Are small case-loads beautiful in severe mental illness?

The evidence-based group-level symptom-reduction model as the organizing principle for mental health care: time for change?

The content and organization of mental health care have been heavily influenced by the view that mental difficulties come as diagnosable disorders that can be treated by specialist practitioners who apply evidence-based practice (EBP) guidelines of symptom reduction at the group level. However, the EBP symptom-reduction model is under pressure, as it may be disconnected from what patients need, ignores evidence of the trans-syndromal nature of mental difficulties, overestimates the contribution of the technical aspects of treatment compared to the relational and ritual components of care, and underestimates the lack of EBP group-to-individual generalizability. A growing body of knowledge indicates that mental illnesses are seldom "cured" and are better framed as vulnerabilities. Important gains in well-being can be achieved when individuals learn to live with mental vulnerabilities through a slow process of strengthening resilience in the social and existential domains. In this paper, we examine what a mental health service would look like if the above factors were taken into account. The mental health service of the 21st century may be best conceived of as a small-scale healing community fostering connectedness and strengthening resilience in learning to live with mental vulnerability, complemented by a limited number of regional facilities. Peer support, organized at the level of a recovery college, may form the backbone of the community. Treatments should be aimed at trans-syndromal symptom reduction, tailored to serve the higher-order process of existential recovery and social participation, and applied by professionals who have been trained to collaborate, embrace idiography and maximize effects mediated by therapeutic relationship and the healing effects of ritualized care interactions. Finally, integration with a public mental health system of e-communities providing information, peer and citizen support and a range of user-rated self-management tools may help bridge the gap between the high prevalence of common mental disorder and the relatively low capacity of any mental health service.

A comparison of the implementation of assertive community treatment in Melbourne, Australia and London, England

AIMS

The efficacy of Assertive Community Treatment (ACT) is well established in the USA, and to a lesser extent in Australia, whereas UK studies suggest little advantage for ACT over usual care. Implementation of ACT varies and these differences may explain variability in reported efficacy. We aimed to investigate differences in ACT implementation between Melbourne, Australia and London, UK.

METHODS

In a cross-sectional survey, we investigated team organisation, staff and client characteristics from four Melbourne ACT teams using almost identical methods to the Pan London Assertive Outreach studies of 24 ACT teams.

RESULTS

Client characteristics, staff satisfaction and burnout were very similar. Three of four Melbourne teams made over 70% of client contacts 'in vivo' compared to only one-third of comparable London teams, although all teams were rated as 'ACT-like'. Melbourne teams scored more highly on team approach. Three quarters of clients were admitted in the preceding 2 years but Melbourne clients had shorter stays.

CONCLUSIONS

Differences in the implementation of 'active components' of home treatment models that have been associated with better client outcomes (home visiting, team approach) may explain international differences in ACT efficacy. Existing fidelity measures may not adequately weight these important elements of the model.

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.

Initial Assessment and Eligibility for Secondary Care Mental Health Services: Not a Simple Equation

This paper identifies the challenges of interpreting and implementing appropriate eligibility criteria and assessment processes in adult mental health services, with reference to an inner‐city Trust's own protocols. Central guidance, local interpretation and professional judgment are all legitimate contributions, but also confound both the concept and processes of entry to service.

Why are programmes for offenders with personality disorder not informed by the relevant scientific findings?

This paper examines the evidence to justify intervening in those with personality disorder, specifically antisocial personality disorder (ASPD) as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association 1994). The evidence from randomized controlled trials in the mental health literature is reviewed and found to be deficient with only five trials satisfying Cochrane criteria, all of which had a reduction in substance misuse as their primary outcome, rather than a change in the personality disorder per se.Next, I consider the contribution of Thomas Kuhn to explain why it is difficult to develop a scientific basis in forensic mental health. I argue that, because forensic mental health is inclusive in its purpose (interacting with the law, social services and the penal system, all of which have different rules and agendas), it is difficult to develop a consensus on fundamentals, this consensus being a hallmark of a science.Finally, I argue that despite the absence of evidence from mental health, providers for ASPD are in a fortunate position in being able to draw upon the correctional literature. This is relevant, provided that we agree that a reduction in offending is the primary outcome. While mental health can learn much from correctional practice, it can also enhance the efficacy of the latter by, for instance, drawing attention to the specific vulnerabilities of the personality structure that might impede programme delivery in correctional settings. Means of achieving a conjunction of mental health and correctional practice are urgently required as this would be beneficial to both.

