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Evaluation of a community based rehabilitation for chronic schizophrenia in India
Abstract
There are no community services for the majority of the estimated 10 million persons with schizophrenia in India. Community-based rehabilitation (CBR) is a model of care which has been widely used for physical disabilities in resource-poor settings.
To compare CBR with out-patient care (OPC) for schizophrenia in a resource-poor setting in India.
A longitudinal study of outcome in patients with chronic schizophrenia contrasted CBR with OPC. Outcome measures were assessed using the Positive and Negative Symptom Scale and the modified WHO Disability Assessment Schedule at 12 months.
Altogether, 207 participants entered the study, 127 in the CBR group and 80 in the OPC group. Among the 117 fully compliant participants the CBR model was more effective in reducing disability, especially in men. Within the CBR group, compliant participants had significantly better outcomes compared with partially compliant or non-complaint participants (P<0.001). Although the subjects in the CBR group were more socially disadvantaged, they had significantly better retention in treatment.
The CBR model is a feasible model of care for chronic schizophrenia in resource-poor settings.
... For developed countries, two studies were conducted in the United Kingdom [32,33], and two studies were in America [25,34]; three studies were conducted in Portugal [29], Sweden [35], and Italy [36], respectively. For developing countries, two studies, reported in three papers, were conducted in India [18,31,37]; seven studies, reported in eight papers, were conducted in China [24,26,28,30,[38][39][40][41]; two studies were Studies included in the metaanalysis (N=20) Greater improvements in cognitive function conducted in Iran [42,43]; one study, reported in two papers, was conducted in South Africa [44,45]; and two studies were conducted in Turkey [27,46]. ...
... Four studies used a cluster randomized design [30,33,38,41], whilst rest of the studies used an individually randomized design. Four studies were conducted at multiple sites [18,33,37,40]. ...
... Group Two consisted of more comprehensive multi-faceted interventions including family intervention, support for the development of social and independent living skills, drug adherence, crisis intervention and dealing with stigma. This group included the Indian community-based rehabilitation, Chatterjee et al. [37] and [18], six Chinese RCTs, Xianzuo et al. [24], Guo et al. [28], Cai et al. [40], Li et al. [26], Ran et al. [41] and [30], one Sweden study Malm et al. [35], one American study Mueser et al. [34], and one study from the United Kingdom, Slade et al. [33]. ...
Schizophrenia is a serious mental illness that imposes huge burden of illness on the society. We aimed to conduct a meta-analytic and systematic review of literature on the effectiveness of community-based rehabilitation interventions on symptoms and functioning for people with schizophrenia. The PubMed, Embase, the Cochrane Library, Web of Science, and CINAHL databases were searched through April 16 and 17, 2021, including clinical trial registries and previous Cochrane reviews. We included 24 randomized controlled trials in this review. The content of interventions varied from single-faceted rehabilitation intervention or cognitive retraining, to multi-component rehabilitation interventions or case management. Among 20 studies that reported effects of community-based rehabilitation interventions on symptoms, the pooled SMDs across all interventions was 0.94 (95% CI = 0.11, 1.76; P < 0.001; I² = 99.1%; n = 3694), representing a strong effect. 21 included studies showed that community-based rehabilitation interventions also had beneficial impacts on functioning (SMD = 1.65; 95% CI = 0.88, 2.43; P < 0.001; I² = 98.9%; n = 3734). Overall quality of evidence was moderate with a high level of heterogeneity. Community-based rehabilitation interventions have positive effectiveness in improving patients’ symptoms and functioning. Community-based rehabilitation interventions should therefore be provided as an adjuvant service in addition to facility-based care for people with schizophrenia.
... Fo r the study, we would allocate areas that are currently not being covered proactively by ASHAs randomly in a 1:1 ratio via co mputergenerated randomization list to receive (LAMIC's). The most methodologically robust CBR intervention studies were conducted by Chatterjee et al. (2003Chatterjee et al. ( , 2009. 5-7 Chatterjee et al. (20035-7 Chatterjee et al. ( , 2009 5,6 reported outcomes of the CBR program implemented by Ashagram Trust, a community-based nongovernmental organization (NGO) working toward the rehabilitation of people affected by leprosy, in Barwani district, Madhya Pradesh. ...
... 5-7 Chatterjee et al. (20035-7 Chatterjee et al. ( , 2009 5,6 reported outcomes of the CBR program implemented by Ashagram Trust, a community-based nongovernmental organization (NGO) working toward the rehabilitation of people affected by leprosy, in Barwani district, Madhya Pradesh. Chatterjee et al. (2003) compared the effectiveness of CBR (n = 127) and outpatient care (n = 80) for consecutive series of patients diagnosed with chronic schizophrenia (ICD 10, duration >2 years) in Barwani district, Madhya Pradesh. In the outpatient care model, services were provided in a monthly clinic where patients were followed up, treatment reviewed, psychoeducated, family counseled, and rehabilitation strategies were discussed. ...
... In the Indian context, the studies by Chatterjee et al. (2003Chatterjee et al. ( , 2009 [5][6][7] did not use government grass-root level, health staff. It is not clear if the community health workers were volunteers or workers who were paid honorarium/ full salary. ...
This is a special supplement of the Indian Journal of Psychological Medicine, the official publication of the Indian Psychiatric Society South Zone. It includes protocols of 12 single site and multi-site implementation research projects funded by the Indian Council of Medical Research. Projects address the thrust areas of the Indian National Mental Health Programme.
... Fo r the study, we would allocate areas that are currently not being covered proactively by ASHAs randomly in a 1:1 ratio via co mputergenerated randomization list to receive (LAMIC's). The most methodologically robust CBR intervention studies were conducted by Chatterjee et al. (2003Chatterjee et al. ( , 2009Chatterjee et al. ( , and 2014. [5][6][7] Chatterjee et al. (2003Chatterjee et al. ( , 2009 5,6 reported outcomes of the CBR program implemented by Ashagram Trust, a community-based nongovernmental organization (NGO) working toward the rehabilitation of people affected by leprosy, in Barwani district, Madhya Pradesh. ...
... The most methodologically robust CBR intervention studies were conducted by Chatterjee et al. (2003Chatterjee et al. ( , 2009Chatterjee et al. ( , and 2014. [5][6][7] Chatterjee et al. (2003Chatterjee et al. ( , 2009 5,6 reported outcomes of the CBR program implemented by Ashagram Trust, a community-based nongovernmental organization (NGO) working toward the rehabilitation of people affected by leprosy, in Barwani district, Madhya Pradesh. Chatterjee et al. (2003) compared the effectiveness of CBR (n = 127) and outpatient care (n = 80) for consecutive series of patients diagnosed with chronic schizophrenia (ICD 10, duration >2 years) in Barwani district, Madhya Pradesh. ...
... The most methodologically robust CBR intervention studies were conducted by Chatterjee et al. (2003Chatterjee et al. ( , 2009Chatterjee et al. ( , and 2014. [5][6][7] Chatterjee et al. (2003Chatterjee et al. ( , 2009 5,6 reported outcomes of the CBR program implemented by Ashagram Trust, a community-based nongovernmental organization (NGO) working toward the rehabilitation of people affected by leprosy, in Barwani district, Madhya Pradesh. Chatterjee et al. (2003) compared the effectiveness of CBR (n = 127) and outpatient care (n = 80) for consecutive series of patients diagnosed with chronic schizophrenia (ICD 10, duration >2 years) in Barwani district, Madhya Pradesh. ...
Background
Task shifting has been recommended as a strategy to reach out to persons with mental illness and bridge the treatment gap. There is a need to explore task-shifting using existing health staff like Accredited Social Health Activists (ASHAs).
Aim and Context
ASHAs are involved in ongoing community-based rehabilitation (CBR) program run with a public–private partnership over the last 5 years at Jagaluru Taluk (an administrative block) in Davanagere district (Karnataka, India). This article aims to summarize a randomized controlled trial (RCT) to examine whether CBR delivered by ASHAs is more effective than treatment as usual (TAU) control group in reducing disability associated with severe mental illness (SMI).
Method
A group of proactive ASHAs is already working with us for a follow-up of persons with SMI. For the study, we would allocate areas that are currently not being covered proactively by ASHAs randomly in a 1:1 ratio via computer-generated randomization list to receive either ASHAs delivered CBR arm or TAU control group. A sample size of about 100 in each arm is enough to identify an effect size of 0.5 in total IDEAS score between the intervention and control arms with a power of 90% and an alpha of 0.05. We use the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) statement to describe the methods of the trial.
Result
The study has been approved by the institute ethics committee and registered with CTRI (CTRI/2019/08/020585 dated 6th August 2019). The recruitment of subjects is ongoing. The patients will be followed up for 1 year and assessed. The trial is funded by the Indian Council of Medical Research, Government of India.
Discussion
The results of the study will be helpful from a public health perspective in delivering cost-effective and replicable CBR for persons with SMI through ASHAs. If the model turns successful, this could be expanded throughout the state/country. This would go a long way in bridging the huge treatment gap.
