A systematic review of home treatment services--classification and sustainability

Action planning for building public health program sustainability: results from a group-randomized trial

BACKGROUND

Public health programs are charged with implementing evidence-based interventions to support public health improvement; however, to achieve long-term population-based benefits, these interventions must be sustained. Empirical evidence suggests that program sustainability can be improved through training and technical assistance, but few resources are available to support public health programs in building capacity for sustainability.

METHODS

This study sought to build capacity for sustainability among state tobacco control programs through a multiyear, group-randomized trial that developed, tested, and evaluated a novel Program Sustainability Action Planning Model and Training Curricula. Using Kolb's experiential learning theory, we developed this action-oriented training model to address the program-related domains proven to impact capacity for sustainability as outlined in the Program Sustainability Framework. We evaluated the intervention using a longitudinal mixed-effects model using Program Sustainability Assessment (PSAT) scores from three time points. The main predictors in our model included group (control vs intervention) and type of dosage (active and passive). Covariates included state-level American Lung Association Score (proxy for tobacco control policy environment) and percent of CDC-recommended funding (proxy for program resources).

RESULTS

Twenty-three of the 24 state tobacco control programs were included in the analyses: 11 received the training intervention and 12 were control. Results of the longitudinal mixed-effects linear regression model, where the annual PSAT score was the outcome, showed that states in the intervention condition reported significantly higher PSAT scores. The effects of CDC-recommended funding and American Lung Association smoke-free scores (proxy for policy environment) were small but statistically significant.

CONCLUSION

This study found that the Program Sustainability Action Planning Model and Training Curricula was effective in building capacity for sustainability. The training was most beneficial for programs that had made less policy progress than others, implying that tailored training may be most appropriate for programs possibly struggling to make progress. Finally, while funding had a small, statistically significant effect on our model, it virtually made no difference for the average program in our study. This suggests that other factors may be more or equally important as the level of funding a program receives.

TRIAL REGISTRATION

CLINICALTRIALS

gov, NCT03598114. Registered on July 26, 2018.

Madison to Manipal: A narrative review of modified assertive community treatment programs

BACKGROUND

Assertive community treatment (ACT) is a multidisciplinary, team-based approach providing comprehensive individualized care for the patients with various mental illness, has been adapted variably across the world in terms of patient-staff ratio, selection of patients, the pattern of service delivery and frequency of contact. We aim to review the extant literature on the modifications of ACT programs for severe mental disorders and their effectiveness.

METHODS

Studies on modified ACT approaches for mental illnesses were searched in multiple databases. We adopted a rapid appraisal approach. The searches were restricted to articles published in English. We appraised the fidelity assessment of the ACT studies wherever available. In addition, we assessed the study quality using a grading tool based on ten practice components of ACT.

RESULTS

We found 23 reports (10 RCTs and 13 non-controlled studies) on modified ACT. The extant literature on modified ACT programs is heterogeneous. The modifications in ACT included changes in patient-to-staff ratio, team composition, service hours, and interventions carried out. Most controlled studies were conducted in high-income settings and had inconsistent outcome, possibly due to the comprehensive nature of the 'usual care.' In contrast, modified ACT services from low and middle-income countries reduced hospitalization rates and improved treatment adherence.

CONCLUSIONS

Modifications in ACT programs were done to cater to specific subpopulation and the changes in program structure to suit the resources and setting. The outcome of modified ACT appears heterogenous, though the findings from low and middle-income countries are promising.

A comparison of the National Clinical Audit of Psychosis 2019/2020 standards and First Episode Psychosis Services Fidelity Scale 1.0

AIM

The authors compare two approaches to assessment of the quality of early psychosis intervention services, the National Clinical Audit of Psychosis used in the United Kingdom and the First Episode Psychosis Services Fidelity Scale used in North America and Europe.

METHODS

We compare the two approaches on the source of standards, measurement type, data collection, time requirements, scoring and reliability. Finally, we review their strengths and limitations.

RESULTS

Both measures are based on standards derived from the same research evidence base. Both methods rely on data from health records and administrative data. The audit is supplemented with user survey data, the fidelity scale with clinician interviews. The audit requires more time. The audit is based on quality indicators rated as present or absent which yields a statistical benchmark. The Fidelity Scale is based on quality indicators that are rated on a five-point scale yielding a standards-based measure. The two methods cover similar service components, but the FEPS-FS has a broader coverage of team functioning. The National audit also collects data on the user experience directly from patients. The fidelity scale has achieved good to excellent inter-rater reliability, the reliability of the audit has not been tested.

CONCLUSIONS

Both methods have face validity and provide reliable and useful measures of quality of care. The NCAP works in the context of a single provider health system, the FEPS-FS works in a more variable health system. Comparing the two systems in the field would support international comparison of standards of care.

