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

The Relationship Between Psychological Quality Education and Mental Health Level of College Students by Educational Psychology

To enable all college students to have positive psychological quality and sound personalities, their potential should be fully realized, and their comprehensive ability should be improved to adapt to society. Empirical research is carried out by means of questionnaires, and the relationship between psychological quality education and the mental health level of college students is studied through correlation analysis and regression analysis. Firstly, the problems existing in college students’ psychological quality education are summarized from the perspective of educational psychology through questionnaires. Secondly, the data of college students’ psychological quality education and mental health level are collected, and the general situation and the relationship between college students’ psychological quality education and mental health level are analyzed and discussed by processing the existing data. The research results show that 51% of college students think that psychological quality education is only needed when there is a psychological problem; 47% of college students believe that the current educational content of the school’s psychological quality education focuses on the prevention and solution of students’ psychological problems; 83% of the students consider that the psychological quality education currently carried out by the college still adopts the more traditional teaching methods such as classroom lectures, psychological counseling and special lectures. In the process of predicting college students’ mental health level, psychological resilience plays a significant role, which can predict 21.1% of variables. Psychological resilience and optimism can jointly predict 26.4% of variables. These contents broaden the research field of college students’ psychological quality education, enrich the related research on it, and provide a reference for the intervention of college students’ psychological health in school situations.

Research on the Intervention Countermeasures and Mental Health Status of College Music Teachers from the Perspective of Positive Psychology

The goal of education is to train people who are well-rounded and educate people with heart through teachers and determine the direction for the growth of life. Psychological education is one of the top ten education systems in colleges and universities. The psychological health of college teachers is the key to teaching and education. Colleges and universities attach great importance to teachers' educational level and scientific research achievements, pay attention to teachers' instrumental value, and pay little attention to teachers' mental health. Therefore, this study aims to study the mental health status and prevention measures of college music teachers from the perspective of positive psychology. By combining the qualitative method with the quantitative method, this study carries out questionnaire survey and interview on “mental health” of music teachers in four universities and then puts forward relevant intervention countermeasures. Research shows that only one-fifth of the teachers believed that they had received psychological counseling from the school and successfully solved their own problems; nearly 60% of music teachers said that the psychological counseling provided by the school lacked pertinence and professionalism, and lacked practical solutions to their own problems. This shows that the psychological intervention strategies adopted by Chinese colleges and universities for music teachers are far from the expected results.

The Positioning of Mental Health Education in Social Work under the Healthy China Strategy

In recent years, the world mental health movement has developed rapidly, and people are paying more and more attention to mental health. China has clearly put forward the major task of comprehensively promoting the construction of a Healthy China and building a Healthy China by 2035. However, in contrast, the research on mental health in Western countries started earlier than in my country, and for a long period of time, my country has followed the research results of Western mental health ideas. Every different culture has its own unique psychological content. Due to factors such as values, habitual behavior, region, and cultural background, it is necessary to deeply explore the mental health thought resources in Chinese culture and study the mental health thought in Chinese culture. It provides new directions and ideas for our country's psychological counseling and treatment, as well as mental health education and ideological and political education. This article starts from the basic concept of mental health education and sorts out the current research status at home and abroad. By analyzing the main ideas of mental health education work in the context of Healthy China, it explores the positioning of mental health education in social work, and finally, on the basis of strengthening the combination of Chinese culture and mental health thinking, making full use of localized mental health thought and applying it to practice, and drawing inspiration for the study of mental health thought in Chinese culture.

EPA guidance on the quality of mental health services

The main aim of this guidance of the European Psychiatric Association is to provide evidence-based recommendations on the quality of mental health services in Europe. The recommendations were derived from a systematic search of the best available evidence in the scientific literature, supplemented by information from documents retrieved upon reviewing the identified articles. While most recommendations could be based on empirical studies (although of varying quality), some had to be based on expert opinion alone, but were deemed necessary as well. Another limitation was that the wide variety of service models and service traditions for the mentally ill worldwide often made generalisations difficult. In spite of these limitations, we arrived at 30 recommendations covering structure, process and outcome quality both on a generic and a setting-specific level. Operationalisations for each recommendation with measures to be considered as denominators and numerators are given as well to suggest quality indicators for future benchmarking across European countries. Further pan-European research will need to show whether the implementation of this guidance will lead to improved quality of mental healthcare, and may help to develop useful country-specific cutoffs for the suggested quality indicators.

