Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality

BACKGROUND

Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favour of providing care in a variety of non-hospital settings, underpins the rationale behind care in the community. A major thrust towards community care has been the development of community mental health teams (CMHT).

OBJECTIVES

To evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness compared with standard non-team management.

SEARCH STRATEGY

We searched The Cochrane Schizophrenia Group Trials Register (March 2006). We manually searched the Journal of Personality Disorders, and contacted colleagues at ENMESH, ISSPD and in forensic psychiatry.

SELECTION CRITERIA

We included all randomised controlled trials of CMHT management versus non-team standard care.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (WMD) again based on a fixed effects model.

MAIN RESULTS

CMHT management did not reveal any statistically significant difference in death by suicide and in suspicious circumstances (n=587, 3 RCTs, RR 0.49 CI 0.1 to 2.2) although overall, fewer deaths occurred in the CMHT group. We found no significant differences in the number of people leaving the studies early (n=253, 2 RCTs, RR 1.10 CI 0.7 to 1.8). Significantly fewer people in the CMHT group were not satisfied with services compared with those receiving standard care (n=87, RR 0.37 CI 0.2 to 0.8, NNT 4 CI 3 to 11). Also, hospital admission rates were significantly lower in the CMHT group (n=587, 3 RCTs, RR 0.81 CI 0.7 to 1.0, NNT 17 CI 10 to 104) compared with standard care. Admittance to accident and emergency services, contact with primary care, and contact with social services did not reveal any statistical difference between comparison groups.

AUTHORS' CONCLUSIONS

Community mental health team management is not inferior to non-team standard care in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide. The evidence for CMHT based care is insubstantial considering the massive impact the drive toward community care has on patients, carers, clinicians and the community at large.

[Improving the publication rate of Spanish researchers in good journals]

Five obstacles are described that currently prevent Spanish researchers in the psychological sciences from publishing more frequently in journals of high impact factor. These are: a) a general lack of confidence in your ability; b) a tendency for your papers to be driven more by speculation rather than data; c) excessive length of submitted manuscripts; d) higher than expected rates of drop-out and non-participation in studies, and e) lack of independence from pharmaceutical companies. Although many of these problems will require long-term structural changes, others can be addressed immediately and yield improvement rapidly.

Do care patterns change over time in a newly established mental health service? A report from the UK700 trial

PURPOSE

Data on the process of mental health care is scant. Most studies focus on services at their inception when activity may be atypical and then usually present data only mean values for the reported variables over the whole study period. We aimed to test whether care delivery changes over time, and to describe any changes at the individual patient and team levels.

METHODS

Process data on 272 patients in three new intensive case management (ICM) teams were collected over 2 years. Interventions were prospectively recorded using clinician-derived categories. Changes over time are described at both patient and team level.

RESULTS

The number of contacts and the proportion of face-to-face activity were remarkably constant after the first month at the patient level. The proportion of 'psychiatric' interventions (main focus on medication or a specific 'mental health' intervention performed) increased greatly after the first 6 months. The care activity received by individual patients varied considerably. Overall, teams varied significantly in the extent to which their activity rates were sustained over time.

CONCLUSIONS

New ICM teams deliver highly individualised care with more marked differences in treatment patterns between patients in the same team than mean differences between teams. The early 'engagement' period is marked by a greater focus on social care. There is evidence of differences in sustainability of the services by site.

The Nottingham study of neurotic disorder: predictors of 12 year costs

OBJECTIVE

To examine the relationship between clinical, demographic and socio-economic characteristics and the long-term costs of a cohort of neurotic patients.

METHOD

Analysis of the costs of a cohort of 210 people entered in the Nottingham study of neurotic disorders, a randomized controlled evaluation of five treatments for neurotic disorders. Service use data were collected at 5 and 12 years after study entry. Multiple regression analyses were conducted.

RESULTS

The total cost per patient over the 12-year follow-up period was calculated to be $11,940 (SD $15,520) ( pound7450, SD pound9690). Higher costs were significantly associated with the presence of general neurotic syndrome, an initial diagnosis of dysthymia and a recurrent episode of illness.

CONCLUSION

The total costs of care for a range of neurotic disorders are broadly comparable with other estimates of costs reported in the literature for similar populations. Those responsible for higher costs in the longer-term have comorbid anxiety, depressive and personality disorders.