Sustainment of Integrated Care in Addiction Treatment Settings: Primary Outcomes From a Cluster-Randomized Controlled Trial

OBJECTIVE

Integrated treatment services are the gold standard for addressing co-occurring mental and substance use disorders, yet they are not readily available. The Network for the Improvement of Addiction Treatment (NIATx) was hypothesized to be an effective strategy to implement and sustain integrated mental health and substance use care in addiction treatment programs. This study examined sustainment of integrated services for up to 2 years after the active implementation phase.

METHODS

The effectiveness of NIATx strategies to implement and sustain integrated services was evaluated by using a cluster-randomized, waitlist control group design. Forty-nine addiction treatment organizations were randomly assigned to either NIATx1 (active implementation strategy) or NIATx2 (waitlist control). The Dual Diagnosis Capability in Addiction Treatment Index was used to evaluate organizations' capability to provide integrated care. The NIATx Stages of Implementation Completion scale was used to assess participation in and adherence to the NIATx implementation process. Linear mixed-effects modeling was used to evaluate changes from baseline to end of the sustainment period.

RESULTS

Both cohorts sustained their capability to provide integrated treatment services. Both groups achieved successful implementation and sustained integrated services to a similar degree, regardless of sustainment year. Sustainment did not vary as a function of NIATx adherence.

CONCLUSIONS

The delivery of integrated treatment services was sustained for 2 years after receipt of active implementation support. Future research should consider how contextual factors may predict, mediate, and moderate sustainment outcomes.

Is Home Treatment for Everyone? Characteristics of Patients Receiving Intensive Mental Health Care at Home

We aimed at determining differential characteristics of patients treated by a home treatment (HT) team compared to patients treated on hospital wards. Of 412 consecutively admitted patients, 194 (47.1%) were at least partially treated at home, whereas 218 (52.9%) received inpatient treatment only during an episode of acute illness. A multivariate logistic regression model identified current employment to increase the odds of HT (p < 0.001). A primary diagnosis of anxiety or stress-related disorder (p < 0.001), other rare primary diagnoses such as personality disorders (p < 0.001), and more pronounced clinician-rated social problems (p = 0.041) decreased the odds of HT. Overall, it remained difficult to clearly specify suitability for HT based on available sociodemographic and clinical characteristics. This might indicate that responsible clinicians consider HT to be a viable alternative to hospital care and hence initiate HT for a relatively broad spectrum of patients.

Hospital-in-the-Home as a Model for Mental Health Care Delivery: A Narrative Review

Objective: Hospital-in-the-home (HITH) is a service model widely adopted in medical specialties to help alleviate pressure on the availability of inpatient beds and allow patients to receive acute care in familiar surroundings. To date, such models are not widely utilized in mental health care. The authors review existing HITH-type mental health services, focusing on the domains of design, implementation, and outcomes.Methods: An electronic database search was conducted of MEDLINE, PsycINFO, CINAHL, Embase, Scopus, Web of Science, and Google Scholar. Fifty-six studies were eligible for inclusion in this review. Because of heterogeneous methods and outcome reporting in the available research, a narrative approach was used to highlight key themes in the literature.Results: Mental health HITH services exist under a wide range of names with differing theoretical origins and governance structures. Common characteristics and functions are summarized. The authors found moderate evidence for a reduced number and length of hospital admissions as a result of mental health HITH programs. HITH is likely to be cost-effective because of these effects. Limited evidence exists for clinical measures, consumer satisfaction, and effects on caregivers and staff.Conclusions: Mental health HITH services are an effective alternative to inpatient admission for certain consumers. The authors propose a definition of HITH as any service intended to provide inpatient-comparable mental health care in the home instead of the hospital. Standardized studies are needed for systematic analysis of key HITH outcomes.

Provider REport of Sustainment Scale (PRESS): development and validation of a brief measure of inner context sustainment

BACKGROUND

Implementation scientists and practitioners often rely on frontline providers for reporting on implementation outcomes. Furthermore, measures of sustainment are few, and available sustainment measures are mainly setting or evidenced-based practice (EBP) specific, require organizational and system-level knowledge to complete, and often lack psychometric rigor. The aim of this study was to develop a brief, pragmatic, and generalizable measure for completion by frontline service providers of the implementation outcome, sustainment.

METHODS

We utilized a Rasch measurement theory approach to scale the development and testing of psychometric parameters. Sustainment items were developed to be relevant for direct service providers to complete. In order to promote generalizability, data were collected and items were tested across four diverse psychosocial evidence-based practices (motivational interviewing [MI], SafeCare®, classroom pivotal response training [CPRT], and an individualized mental health intervention for children with autism spectrum disorder [AIM-HI]) and in four service settings (substance use disorder treatment, child welfare, education, and specialty mental health). Associations between the sustainment measure and sustainment leadership, sustainment climate, and attitudes towards the adoption and use of each of the EBPs were assessed to confirm construct validity.

RESULTS

Three items for the Provider REport of Sustainment Scale (PRESS) were assessed for measuring the core component of sustainment: continued use of the EBP. Internal consistency reliability was high. The scale indicated fit to the Rasch measurement model with no response dependency, ordered thresholds, no differential item functioning, and supported unidimensionality. Additionally, construct validity evidence was provided based on the correlations with related variables.