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.

Systematic review of case management

The purpose of the present paper was to review the current state of evidence for types of case management, focusing on the last 10 years since publication of the Cochrane Systematic Reviews of case management and assertive community treatment. A literature review of electronic databases from 1995 to the present to identify recent research on psychiatric case management, both original studies and reviews, was carried out. Original articles were organized on basis of year of study, experimental group and outcome variables to determine patterns. Sixty relevant papers were located. Thirty-nine are reports of experimental trials of types of case management and 21 are reviews or discussion papers. The focus of research is on assertive community treatment or intensive case management, with only five papers on other forms of less intense case management. Numerous outcomes have been examined, of those examined often enough to draw meaningful conclusions only one, engagement with services, has been consistently positive. All other outcomes have produced mixed results. The strength of findings in favour of case management has weakened over time. A heterogeneous group of experimental designs limits comparisons. Numerous issues with methodology and definitions of types of case management have beset research in this field. Assertive types of case management (including assertive community treatment and intensive case management) are more effective than standard case management in reducing total number of days spent in hospital, improving engagement, compliance, independent living and patient satisfaction. More important than the type of service configuration is to understand the clinical criteria of the services provided and their effectiveness.

Psychosocial treatment in the 21st century

Over the past 50 years, psychosocial treatment has played an increasingly prominent role in helping persons with mental illness live in communities rather than in institutions. This paper briefly reviews evidence for and discusses three forms of treatment-assertive community treatment, supported employment, and cognitive behavior treatment-which have been studied extensively and are widely accepted as effective interventions. Forces are discussed that have shaped these and other psychosocial treatment over the past five decades. Despite the accumulated evidence, many questions remain about the cost-effectiveness and applicability of these treatments in specific populations and service environments. The development of these and other treatments has been, and continues to be, shaped by concerns about rising health care costs, a heightened emphasis on evidence-based treatment and by consumers taking a more active role in determining the services, and outcomes that are most helpful to them.

An exploratory study of assertive community treatment for people with intellectual disability and psychiatric disorders: conceptual, clinical, and service issues

BACKGROUND

Assertive community treatment (ACT) has been applied to a number of disorders in the adult population, such as schizophrenia, with some degree of success; its use in the treatment of people with intellectual disability (ID) and mental illness has received little attention. Despite the high costs of ID in health and social care, there has been very little evidence-based practice for people with ID and mental illness, and it remains a neglected area of research. Aims The aims of this study were an exploratory comparison of the effectiveness of an ACT model for the treatment of mental illness in people with ID (ACT-ID) with a standard community treatment (SCT-ID) approach.

METHOD

A Randomized controlled trial design was adopted and allocation was made by stratified randomization by an independent statistician. The prognostic factors used in the randomization were gender and psychiatric diagnosis (psychosis vs. affective). Service users were randomly allocated to either ACT-ID or SCT-ID.

RESULTS

There were no statistically significant differences between ACT-ID and SCT-ID in terms of the level of unmet needs, carer burden, functioning and quality of life, but borderline evidence of a difference between treatment groups in quality of life in favour of SCT-ID. Both SCT-ID and ACT-ID groups decreased level of unmet needs and carer burden, and increased functioning. SCT-ID also led to a small increase in quality of life.

„Home treatment“ für psychische Erkrankungen

A number of projects have used home treatment (HT) for severely mentally ill people in recent years. This paper intends to define HT and show the main differences between it and other forms of psychiatric community service, present the existing evidence for HT, and discuss eligibility criteria. Studies about HT's efficacy in treating severely mentally ill adults were identified by electronic (MEDLINE, PsycLIT) and manual search. Six studies met these inclusion criteria. Compared to inpatient treatment, HT was equally or more efficacious in respect to reduction of symptom distress, social (re-)integration, and patient and carer satisfaction. Furthermore, direct costs for HT were often lower than for inpatient care. However, the number of relevant studies is limited and knowledge on the long-term effects of HT is sparse.