Suicidal ideation and suicide attempts among ethnic minority groups in England: results of a national household survey

BACKGROUND

Socio-cultural factors impact on the extent of suicidal ideation and attempted suicide but the relative importance of these factors among people from different ethnic groups in Britain has not been explored. We examined the prevalence of suicidal ideation, the incidence of attempted suicide, and the extent of service utilization following attempted suicide among representative samples of White, Irish, Black Caribbean, Bangladeshi, Indian and Pakistani individuals living in England.

METHOD

We conducted a secondary analysis of data from the EMPIRIC study, a cross-sectional survey of 4281 adults aged 16-74 years, living in private households in England.

RESULTS

Lifetime suicidal ideation was generally lower in ethnic minority groups but higher among those born in the UK than those who migrated to England as adults. Risk factors for suicidal ideation have much in common across different ethnic groups; current symptoms of mental distress being the most important. White British and Irish respondents were twice as likely to receive medical attention following attempted suicide than those from other ethnic groups.

CONCLUSIONS

Services need to adapt in order to ensure that people from ethnic minorities receive appropriate psychological and medical care following attempted suicide.

Randomized controlled trial of assertive community treatment in intellectual disability: the TACTILD study

BACKGROUND

There has been a policy shift away from hospital to community in the services of all those with psychiatric disorders, including those with intellectual disability (ID), in the last 50 years. This has been accompanied recently by the growth of assertive outreach services, but these have not been evaluated in ID services.

METHOD

In a randomized controlled trial we compared assertive outreach with 'standard' community care, using global assessment of function (GAF) as the primary outcome measure, and burden and quality of life as secondary measures.

RESULTS

We recruited 30 patients, considerably less than expected; no significant differences were found between the primary and secondary outcomes in the two groups. The differences were so small that a Type II error was unlikely.

CONCLUSIONS

Reasons for this lack of specific efficacy of the assertive approach are discussed and it is suggested that there is a blurring of the differences between standard and assertive approaches in practice.

Temporal reliability of psychological assessments for patients in a special hospital with severe personality disorder: a preliminary note

BACKGROUND

The new programme for assessing those with dangerous and severe personality disorder relies heavily on psychological assessments of personality disorder and risk.

METHODS

The temporal reliability of assessments of psychopathy (PCL-R), risk (HCR-20) and personality was assessed using the International Personality Disorder Examination (IPDE) in 15 randomly selected male prisoners in a high secure hospital carried out at intervals varying between a mean of nine and 19 months after initial assessments by a variety of assessors.

RESULTS

Using the intra-class correlation coefficient the agreement varied between 0.57 (HCR-20), 0.58 (PCL-R) and 0.38-0.70 for IPDE personality disorders, with the best agreement for antisocial personality disorder (0.70).

COMMENT

These levels of agreement are consistent with other recent work on temporal reliability of personality instruments but are a little too low for confidence in these measures alone in the assessment process.

Therapist competence and clinical outcome in the Prevention of Parasuicide by Manual Assisted Cognitive Behaviour Therapy trial: the POPMACT study

BACKGROUND

Therapist competence may be an important factor in determining clinical outcome in psychological therapies. However, there are few published studies of therapist competence v. patient outcome from randomized controlled trials. We tested the hypothesis that higher levels of therapist competence would lead to better clinical outcomes in both patient- and observer-rated measures at 6- and 12-month follow-up.

METHOD

A random sample of 49 audiotapes of manual assisted cognitive therapy sessions delivered by 21 therapists involved in the Prevention of Parasuicide by Manual Assisted Cognitive Behaviour Therapy trial was rated to assess the level of therapist competence. Patient outcome was assessed using self and observer ratings of depressive and anxiety symptoms, social functioning, global functioning and number of episodes of deliberate self-harm.

RESULTS

At 6-month follow-up, there was a statistically significant association between therapist level of competence and observer-rated depression only. At 12-month follow-up, significant associations were noted between therapist competence and all observer-rated clinical outcomes but not for self-rated outcome measures. However, there was no association between therapist competence and the number of self-harm episodes during follow-up.

CONCLUSIONS

When treated by therapists rated as more competent than other therapists who received equivalent brief training, patients with recurrent self-harm show significant clinical improvements. However, this benefit is not identified across all outcome measures and is not fully apparent until 12-month follow-up.

Persistent social dysfunction in anxious and depressed patients with personality disorder

OBJECTIVE

To determine the long-term social function of psychiatric patients with anxiety and depressive disorders and to relate this to personality status and other factors.

METHOD

A cohort of 210 patients (mean age 35 years) with dysthymic disorder, generalized anxiety disorder or panic disorder diagnosed using a structured interview (SCID) were assessed at baseline for personality status using the Personality Assessment Schedule (PAS) and ratings of anxiety and depression. Exactly 12 years later social function was assessed using the Social Functioning Questionnaire (SFQ) and personality reassessed with the PAS by a rater blind to initial personality status. Individual social function items were examined in those with and without personality disorders.

