Intensive case management for severe mental illness

Engagement strategies in an assertive outreach context: a mixed-methods systematic review

BACKGROUND

Assertive outreach (AO) is a systematic approach to engage vulnerable patients with serious mental illness.

AIMS

This review aims to provide a comprehensive analysis of engagement strategies in relation to principles of the AO model to clarify effective components of AO, better understand engagement in an AO context, and consider encompassing change mechanisms.

METHODS

A systematic mixed-methods review was completed from 1806 to December 2022 (no pre-registration). Articles meeting the inclusion criteria were rated for methodological quality using the JBI scales and thematic synthesis using a meta-aggregative approach. Reporting was according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.

RESULTS

Eighteen articles met the inclusion criteria. The literature was defined by three main themes: definition and perspectives of engagement; key principles of AO in relation to engagement; and additional principles and strategies enhancing engagement.

CONCLUSION

Despite the heterogeneity in defining engagement, the relationship between AO professionals and patients emerged as crucial in the process of engagement. Subsequently, the four key principles of AO emerged as central to promoting engagement. Finally, we identified a number of additional principles that are considered crucial in the engagement process in AO. The review concludes with recommendations for future research and the implementation of AO in routine clinical care.

Community Mental Health Services for Frequent Emergency Department Users: A Qualitative Study of Outcomes Perceived by Program Clients and Case Managers

PURPOSE OF STUDY

This study aimed to investigate the perceived outcomes and mechanisms of change of a community mental health service combining system navigation and intensive case management supports for frequent emergency department users presenting with mental illness or addiction.

PRIMARY PRACTICE SETTING

The study setting was a community mental health agency receiving automated referrals directly from hospitals in a midsize Canadian city for all individuals attending an emergency department two or more times within 30 days for mental illness or addiction.

METHODOLOGY AND SAMPLE

Qualitative interviews with 15 program clients. Focus groups with six program case managers. Data were analyzed using pragmatic qualitative thematic analysis.

RESULTS

Participants generally reported perceiving that the program contributed to reduced emergency department use, reduced mental illness symptom severity, and improved quality of life. Perceived outcomes were more mixed for outcomes related to addiction. Reported mechanisms of change emphasized the importance of positive working relationships between program clients and case managers, as well as focused efforts to develop practical skills.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Community mental health services including intensive case management for frequent emergency department users presenting with mental illness or addiction were perceived to effectively address client needs while reducing emergency department resource burden. Similar programs should emphasize the development of consistent and warm working relationships between program clients and case managers, as well as practical skills development to support client health and well-being.

Empowering Victims of Lived Violence: Delaware's Hospital Violence Intervention Program (HVIP)

Hospital Violence Intervention Programs (HVIP) are increasingly implemented across a variety of healthcare-associated contexts to prevent and address violent intentional injury. We describe the establishment of a health system funded HVIP in Delaware and the direct experiences of staff and violence-specialized Community Health Workers.

Comparing interventions for early psychosis: a systematic review and component network meta-analysis

Background

'Early Intervention in Psychosis' (EIP) services have been associated with improved outcomes for early psychosis. However, these services are heterogeneous and many provide different components of treatment. The impact of this variation on the sustained treatment effects is unknown.

Methods

We performed a systematic review and component network meta-analysis (cNMA) of randomised controlled trials (RCTs) that compared specialised intervention services for early psychosis. We searched CENTRAL (published and unpublished), EMBASE, MEDLINE, CINAHL, PsycINFO and Web of Science from inception to February 2023. Primary outcomes were negative and positive psychotic symptoms at 3-month and 1-year follow-up and treatment dropouts. Secondary outcomes were depressive symptoms and social functioning at 1-year follow-up. We registered a protocol for our study in PROSPERO (CRD42017057420).

Findings

We identified 37 RCTs including 4599 participants. Participants' mean age was 25.8 years (SD 6.0) and 64.0% were men. We found evidence that psychological interventions (this component grouped all psychological treatment intended to treat, or ameliorate the consequences of, psychotic symptoms) are beneficial for reducing negative symptoms (iSMD -0.24, 95% CI -0.44 to -0.05, p = 0.014) at 3-month follow-up and may be associated with clinically relevant benefits in improving social functioning scores at 1-year follow-up (iSMD -0.52, 95% CI -1.05 to 0.01, p = 0.052). The addition of case management has a beneficial effect on reducing negative symptoms (iSMD -1.17, 95% CI -2.24 to -0.11, p = 0.030) and positive symptoms (iSMD -1.05, 95% CI -2.02 to -0.08, p = 0.033) at 1-year follow-up. Pharmacotherapy was present in all trial arms, meaning it was not possible to examine the specific effects of this component.

Interpretation

Our findings suggest psychological interventions and case management in addition to pharmacotherapy as the core components of services for early psychosis to achieve sustained clinical benefits. Our conclusions are limited by the small number of studies and sparsely connected networks.

Funding

National Institute for Health and Care Research.

Incidence and Risk Profiles for Suicide Mortality in Patients With Schizophrenia Receiving Homecare Case Management in Taiwan

Case management (CM)-based community therapy for patients with schizophrenia had little effect on reducing suicide mortality. We investigate the long-term suicide mortality outcome and associated risk factors in patients with schizophrenia receiving homecare (CM) in Taiwan. We enrolled a nationwide cohort of patients with schizophrenia who newly received homecare CM intervention (n = 13 317) between January 1, 2001, and December 31, 2015; their data were derived from Taiwan's National Health Insurance Research Database. We calculated the incidence rate of suicide methods. We examined the demographic and medical utilization profile for suicide and then performed a nested case-control study and multivariate regression to identify independent risk factors for suicide mortality. Among the 13 317 patients who received homecare CM intervention, 1766 died during the study period, of whom 213 died by suicide, which is the leading cause of unnatural death. Jumping from a high place, self-poisoning, and hanging were the top 3 suicide methods. Increased medical utilization was noted for both psychiatric and non-psychiatric services within 3 months of suicide mortality. Comorbidities of depressive disorder, nonspecific heart diseases, pneumonia, and gastrointestinal ulcers were identified as independent risk factors for suicide mortality. Suicide was the leading cause of unnatural mortality in patients with schizophrenia receiving homecare CM intervention in Taiwan. We noted the preferred suicide methods, high medical utilization, and comorbidities before suicide. Thus, we suggest that the CM team should assess lethal methods for suicide and ensure that patients adhere to psychiatry treatment for improving the current care model for this specified population.

Evaluation of intensive community care services for young people with psychiatric emergencies: study protocol for a multi-centre parallel-group, single-blinded randomized controlled trial with an internal pilot phase

BACKGROUND

Over 3000 young people under the age of 18 are admitted to Tier 4 Child and Adolescent Mental Health Services (CAMHS) inpatient units across the UK each year. The average length of hospital stay for young people across all psychiatric units in the UK is 120 days. Research is needed to identify the most effective and efficient ways to care for young people (YP) with psychiatric emergencies. This study aims to evaluate the clinical effectiveness and cost-effectiveness of intensive community care service (ICCS) compared to treatment as usual (TAU) for young people with psychiatric emergencies.

METHODS

This is a multicentre two-arm randomized controlled trial (RCT) with an internal pilot phase. Young people aged 12 to < 18 considered for admission at participating NHS organizations across the UK will be randomized 1:1 to either TAU or ICCS. The primary outcome is the time to return to or start education, employment, or training (EET) at 6 months post-randomization. Secondary outcomes will include evaluations of mental health and overall well-being and patient satisfaction. Service use and costs and cost-effectiveness will also be explored. Intention-to-treat analysis will be adopted. The trial is expected to be completed within 42 months, with an internal pilot phase in the first 12 months to assess the recruitment feasibility. A process evaluation using visual semi-structured interviews will be conducted with 42 young people and 42 healthcare workers.

DISCUSSION

This trial is the first well-powered randomized controlled trial evaluating the clinical and cost-effectiveness of ICCS compared to TAU for young people with psychiatric emergencies in Great Britain.