Assertive community treatment of the mentally ill: service model and effectiveness

OBJECTIVE

To provide a description of the service delivery model of an assertive community treatment (ACT) team in the management of a group of severely mentally ill patients and examine the effectiveness of this team in reducing readmissions to a psychiatric inpatient service.

METHOD

A clinical case audit was performed on a single day in September 2001. Admission episodes and duration were collected for patients registered with the team in the 12 month period prior to ACT and for a period of 12 months ending on the day of the audit. Forty-three patients were registered with the team at the time of data collection. The majority (79%) were diagnosed with schizophrenia and there were high rates of comorbidity (76%) and disability (mean Global Assessment of Functioning score 45.9). The main outcome measures were the number of readmissions and readmission days before and after the institution of ACT.

RESULTS

The mean number of readmission days reduced from 70.9 to 10.2 (p<0.05) following the institution of ACT.

CONCLUSION

Assertive community treatment conducted in a naturalistic clinical environment is effective in significantly reducing the number of readmission days in a group of patients suffering from long-term and persistent severe mental illness.

Assessing the value of assertive outreach. Qualitative study of process and outcome generation in the UK700 trial

BACKGROUND

It is unclear why intensive case management (ICM) failed to reduce hospitalisation in the UK700 trial.

AIMS

To investigate outcome generation in the UK700 trial.

METHOD

A qualitative investigation was undertaken in one UK700 centre.

RESULTS

Both intensive and standard case management practised individual casework, employed assertive outreach with comparable frequency, and performed similarly in the out-patient management of emergencies and in-patient discharge. However, ICM was advantaged in managing some non-compliance and undertaking casework that prevented psychiatric emergencies. Absence of team-based management and bureaucratised access to social care limited the impact of these differences on outcomes and the effective practice of assertive outreach, although this was relevant to only a sub-population of patients.

CONCLUSIONS

The impact of ICM was undermined by organisational factors. Sensitive anticipatory casework, which prevents psychiatric emergencies, may make ICM more effective than an exclusive focus on assertive outreach. Our findings demonstrate the value of qualitative research in evaluating complex interventions.

Improving the vocational status of patients with long-term mental illness: a randomised controlled trial of staff training

OBJECTIVE

To investigate the impact of training CMHT members in the practice of Individual Placement and Support on the vocational status of long-term patients.

METHOD

Six CMHTs received vocational training by a work co-ordinator; four continued with standard care. The best vocational status of the 1037 subjects was ascertained after one year. Factors associated with improvement in vocational status were identified.

RESULTS

There was no difference in change of vocational status. Age, previous employment and diagnosis influenced outcome.

CONCLUSION

Training in IPS at team level did not improve employment status. A dedicated, vocational worker appears to be essential for successful IPS.

Case management models and the care programme approach: how to make the CPA effective and credible

The care programme approach (CPA), a form of case management, is a key mental health policy in England. Yet after over 10 years, it remains poorly and unevenly implemented with few benefits for service users, carers or mental health staff. This paper reviews the wider literature on case management and identifies and considers the principal models that might have informed the development of the CPA. After discussing the evidence for each of the clinical, strengths, intensive and assertive case management models, the paper identifies the key components that appear to be central to effective case management across these models. These components are then considered in relation to the CPA. It is argued that the CPA has been undermined by a failure to incorporate and build on certain important features of the major models of case management. The paper concludes by suggesting the key developments required to make the CPA more effective and to underpin the policy with a unifying philosophy while endorsing it with much needed credibility among both clinicians and service users.

Clinical and social changes in severely mentally ill individuals admitted to an outpatient psychosis team: an 18-month follow-up study

AIM

The study investigated clinical and social changes during an 18-month follow-up period in a group (n = 76) of schizophrenic outpatients admitted to a newly implemented outpatient psychosis team. Changes related to level of contact with the psychosis team were also examined as well as aspects of the content of the treatment interventions and work situation from a staff perspective.

METHODS

Structured face-to-face interviews with the patients were performed at baseline and after 18 months. The Camberwell Assessment of Need instrument, the Lancashire Quality of Life Profile and the Interview Schedule for Social Interaction were used on both interview occasions along with Global Assessment of Functioning Scale and Brief Psychiatric Rating Scale. Thematic open-ended questions were used in staff interviews.