RESULTS

Social function was significantly better in those with little or no baseline personality disturbance (P < 0.001) and the domains of close relationships, stress in completing tasks, use of spare time and family relationships showed the largest personality differences. A multiple linear regression model showed that self-rated depression scores, single marital status and personality status were the main baseline variables predicting social function at 12 years.

CONCLUSION

Although personality characteristics may change over time social dysfunction persists and persistent social dysfunction in mental state disorders may be a strong indicator of personality disturbance rather than an indicator of treatment resistance.

Comorbidity of substance misuse and mental illness in community mental health and substance misuse services

BACKGROUND

Improved management of mental illness and substance misuse comorbidity is a National Health Service priority, but little is known about its prevalence and current management.

AIMS

To measure the prevalence of comorbidity among patients of community mental health teams (CMHTs) and substance misuse services, and to assess the potential for joint management.

METHOD

Cross-sectional prevalence survey in four urban UK centres.

RESULTS

Of CMHT patients, 44% (95% CI 38.1-49.9) reported past-year problem drug use and/or harmful alcohol use; 75% (95% CI 68.2-80.2) of drug service and 85% of alcohol service patients (95% CI 74.2-93.1) had a past-year psychiatric disorder. Most comorbidity patients appear ineligible for cross-referral between services. Large proportions are not identified by services and receive no specialist intervention.

CONCLUSIONS

Comorbidity is highly prevalent in CMHT, drug and alcohol treatment populations, but may be difficult to manage by cross-referral psychiatric and substance misuse services as currently configured and resourced.

Cost-effectiveness of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: a decision-making approach

BACKGROUND

Deliberate self-harm can be costly, in terms of treatment and subsequent suicide. Any intervention that reduces episodes of self-harm might therefore have a major impact on the costs incurred by service providers and the productivity losses due to illness or premature death.

METHOD

Four hundred and eighty patients with a history of recurrent deliberate self-harm were randomized to manual-assisted cognitive behaviour therapy (MACT) or treatment as usual. Economic data were collected from patients at baseline, 6 and 12 months, and these data were complete for 397 patients. Incremental cost-effectiveness was explored using the primary outcome measure, proportion of patients having a repeat episode of deliberate self-harm, and quality of life. The uncertainty surrounding costs and effects was represented using cost-effectiveness acceptability curves.

RESULTS

Differences in total cost per patient were statistically significant at 6 months in favour of MACT (pounds sterling -897, 95 % CI -1747 to -48, P=0.04), but these differences did not remain significant at 12 months (pounds sterling -838, 95% CI -2142 to 466, P=0.21). Nevertheless, exploration of the uncertainty surrounding these estimates suggests there is >90% probability that MACT is a more cost-effective strategy for reducing the recurrence of deliberate self-harm in this population over 1 year than treatment as usual. The results for quality of life were not conclusive.

CONCLUSION

Cost-effectiveness acceptability curves demonstrate that, based on the evidence currently available, to reject MACT on traditional grounds of statistical significance and to continue funding current practice has <10% chance of being the correct decision in terms of cost-effectiveness.

Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study

BACKGROUND

We carried out a large randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behaviour therapy (MACT) versus treatment as usual (TAU) for deliberate self-harm.

METHOD

Patients presenting with recurrent deliberate self-harm in five centres were randomized to either MACT or (TAU) and followed up over 1 year. MACT patients received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to five plus two booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months.

RESULTS

Four hundred and eighty patients were randomized. Sixty per cent of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those repeating deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (OR 0.78, 95% CI 0.53 to 1.14, P=0.20).

CONCLUSION

Brief cognitive behaviour therapy is of limited efficacy in reducing self-harm repetition, but the findings taken in conjunctin with the economic evaluation (Byford et al. 2003) indicate superiority of MACT over TAU in terms of cost and effectiveness combined.

"Cold calling" in psychiatric follow up studies: is it justified?

BACKGROUND

The ethics of cold calling-visiting subjects at home without prior appointment agreed-in follow up research studies has received little attention although it is perceived to be quite common. We examined the ethical implications of cold calling in a study of subjects with defined neurotic disorders followed up 12 years after initial assessment carried out to determine outcome in terms of symptoms, social functioning, and contact with health services. The patients concerned were asked at original assessment if they would agree to be followed up subsequently and although they agreed no time limit was put on this.

