Effectiveness of intensive treatment in severe mental illness

Predicting outcome of assertive outreach across England

BACKGROUND

Assertive community treatment for the severely mentally ill is being implemented increasingly internationally. It is unclear whether recommended characteristics of assertive outreach (AO) teams influence care and outcomes. We hypothesised that recommended characteristics of AO teams such as joint health and social care management would predict reduced hospitalisation in the first year of an AO client programme and related outcomes throughout England.

METHODS

A two-stage design was used: a stratified sample of 100 of the 186 'stand-alone' AO teams in England and a systematic sample of clients from each team with stratification for black and ethnic minority patients. Team characteristics, treatment and outcomes were collected from teams. Analyses took account of patients' histories, clustering and ethnic minority over-sampling.

RESULTS

Under AO the proportion of time spent in hospital following admission decreased. Only 3/1,096 patients went missing in 9 months. Although patient' histories significantly predicted outcomes almost no team characteristics predicted re-admission or other patient outcomes after 1 and 3 years. Ethnic minority clients were more likely to be on compulsory orders only on jointly managed teams (P = 0.030). Multidisciplinary teams and teams not working out of hours significantly predicted that patients received psychological interventions, but only 17% of sampled patients received such treatments.

CONCLUSIONS

Characteristics of AO teams do not explain long-term patient outcomes. Since recommended team characteristics are not effective new models of care should be developed and the process of care tested. Managing teams to implement evidence-based psychological interventions might improve outcomes.

The future of specialist community teams in the care of those with severe mental illness

Aims – Specialist interventions in community psychiatry for severe mental illness are expanding and their place needs to be re-examined. Methods – Recent literature is reviewed to evaluate the advantages and disadvantages of specialist teams. Results – Good community mental health services reduce drop out from care, prevent suicide and unnatural deaths, and reduce admission to hospital. Most of these features have been also demonstrated by assertive community outreach and crisis resolution teams when good community services are not available. In well established community services assertive community teams do not reduce admission but both practitioners and patients prefer this service to other approaches and it leads to better engagement. Crisis resolution teams appear to be more successful than assertive community teams in preventing admission to hospital, although head- to-head comparisons have not yet been made. All specialist teams have the potential of fragmenting services and thereby reducing continuity of care. Conclusions – The assets of improved engagement and greater satisfaction with assertive, crisis resolution and home treatment teams are clear from recent evidence, but to improve integration of services they are probably best incorporated into community mental health services rather than standing alone.

Declaration of Interest: The author has been the sole consultant in two assertive outreach teams since 1994 and might there- fore be expected to be in favour of this genre of service. He has received grants for evaluation of different services models from the Department of Health (UK) and the Medical Research Council (UK).

Reducing 30-day inpatient psychiatric recidivism and associated costs through intensive case management

PURPOSE OF THE STUDY

Intensive case management (ICM) holds promise in reducing 30-day inpatient psychiatric recidivism and associated costs. The purpose of this study is to determine the impact of ICM on 30-day inpatient psychiatric recidivism and associated costs among adult health plan members at elevated risk of psychiatric hospitalization.

PRIMARY PRACTICE SETTING

Psychiatric settings.

METHODOLOGY AND SAMPLE

An intent-to-treat, historical control design was used to examine utilization differences between 305 intervention group members eligible to receive ICM services and a cohort of 347 baseline group members identified retrospectively using identical criteria during a similar 1-year time period before implementation of the ICM program.

RESULTS

The 30-day recidivism rate for baseline group members was 29.11% as compared with 8.52% among intervention group members. Logistic regression results indicated a significant main effect for the ICM intervention. Inpatient psychiatric costs for the 30-day outcome period were on $1,528.91 lower per member in the intervention group. Regression results indicated a main effect for the ICM intervention. Program costs were estimated at $41.39 per member.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The ICM intervention was associated with significant reductions in inpatient, psychiatric 30-day readmission rates, and associated costs among adult members who are at elevated risk of inpatient, psychiatric recidivism. The intervention, enrollment process, and measurement strategies can be adapted for use by case managers in a variety of different settings.

Perceptions of assertive community treatment in the UK and Lithuania

BACKGROUND

There is current uncertainty over the future of assertive community and outreach teams in view of recent evidence suggesting that they no longer reduce hospital admissions. Despite this, assertive teams remain popular among practitioners.

AIMS

To examine the views of assertive community team members and other mental health professionals in London (UK) and Vilnius (Lithuania) to determine important differences in attitudes.

METHOD

A questionnaire, involving the assessment of statements giving common opinions on assertive community teams, was given to 62 staff in Vilnius, Lithuania and West London, UK, 33 from assertive community or outreach teams and 29 from other mental health professionals.

RESULTS

The results of the questionnaire showed that personnel in experienced assertive outreach teams in London believed that they gave more intensive care (p < 0.001), felt it of greater value to see patients in the community (p < 0.001) and were not just well-resourced community teams with low caseloads (p < 0.01) than did other groups, but they placed lower value on assertiveness (p = 0.04) and comprehensive care (p < 0.04). These differences were less marked in Lithuania where staff regarded home treatment as similar to clinic treatment and were more supportive of comprehensive care.

CONCLUSION

The results suggest that in experienced community teams the notion of assertiveness has become less important in planned intensive community care and so the term ACT may be outmoded. However, for countries such as Lithuania, somewhat similar to the United States in 1972 when ACT began, the original principles are still appropriate and 'assertive' is a major component of their effectiveness.

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.