... These concepts have been incorporated into the core operational aspects of NMHP/DMHP as mentioned earlier. The next set of research focused on specific disorders and populations (for example, the elderly, persons with schizophrenia or depression, etc.) [35][36][37][38][39][40][41][42][43] . These have potentially informed newer inclusions into the NMHP (guidelines for implementing district-level activities under the 12 th five-year plan period). ...
... With regard to severe mental illnesses, the community-based approaches (community-based interventions) have been shown to be effective in not only symptomatic control but also in limiting disability, meaningfully improving work functioning (even long term) and lastly demonstrating that available resources can be effectively utilized for rehabilitation programmes [35][36][37][38][39][40][41][42][43] . Research has also shown a significant reduction of out-of-pocket expenses if patients use these community resources instead of tertiary care centres 45 , etc. Since 2020, the following initiatives are underway: systematic assessment to examine the extent of reduction of treatment gap by these community interventions including DMHP, impact of care at doorsteps from the DMHP machinery, to evaluate the impact of technology-based mentoring programme for DMHP staff of a rural DMHP district, evaluation of the impact of Tele-On Consultation Training, validation of the Clinical Schedules for Primary Care Psychiatry and the impact of such community intervention programmes on the number/ cost of hospitalizations of persons with schizophrenia, etc. ...
Mental disorders in India form a major public health concern and the efforts to tackle these dates back to four decades, by way of the National Mental Health Programme (NMHP) and its operational arm, the District Mental Health Programme (DMHP). Although the progress of NMHP (and DMHP) was relatively slower till recently, the last 4-5 years have seen rapid strides with several initiatives, including (i) expansion of DMHPs to 90 per cent of the total districts of the country, (ii) the National Mental Health Policy and (iii) strengthening the Mental Health Legislation by way of providing explicit provisions for rights of persons with mental illnesses. Among others, factors responsible for this accelerated growth include the easily accessible digital technology as well as judicial activism. Federal and State cooperation is another notable feature of this expansion. In this review, the authors summarize the available information on the evolution of implementation and research aspects related to India's NMHP over the years and provide a case for the positive turn of events witnessed in the recent years. However, the authors caution that these are still baby steps and much more remains to be done.
... 9 For instance, CBR programmes incorporating microfinance schemes for people with psychotic disorders were efficient in reducing disability severity and overcoming the economic, cultural, and geographical barriers in India. 10,11 In Kenya, an integrated CBR and microfinance intervention led to significant improvements in mental health, quality of life, social functioning, and economic activity. 12 Integrated microfinance and health interventions were found to be effective in reducing communicable diseases in Africa. ...
... However, existing studies are not methodologically rigorous as they followed either quasi-experimental 15 or cross-sectional design. [10][11][12]14 Health interventions should be tailored based on the needs of the target population. 17 Earlier studies suggest that rehabilitation programmes should incorporate livelihood support to provide equal opportunities for people with disabilities in LMICs. ...
Aim
To test the efficacy of an integrated microfinance/livelihood and community‐based rehabilitation (IMCBR) programme in improving health‐related quality of life (HRQoL) and motor function of children with cerebral palsy (CP) and gain in social capital to their ultra‐poor families in rural Bangladesh.
Method
This was an open‐label cluster randomized control trial. Children with CP aged 5 years or under were randomly allocated to three arms; Arm A: IMCBR; Arm B: community‐based rehabilitation (CBR); and Arm C: care‐as‐usual. The CBR was modified with phone follow‐up followed by home‐based CBR at 2.5 months post‐enrolment because of the COVID‐19 pandemic. Intention‐to‐treat analysis was performed.
Results
Twenty‐four clusters constituting 251 children–primary caregivers' dyads were assigned to three arms (Arm A = 80; Arm B = 82; Arm C = 89). Between baseline and endline, the percentage mean change in the physical functioning domain of HRQoL was highest in Arm A (30.0%) with a significant mean difference between Arm A and Arm B (p = 0.015). Improvement in the mean social capital score was significantly higher in Arm A compared to Arm C (p < 0.001).
Interpretation
The findings suggest that IMCBR could improve the HRQoL of children with CP and the social capital of their ultra‐poor families. Long‐term follow‐up of the trial participants and future exploration of such interventions are essential. The integrated livelihood and CBR programme holds potential to improve health and well‐being of children with CP and their ultra‐poor families.
What this paper adds
Half of the families who received livelihoods were impacted by a cold‐wave, suggesting the need for a more disaster‐resilient livelihood asset.
The integration of livelihood with community‐based rehabilitation programme helps to improve health‐related quality of life of children with cerebral palsy and the social capital of their ultra‐poor families.
... Utilizing the capacities of the community, the neighborhood environment, and the individual support network helps to form a network of local volunteers to care for the patient and prevent relapse, in addition to strengthening patient-family social relationships. Studies in India and other countries have evaluated the effectiveness of a community-based rehabilitation model for PLS in low resource settings and results show that such models are effective in reducing disability, psychotic symptoms, relapse and hospitalization, increased communication with treatment teams, and increasing adherence and persistence in treatment (Chatterjee et al., 2003(Chatterjee et al., , 2014. WHO, meanwhile, divides the responsibility for mental health screening, referral, management, and follow-up among non-specialist health workers and health professionals by providing a model of task-sharing or task-shifting. ...
... At the second level, they trained health workers to provide mental health services in local communities, and at the third level, they involved family members and key people in the individual's support network to actively participate in the care of PLS. The results of this research showed that the people who received this intervention had better adherence to treatment than the people who received the intervention of experts (Chatterjee et al., 2003). In other studies, in India and Pakistan, shifting the tasks of experts to trained health workers was examined. ...
Background
People living with schizophrenia (PLS) suffer frequent relapse accompanied by emergency room visits, premature mortality, lower quality of life and a substantial social and economic burden on families and health systems. There is a dearth of community-based relapse prevention interventions (RPIs) in Iran.
Aims
To determine an ideal model for a community-based RPIs for PLS.
Methods
A qualitative study with 27 experts in Iran was carried out to understand the ideal RPIs for PLS and the key components of such interventions.
Results
In 16 semi-structured interviews and 8 group-discussions, the participants identified six major stages of family and community-based RPIs including preparation, social mobilization, local team formation, design an RPI, implementing the RPI, participatory monitoring, and evaluation of the RPI.
Conclusions
Given the suboptimal healthcare systems and lack of professionals and services, PLS in Iran may benefit from family and community-based RPIs. Our findings warrant pilot testing of such initiatives across developing communities like Iran to improve health outcomes of PLS.
... It is on record that measurement and documentation of incidents associated with drug use and its attendant health and social problems have been facilitated by involving community members (Tosin and Tshitangano, 2016;Thomson, 2015;Kresina, Bruce and Mulvey, 2013;Chatterjee, Patel, Chatterjee, Weiss,2003). In a study conducted by Chatterjee, Patel, Chatterjee and Weiss (2003) on the awareness of public perception of drug-reduction programmes, 24.8% of the sampled population was aware of the effectiveness of community participation in drug reduction. Further questions on community-based reduction programmes showed that 59.6% of the respondents were interested in joining a drug reduction programme, while 98.2% emphasised the importance of community participation in drug reduction in their respective socio-cultural communities. ...
... On the whole, many research inquiries have shown that several reviews of the drug use reduction by primary prevention programmes in literature have yielded equivocal results and have not systematically evaluated any dramatic decrease in the use of drugs among the populace (Thomson, 2015;Chatterjee, Patel, Chatterjee, Weiss, 2003). To fill in this huge gap in the literature, questions raised by previous studies have been critically analysed in this study to re-assess and evaluate the invaluable potential of community participation in the fight against illicit drug use in South Africa. ...
... The socio-cultural and demographic diversity across the states of India requires that the policies and interventions to contain the burden of schizophrenia and other severe mental disorders be well suited to local contexts. Although there are few reports on the effectiveness of community-based rehabilitation approaches in India (Basavaraju et al., 2020;Chatterjee et al., 2003Chatterjee et al., , 2009Srinivasa Murthy et al., 2005), there are no reports on modified ACT program implementation. We aimed to study the effectiveness of the modified ACT program in schizophrenia patients being adapted in a South Indian setting, i.e., Manipal Assertive Community Treatment (M-ACT), and describe the perspectives of patients and caregivers who participated in the program. ...
... The effectiveness of the assertive community treatment program in our study setting is unlikely to be due to medication adherence alone, as the dose of antipsychotic medication remained more or less the same over the duration of the assertive service. Although there has been no report on assertive community services for severe mental disorders from India, the earlier reports have highlighted good clinical outcomes in patients with severe mental illness who received community-based rehabilitation services (Basavaraju et al., 2020;Chatterjee et al., 2003Chatterjee et al., , 2009Srinivasa Murthy et al., 2005). Few unique characteristics of our M-CAT program are noteworthy. ...