Improved Rehabilitation Outcomes for Persons With and Without Problematic Substance Use After 2 Years With Assertive Community Treatment-A Prospective Study of Patients With Severe Mental Illness in 12 Norwegian ACT Teams

Background: Persons with severe mental illness often face difficulties in accessing and receiving adequate services enabling them to live independently. Many have co-occurring substance use problems that increase the risk of adverse outcomes. Community-based service models have been implemented around the world, including assertive community treatment (ACT), but the knowledge of rehabilitation outcomes in different subgroups is limited. We aimed to explore rehabilitation outcomes among patients suffering severe mental illness with and without substance use problems who had received ACT services for at least 2 years. Additionally, we compared differences in changes between the two groups. Methods: A total of 142 patients who received services for 2 years from the first 12 Norwegian ACT teams were included. Eighty-four (59%) had problematic substance use, while 58 (41%) did not. Data regarding housing, activity, symptoms, functioning, and subjective quality of life were collected upon enrollment into ACT and at 2 years of follow-up. Clinician-rated scales and self-report questionnaires were used. Changes within the two groups and differences in change between the groups were assessed using generalized linear mixed models. Results: Both groups were more likely to have good housing, higher level of functioning, and less anxiety and depressive symptoms after 2 years. The odds of good housing among participants with problematic substance use increased only after adjusting for age and gender. Participants with problematic substance use had less severe symptoms, particularly negative and manic symptoms, while participants without problematic substance use reported improved satisfaction with life in general. Neither group experienced a change in having a meaningful daily activity, positive symptoms, practical and social functioning, or subjective quality of life. The reduction of manic symptoms in the substance use group was the only difference between the groups. Conclusion: After 2 years, patients with and without problematic substance use experienced improvements in several important domains. Furthermore, the improvements were similar in both groups for most outcomes. This may suggest that ACT has a place in the continued effort toward integrated and comprehensive community services empowering patients with severe mental illness to achieve and sustain an independent life, including marginalized groups with severe substance use.

Effectiveness of multidisciplinary psychiatric home treatment for elderly patients with mental illness: a systematic review of empirical studies

BACKGROUND

The vast majority of older people with mental illness prefer to live independently in their own homes. Barriers caused by the health care system often prevent adequate, adapted treatments. With regard to the increasing ageing of the population, the determination of effective, age-appropriate service models for elderly patients with mental illness is clearly required. The aim of this review is to examine and to evaluate multidisciplinary psychogeriatric treatment models that include home visits, particularly with regard to the effects on psychiatric symptoms, social and mental health rehabilitation and quality of life.

METHODS

A systematic review was carried out of empirical studies with participants who were diagnosed with a mental illness according to ICD-10, aged 60 years or older, and who were living at home. The inclusion criteria comprised a duration of intervention of at least 12 weeks and a minimum of two interventions and domiciliary visits delivered by a multidisciplinary team. The online databases Medline, PsychInfo, Web of Science, Cochrane Register of Controlled Trials, and Google Scholar, as well as hand search, were used to search for relevant studies published between 1996 and 2016. An additional search was performed for studies published between 2016 and 2019. After removing duplicates, abstracts were screened and the remaining articles were included for full-text review.

RESULTS

Of the 3536 records discovered in total, 260 abstracts appeared to be potentially eligible. Of these, 30 full-text articles were assessed for eligibility. For the additional search 415 records and abstracts were screened and 11 articles were read full text. Finally, only three studies fully met the inclusion criteria for this review. The results indicate that psychogeriatric home treatment is associated with significant improvements of psychiatric symptoms and psychosocial problems, fewer admissions to hospital and nursing homes, as well as lower costs of care.

CONCLUSIONS

Psychogeriatric home treatment has positive effects on older people with mental illness. However, these findings are based upon a small number of studies. The need for further research, especially to specify the effective factors in psychogeriatric home treatment, is clearly indicated.

