Correspondence
for a key component of any such service arrangement in low-income countries with scare specialist resources for mental health—the use of non-specialist health workers to supplement care usually delivered by specialists. In our understanding, to treat people with moderate-to-severe forms of schoziphrenia staff need training in psychiatric skills, which is seen in usual care for patients in India, irrespective of location. Not providing these staff skilled in psychiatric care for this population would not be ethical. Furthermore, a large number of participants with ongoing treatment met the trial inclusion criteria. At the rural Tamil Nadu site, many participants were not receiving treatment and as a result, the intervention effect size was more substantial, showing the value of community health workers in low-resource settings to deliver psychosocial interventions for people with moderate-to-severe schizophrenia. We believe that at 12 months of treatment, a 20% reduction in overall symptom and disability ratings in people with schizophrenia is a reasonable and substantial change to achieve. Finally, we agree with the authors that more rigorous trials with different populations are needed to ascertain the role of community health workers in helping to address the treatment gap of people with schizophrenia in low-resource settings. We declare no competing interests.
*Graham Thornicroft, Sudipto Chatterjee, Rangaswamy Thara, Vikram Patel [email protected] King’s College London, Institute of Psychiatry, London SE5 8AF, UK (GT); Sangath, Goa, India (SC, VP); Schizophrenia Research Foundation, Chennai, India (RT); Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, London, UK (VP); and Public Health Foundation of India, New Delhi, India (VP) 1
1574
Chatterjee S, Naik S, John S, et al. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial. Lancet 2014; 383: 1385–94.
2
3
World Health Organization. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings. http://www.who.int/mental_ health/publications/mhGAP_intervention_ guide/en/ (accessed March 4, 2014). Government of India Ministry of Health and Family Welfare. National Mental Health Programme (NMHP). http://mohfw.nic.in/ index1.php?lang=1&level=2&sublinkid=2381&l id=1962 (accessed Sept 25, 2014).
Survival in acute myocardial infarction In their Article (April 2, p 1305),1 Sheng-Chia Chung and colleagues establish a comparison between Sweden and the UK in which only 2·3% (95% CI 2·2–2·3) of patients in the UK and 1·3% (1·3–1·4) of patients in Sweden had been recorded as being admitted to hospital after out-of-hospital cardiac arrest. In our Viewpoint,2 we pointed out that resuscitation from cardiac arrest had prevented 4 times as many deaths than the then prevalent method for reperfusion (streptokinase) and that in the studies on which these estimates were based,3,4 the percentage of patients who had survived out-of-hospital arrest was 5·0% for The United Kingdom Heart Attack Study Collaborative Group and 4·4% for the Southern Heart Attack Response Project. These patients have a high hospital fatality rate (odds ratio for deaths is 4·55 in Sweden and 4·78 in the UK, as stated in their supplementary appendix).1 It is difficult to escape the conclusion that patients surviving out-of-hospital cardiac arrest were under-reported in the registries of both countries and that fuller reporting would have increased the fatality rates, more so in Sweden than in the UK. Survival from out-of-hospital cardiac arrest varies widely among ambulance districts5 and in one district was improved markedly after rigorous retraining of paramedics.6 Resuscitation from cardiac arrest is still a very important but neglected specialty in audits of treatment for the acute coronary syndromes.
I declare no competing interests.
Robin Norris [email protected] 17 Aberdeen Rd, Castor Bay, Auckland 0620, New Zealand 1
2
3
4
5
6
Chung S-C, Godeborg R, Nicholas O, et al. Acute myocardial infarction: a comparison of short-term survival in national outcome registries in Sweden and the UK. Lancet 2014; 383: 1305–12. Julian DG, Norris RM. Myocardial Infarction: is evidence-based medicine the best? Viewpoint. Lancet 2002; 359: 1515–16. The United Kingdom Heart Attack Study Collaborative Group. Effect of time from onset to coming under care on fatality of patients with acute myocardial infarction: effect of resuscitation and thrombolytic treatment. Heart 1998; 80: 114–20. Norris RM, for the Southern Heart Attack Response Project (SHARP) investigators. A new performance indicator for acute myocardial infarction. Heart 2001; 85: 395–401. Perkins GD, Cooke MW. Variability in cardiac arrest survival: the NHS Ambulance Service Quality Indicators. Emerg Med J 2012; 29: 3–5. Fletcher D, Chamberlain D, Handley A, et al. Utstein-style audit of Protocol C: a non-standard resuscitation protocol for healthcare professionals. Resuscitation 2011; 82: 1265–72.