Background
Schizophrenia is a disabling mental illness. Antipsychotic treatment in conjunction with comprehensive psychosocial rehabilitation services is essential in promoting functional recovery. Assertive Community Treatment (ACT) is an evidence-based approach in promoting recovery in schizophrenia. The evidence for the effectiveness and feasibility of such community-based assertive interventions in low and middle-income countries is limited.
Aim
To evaluate the effectiveness of modified assertive community treatment in a South Indian setting and evaluate the perspectives of patients and caregivers who participated in the program.
Methodology
Socio-demographic details, illness characteristics, course of the illness including the number of relapses and hospitalization, adherence level at baseline, the scores on the Social and Occupational Functioning Assessment Scale (SOFAS), and Global disability score on Indian Disability Evaluation and Assessment Scale (IDEAS) were compared before and after the initiation of the M-CAT program using retrospective file review. The perspectives of the clients were assessed using a 6 item questionnaire.
Results
Ten patients (six male and four female) with a diagnosis of Schizophrenia were under the Manipal Assertive Community Treatment (M-ACT) program for a median duration of 3 years (IQR 1.25) participated in the study. There was a significant improvement in the overall level of functioning, medication adherence, relapse rates, and disability after the enrolment into the program. The majority of the respondents had a positive attitude towards the M-ACT program.
Conclusion
Assertive community interventions with suitable modifications for local resource-limited conditions may be an effective option in promoting functional recovery in Schizophrenia.
... For example, PWs have been involved in supporting and befriending carers and in ensuring intervention adherence (Tol 2020). Nurses, social workers, and CWs may also take on follow-up or educational/ promotive roles (Araya 2003;Chatterjee 2003;Patel 2008). In addition, doctors with general mental health training have been involved in identification, diagnosis, treatment, and referral of complex cases (Patel 2008). ...
... It has been suggested that PWs could deliver general and mental health interventions that are at least as e ective and acceptable as those delivered by specialist health workers (Chatterjee 2003). In addition, PW interventions o en have lower up-front costs compared with those provided by professional specialist health workers. ...
Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To assess the effectiveness of delivery by primary workers of interventions for promotion of mental health and for prevention of mental disorders or symptoms of mental illness in LMICs To examine the impact of intervention delivery by primary workers on resource use and costs associated with provision of mental health care in LMICs. Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
... In this context, a four-year follow-up of a cohort of individuals with severe mental disorders revealed that participation in community strategies emerged as an independent predictor of improvement in social functioning. This improvement was evident in activities such as voting, attending festivals, and engaging in work-related activities (Chatterjee et al., 2003). The above-mentioned is in line with the findings of the present study, which shows an improvement in psychosocial disability among individuals who participated in these strategies. ...
Based on the need to implement strategies to reduce recovery gaps in mental health with the community as axes of recovery, the objective of the present study was to assess the impact on psychosocial disability and care continuity in individuals with suicidal behavior, of the clinical and community components of the Mental Health Gap Action Program (mhGAP), versus exclusive psychiatric care. For this, a controlled community trial carried out in 2023 was conducted, comprising intervention groups: Support Group (SG), mhGAP Group (mhGAPG) and a Control Group (CG). Self-report measurements were collected pretest and posttest, utilizing the Psychosocial Disability Scale and the Alberta Continuity of Care Scale. The study involved the participation of 94 individuals with a history of suicidal behavior, with 30 individuals in the SG, 34 in the mhGAP group, and 30 in the CG. Categorical variables were summarized using frequency distribution tables. Descriptive statistics were used to examine participants’ characteristics at the study outcome and estimate treatment compliance. The Mann–Whitney U Test examined differences in sociodemographic variable frequencies. The Jarque-Bera test confirmed a normal distribution for psychological variables, warranting the use of parametric tests. Differences in mean values across groups, each with two measurements per individual, were assessed using a type II repeated measures ANOVA. There were significant differences based on the intervention, with the effect being greater in the SG across all domains. Significant improvement was observed in all domains of the disability and continuity of care scale within the intervention groups. Both groups showed improvement, with better results for the SG. In conclusion, a methodology is proposed for implementing support groups based on core components, which effectively enhances psychosocial disability and the continuity of mental health care, especially in suicidal behavior.
... Community-based rehabilitation is a model that should be established in low-income and developing countries in order to overcome recent barriers. What makes the community-based rehabilitation model effective and sustainable is that it increases accessibility, cultural sensitivity and social participation 30 . In the process of building community-based regimes in the rehabilitation of war victims and refugees, mental health service models for individuals; struggling with severe mental illnesses in various tough circumsistances can be taken as an example. ...
Many family physicians and other medical professionals are really worried about the
ecological and climate crises. However, they frequently have trouble coming up with
practical solutions to deal with it in their work. To address this issue, this
session will respond to the question, "What can I do in my practice?"
Fortunately, there is already existing advice. Some of the family practice guidelines
that have been created by various nations will be shared and debated during this
session. This toolkit acts as a mechanism for continuous quality improvement by
defining the justification for each step, offering advice on how to execute it, and
showing the way to a practice with net-zero carbon emissions.
Lifestyle Medicine (LM) is evidence-based, clinical care that supports behavior
change through person-centered techniques to improve mental well-being, social
connection, healthy eating, physical activity, sleep, and minimization of harmful
substances. This is highly relevant in the context of family medicine and the current
non-communicable disease pandemic.
... The launch of the global mental health movement in a Lancet series in 2007, identified task-shifting as a key role of CHWs to address the shortage of professional human resources. Several studies have demonstrated the importance of community-based workers to promote mental health in communities [12][13][14]35] and particularly, in delivering psychosocial interventions, for example, in the Problem Management Plus intervention where CHWs delivering a structured and locally accessible psychosocial intervention [20]. ...
Community-based workers promote mental health in communities. Recent literature has called for more attention to the ways they operate and the strategies used. For example, how do they translate biomedical concepts into frameworks that are acceptable and accessible to communities? How do micro-innovations lead to positive mental health outcomes, including social inclusion and recovery? The aim of this study was to examine the types of skills and strategies to address social dimensions of mental health used by community health workers (CHWs) working together with people with psychosocial disability (PPSD) in urban north India.
We interviewed CHWs (n = 46) about their registered PPSD who were randomly selected from 1000 people registered with a local non-profit community mental health provider. Notes taken during interviews were cross-checked with audio recordings and coded and analyzed thematically.
CHWs displayed social, cultural, and psychological skills in forming trusting relationships and in-depth knowledge of the context of their client's lives and family dynamics. They used this information to analyze political, social, and economic factors influencing mental health for the client and their family members. The diverse range of analysis and intervention skills of community health workers built on contextual knowledge to implement micro-innovations in a be-spoke way, applying these to the local ecology of people with psychosocial disabilities (PPSD). These approaches contributed to addressing the social and structural determinants that shaped the mental health of PPSD.
Community health workers (CHWs) in this study addressed social aspects of mental health, individually, and by engaging with wider structural factors. The micro-innovations of CHWs are dependent on non-linear elements, including local knowledge, time, and relationships. Global mental health requires further attentive qualitative research to consider how these, and other factors shape the work of CHWs in different locales to inform locally appropriate mental health care.
... However, these instruments are aimed at clinical professionals and not at facilitators of community strategies, who do not necessarily have a profession, like the sample of the present research.Regarding each component, there is the support interaction, which refers to the communication of feelings and the exchange of mutual support and experiential knowledge among the members of the group, which tends to have a positive influence on adherence to treatment of the members.27 During a 4-year follow-up of a cohort of people with severe mental disorders, participation in community strategies was an independent predictor of improvement in social functioning, for example, voting, attending festivals and working.38 The mentioned above is in dialogue with the findings of the present study, which shows an association between the Mutual Aid component and Improvement in the quality of life, Building Skills for Like and Increasing Hope.Other components coincide with some guidelines proposed by Pearce et al.,39 who mention as core components of support for self-management of non-communicable problems and disorders: understandable language, report on available resources, training in life skills, training in psychological strategies, social support, advice on lifestyles, which is reaffirmed in the correlation between the Strategies for Mental Health, and the benefits of Learning in mental health and Building skills for life (Appendix 1).Although people from various regions of Colombia were considered, future studies could strengthen the validation process by increasing the population with samples from different regions, including an ethical approach and with groups of different ages. ...
Aims
To develop and validate an instrument to identify the core components of community strategies for mental health, especially mutual aid groups: The Mutual Aid Scale .
Methods
135 community strategies leaders participated in the study. The core components are active agency, coping strategies, recognition, and management of emotions, problem‐solving strategies, supportive interaction, trust, self‐identity construction, and strengthening of social networks. With these components a scale was designed. Content validity was carried out in addition to an exploratory factor analysis.
Results
Two dimensions resulted, strengthening of agency capacity and Coping strategies, and the internal consistency of both factors was acceptable, with a Cronbach's alpha of 0.722 and 0.727, respectively. The Kaiser‐Meyer‐Olkin (KMO) statistic was used with a score of 0.831 and the Barlett Sphericity Test, with a significant value of 265.175.