Model fidelity and team members' experiences of assertive community treatment in Norway: a sequential mixed-methods study

Background

Assertive community treatment (ACT) is an evidence-based treatment for people with severe mental illness, and this model is used widely throughout the world. Given the various adaptations in different contexts, we were interested in studying the implementation and adaptation of the ACT model in Norway. The first 12 Norwegian ACT teams were established between 2009 and 2011, and this study investigated the teams' model fidelity and the team members' experiences of working with ACT.

Methods

To investigate implementation of the ACT model, fidelity assessments were performed 12 and 30 months after the teams started their work using the Tool for Measurement of Assertive Community Treatment (TMACT). Means and standard deviations were used to describe the ACT teams' fidelity scores. Cohen's effect size d was used to assess the changes in TMACT scores from the first to second assessment. Qualitative focus group interviews were conducted in the 12 teams after 30 months to investigate the team members' experiences of working with the ACT model.

Results

The fidelity assessments of the Norwegian teams showed high implementation of the structural and organizational parts of the ACT model. The newer parts of the model, the recovery and evidence-based practices, were less implemented. Four of the six subscales in TMACT improved from the first to the second assessment. The team members experienced the ACT model to be a good service model for the target population: people with severe mental illness, significant functional impairment, and continuous high service needs. Team members perceived some parts of the model difficult to implement and that it was challenging to find effective ways to collaborate with existing health and social services.

Conclusion

The first 12 Norwegian ACT teams implemented the ACT model to a moderate degree. The ACT model could be implemented in Norway without extensive adaptations. Although the team members were satisfied with the ACT model, especially the results for their service users, inclusion of the ACT team to the existing service system was perceived as challenging.

Psychiatric Home Hospitalization Unit of the Hospital del Mar. A crisis resolution and home treatment team in Barcelona

INTRODUCTION

Although home hospitalization has begun to develop widely in recent years there is a notable lack of studies. The following study includes data from the Psychiatric Home Hospitalization Unit of the Hospital del Mar (HADMar). This program has been running for 2years and takes place in a socio-demographically depressed area in Barcelona. It receives patients from community and hospital services. Monitoring is limited in time and at discharge patient are referred to the ambulatory unit.

MATERIAL AND METHODS

All patients visited from 2015 to the present time were selected. A total of 135 patients were included in the sample. A qualitative descriptive study was carried out in order to define the socio-demographic characteristics. The severity of symptoms, suicidal risk and changes in the functionality were considered as clinical outcomes.

RESULTS

The mean age of patients was 44.6 years and there were no gender differences. A total of 26 patients had a history of suicidal attempts and 11.1% lived alone; 51.1% were diagnosed with a psychotic disorder. The mean GEP score for the severity of the psychiatric symptoms was 2.39 and the mean risk of suicide was 0.49. There is an increase in the EEAG score from admission to discharge, which means an improvement in the functionality of patients.

CONCLUSIONS

The results obtained in our study are consistent with previous results. Home crisis intervention teams have proved to be an alternative to traditional hospitalization. However, more studies are needed to support these results.

Psychiatry in the future

The 1990s witnessed a strikingly accelerated rate of change in the structure and delivery of mental health care in the UK. The preceding 15 years had been marked, in my practice, by two inexorable processes which transformed the face of clinical psychiatry, but without the convulsive upheavals and discontinuities that we have come to live with since. The first was the running down and eventual closure of the large mental hospitals – a change so fundamental that it may be difficult for those trained recently to grasp just how different mental health care was then. The second was the internationalisation of research, and the growing influence of evidence and formal instruction as a determinant of practice, rather than simply relying on the consultants to whom one was apprenticed. For all the occasional criticisms of it, evidence-based medicine dominates modern psychiatry, and this is evident in the much greater consistency of practice than 30 years ago. The changes in the 1970s and early 1980s were essentially egosyntonic within the profession; the past 15 years have been more dramatic and less comfortable.

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.

Predictors of Clinical Outcome of Assertive Community Treatment (ACT) in a Rural Area in Denmark: An Observational Study with a Two-Year Follow-Up

Assertive Community Treatment (ACT) is a multidisciplinary team approach to community care treatment, mainly characterised by small caseload and individualised care. The aim of the present study was to identify predictors of clinical outcome in ACT using an observational design. Three ACT Teams were established in The North Denmark Region to treat patients with severe mental illness. The patients were identified and followed in regional and national psychiatric registers, and in social and somatic case registers, 2 years before and 2 years after inclusion. The results showed that the use of psychiatric hospital services decreased significantly for the 240 included patients. Furthermore, the psychopharmacological profile was improved. No significant change occurred in the consumption of the somatic hospitals. Clinical outcome, defined as halving of admissions or bed days, was in a logistic analysis predicted by the patient's psychiatric use of inpatient service prior to inclusion in an ACT Team.

