Psychiatric hospital reform in low-income and middle-income countries; structured individualised intervention and recovery (SITAR)

Abstract

Background: Low- and Middle-Income countries (LMICs) like India have large treatment gaps in mental health care. People with Severe Mental Disorders (SMD) face impediments to their clinical and functional recovery and have many unmet needs. The infrastructure and standards of care are poor in colonial-period mental hospitals, with no clear pathways to discharge and reintegration into the community. Despite concerns over quality of care and human rights violations these hospitals continue to provide the majority of mental health care for SMD in most LMICs. LMICs need a pragmatic approach to implementing mental health, with evidence-based reforms of psychiatric institutions to meet the needs of service users today. Objective: The aim of the research was to examine the impact of hospital reform on outcomes for long-stay patients. We compared whether larger structural and process reform of a mental hospital brings about change in patient outcomes or a case management based individual service package is needed to effectively translate larger hospital reform into discernible difference in outcomes for long-stay patients often living in closed hospital wards. Methods: This research study comprised three interlinked phases in a mixed methods design. In phase one, a systematic literature review was undertaken to examine evidence on psychiatric hospital reform in LMICs. Phase two comprised a pragmatic randomised clinical trial, called Structured Individualised inTervention And Recovery (SITAR), to study the impact of psychiatric hospital reform. The trial also aimed to study the modality in which reform would reach the service user. SITAR used Need-Based Intensive Case Management (NB-ICM) within the context of the hospital. ’Patients’ experiences of reform were also studied using qualitative methodology. In the third phase, an economic evaluation was undertaken to study the affordability of psychiatric hospital reform as a viable care pathway for very vulnerable people who are long-stay in psychiatric hospitals. Results: Systematic psychiatric hospital reform has a positive impact on outcomes of disability, symptom, social and occupational functioning, and quality of life. NB-ICM has an important role to play in terms of patient’s lived experience of reformed care, it however, did not show a significant impact on measured outcomes in the time period of the study. Conclusion: Systematic reform of psychiatric hospitals appears feasible and affordable and might be an important alternative to the limited care pathways for people with Severe Mental Disorders who have high care needs in LMICs