Conclusion
This scale identifies the components of community interventions for mental health and can contribute to a better implementation of these strategies. It also articulates autonomous community processes with strategies developed in health services.
... This strategy may be especially beneficial in areas where mental health literacy is low, and where formal health services are not necessarily seen as a place to seek treatment for mental health problems. Furthermore, community members use shared cultural idioms which could promote more effective communication, facilitate trust and therefore lower barriers to seeking help and ultimately, reduce stigma [82,83]. These in-person interventions all linked people to mental healthcare based in the community, and one in schools [77]. ...
Mental health problems are a significant and growing cause of morbidity worldwide. Despite the availability of evidence-based interventions, most people experiencing mental health problems remain untreated. This treatment gap is particularly large in low- and middle-income countries (LMIC) and is due to both supply-side and demand-side barriers. The aim of this systematic review is to identify and synthesise the evidence on interventions to improve help-seeking for mental health problems in LMICs. The protocol was registered a priori (Registration number: CRD42021255635). We searched eight databases using terms based on three concepts: ‘mental health/illness’ AND ‘help-seeking’ AND ‘LMICs’; and included all age groups and mental health problems. Forty-two papers were eligible and included in this review. Intervention components were grouped into three categories following the steps in the help-seeking process: (1) raising mental health awareness among the general population (e.g., distribution of printed or audio-visual materials), (2) identification of individuals experiencing mental health problems (e.g., community-level screening or detection), and (3) promoting help-seeking among people in need of mental health care (e.g., sending reminders). The majority of interventions (80%) included components in a combination of the aforementioned categories. Most studies report positive outcomes, yet results on the effectiveness is mixed, with a clear trend in favour of interventions with components from more than one category. Ten out of 42 studies (24%) yielded a statistically significant effect of the intervention on help-seeking; and all targeted a combination of the aforementioned categories (i.e., raising awareness, identification and help-seeking promotion). Only six studies (14%) focused on children and adolescents. Due to the limited number of robust studies done in LMICs and the heterogeneity of study designs, outcomes and components used, no definite conclusions can be drawn with regards to the effects of individual strategies or content of the interventions.
... The community-based rehabilitation (CBR) intervention has been demonstrated to be feasible and effective in multiple community settings, but not in an integrated manner with tertiary care hospitals (Chatterjee et al., 2003(Chatterjee et al., , 2009. The main implementation question addressed in this study was whether tertiary care institutions in India could be successfully engaged in increasing the availability of catchment area-based, recovery-oriented community services for PLwS. ...
Background
There is a priority need to make community-based care widely available for people living with schizophrenia (PLwS) in low- and middle-income countries. An innovative approach for increasing access could be to integrate clinical services available in tertiary care hospitals with community-based care through a task-sharing approach. We describe such an integrated intervention that was implemented at Tezpur in northeast India in collaboration with the Lokopriya Gopinath Bordoloi Regional Institute of Mental Health (LGBRIMH).
Method
The objectives of the study were to illustrate the feasibility of integrating and implementing the intervention and to describe its individual, systemic, and public health impacts. Due to the limited resources available, we conducted a pragmatic single-arm longitudinal evaluation of the intervention cohort over 24 months.
Results
Of the 239 PLwS enrolled in the intervention, 198 (83%) were followed up for 24 months, with nearly three-quarters reporting a >70% reduction in disabilities, most notably between 6 and 18 months. There was a marked reduction in unmet needs across multiple domains, and at 24 months, 62% of the cohort was engaged in individual jobs or other market-linked livelihood opportunities. There was greater uptake and retention with outpatient contacts at the LGBRIMH, and PLwS experienced a marked (82%) reduction in inpatient admissions rates, as compared to before enrolment. Over a period of 24 months, primary caregivers reported that their families experienced significantly fewer social difficulties such as unemployment, interpersonal conflicts, and social isolation. The intervention had a significant public health impact, with an estimated 51.8% effective treatment coverage rate for the integrated intervention.
Conclusion
Our findings provide preliminary evidence of the feasibility of implementing the integrated intervention and its effectiveness. We believe that there is merit in further in-depth refinement and exploration of this implementation-related research and cost analysis while replicating the intervention in other tertiary care institutions.
... Many quantitative studies evaluate the health component of CBR [35], a lot less education, less access to assistive devices [36,37], nutrition [38], immunization [39], livelihoods [40] and social inclusion [41], and almost no empowerment [34]. The existing research does not look usually at various disabilities but instead focus on one condition or type of disability [42]. Few studies focus on service delivery outcomes and the improvement in wellbeing [27,36]. ...
The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), ratified in 2006, states that the achievement of equal rights, empowerment, and social inclusion of people with disabilities requires comprehensive rehabilitation services involving educational, social, economic, and medical interventions, all dimensions of the World Health Organization Community based rehabilitation (CBR) matrix. CBR programs aim at achieving those goals. In the present study, we investigated whether a large scale CBR program is improving access to multiple services (namely physical therapy, assistive technology, education, employment, advocacy, and community awareness) and providing satisfactions (by measuring the reduction in unmet needs) of Afghans with disabilities. We enrolled in the study 1861 newly recruited CBR participants with disabilities from 169 villages between July 2012 and December 2013, and 1132 controls screened with disabilities randomly selected with a two-stage process within 6000 households from 100 villages in the same provinces as the CBR but outside its catchment area. Using propensity score matching (PSM) and difference in difference analysis, we estimated the differences in accessing services. There were statistically significant differences between participants and controls on the access of available services between the baseline and endline. Using PSM we also found that needs were more often met among CBR participants compared to the controls. Our study indicates that a CBR program may be an effective way to provide services for persons with disabilities even in a conflict context such as Afghanistan. It contributes to addressing the longstanding question whether CBR can actually improve the rehabilitation of persons with disabilities.
... A study by Ashagram demonstrated the effectiveness of the community-based rehabilitation (CBR) model for the treatment of chronic schizophrenia in a rural setup. 18 Similarly, SCARF has been using telemedicine to expand access to specialist mental health services in rural areas. 6 Such measures ensure that the MHNGOs act as a means of providing mental health for all. ...
... CBR is a feasible model of rehabilitation for people with schizophrenia even in economically deprived settings, and that outcomes are better, at least for those who are treatment compliant. [22] Lack of mental health professional has been seen in the country like India and other developing countries (especially in rural settings). The CBR method offers a model which involves active local community participation and low levels of technical expertise to deliver services. ...
Community Based Rehabilitation (CBR) is implemented through the combined efforts of people with Severe Mentally Ill (SMI) themselves, their families, organisations and communities, as well as the relevant governmental and non-governmental sector, education, vocational, social and other services. country like India has a unique geographical area, limited recourses, utilization of available infrastructure, available negative attitude and social stigma pull the CBR for the mainstreaming and welfare of SMI as well as reduce the burden of their family members/care givers in India. The purpose of the study is to provide information about emergence of Severe Mentally ill. Literature has been searched of both electronic databases including PubMed and manual searches. CBR emphasis to encourage the community to create awareness about negative attitudes and behaviours towards people with SMI and their families, that the community is supportive of them, and that people with SMI is mainstreamed across all development sectors. There is right time to work together and also needed strong liaisons between various stock holders those are working in the area of chronic mentally illness.
... [22][23][24] There is an urgent need to infuse more financial and human resources that can be utilized in organizing awareness campaigns; mobilize community resources by training the community health workers, laypersons, and community members in rehabilitative services; provide rehabilitative services at multiple levels (daycare and residential care, routine psychosocial activities, outreach activities, livelihood activities, etc.); and set up integrated CBR programs by involving various stakeholders. 25,26 The NMHPolicy proposes evidencebased care for PWMI. However, the evaluation of MH care services of the country, including the latest national MH survey (2016), highlighted the scarcity of MHPs and medical officers (medical graduates who are trained in providing routine psychiatric care) at the community level, thereby limiting the full realization of the NMHPolicy. ...
... The framework for the development of Counselling for Alcohol Problems (CAP) was informed by our systematic review of methods used for cultural adaptations of PTs for depression (Chowdhary et al., 2013), the approach of "dismantling" evidence-based PT to "distill" core treatment strategies which could be more easily taskshared with less qualified therapists (Chorpita et al., 2005), and the methodology adopted by the research team in India for the development of psychosocial interventions for delivery by lay counselors for other mental disorders (Chatterjee et al., 2003(Chatterjee et al., , 2008Dias et al., 2008). Based on these experiences, our methodology involved 3 sequential stages: (i) identifying potential treatment strategies; (ii) developing a theoretical framework for the treatment; and (iii) evaluating the acceptability, feasibility, and impact of the treatment. ...
... The improved compliance was due to improved communication with patients and their families by the mental health workers, who belonged to the local community, thereby promoting treatment adherence. [17] Prior to this two landmark projects of Raipur Rani and Sakalwara carried out in north and south India emphasized the necessity as well as practicability of effectual community psychiatry outreach services in the country. [16] ...