OBJECTIVES

To decide if cold calling was ethically justifiable and, if so, to set guidelines for researchers.

DESIGN

The study was a cohort study of patients with neurotic disorder treated initially for 10 weeks in a randomised controlled trial.

FINDINGS

At follow up by a research medical practitioner 18 of the 210 patients had died and of the remaining 192 patients 186 (97%) were seen or had a telephone interview. Four patients refused and two others did not have interviews but agreed to some data being obtained. However, only 104 patients (54%) responded to letters inviting them to make an appointment or to refuse contact and the remainder were followed up by cold calling, with most patients agreeing readily to the research interview. The findings illustrate the dilemma of the need to get the maximum possible data from such studies to achieve scientific validity (and thereby justify the ethics of the study) and the protection of subjects' privacy and autonomy.

CONCLUSIONS

More attention needs to be paid to consent procedures if cold calling is to be defended on ethical grounds but it is unreasonable to expect this to be obtained at the beginning of a research study in a way that satisfies the requirements for informed consent. A suggested way forward is to obtain written consent for the research at the time that cold calling takes place before beginning the research.

Does co-morbid personality disorder increase the risk of suicidal behaviour in psychosis?

OBJECTIVE

To examine the association between co-morbid personality disorder (PD) and suicidal behaviour over a 2-year period in a sample of patients with psychosis.

METHOD

A total of 670 patients with established psychotic illness were interviewed using a battery of instruments including a screen for co-morbid PD. The prevalence of attempted and completed suicide was measured over the next 2 years using multiple data sources. Logistic regression was used to examine whether those with co-morbid PD were at greater risk of suicidal behaviour compared with others.

RESULTS

One hundred and eighty six patients (28%) were rated as having a co-morbid PD. After adjusting for all covariates, patients with co-morbid PD were significantly more likely to attempt or complete suicide over the 2-year period (adjusted odds ratio: 1.87; 95% CI: 1.02-3.42).

CONCLUSION

Co-morbid PD is independently associated with an increased risk of suicidal behaviour in psychosis. Early assessment of personality status should be part of the routine assessment of all psychiatric patients.

User involvement in the planning and delivery of mental health services: a cross-sectional survey of service users and providers

OBJECTIVE

To identify methods for involving service users in the planning and delivery of psychiatric services and factors which may assist and impede this process.

METHOD

A cross-sectional postal survey of user groups and providers of psychiatric services throughout Greater London (UK).

RESULTS

Seventeen (94%) service providers and 29 (48%) user groups responded to the survey. Service providers employed a wide variety of different methods for involving users but none met national standards for user involvement (UI). Service providers stated that the main obstacle to UI was that users who took part were not representative of local patients. User groups highlighted staff resistance as a major obstacle and 80% stated that they were not satisfied with current arrangements for UI.

CONCLUSION

While users and providers of mental health services were able to identify changes resulting from UI the responsiveness of staff and the representativeness of service users may be impeding this process.

The effect of alcohol consumption on cost of care in severe psychotic illness: a report from the UK700 study

OBJECTIVE

Alcohol misuse in psychotic patients is common and leads to poor treatment outcome. This study examines the relationship between alcohol consumption and cost of care in patients with a severe psychotic illness.

METHOD

Patient care was evaluated over 2 years for 708 patients. Patient reported alcohol consumption was evaluated at initial interview. The outcome measure was cost of care over 2 years.

RESULTS

There was no difference in mean cost of care between non-drinkers, moderate and heavy drinkers. Increased alcohol consumption (measured as a continuous variable, adjusted for baseline characteristics) was associated with lower cost of care.

CONCLUSION

Heavier alcohol consumers did not incur more treatment costs and may, indeed, cost less than other patients. This may reflect higher levels of drinking being associated with better overall functioning, poorer engagement with services or exclusion from services.

The measurement of engagement in the homeless mentally ill: the Homeless Engagement and Acceptance Scale--HEAS

BACKGROUND

Much of the difficulty in helping the homeless mentally ill arises as a consequence of their resistance to engagement. A refused intervention can seldom influence a client's problems and engagement status can be argued as being an important independent predictor of outcome. No instrument could be identified which systematically measured the factors involved. This paper describes the development and psychometric properties of a new scale, the Homeless Engagement and Acceptance Scale (HEAS).

METHOD

Staff from an established project for the homeless mentally ill helped to identify relevant questions used to develop a five-item rating scale for completion by an informant. After piloting, the instrument was tested in a study in which subjects were assessed twice over 12 months by informants. Item analysis was undertaken and predictive validity was assessed.

