While adding community care to specialist treatment may be more expensive, it is more effective than standard facility-based care alone, according to the results of a multi-site study from India reported this month (5 March) in the Lancet.
This is the first ever randomised trial to test the relevance of community-based care in treating schizophrenia in a low-income country. A severe mental disorder, schizophrenia is often accompanied by abnormal speech and behaviour, delusions, hallucinations and emotional problems.
A joint team of researchers from India and the UK studied 282 schizophrenics over a 12-month period from 2009. While 187 received the services of both community health workers and specialists, the rest were provided only facility-based care.
The researchers assessed changes in symptoms and disability as primary outcomes of effectiveness. The secondary outcomes assessed included adherence to treatment, experiences in stigma and discrimination, changes in perception of burden by care-givers and cost-effectiveness.
The researchers reported that combined intervention was “modestly more effective” in reducing symptoms and disability and in improving acceptance of medication in patients with moderate to severe schizophrenia.
The symptoms and disability outcomes with combined community care were better at a rural site in Tamil Nadu state, as compared to two urban sites in Goa and Maharashtra states. However, they did not reduce the experience of stigma and discrimination, or burden in care-givers.
Intervention costs were higher when community-based health care was included, with one-third of the additional costs attributed to staff supervision.
“Any additional health intervention that is over and above usual care is going to cost more than usual care. Thus, the key issue is not that it costs more, but how much additional benefit it offers,” says Vikram Patel, an author of the study and professor at the Centre for Global Mental Health, London.
“As a first step, we should strive to ensure high coverage and quality of facility-based care. Once we achieve these targets, community-based interventions such as ours should be considered to further enhance the outcomes,” Patel tells SciDev.Net.
Mirja Koschorke, a psychiatrist at King’s College, London, who focussed on the stigma aspect of the study, says: “What we were concerned about in the trial was to see whether the degree to which people who were negatively affected by the consequences of stigma changed. Overall, there was a large drop in the stigma experiences reported from baseline to endline.”
The community intervention did not increase stigma, which is encouraging, Koschorke says.
The link to Lancet paper