Psychiatric disorders are among the leading causes of disability the world over. With the World Health Organization, spearheading the crusade to incorporate the mental health component into primary health care, developing countries also have accepted the need for community care of patients with psychiatric disorders. Since independence various initiatives by the government has led to a significant change in the place of mental health care as part of the general health care. At the time of independence apart from mental hospitals, there was practically no organized mental health care. Since then General Hospital Psychiatry units and also Psychiatric Nursing homes have started. Currently, mental health issues are actively seen as part of the public agenda in the various forms. The overall effect has been the movement to recognize mental health as an important issue in the community and services to move beyond mental hospital care to care to the community. Majority of population in Jharkhand is residing in rural areas. Due to the lack of proper communications and infrastructure, Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS) had started community outreach program way back in 1999. At present, these centers are running in four different areas of the state with great success. RINPAS experience shows that how even with resource constraints, quality services can be provided to unreached population.
... It raises awareness about mental health in the community and empowers people with mental illnesses to develop skills and supports that will reduce stigma and promote social inclusion. A promising evidence base regarding CBR models is growing in LMIC (Chatterjee et al., 2003;2014;Cleaver & Nixon, 2014;Finkenfl€ ugel et al., 2005;Wiley-Exley, 2007); BasicNeeds, an organization focused on improving the health and community participation of people with mental illness, is one such example (Lund et al., 2013;Raja et al., 2012). ...
A significant burden and treatment gap associated with serious mental illness (SMI) exists in low- and middle-income countries (LMIC). In order to address these issues, a range of community-based rehabilitation models in alignment with the Capabilities Approach is necessary, including opportunities for people with SMI to be rapidly engaged in meaningful work within their communities. This paper outlines the development processes and evaluation of the proof of concept for the Community REcovery Achieved Through Entrepreneurship (CREATE) strategy in Kenya. The CREATE strategy pairs Work Integration Social Enterprises (WISE) with a focused, low-cost, recovery-oriented Psychosocial Rehabilitation (PSR) toolkit within a peer involvement/support model as a means of addressing marginalization and fostering health, wellbeing, and participation of people living with SMI. Qualitative research methods were used to understand the experiences of a range of stakeholders involved in CREATE implementation in Kenya. Three overarching themes explicated the experiences of the various stakeholders involved: (1) experiencing a business like other businesses – yet different; (2) expanding capacities, opportunities, and networks through meaningful work; and (3) promoting knowledge and empowerment through education. Within each theme, there was evidence of the attenuation of central elements of marginalization. The CREATE strategy demonstrated acceptability and a variety of potential positive impacts in a low resource setting in Kenya. Application of the CREATE strategy to other low resource settings within Kenya and other LMIC merits further exploration.
... Hospitals and long-stay institutions do not feature in the top 25 Grand Challenges in Global Mental Health [7,8]. The fight to improve the appalling conditions and reduce incidence of abuse in these hospitals has been left to media, non-governmental organizations and human rights commissions [9][10][11][12][13].There is a disconnect between this community-based focus of global mental health and the plight of the severely mentally ill who are often behind closed walls of institutions. Mental hospitals continue to remain an important provider of care and there is an urgent need to reform practices to improve quality of care and reclaim dignity for service users. ...
Purpose
Psychiatric hospitals or mental asylums grew across the world in the colonial era. Despite concerns over quality of care and human rights violations, these hospitals continue to provide the majority of mental health care in most low- and middle-income countries (LMICs). We sought to review the evidence of reform of mental hospitals and associated patient outcomes.
Methods
We adopted an integrative review methodology by including experimental and non-experimental research. The review protocol was registered on PROSPERO (CRD42019130399). A range of databases and systematic hand searches were conducted by two independent reviewers. Research conducted between 1980 and May 2019, that focused on any aspect of reform in mental hospitals for adults (age 18 and upwards) with severe mental illness and published in English, were considered.
Results
16 studies were included in the review. 12 studies met inclusion criteria, and four additional reports emerged from the hand search. Studies covered—India, China, South Africa, Grenada, Georgia, Sri Lanka, Argentina and Brazil. Key findings emphasise the role of judicial intervention as a critical trigger of reform. Structural reform composed of optimisation of resources and renovations of colonial structures to cater to diverse patient needs. Process reforms include changes in medical management, admission processes and a move from closed to open wards. Staff engagement and capacity building have also been used as a modality of reform in mental hospital settings.
Conclusion
There is some documentation of reform in psychiatric hospitals. However, poor methodological quality and variation in approach and outcomes measured, make it challenging to extrapolate specific findings on process or outcomes of reform. Despite being integral service providers, psychiatric hospitals still do not adopt patient centric, recovery-oriented processes. Hence, there is an urgent need to generate robust evidence on psychiatric reform and its effect on patient outcomes.
... Conceptually speaking, home care services for persons with severe mental disorders fall under the rubric of Community Based Rehabilitation (CBR) advocated by the WHO which is to be carried out by resources that are locally available and sustainable (Ruggeri et al., 2004). In the Indian context, a couple of research projects have shown CBR to be successful (Chatterjee et al., 2003(Chatterjee et al., , 2009), though they were not home-based. Home based services are also shown to be better (as compared to out-patient treatment) in terms of symptom reduction, social functioning, family burden, and reduced need for hospitalization, particularly for those treatment seekers at psychiatric institutes (Pai & Kapur, 1983;Pai et al., 1985). ...
Care at Doorstep (CAD) is a home care service that includes medical and social care by skilled professionals. The purpose of this paper is to explore the need for CAD among users of the district mental health programme (DMHP) in Ramanagaram, Karnataka, India who have severe mental illness. The design of this study was descriptive where a qualitative inductive methodology was adopted. Data was collected from interviews of 20 caregivers and 7 mental health service providers linked to the DMHP. Socio demographic information was collected from participants and a semi-structured interview guides were used to explore needs and challenges in delivering care at home by the professionals. The themes that emerged from the manually transcribed and coded data were categorized as needs and challenges and used for developing a CAD model.
... But it was seen on evaluation that in rural India CBR programmes can have positive outcomes in people with chronic schizophrenia. It is important find as it was seen in resource limited country (Chatterjee S, et al 2003). It was seen that it was helpful to engage and train local leaders as CBR workers as they could help in identifying chronic patients, providing home based treatment to them, improving their accessibility to clinics, ensuring regular follow ups and educating community including patients and their family about the same. ...
Schizophrenia is a chronic, stress-related and neurobiological disorder characterized by disturbances in the form and content of an individual's thought and perceptual processes, affect and social and instrumental role behavior. Psychiatric rehabilitation denotes wide range of interventions to help people with disabilities due to mental illness in improving their functioning, quality of life, and recovery by enhancing the opportunities, skills and supports they need to succeed in regular adult roles and in the environments of their choice. Rehabilitation interventions have been developed to improve functional outcomes and to promote recovery. The purpose of this article is to study the efficacy of rehabilitation in the management of schizophrenia. Literature has been searched of both electronic databases including PubMed and manual searches. It can be said that rehabilitation in schizophrenia is an integrated approach that incorporates early detection and treatment of schizophrenia symptoms, collaboration between person with schizophrenia and caregivers in managing treatment, family and social supports and training in social, instrumental and coping skills has been documented to improve the course and outcome of schizophrenia as measured by symptoms recurrence, social functioning and quality of life.
... CBR is one of the models of community care (Chatterjee, Patel, Chatterjee, & Weiss, 2003). It has been attracting academic attention for decades, as reflected in the increased number of academic publications on CBR (Finkeflügel, Wolffers, & Huijsma, 2005;Cleaver & Nixon, 2014). ...
Community care is one of the worldwide strategies for governments to manage contemporary healthcare challenges and long-term care. In response to an ageing population, the Hong Kong government has been promoting the concepts of community care and made initiatives, inter alia, in community-based rehabilitation (CBR). Despite these new drives, there is insufficient supply of CBR services. Provisions of CBR are currently fragmented, project-based, or on a self-financed basis. The authors argue that there is a lack of longer-term plan on CBR and that the government still relies on the heavily subsidized public hospital system. In this chapter, the authors share their views on the opportunities and challenges of CBR in Hong Kong.
... This type of care relies on the participation of the community, family, available professionals and the persons with disabilities themselves. Therefore, the CBR programs can operate in rural areas which have limited infrastructure and standardised services (Chatterjee, et al., 2003;Lagerkvist, 1992;Evans et al., 2001 provided assistance for the disabled to build their home business through provision of such items as fully equipped computers, cooking appliances and sewing machines. ...
