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

Effect of COGNI-MACHINE computational thinking training on executive functions in children aged 9 to 11: Protocol of a cluster randomized controlled trial

We designed a controlled trial protocol that seeks to contribute to cognitive science by studying the effect of thought training on children's executive functions. The study design is a cluster randomized controlled trial, with intra-subject and inter-subject evaluation, with two parallel groups: an experimental group and a TAU control group. With three measures, pre-test, post-test, and follow-up after three months. The participants will be children aged 9 to 11. The allocation will be randomized by groups and not individually. The sample will be a minimum of 44 participants. The primary measures will be neuropsychological tests to assess executive functions. Secondary measures will be a computational thinking test, neuropsychological tests to assess metacognition and attention, and an acceptability scale. The experimental group will participate in the COGNI-MACHINE computational thinking training designed by the first author. The training frequency will be twice a week in 60 min sessions for 12 weeks. The TAU control group will receive computer science classes as usual during the same time as the experimental group. The evaluators taking the measurements will be blinded to the assignment. The investigators in charge of the intervention will be blinded to the results of the evaluations.

Cognitive stimulation of executive functions through computational thinking

The healthy development of cognitive functions, including executive functions, has been shown to depend mainly on the experiences and learning opportunities of people, especially during childhood. Over the past few years, researchers have been studying the impacts of diverse types of interventions on children's cognitive development in which computational thinking programs are a recent field. This pilot study evaluated the effect of computational thinking training based on the "Programming for Children" program on the executive functions of children aged 10 and 11 years: working memory, inhibition, and planning (N = 30). The results showed that children in the experimental group improved on tests of visuospatial working memory, cognitive inhibition, and sequential planning compared with the control group. However, tests of verbal working memory, memory strategy, and visual spatial planning did not show any observed changes. Although this was an exploratory study, and its findings should be interpreted cautiously due to the small sample size, the findings support the relevance and feasibility of conducting similar larger studies with larger samples.

Effect of specialised versus generalised outpatient treatment for bipolar disorder: the CAG Bipolar trial - study protocol for a randomised controlled trial

INTRODUCTION

Despite current available treatment patients with bipolar disorder often experience relapses and decreased overall functioning. Furthermore, patients with bipolar disorder are often not treated medically or psychologically according to guidelines and recommendations. A Clinical Academic Group is a new treatment initiative bringing together clinical services, research, education and training to offer care and treatment that is based on reliable evidence backed up by research. The present Clinical Academic Group for bipolar disorder (the CAG Bipolar) randomised controlled trial (RCT) aims for the first time to investigate whether specialised outpatient treatment in CAG Bipolar versus generalised community-based treatment improves patient outcomes and clinician's satisfaction with care in patients with bipolar disorder.

METHODS AND ANALYSIS

The CAG Bipolar trial is a pragmatic randomised controlled parallel-group trial undertaken in the Capital Region of Denmark covering a catchment area of 1.85 million people. Patients with bipolar disorder are invited to participate as part of their outpatient treatment in the Mental Health Services. The included patients will be randomised to (1) specialised outpatient treatment in the CAG Bipolar (intervention group) or (2) generalised community-based outpatient treatment (control group). The trial started 13 January 2020 and has currently included more than 600 patients. The outcomes are (1) psychiatric hospitalisations and cumulated number and duration of psychiatric hospitalisations (primary), and (2) self-rated depressive symptoms, self-rated manic symptoms, quality of life, perceived stress, satisfaction with care, use of medication and the clinicians' satisfaction with their care (secondary). A total of 1000 patients with bipolar disorder will be included.

ETHICS AND DISSEMINATION

The CAG Bipolar RCT is funded by the Capital Region of Denmark and ethical approval has been obtained from the Regional Ethical Committee in The Capital Region of Denmark (H-19067248). Results will be published in peer-reviewed academic journals, presented at scientific meetings and disseminated to patient organisations and media outlets.

TRIAL REGISTRATION NUMBER

NCT04229875.

Mechanisms of change in Internet- and mobile-based interventions for PTSD: a systematic review and meta-analysis

Background: While Internet- and mobile-based interventions (IMIs) are potential options to increase the access to evidence-based therapies for post-traumatic stress disorder (PTSD), comprehensive knowledge on their working mechanisms is still scarce. Objective: We aimed to evaluate studies investigating the efficacy and mechanisms of change in IMIs for adults with PTSD. Method: In this systematic review and meta-analysis (PROSPERO CRD42019130314), five databases were consulted to identify relevant studies, complemented by forward (i.e. citation search) and backward (i.e. review of reference lists from included studies) searches. Randomized controlled trials (RCTs) investigating the efficacy of IMIs compared to active controls, as well as component and mediation studies were included. Two independent reviewers extracted the data and assessed the risk of bias and requirements for process research. Random-effects meta-analyses on PTSD symptom severity as primary outcome were conducted and further information was synthesized qualitatively. Results: In total, 33 RCTs were included (N = 5421). The meta-analysis comparing IMIs to non-bonafide active controls yielded a significant standardized mean difference (SMD) of -0.36 (95%CI -0.53 to -0.19) favouring IMIs. Although meta-analytic pooling was not possible for the component and mediation studies, evidence suggests no differential effects regarding PTSD symptom reduction between different levels of support and personalization and between different types of exposure. Moreover, mediation studies revealed significant intervening variable effects for self-efficacy beliefs, perceived physical impairment, social acknowledgement, and trauma disclosure. Conclusions: Results indicate that IMIs for PTSD are superior to active controls. Furthermore, findings may contribute to the development of new interventions by outlining important directions for future research (e.g. regarding requirements for process research) and highlighting potential mechanisms of change (i.e. self-efficacy, perceived physical impairment, social acknowledgement, and trauma disclosure).

