Near zero treatment gap for schizophrenia: Can it be reality in rural India?

doi:10.21203/rs.3.rs-4911525/v1

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Near zero treatment gap for schizophrenia: Can it be reality in rural India?

https://doi.org/10.21203/rs.3.rs-4911525/v1

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Background: Treatment gap is a key indicator of adequacy of mental health services that drives policies and financial allocation for the sector. Impact of public health interventions on this gap is sparsely studied.

Methods: To demonstrate reduction in treatment gap for Schizophrenia in rural south Indian setting following a community intervention program running in two taluks of Karnataka, India (Thirthahalli and Turuvekere) between July 2018 and February 2019. Population based sampling of persons with Schizophrenia who consented were included and subjects who migrated, died, had changed/other diagnosis, did not consent were excluded Prevalence was measured by adding already existing cases with the ones identified by way of house-to-house survey, conducted by trained Accredited Social Health Activists (ASHAs). Screen-positives were further scrutinized by research social workers and psychiatrists to confirm the diagnosis. Gap was calculated by noting difference between target population and ones who had not contacted any service even once for psychiatric treatment.

Results: In Thirthahalli, out of 364 patients, 14 had not contacted any service even once, pegging the gap at 3.84%. In Turuvekere, out of 236 cases, 29 had not contacted, pegging the gap at 12.28%. Overall, 7.16% was the gap in both taluks. For the taluk of Thirthahalli, the previous treatment gap was measured as 58% for Schizophrenia in 2009 by the authors; thus, reducing it by almost 54% over one and a half decade of this intervention.

Conclusion: Meaningful reduction of gap for schizophrenia is a feasible target. Policies commensurate with this aim should be considered.

Treatment gap

Schizophrenia

Psychosis

Rural India

Community intervention

Schizophrenia is one of the most disabling medical disorders contributing to about 10% DALYs (Disability Adjusted Life Years) between 1990 and 2017 [1]. Though a low prevalence of less than 1%, the sheer population of India makes it one of the important public health concerns necessitating commensurate response from the health systems. Unfortunately, most of those in need of treatment and care do not receive them [2]. This difference between the true prevalence of a disorder and the treated proportion of individuals affected by the disorder is termed ‘treatment-gap’. In other terms, treatment gap means the percentage (proportion) of individuals who require care but do not receive treatment [3]. A closer look at the definition brings out many unclear aspects related to the concept. For example, a recent critique states that the interpretation of its definition refers to only clinical psychiatric interventions thereby excluding a range of psychosocial interventions and the physical healthcare gap, the latter referring to the common occurrence of physical co-morbidity among those with severe mental illnesses [4].

On the other hand, the concept of treatment-gap can also be viewed from a ‘health-services-coverage’ point of view. This coverage is expressed by the proportion of the target population who can receive or have received the service. Further, the ratio of those who receive services and the size of the target population (service target; total number of those who are eligible to receive care and services) is termed as the ‘actual coverage’. Finally, ‘actual coverage’ can be divided into contact coverage (measuring the numbers of contacts between the user and the provider irrespective of whether the contact results in satisfaction related to user’s health problem or not) and effectiveness (number of people who have received satisfactory service) coverage [5]. Whatever be the debate, treatment-gap has emerged as an indicator of service provision and is a popular measure in guiding planning and policy making ` Erstwhile studies on treatment gap for schizophrenia in India have indicated high figures though there is variability ranging from 40–95% [6]. Most recent and representative survey, the National Mental Health Survey [7] pegs this figure at 73.5%. Elegant community based treatment/care modules are present for schizophrenia ranging from specialist to collaborative care (collaboration between psychiatrists on the one hand and trained but non-specialist health workers on the other) [8–12]. As regards the impact of these programs, though an increase in contact coverage [13–16] has been noted, there are hardly any studies that have looked into a reduction of the treatment gap. In this study, the authors present the impact of community intervention programs on the reduction of treatment gap of persons with schizophrenia living in two rural blocks (talukas) of Karnataka State of South India; Thirthahalli and Turuvekere.

Study settings:

Thirthahalli taluk (an administrative block) belongs to Shivamogga district in Midwest Karnataka and has a population of 1,42,006 [17]. It has seven villages and a town. Turuvekere is located in Tumakuru district in the south of Karnataka state in India. Turuvekere has a population of 1,68,994 [18].