This thesis examines both disaster and disability experiences of newly disabled women who are wheelchair users as a result of injuries they sustained in the 2006 earthquake in Java. This study is based on 14 months' ethnographic fieldwork conducted in the period of January 2015 to March 2016, during which time the newly disabled women were in the phase of long-term adaptation of their lives after the earthquake. Examining the disaster and post-disaster experiences of those women, I argue that the disability-focused humanitarian and development intervention of that emergency contributed to the disempowerment of the women in their home, family and neighbourhood. The programs of relief and long-term recovery overemphasised the individualisation, independence and self-reliance of these 'victims' rather than tap into cultural and social resources that were potentially available to them (Reindal, 1999). I argue in my thesis that the emphasis on establishing newly disabled women as independent individuals resulted in their marginalisation and alienation in their interaction with the community and confined them to prolonged isolation in their village homes. Rather than give them protection, dignity and guidance to return into their 'normal' life these interventions rather reduced them to 'bare life' (Agamben, 1998), which put them in specialised programs but disregarded their needs to connect with their community. The unintentional marginalisation they have experienced during the process of recovery happened because the humanitarian and development interventions created short-term programs and ignored the women's long term needs to integrate with their community. The program's priority on the medicalisation and independence of people with disabilities during the process of recovery suspended the social life of the newly disabled women for a long time. In addition the villagers' lack of knowledge on how to engage with disabled people resulted in exceptionality, avoidance, prejudice and awkwardness in the relationship between disabled and non-disabled people in the kampong. It exacerbated the segregation and this led to the newly disabled women living their life outside the mainstream of the village. Despite these challenges, I demonstrate that these women became resilient and adaptable during this long-term crisis in their personal lives. They exercised agency in their negotiations within the household and extended family, with the relief organisations and with neighbours. In the emergency, rehabilitation, reconstruction and post-disaster recovery, the newly disabled women applied various forms of agency to rebuild their everyday lives and to regain their power as tiang rumah tangga (household pillar). They cultivated Javanese feminine values of sabar (patience), pasrah (surrender) and nrima (acceptance) as tools to keep going in nurturing their personal and family lives. They also applied strategies, tactics and manoeuvres to rebuild their livelihoods and to reconnect to their community. I demonstrate in this thesis that through the phases of their disaster recovery, they were resilient in countering the passivity imposed on them by the programs of NGOs and government. This research contributes to the understanding of disaster intervention and calls for rehabilitation and development strategies that integrate all survivors in the process of recovery to maintain their sense of belonging as active members in their community.
... For example, lay health workers have been involved in supporting carers, befriending, ensuring adherence and delivering simple mental health interventions . Nurses, social workers and CWs may also take on follow-up or educational/promotional roles (Araya et al., 2003;Chatterjee et al., 2003;Chatterjee et al., 2008). In addition, doctors with general mental health training have been involved in the identification, diagnosis, treatment and referral of complex cases . ...
Recently, mental health and ill health have been reframed to be seen as a continuum from health to ill health, through the stages of being asymptomatic ‘at risk’, to experiencing ‘mental distress’, ‘sub-syndromal symptoms’ and finally ‘mental disorders’. This new conceptualisation emphasised the importance of mental health promotion and prevention interventions, aimed at reducing the likelihood of future disorders with the general population or with people who are identified as being at risk of a disorder. This concept generated discussion on the distinction between prevention and treatment interventions, especially for those mental health conditions which lie between psychological distress and a formal psychiatric diagnosis. The present editorial aims to clarify the definition of promotion, prevention and treatment interventions delivered through a task-shifting approach according to a global mental health perspective.
... The CBR matrix has five domains including health, education, livelihood, empowerment and social. Studies on efficacy of CBR in India, have assessed outcomes such as medication adherence, level of disability, participation in selfhelp groups, involving in social activities, family based psycho educational programme and assessing the community resources (Chatterjee et al., 2009(Chatterjee et al., , 2003. However these domains discuss mainly individual centric approaches through collaboration with various resources in the community rather than focusing on the family. ...
Purpose of the study
In India, people live in a collective society wherein family members are the primary caregivers for the person suffering from mental illness (PMI). Psychiatric rehabilitative models are individual-centric, focusing on individual level skills (emotional, social, self-management and vocational) and development to enhance successful community reintegration. If the entire family is considered to be a unit for rehabilitation, i.e. family centric rehabilitation, the possibility of empowering the family to function effectively is higher despite the illness. The objective of the case study is to conceptualize the framework ‘Family centric Rehabilitation’.
Methods
Case study design.
Results
Family centric rehabilitation can be conceptualized as ‘a process that facilitates families, dysfunctional due to PMI, to reach their optimal level of independent functioning by harnessing resources available within the community’. Family centric rehabilitation focuses on enhancing global functioning of the “family unit”, in essence all members, rather than just the PMI. Strategies deployed include concurrently addressing and minimizing anticipated challenges across domains including medical, psychosocial, vocational as well as economic, thereby aiding in recovery of the family unit as a whole.
Conclusions
Family centric rehabilitation is an important culture specific concept that aims to provide optimal level of functioning of all family members and can contribute to the family achieving self-sustenance, a sense of autonomy and empowerment.
... Services addressing these domains would facilitate the participation of individuals with disabilities in activities that have components of enriched environment. Models of community-based rehabilitation, particularly in low-resource countries, include group activities to promote social and vocational skills, enhancement of social networks and provision of access to social benefits [23,24], all of which may contribute to enrichment of their environments. While there is evidence that these help in reduction of symptoms and improvement in functioning, there is need to systematically study if participating in these activities has additional benefits of alleviation of cognitive deficits. ...
... PANSS total score of Group 1 significantly decreased at the end of followup. Correlatively Chatterjee et al. indicated a significant decrease in PANSS scores of schizophrenia patients who regularly apply to CMHC (24). There was a significant decrease in PANSS total score of Group 2 at the end of follow-up. ...
Introduction:
Antipsychotic drugs are effective in relieving symptoms in the treatment of schizophrenia, but decreased social functioning is resistant to drugs. In this study, the effect of adjunct Psychosocial Skills Training (PSST) on social functioning for schizophrenia patients who receive service in the community mental health center (CMHC) was investigated.
Method:
Schizophrenia patients who received routine case management and occupational therapy in CMHC (n=22), patients receiving PSST in addition to CMHC service (n=21) and patients who were followed up in the Psychotic Disorders Outpatient Clinic as control group (n=21), three groups were formed. In the initial evaluations of the participants, the sociodemographic data form was filled. Social functioning and severity of clinical symptoms were evaluated at the beginning and at end of three-month follow-up period with the Social Functionality Scale (SFS), Personal and Social Performance Scale (PSP), Positive and Negative Syndrome Scale (PANSS).
Results:
At the end of the follow-up period, there was a significant decrease in PANSS total scores, a significant increase in PSP and SFS total scores in the last test evaluations of the study groups. There was not any statistically significant change in the control group. The decrease in PANSS total score in PSST group is significantly higher than CMHC group. There was no significant difference between PSP and SFS scores between intervention groups.
Conclusion:
The psychiatric rehabilitation in CMHC has a positive effect on the social functioning and clinical symptoms of schizophrenic patients. Adjunct PSST to routine service seems to help relieving clinical symptoms.
A BSTRACT
Background
The role of caregivers in grooming the neuro-developmental outcome of high-risk newborns and developmental challenges in children needs to be explored.
Objectives
To find the knowledge and perception among parents regarding the neuro-developmental outcome of high-risk newborns, methods adopted to address these problems, and to identify areas on which awareness generation needs to focus.
Materials and Methods
A questionnaire-based awareness survey was conducted to understand the knowledge, attitude, and practices of families of children with developmental challenges.
Results
The study revealed that more than 70 percent of families lack information about child development, developmental challenges, and means to deal with them. They are unaware of the available health care services and other resources. One in three families has misconceptions on developmental disabilities; consider them as curse or jinx and consequently neglected. Female children with developmental problems are further ostracized due to gender inequity in families. About 10 percent of families have shown great openness toward acquiring new skills and knowledge for handling their children with developmental delays.
Conclusions
This study is based on the précis research findings of our grass-root level fieldwork conducted in remote rural Bengal areas. The observation will be of interest and learning materials for general primary care practitioners, family physicians, and stakeholders to initiate appropriate intervention strategies for properly rehabilitating children with developmental delay at grass-root levels of primary health care.
Background
There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.
Objectives
To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low‐ and middle‐income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.
Search methods
We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.
Selection criteria
Randomized controlled trials (RCTs) of primary‐level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.
Data collection and analysis
Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random‐effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post‐intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.
Main results
Description of studies
We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta‐analyses) for inclusion. Nineteen RCTs were conducted in low‐income countries, 27 in low‐middle‐income countries, 2 in middle‐income countries, 58 in upper‐middle‐income countries and 7 in mixed settings. Eighty‐three RCTs included adults and 30 RCTs included children. Cadres of primary‐level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs.
Risk of bias
The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias.
Intervention effects
'Probably', 'may', or 'uncertain' indicates 'moderate‐', 'low‐', or 'very low‐'certainty evidence.
*Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post‐intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain.