Structures and processes necessary for providing effective home treatment to severely mentally ill persons: a naturalistic study

BACKGROUND

Home treatment for severely mentally ill persons is becoming increasingly popular. This research aims to identify structures and processes in home treatment that impact on patient-related outcomes.

METHODS

We analysed 17 networks that provide home treatment to severely mentally ill persons using a naturalistic approach. The networks were similar with regard to central components of home treatment such as case management, 24 h crisis hotline and home visits, but differed in all other aspects such as the multidisciplinary teams, time spent with patients, etc. To determine treatment outcome, patients' psychosocial functioning was measured using the Health of the Nation Outcome Scales (HoNOS). Structures and processes were assessed using claims data and questionnaires answered by the different networks. Primary outcome was highlighted by the change in HoNOS scores from the start of home treatment compared with 6 months later. We sought to explain this outcome through patient and network characteristics using regression analysis. Data on 3,567 patients was available.

RESULTS

On average, psychosocial functioning improved by 0.84 across networks between t0 and t1. There were more similarities than differences between the networks with regard to the structures and processes that we tested. A univariate regression analysis found staff's prior experience in mental health care and the effort that they invested in their work correlated positively with patient outcome. This needs to be interpreted under considering that univariate analysis does not show causal relationship. A high case load per case manager, increased and longer patient contact and more family intervention were correlated with worse patient outcome, probably indicating that sicker patients receive more care and intervention.

CONCLUSION

Home treatment networks succeed in delivering care tailored to the needs of patients. In order to improve the quality of care in home treatment, this study suggests employing experienced staff who is ready to invest more effort in their patients. Further research needs to consider a longer follow-up time.

Hospitalization of high and low inpatient service users before and after enrollment into Assertive Community Treatment teams: a naturalistic observational study

Background

Assertive Community Treatment (ACT) is more successful in reducing hospitalization when baseline use is high. However, with a growing recovery-focus, ACT may be useful for people with severe mental illness who are difficult to engage but not high users of inpatient services. This study investigated hospitalization 2 years before and 2 years after ACT enrollment amongst patients both with and without high inpatient services use before enrollment into ACT.

Methods

This naturalistic observational study included 142 patients from 12 different ACT teams throughout Norway. Of these, 74 (52 %) were high users of inpatient services before ACT. The teams assessed the patients upon enrollment using clinician-rated and self-reported questionnaires. Hospitalization data from 2 years before and 2 years after enrollment into ACT were obtained from the Norwegian Patient Registry. Linear mixed models were used to assess changes in hospitalization and to explore associations between these changes and patient characteristics.

Results

When the participants enrolled into the ACT teams, high users of inpatient care were younger, more often living alone and more often subject to involuntary outpatient treatment than low users. The participants spent significantly fewer days in hospital during the 2 years of ACT follow-up compared to the 2 years before enrollment. The reduction was more evident amongst high users, whereas low users had an initial increase in inpatient days in the first year of ACT and a subsequent decrease in the second year. More severe negative symptoms and previous high use of inpatient care were associated with a reduction in both total and involuntary inpatient days. Additionally, a reduction in involuntary inpatient days was associated with being subject to involuntary outpatient treatment upon enrollment into ACT.

Conclusion

The findings in this study may suggest that ACT contributes to more appropriate use of inpatient care, possibly by reducing the presumably avoidable hospitalization of high users and increasing the presumably needed inpatient care of low users.

Home treatment in preventing hospital admission for moderate and severe mentally ill people

A Home Treatment team was compared with a Psychiatric Emergency Department (PED) on preventing hospitalization among two cohorts of 448 patients matched by diagnosis, sex, and age. The logistic regression showed that HT people were 4.6 times less likely to be admitted than those from PED.

