Can community-based psychosocial interventions help people with schizophrenia?
Laura Asher is a Clinical Research Fellow in the Centre for Global Mental Health at the London School of Hygiene & Tropical Medicine.
People with psychosis living in low and middle-income countries are arguably amongst the most vulnerable groups globally. Through my research in Ethiopia I heard numerous stories of the struggles of people with the illness, and often more heartbreakingly, stories told by their relatives, often their wives, mothers or sisters, of the daily battle to do what is best for their family member. With little or no medical or social support available, they are often driven to chaining up their relative, as the only means to contain behaviour. Even once people who have had psychosis feel well, the memory of their illness seems to linger in their communities, making it difficult to find a spouse, be taken seriously in community meetings or to get a job.
Yet in the field of global mental heath, psychosis has received relatively little attention. My new systematic review of community based psychosocial interventions for people with schizophrenia in low and middle-income countries sheds some light on the best ways to support this group. The review included 11 randomised controlled trials, all of which took place in upper-middle income countries, with the exception of two in lower-middle income countries. A broad range of intervention models were identified, including single-faceted psychoeducational interventions, multi-component rehabilitation-focused interventions and case management interventions.
The review found that psychosocial interventions may have a significant impact on both symptoms and functioning of people with schizophrenia. However the quality of studies was sometimes low and there were some important gaps in the evidence. In particular, only in one study was the intervention delivered by trained lay persons. It is widely accepted that due to the severe shortage of mental health specialists in low and middle-income countries, non-specialists may be the most feasible mental healthcare providers. It was also interesting to note that interventions appeared to be effective even without employing community mobilisation. Such models of support, in particular community-based rehabilitation, have been recommended as appropriate approaches for low and middle income country contexts. Further research is needed, particularly in low-income countries, to understand the role and utility of wider community engagement on outcomes for individuals and whether psychosocial interventions are effective when delivered in scalable formats using non-specialist workers.
The Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) project may help to fill some of these gaps. The RISE intervention development was guided by the community-based rehabilitation model. This means that the intervention tries to ensure the illness is treated as well as possible, for example by supporting individuals to access and adhere to antipsychotic medication. But RISE is broader than that: it also supports the family, involves stigma reduction work in the wider community and tries to draw out practical support from community members. The findings of the RISE pilot and cluster randomised trial will be published in the coming months. In the meantime the RISE training manual (see Resources section) for community-based rehabilitation workers is available as a resource for non-governmental organisations, researchers, health or social services. This manual has been designed to be used by lay persons to support people with schizophrenia following a five week training programme, in parallel to them receiving facility-based care. The training programme materials are also available on request.