Adults
Promotion/universal prevention, compared to usual care:
‐ probably slightly reduced anxiety symptoms (MD ‐0.14, 95% confidence interval (CI) ‐0.27 to ‐0.01; 1 trial, 158 participants)
‐ may slightly reduce distress/PTSD symptoms (SMD ‐0.24, 95% CI ‐0.41 to ‐0.08; 4 trials, 722 participants)
Selective prevention, compared to usual care:
‐ probably slightly reduced depressive symptoms (SMD ‐0.69, 95% CI ‐1.08 to ‐0.30; 4 trials, 223 participants)
Indicated prevention, compared to usual care:
‐ may reduce adverse events (1 trial, 547 participants)
‐ probably slightly reduced functional impairment (SMD ‐0.12, 95% CI ‐0.39 to ‐0.15; 4 trials, 663 participants)
Children
Promotion/universal prevention, compared to usual care:
‐ may improve the quality of life (SMD ‐0.25, 95% CI ‐0.39 to ‐0.11; 2 trials, 803 participants)
‐ may reduce adverse events (1 trial, 694 participants)
‐ may slightly reduce depressive symptoms (MD ‐3.04, 95% CI ‐6 to ‐0.08; 1 trial, 160 participants)
‐ may slightly reduce anxiety symptoms (MD ‐2.27, 95% CI ‐3.13 to ‐1.41; 1 trial, 183 participants)
Selective prevention, compared to usual care:
‐ probably slightly reduced depressive symptoms (SMD 0, 95% CI ‐0.16 to ‐0.15; 2 trials, 638 participants)
‐ may slightly reduce anxiety symptoms (MD 4.50, 95% CI ‐12.05 to 21.05; 1 trial, 28 participants)
‐ probably slightly reduced distress/PTSD symptoms (MD ‐2.14, 95% CI ‐3.77 to ‐0.51; 1 trial, 159 participants)
Indicated prevention, compared to usual care:
‐ decreased slightly functional impairment (SMD ‐0.29, 95% CI ‐0.47 to ‐0.10; 2 trials, 448 participants)
‐ decreased slightly depressive symptoms (SMD ‐0.18, 95% CI ‐0.32 to ‐0.04; 4 trials, 771 participants)
‐ may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI ‐1.28 to 1.76; 2 trials, 448 participants).
Authors' conclusions
The evidence indicated that prevention interventions delivered through primary workers ‐ a form of task‐shifting ‐ may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.
Problematic drinking is found to be common among Indian farmers. This study aims to improve our understanding of the causes, consequences, and culture surrounding drinking in Indian farming communities. 36 semi-structured interviews with male and female farmers were thematically analyzed. Problematic drinking in male farmers was found to significantly impact farmer's relationships, work, finances, and health, and to be related to spousal abuse and neglect. Drinking to cope with mental and physical pain was common, and stigma around drinking appears to be a barrier to social support. Implications for future research and treatment efforts for Indian farmers are discussed.
The paper explores how chronicities and chronic relationships are fostered at a state-sponsored community psychiatry clinic that has been affiliated with a Sufi shrine in western India. The clinic provides free psychotropic treatment to patients, most of whom are pilgrims visiting the shrine. While the clinic has been lauded for its collaborative approach of blending 'medicine and prayer' in the provision of mental health care, observations of clinical encounters reflect the prevalence of a strongly medicalized perspective of mental illness, where local narratives of distress are reframed as globalized categories of mental disorder, thereby permitting pharmacological intervention. Importantly, in a context where free medicines are offered just as other freebies are in development initiatives in India, this results in the creation of long-term, 'chronic' relationships with patients who only seem to return for medicines, never recovering. This paper illustrates how 'chronicity', in many ways, is built into the project from the beginning itself. It becomes evident in the assumptions of the officials and psychiatrists that mental illness is chronic, in the case files of patients that record their consultation and medication histories, and in the clinical conversations about the importance of compliance to treatment. Given that historically, community mental health emerged in the context of reducing long hospital stays and deinstitutionalizing mental health care, it is important to reflect on how these policies and practices result in the creation of a cadre of chronic out-patients.
The Coping Patterns among Primary Care Givers of the Persons
with Schizophrenia - An Empirical Study
Supervision of nonspecialist clinicians by trained mental health professionals is integral to developing capacity for providing mental health care in low-resource settings. Current supervision efforts in low-resource settings, however, are often variable in quality. Scant published literature addresses how supervision practices affect treatment outcomes; only a few studies have been published on evidence-based supervision methods. Additionally, in low-resource settings many systems-level obstacles exist in providing adequate mental health supervision to nonspecialist clinicians. This article seeks to address psychiatrists' role in providing supervision and promoting quality of care in low-resource settings. We review the literature on evidence-based supervision practices, address obstacles and current practices of providing high-quality mental health supervision in low-resource settings, and weave this knowledge with our experiences learning from the clinicians at Partners in Health in Haiti. We also discuss feasible strategies and provide recommendations for strengthening the supervision process in resource-limited settings.
he lack of media information about Schizophrenia in Aceh explains caregivers’ limited understanding of mental disorders. Research on patient discharge systems found that communication media about Schizophrenia were still limited, mostly in the form of posters, flyers, or booklets. There was no specific information about the mental illness needed by the family or caregivers after the patient's discharged from the hospital. This study aims to develop and test a communication medium that can support the recovery process of post-discharge patients from the Mental Health Hospital or Rumah Sakit Jiwa (RSJ) in Aceh. This action research was carried out through focus group discussions (FGDs), interviews, and surveys to health practitioners (mental health nurses, psychiatrists, psychologists, community leaders) and family or caregivers of Patients with Schizophrenia (PWS). The study found that messages about Schizophrenia which are developed through a community-based approach are likely to be better accepted than the expert-led information.
This paper presents data from a qualitative study on the community engagement experience at the Bhagat Phool Singh Mahila Vishwavidyalaya, to prepare students for social work practice. It focuses on how students and academics understand engagement, the values derived from the engagement experience and the particular activities that formed part of the engagement process. Data were collected using in-depth interviews with six academics and eleven students. Using a process of thematic analysis, the study found that service learning within the context of rural villages presented a rich opportunity to prepare students for social work practice and, more importantly, to facilitate the social justice mandate of the profession.
In this volume, prominent anthropologists, public health physicians, and psychiatrists respond sympathetically but critically to the Movement for Global Mental Health (MGMH), which seeks to export psychiatry throughout the world. They question some of its fundamental assumptions: the idea that "mental disorders" can clearly be identified; that they are primarily of biological origin; that the world is currently facing an "epidemic" of them; that the most appropriate treatments for them normally involve psycho-pharmaceutical drugs; and that local or indigenous therapies are of little interest or importance for treating them.
Community psychiatry is a vast area for both enquiry and intervention. The seemingly infinite content may be somewhat overwhelming for entrants to psychiatry. A focused understanding of this discipline might help the resident to develop a basic foundation to understand the policies, programs, challenges and opportunities for service delivery in the community. Understanding and appreciating these issues are important not only from a knowledge perspective but to also generate innovative ideas to bridge the large treatment gap for mental illnesses. To transform a huge but seemingly tedious topic into a stimulating, simple, and an interesting one for a psychiatry trainee is a challenge for teachers in the area.
Introduction:
there is increasing levels of stressors and hardship among higher education students especially in low and middle income countries. Higher education institutions have an important role to play in the provision of robust and comprehensive support for students who experience stressors and hardship. Research and action in this area has however not been prioritized by the institutions in Zimbabwe. This study examined students´ expression of their experience with stressors and problems of studying in higher education in the Eastern Highlands of Zimbabwe.
Methods:
the study employed a qualitative approach using the phenomenology approach. Three institutions of higher education in the eastern border highlands of Zimbabwe were considered. Four focus group discussions were conducted with eight participants in each group. A one-to-one semi-structured interview with eight individual participants was also conducted to further examine the issues raised in the focus groups. Data were analyzed thematically using the Silences Framework theoretical model.
Results:
five overarching themes emerged from the analysis: (i) the stress of completing assessments without adequate learning materials. (ii) Unfair placement workload results into poor assessment outcomes. (iii) College-life is more difficult due to financial constraints. (iv) Marital problems interfering with college work: there is no mental health service available. (v) Enduring pains of bereavement with no emotional support or helpline.
Conclusion:
the study recommends the need to develop an inter-ministerial mental health strategy for institutions of higher learning with the view of implementing policies that address students suffering in Zimbabwean HE institutions.
In this chapter, I tested the notion that performances on the IQ test, the Mooney problem checklist as a reflection of the quality of life (QoL), and metacognition were intercorrelated. It was also intended to find if there were significant differences between the normally achieving and the low-achieving participants on the Mooney scale and on the metacognitive instrument (i.e. the metacognitive test, reaction time, and the metacognitive test scores divided by mean reaction time) when controlling for the effect of influencing variables. Results revealed that only the performance of the normally achieving participants was consistent with the notion stated. The heterogeneity of the low-achieving group was presented as one of the many explanations for the lack of significant association between their performances on the three measures. Overall, participants with high IQs obtained high scores on the metacognitive test; and older participants obtained better scores on the metacognitive test and on the metacognitive test scores divided by mean reaction time compared to the younger ones. The analysis showed no significant differences existed between the two participating groups in responding to items on the Mooney scale or the metacognitive instrument when controlling for influencing variables. Insights, discussions, and suggestions for future research were presented.