Effectiveness of an Individual Cognitive-Behavioral Intervention for Serious, Young Male Violent Offenders: Randomized Controlled Study With Twenty-Four-Month Follow-Up

Background: Psychological recidivism-reducing interventions with serious, young violent offenders in residential care have unsatisfactory effects. We tested if a complementary individual cognitive behavioral therapy (iCBT) intervention focusing problem-solving, cognitive self-control, and relapse prevention reduces criminal recidivism beyond usual institutional care encompassing interventions such as social skills training and prosocial modeling (treatment-as-usual; TAU). Method: We consecutively approached 115 eligible serious, male violent crime offenders in five residential treatment homes run by the Swedish National Board of Institutional Care. Eighty-one (70%) 16 to 21-year-old youth at medium-high violent recidivism risk were included and randomized to an individualized 15 to 20-session CBT intervention plus TAU (n = 38) or to TAU-only (n = 43), 4-6 months before release to the community. Participants were assessed pre- and post-treatment, at 12 months (self-reported aggressive behavior, reconvictions) and 24 months (reconvictions) after release. Intent-to-treat analyses were applied. Results: The violent reconviction rate was slightly higher for iCBT+TAU vs. TAU-only youth at 12 months (34 vs. 23%, d = 0.30, 95% CI: -0.24 to 0.84) and 24 months following release (50 vs. 40%, d = 0.23, 95% CI: -0.25 to 0.72), but neither of these differences were significant. Cox regression modeling also suggested non-significantly, negligibly to slightly more violent, and any criminal recidivism in iCBT+TAU vs. TAU-only youth during the entire follow-up. Further, we found no significant between-group differences in conduct problems, aggression, and antisocial cognitions, although both iCBT+TAU and TAU-only participants reported small to large within-group reductions across outcome measures at post-treatment. Finally, the 12-month follow-up suggested marginally more DSM-5 Conduct Disorder (CD) symptoms of "aggression to people and animals" in iCBT+TAU vs. TAU-only youth (d = 0.10, 95% CI: -0.40 to 0.60) although this difference was not significant. Conclusion: We found no additive effect of individual CBT beyond group-based TAU in residential psychological treatment for serious, young male violent offenders. Limited sample size and substantial treatment dropout reduced the robustness of intent-to-treat effect estimates. We discuss the possible impact of treatment dose and integrity, participant retention, and TAU quality.

Decrease of hospitalizations and length of hospital stay in patients with schizophrenia spectrum disorders treated in a community mental health service in rural Greece

BACKGROUND

The treatment of severe and chronic mental disorders, such as schizophrenia and related syndromes, is largely based on community mental health services.

AIMS

The objective of the present study was to assess hospital admissions and length of hospital stay in patients with schizophrenia and related disorders, who are engaged to treatment with a Mobile Mental Health Unit (MMHU I-T) in a defined rural catchment area in Greece.

METHOD

Data were retrieved retrospectively for 76 patients with schizophrenia and related disorders. For each patient, comparison was made for the same interval prior and after engagement to treatment with the MMHU I-T.

RESULTS

The average age of patients was 56 years and the mean illness duration was 28 years. The mean follow-up duration was 5.3 years. There was a statistically significant decrease in the annual average of the number of voluntary and involuntary hospitalizations and on days of hospital stay after treatment engagement with the MMHU I-T.

CONCLUSIONS

Treatment of schizophrenia spectrum disorders in rural residents by the MMHUs may contribute to the reduction of patients' admissions and length of hospital stay. Future research should address the cost-effectiveness of such interventions.

Is adjunctive CBT really effective for schizophrenia?

Although antipsychotic medication remains the mainstay of treatment for schizophrenia, medications alone are not always successful. Cognitive–behavioural therapy (CBT) is recommended as an adjunct to pharmacological treatment. The Cochrane review under consideration evaluates the effects of offering CBT as an add-on to standard care compared with standard care alone, and this commentary puts those findings into their clinical context.

DECLARATION OF INTEREST

None.

Efficacy and safety of electroacupuncture on treating depression-related insomnia: a study protocol for a multicentre randomised controlled trial

INTRODUCTION

Sleep disorders including insomnia occur frequently in depressive patients. Acupuncture is a widely recognised therapy to treat depression and sleep disorders in clinical practice. This multicentre randomised controlled trial (RCT) is aimed to investigate the efficacy and safety of electroacupuncture (EA) in the treatment of depression patients with insomnia.