TRIAL REGISTRATION

ISRCTN ISRCTN42999542, Registration on April 29, 2020.

A flexible approach to measure care coordination based on patient-sharing networks

BACKGROUND

Effective care coordination may increase clinical efficiency, but its measurement remains difficult. The established metric "care density" (CD) measures care coordination based on patient-sharing among physicians, but it may be too rigid to generalize across disorders and countries. Therefore, we propose an extension called fragmented care density (FCD), which allows varying weights for connections between different types of providers. We compare both metrics in their ability to predict hospitalizations due to schizophrenia.

METHODS

We conducted a longitudinal cohort study based on German claims data from 2014 through 2017 to predict quarterly hospital admissions. 21,016 patients with schizophrenia from the federal state Baden-Württemberg were included. CD and FCD were calculated based on patient-sharing networks. The weights of FCD were optimized to predict hospital admissions during the first year of a 24-month follow-up. Subsequently, we employed likelihood ratio tests to assess whether adding either CD or FCD improved a baseline model with control variables for the second follow-up year.

RESULTS

The inclusion of FCD significantly improved the baseline model, Χ2(1) = 53.30, p < 0.001. We found that patients with lower percentiles in FCD had an up to 21% lower hospitalization risk than those with median or higher values, whereas CD did not affect the risk.

CONCLUSIONS

FCD is an adaptive metric that can weight provider relationships based on their relevance for predicting any outcome. We used it to better understand which medical specialties need to be involved to reduce hospitalization risk for patients with schizophrenia. As FCD can be modified for different health conditions and systems, it is broadly applicable and might help to identify barriers and promoting factors for effective collaboration.

Toplum Ruh Sağlığı Merkezlerinde Vaka Yöneticiliği Yapılan Şizofreni Hastaları Daha Mutlu mu?

Şizofreni hastaları için iyileşmeden bahsedilirken belirtilerin olmaması ile yetinilmiş ve mutluluk kavramı genelde göz ardı edilmiştir. Çalışmamızda toplum ruh sağlığı merkezi (TRSM) tarafından takip edilip vaka yöneticisi olan şizofreni hastaları ile sadece poliklinik takibi yapılan remisyondaki şizofreni hastalarının mutluluk düzeylerini ve bu mutluluğu etkilediği düşünülen duygu dışavurumu, hastanın algıladığı destek düzeyi ve yaşam niteliğini karşılaştırmayı amaçladık. En az 1 yıldır düzenli TRSM takibi yapılan ve vaka yöneticisi (VY) olan (n:100) ve poliklinik takibi yapılan en az 3 aydır remisyonda olan (n:100) şizofreni hastaları çalışmaya alındı. Her iki gruba Öznel Mutluluk Ölçeği (ÖMÖ), Algılanan Elde Edilebilir Destek Ölçeği (AEEDÖ), Yaşam Niteliği Ölçeği (YNÖ), Duygu Dışavurum Düzeyi Ölçeği (DDDÖ) uygulandı. ÖMÖ, AEEDÖ, DDDÖ, YNÖ puanları VY olan grupta istatistiki olarak anlamlı farklıydı. Duygu Dışavurum Düzeyini gösteren alt ölçekler ile ÖMÖ puanları arasında negatif korelasyon saptandı. YNÖ ve AEEDÖ puanları ile ÖMÖ puanları arasında ise pozitif korelasyon saptandı. VY olması durumunda AEEDÖ puanlarının ÖMÖ puanları üzerinde aracı bir etkisi olduğu; YNÖ puanlarının aracı bir etkisi olmadığı saptandı. DDDÖ alt ölçekleri olan müdahalecilik, duygusal tepki ve hoşgörü/beklenti düzeylerinin ÖMÖ puanları üzerinde aracı bir etkiye sahip olduğu; hastalığa karşı tutum düzeylerinin aracı etkiye sahip olmadığı saptandı. Şizofreni hastaları için iyileşmeden bahsederken genelde mutluluk göz ardı edilen bir kavramdır. Çalışmamızda TRSM hizmeti kapsamındaki vaka yöneticiliğinin etkisini değerlendirdik ve şizofreni hastalarının mutluluğuna olumlu etkisi olduğunu saptadık.

Service users' perceptions of relevant and helpful components of an integrated care concept (ACCESS) for psychosis

Introduction

Psychotic disorders have a significant impact on patients' lives and their families, and long-term treatment with individually tailored multimodal combinations of therapies is often required. Integrated care (IC) concepts such as the "Hamburg Model (ACCESS)" with a focus on psychotic disorders, includes different (therapeutic) components with pharmaco- and psychotherapy, family involvement, home treatment and the option of using a 24/7 crisis hotline. All components are offered by a therapeutically-oriented assertive community treatment (TACT) team in a need-adapted manner. So far, however, little is known about which specific components are regarded as especially relevant and helpful by the users of IC.

Methods

Patients currently participating in IC completed a questionnaire as part of the continuous quality assurance study (ACCESS II) in which they were asked to rate the different components of treatment according to their relevance and helpfulness, considering the individual's unique experiences with IC and needs in mental health care. Furthermore, they were asked to make suggestions regarding additional helpful components of treatment.

Results

Fifty patients participated in this survey (23% of the patients currently participating in the IC concept). For participants, the most helpful and important factors were having the same therapist in the long-term and the 24/7 crisis telephone. Additional components suggested by patients included more addiction-specific therapies and increased focus on vocational rehabilitation and integration.

Conclusion

From the perspective of the users of IC, long-term care from a trusted therapist with whom there is a therapeutic relationship and the possibility to reach someone they already know from the TACT team 24/7 serves as the best basis for effective care, fostering trust, understanding, and open communication. In contrast, home treatment remains a relevant aspect of evidence-based care for people with severe mental illness, but perhaps surprisingly, is not viewed as the most important issue.

Enhancing panic disorder treatment with mobile-aided case management: an exploratory study based on a 3-year cohort analysis

Background

Individuals with panic disorder frequently face ongoing symptoms, suboptimal treatment adherence, and increased relapse rates. Although mobile health interventions have shown promise in improving treatment outcomes for numerous mental health conditions, their effectiveness, specifically for panic disorder, has yet to be determined.

Objective

This study investigates the effects of a mobile-aided case management program on symptom reduction and quality of care among individuals with panic disorder.

Methods

This 3-year cohort study enrolled 138 participants diagnosed with panic disorder. One hundred and eight participants joined the mobile-aided case management group and 30 in the treatment-as-usual group. Data were collected at baseline, 3-month, 6-month, and 12-month treatment checkpoints using self-report questionnaires, in-depth interviews, direct observation, and medical record analysis.

Results

During the maintenance treatment phase, the mobile-assisted case management group decreased both panic severity (p = 0.008) and state anxiety (p = 0.016) more than the control group at 6 months. Participants who underwent case management experienced enhanced control over panic symptoms, heightened self-awareness, and elevated interpersonal support.

Conclusion

The mobile-aided case management is beneficial in managing panic disorder, especially maintenance treatment.

Impact of community mental health services on the adult psychiatric admission through the emergency unit: a 20-year population-based study

Background

There is a lack of real-life population-based study examining the effect of community mental health services on psychiatric emergency admission. In Hong Kong, Integrated Community Center for Mental Wellness (ICCMW) and telecare service were introduced in 2009 and 2012, respectively. We examined the real-life impact of these services on psychiatric emergency admissions over 20 years.

Methods

Number of psychiatric emergency admissions between 2001 and 2020 was retrieved from the Hong Kong Clinical Data Analysis & Reporting System. We used an interrupted time series analysis to examine monthly psychiatric admission trend before and after service implementation, considering socioeconomic and environmental covariates.

