don’t mean that community health workers may eventually replace psychiatrists, who supervised the health workers and advised them about their patients. The researchers reported that this supervision was the most costly part of their study.

This means that funding for supervision may determine how far one may stretch the expertise of a single psychiatrist in these settings. "Maintenance of supervision in very low-resource settings is a major challenge, because of cost and the perennial issue of loss of skilled professionals," write Silove and Ward.

That will be the challenge for reshaping the roles of psychiatrists and lay health workers so that mental health care may reach all that need it, in poor and rich countries alike.—Michele Solis.

Chatterjee S, Naik S, John S, Dabholkar H, Balaji M, Koschorke M, Varghese M, Thara R, Weiss HA, Williams P, McCrone P, Patel V, Thornicroft G. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial. Lancet. 2013 Mar 4. Abstract

Silove D, Ward PB. Challenges in rolling out interventions for schizophrenia. Lancet. 2014 Mar 4. Abstract

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