Community Intervention Programs:

A team including the authors, as a part of their affiliated Institution have been running community intervention programs in both these taluks from 2005 and 2009 respectively. As part of these, persons with schizophrenia are identified, treated and are being followed up till date. More details of these cohorts are mentioned elsewhere [12, 19–23]. Suffice here to state that in collaboration with local health administrations, patients are cared for at their nearest primary health centres (PHCs; in Thirthahalli) or in the taluk hospital (in Turuvekere) regularly. Case-identification is with the help of trained community health workers. Key-informant method and snow-balling techniques are also used. After confirmation of the diagnosis (by psychiatrists), psychopharmacotherapy is initiated and basic psychoeducation are given. They are then followed up regularly. For those who drop out of the care umbrella, the team reaches out to them either through telephone or periodic house visits. Not all patients wish to be followed up with our team. Such families continue their care with clinicians of their choice, but we reach out to them for periodic assessments. Psychosocial interventions are restricted to guidance towards obtaining disability certificates and vocational counselling and networking [11, 12, 24, 25].

Assessments:

At the time of writing this manuscript, 380 patients are registered in Thirthalli and 260 are registered in Turuvekere. In this study, we intended to assess the impact of these intervention programs on the treatment gap in both these places (individually and also collectively).

For calculating the treatment-gap, we used the following method [5].

We counted the ‘target-population’, i.e., the total number of persons with schizophrenia in the following manner: the number of persons in the cohort (mentioned above) was noted as a first step. Two rounds of house-to-house survey were then conducted in order to identify newer cases (hitherto unidentified and not part of the existing cohort/s).

In the first round of survey, all houses in both taluks were visited by the Accredited Social Health Activists. (ASHAs; 26,823 in Thirthahalli and 42,761 in Turuvekere) 326 ASHAs were trained in case-screening. Half-a-day training was imparted to them (160 ASHAs in Thirthahalli and 166 ASHAs in Turuvekere) in administering a screening tool named ‘Symptoms-in-Others’ [26, 27].This is a simple tool with 15 questions and takes about two (2) minutes to administer. ASHAs are women Community Health Workers (CHWs) of the Indian public healthcare system, who reside in the community she would be working with. Apart from psychoses, the Symptoms-in-Others tool contains questions targeting epilepsy, substance use problems and intellectual disability disorders as well. The cadre was created in 2006 by the Union health ministry’s flagship program, the National Rural Health Mission [28]. In addition to the maternal and child health, ASHAs are involved in identification of various communicable diseases (Tuberculosis, Leprosy, Malaria, sexually transmitted diseases) and non-communicable diseases. ASHAs’ role in mental health too is coming to the forefront in recent times [27–30]. Each ASHA generally looks after 1000 residents on an average. During her customary visits to each house, the screening tool was administered to one person of the household (a responsible adult, usually the head of the household). Screen positive cases were referred to the research social workers (SKK and DMH) of the team. In total, 26,823 households were screened in Thirthahalli and 42,761 households were screened in Turuvekere. This round of screening was completed between July 2018 and February 2019. Research social workers then evaluated (interview either in person or telephonically) to rule out other diagnostic possibilities. Further, cases with features of psychosis were referred to research psychiatrists for a diagnostic interview (clinical). Diagnostic interview by psychiatrists occurred predominantly telephonically or via video calling. After confirmation, patients were referred to either the PHCs (Thirthahalli) or the taluk hospital (Turuvekere) for treatment and care.

Second house-to-house survey was conducted by the research social workers in randomly selected 10% of the total households in the taluks. This was done to screen possible missing cases in the ASHAs survey. This method of case-finding has been used in an earlier study [25]. Hitherto unidentified suspected patients were interviewed by research psychiatrists (via telephone or video calling) to confirm the diagnosis of schizophrenia. This number was multiplied by a factor of 10, to get the probable number of missed cases.

Data collection for this study started in July 2018 and ended in February 2021. Ethical Committee of NIMHANS, Bengaluru approved the study.

Measurement of treatment Gap:

The above mentioned three tier method gives us three groups of patients (a) those already registered and are continuing care with our team (existing cases in the cohorts) (b) new cases identified through ASHAs’ first round of house-to-house survey and finally (c) new additions identified during the 10% survey of houses. Adding all three will give the prevalence figures (in other words, the total number of persons with schizophrenia) in both taluks. We then calculated the number of ‘ever-treated’ and number of persons who were ‘never-treated’. These details were noted down for individual patients after oral enquiry with patients and/or family members. Ever-treated means those with history of having consulted an allopathic Psychiatrist (with DPM/MD/DNB degree) at least once in lifetime for the psychotic illness. Patients who consulted other systems of medicine or faith healers without consulting allopathy even once were NOT considered as ever-treated. Never-treated meant those with schizophrenia without having consulted a doctor (allopathic physician even once). The difference between the prevalence figures and the number of ever-treated persons constituted the treatment gap. psychiatrist (with DPM/MD/DNB degree) at least once in lifetime for the psychotic illness. Patients who consulted other systems of medicine or faith healers without consulting allopathy even once were NOT considered as ever-treated. Never-treated meant those with schizophrenia without having consulted a Psychiatrist. The difference between the prevalence figures and the number of ever-treated persons constituted the treatment gap.