Psychosocial interventions in people with severe mental illness: a Bleulerian perspective

BACKGROUND

Eugen Bleuler, in his book Dementia praecox oder Gruppe der Schizophrenien, discussed issues of social psychiatry, and he considered complex interventions pivotal in the care for people with schizophrenia. Bleuler emphasised the potential of therapeutic communities in providing care, the drawbacks of extended hospitalisation and the therapeutic potential of planned 'early discharge' and job integration.

METHODS

Some of the current evidence on therapeutic communities, planned early hospital discharge, alternatives to inpatient care and job integration in people with severe mental illness are reviewed.

RESULTS

(i) Current evidence suggests that therapeutic communities (and new forms of milieu therapy, e.g. Soteria) are an effective ingredient of care; (ii) the evidence on planned early discharge suggests that there is scope for early discharge if continuity of care is ensured, and (iii) the evidence on supported employment suggests that there is scope for early job placement/supported employment among people with schizophrenia with little risk to clinical stability.

CONCLUSION

Eugen Bleuler was a far-sighted social psychiatrist who concentrated on treatment issues and complex interventions that are considered cornerstones of care for people with severe mental illness one hundred years later.

Clinical outcome of assertive community treatment (ACT) in a rural area in Denmark: a case-control study with a 2-year follow-up

AIM

The aim of the present study was to evaluate the effect of assertive community treatment (ACT) in the Tønder Region, South Jutland, where the first Danish ACT team was established to treat patients with severe and persistent mental illness (SMI).

METHODS

The study compares outcome over a 2-year period between recipients of ACT and standard community mental healthcare.

RESULTS

The study included 86 cases and 88 controls. At the time of recruitment, the cases and the controls did not differ significantly in demographic details and eligibility criteria. At the 2-year follow-up, the ACT patients showed a significant reduction in admissions, bed days and day hospital days, and a significant increase in the number of consultations compared with the controls. Adherence to outpatient services was higher in the ACT group. No significant improvements in psychopathology were found after 2 years, but a significant improvement in met needs and fewer unmet needs, indicating better functioning, occurred. Clients' satisfaction with care (Client Satisfaction Questionnaire, CSQ) was significantly higher among ACT patients than among controls.

CONCLUSION

The treatment of these patients in this ACT service has yielded promising results, suggesting that ACT treatment may be a useful intervention for SMI patients. However, large, rigorous, randomized control trials with ACT are needed in Europe as the existing evidence mainly comes from American studies.

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.

Developing mental health services in response to research evidence

Over the last thirty to forty years, psychiatric care in England has relocated from hospital-based settings to community mental health teams (CMHTs) and supported accommodation. Since the 1980s, two forms of intensive home based treatment have evolved in addition to CMHTS, assertive community treatment (ACT) and crisis resolution teams (CRTs). On the basis of evidence for their efficacy in the US and other countries, they have been implemented across England through the Government's National Service Framework for Mental Health. This paper describes this evidence and the first UK studies that were carried out to evaluate these newly implemented services.Methods– Descriptions of the evaluations of ACT and CRTs in the inner London boroughs of Camden and Islington.Results– The implementation of CRTs in North London were associated with reduced use of inpatient services, but the ACT teams were not. Both types of team were associated with greater patient satisfaction with services and the ACTs were better able to engage patients than CMHTs.Conclusions– The authors comment on the implications of the findings for service planners in terms of the difficulties in implementing innovative approaches based on the best available evidence when it originates outside the local context.

Declaration of Interest:These studies were funded by Camden and Islington Health Authority, the King's Fund and the Department of Health.

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.

Successful engagement: a mixed methods study of the approaches of assertive community treatment and community mental health teams in the REACT trial

BACKGROUND

The only randomised trial of assertive community treatment (ACT) carried out in England (the "REACT" study: randomised evaluation of assertive community treatment in North London) found no clinically significant advantage over usual care from community mental health teams (CMHTs). However, ACT clients were more satisfied and better engaged with services. To understand these findings better, we investigated the content of care and interventions offered to study participants.

METHOD

Quantitative data were collected to compare team structures and processes. Qualitative interviews with care co-ordinators of 40 of the 251 REACT study participants (20 ACT, 20 CMHT clients) were carried out and thematic analysis was used to explore differences in the approaches of the two types of team.

RESULTS

CMHTs scored low for ACT model fidelity and ACTTs scored high or ACT-like. All staff cited client engagement as their primary aim, but ACT approaches were less formal, more frequent and more successful than CMHTs'. Two aspects of ACT appeared important for engagement: small case loads and the team approach. Successful client engagement appeared to be associated with greater staff satisfaction.

