Challenges in rolling out interventions for schizophrenia
2014; Elsevier BV; Volume: 383; Issue: 9926 Linguagem: Inglês
10.1016/s0140-6736(14)60085-4
ISSN1474-547X
AutoresDerrick Silove, Philip B. Ward,
Tópico(s)Schizophrenia research and treatment
ResumoThe Global Mental Health (GMH) movement has played a pivotal part in bringing to attention the unmet needs of patients with mental disorders, particularly in low-income and middle-income countries.1Prince M Patel V Saxena S et al.No health without mental health.Lancet. 2007; 370: 859-877Summary Full Text Full Text PDF PubMed Scopus (2147) Google Scholar, 2Collins PY Patel V Joestl SS et al.Grand challenges in global mental health.Nature. 2011; 475: 27-30Crossref PubMed Scopus (1286) Google Scholar Schizophrenia is of primary concern in view of the high level of associated disability and stigma, and the risk that, without treatment, patients will experience prolonged institutionalisation, neglect, and abuse.3Gore F Bloem P Patton G Global burden of disease in young people aged 10–24 years: a systematic analysis.Lancet. 2011; 377: 2093-2102Summary Full Text Full Text PDF PubMed Scopus (1268) Google Scholar, 4Silove D Ekblad S Mollica R The rights of the severely mentally ill in post-conflict societies.Lancet. 2000; 355: 1548-1549Summary Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 5Patel V Kleinman A Saraceno B Protecting the rights of people with mental illness: a call to action for global mental health.in: Dudley M Silove D Gayle F Mental health and human rights. Oxford University Press, Oxford2012: 362-375Crossref Google ScholarSudipto Chatterjee and colleagues' multicentre, randomised controlled COmmunity care for People with Schizophrenia in India (COPSI) trial,6Chatterjee S Naik S John S et al.Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial.Lancet. 2014; (published online March 5.)http://dx.doi.org/10.1016/S0140-6736(13)62629-XPubMed Google Scholar in The Lancet, represents a milestone by showing the benefits of a collaborative community-based care plus facility-based care model compared with conventional facility-based care alone for treatment of moderate to severe schizophrenia. However, implementation of collaborative community-based care in low-income and middle-income countries has several issues that need further consideration, such as ensuring continuity in supervision of community workers, safeguarding the physical health of patients, and embedding services within the local context and culture.Collaborative community-based care makes sense: physical facilities (eg, clinics and hospitals) are not needed, demand on professional skills is low, and the family remains the core unit of care. COPSI is the first trial to test collaborative community-based care rigorously in a developing country, India.6Chatterjee S Naik S John S et al.Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial.Lancet. 2014; (published online March 5.)http://dx.doi.org/10.1016/S0140-6736(13)62629-XPubMed Google Scholar 187 participants were randomised to receive community-based care, and 95 to facility-based care alone. At 12 months, the collaborative community-based care intervention showed a non-significant improvement in symptoms of psychosis as measured by the positive and negative symptom scale (PANSS), and a clearer difference in improvement of disability according to the Indian disability evaluation and assessment scale [IDEAS]; (PANSS adjusted mean difference −3·75, 95% CI −7·92 to 0·42; p=0·08; IDEAS −0·95, −1·68 to −0·23; p=0·01). Furthermore, adherence to treatment was higher in the intervention group (adjusted odds ratio 2·93, 95% CI 1·34–6·39; p=0·01). Collaborative community-based care was no more effective than facility-based care alone for reducing stigma and discrimination, alleviating carer burden, or improving illness-relevant knowledge amongst family members. In assessment of these outcomes, it is important to keep in mind that chronic schizophrenia is a disabling disorder that is difficult to treat in any situation. Noteworthy, therefore, is that findings from COPSI were broadly the same as those from similar trials of collaborative community-based care done in high-income countries.6Chatterjee S Naik S John S et al.Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial.Lancet. 2014; (published online March 5.)http://dx.doi.org/10.1016/S0140-6736(13)62629-XPubMed Google ScholarWhat lessons can be learned from COPSI? Supervision was the most costly component of the collaborative community-based care intervention. Maintenance of supervision in very low resource settings is a major challenge, because of cost and the perennial issue of loss of skilled professionals. In Timor-Leste, for example, discontinuation of donor funding in 2005 left 15 national community mental health workers with no professional supervision for 3 years, until the return of the first trained Timorese psychiatrist.7WHOTimor-Leste.in: Silove D Tilman T Hawkins Z Building back better: sustainable mental health care after emergencies. World Health Organization, Geneva2013: 83-88Google Scholar Scarcity of supervision results in worker isolation, demoralisation, and attenuation of skills. Assessments can become cursory, leading to misdiagnosis and inaccurate prescribing of psychotropic drugs, which are commonly dispensed for indefinite periods without critical review. These practices increase the prevalence of serious adverse effects, particularly the metabolic syndrome with modern atypical antipsychotic drugs.8Mitchell A Davy V Kim S et al.Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders—a systematic review and meta-analysis.Schizophr Bull. 2013; 39: 306-318Crossref PubMed Scopus (665) Google ScholarIndia offers an important case in point. The population is at increased genetic risk for type 2 diabetes, with rising obesity in adolescents and young adults adding to the epidemic.9Khandelwal S Reddy K Eliciting a policy response for the rising epidemic of overweight-obesity in India.Obes Rev. 2013; 14: 114-125Crossref PubMed Scopus (42) Google Scholar Prescription of antipsychotic drugs for schizophrenia—a disorder for which onset peaks in adolescence and young adulthood—greatly increases risk of the metabolic syndrome.10Pérez-Iglesias R Martínez-García O Pardo-Garcia G et al.Course of weight gain and metabolic abnormalities in first treated episode of psychosis: the first year is a critical period for development of cardiovascular risk factors.Int J Neuropsychopharmacol. 2014; 17: 41-51Crossref PubMed Scopus (73) Google Scholar People with schizophrenia are at risk of cardiovascular disease because of their high rates of smoking and poor attention to diet and exercise.11Wildgust H Beary M Are there modifiable risk factors which will reduce the excess mortality in schizophrenia?.J Psychopharmacol. 2010; 24: 37-50Crossref PubMed Scopus (74) Google Scholar Therefore, the GMH movement needs to confront the reality that rollout of collaborative community-based care for schizophrenia, particularly in poorly supervised settings, might add to the looming epidemic of cardiovascular disease. There can be no mental health without physical health, and the challenge is to devise strategies to support community mental health workers in monitoring and responding to the health risks associated with treatment of schizophrenia in low-resource environments—a formidable task.A key criticism of the GMH movement is that it has blinded itself to the complexity of culture in its haste to roll out packaged programmes of care in low-income and middle-income countries.12Summerfield D “Global mental health” is an oxymoron and medical imperialism.BMJ. 2013; 346: f3509Crossref PubMed Scopus (54) Google Scholar In many cultures, psychotic symptoms are still attributed to curses, spirit possession, and communication with ancestors, and patients commonly first consult a traditional or religious leader for assistance.13Silove D Bateman C Brooks R et al.Estimating clinically relevant mental disorders in a rural and an urban setting in postconflict Timor Leste.Arch Gen Psychiatry. 2008; 65: 1205-1212Crossref PubMed Scopus (65) Google Scholar Introduction of evidence-based treatments without acknowledgment of the cultural meaning of illnesses and traditional approaches to healing can result in confusion amongst patients and carers. At worst, competition and even tension might develop between clinical services and traditional healers. Unfortunately, however, the stridency with which the cultural message has been presented risks blunting its effect on mainstream psychiatry.12Summerfield D “Global mental health” is an oxymoron and medical imperialism.BMJ. 2013; 346: f3509Crossref PubMed Scopus (54) Google Scholar A strong consensus already exists that the first step in initiation of mental health services in low-income and middle-income countries includes a comprehensive analysis of the culture, context, history, prevailing health belief systems, social structures, and politics of funding in each setting.Sustaining of mental health initiatives, particularly in low-resource settings, needs a comprehensive, multisectoral approach based on genuine engagement with the community. The sense of local ownership and involvement is essential to ensure that the complexities of disorders such as schizophrenia are addressed at both a clinical and wider social level. Social programmes are needed to overcome stigma and discrimination, relieve carer burden, and educate families about the nature of the disorder—areas in which COPSI was notably less successful. These social components of interventions are often best provided by local non-government agencies and voluntary associations, whereas core services attend to the direct clinical needs of patients.The active involvement of local leadership and stakeholder groups is crucial to sustain and develop programmes; mental health for all means all need to play a part. Therefore, as services are rolled out across low-income and middle-income countries, the global must engage with the local to forge an equal partnership to improve the lives of people with schizophrenia and their families.We declare that we have no competing interests. The Global Mental Health (GMH) movement has played a pivotal part in bringing to attention the unmet needs of patients with mental disorders, particularly in low-income and middle-income countries.1Prince M Patel V Saxena S et al.No health without mental health.Lancet. 2007; 370: 859-877Summary Full Text Full Text PDF PubMed Scopus (2147) Google Scholar, 2Collins PY Patel V Joestl SS et al.Grand challenges in global mental health.Nature. 