RESULTS

Psychiatric symptoms, number of needs and number of met needs decreased, and perceived quality of life improved for the total sample during the follow-up period. Patients only in contact with a psychiatrist in the psychosis team improved more in symptoms and spent fewer days in hospital during follow-up time compared with those who had combined psychiatric and supportive contacts, and were also more satisfied with their medication. Patients with a combined contact deteriorated in psychosocial functioning compared with the group only in contact with a psychiatrist. Some of the elements in treatment interventions and work situation as well as hindrances in providing community-based care adapted to the patients' needs were identified.

CONCLUSIONS

Community-based psychiatric services, to a larger extent, need to embrace evidence-based interventions and to perform regular, structured and comprehensive need assessments in order to ensure the effectiveness of interventions. Attention should be paid to staff motivation and education as well as to providing practical guidelines, supervision and support.

Assertive community treatment across the Atlantic: comparison of model fidelity in the UK and USA

BACKGROUND

The significant reductions in hospital admission demonstrated in US assertive community treatment (ACT) studies have not been replicated in the UK. Explanations cite poor UK 'model fidelity' and/or better UK standard care. No international model-fidelity comparisons exist.

AIMS

To compare high-fidelity US ACT teams with a UK team.

METHOD

The UK 700's ACT team (n=97) was compared with high-fidelity US ACT teams (n=73) by using two measures: a forerunner of the Dartmouth Assertive Community Treatment schedule (to assess adherence to ACT principles) and 2-year prospective activity data.

RESULTS

The UK and US teams had similar high-fidelity scores. Although significant differences were found in the amount and type of activity, practice differences in areas central to ACT were not great.

CONCLUSIONS

The failure of UK ACT studies to demonstrate the outcome differences of early US studies cannot be attributed entirely to the lack of ACT fidelity.

International differences in home treatment for mental health problems. Results of a systematic review

BACKGROUND

It is perceived that North American home treatment studies reveal greater success in reducing days in hospital than do European studies. There are difficulties in extrapolating findings internationally.

AIMS

We aimed to determine whether North American studies find greater reductions in days in hospital and whether experimental service patients in North American studies spend less time in hospital.

METHOD

The results of a systematic review were analysed with respect to study location. Service components ascertained through follow-up were utilised to interpret the meta-analyses conducted.

RESULTS

Most of the 91 studies found were from the USA and UK. North American studies found a difference of one hospital day (per patient per month) more than European studies but there was no difference in experimental data between the two locations.

CONCLUSIONS

North American studies demonstrate greater differences in days in hospital but patients in their experimental services seem to spend no fewer days in hospital, implying a disparity in control services.

Mental health service provision in England

OBJECTIVE

To describe mental health service provision for adults of working age in England.

METHOD

Services in an inner London area are described so as to illustrate current patterns of service organization in England. National trends are then discussed.

RESULTS

Despite relatively low public expenditure, substantial progress has been made in deinstitutionalization and development of comprehensive community-based services. Persisting difficulties include high staff turnover, a minority of patients. who do not engage with community services, user and carer dissatisfaction with emergency services, and social exclusion because of stigma. Recent government policy advocates resolving some of these problems using new service models such as assertive outreach and crisis teams.

CONCLUSION

Closure of the large asylums has largely been accomplished. England is now entering a new phase in community service development, with a range of innovative developments aimed at resolving problems still encountered after the initial phases of integrated community service development.

Case management: an update

BACKGROUND

Case management in its various forms represents a major innovation in mental health care. Its efficacy remains controversial.

AIMS

To update after a decade a previous review article (Holloway, 1991).

METHODS

Descriptive literature and controlled trials of case management and its derivative Assertive Community Treatment (ACT) was accessed through four comprehensive and systematic reviews of the literature, repeated Medline and Embase searches and personal contacts.

RESULTS AND CONCLUSIONS

The concept of case management has continued to evolve over the past decade. No controlled trial has been published exploring the model of the case manager as a service broker without responsibility for the provision of care. Basic case management principles have frequently been incorporated within routine clinical practice. Published controlled trials of ACT, which were almost exclusively carried out in North America, have shown markedly positive results. However caution is required in extrapolating these findings to routine clinical practice within different systems of health and social care. Case management is not in itself an effective treatment for severe mental illness.