CONCLUSION

The PRESS measure is a brief, three-item measure of sustainment that is both pragmatic and useable across different EBPs, provider types, and settings. The PRESS captures frontline staffs' report of their clinic, team, or agency's continued use of an EBP. Future testing of the PRESS for concurrent and predictive validity is recommended.

Developing an evidence-based program sustainability training curriculum: a group randomized, multi-phase approach

Background

The emergence of dissemination and implementation (D&I) science has driven a rapid increase in studies of how new scientific discoveries are translated and developed into evidence-based programs and policies. However, D&I science has paid much less attention to what happens to programs once they have been implemented. Public health programs can only deliver benefits if they reach maturity and sustain activities over time. In order to achieve the full benefits of significant investment in public health research and program development, there must be an understanding of the factors that relate to sustainability to inform development of tools and trainings to support strategic long-term program sustainability. Tobacco control programs, specifically, vary in their abilities to support and sustain themselves over time. As of 2018, most states still do not meet the CDC-recommended level for funding their TC program, allowing tobacco use to remain the leading cause of preventable disease and death in the USA. The purpose of this study is to empirically develop, test, and disseminate training programs to improve the sustainability of evidence-based state tobacco control programs and thus, tobacco-related health outcomes.

Methods

This paper describes the methods of a group randomized, multi-phase study that evaluates the empirically developed “Program Sustainability Action Planning Training” and technical assistance in US state-level tobacco control programs. Phase 1 includes developing the sustainability action planning training curriculum and technical assistance protocol and developing measures to assess long-term program sustainability. Phase 2 includes a group randomized trial to test the effectiveness of the training and technical assistance in improving sustainability outcomes in 24 state tobacco control programs (12 intervention, 12 comparison). Phase 3 includes the active dissemination of final training curricula materials to a broader public health audience.

Discussion

Empirical evidence has established that program sustainability can improve through training and technical assistance; however, to our knowledge, no evidence-based sustainability training curriculum program exists. Therefore, systematic methods are needed to develop, test, and disseminate a training that improves the sustainability of evidence-based programs.

Trial registration

NCT03598114. Registered 25 July 2018—retrospectively registered.

Assertive community treatment in UK practice

Since 2000 assertive outreach has been a requirement of community mental health provision in the UK. This has led to rapid proliferation of assertive community treatment teams offering a pure form of clinical case management to people with severe mental illness. The teams provide intensive support in obtaining material essentials such as food and shelter and place a greater emphasis on social functioning and quality of life than on symptoms. People with psychotic illness with fluctuating mental state and social functioning and poor medication adherence are most likely to benefit. Teams are ideally placed to monitor clozapine treatment in the community. Teams require a broad skills mix, and team members need some competence across a wide range of areas. Teams should include a psychiatrist or have regular access to one. Ideal individual case-loads are 10–12 patients. Around-the-clock availability is no longer considered essential, particularly in view of the rise of crisis resolution/home treatment teams.

Japanese Outreach Model Project for patients who have difficulty maintaining contact with mental health services: Comparison of care between higher-functioning and lower-functioning groups

AIM

The Japanese Ministry of Health, Labor and Welfare sponsored the current examination of a new community mental health service, the Japan Outreach Model Project (JOMP), for persons with mental illnesses and who find it difficult to continue with ongoing treatment. Shorter readmission rates and hospital stays were found. In this study, the amount and type of care that were delivered by the JOMP were examined in order to inform the process of establishing the public insurance system.

METHODS

The data were collected from 32 JOMP outreach teams from 21 prefectures in Japan that agreed to participate; 415 patients were included in the analysis. The clients' characteristics, social functions, problematic behavior score, and the amount and type of care that were delivered were examined.

RESULTS

Higher amounts of care were delivered in the first month, compared to the remaining months, and the care was relatively stable from months 2-5. This suggests that consistently high care was needed for the JOMP clients who found it difficult to maintain contact with mental health services. Those clients with an increased overall global assessment functioning score at 6 months (n = 151) had received significantly more care than those whose functioning had decreased or remained stable (n = 150). The types of increased care that were provided to the higher functioning group were: "assistance with daily living tasks," "medical support for psychiatric symptoms," "empowering the client," "communication and coordination," "support for physical health," and "vocational and educational support."

CONCLUSION

The type and amount of care can positively influence good functional outcomes for those in the community who find it difficult to maintain contact with mental health services.