Findings

A total of 108,492 psychiatric emergency admissions (47.8% males; 64.9% aged 18-44 years) were identified from the study period, of which 56,858, 12,506, 12,295, 11,791, and 15,051 were that for schizophrenia-spectrum disorders, bipolar affective disorders, unipolar mood disorders, neuroses, and substance use disorders. ICCMW introduction has an immediate effect on psychiatric emergency admission (adjusted estimate per 100,000: -10.576; 95% CI, -16.635 to -4.518, p < 0.001), particularly among adults aged 18-44 years (-8.543; 95% CI, -13.209 to -3.877, p < 0.001), females (-5.843; 95% CI, -9.647 to -2.039, p = 0.003), and with neuroses (-3.373; 95% CI, -5.187 to -1.560, p < 0.001), without a significant long-term effect. Unemployment, seasonality, and infectious disease outbreak were significant covariates.

Interpretation

ICCMW reduced psychiatric emergency admission, but no further reduction following full implementation. Community mental health services should be dynamically tailored for different populations and socioeconomic variations over time.

Funding

None.

Health and Social Case Management for the Inclusion of People Living with a Schizophrenic Disorder: The PASSVers Experience

The way the social protection system in France is organized frequently leads to coordination difficulties between the social and healthcare sectors. A health and social program has been implemented in a French medical-psychological center to optimize the coherence of the pathway for people living with schizophrenia. This study evaluated the way users and professionals perceive this program so as to assess the relevance of double case management. Semi-structured interviews were conducted with users (N = 21) and professionals (N = 11) of this program and then analyzed with Alceste software. The results highlight the overall satisfaction of the participants with the program, and the double case management was shown to be beneficial in supporting people living with schizophrenia in their life project. These results indicate that this program enabled the emergence of a collective empowerment, which could assist with the recovery process of schizophrenia.

Community-based models of care facilitating the recovery of people living with persistent and complex mental health needs: a systematic review and narrative synthesis

Objective

This study aims to assess the effectiveness of community-based models of care (MoCs) supporting the recovery of individuals who experience persistent and complex mental health needs.

Method

We conducted a systematic review and narrative synthesis of MoC studies reporting clinical, functional, or personal recovery from October 2016 to October 2021. Sources were Medline, EMBASE, PsycInfo, CINAHL, and Cochrane databases. Studies were grouped according to MoC features. The narrative synthesis was led by our researchers with lived experience.

Results

Beneficial MoCs ranged from well-established to novel and updated models and those explicitly addressing recovery goals and incorporating peer support: goal-focused; integrated community treatment; intensive case management; partners in recovery care coordination; rehabilitation and recovery-focused; social and community connection-focused; supported accommodation; and vocational support. None of our diverse group of MoCs supporting recovery warranted a rating of best practice. Established MoCs, such as intensive case management, are promising practices regarding clinical and functional recovery, with potential for enhancements to support personal recovery. Emerging practice models that support personal and functional recovery are those where consumer goals and priorities are central.

Conclusion

Evidence for established models of care shows that there is a need for inevitable evolution and adaptation. Considering the high importance of effective MoCs for people experiencing persistent and complex mental health needs, further attention to service innovation and research is required. Greater emphasis on the inclusion of lived and living experience in the design, delivery, implementation, and research of MoCs is needed, to enhance MOCs' relevance for achieving individual consumer recovery outcomes.

Service intensity of community mental health outreach among people with untreated mental health problems in Japan: A retrospective cohort study

Aim

This study aimed to clarify the association between treatment status (untreated or treated) at the start of community mental health outreach services and service intensity.

Methods

This retrospective cohort study was conducted using the Tokorozawa City mental health outreach service users' data. Treatment status at the start of service (exposure variable) and the service intensity (outcome variables) were taken from clinical records. Poisson regression and linear regression analyses were conducted. The frequency of medical or social service use 12 months after service initiation was also calculated. This study was approved by the Research Ethics Committee at the National Center of Neurology and Psychiatry (No. A2020-081).

Results

Of 89 people, 37 (42%) were untreated. Family members in the untreated group were more likely to be targets or recipients of services than in the treated group (b = 0.707, p < 0.001, Bonferroni-adjusted p < 0.001). Compared to the treated group, the untreated group received fewer services themselves (b = -0.290, p = 0.005), and also fewer services by telephone (b = -0.252, p = 0.012); by contrast, they received more services at the health center (b = 0.478, p = 0.031) and for family support (b = 0.720, p = 0.024), but these significant differences disappeared after Bonferroni adjustment. At least 11% of people in the untreated group were hospitalized and 35% were outpatients 12 months after service initiation.

Conclusion

Family involvement may be a key service component for untreated people. The service intensity with and without treatment may vary by service location.

Intensive community care services for children and young people in psychiatric crisis: an expert opinion

BACKGROUND

Children and young people's (CYP) mental health is worsening, and an increasing number are seeking psychiatric and mental health care. Whilst many CYPs with low-to-medium levels of psychiatric distress can be treated in outpatient services, CYPs in crisis often require inpatient hospital treatment. Although necessary in many cases, inpatient care can be distressing for CYPs and their families. Amongst other things, inpatient stays often isolate CYPs from their support networks and disrupt their education. In response to such limitations, and in order to effectively support CYPs with complex mental health needs, intensive community-based treatment models, which are known in this paper as intensive community care services (ICCS), have been developed. Although ICCS have been developed in a number of settings, there is, at present, little to no consensus of what ICCS entails.

METHODS

A group of child and adolescent mental health clinicians, researchers and academics convened in London in January 2023. They met to discuss and agree upon the minimum requirements of ICCS. The discussion was semi-structured and used the Dartmouth Assertive Community Treatment Fidelity Scale as a framework. Following the meeting, the agreed features of ICCS, as described in this paper, were written up.

RESULTS

ICCS was defined as a service which provides treatment primarily outside of hospital in community settings such as the school or home. Alongside this, ICCS should provide at least some out-of-hours support, and a minimum of 90% of CYPs should be supported at least twice per week. The maximum caseload should be approximately 5 clients per full time equivalent (FTE), and the minimum number of staff for an ICCS team should be 4 FTE. The group also confirmed the importance of supporting CYPs engagement with their communities and the need to remain flexible in treatment provision. Finally, the importance of robust evaluation utilising tools including the Children's Global Assessment Scale were agreed.

CONCLUSIONS

This paper presents the agreed minimum requirements of intensive community-based psychiatric care. Using the parameters laid out herein, clinicians, academics, and related colleagues working in ICCS should seek to further develop the evidence base for this treatment model.

Case managers' reflections of a brief case management intervention in Canada

Introduction

As demand for intensive case management services continues to outpace supply, community mental health agencies in Toronto, Ontario, introduced Short-Term Case Management (STCM).

Objective

This study sought to explore case managers' perspectives and experiences with this new service delivery model.

Methods

Focus groups were conducted with twenty-one case managers, and transcripts analyzed using thematic analysis.

Results

Emerging themes suggest that despite embracing a recovery approach, case managers expressed mixed views on the acceptability and appropriateness of this service delivery model as an intervention.

Conclusion

The ideal population for this intervention are adults with mental health issues in need of system navigation, and those motivated to address their goals. Further research is needed to establish fidelity criteria.

Identifying Unique Subgroups of High-Cost Patients With Schizophrenia: A Population-Based Study Using Latent Class Analysis

Schizophrenia does not present uniformly among patients and as a result this patient population is characterized by a diversity in the type and amount of healthcare supports needed for daily functioning. Despite this, little work has been completed to understand the heterogeneity that exists among these patients. In this work we used a data-driven approach to identify subgroups of high-cost patients with schizophrenia to identify potentially actionable interventions for the improvement of outcomes and to inform conversations on how to most efficiently allocate resources in an already strained system. Administrative health data was used to conduct a retrospective analysis of "high-cost" adult patients with schizophrenia residing in Alberta, Canada in 2017. Costs were derived from inpatient encounters, outpatient primary care and specialist encounters, emergency department encounters, and drug costs. Latent class analysis was used to group patients based on their unique clinical profiles. Latent class analysis of 1659 patients revealed the following patient groups: (1) young, high-needs males early in their disease course; (2) actively managed middle-aged patients; (3) elderly patients with multiple chronic conditions and polypharmacy; (4) unstably housed males with low treatment rates; (5) unstably housed females with high acute care use and low treatment rates. This taxonomy may be used to inform policy, including the identification of interventions most likely to improve care and reduce health spending for each subgroup.