METHODS AND ANALYSIS

We describe a protocol for a multicentre RCT. A total of 270 eligible patients in three different healthcare centres in Shanghai will be randomly assigned to one of these three groups: treatment group (EA + standard care), control A group (sham electroacupuncture + standard care) and control B group (standard care). Treatment will be given three times per week for 8 consecutive weeks. The primary outcome is the Pittsburgh Sleep Quality Index. The secondary outcomes are sleep parameters recorded in the actigraphy, Hamilton Rating Scale for Depression score and Self-rating Anxiety Scale score. Daily dose of patients' antidepressant and sedative-hypnotic medication will be recorded in the dairy. All adverse effects will be assessed by the Treatment Emergent Symptom Scale. Outcomes will be evaluated at baseline, 4 weeks post-treatment and 8 weeks post-treatment, as well as at 1-month, 3-month and 6-month follow-up.

ETHICS AND DISSEMINATION

The trial has been approved by the Ethics Committee of Shanghai Municipal Hospital of Traditional Chinese Medicine (2017SHL-KY-04). Written informed consent will be obtained from all participants. The results of this study will be published in peer-reviewed journals or presented at academic conferences.

TRIAL REGISTRATION NUMBER

NCT03122080; Pre-results.

Control freaks: Towards optimal selection of control conditions for fMRI neurofeedback studies

fMRI Neurofeedback research employs many different control conditions. Currently, there is no consensus as to which control condition is best, and the answer depends on what aspects of the neurofeedback-training design one is trying to control for. These aspects can range from determining whether participants can learn to control brain activity via neurofeedback to determining whether there are clinically significant effects of the neurofeedback intervention. Lack of consensus over criteria for control conditions has hampered the design and interpretation of studies employing neurofeedback protocols. This paper presents an overview of the most commonly employed control conditions currently used in neurofeedback studies and discusses their advantages and disadvantages. Control conditions covered include no control, treatment-as-usual, bidirectional-regulation control, feedback of an alternative brain signal, sham feedback, and mental-rehearsal control. We conclude that the selection of the control condition(s) should be determined by the specific research goal of the study and best procedures that effectively control for relevant confounding factors.

Reporting of interventions and "standard of care" control arms in pediatric clinical trials: a quantitative analysis

BACKGROUND

In pediatric medicine, the usual treatment received by children ("standard of care") varies across centers. Evaluations of new treatments often compare to the existing "standard of care" to determine if a treatment is more effective, has a better safety profile, or costs less. The objective of our study was to evaluate intervention and "standard of care" control arms reported in published pediatric clinical trials.

METHODS

Pediatric clinical trials, published in 2014, reporting the use of a "standard of care" control arm were included. Duplicate assessment of reporting completeness was done using the 12-item TIDieR (Template for Intervention Description and Replication) checklist for both the "standard of care" control arms and intervention arms within the same published study.

RESULTS

Following screening, 214 pediatric trials in diverse therapeutic areas were included. Several different terms were used to describe "standard of care." There was a significant difference between the mean reported TIDieR checklist items of "standard of care" control arms (5.81 (SD 2.13) and intervention arms (8.45 (SD 1.39, p < 0.0001).

CONCLUSIONS

Reporting of intervention and "standard of care" control arms in pediatric clinical trials should be improved as current "standard of care" reporting deficiencies limit reproducibility of research and may ultimately contribute to research waste.

Treatment as usual (TAU) as a control condition in trials of cognitive behavioural-based psychotherapy for self-harm: Impact of content and quality on outcomes in a systematic review

BACKGROUND

Randomized controlled trials (RCTs) are the mainstay of evaluations of the efficacy of psychosocial interventions. In a recent Cochrane systematic review we analysed the efficacy of cognitive behavioural-based psychotherapies compared to treatment as usual (TAU) in adults who self-harm. In this study we examine the content and reporting quality of TAU in these trials and their relationship to outcomes.

METHODS

Five electronic databases (CCDANCTR-Studies and References, CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched for RCTs, indexed between 1 January 1998 and 30 April 2015, of cognitive-behavioural interventions compared to TAU for adults following a recent (within six months) episode of self-harm. Comparisons were made between outcomes for trials which included different categories of TAU, which were grouped as: multidisciplinary treatment, psychotherapy only, pharmacotherapy only, treatment by primary care physician, minimal contact, or unclear.

RESULTS

18 trials involving 2433 participants were included. The content and reporting quality of TAU varied considerably between trials. The apparent effectiveness of cognitive behavioural psychotherapy varied according to TAU reporting quality and content. Specifically, effects in favour of cognitive-behavioural psychotherapy were strongest in trials in which TAU content was not clearly described (Odds Ratio: 0.29, 95% Confidence Interval 0.15-0.62; three trials) compared to those in which TAU comprised multidisciplinary treatment (Odds Ratio: 0.79, 95% CI 0.63 to 0.97; 12 trials).

LIMITATIONS

The included trials had high risk of bias with respect to participant and clinical personnel blinding, and unclear risk of bias for selective outcome reporting.

CONCLUSIONS

TAU content and quality represents an important source of heterogeneity between trials of psychotherapeutic interventions for prevention of self-harm. Before clinical trials begin, researchers should plan to carefully describe both aspects of TAU to improve the overall quality of investigations.