The Roles of System and Organizational Leadership in System-Wide Evidence-Based Intervention Sustainment: A Mixed-Method Study

If evidence-based interventions (EBIs) are not sustained, investments are wasted and public health impact is limited. Leadership has been suggested as a key determinant of implementation and sustainment; however, little empirical work has examined this factor. This mixed-methods study framed using the Exploration, Preparation, Implementation, Sustainment (EPIS) conceptual framework examines leadership in both the outer service system context and inner organizational context in eleven system-wide implementations of the same EBI across two U.S. states and 87 counties. Quantitative data at the outer context (i.e., system) and inner context (i.e., team) levels demonstrated that leadership predicted future sustainment and differentiated between sites with full, partial, or no sustainment. In the outer context positive sustainment leadership was characterized as establishing a project's mission and vision, early and continued planning for sustainment, realistic project plans, and having alternative strategies for project survival. Inner context frontline transformational leadership predicted sustainment while passive-avoidant leadership predicted non-sustainment. Qualitative results found that sustainment was associated with outer context leadership characterized by engagement in ongoing supportive EBI championing, marketing to stakeholders; persevering in these activities; taking action to institutionalize the EBI with funding, contracting, and system improvement plans; and fostering ongoing collaboration between stakeholders at state and county, and community stakeholder levels. For frontline leadership the most important activities included championing the EBI and providing practical support for service providers. There was both convergence and expansion that identified unique contributions of the quantitative and qualitative methods. Greater attention to leadership in both the outer system and inner organizational contexts is warranted to enhance EBI implementation and sustainment.

Mixed-method study of a conceptual model of evidence-based intervention sustainment across multiple public-sector service settings

BACKGROUND

This study examines sustainment of an EBI implemented in 11 United States service systems across two states, and delivered in 87 counties. The aims are to 1) determine the impact of state and county policies and contracting on EBI provision and sustainment; 2) investigate the role of public, private, and academic relationships and collaboration in long-term EBI sustainment; 3) assess organizational and provider factors that affect EBI reach/penetration, fidelity, and organizational sustainment climate; and 4) integrate findings through a collaborative process involving the investigative team, consultants, and system and community-based organization (CBO) stakeholders in order to further develop and refine a conceptual model of sustainment to guide future research and provide a resource for service systems to prepare for sustainment as the ultimate goal of the implementation process.

METHODS

A mixed-method prospective and retrospective design will be used. Semi-structured individual and group interviews will be used to collect information regarding influences on EBI sustainment including policies, attitudes, and practices; organizational factors and external policies affecting model implementation; involvement of or collaboration with other stakeholders; and outer- and inner-contextual supports that facilitate ongoing EBI sustainment. Document review (e.g., legislation, executive orders, regulations, monitoring data, annual reports, agendas and meeting minutes) will be used to examine the roles of state, county, and local policies in EBI sustainment. Quantitative measures will be collected via administrative data and web surveys to assess EBI reach/penetration, staff turnover, EBI model fidelity, organizational culture and climate, work attitudes, implementation leadership, sustainment climate, attitudes toward EBIs, program sustainment, and level of institutionalization. Hierarchical linear modeling will be used for quantitative analyses. Qualitative analyses will be tailored to each of the qualitative methods (e.g., document review, interviews). Qualitative and quantitative approaches will be integrated through an inclusive process that values stakeholder perspectives.

DISCUSSION

The study of sustainment is critical to capitalizing on and benefiting from the time and fiscal investments in EBI implementation. Sustainment is also critical to realizing broad public health impact of EBI implementation. The present study takes a comprehensive mixed-method approach to understanding sustainment and refining a conceptual model of sustainment.

Community psychiatry's achievements

Mental health care in the second half of the 20th century in much of the developed world has been dominated by the move out from large asylums. Both in response to this move and to make it possible, a pattern of care has evolved which is most commonly referred to as 'Community Psychiatry'. This narrative review describes this process, from local experimentation into the current era of evidence-based mental health care. It focuses on three main areas of this development: (i) the reprovision of care for those discharged during deinstitutionalisation; (ii) the evolution and evaluation of its characteristic feature the Community Mental Health Team; and (iii) the increasing sophistication of psychosocial interventions developed to support patients. It finishes with an overview of some current challenges.

Staying the course? Challenges in implementing evidence-based programs in community mental health services

This paper focuses on the second phase of the deinstitutionalisation of mental health care in which the development of community-based interventions are supposed to be implemented in local community mental health care systems. The challenge to sustainable implementation is illustrated by the Swedish case where the government put forward a national training program that sought to introduce Assertive Community Treatment (ACT) for people with severe mental illness. This study is based on document analysis and qualitative interviews with actors at the national, regional, and local levels covering a total of five regions and 15 municipalities that participated in the program. The analysis of the national experiences is put in relation to both research on public administration and policy analysis as well as to current research on implementation of evidence-based programs. The results showed a “drift” of the original model, which had already begun at the policy formulation stage and ended up in a large number of different local arrangements where only a few of the original components of ACT remained. We conclude that issues with implementation can only be fully understood by considering factors at different analytical levels.

Effectiveness and efficiency of assertive outreach for Schizophrenia in Germany: study protocol on a pragmatic quasi-experimental controlled trial

BACKGROUND

A model of assertive outreach (AO) in which office-based psychiatrists collaborate with ambulatory nursing services for providing intensive home-treatment is currently being implemented in rural areas of Lower Saxony, Germany. The costs of the model are reimbursed by some of the statutory health insurance companies active in Lower Saxony. Effectiveness and efficiency of this model for patients suffering from schizophrenia is evaluated in a pragmatic and prospective trial.