Authors’ reply We thank Robin Norris for his comments on our study, 1 and we strongly agree with him that resuscitation after out-of-hospital cardiac arrest is an important aspect of the quality of care of patients with acute coronary syndromes. We propose linkage of electronic health records across primary care, the ambulance service, and national quality registries for cardiac arrest and cardiac diseases to better understand, and improve management and outcome. Norris is correct in stating that the national acute coronary syndrome (ACS) registry data that we report only includes patients admitted to hospital, and therefore excludes patients who died before reaching hospital. Specifically, for acute myocardial infarction patients with out-of-hospital cardiac arrest, only patients who were resuscitated and admitted to hospital were included. In our study,1 such patients had an increased 30-day mortality in Sweden (25%) and the UK (32%) than the overall acute myocardial infarction www.thelancet.com Vol 384 November 1, 2014
for a key component of any such service arrangement in low-income countries with scare specialist resources for mental health—the use of non-specialist health workers to supplement care usually delivered by specialists. In our understanding, to treat people with moderate-to-severe forms of schoziphrenia staff need training in psychiatric skills, which is seen in usual care for patients in India, irrespective of location. Not providing these staff skilled in psychiatric care for this population would not be ethical. Furthermore, a large number of participants with ongoing treatment met the trial inclusion criteria. At the rural Tamil Nadu site, many participants were not receiving treatment and as a result, the intervention effect size was more substantial, showing the value of community health workers in low-resource settings to deliver psychosocial interventions for people with moderate-to-severe schizophrenia. We believe that at 12 months of treatment, a 20% reduction in overall symptom and disability ratings in people with schizophrenia is a reasonable and substantial change to achieve. Finally, we agree with the authors that more rigorous trials with different populations are needed to ascertain the role of community health workers in helping to address the treatment gap of people with schizophrenia in low-resource settings. We declare no competing interests.
*Graham Thornicroft, Sudipto Chatterjee, Rangaswamy Thara, Vikram Patel [email protected] King’s College London, Institute of Psychiatry, London SE5 8AF, UK (GT); Sangath, Goa, India (SC, VP); Schizophrenia Research Foundation, Chennai, India (RT); Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, London, UK (VP); and Public Health Foundation of India, New Delhi, India (VP) 1
1574
Chatterjee S, Naik S, John S, et al. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial. Lancet 2014; 383: 1385–94.
2
3
World Health Organization. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings. http://www.who.int/mental_ health/publications/mhGAP_intervention_ guide/en/ (accessed March 4, 2014). Government of India Ministry of Health and Family Welfare. National Mental Health Programme (NMHP). http://mohfw.nic.in/ index1.php?lang=1&level=2&sublinkid=2381&l id=1962 (accessed Sept 25, 2014).
Survival in acute myocardial infarction In their Article (April 2, p 1305),1 Sheng-Chia Chung and colleagues establish a comparison between Sweden and the UK in which only 2·3% (95% CI 2·2–2·3) of patients in the UK and 1·3% (1·3–1·4) of patients in Sweden had been recorded as being admitted to hospital after out-of-hospital cardiac arrest. In our Viewpoint,2 we pointed out that resuscitation from cardiac arrest had prevented 4 times as many deaths than the then prevalent method for reperfusion (streptokinase) and that in the studies on which these estimates were based,3,4 the percentage of patients who had survived out-of-hospital arrest was 5·0% for The United Kingdom Heart Attack Study Collaborative Group and 4·4% for the Southern Heart Attack Response Project. These patients have a high hospital fatality rate (odds ratio for deaths is 4·55 in Sweden and 4·78 in the UK, as stated in their supplementary appendix).1 It is difficult to escape the conclusion that patients surviving out-of-hospital cardiac arrest were under-reported in the registries of both countries and that fuller reporting would have increased the fatality rates, more so in Sweden than in the UK. Survival from out-of-hospital cardiac arrest varies widely among ambulance districts5 and in one district was improved markedly after rigorous retraining of paramedics.6 Resuscitation from cardiac arrest is still a very important but neglected specialty in audits of treatment for the acute coronary syndromes.
I declare no competing interests.
Robin Norris [email protected] 17 Aberdeen Rd, Castor Bay, Auckland 0620, New Zealand 1
2
3
4
5
6
Chung S-C, Godeborg R, Nicholas O, et al. Acute myocardial infarction: a comparison of short-term survival in national outcome registries in Sweden and the UK. Lancet 2014; 383: 1305–12. Julian DG, Norris RM. Myocardial Infarction: is evidence-based medicine the best? Viewpoint. Lancet 2002; 359: 1515–16. The United Kingdom Heart Attack Study Collaborative Group. Effect of time from onset to coming under care on fatality of patients with acute myocardial infarction: effect of resuscitation and thrombolytic treatment. Heart 1998; 80: 114–20. Norris RM, for the Southern Heart Attack Response Project (SHARP) investigators. A new performance indicator for acute myocardial infarction. Heart 2001; 85: 395–401. Perkins GD, Cooke MW. Variability in cardiac arrest survival: the NHS Ambulance Service Quality Indicators. Emerg Med J 2012; 29: 3–5. Fletcher D, Chamberlain D, Handley A, et al. Utstein-style audit of Protocol C: a non-standard resuscitation protocol for healthcare professionals. Resuscitation 2011; 82: 1265–72.
Authors’ reply We thank Robin Norris for his comments on our study, 1 and we strongly agree with him that resuscitation after out-of-hospital cardiac arrest is an important aspect of the quality of care of patients with acute coronary syndromes. We propose linkage of electronic health records across primary care, the ambulance service, and national quality registries for cardiac arrest and cardiac diseases to better understand, and improve management and outcome. Norris is correct in stating that the national acute coronary syndrome (ACS) registry data that we report only includes patients admitted to hospital, and therefore excludes patients who died before reaching hospital. Specifically, for acute myocardial infarction patients with out-of-hospital cardiac arrest, only patients who were resuscitated and admitted to hospital were included. In our study,1 such patients had an increased 30-day mortality in Sweden (25%) and the UK (32%) than the overall acute myocardial infarction www.thelancet.com Vol 384 November 1, 2014