Impact of COVID-19 on the lives of people with severe mental illness-front-line community psychiatry workers observation from a provincial survey of assertive community treatment teams in Ontario, Canada

Using an online survey distributed to members of the provincial organization that represents the 88 Assertive Community Treatment (ACT) and Flexible ACT teams in Ontario, Canada, this descriptive study relied on the unique vantage points and observations of the front-line community psychiatry workers who maintained contact with patients through outreach and telecommunication during the height of COVID-19. The patients who suffer from serious mental illness (SMI) were uniquely affected by COVID-19 due to the changes, reduction or shut down of many essential clinical and community support services. Thematic and quantitative analyses of the workers' observations highlighted 6 main areas of note, including significant social isolation and loneliness, clinical course deterioration and life disruption, increased hospital and ER use, police and legal contacts, and substance abuse and related deaths. There were also encouraging signs of positive adaptations in terms of independence and resilience. Reflections of these impacts and potential ameliorating approaches are further discussed.

Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis

Background

Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority.

Objectives

To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact.

Search Methods

We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies.

Selection Criteria

We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation.

Data Collection and Analysis

We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data.

Main Results

We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings.

Case Management and Housing Outcomes

Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches.

Case Management and Mental Health Outcomes

The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817).

Case Management and Other Outcomes

Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment.

Case Management Components

For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services.

Characteristics of Persons Experiencing Homelessness

No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3.

The Broader Context of Delivery of Case Management Programmes

Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice.

Cost Effectiveness

The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed.

Authors' Conclusions

Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.

Managing disabled workers due to occupational accidents in Indonesia: a case study on return to work program

BACKGROUND

Limited research and studies prove the usefulness of case management for persons with disabilities, which helps disabled employees recover their dignity through medical vocational, and psychological rehabilitation in underdeveloped countries' Return To Work (RTW) programs.

METHODS

This qualitative case study design involved semi structured interviews with case managers as the primary data source, supplemented by secondary data from BPJS Ketenagakerjaan. Data analysis utilized QDA Miner Lite and Python with ArcGIS integration for descriptive visualization.

RESULTS

The RTW program of BPJS Ketenagakerjaan has already adopted ILO's fundamental suggestion, which creates two central themes: internal aspects that are essential to the RTW framework and external variables that impact RTW practice. The key themes produce six main pieces to discuss further: personal skill, personal literacy, providers, guidelines, authorities, and stakeholder support.

CONCLUSION

Return to Work Program benefits companies, and the implementation of a career development service or a partnership with non-governmental organizations guarantees that disabled employees who cannot return to work with their former employers are still in the global economy.

Evaluation of disparities in impact of mental health intensive case management on 6-month symptoms, functioning, and quality of life between black and white veterans diagnosed with schizophrenia

BACKGROUND

Substantial health disparities have been reported between Black and White Americans diagnosed with schizophrenia. The nature and extent of these disparities among individuals receiving services in an equal-access health care system remains understudied.

PURPOSE AND AIMS

The purpose of this study was to examine disparities in enrollment characteristics, service delivery and clinical outcomes between Black and White veterans diagnosed with schizophrenia who received care in the Veterans Health Administration (VHA), an equal-access health care system.

METHODS

National program evaluation data from the VHA Intensive Community Mental Health Recovery (ICMHR) program were used to evaluate disparities between 2436 Black and 3565 White veterans who enrolled between 1999 and 2013. Veterans and case managers completed measures of sociodemographic factors, clinical history, clinical characteristics, and justice system involvement at enrollment and six months. Chi square and ANOVAs were used to evaluate enrollment and service delivery differences. Six-month changes were evaluated using multiple regression controlling for potentially confounding baseline characteristics. Effect sizes were evaluated with Cohen's d.

RESULTS

Results indicated differences between Black and White veterans in clinical history, justice system involvement, and clinical characteristics at enrollment. Minimal differences in service delivery were noted and longitudinal analyses revealed no significant differences between Black and White veterans on the majority of outcomes.

CONCLUSION

Fewer racial disparities in service use and outcomes were observed in ICMHR than in standard non-VA clinic settings. This study demonstrates that disparities may emerge more strongly from systemic rather than individual-level differences.

Case management and care expertise as a prevention approach for adults with intellectual disabilities (FaPP-MgB): study protocol for a randomized-controlled trial

BACKGROUND

Adults with intellectual disabilities have a higher prevalence of unhealthy eating habits, stress, low levels of mobility, and comparable drug consumption as the general population. Consequently, they suffer from several chronic diseases earlier and more often, but there are fewer prevention and health promotion services including this population. The goal of this study is to determine if an advanced practice nursing approach in the community with home visits is an effective way to improve the health status of adults with intellectual disabilities.

METHODS

We will conduct a randomized-controlled trial with waiting list design in Hamburg, Germany. Inclusion criteria are diagnosis ICD F70-F79 and exclusion criteria are care level > 3 according to the German Social Code XI or being at the end-of-life. Participants will be block randomized. The intervention consists of advanced practice nurses performing case management, social space analysis, prevention planning, and counseling through four outreach home visits on nutrition, mobility, addiction, and stress. Comparison is usual care. The primary outcome is health status (WHODAS) after 12 months. Secondary outcomes are health-related quality of life (EQ-5D) and resilience (RS-11) after 6 and 12 months. The calculated sample size is 256 with an estimated dropout of 30%. Raters and analysts will be blinded. Analysis will be performed using ANCOVAs.

DISCUSSION

By providing case management and utilizing their nursing expertise, advanced practice nurses will provide valuable input and guidance on prevention and health promotion for people with intellectual disabilities. They will close the gap between health and social care, which is prominent in Germany, through cooperation between the existing care sectors. The findings will be disseminated in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00028771 , registered 4 July 2022, Universal Trial Number: U1111-1277-0595.

The relationship between area levels of involuntary psychiatric care and patient outcomes: a longitudinal national register study from Norway

BACKGROUND

Mental health legislation permits involuntary care of patients with severe mental disorders who meet set legal criteria. The Norwegian Mental Health Act assumes this will improve health and reduce risk of deterioration and death. Professionals have warned against potentially adverse effects of recent initiatives to heighten involuntary care thresholds, but no studies have investigated whether high thresholds have adverse effects.

AIM

To test the hypothesis that areas with lower levels of involuntary care show higher levels of morbidity and mortality in their severe mental disorder populations over time compared to areas with higher levels. Data availability precluded analyses of the effect on health and safety of others.

METHODS

Using national data, we calculated standardized (by age, sex, and urbanicity) involuntary care ratios across Community Mental Health Center areas in Norway. For patients diagnosed with severe mental disorders (ICD10 F20-31), we tested whether lower area ratios in 2015 was associated with 1) case fatality over four years, 2) an increase in inpatient days, and 3) time to first episode of involuntary care over the following two years. We also assessed 4) whether area ratios in 2015 predicted an increase in the number of patients diagnosed with F20-31 in the subsequent two years and whether 5) standardized involuntary care area ratios in 2014-2017 predicted an increase in the standardized suicide ratios in 2014-2018. Analyses were prespecified (ClinicalTrials.gov NCT04655287).

RESULTS

We found no adverse effects on patients' health in areas with lower standardized involuntary care ratios. The standardization variables age, sex, and urbanicity explained 70.5% of the variance in raw rates of involuntary care.

CONCLUSIONS

Lower standardized involuntary care ratios are not associated with adverse effects for patients with severe mental disorders in Norway. This finding merits further research of the way involuntary care works.

Service Needs of Clients Before and After Short Term Community Mental Health Case Management

This study evaluated level of service need before and after a short-term community mental health case management intervention from the perspective of both clients and case managers. Ontario Common Assessment of Need data were used to describe client needs. McNemar's test was applied to assess differences in pre- and post- need scores. Psychological distress, company, daytime activities, and physical health were most commonly rated by clients as unmet needs at enrolment. At discharge, there was a significant change in psychological distress from the perspective of clients, and in psychological distress and daytime activities from the perspective of case managers. Statistically significant changes were observed for Total Need, Total Unmet Need and Met Need scores from the perspective of case managers. While both clients and case managers reported changes in total service needs between admission and discharge from short-term case management, clients were less likely to report a difference in needs.

