London School of Hygiene & Tropical Medicine

Community-based treatment led by lay health workers is more effective than standard facility-based care at reducing disability and psychotic symptoms according to new research, co-authored by researchers at the London School of Hygiene & Tropical Medicine.

The COmmunity care for People with Schizophrenia in India (COPSI) Trial, published in The Lancet, is the first randomised trial to rigorously test community-based care for people with schizophrenia in a low-income country.

Vikram Patel, Professor of International Mental Health at the London School of Hygiene & Tropical medicine, and co-author of the study, said: "This trial shows that it is possible to reduce disability, a key goal in the recovery process, in people with severe and long-standing schizophrenia through a community based intervention delivered by lay health workers, especially in rural areas of India."

The trial randomly assigned individuals with moderate to severe schizophrenia aged 16 to 60 years to receive either collaborative community-based care plus facility-based care (187 patients) or facility-based care alone (95) at three sites in India.

For the community intervention, lay health workers were trained to deliver a package of personal, evidence-based treatments to the patient at home, under close supervision from psychiatric social workers, and also to support family members.

The study's main measures of success were changes in symptoms and disabilities over 12 months rated on the Positive and Negative Syndrome Scale (PANSS) and the Indian Disability Evaluation and Assessment Scale (IDEAS).

After one year, total PANSS and IDEAS scores were better in the community intervention group than in the usual care group. In particular, a significant symptom and disability reduction was noted at the site of Tamil Nadu, the most rural and deprived of the study sites. Additionally, patients receiving the community intervention were almost three times more likely to continue taking their antipsychotic medication than those given usual care.

However, the study also found that community-based care was no more effective for reducing stigma and discrimination, lessening a caregiver's burden, or increasing knowledge about the disorder amongst family members.

The authors also note that costs in the intervention group were higher than in the usual care group, and said that a judgment should be taken as to the value in terms of the clinical and social improvements identified for a group of highly vulnerable people.

The study was funded by the Wellcome Trust.

Publication

• Sudipto Chatterjee, Smita Naik, Sujit John, Hamid Dabholkar, Madhumitha Balaji, Mirja Koschorke, Mathew Varghese, Rangaswamy Thara, Helen A Weiss, Paul Williams, Paul McCrone, Vikram Patel, Graham Thornicroft. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial. The Lancet. DOI: 10.1016/S0140-6736(13)62629-X