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Effectiveness and cost-effectiveness of community-based mental health services for individuals with severe mental illness in Iran: a systematic review and meta-analysis | BMC Psychiatry


Seventy-one articles were selected through the English-language website, and fifty-six Persian-language articles were selected through the Iranian website. After removing duplicates, 115 articles remained. In the next steps, the titles and abstracts were reviewed, and 84 articles were excluded. The full text of thirty-one articles was reviewed, of which 14 unrelated articles were excluded. Finally, 17 English and Persian articles were included in the study (Fig. 1).

Fig. 1
figure 1

PRISMA flow chart to illustrate the article search and selection process

Critical appraisal and risk of bias assessment

The results of the risk of bias and critical appraisal in the qualitative assessment of the articles are as follows. We have 8 experimental articles that meet the inclusion criteria for our study. These articles were selected based on their relevance to our research question and their adherence to our predetermined criteria for experimental design. We evaluated the articles based on the JBI critical appraisal checklist (Fig. 2). Question four (Were participants blind to treatment assignment?) And question five (Were those delivering treatment blind to treatment assignment?) Were not applicable for most of the studies as in the communicate based intervention it is not feasible for the participants and the person who deliver the services to be blind of interventions. The rest of the items were enough qualified to rely on the results (Fig. 2). The result of the quasi experimental and economy studies checklists depicted in the Supplementary Material 1:Appendix.

Fig. 2
figure 2

Quality assessment of experimental studies

The demographic characteristics of included articles

Demographic characteristics of included articles revealed Table 1.

Table 1 The characteristics of included articles

The results of intervention comparing before and after 12-months follow-up presented. The findings related to the tools used in intervention studies are presented in Table 2. As noted, most tools reported a weak level of heterogeneity(I2), so the meta-analysis has not been performed. The meta-analysis was conducted for rehospitalization, PANSS (Positive and Negative Syndrome Scale) as a psychopathology assessment tool and KELS (Kohlman Evaluation of Living Skills of the patients) and FEIS variables indicating psychological distress in caregivers.

Table 2 The effectiveness of intervention for the period of 12 months follow-up

The rehospitalization rate

One of the study’s primary goals was to evaluate the effect of any CBMHS on rehospitalization after the index discharge. The CBMHS included home-visit and telephone follow-ups, the rehospitalization rate among patients who received CBMHS (with a total of 595 participants in both intervention and control groups) was 2.14 times lower compared to those who received treatment as usual (OR: 2.14,95%CI: 1.44, 3.19). Mohebi [17] was the only article that used Medication Adherence Rating Scale (MARS) to evaluate the compliance of the patient with treatment (SMD: 3.15, CI: 95% 2.31, 3.98). The result of the meta-analysis of rehospitalization among four studies showed in Fig. 3. There was not any publication bias. It shown as Fig. 4.

Fig. 3
figure 3

The result of the meta-analysis of rehospitalization among four studies

Fig. 4
figure 4

Funnel plot, publication bias for rehospitalization in studies

Severity of psychopathology

Out of 17 studies, 5 used PANSS to evaluate the effect of intervention on psychopathology, whose data were amenable to analysis (with a total of 669 participants in both intervention and control groups). Meta-analysis shows that after 12 months of intervention, CBMHS are successful in reducing significantly of the severity of psychopathology (SMD: -0.31, 95%CI: -0.49 to -0.13, I2 = 40.23%). Akbari [18] was the only one that used ANSQ -Anderson Negative Symptoms- (SMD: -0.581, 95%CI: -1.312, 0.149). The meta-analysis of the studies for PANSS showed in Fig. 5.

Fig. 5
figure 5

The meta-analysis of the studies for PANSS

The result of meta-analysis on the YOUNG (evaluating the severity of Bipolar mood disorder) shows significant difference by implementing the intervention (SMD: -0.764, 95% CI: -1.274, -0.253, I2 = 85.22%), however the heterogeneity among four studies were not acceptable.

Upon visual examination of the funnel plot, no significant signs of asymmetry were observed (located in the Supplementary Material 1: Appendix).