The efficacy of homestyle rehabilitation on negative symptoms in chronic schizophrenia: A randomized controlled trial

Objective

Schizophrenia is a debilitating mental disorder with a high disability rate that is characterized by negative symptoms such as apathy, hyperactivity, and anhedonia that can make daily life challenging and impair social functioning. In this study, we aim to investigate the effectiveness of homestyle rehabilitation in mitigating these negative symptoms and associated factors.

Methods

A randomized controlled trial was conducted to compare the efficacy of hospital rehabilitation and homestyle rehabilitation for negative symptoms in 100 individuals diagnosed with schizophrenia. The participants were divided randomly into two groups, each persisting for 3 months. The primary outcome measures were the Scale for Assessment of Negative Symptoms (SANS) and Global Assessment of Functioning (GAF). The secondary outcome measures included the Positive Symptom Assessment Scale (SAPS), Calgary Schizophrenia Depression Scale (CDSS), Simpson-Angus Scale (SAS), and Abnormal Involuntary Movement Scale (AIMS). The trial aimed to compare the effectiveness of the two rehabilitation methods.

Results

Homestyle rehabilitation for negative symptoms was found to be more effective than hospital rehabilitation, according to the changes in SANS (T = 2.07, p = 0.04). Further analysis using multiple regression indicated that improvements in depressive symptoms (T = 6.88, p < 0.001) and involuntary motor symptoms (T = 2.75, p = 0.007) were associated with a reduction in negative symptoms.

Conclusion

Homestyle rehabilitation may have greater potential than hospital rehabilitation in improving negative symptoms, making it an effective rehabilitation model. Further research is necessary to investigate factors such as depressive symptoms and involuntary motor symptoms, which may be associated with the improvement of negative symptoms. Additionally, more attention should be given to addressing secondary negative symptoms in rehabilitation interventions.

[Person-Centered Psychosocial Complex Care for People with Severe Mental Illness: Implementation and Evaluation of a Cross-Sectoral Care Model at a Psychiatric Hospital]

AIM OF THE STUDY

Implementation and evaluation of a cross-sectoral complex care model for persons with severe mental illness (SMI).

METHODS

The care model was implemented at a psychiatric-psychotherapeutic specialized clinic. Within this patient-centered and needs-oriented complex care model, intensive case management was applied to transition persons with SMI between inpatient and outpatient mental health care. Evaluation was conducted using a matched control group design (n = 46/21).

RESULTS

According to clinical assessment, two thirds of the patients benefited from the care model. In the course of treatment, the patients showed a significant reduction in the use of inpatient psychiatric care structures and an improvement in clinical symptoms.

CONCLUSION

For people with SMI, there is a care gap in the in the transition from inpatient to outpatient care, which could be partially closed.

Development of a breast cancer case management information platform (BC-CMIP) module based on patient-perceived value

Objective

To construct a content module for a breast cancer case management information platform (BC-CMIP) based on patient-perceived value (PPV).

Methods

A questionnaire was used to investigate the service needs of breast cancer patients and their families for the information platform. Based on the value dimensions of PPV, the module content of the BC-CMIP was initially constructed, and the Delphi method was used to justify and revise the module content. Excel 2019 and SPSS 26.0 were used for statistical analysis.

Results

The information platform includes the patient side and the medical side. The index content includes four primary indicators: functional value, emotional value, efficiency value and social value; it can realize all patient case management needs, such as diagnosis and treatment services, health education, telemedicine, treatment tracking, psychological support, case assessment and positive warning.

Conclusion

Based on the PPV, the module design of the BC-CMIP is reasonable and comprehensive, and it can scientifically and effectively meet the health needs of patients and provide a theoretical basis for subsequent platform development and application.

Crisis interventions for adults with borderline personality disorder

BACKGROUND

People diagnosed with borderline personality disorder (BPD) frequently present to healthcare services in crisis, often with suicidal thoughts or actions. Despite this, little is known about what constitutes effective management of acute crises in this population and what type of interventions are helpful at times of crisis. In this review, we will examine the efficacy of crisis interventions, defined as an immediate response by one or more individuals to the acute distress experienced by another individual, designed to ensure safety and recovery and lasting no longer than one month. This review is an update of a previous Cochrane Review examining the evidence for the effects of crisis interventions in adults diagnosed with BPD.

OBJECTIVES

To assess the effects of crisis interventions in adults diagnosed with BPD in any setting.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases and three trials registers up to January 2022. We also checked reference lists, handsearched relevant journal archives and contacted experts in the field to identify any unpublished or ongoing studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing crisis interventions with usual care, no intervention or waiting list, in adults of any age diagnosed with BPD.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included two studies with 213 participants. One study (88 participants) was a feasibility RCT conducted in the UK that examined the effects of joint crisis plans (JCPs) plus treatment as usual (TAU) compared to TAU alone in people diagnosed with BPD. The primary outcome was self-harm. Participants had an average age of 36 years, and 81% were women. Government research councils funded the study. Risk of bias was unclear for blinding, but low in the other domains assessed. Evidence from this study suggested that there may be no difference between JCPs and TAU on deaths (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.06 to 14.14; 88 participants; low-certainty evidence); mean number of self-harm episodes (mean difference (MD) 0.30, 95% CI -36.27 to 36.87; 72 participants; low-certainty evidence), number of inpatient mental health nights (MD 1.80, 95% CI -5.06 to 8.66; 73 participants; low-certainty evidence), or quality of life measured using the EuroQol five-dimension questionnaire (EQ-5D; MD -6.10, 95% CI -15.52 to 3.32; 72 participants; very low-certainty evidence). The study authors calculated an Incremental Cost Effectiveness Ratio of GBP -32,358 per quality-adjusted life year (QALY), favouring JCPs, but they described this result as "hypothesis-generating only" and we rated this as very low-certainty evidence.  The other study (125 participants) was an RCT conducted in Sweden of brief admission to psychiatric hospital by self-referral (BA) compared to TAU, in people with self-harm or suicidal behaviour and three or more diagnostic criteria for BPD. The primary outcome was use of inpatient mental health services. Participants had an average age of 32 years, and 85% were women. Government research councils and non-profit foundations funded the study. Risk of bias was unclear for blinding and baseline imbalances, but low in the other domains assessed. The evidence suggested that there is no clear difference between BA and TAU on deaths (RR 0.49, 95% CI 0.05 to 5.29; 125 participants; low-certainty evidence), mean number of self-harm episodes (MD -0.03, 95% CI -2.26 to 2.20; 125 participants; low-certainty evidence), violence perpetration (RR 2.95, 95% CI 0.12 to 71.13; 125 participants; low-certainty evidence), or days of inpatient mental health care (MD 0.70, 95% CI -14.32 to 15.72; 125 participants; low-certainty evidence). The study suggested that BA may have little or no effect on the mean number of suicide attempts (MD 0.00, 95% CI -0.06 to 0.06; 125 participants; very low-certainty evidence). We also identified three ongoing RCTs that met our inclusion criteria. The results will be incorporated into future updates of this review.

AUTHORS' CONCLUSIONS

A comprehensive search of the literature revealed very little RCT-based evidence to inform the management of acute crises in people diagnosed with BPD. We included two studies of two very different types of intervention (JCP and BA). We found no clear evidence of a benefit over TAU in any of our main outcomes. We are very uncertain about the true effects of either intervention, as the evidence was judged low- and very low-certainty, and there was only a single study of each intervention. There is an urgent need for high-quality, large-scale, adequately powered RCTs on crisis interventions for people diagnosed with BPD, in addition to development of new crisis interventions.