Introduction
Low-income and middle-income settings like India have large treatment gaps in mental healthcare. People with severe mental disorders face impediments to their clinical and functional recovery, and have large unmet needs. The infrastructure and standards of care are poor in colonial period psychiatric hospitals, with no clear pathways to discharge and successfully integrate recovered individuals into the community. Our aim is to study the impact of psychiatric hospital reform on individual patient outcomes in a psychiatric hospital in India.
Methods and analysis
Structured Individualised inTervention And Recovery (SITAR) is a two-arm pragmatic randomised controlled trial, focusing on patients aged 18–60 years with a hospital stay of 12–120 months and a primary diagnosis of psychosis. It tests the effectiveness of structural and process reform with and without an individually tailored recovery plan on patient outcomes of disability (primary outcome WHO Disability Assessment Scale), symptom severity, social and occupational functioning and quality of life. A computer-generated permuted block randomisation schedule will allocate recruited subjects to the two study arms. We aim to recruit 100 people into each trial arm. Baseline and outcome measures will be undertaken by trained researchers independent to the case managers providing the individual intervention. A health economic analysis will determine the costing of implementing the individually tailored recovery plan.
Ethics and dissemination
The study will provide answers to important questions around the nature and process of reforms in institutional care that promote recovery while being cognizant of protecting human rights, and dignity. Ethical approval for SITAR was obtained from a registered ethics committee in India (Institutional Ethics Committee VikasAnvesh Foundation, VAF/2018-19/012 dated 6 December 2018) and the University of Warwick’s Biomedical and Scientific Research Ethics Committee (REGO-2019–2332, dated 21 March 2019), and registered on the Central Trial Registry of India (CTRI/2019/01/017267). Trial results will be published in accordance to CONSORT guidelines.
Community psychiatry in India has evolved as a discipline for more than five decades now. In describing this evolution as well as current approaches, this booklet tries to combine traditional concepts, such as community-based interventions and epidemiological perspectives, with newer concepts, such as primacy care psychiatry, taluk mental health, & telemedicine which have shaped the field over the past decade. It is thus essential for any psychiatrist or any mental health professional to gain knowledge on this perspective, preferably during their training period.
Measurement of Disability is one of the off-shoot projects of the major multicentred study on 'Factors Affecting Course and Outcome of Schizophrenia' being held at Madras, Vellore and Lucknow. As part of this study, modification of the Disability Assessment Schedule (II) was carried out at the Madras centre. Certain items of the DAS were deleted and the rest were regrouped into 4 main areas of personal, social, occupational and global disability. This modified instrument called the Schedule for Assessment of Psychiatric Disability (SAPD) was administered to 30 patients each of the 3 groups of psychoses, neurotics and diabetics. It was found that the SAPD effectively discriminated the psychotic group from the other 2 groups. The authors recommend this instrument for measurement of disability in an outpatient psychiatric population.
Much of the debate on community care for individuals with mental disorders has focused on issues relevant to industrialised nations. Developing countries also have accepted the need for community care, with the World Health Organization spearheading the crusade to incorporate the mental health
Almost all governments and non-governmental organisations in developing countries use a community-based rehabilitation (CBR) approach to work with disabled people. Although disabled people's organisations reject the categorisation of disability in individual terms, 'medical rehabilitation' is still regarded as an important but time limited process within rehabilitation. The paper lists measures and methods used in a comprehensive evaluation, and presents a practical method to examine the quality of medical rehabilitation. The method was developed and applied in an evaluation of service needs and service provision for disabled people in low-income communities, for the Ministry of Welfare, Government of India. The method described is a tracer approach. It assesses quality in three aspects of medical rehabilitation: The method differs from most others in that it is process oriented, as opposed to output oriented. The method meets the challenges of providing low-cost assessment of a difficult outcome measure (the quality of medical rehabilitation), within a complex process (CBR). It is anticipated that the tracer method will be useful to the objective evaluation of disability services throughout the developing world.
to evaluate the achievements of a CBR programme initiated for individuals ascertained in house-to-house surveys.
assessment of changes in status for six types of disability after at least 6 months duration of the programme, with family participation.
home, school, or workplaces in villages in the Philippines and Zimbabwe.
a sample of recipients of programme activities in each of the two countries.
history, testing of ability in ADL and communication, and family discussion.
general gain in ability scores in 78% and 93% of the samples in the two countries respectively, together with encouraging rates of starting school or taking up an occupation.
the WHO CBR programme is highly effective for disabled people in the community being trained at home, for both children and adults, and yields similar results in different types of society; it can be accomplished at very low cost by recruiting volunteers, and mobilizes human resources in the community while promoting self-esteem.
The variable results of positive-negative research with schizophrenics underscore the importance of well-characterized, standardized
measurement techniques. We report on the development and initial standardization of the Positive and Negative Syndrome Scale
(PANSS) for typological and dimensional assessment. Based on two established psychiatric rating systems, the 30-item PANSS
was conceived as an operationalized, drug-sensitive instrument that provides balanced representation of positive and negative
symptoms and gauges their relationship to one another and to global psychopathology. It thus constitutes four scales measuring
positive and negative syndromes, their differential, and general severity of illness. Study of 101 schizophrenics found the
four scales to be normally distributed and supported their reliability and stability. Positive and negative scores were inversely
correlated once their common association with general psychopathology was extracted, suggesting that they represent mutually
exclusive constructs. Review of five studies involving the PANSS provided evidence of its criterion-related validity with
antecedent, genealogical, and concurrent measures, its predictive validity, its drug sensitivity, and its utility for both
typological and dimensional assessment.
Historical records suggest dyskinesia was observed in severely ill institutionalised patients with schizophrenia in the pre-neuroleptic era. More recent work has not found dyskinesia in never-medicated younger and middle aged patients. The present study complements this recent work and avoids the confounders of severity of illness and institutionalism by examining elderly patients in a wide variety of community settings.
Movement disorders were examined in 308 elderly individuals in Madras, India, using the Abnormal Involuntary Movements Scale, the Simpson and Angus Parkinsonism Scale and the Barnes Akathisia Scale. Patients' mental state was assessed by the Positive and Negative Syndrome Scale.
Dyskinesia was found in 15% of normal subjects (n = 101, mean age 63 years), 15% of first degree blood relatives of younger schizophrenic patients (n = 103, mean age 63 years), 38% of never medicated patients (n = 21, mean age 65 years) and 41% of medicated patients (n = 83, mean age 57 years). The respective prevalences for Parkinsonism were 6%, 11%, 24% and 36%; and for akathisia 9%, 5%, 21% and 23%. Dyskinesia was associated with negative schizophrenic symptoms.
Dyskinesia in elderly schizophrenic patients is an integral part of the illness and not associated with antipsychotic medication.
CBR for mentalillnessin a rural/tribalsetting. mentalillnessin a rural/tribalsetting
- S Chatterjee
- A Chatterjee
- S Chatterjee
- A Chatterjee
Chatterjee, S. & Chatterjee, A. (1999)Chatterjee, S. & Chatterjee, A. (1999) CBR for mentalillnessin a rural/tribalsetting. mentalillnessin a rural/tribalsetting. Action Aid Disability Journal Journal, 10 10, 47^51. , 47^51
et al Evaluation of medicalrehabilitation in community basedEvaluation of medicalrehabilitation in community based rehabilitation
- Disability Evans
- P J Zinkin
- P Harpham
- T Evans
- P J Zinkin
- P Harpham
CBR for Action Aid Disability Evans, P. J., Zinkin, P., Harpham,T., Evans, P. J., Zinkin, P., Harpham,T., et al Evaluation of medicalrehabilitation in community basedEvaluation of medicalrehabilitation in community based rehabilitation.rehabilitation. Social Science and MedicineSocial Science and Medicine, 53 et al (2001) (2001) 53, 333^348. , 333^348
Fax: +91 832 415244; E-mail: vikpat 41524 4; E-mail: vikpat@ @goatelecom.com goatelecom.com (First received
- Sangath Dr Vikram Patel
- Centre
Correspondence: Dr Vikram Patel, Sangath Centre, 841/1Alto Porvorim,Goa 4 03521, India. Fax: +91 832
415244; E-mail: vikpat
41524 4; E-mail: vikpat@ @goatelecom.com goatelecom.com
(First received 19 April 2002, final revision 29 August 2002, accepted 30 August 2002)
(First received 19 April 2002, final revision 29 August 2002, accepted 30 August 2002)
CBR for mental illness in a rural/tribal setting
- Chatterjee