Figures 1,2 and 3 gives the treatment gap for Thirthahalli, Turuvekere and overall (both taluks put-together) respectively. As it can be made out, the gap is 3.84% in Thirthahalli; 12.28% in Turuvekere and 7.16% overall. We have not reported the clinical and demographic details as these were not available for all patients.

This study shows that the treatment gap for schizophrenia in the two talukas of South India; Thirthahalli and Turuvekere (both, belonging to Karnataka state) is significantly lower (7.16%) than the national average (73.5%). As is construed in the study, treatment gap meant the proportion of persons (never treated persons with schizophrenia) not coming into contact with psychiatric medical services that are present in these areas. In other words, the contact coverage [5] is 93% and only seven out of the hundred needy persons did not utilize the existing

services. To the best of the knowledge of the authors, this is the first study to assess the treatment gap for schizophrenia in a defined administrative block in India. In Thirthalli, the previous gap was 58% [25], that reduced to 3.84% over one and a half decade of this intervention program. Studies elsewhere have shown substantial increase in contact coverage [15] over 12 months across LAMIC centres following implementation of a mental health intervention program at primary health centres (PHCs). The team measured the increase in the proportion of adults seeking treatment using survey method. It revealed an increase in treatment contact coverage at PHCs for common mental disorders that ranged from 8.1% in Nepal to 23.5% in India. However, the drawback in this survey was a possibility of not reaching out to untreated persons living in the community. Thus, treatment gap wasn’t measured in this study rather increase in service utility. The magnitude of reduction in the gap can be essentially seen as a result of the community intervention programs successfully running in these two blocks (taluks) since the past one and a half decade [31]. Public health implications of this finding are potentially far-reaching. It points to the need to provide for a block level (taluk level) mental health program for the country and shows what could be achieved if such a program functions optimally. As is shown in several studies [11, 12, 19, 20, 22, 24, 25, 32–34], the effectiveness of coverage is quite good among those who are in contact with the services. In these lines of contact coverage, certain research groups have demonstrated reduction for depression and alcohol use disorders. Luitel et al compared the contact coverage between baseline and post implementation of a mental health care plan at Nepal based on ‘task shifting’ based intervention for 3 years. It found an increase in the coverage from 8.1–11.8% for depression and 5.1–10.3% for alcohol use disorders. Essentially, our community intervention programs consist of regular outpatient services and periodic outreach to those who drop out of the treatment umbrella. Psychotropic medications and low intensity psychosocial interventions covering education about the illness, need for continued medication adherence, guidance to obtain disability benefits, and vocational avenues etc. are being offered. One psychiatrist (for regular consultations) and a resident non-specialist social worker (for all other psychosocial needs of the patients and logistical aspects of co-ordinating care) are looking after this target population. This approach can roughly cater to two-thirds of the target population (meaningful and effective care over long periods of time). Also, this could be the essential first step in broadening the service delivery scope to the psychosocial domain. For the remaining patient population (one-third), we believe that this low-intensity approach may not work. They require specialized multidisciplinary care in tertiary care centres where full-fledged clinical and psychosocial care is available. Ideally, specialist mental health professionals are to be available for all those in need. Prudence and pragmatism (considering the current human resources scenario) however dictates a measured and phase-wise expansion. As on today, the District Mental Health Program(DMHP); operational arm of the centrally funded National Mental Health Program, is implemented in more than 90% of the districts of India (704 of them as on February 2022, each district having a population of roughly two million) [35]. Each DMHP provides for a team of one psychiatrist, one clinical psychologist, one psychiatric social worker, two nurses and two support staffs). Though the NMHP has been successful in providing near-universal speciality coverage, exhibiting the reduction in treatment gap by the system is lacking. The next logical step would be to expand specialist mental health team to the sub-district (called as blocks or taluks). India has about 8000 taluks and there is provision for one medical officer and one social worker [36]. At the minimum, a medical officer (with MBBS qualification) can be posted at the taluk headquarter to look after the entire region, along with a social worker. Easily available digital technology will ensure collaborative care to those in need [29, 30, 37–42]. An added advantage of this approach is the good service coverage for all other psychiatric disorders as well (common mental disorders and the substance use disorders).

The above plans will not in any way negate the need for exponentially increasing the number of mental health professionals. Indeed, the National Mental Health Policy and the Mental Healthcare Act, 2017 both point towards the state obligations to increase the mental health human resources. Also, our findings are not withstanding the expanding and emerging scope of the concept ‘treatment-gap’ that now specifically adds gap in accessing and accepting psychosocial care. The same applies to the physical health gap too. In any case, the term ‘treatment-gap’ is well entrenched in the terminology of policy makers and serves a utilitarian value. Moreover, in a LAMIC like India, it may be wise to prioritize the clinical gap before targeting the comprehensive mental healthcare gap.