Mental Healthcare Delivery in Rural Greece: A 10-year Account of a Mobile Mental Health Unit

Introduction:

Patients living in rural and remote areas may have limited access to mental healthcare due to lack of facilities and socioeconomic reasons, and this is the case of rural areas in Eastern Europe countries. In Greece, community mental health service delivery in rural areas has been implemented through the development of the Mobile Mental Health Units (MMHUs).

Methods:

We present a 10-year account of the operation of the MMHU of the prefectures of Ioannina and Thesprotia (MMHU I-T) and report on the impact of the service on mental health delivery in the catchment area. The MMHU I-T is a multidisciplinary community mental health team which delivers services in rural and mountainous areas of Northwest Greece.

Results:

The MMHU I-T has become an integral part of the local primary care system and is well known to the population of the catchment area. By the end of 2016, the majority of patients (60%) were self-referred or family-referred, compared to 24% in the first 2 years. Currently, the number of active patients is 293 (mean age 63 years, 49.5% are older adults), and the mean caseload for each member of the team is 36.6. A significant proportion of patients (28%) receive care with regular domiciliary visits, and the provision of home-based care was correlated with the age of the patients. Within the first 2 years of operation of the MMHU I-T hospitalizations of treatment, engaged patients were reduced significantly by 30.4%, whereas the treatment engagement rates of patients with psychotic disorders were 67.2% in 5 years.

Conclusions:

The MMHU I-T and other similar units in Greece are a successful paradigm of a low-cost service which promotes mental health in rural, remote, and deprived areas. This model of care may be informative for clinical practice and health policy given the ongoing recession and health budget cuts. It suggests that rural mental healthcare may be effectively delivered by integrating generic community mental health mobile teams into the primary care system.

Adherence to NICE guidance on lifestyle advice for people with schizophrenia: a survey

Aims and method The STEPWISE trial (STructured lifestyle Education for People WIth SchizophrEnia, schizoaffective disorder and first episode psychosis) is currently evaluating a lifestyle education programme in addition to usual care. However, it is difficult to define what constitutes 'usual care'. We aimed to define 'usual care' for lifestyle management in people with schizophrenia, schizoaffective disorder and first-episode psychosis in STEPWISE study sites. Ten National Health Service (NHS) mental health trusts participated in a bespoke survey based on the National Institute for Health and Care Excellence (NICE) guidance. Results Eight trusts reported offering lifestyle education programmes and nine offered smoking cessation support. Reported recording of biomedical measures varied. Clinical implications Although recommended by NICE, lifestyle education programmes are not consistently offered across UK NHS mental health trusts. This highlights missed opportunities to improve the physical health of people with psychotic illness. Our survey benchmarks 'usual care' for the STEPWISE study, against which changes can be measured. Furthermore, future studies will be able to identify whether any progress in clinical practice has been made towards achieving the NICE recommendations.

The effect of treatment as usual on major depressive disorder: A meta-analysis

BACKGROUND

Health-economic models are used to evaluate the long-term cost-effectiveness of an intervention and typically include treatment as usual (TAU) as comparator. Part of the data used for these models are acquired from the literature and thus valid information is needed on the effects of TAU on depression. The aim of the current meta-analysis was to examine positive and negative outcomes of major depression for patients receiving TAU.

METHODS

We conducted a systematic literature search in PubMed, EMBASE, PsycInfo, and the Cochrane Central Register of Controlled Trials. Eligible studies were randomized controlled trials including a TAU group for depression. The quality of the included studies was assessed using the criteria described in the "Risk of bias assessment tool". Four separate meta-analyses were performed to estimate remission, response, reliable change and deterioration rates at short-term (≤6 months from baseline).

RESULTS

Thirty-eight studies including 2099 patients in the TAU were identified. Nine studies (24%) met five or six quality criteria, 17 studies (44%) met three or four quality criteria and 12 studies (32%) met one or two quality criteria. After adjusting for publication bias, the first meta-analysis (n=33) showed that 33% of the patients remitted from depression. The second meta-analysis (n=13) demonstrated that 27% of the patients responded to treatment, meaning that their depressive symptom decreased at least 50% from baseline to follow-up measurement. The third meta-analysis (n=7) indicated that 31% of the patients showed a reliable change, meaning that their depressive symptoms improved more than expected by random variation alone. Finally, 12% of the patients deteriorated, meaning that their depressive symptoms became more severe.

LIMITATIONS

Statistical heterogeneity was substantial in most analyses and was not fully explained by subgroup analyses. The quality of the included studies was moderate. This may result in overestimation of the true effects.

CONCLUSIONS

The treatments labelled as TAU for depression were clinically and statistically heterogeneous. We demonstrated that a few patients benefited from TAU and a small number of patients suffered from worsened depressive symptoms at the short term. The results can be included in health-economic models that compare depression treatments to TAU.

Intensive case management for severe mental illness

BACKGROUND

Intensive Case Management (ICM) is a community-based package of care aiming to provide long-term care for severely mentally ill people who do not require immediate admission. Intensive Case Management evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (fewer than 20) and high-intensity input.

OBJECTIVES

To assess the effects of ICM as a means of caring for severely mentally ill people in the community in comparison with non-ICM (caseload greater than 20) and with standard community care. We did not distinguish between models of ICM. In addition, to assess whether the effect of ICM on hospitalisation (mean number of days per month in hospital) is influenced by the intervention's fidelity to the ACT model and by the rate of hospital use in the setting where the trial was conducted (baseline level of hospital use).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (last update search 10 April 2015).