CONCLUSIONS

The findings from this study assist in understanding why the ACT approach is more acceptable to clients deemed by CMHTs as "hard to engage". The key elements of ACT that facilitate client engagement may not be easily replicated within CMHTs due to their larger, varied caseloads.

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.

Graduate mental health worker case management of depression in UK primary care: a pilot study

BACKGROUND

Based on data from large multicentre US trials, the National Institute for Health and Clinical Excellence (NICE) is advocating a stepped-care model for the management of depression, with 'case management' or 'collaborative care' for selected patients in primary care.

AIM

To conduct a pilot study examining the use of graduate mental health workers case managing depressed primary care NHS patients.

DESIGN OF STUDY

A randomised controlled trial comparing usual GP care with or without case management over 16 weeks of acute antidepressant drug treatment.

SETTING

Three primary care practices in the North East of England.

METHOD

Patients with depression, aged 18-65 years, who had failed to adequately respond to antidepressant treatment, were randomised to the two treatments. Assessments were made at baseline, 12, and 24 weeks using a combination of observer and self ratings.

RESULTS

Randomisation of 62 patients required screening of 1073 potential patients. There was little difference in outcome between the two treatment arms but a gradual improvement in symptoms over time was seen. Client satisfaction was assessed as high across both treatments.

CONCLUSION

While this pilot study confirmed the integrity of the study protocol and the suitability of the outcome measures and randomisation procedure, it raises questions regarding the practicality of recruitment and feasibility of the intervention. It would be crucial to address these issues prior to the implementation of a large multi-centre randomised controlled trial.

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.

Assertive community treatment in psychiatry

May not reduce inpatient visits, but its success in engaging marginalised patients should not be ignored

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.

The REACT study: randomised evaluation of assertive community treatment in north London

OBJECTIVE

To compare outcomes of care from assertive community treatment teams with care by community mental health teams for people with serious mental illnesses.

DESIGN

Non-blind randomised controlled trial.

SETTING

Two inner London boroughs.

PARTICIPANTS

251 men and women under the care of adult secondary mental health services with recent high use of inpatient care and difficulties engaging with community services.

INTERVENTIONS

Treatment from assertive community treatment team (127 participants) or continuation of care from community mental health team (124 participants).

MAIN OUTCOME MEASURES

Primary outcome was inpatient bed use 18 months after randomisation. Secondary outcomes included symptoms, social function, client satisfaction, and engagement with services.

RESULTS

No significant differences were found in inpatient bed use (median difference 1, 95% confidence interval -16 to 38) or in clinical or social outcomes for the two treatment groups. Clients who received care from the assertive community treatment team seemed better engaged (adapted homeless engagement acceptance schedule: difference in means 1.1, 1.0 to 1.9), and those who agreed to be interviewed were more satisfied with services (adapted client satisfaction questionnaire: difference in means 7.14, 0.9 to 13.4).

CONCLUSIONS

Community mental health teams are able to support people with serious mental illnesses as effectively as assertive community treatment teams, but assertive community treatment may be better at engaging clients and may lead to greater satisfaction with services.

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.

„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.

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

BACKGROUND

In view of the plethora of different community-based mental health services, there is a clear need for a classification based on service components rather than labels. Moreover, the sustainability of experimental services beyond their research studies is rarely reported.

METHODS

As part of a systematic review of home treatment for mental health problems, authors of all included studies were followed up for data on service components and sustainability. Associations between components were explored.

RESULTS

There was evidence of a core group of components co-occurring in home treatment services: regularly visiting at home, taking responsibility for health and social care, having smaller caseloads, multidisciplinary teams, integrated psychiatrists and a high proportion of contacts at home. Fifty-four per cent of services no longer existed, of which almost half had ended by the study's publication date. There was a significant association between sustainability and the study's hospitalisation outcome.

CONCLUSIONS

Some of the related service components presented here were associated with reducing hospitalisation. This group cannot, however, be used to provide a new taxonomy of services. It is imperative that future studies prospectively record and report service components to enable better classification. It is of concern that policy is currently predicated on research findings regardless of whether or not the experimental service was sustainable.