RESULTS

Item analysis indicated a good facility index signifying all items were able to differentiate subjects according to the characteristic being measured, and a high discrimination index demonstrating that all items were measuring the same concept. Predictive validity and internal consistency coefficients were both good. The 3 month HEAS score was found to be a significant predictor of accommodation status and adequacy of a support network at 12 months.

CONCLUSIONS

The good psychometric properties and predictive validity of the scale suggest the HEAS is likely to be a useful tool in assessing engagement status. One of the five questions (Q4) can be omitted for those who are not homeless and the scale termed the Engagement and Acceptance Scale (EAS).

A randomised controlled trial of enhanced key-worker liaison psychiatry in general practice

BACKGROUND

Despite much interest in the development of liaison psychiatry in general practice there is no clear evidence that any form of intervention is effective. We carried out a pilot randomised controlled trial, the first we believe into this type of care, of one such model; enhanced liaison with individual patients by key workers, in general practices in Paddington and North Kensington in London.

METHODS

All patients referred from primary to secondary psychiatric care from four general practices over a 10-month period, and still in contact with services, were eligible to be included in the study. The practices were allocated in a constrained randomised procedure to either normal care or enhanced key-worker liaison. The latter involved encouraging individual key workers to adopt improved communication between primary and secondary care. Baseline assessments of symptomatology and social functioning were made before randomisation and after 6 months by an independent researcher.

RESULTS

Of the 84 eligible patients, 43 were seen at baseline and 34 re-assessed after 6 months. There was no difference between the clinical outcomes in the two groups but self-rated social function was significantly improved in the enhanced liaison service compared with standard care (adjusted P = 0.05). Costs were similar but somewhat more expensive for enhanced liaison. Less than half (42 %) of all key workers in the enhanced liaison arm felt they had involved the primary health care team more in the care of their patient, with 21 % of these altering their practice markedly during the study.

CONCLUSIONS

It is concluded that without additional resources enhanced key-worker liaison for psychiatry in primary and secondary care has limited benefits although this does not necessarily apply to other forms of liaison practice.

Difficulties in conducting a randomized controlled trial of health service interventions in intellectual disability: implications for evidence-based practice

BACKGROUND

In an era of evidence-based medicine, practice is constantly monitored for quality in accordance with the needs of clinical governance (Oyebode et al. 1999). This is likely to lead to a dramatic change in the treatment of those with intellectual disability (ID), in which evidence for effective intervention is limited for much that happens in ordinary practice. As Fraser (2000, p. 10) has commented, the word that best explains "the transformation of learning disability practice in the past 30 years is 'enlightenment'." This is not enough to satisfy the demands of evidence, and Fraser exhorted us to embrace more research-based practice in a subject that has previously escaped randomized controlled trials (RCTs) of treatment because of ethical concerns over capacity and consent, which constitute a denial of opportunity which "is now at last regarded as disenfranchising".

CONCLUSIONS

The present paper describes the difficulties encountered in setting up a RCT of a common intervention, i.e. assertive community treatment, and concludes that a fundamental change in attitudes to health service research in ID is needed if proper evaluation is to prosper.

Heavy users of acute psychiatric beds: randomized controlled trial of enhanced community management in an outer London borough

BACKGROUND

Heavy users of psychiatric services, often defined as the population that uses the most beds, consume a large part of the resources used by the whole service, despite being relatively small in number. Any intervention that reduces heavy use is therefore likely to lead to significant savings, and enhancement of standard care using a form of intensive case management akin to assertive community treatment was thought to be a pragmatic strategy for testing in this group.

METHODS

The effectiveness of enhanced community management (ECM) was compared with standard care alone in heavy users, who represented the 10% of patients with the highest number of hospital admissions and occupied bed days over the previous 6.5 years in an outer London borough. One hundred and ninety-three patients were randomly assigned to ECM or standard care and their use of services was determined after 1 and 2 years, with assessments of costs, clinical symptoms, needs, and social function made before entry into the study and after 1 and 2 years.

RESULTS

Despite a 24 fold increase in community contacts in the study group, there were no significant differences between the two groups in any of the main outcome measures. Small savings on in-patient and day-hospital service costs were counterbalanced by the increased costs of outpatient and community care for the subjects assigned to ECM. Clinical outcome data derived from interviews in two-thirds of the subjects were similar in both groups.

CONCLUSIONS

Providing additional intensive community focused care to a group of heavy users of psychiatric in-patient services in an outer London borough does not lead to any important clinical gains or reduced costs of psychiatric care.