Attitudes toward innovative mental health treatment approaches in Germany: E-mental health and home treatment

E-mental health and home treatment are treatment approaches that have proven to be effective, but are only slowly implemented in the German health care system. This paper explores the attitudes toward these innovative treatment approaches. Data was collected in two large, non-clinical samples representative of the German population in spring 2020 (N = 2,503) and winter 2020/2021 (N = 2,519). Statistical associations between variables were examined using two-tailed tests. Binary and multinomial logistic regressions were performed to predict attitudes toward online-based treatment concepts and home treatment approaches. Only few (<20%) people preferred online-based treatment approaches, while a larger proportion (~50%) could imagine being treated at home. Overall, younger subjects were more open to online-therapy approaches, while people with lower education preferred more often a traditional therapy setting. Acceptance of online-therapy did not raise significantly during the first months of the COVID-19 pandemic. When different online-based treatment options were available, the probability of accepting home treatment significantly increased with increasing levels of therapeutic support. Further promotion of acceptance for online-therapy and home treatment seems to be necessary. In the future, more information on innovative treatment approaches should be actively provided.

The Cost-Effectiveness Analysis of an Integrated Mental Health Care Programme in Germany

The network for mental health (NWpG = Netzwerk psychische Gesundheit) is an umbrella association for non-medical community mental health care facilities across Germany which are enabled to provide multi-professional mental health care packages including medical and psychosocial services reimbursed by German statutory health insurances since 2009. The aim of this study is to analyse the cost-effectiveness of providing NWpG mental health care packages plus treatment as usual (NWpG) to treatment as usual alone (TAU) in Germany. In a prospective, multicenter, controlled trial over 18 months, a total of 511 patients (NWpG = 251; TAU = 260) were observed in five regions, four times at six-month intervals. The EQ-5D-3L and the Client Sociodemographic and Service Receipt Inventory (CSSRI) were used to estimate quality-adjusted life-years and total costs of illness. Propensity score-adjusted cost–utility analysis was applied using the net benefit approach. No significant differences in costs and QALYs between NWpG and TAU groups were identified. The probability of NWpG being cost-effective compared to TAU was estimated below 75% for maximum willingness to pay (MWTP) values between 0 and 125,000 EUR. The additional provision of the NWpG package is not cost-effective compared to TAU alone.

Negative symptoms in first episode schizophrenia: treatment response across the 2-year follow-up of the "Parma Early Psychosis" program

Negative symptoms (NS) severely interfere with real-world performance, already at the onset of schizophrenia and in "clinical high risk" mental states. However, most of the empirical studies specifically examining treatment effectiveness on NS included patients with stable, prolonged schizophrenia. Moreover, research on psychosocial interventions for NS in early schizophrenia is still relatively scarce. Thus, the aims of this study were (1) to longitudinally monitor the NS stability in young individuals with First Episode Schizophrenia (FES) across a 2-year follow-up period, and (2) to investigate any significant association of NS with functioning, other aspects of FES psychopathology and the specific treatment component effects on NS of an "Early Intervention in Psychosis" (EIP) program during the 2 years of follow-up. At entry, 159 FES participants (aged 12-35 years) completed the Positive And Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF). Spearman's correlations and multiple linear regression analyses were performed. NS had relevant enduring associations with PANSS disorganization scores and GAF functioning decline. Across the follow-up, FES individuals showed a significant improvement in NS levels. This was specifically associated with the number of individual psychotherapy and intensive case management sessions provided during the 2 years of our EIP program, as well as with the antipsychotic dosage at entry. NS are clinically relevant in FES, already at the enrollment in specialized EIP services. However, their clinical severity seems to decrease over time, together with the delivery of specific, patient-tailored EIP interventions.

Patterns of Service Use in Intensive Case Management: A Six Year Longitudinal Study

An Intensive Case Management (ICM) intervention has been developed in Lausanne, Switzerland. It aims to promote access to care for people with severe mental disorders who have difficulties to engage with mental health services because of the severity of their disorders and/or their marginality. ICM embrace components of assertive community treatment and critical time intervention. It is time limited and focused on critical phases of recovery. The goal of this study was to examine the heterogeneity of service use patterns of people who required ICM interventions and identify differences in patterns of duration and timing of the intervention. Records of 471 patients from the Department of Psychiatry of Lausanne University Hospital for whom the ICM team intervention was requested were analysed over a 6 year period with discrete sequential-state analysis. Trajectories could be split between six meaningful clusters including service light use and critical time intervention (58.0%), transition to long-term regular ambulatory-care (11.3%), partial transition to ambulatory care (14.4%), alternative to hospitalization (10.4%), continued ICM (4.9%) and long hospital stays (1.1%). Diagnoses of substance abuse were overrepresented among heavy users and diagnoses of schizophrenia were the most frequent diagnostic overall. Profiles of service use for ICM patients were very diverse. Long term interventions were frequently not necessary. A time-limited intervention was likely sufficient to stabilize the situation and/or engage the patient in care. A small number of situations required a sustained and long-term investment and did not always allowed for a reduction in the need for hospitalization. A general reflection on alternatives to hospitalization must be pursued, in particular for these patients.

Case Management Improves Satisfaction, Anxiety, and Depression of Patients with Pregnancy Loss after In Vitro Fertilization and Embryo Transfer

Objective

Pregnancy loss has negative impacts on both the physical and the mental health of expectant mothers, which calls for an in-depth investigation. In this study, we examined the effects of case management on patients with pregnancy loss after in vitro fertilization and embryo transfer (IVF-ET).

Methods

100 participants that had suffered pregnancy loss after IVF-ET-assisted pregnancy from January 2019 to March 2020 were divided into routine care and case management groups, each with 50 cases. For the routine care group, a doctor led the diagnostic and treatment processes and a nurse assisted with the treatment. For the case management group, a nurse led the patient diagnostic and treatment processes and a doctor controlled the diagnosis and treatment plan formulation. Case management models were established according to the comprehensive peripregnancy loss care of patients with pregnancy loss after IVF-ET-assisted pregnancy. The participants' outcomes (satisfaction, anxiety, and depression) were assessed at the time of pregnancy loss and 1 and 3 months after pregnancy loss during follow-up of the routine care and case management groups.

Results

There was no statistical difference between the patients in the two groups with regard to their general information statistics (P > 0.05) or their satisfaction, anxiety, and depression at the time of pregnancy loss (P > 0.05). One month after pregnancy loss, there was no statistical difference in anxiety between the two groups (P > 0.05), but satisfaction was greater and depression was significantly reduced in the case management group compared with the routine care group (P < 0.05).

Conclusion

Case management care can have a positive effect on improving the satisfaction, anxiety, and depression of patients that have had pregnancy loss after IVF-ET.

The mental health nurse as case manager of a patient with severe schizophrenia

Community-based programmes for people with severe mental illness (SMI), with a case management methodology, have shown high treatment adherence and a decrease in psychiatric hospitalizations. There is a need for continuity of care through a good therapeutic relationship, maintained throughout the care process until reaching clinical stabilization. The proposed case shows the treatment of a woman with a diagnosis of schizophrenia who began treatment in a mental health centre and was later referred to a case managed SMI programme. A nursing assessment was carried out from the beginning and a care plan was made based on the NANDA (North American Nursing Diagnosis Association), NOC (Nursing Outcomes Classification), NIC (Nursing Interventions Classification) taxonomy. The outcomes over the years are remarkable, achieving among other objectives not only clinical stabilization but also a normal life.

A principles-focused evaluation of community mental health short-term case management

Principles-focused evaluations allow evaluators to appraise each principle that guides an organization or program. This study completed a principles-focused evaluation of a new community mental health intervention called Short Term Case Management (STCM) in Toronto, Canada. STCM is a time limited intervention for clients to address unmet needs and personalized goals over 3 months. Findings showcase that a principles-focused evaluation, assessing whether program principles are guiding, useful, inspiring, developmental and/or evaluable (GUIDE), is a practical formative evaluation approach. Specifically, offering an understanding of a novel intervention, including its key components of assessment and planning, support plan implementation and evaluation and care transitions. Findings also highlight that STCM may work best for those clients ready to participate in achieving their own goals. Future research should explore how best to apply the GUIDE framework to complex interventions, including multiple principles, to increase evaluation feasibility and focus.