SELECTION CRITERIA

All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community care setting, where ICM is compared to non-ICM or standard care.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed quality, and extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated mean difference (MD) between groups and its 95% CI. We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect. We assessed overall quality for clinically important outcomes using the GRADE approach and investigated possible risk of bias within included trials.

MAIN RESULTS

The 2016 update included two more studies (n = 196) and more publications with additional data for four already included studies. The updated review therefore includes 7524 participants from 40 randomised controlled trials (RCTs). We found data relevant to two comparisons: ICM versus standard care, and ICM versus non-ICM. The majority of studies had a high risk of selective reporting. No studies provided data for relapse or important improvement in mental state.1. ICM versus standard careWhen ICM was compared with standard care for the outcome service use, ICM slightly reduced the number of days in hospital per month (n = 3595, 24 RCTs, MD -0.86, 95% CI -1.37 to -0.34,low-quality evidence). Similarly, for the outcome global state, ICM reduced the number of people leaving the trial early (n = 1798, 13 RCTs, RR 0.68, 95% CI 0.58 to 0.79, low-quality evidence). For the outcome adverse events, the evidence showed that ICM may make little or no difference in reducing death by suicide (n = 1456, 9 RCTs, RR 0.68, 95% CI 0.31 to 1.51, low-quality evidence). In addition, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment due to very low-quality evidence (n = 1129, 4 RCTs, RR 0.70, 95% CI 0.49 to 1.0, very low-quality evidence).2. ICM versus non-ICMWhen ICM was compared with non-ICM for the outcome service use, there was moderate-quality evidence that ICM probably makes little or no difference in the average number of days in hospital per month (n = 2220, 21 RCTs, MD -0.08, 95% CI -0.37 to 0.21, moderate-quality evidence) or in the average number of admissions (n = 678, 1 RCT, MD -0.18, 95% CI -0.41 to 0.05, moderate-quality evidence) compared to non-ICM. Similarly, the results showed that ICM may reduce the number of participants leaving the intervention early (n = 1970, 7 RCTs, RR 0.70, 95% CI 0.52 to 0.95,low-quality evidence) and that ICM may make little or no difference in reducing death by suicide (n = 1152, 3 RCTs, RR 0.88, 95% CI 0.27 to 2.84, low-quality evidence). Finally, for the outcome social functioning, there was uncertainty about the effect of ICM on unemployment as compared to non-ICM (n = 73, 1 RCT, RR 1.46, 95% CI 0.45 to 4.74, very low-quality evidence).3. Fidelity to ACTWithin the meta-regression we found that i.) the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36, 95% CI -0.66 to -0.07); and ii.) the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20, 95% CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but the 'baseline hospital use' result still significantly influences time in hospital (regression coefficient -0.18, 95% CI -0.29 to -0.07, P = 0.0027).

AUTHORS' CONCLUSIONS

Based on very low- to moderate-quality evidence, ICM is effective in ameliorating many outcomes relevant to people with severe mental illness. Compared to standard care, ICM may reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. Intensive Case Management is at least valuable to people with severe mental illnesses in the subgroup of those with a high level of hospitalisation (about four days per month in past two years). Intensive Case Management models with high fidelity to the original team organisation of ACT model were more effective at reducing time in hospital.However, it is unclear what overall gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, however we currently know of no review comparing non-ICM with standard care, and this should be undertaken.

Effectiveness of interventions for adults with mild to moderate intellectual disabilities and mental health problems: systematic review and meta-analysis

BACKGROUND

There is a lack of available evidence in relation to the effectiveness of interventions for adults with mild to moderate intellectual disability and mental health problems.

AIMS

To evaluate the efficacy of interventions for adults with mild to moderate intellectual disabilities and co-occurring mental health problems.

METHOD

An electronic literature search of the databases Medline, EMBASE, PsycINFO and EBM Reviews aimed at identifying randomised controlled trials (RCTs) and controlled trials testing any type of intervention (psychotherapy, biological or system level) for people with mild to moderate intellectual disabilities (IQ score 35-69) targeting comorbid mental health problems. Additionally a meta-analysis was conducted.

RESULTS

Twelve studies met the inclusion criteria. No significant effect was found for the predefined outcome domains behavioural problems, depression, anxiety, quality of life and functioning. The effect size for depression (d = 0.49) was moderate but non-significant. Quality of studies was moderate and heterogeneity was high.

CONCLUSIONS

There is no compelling evidence supporting interventions aiming at improving mental health problems in people with mild to moderate intellectual disability. The number of available trials is too low for definite conclusions. Some interventions are promising and should be evaluated further in larger and more rigorous trials.

Aro T, Mikkonen TN, O. Katila H. Psychotherapy effectiveness for major depression: a randomized trial in a Finnish community

BACKGROUND

The purpose of this study is to assess the relative effectiveness of Interpersonal Psychotherapy (IPT), Psychoeducative Group Therapy (PeGT), and treatment as usual (TAU) for patients with Major Depressive Disorder (MDD) in municipal psychiatric secondary care in one Finnish region.