Social skills as secondary outcomes of the study could be considered as one of the outcomes of any intervention that aims to help the patient to be as independent as possible in the family and society. Just two studies used KELS to evaluate the social skills of the patients. The result of KELS shows a high effect size (SMD: -0.7, 95%CI: -0.98 to -0.44, I2 = 0.00%), and the community-based interventions are more promising. The same result was revealed by the study of Shahmiri (2014) by Matson evaluation of social skills (MESS) (SMD: -0.877, 95%CI: -1.749, 0.041) (lower scores indicating better functioning).

The tools of ACIS Assessment of Communication and Interaction Skills (mean difference 1.747 (CI: 1.08, 2.41).) Higher scores indicate better skills, such as DSK Dehbozorgi’s social skills (SMD: 0.835, 95%CI: 0.088, 1.581). (Lower scores indicate lower social skills).

The burden of the caregivers was evaluated by FEIS (evaluating the burden of the caregivers) in the meta-analysis (not shown in the article). It shows that again in the two articles, the effect size was -0.55 (SMD: -0.55, 95%CI: -0.99, -0.1, I2 = 63.2) (in favor of community-based services.

For the CSQ, which evaluated the satisfaction of the clients from the services, there were not any significant differences with the control group. In the study of Sharifi [14], the quality of life of (WHOQOL) patients has been improved marginally (SMD:-0.246, 95%CI: -0.500, 0.007) (P = 0.057). However, in the study of Hojati- Abad [27] WQOLCQ (Wisconsin Quality of Life Client Questionnaire (SMD: 0.798, 95%CI: 0.29, 5, 1.301), there was not any significant difference.

Economic evaluation studies

For economic evaluation we considered tow indexes reported incremental cost-effectiveness ratios (ICER) [28] and Quality-Adjusted Life Year (QUALY) [29, 30], which is are more common indexes economic evaluation.

The QALY serves as a metric for assessing the worth of health outcomes. As health is contingent upon both lifespan and well-being, the QALY was formulated as an endeavor to amalgamate the value of these attributes into a solitary index. In the field of mental health, improving the quality of life for patients and reducing the burden of the disease not only for the patients themselves but also for their families and society as a whole. QALYs can be integrated with medical expenses to derive a final universal measure of cost/QALY. This parameter facilitates the comparison of the cost-effectiveness of various treatments without bias.

In numerous healthcare systems, determinations regarding the reimbursement and availability of new medications hinge upon health technology assessments. These assessments, involve the evaluation of an ICER. Decision-makers then weigh the ICER against a predetermined benchmark for cost-effectiveness, referred to as the cost-effectiveness threshold (CET), in order to ascertain whether reimbursement should be granted or withheld [28].

We identified two reports that met our inclusion criteria concerning economic evaluations of community-based interventions to improve the mental health of individuals with SMI [13, 21]. In both studies were included QUALY and ICER.

Malakouti et al. ICER for aftercare home services following the discharge of individuals with SMI. Their analysis was based on a 12-month follow-up of participants in a clinical trial conducted between 2007 and 2008. They found that the ICER was 5.7 million Rials (IRR) per QALY when using general practitioners (GPs) as care providers during home visits and 5.0 million IRR per QALY when replacing GPs with nurses [13]. In a separate study, Moradi-Lakeh et al. conducted a cost-utility analysis of aftercare services following the discharge of individuals hospitalized for SMI. Their analysis was based on a clinical trial performed from 2012 to 2014, with a 20-month follow-up. They reported an ICER of US$8,399 (95% CI: 8,178–8,620) per QALY for the intervention [13]. It is worth noting that the services provided by the second study were more comprehensive. In these two studies showed that community-based interventions can be useful in terms of cost–benefit and cost-effectiveness.

While the ICER measures in these two studies differed considerably (partly due to a significant fluctuation in IRR-USD exchange rates $1 = 935 to 10,402 IRR, and other services provided by the second study included the expenses of general psychologists, supervising psychiatrists, as well as the costs of weekly co-ordination meetings of home visit teams, costs of classes for caregivers’ education, training of social skills), both were found to be below the World Health Organization’s recommended threshold for cost-effectiveness of health interventions [13, 21]. The second study aimed to provide the cheapest and most effective intervention and evaluated the feasibility of providing such CBMHS. However, from $ 613 to $8400, it is feasible to provide such services while considering the exchange and inflation rates.



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