Predictors of community mental health nursing services use in Switzerland: Results from a representative national survey

Community mental health services are the service of choice in the mental health field. In recent years, demand for these services has increased significantly. Nurses play a central role in community mental health services. Nevertheless, predictive factors of the use of such services are unclear, especially in Switzerland. This study aimed to examine relevant predictors of persons with mental health problems' use of community mental health nursing services in Switzerland. Swiss Health Survey 2017 data were used to compare those who use community mental health nursing services with those who do not. We found that age, number of doctor visits, problems with instrumental activities of daily life, use of informal help, use of emergency services, taking psychotropic medication, being female, and living without a partner were positive predictors, while experiencing severe physical symptoms was a negative predictor. Several of our findings confirm the similarity between the utilization of community mental health nursing services and the use of community mental health services in general. Our results suggest that community mental health nursing services deserve the same prominent place in the mental health system and its corresponding policies. This should be taken as an argument for policy development and better reimbursement. In research, health surveys should focus on nursing and need-related questions. Additionally, it is necessary to develop community mental health nursing services from an add-on service into independent nursing services and evaluate these services.

The foundations of the working alliance in assertive community treatment teams

BACKGROUND

In this study, we aimed to identify and define the fundamental components of the working alliance in multidisciplinary (Flexible) Assertive Community Treatment teams with shared caseloads, in order to support their daily practice and further research.

METHODS

After reviewing the literature, concept mapping with professionals and clients was used to define the working alliance in (F) ACT teams. The resulting concept maps formed the basis for the working alliance assessment instrument, which was pilot tested with professionals and clients through cognitive interviews with a think-aloud procedure.

RESULTS

The study led to the development of a twenty five-item assessment instrument to evaluate working alliances in multidisciplinary teams (WAM) that was comprised of three subscales: bond, task/goal and team. Two different versions were developed for clients and professionals.

CONCLUSIONS

The WAM instrument was developed to determine the quality of the working alliance in (F) ACT teams. Future research will focus on testing its psychometric properties and predictive value.

The impact of implementing a psychiatric emergency hotline on the reduction of acute hospitalizations in a Swiss tertiary hospital

BACKGROUND

Inpatient treatment is not the most beneficial treatment setting for many patients with psychiatric disorders and overcrowding is a recurrent problem for psychiatric hospitals. Therefore, it is important to develop strategies to limit avoidable inpatient treatment. This study sought to evaluate the impact of an emergency hotline that was developed to better manage psychiatric patients, particularly for identifying those requiring a hospital admission.

METHODS

This pre-post intervention quality improvement study compared changes in the management of psychiatric patients' admission before and after the introduction of an emergency hotline where a specialist in psychiatry examines all inpatient referral from private practitioners. Main outcomes were the change in proportion of hospital admissions after referral from a private practitioner before and within 3 months after the intervention. Secondary outcomes were the average length of hospital stay, proportion of non-voluntary admission, the time required for triage and the impact of the intervention on treatments' costs. Fisher's Exact test was used to test the primary hypothesis of difference in the proportion of hospitalized patients before and after introduction of the emergency hotline. Secondary outcomes were tested with Student's t-test for continuous variables and Fishers's Exact test for proportions.

RESULTS

Among 45 admission requests from private practitioners during the 3 months after introduction of the new emergency hotline, 25 (55.6%) were accepted as inpatient treatment, while 20 (44%) were redirected to more appropriate outpatient treatments. There was a highly significant difference from the baseline period during which all 34 requests were accepted (44% vs 100%, p < 0.001). In addition, for the patients hospitalized after the introduction of the emergency hotline there was a trend-level reduction of the average length of stay (9.32 days vs 17.35 days).

CONCLUSION

Implementation of an emergency hotline manage by a specialist in psychiatry for admissions to acute psychiatric wards is feasible and simple to use. Importantly, it allows to significantly decrease the proportion of hospitalizations. Additional studies are needed to assess the generalizability of these exploratory results to other health care settings.

A systematic review of longitudinal studies investigating the impact of cannabis use in patients with psychotic disorders

Introduction: Research has established a link between cannabis use and adverse psychotic outcomes in psychosis patients. However, we have yet to determine if this relationship is maintained when controlling for important confounding variables. The following systematic review aims to investigate if the association between cannabis use and psychotic outcomes is preserved when accounting for important confounders, and if discontinued use mitigates any potential negative impacts.Areas covered: The authors conducted an exhaustive search of the MEDLINE database and Google Scholar to identify articles pertaining to the systematic review. Thirty-three articles were retained for meeting the eligibility criteria.Expert opinion: The evidence confirms an overarching pattern of negative psychotic outcomes of cannabis intake in psychosis populations, even when accounting for crucial confounders. Psychosis patients should be informed with evidence-based health information regarding the effects of cannabis use. Clinicians should systematically evaluate cannabis intake patterns in psychosis patients and offer intervention services geared toward reducing problematic consumption. Researchers should record confounding factors in a more systematic manner in future longitudinal investigations while paying careful attention to the potency and dose-response effects of the ingested cannabis. Deciders will need to investigate the impact of cannabis regulations on psychosis populations.

[Evidence on the effects of crisis resolution teams, home treatment and assertive outreach for people with mental disorders in Germany, Austria and Switzerland - a systematic review]

BACKGROUND

Based on international randomized controlled trials (RCT) the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) recommends acute treatment in the domestic environment (AHU) and intensive outreach treatment (IAB) with the highest level of evidence; however, due to large differences in national healthcare systems the transference of results from international studies to the healthcare systems in Germany, Austria and Switzerland could be limited.

OBJECTIVE

Evaluation of studies on outreach psychiatric treatment forms in Germany, Austria and Switzerland and discussion of the results in the light of international evidence.

MATERIAL AND METHODS

A systematic literature search for clinical trials on outreach community treatment from Germany, Austria and Switzerland was conducted in the PubMed database.

RESULTS

A total of 19 publications were identified which could be assigned to 5 publications on 4 studies with 2857 patients on AHU and 14 publications on 10 studies with 3207 patients on IAB. The studies on AHU showed this treatment form to be superior regarding the duration of inpatient stay and healthcare costs. The studies on IAB showed more positive outcomes in comparison to controls regarding symptoms, severity of illness, substance abuse, functioning level, remission, satisfaction with treatment, quality of life, healthcare costs, work and housing situations.

CONCLUSION

The studies from Germany, Austria, and Switzerland suggest that outreach community treatment is superior regarding several outcome parameters. Thus, there are no indications suggesting that international evidence could not be valid for these countries. Additionally, with one RCT for AHU and one for IAB the requirements for an evidence level of 1b for outreach community treatment in the healthcare systems in question are fulfilled.

A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness

Background

Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness.

Objectives

The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness.

Search Methods

In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies.

Selection Criteria

Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income.

Data Collection and Analysis

Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model.

Main Results

The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, -$19, -$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services.

Authors' Conclusions

PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.

Non-pharmacological strategies for self-directed and interpersonal violence in people with severe mental illness: a rapid overview of systematic reviews

INTRODUCTION

Self-directed and interpersonal violence among people with severe mental illness has become a health priority. Though non-pharmacological interventions have been investigated, to our knowledge, no summary of all systematic reviews on this topic has been reported. We will conduct a rapid overview of reviews to synthesise evidence available by identifying systematic reviews on non-pharmacological interventions for self-directed or interpersonal violence in people with severe mental illness.