METHODS

All adult patients (N = 1515) with MDD symptoms referred to secondary care in 2004-2006 were screened. Eligible, consenting patients were assigned randomly to 10-week IPT (N = 46), PeGT (N = 42), or TAU (N = 46) treatment arms. Antidepressant pharmacotherapy among study participants was evaluated. The Hamilton Depression Rating scale (HAM-D) was the primary outcome measure. Assessment occurred at 1, 5, 3, 6, and 12 months. Actual amount of therapists' labor was also evaluated. All statistical analyses were performed with R software.

RESULTS

All three treatment cells showed marked improvement at 12-month follow-up. At 3 months, 42 % in IPT, 61 % in PeGT, and 42 % in TAU showed a mean ≥50 % in HAM-D improvement; after 12 months, these values were 61 %, 76 %, and 68 %. Concomitant medication and limited sample size minimized between-treatment differences. Statistically significant differences emerged only between PeGT and TAU favoring PeGT. Secondary outcome measures (CGI-s and SOFAS) showed parallel results.

CONCLUSION

All three treatments notably benefited highly comorbid MDD patients in a public sector secondary care unit.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02314767 (09.12.2014).

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.

Assessing treatment-as-usual provided to control groups in adherence trials: Exploring the use of an open-ended questionnaire for identifying behaviour change techniques

OBJECTIVE

Reporting guidelines call for descriptions of control group support in equal detail as for interventions. However, how to assess the active content (behaviour change techniques (BCTs)) of treatment-as-usual (TAU) delivered to control groups in trials remains unclear. The objective of this study is to pre-test a method of assessing TAU in a multicentre cost-effectiveness trial of an HIV-treatment adherence intervention.

DESIGN

HIV-nurses (N = 21) completed a semi-structured open-ended questionnaire enquiring about TAU adherence counselling. Two coders independently coded BCTs.

MAIN OUTCOME MEASURES

Completeness and clarity of nurse responses, inter-coder reliabilities and the type of BCTs reported were examined.

RESULTS

The clarity and completeness of nurse responses were adequate. Twenty-three of the 26 identified BCTs could be reliably coded (mean κ = .79; mean agreement rate = 96%) and three BCTs scored below κ = .60. Total number of BCTs reported per nurse ranged between 7 and 19 (M = 13.86, SD = 3.35).

CONCLUSIONS

This study suggests that the TAU open-ended questionnaire is a feasible and reliable tool to capture active content of support provided to control participants in a multicentre adherence intervention trial. Considerable variability in the number of BCTs provided to control patients was observed, illustrating the importance of reliably collecting and accurately reporting control group support.

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.

Ten year outcomes of participants in the REACT (Randomised Evaluation of Assertive Community Treatment in North London) study

BACKGROUND

A previous randomised controlled trial that investigated Assertive Community Treatment (ACT) in the UK (the REACT Study) found no clinical advantage over usual care delivered by Community Mental Health Teams (CMHTs) at 18 and 36 month follow-ups. No studies have investigated long term clinical and social outcomes for patients receiving ACT.

METHOD

We investigated inpatient service use, social outcomes, service contact and adverse events for the 251 REACT study participants 10 years after randomisation through case note review. Data were analysed using regression models adjusted for original treatment group allocation and changes in treatment group.

RESULTS

We found no statistically significant differences in outcomes by original treatment group over the 10 years. Those whose care remained with ACT, or transferred to ACT or forensic services, had more inpatient days over the 10 years (coefficient 223, 95% CI 83 to 363, p = 0.002) than those whose care remained with the CMHTs or were discharged to primary care. Being subject to a Community Treatment Order was associated with a greater chance of being under ACT at 10 year follow-up (OR 6.39, 95% CI 2.98 to 13.70, p <0.001).

CONCLUSIONS

The ACT teams in this study showed no clinical advantage over usual care provided by CMHTs at 10 year follow-up. We also found that the ACT teams accrued patients from the original study sample who had more complex needs than those who remained with or transferred to the CMHTs or primary care during this period. Further well conducted trials are needed to identify the most cost-effective approaches to supporting successful community living and optimum long term outcomes for this group.

How standard is standard care? Exploring control group outcomes in behaviour change interventions for young people with type 1 diabetes

OBJECTIVE

Poor descriptions of standard care may compromise interpretation of results in randomised controlled trials (RCTs) of health interventions. We investigated quality of standard care in RCTs of behaviour change interventions for young people with type 1 diabetes and consider implications for evaluating trial outcomes.

DESIGN

We conducted systematic searches for articles published between 1999 and 2012. We extracted standard care descriptions and contacted trial authors to complete a checklist of standard care activities. The relationship between standard care quality and outcomes was examined via subgroup meta-analyses and meta-regression.

MAIN OUTCOME MEASURES

Standard care descriptions, standard care quality, and relationships between standard care quality with medical and psychological outcomes.

RESULTS

We identified 20 RCTs described across 26 articles. Published descriptions of standard care were limited to service-level features. Author responses indicated standard care provision extended beyond published accounts. Subgroup analyses suggested control groups receiving higher standard care quality showed larger improvements in both medical and psychological outcomes, although standard care quality did not predict outcomes significantly.