2011; 475: 27-30Crossref PubMed Scopus (1286) Google Scholar Schizophrenia is of primary concern in view of the high level of associated disability and stigma, and the risk that, without treatment, patients will experience prolonged institutionalisation, neglect, and abuse.3Gore F Bloem P Patton G Global burden of disease in young people aged 10–24 years: a systematic analysis.Lancet. 2011; 377: 2093-2102Summary Full Text Full Text PDF PubMed Scopus (1268) Google Scholar, 4Silove D Ekblad S Mollica R The rights of the severely mentally ill in post-conflict societies.Lancet. 2000; 355: 1548-1549Summary Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 5Patel V Kleinman A Saraceno B Protecting the rights of people with mental illness: a call to action for global mental health.in: Dudley M Silove D Gayle F Mental health and human rights. Oxford University Press, Oxford2012: 362-375Crossref Google Scholar Sudipto Chatterjee and colleagues' multicentre, randomised controlled COmmunity care for People with Schizophrenia in India (COPSI) trial,6Chatterjee S Naik S John S et al.Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial.Lancet. 2014; (published online March 5.)http://dx.doi.org/10.1016/S0140-6736(13)62629-XPubMed Google Scholar in The Lancet, represents a milestone by showing the benefits of a collaborative community-based care plus facility-based care model compared with conventional facility-based care alone for treatment of moderate to severe schizophrenia. However, implementation of collaborative community-based care in low-income and middle-income countries has several issues that need further consideration, such as ensuring continuity in supervision of community workers, safeguarding the physical health of patients, and embedding services within the local context and culture. Collaborative community-based care makes sense: physical facilities (eg, clinics and hospitals) are not needed, demand on professional skills is low, and the family remains the core unit of care. COPSI is the first trial to test collaborative community-based care rigorously in a developing country, India.6Chatterjee S Naik S John S et al.Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial.Lancet. 2014; (published online March 5.)http://dx.doi.org/10.1016/S0140-6736(13)62629-XPubMed Google Scholar 187 participants were randomised to receive community-based care, and 95 to facility-based care alone. At 12 months, the collaborative community-based care intervention showed a non-significant improvement in symptoms of psychosis as measured by the positive and negative symptom scale (PANSS), and a clearer difference in improvement of disability according to the Indian disability evaluation and assessment scale [IDEAS]; (PANSS adjusted mean difference −3·75, 95% CI −7·92 to 0·42; p=0·08; IDEAS −0·95, −1·68 to −0·23; p=0·01). Furthermore, adherence to treatment was higher in the intervention group (adjusted odds ratio 2·93, 95% CI 1·34–6·39; p=0·01). Collaborative community-based care was no more effective than facility-based care alone for reducing stigma and discrimination, alleviating carer burden, or improving illness-relevant knowledge amongst family members. In assessment of these outcomes, it is important to keep in mind that chronic schizophrenia is a disabling disorder that is difficult to treat in any situation. Noteworthy, therefore, is that findings from COPSI were broadly the same as those from similar trials of collaborative community-based care done in high-income countries.6Chatterjee S Naik S John S et al.Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial.Lancet. 2014; (published online March 5.)http://dx.doi.org/10.1016/S0140-6736(13)62629-XPubMed Google Scholar What lessons can be learned from COPSI? Supervision was the most costly component of the collaborative community-based care intervention. Maintenance of supervision in very low resource settings is a major challenge, because of cost and the perennial issue of loss of skilled professionals. In Timor-Leste, for example, discontinuation of donor funding in 2005 left 15 national community mental health workers with no professional supervision for 3 years, until the return of the first trained Timorese psychiatrist.7WHOTimor-Leste.in: Silove D Tilman T Hawkins Z Building back better: sustainable mental health care after emergencies. World Health Organization, Geneva2013: 83-88Google Scholar Scarcity of supervision results in worker isolation, demoralisation, and attenuation of skills. Assessments can become cursory, leading to misdiagnosis and inaccurate prescribing of psychotropic drugs, which are commonly dispensed for indefinite periods without critical review. These practices increase the prevalence of serious adverse effects, particularly the metabolic syndrome with modern atypical antipsychotic drugs.8Mitchell A Davy V Kim S et al.Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders—a systematic review and meta-analysis.Schizophr Bull. 2013; 39: 306-318Crossref PubMed Scopus (665) Google Scholar India offers an important case in point. The population is at increased genetic risk for type 2 diabetes, with rising obesity in adolescents and young adults adding to the epidemic.9Khandelwal S Reddy K Eliciting a policy response for the rising epidemic of overweight-obesity in India.Obes Rev. 2013; 14: 114-125Crossref PubMed Scopus (42) Google Scholar Prescription of antipsychotic drugs for schizophrenia—a disorder for which onset peaks in adolescence and young adulthood—greatly increases risk of the metabolic syndrome.10Pérez-Iglesias R Martínez-García O Pardo-Garcia G et al.Course of weight gain and metabolic abnormalities in first treated episode of psychosis: the first year is a critical period for development of cardiovascular risk factors.Int J Neuropsychopharmacol. 2014; 17: 41-51Crossref PubMed Scopus (73) Google Scholar People with schizophrenia are at risk of cardiovascular disease because of their high rates of smoking and poor attention to diet and exercise.11Wildgust H Beary M Are there modifiable risk factors which will reduce the excess mortality in schizophrenia?.J Psychopharmacol. 2010; 24: 37-50Crossref PubMed Scopus (74) Google Scholar Therefore, the GMH movement needs to confront the reality that rollout of collaborative community-based care for schizophrenia, particularly in poorly supervised settings, might add to the looming epidemic of cardiovascular disease. There can be no mental health without physical health, and the challenge is to devise strategies to support community mental health workers in monitoring and responding to the health risks associated with treatment of schizophrenia in low-resource environments—a formidable task. A key criticism of the GMH movement is that it has blinded itself to the complexity of culture in its haste to roll out packaged programmes of care in low-income and middle-income countries.12Summerfield D “Global mental health” is an oxymoron and medical imperialism.BMJ. 2013; 346: f3509Crossref PubMed Scopus (54) Google Scholar In many cultures, psychotic symptoms are still attributed to curses, spirit possession, and communication with ancestors, and patients commonly first consult a traditional or religious leader for assistance.13Silove D Bateman C Brooks R et al.Estimating clinically relevant mental disorders in a rural and an urban setting in postconflict Timor Leste.Arch Gen Psychiatry. 2008; 65: 1205-1212Crossref PubMed Scopus (65) Google Scholar Introduction of evidence-based treatments without acknowledgment of the cultural meaning of illnesses and traditional approaches to healing can result in confusion amongst patients and carers. At worst, competition and even tension might develop between clinical services and traditional healers. Unfortunately, however, the stridency with which the cultural message has been presented risks blunting its effect on mainstream psychiatry.12Summerfield D “Global mental health” is an oxymoron and medical imperialism.BMJ. 2013; 346: f3509Crossref PubMed Scopus (54) Google Scholar A strong consensus already exists that the first step in initiation of mental health services in low-income and middle-income countries includes a comprehensive analysis of the culture, context, history, prevailing health belief systems, social structures, and politics of funding in each setting. Sustaining of mental health initiatives, particularly in low-resource settings, needs a comprehensive, multisectoral approach based on genuine engagement with the community. The sense of local ownership and involvement is essential to ensure that the complexities of disorders such as schizophrenia are addressed at both a clinical and wider social level. Social programmes are needed to overcome stigma and discrimination, relieve carer burden, and educate families about the nature of the disorder—areas in which COPSI was notably less successful. These social components of interventions are often best provided by local non-government agencies and voluntary associations, whereas core services attend to the direct clinical needs of patients. The active involvement of local leadership and stakeholder groups is crucial to sustain and develop programmes; mental health for all means all need to play a part. Therefore, as services are rolled out across low-income and middle-income countries, the global must engage with the local to forge an equal partnership to improve the lives of people with schizophrenia and their families. We declare that we have no competing interests. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trialThe collaborative community-based care plus facility-based care intervention is modestly more effective than facility-based care, especially for reducing disability and symptoms of psychosis. Our results show that the study intervention is best implemented as an initial service in settings where services are scarce, for example in rural areas. Full-Text PDF Open AccessThe COPSI Trial: additional fidelity testing neededIndia has been at the forefront of using non-specialist health personnel for mental health care worldwide for more than three decades.1 The COPSI trial (April 19, p 1385)2 is an important study in terms of its objectives, design, and rigorous methods. However, India has a large resource constraint for psychiatrists with an average national deficit of 77% and a greater scarcity of other types of mental health professionals.3 Three challenges exist for organisation of mental health care in India and other developing countries: accessibility, acceptability, and affordability. Full-Text PDF
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