METHODS AND ANALYSIS

This is a protocol for a rapid overview of reviews. The overview will include any systematic reviews (with or without meta-analyses) of randomised controlled trials (RCTs) or cluster RCTs that examine the effect of non-pharmacological interventions on self-directed or interpersonal violence in people with severe mental illness. This protocol applies the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols, the criteria for conducting overviews of reviews in the Cochrane Handbook of Systematic Reviews of Interventions and the criteria for the Cochrane Rapid Reviews. To identify studies, a search will be performed in the following databases: PubMed, EMBASE, PsycINFO, CINAHL, LILACS, SciELO, Web of Science, Scopus, ProQuest, the Cochrane Database of Systematic Reviews through the Cochrane Library and the Epistemonikos database of systematic reviews. The searches date from inception to September 2020. The study selection process will be described using a PRISMA flow diagram, we will assess the quality of evidence in systematic reviews included and the quality of the systematic reviews themselves and the main results will be summarised in categories to provide a map of the evidence available.

ETHICS AND DISSEMINATION

No patients or other participants will be involved in this study. The results will be presented at mental health conferences and for publication in a peer-reviewed journal.

REGISTRATION DETAILS

The protocol was registered on the Open Science Framework (https://osf.io/myzd9/).

Improving Care for Deinstitutionalized People With Mental Disorders: Experiences of the Use of Knowledge Translation Tools

Background: The deinstitutionalization process is complex, long-term and many countries fail to achieve progress and consolidation. Informing decision-makers about appropriate strategies and changes in mental health policies can be a key factor for it. This study aimed to develop an evidence brief to summarize the best available evidence to improve care for deinstitutionalized patients with severe mental disorders in the community. Methods: We used the SUPPORT (Supporting Policy Relevant Reviews and Trials) tools to elaborate the evidence brief and to organize a policy dialogue with 24 stakeholders. A systematic search was performed in 10 electronic databases and the methodological quality of systematic reviews (SRs) was assessed by AMSTAR 2. Results: Fifteen SRs were included (comprising 378 studies and 69,736 participants), of varying methodological quality (3 high-quality SRs, 2 moderate-quality SRs, 7 low-quality SRs, 3 critically low SRs). Six strategies were identified: (i). Psychoeducation; (ii). Anti-stigma programs, (iii). Intensive case management; (iv). Community mental health teams; (v). Assisted living; and (vi). Interventions for acute psychiatric episodes. They were associated with improvements on a global status, satisfaction with the service, reduction on relapse, and hospitalization. Challenges to implementation of any of them included: stigma, the shortage of specialized human resources, limited political and budgetary support. Conclusions: These strategies could guide future actions and policymaking to improve mental health outcomes.

An implementation evaluation of "Zero Suicide" using normalization process theory to support high-quality care for patients at risk of suicide

Background

Suicide rates continue to rise across the United States, galvanizing the need for increased suicide prevention and intervention efforts. The Zero Suicide (ZS) model was developed in response to this need and highlights four key clinical functions of high-quality health care for patients at risk of suicide. The goal of this quality improvement study was to understand how six large health care systems operationalized practices to support these functions-identification, engagement, treatment and care transitions.

Methods

Using a key informant interview guide and data collection template, researchers who were embedded in each health care system cataloged and summarized current and future practices supporting ZS, including, (1) the function addressed; (2) a description of practice intent and mechanism of intervention; (3) the target patient population and service setting; (4) when/how the practice was (or will be) implemented; and (5) whether/how the practice was documented and/or measured. Normalization process theory (NPT), an implementation evaluation framework, was applied to help understand how ZS had been operationalized in routine clinical practices and, specifically, what ZS practices were described by key informants (coherence), the current state of norms/conventions supporting these practices (cognitive participation), how health care teams performed these practices (collective action), and whether/how practices were measured when they occurred (reflexive monitoring).

Results

The most well-defined and consistently measured ZS practices (current and future) focused on the identification of patients at high risk of suicide. Stakeholders also described numerous engagement and treatment practices, and some practices intended to support care transitions. However, few engagement and transition practices were systematically measured, and few treatment practices were designed specifically for patients at risk of suicide.

Conclusions

The findings from this study will support large-scale evaluation of the effectiveness of ZS implementation and inform recommendations for implementation of high-quality suicide-related care in health care systems nationwide.

Adaptations and Innovations to Minimize Service Disruption for Patients with Severe Mental Illness during COVID-19: Perspectives and Reflections from an Assertive Community Psychiatry Program

Changes to community psychiatry during COVID-19 are unprecedented and without clear guidelines. Minimizing disruption, ensuring quality care to the already vulnerable people with serious mental illness is crucial. We describe and reflect our adaptations and innovations at one community psychiatry program, based on three key principles. In (i) Defining and maintaining essential services while limiting risk of contagion, we discuss such strategies and ways to assess risks, implement infection control, and other creative solutions. In (ii) Promoting health and mitigating physical and mental health impacts, we reflect on prioritizing vulnerable patients, dealing with loss of community resources, adapting group programs, and providing psychoeducation, among others. In (iii) Promoting staff resilience and wellness, we describe building on strength of the staff early, addressing staff morale and avoiding moral injury, and valuing responsive leadership. We also identify limitations and potential further improvements, mindful that COVID-19 and similar crises are likely recurring realities.

Qualitative study of the implementation of the Continuity of Care and Rehabilitation Program for people with severe mental disorders in Peru

Objective.

Describe the implementation of the Continuity of Care and Rehabilitation Program (PCC-R) in community mental health centers (CSMCs, Spanish acronym) in Peru.

Methods.

Qualitative study of the implementation of the PCC-R in four CSMCs in Lima and La Libertad, Peru. Forty-two individual semi-structured interviews were conducted, as well as a focus group with five participants, for a total of 47 informants, including users, family members, and professionals involved in the design, implementation, and monitoring of the program.

Results.

The PCC-R is a key program for community mental health services in Peru and it enjoys broad acceptability. Providers and users report satisfaction with its results; however, the program lacks a policy document specifying its objectives, organization, and activities. This would explain the variability in its implementation. The PCC-R has limitations in terms of management of financial and human resources, and it is necessary to improve training and supervision. There is consensus on the need, usefulness, and viability of developing a system to monitor the PCC-R. Good practices and suggestions are presented with a view to addressing these challenges.

Conclusions.

The PCC-R is a flagship program for the CSMCs and for mental health reform in Peru. It has achieved broad acceptability among providers and users. Its implementation combines successes and difficulties, with pending tasks that include developing a policy document, improving resource management, strengthening training and supervision, and implementing a monitoring system for continuous improvement of the program.

[Qualitative study of the implementation of the Continuity of Care and Rehabilitation Program for people with severe mental disorders in PeruEstudo qualitativo sobre a implementação do Programa de Continuidade de Cuidados e Rehabilitação para pessoas com transtornos mentais graves no Peru]

Objetivo.

Describir la implementación del Programa de continuidad de cuidados y rehabilitación (PCC-R) en centros de salud mental comunitaria (CSMC) del Perú.

Métodos.

Estudio cualitativo sobre la implementación del PCC-R en cuatro CSMC de Lima y La Libertad, Perú. Se realizaron 42 entrevistas semiestructuradas individuales y un grupo focal con cinco participantes, para un total de 47 informantes entre usuarios, familiares y profesionales vinculados al diseño, la implementación y el monitoreo del PCC-R.

Resultados.

El PCC-R es un programa central de los servicios de salud mental comunitaria en Perú, goza de amplia aceptación y los prestadores y usuarios refieren estar satisfechos con sus resultados. Sin embargo, el programa carece de un documento normativo que detalle sus objetivos, organización y actividades, lo que explicaría la variabilidad en su aplicación. Existen limitaciones en la gestión de recursos financieros y humanos del PCC-R y necesidades de capacitación y supervisión, que deben ser mejoradas. Existe consenso sobre la necesidad, la utilidad y la viabilidad de desarrollar un sistema de monitoreo del PCC-R. Se recogen buenas prácticas y sugerencias para enfrentar estos retos.

Conclusiones.

El PCC-R es un programa insignia de los CSMC y de la reforma de la salud mental en Perú, y ha logrado amplia aceptación entre los prestadores y usuarios. Su implementación combina aciertos y dificultades, y revela tareas pendientes como desarrollar un documento normativo, mejorar la gestión de recursos, fortalecer la capacitación y acompañamiento, y aplicar un sistema de monitoreo para favorecer la mejora continua del programa.