METHODS

Quasi-experimental controlled trial: patients receiving the intervention are all those receiving AO; controls are patients not eligible for AO based on their health insurance affiliation.

ELIGIBILITY CRITERIA

clinical diagnosis of schizophrenia (ICD-10 F.20), aged at least 18 years and being moderately to severely impaired in global functioning.

PRIMARY OUTCOME

admission and days spent in psychiatric inpatient care; secondary outcomes: clinical and functional status; patient satisfaction with chronic care; health care costs. Follow-up time: 6 and 12 months.

DISCUSSION

The study faces many challenges typical to pragmatic trials such as the rejection of randomisation by service providers, the quality of treatment as usual (TAU) to which the intervention will be compared, and the impairment of the study subjects. Solutions of how to deal with these challenges are presented and discussed in detail.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number: http://ISRCTN34900108, German Clinical Trial Register: http://DRKS00003351.

The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research

BACKGROUND

The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research.

METHODS

Two coders identified 125 studies on sustainability that met eligibility criteria. An initial coding scheme was developed based on constructs identified in previous literature on implementation. Additional codes were generated deductively. Related constructs among factors were identified by consensus and collapsed under the general categories. Studies that described the extent to which programs or innovations were sustained were also categorized and summarized.

RESULTS

Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves.

CONCLUSIONS

Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment.

No psychiatry without psychopharmacology

The use of psychotropic medication is an important part of most psychiatrists' clinical practice. We propose here that psychiatry needs to give more prominence to psychopharmacology in order to ensure that psychiatric drugs are used effectively and safely. The issue has several ramifications, including the future of psychiatry as a medical discipline.

Lessons learned in developing community mental health care in Europe

This paper summarizes the findings for the European Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. The article presents a description of the region, an overview of mental health policies and legislation, a summary of relevant research in the region, a precis of community mental health services, a discussion of the key lessons learned, and some recommendations for the future.

Case management and assertive community treatment. What is the difference?

There has been a long-running controversy about the relative benefits of Assertive Community Treatment (ACT) compared to Case Management (CM). Several health care systems have initiated major service overhauls on the basis of published evidence. Yet this evidence has been ambiguous and supports differing interpretations. Research is examined which explores the differences in outcomes reported. It uses a range of approaches, most prominently meta-regression, to test a small range of hypotheses to explain the heterogeneity in outcomes. The main determinant of differences between ACT and CM studies is the local bed management procedures and occupancy practice. Those organizational aspects of ACT which are generally shared by CM teams are associated with reduced hospital care but the stringent staffing proposed for ACT does not affect it. ACT is a specialized form of CM, not a categorically different approach. The benefits of introducing it will depend on the nature of current local practice. Important lessons about the need to focus on treatments rather than structures seem not to have been learnt. Psychiatry's recent excessive focus on service structures may have had unintended consequences for our professional identity.

Assertive community treatment in the Netherlands: outcome and model fidelity

OBJECTIVE

The implementation of assertive community treatment (ACT) varies widely. To date, the association between model fidelity and effect has not been investigated in Europe. We investigated the association between model fidelity and outcome in the Dutch mental health system.

METHOD

In a prospective longitudinal study, ACT model fidelity and patient outcomes were assessed in 20 outpatient treatment teams. Patients with severe mental illness (n = 530) participated in the study. Outcomes were assessed 3 times using the Health of the Nation Outcome Scales (HoNOS), the Camberwell Assessment of Need Short Assessment Schedule (CANSAS), and the number of hospital days and homeless days during a 2-year follow-up period. Data were analyzed using multilevel statistics.

RESULTS

High ACT model fidelity was associated with better outcomes on the HoNOS and less homeless days. Among all of the ACT ingredients, team structure was associated with better outcomes. No associations were found between ACT model fidelity, number of hospital days, and CANSAS scores.

CONCLUSIONS

Our evidence supports the importance of model fidelity for improving patient outcomes.

Assertive community treatment for elderly people with severe mental illness

BACKGROUND

Adults aged 65 and older with severe mental illnesses are a growing segment of the Dutch population. Some of them have a range of serious problems and are also difficult to engage. While assertive community treatment is a common model for treating difficult to engage severe mental illnesses patients, no special form of it is available for the elderly. A special assertive community treatment team for the elderly is developed in Rotterdam, the Netherlands and tested for its effectiveness.

METHODS

We will use a randomized controlled trial design to compare the effects of assertive community treatment for the elderly with those of care as usual. Primary outcome measures will be the number of dropouts, the number of patients engaged in care and patient's psychiatric symptoms, somatic symptoms, and social functioning. Secondary outcome measures are the number of unmet needs, the subjective quality of life and patients' satisfaction. Other secondary outcomes include the number of crisis contacts, rates of voluntary and involuntary admission, and length of stay. Inclusion criteria are aged 65 plus, the presence of a mental disorder, a lack of motivation for treatment and at least four suspected problems with functioning (addiction, somatic problems, daily living activities, housing etc.). If patients meet the inclusion criteria, they will be randomly allocated to either assertive community treatment for the elderly or care as usual. Trained assessors will use mainly observational instruments at the following time points: at baseline, after 9 and 18 months.