In the study, fairly rigorous and robust methods of case-finding were used [25]. One round of survey by the community health workers (ASHAs) covering all households in both taluks which was followed by repeat visits to 10% households by social workers (aided by psychiatrists over phone/video call). Suspected cases were interviewed by qualified psychiatrists confirming or disconfirming the diagnosis of schizophrenia. Additionally, the authors have accounted for missing cases. Hence, the chance of underestimation of the denominator (target population; total number of persons with schizophrenia residing in a particular area) is extremely small. Also, there are multiple complex reasons for patients not accepting the treatment and also for those who drop out of treatment/care umbrella (demand side challenges) [27, 43, 44]. Evidently, each patient/family has its own set of signature reasons/factors for not contacting the available care or to drop out of the care umbrella. Repeated efforts in bringing such people back into the care bracket may be practically impossible. Treating teams are simply not welcome to their homes. It is also unreasonable for the state to own up and provide all dimensions of care for all such cases. The estimated funds for such an endeavour is mind boggling and appears unfeasible in the near future to dedicate such amount (which comes up to one third of the entire health budget of the country) [45, 46].

Secondly, difference in the ‘gap’ between two cohorts can be attributed to (among others) the variable accessibility of services. While in Thirthahalli, the collaborative care is accessible in the nearest primary health centre (available within 2.5 miles from patients’ houses, roughly), patients in Turuvekere have to travel to the Taluk Headquarter (which is considerably farther from individuals’ houses). It may be noted that ‘distance’ from the care centre is one of the important reasons for not accessing treatment [27]. It is hereby put forth that care-at-doorstep models are useful in ensuring continuity of care [47]. Lastly, we make a mention on the cost-effectiveness of the model of care. This is an area with requires attention in the near future. Potential limitations of the study include not using any diagnostic tools and diagnosis via telephone. The fact that ASHAs did not identify all the cohort patients is another shortcoming. However, as mentioned elsewhere, it could be because not all provided consent for their survey, respondents might have been unaware that they or their family member was not taking treatment for mental illness. Hence, they might have provided a response of ‘no’ for the question on SIO – ‘whether any member of your house has received treatment for a mental illness’, patient was receiving treatment for 'mental illness'. Thus, a possibility of ASHAs missing those who were doing well could be another explanation.

Meaningful reduction of treatment gap (meaning considerable contact coverage) for persons with schizophrenia is achievable with a framework of collaborative care. Further studies should explore cost effectiveness. The finding has implications for future policies too.

Author Contribution

CNK for conceptualisation, data curation, formal analysis, methodology. project administration, resources, Supervision, visualisation, writing - original draft, and writing - review & editing.RCK: formal analysis, investigation, methodology, resources, writing - original draft, and writing -review & editing.SG: project administration, investigation -data collection, resources,KSK: project administration, investigation -data collection, resources, HMD: investigation - project administration, data collection, resourcesPR: investigation - data collection, resourcesSP: investigation - data collection, resourcesPV: investigation -data collection, resourcesVB: conceptualisation, resources, investigation, supervision, visualisationNM: conceptualisation, resources, supervision, visualisationSBM: conceptualisation, resources, supervision, visualisationJT: conceptualisation, data curation, formal analysis, funding acquisition,investigation, methodology. project administration, resources, supervision, visualisation, and writing - review.The authors do not have any conflicts of interest to declare. There was no financial or other support taken in preparing the manuscript. The manuscript has been read and approved by all the authors, the requirements for authorship have been met as per the Journal, and that each author believes that the manuscript represents honest work.

Acknowledgement

The authors would like to acknowledge persons with schizophrenia and their families for having co-operated for the data collection. ASHAs of Thirthahalli and Turuvekere deserve a rich round of applause for their co-operation for the work. The taluk health administration too are acknowledged. Authors would also acknowledge several volunteer donors contributing generously towards sustaining the community intervention programs in these two taluks. We also acknowledge the contribution of ‘Chittasanjeevini Charitable Trust, that is contributing free psychotropic medications for patients of both these taluks. Finally, Mr. Pramodha, Social worker did contribute parttime for the data collection.

Data Availability

The data supporting the results reported in this published article can be accessed by mailing the authors

Author Declaration: The authors do not have any conflicts of interest to declare. There was no financial or other support taken in preparing the manuscript. The manuscript has been read and approved by all the authors, the requirements for authorship have been met as per the Journal, and that each author believes that the manuscript represents honest work.

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No competing interests reported.

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Near zero treatment gap for schizophrenia: Can it be reality in rural India?

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