CONCLUSION

The quality of care delivered to control group participants can influence outcomes of RCTs. Inadequate reporting exacerbates this issue by masking variations between trials. We argue for increased clarity in reporting standard care in future trials.

Use of community treatment orders in an inner-London assertive outreach service

Aims and method To compare admission rates and bed occupancy before and after the introduction of community treatment orders (CTOs) in 37 assertive outreach service patients. The effect of CTOs on treatment adherence and illicit drug use were also evaluated. The views of patients and care coordinators were obtained through a focus group. Results When CTOs were introduced, admission rates fell from 3.3 to 0.3 per year and average bed occupancy declined from 133.2 to 10.8 days per year. Treatment adherence improved from 4 (10.8%) to 31 (83.7%) patients, and an objective reduction in substance misuse was observed in 25 (67.5%) patients. Whereas patients expressed ambivalence towards CTOs, their care coordinators generally had a more positive view. Clinical implications The decline in hospital usage following the introduction of CTOs is encouraging and could reflect improved adherence and engagement through intensive case management, leading to a reduction in readmissions. However, further studies need to look at quality of life, cost-effectiveness and the impact on patients.

The rise of assertive community interventions in South Africa: a randomized control trial assessing the impact of a modified assertive intervention on readmission rates; a three year follow-up

BACKGROUND

Many countries have over the last few years incorporated mental health assertive interventions in an attempt to address the repercussions of deinstitutionalization. Recent publications have failed to duplicate the positive outcomes reported initially which has cast doubt on the future of these interventions. We previously reported on 29 patients from a developing country who completed 12 months in an assertive intervention which was a modified version of the international assertive community treatment model. We demonstrated reduction in readmission rates as well as improvements in social functioning compared to patients from the control group. The obvious question was, however, if these outcomes could be sustained for longer periods of time. This study aims to determine if modified assertive interventions in an under-resourced setting can successfully maintain reductions in hospitalizations.

METHODS

Patients suffering from schizophrenia who met a modified version of Weidens' high frequency criteria were randomized into two groups. One group received a modified assertive intervention based on the international assertive community treatment model. The other group received standard care according to the model of service delivery in this region. Data was collected after 36 months, comparing readmissions and days spent in hospital.

RESULTS

The results demonstrated significant differences between the groups. Patients in the intervention group had significantly less readmissions (p = 0.007) and spent less days in hospital compared to the patients in the control group (p = 0.013).

CONCLUSION

Modified assertive interventions may be successful in reducing readmissions and days spent in hospital in developing countries where standard care services are less comprehensive. These interventions can be tailored in such a way to meet service needs and still remain affordable and feasible within the context of an under-resourced setting.

Do young adults with bipolar disorder benefit from early intervention?

BACKGROUND

It is unknown whether young adults with bipolar disorder are able to benefit from early intervention combining optimised pharmacological treatment and group psychoeducation. The aim of the present report was to compare the effects of early intervention among patients with bipolar disorder aged 18-25 years to that of patients aged 26 years or older.

METHODS

Patients were randomised to early treatment in a specialised outpatient mood disorder clinic versus standard care. The primary outcome was risk of psychiatric re-hospitalisation.

RESULTS

A total of 158 patients with mania/bipolar disorder were included among whom 29 (18.4%) were between 18 and 25 years and 129 patients were 26 years or older. For both age groups, the point estimate of the hazard ratio of re-hospitalisation was insignificantly decreased for patients treated in the mood disorder clinic versus standard treatment but more so for patients between 18 and 25 years (HR 0.33, 95% CI 0.10-1.07; p=0.064) than for patients 26 years or older (HR 0.68, 95% CI 0.40-1.14, p=0.14). Younger adults treated in the mood disorder clinic used mood stabilisers and antipsychotics more in contrast to those treated in standard care. The differences between the estimates of effects did not reach significance in tests of interactions (p>0.2).

LIMITATIONS

The study was based on a post hoc subgroup analysis and due to the small number of patients aged 18-25 years, type II errors cannot be excluded.

CONCLUSIONS

Although not statistically different, the observed differences of the point estimates was surprisingly larger for young adults suggesting that young adults with bipolar disorder may benefit even more than older adults from early intervention combining pharmacological treatment and group psychoeducation.

Treatment in a specialised out-patient mood disorder clinic v. standard out-patient treatment in the early course of bipolar disorder: randomised clinical trial

BACKGROUND

Little is known about whether treatment in a specialised out-patient mood disorder clinic improves long-term prognosis for patients discharged from initial psychiatric hospital admissions for bipolar disorder.

AIMS

To assess the effect of treatment in a specialised out-patient mood disorder clinic v. standard decentralised psychiatric treatment among patients discharged from one of their first three psychiatric hospital admissions for bipolar disorder.

METHOD

Patients discharged from their first, second or third hospital admission with a single manic episode or bipolar disorder were randomised to treatment in a specialised out-patient mood disorder clinic or standard care (ClinicalTrials.gov: NCT00253071). The primary outcome measure was readmission to hospital, which was obtained from the Danish Psychiatric Central Register.