DISCUSSION

This study will help establish whether assertive community treatment for the elderly produces better results than care as usual in elderly people with severe mental illnesses who are difficult to engage. When assertive community treatment for the elderly proves valuable in these respects, it can be tested and implemented more widely, and mechanisms for its effects investigated.

TRIAL REGISTRATION

The Netherlands National Trial Register NTR1620.

The rise and fall of assertive community treatment?

Assertive community treatment is one of the most researched and clinically replicated of all community mental health teams. It is clearly defined with established scales to measure its model fidelity. In the last decade its earlier claims to substantially reduce hospitalization have not been replicated in research studies. This inconsistency has generated considerable controversy. A careful systematic review and meta-regression analysis was conducted of 64 trials including 7,819 patients. The review included measures of model fidelity and hospitalization outcomes. Variation in reduced hospitalization was found to be mainly due to variation in control service practice but model fidelity to team organization principles was also associated with reduced hospitalization. Low caseloads and specified ACT staffing, however, had no effect at all on outcome. 'Ordinary CMHTs' share most of the organizational aspects of ACT and appear to deliver equal outcomes with much reduced resources. The value of investing in high fidelity ACT teams must, therefore, be in doubt.

Community treatment orders: how ethical without experimental evidence?

Compulsory community treatment orders are a feature of most advanced mental health systems without convincing experimental evidence of benefits. Is it ethical to continue without such evidence ? This paper argues that the responsibility for ensuring it is collected lies as much with Parliament as with researchers.

Schizophrenia

Schizophrenia is still one of the most mysterious and costliest mental disorders in terms of human suffering and societal expenditure. Here, we focus on the key developments in biology, epidemiology, and pharmacology of schizophrenia and provide a syndromal framework in which these aspects can be understood together. Symptoms typically emerge in adolescence and early adulthood. The incidence of the disorder varies greatly across places and migrant groups, as do symptoms, course, and treatment response across individuals. Genetic vulnerability is shared in part with bipolar disorder and recent molecular genetic findings also indicate an overlap with developmental disorders such as autism. The diagnosis of schizophrenia is associated with demonstrable alterations in brain structure and changes in dopamine neurotransmission, the latter being directly related to hallucinations and delusions. Pharmacological treatments, which block the dopamine system, are effective for delusions and hallucinations but less so for disabling cognitive and motivational impairments. Specific vocational and psychological interventions, in combination with antipsychotic medication in a context of community-case management, can improve functional outcome but are not widely available. 100 years after being so named, research is beginning to understand the biological mechanisms underlying the symptoms of schizophrenia and the psychosocial factors that moderate their expression. Although current treatments provide control rather than cure, long-term hospitalisation is not required and prognosis is better than traditionally assumed.

End of the road for treatment-as-usual studies?

Using treatment as usual (TAU) in trials has obscured the repeated finding that assertive outreach has never reduced hospitalisation when compared with treatment by multidisciplinary teams (community mental health teams, CMHTs). Its use has delayed recognising that CMHTs are the more cost-effective, evidence-based approach. The term should be abandoned and trials should compare two equally well-defined services.

Connecting patient needs with treatment management

OBJECTIVE

To propose ideas for the development of a core strategy for monitoring patients with schizophrenia to ensure physical health and optimal treatment provision.

METHOD

A panel of European experts in the field of schizophrenia met in Bordeaux in June 2006 to discuss, 'Patient management optimisation through improved treatment monitoring.'

RESULTS

Key consensus from the discussion deemed that weight gain, oral health and ECG parameters were core baseline parameters to be monitored in all patients with schizophrenia. Further, an identification of a patient's own barriers to treatment alongside local health service strategies might comprise elements of an individualised management strategy which would contribute to optimisation of treatment. Any monitoring strategy should be kept simple to encourage physician compliance.

CONCLUSION

A practical solution to the difficulties of providing holistic patient care would be to suggest a limited set of physical parameters to be monitored by physicians on a regular basis.

Schizophrenia treatment: content versus delivery

OBJECTIVE

To review the evidence supporting the importance of ensuring that patients with psychiatric disorders receive an optimal and appropriate level of non-pharmacological treatment, and how Assertive Community Treatment (ACT) may be able to contribute to this aim.

METHOD

Analysis of data from selected individual published studies on ACT, in addition to reviews from the Cochrane Library, and other study groups.

RESULTS

Treatment management using ACT appears to offer benefits in terms of reduction in hospitalisation, although there is some debate as to whether this is the most representative outcome measure. Preliminary indications using remission as an outcome measure have also shown promising results in favour of ACT.

CONCLUSION

While further investigation and validation are necessary, current data indicate that ACT may be an appropriate strategy to facilitate the delivery of treatment to patients with psychotic disorders.

Individual Placement and Support in Europe: the EQOLISE trial

BACKGROUND

Individual Placement and Support (IPS) has been demonstrated to increase return to open employment significantly in individuals with mental health problems in the USA. Previous experience (e.g. with assertive community treatment) has demonstrated the sensitivity of complex community mental health interventions to local social and healthcare cultures. Europe has conditions of generally greater employment security than the USA, and varying (generally higher) unemployment rates and welfare benefits. Evidence of the effectiveness of IPS in these conditions, and its potential variation across them, would guide local policy and provide possible insights into its mechanism.

METHODS

We conducted a randomized controlled trial of IPS versus high-quality train-and-place vocational rehabilitation in six European centres with very different labour market and health and social care conditions. A sample of 312 individuals with psychotic illness was randomly allocated (50 per site). Inclusion criteria were a minimum of two years illness duration, with at least one year of continuous unemployment and six months contact with their current mental health services. Follow-up was 18 months. The primary outcome was any open employment, and secondary outcomes included time to employment, duration of employment and hospital admission.

FINDINGS

IPS was more effective than the vocational services for all vocational outcomes. 85 IPS patients (54.5%) worked for at least one day compared to 43 vocational service patients (27.6%). They were significantly less likely to have been rehospitalized. Local unemployment rates explained a significant amount of the variation in IPS effectiveness and both national economic growth and welfare systems influenced overall employment rates in both services.

CONCLUSIONS

IPS doubles the access to work of people with psychotic illnesses, without any evidence of increased relapse. Its effectiveness is not independent of external circumstances, particularly local unemployment rates.

Community treatment orders are not a good thing

Does politicians' enthusiasm for community treatment orders lie primarily in the area of public protection? If so, can such orders reduce homicide rates? Is there adequate evidence of their value, given their adverse effects on individual liberty? This well-researched and provocative debate will enlighten readers on these and many more of the complicated questions surrounding this issue.

Hospitalisation as an outcome measure in schizophrenia

BACKGROUND

People with schizophrenia comprise the majority of patients with severe mental illness recruited to recent mental health service studies of new teams (e.g. assertive outreach, crisis resolution). Reduction in hospitalisation has been the most consistent outcome measure in these studies, but results are inconsistent.

AIMS

To understand inconsistency of results from studies using hospitalisation as an outcome measure.

METHOD

The advantages and disadvantages of hospitalisation are explored, including the ways in which it is recorded. Regional variation in outcomes and the impact of control services are reviewed.

RESULTS

Hospitalisation has face validity as an outcome but translates poorly between differing healthcare contexts. These variations can be exploited positively to distinguish potentially effective ingredients in community care (outreach, combined health and social care, team structure) from redundant components.

CONCLUSIONS

Hospitalisation is a good proxy outcome measure in schizophrenia care in randomised controlled trials, but the dangers of extrapolating to new contexts require care.

Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression

OBJECTIVES

To explain why clinical trials of intensive case management for people with severe mental illness show such inconsistent effects on the use of hospital care.

DESIGN

Systematic review with meta-regression techniques applied to data from randomised controlled trials.

DATA SOURCES

Cochrane central register of controlled trials, CINAHL, Embase, Medline, and PsychINFO databases from inception to January 2007. Additional anonymised data on patients were obtained for multicentre trials.

REVIEW METHODS

Included trials examined intensive case management compared with standard care or low intensity case management for people with severe mental illness living in the community. We used a fidelity scale to rate adherence to the model of assertive community treatment. Multicentre trials were disaggregated into individual centres with fidelity data specific for each centre. A multivariate meta-regression used mean days per month in hospital as the dependent variable.

RESULTS

We identified 1335 abstracts with a total of 5961 participants. Of these, 49 were eligible and 29 provided appropriate data. Trials with high hospital use at baseline (before the trial) or in the control group were more likely to find that intensive case management reduced the use of hospital care (coefficient -0.23, 95% confidence interval -0.36 to -0.09, for hospital use at baseline; -0.44, -0.57 to -0.31, for hospital use in control groups). Case management teams organised according to the model of assertive community treatment were more likely to reduce the use of hospital care (coefficient -0.31, -0.59 to -0.03), but this finding was less robust in sensitivity analyses and was not found for staffing levels recommended for assertive community treatment.

CONCLUSIONS

Intensive case management works best when participants tend to use a lot of hospital care and less well when they do not. When hospital use is high, intensive case management can reduce it, but it is less successful when hospital use is already low. The benefits of intensive case management might be marginal in settings that have already achieved low rates of bed use, and team organisation is more important than the details of staffing. It might not be necessary to apply the full model of assertive community treatment to achieve reductions in inpatient care.

Using activity data to explore the influence of case-load size on care patterns

BACKGROUND

A limited case-load size is considered crucial for some forms of intensive case management and many countries have undertaken extensive reorganisation of mental health services to achieve this. However, there has been limited empirical work to explore this specifically.

AIMS

To test whether there is a discrete threshold for changes in intensive case management practice determined by case-load size.

METHOD

"Virtual" case-load sizes were calculated for patients from their actual contacts over a 2-year period and were compared with the proportions of contacts devoted to medical and non-medical care (as a proxy for a more comprehensive service model).

RESULTS

There were 39 025 recordings for 545 patients over 2 years, with a mean rate of contacts per full-time case manager per month of 48 (range 35-60). There was no variation in the proportion of non-medical contacts when case-load sizes were over 1:20 but there was a convincing linear relationship when sizes were between 1:10 and 1:20.

CONCLUSIONS

Case-load size between 1:10 and 1:20 does affect the practice of case management. However, there is no support for a paradigm shift in practice at a discrete level.

An observational, "real life" trial of the introduction of assertive community treatment in a geographically defined area using clinical rather than service use outcome criteria

INTRODUCTION

Assertive outreach methods of service delivery hold promise, but have been evaluated mostly in the context of short-lived experiments of limited sustainability and a focus on service use outcomes. The aim of the current investigation was to conduct an observational, "real life", pre-post comparison of the introduction of assertive outreach in a geographically defined area using clinical rather than service use outcome criteria.

METHOD

Assertive outreach was implemented in 2002 in a catchment area of 250,000, where cumulative routine outcome measurements had been in place since 1998. Clinical outcome, defined as making a transition to meeting the recently introduced remission criterion, was compared for two non-overlapping cohorts of patients treated in the period 1998-2001 and in the period 2002-2005.

RESULTS

The proportion of patients that made the transition to remission increased from 19% in the period before the introduction of assertive outreach, to 31% in the period after (OR = 2.21, 95% CI 1.03-4.78).

CONCLUSION

Assertive outreach in real life routine clinical practice brings about detectable changes in clinical outcome. ACT may bring improvement to the lives of patients living in countries characterised by fragmented and hospital-based mental health services.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

De-constructing home-based care for mental illness: can one identify the effective ingredients?

OBJECTIVE

Home-based care for severe mental illness has been the focus of intense research over the last 30 years and has produced mixed results. Replications of Assertive Community Treatment (ACT) in Europe have consistently failed to find these differences and various explanations have been advanced for this.

METHOD

Studies were compared in context of health care, and then identifying and rating the components of the differing teams rather than simply their designation. Cluster analysis was used for the identification of common service characteristics and regression analysis to test for correlation with reduction in hospitalization.

RESULTS

The nature of the control service may significantly explain the international variation in results. Six regularly occurring features of experimental services were identified from the examination of the components - smaller case loads, regularly visiting at home, a high percentage of contacts at home, responsibility for health and social care, multidisciplinary teams and a psychiatrist integrated in the team. Two of these, regularly visiting at home and responsibility for health and social care, are significantly associated with a reduction in hospitalization.

CONCLUSIONS

It is premature to define an optimal configuration for home based care services. The need for introducing differing components of such care will depend on what is currently available locally. Where regular home visiting to psychotic patients plus a broad service model incorporating health and social care objectives are provided, major reductions in in-patient care are not currently to be anticipated by service re-configurations.

Access to mental health supports in England: crisis resolution teams and day services

Access to health care is a complex issue with multiple supply and demand side facets. Here just two issues are explored; the potential for access through availability and the actual access made as indicated by utilisation rates. These perspectives are explored for two mental health services, crisis resolution teams and day hospitals, both of which are recommended components for a comprehensive local mental health care service in England. The geographical spread of these services is considered alongside the level of provision and the extent of their use. Associations between availability and needs, and between use and needs are tested. Tracking resources from funding allocations to provision is also complex and issues around resource allocation are discussed.

Is it possible to carry out high-quality epidemiological research in psychiatry with limited resources?

PURPOSE OF REVIEW

This review covers the epidemiological research from developing countries to identify the scope of research in the various aspects of epidemiology and the strengths of research. The period covered is June 2004 to June 2005. The literature survey used searches of Medline, key psychiatric journals and personal correspondence with leading psychiatric researchers from developing countries.

RECENT FINDINGS

There is a new interest in epidemiological studies in developing countries. These studies have been driven by three factors, namely international collaboration; specific situations like disasters, terrorism and severe acute respiratory syndrome; and international attention to specific topics like maternal depression. There is limited long-term research on specific conditions. There are a number of leads suggesting local social-cultural factors contribute to the distribution of psychiatric problems. Child psychiatry continues to be low in priority. There is also lack of research in areas such as personality disorders and organic psychiatric disorders.

SUMMARY

It is possible to carry out high quality epidemiological research in developing countries. Such research has provided new insights into the distribution, causation, course and outcome of mental disorders. There is need for greater attention to the development of epidemiological assessment tools to suit local conditions. Specific centers/institutions developing long-term research interests on specific subjects would be valuable for future efforts. There is also need to widen the conditions to be studied.