RESULTS

A total of 158 patients with mania/bipolar disorder were included. The rate of readmission to hospital was significantly decreased for patients treated in the mood disorder clinic compared with standard treatment (unadjusted hazard ratio 0.60, 95% CI 0.37-0.97, P = 0.034). Patients treated in the mood disorder clinic more often used a mood stabiliser or an antipsychotic and satisfaction with treatment was more prevalent than among patients who received standard care.

CONCLUSIONS

Treatment in a specialised mood disorder clinic early in the course of bipolar disorder substantially reduces readmission to a psychiatric hospital and increases satisfaction with care.

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.

[Team-based community psychiatry: importance of context factors and transferability of evidence from studies]

The German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) guidelines on psychosocial interventions for people with severe mental illness appraise the transferability of results of trials evaluating community-based mental health services to the German situation. This assessment has to draw on research results on factors determining effectiveness. This must be seen against the background of a lack of high-quality trials in Germany. The article discusses system, context and setting factors related to the transfer of evidence on community-based service models from other countries. These issues are discussed on the basis of evidence concerning the models of case management, assertive community treatment and community mental health teams. International differences in study findings are highlighted and the importance of treatment-as-usual in influencing study results is emphasized. The more control services including elements of community-based care there are and the less the pressure to reduce inpatient treatment (threshold to inpatient care admission), the smaller the relative effect sizes of innovative care models will be.In the absence of direct evidence, careful examination of transferability is required before introducing health care models. Research has revealed solid evidence for several factors influencing the effects of innovative community mental health care. Among key factors in the care of people with severe mental illness, home visits and joint team responsibility for both psychiatric and social care were identified. This evidence can facilitate the adaptation of successful mental health care models in Germany.

[Arts therapies in severe mental illness: are they effective?]

Arts therapies are widely used treatment strategies for people with severe mental illness. Generally, only a few randomized trials are available, however, the studies show that additional use of arts therapies reduces the appearance of negative symptoms among people with schizophrenia. The most significant evidence can be seen with music therapy. The treatment of severe depression has shown that additional music therapy improves depression. The S3 guidelines on psychosocial therapies in severe mental illness of the Germany Society for Psychiatry, Psychotherapy and Neurology (DGPPN) recommended arts therapies are with recommendation level B.

Where are the hypotheses when you need them?

Poor staff morale is a pressing problem in UK mental health services, especially for acute in-patient wards, community mental health teams and social workers. Instead of interpreting low morale using a demand-control-support model, it is suggested here that simply being honest about what should be expected of staff and stopping constant criticism and reorganisation might be more fruitful.

The effects of centralised and specialised intervention in the early course of severe unipolar depressive disorder: a randomised clinical trial

BACKGROUND

Little is known on whether centralised and specialised combined pharmacological and psychological intervention in the early phase of severe unipolar depression improve prognosis. The aim of the present study was to assess the benefits and harms of centralised and specialised secondary care intervention in the early course of severe unipolar depression.

METHODS

A randomised multicentre trial with central randomisation and blinding in relation to the primary outcome comparing a centralised and specialised outpatient intervention program with standard decentralised psychiatric treatment. The interventions were offered at discharge from first, second, or third hospitalisation due to a single depressive episode or recurrent depressive disorder. The primary outcome was time to readmission to psychiatric hospital. The data on re-hospitalisation was obtained from the Danish Psychiatric Central Register. The secondary and tertiary outcomes were severity of depressive symptoms according to the Major Depression Inventory, adherence to medical treatment, and satisfaction with treatment according to the total score on the Verona Service Satisfaction Scale-Affective Disorder (VSSS-A). These outcomes were assessed using questionnaires one year after discharge from hospital.

RESULTS

A total of 268 patients with unipolar depression were included. There was no significant difference in the time to readmission (unadjusted hazard ratio 0.89, 95% confidence interval 0.60 to 1.32; log rank: χ(2) = 0.3, d.f. = 1, p = 0.6); severity of depressive symptoms (mood disorder clinic: median 21.6, quartiles 9.7-31.2 versus standard treatment: median 20.2, quartiles 10.0-29.8; p = 0.7); or the prevalence of patients in antidepressant treatment (73.9% versus 80.0%, p = 0.2). Centralised and specialised secondary care intervention resulted in significantly higher satisfaction with treatment (131 (SD 31.8) versus 107 (SD 25.6); p<0.001).

CONCLUSIONS

Centralised and specialised secondary care intervention in the early course of severe unipolar depression resulted in no significant effects on time to rehospitalisation, severity of symptoms, or use of antidepressants, but increased patient satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00253071.

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.

Needs-oriented discharge planning for high utilisers of psychiatric services: multicentre randomised controlled trial

AIMS

Attempts to reduce high utilisation of mental health inpatient care by targeting the critical time of hospital discharge are rare. In this study, we test the effect of a needs-oriented discharge planning intervention on number and duration of psychiatric inpatient treatment episodes (primary), as well as on outpatient service use, needs, psychopathology, depression and quality of life (secondary).

METHODS

Four hundred and ninety-one adults with a defined high utilisation of mental health care gave informed consent to participate in a multicentre RCT carried out at five psychiatric hospitals in Germany (Düsseldorf, Greifswald, Regensburg, Ravensburg and Günzburg). Subjects allocated to the intervention group were offered a manualised needs-led discharge planning and monitoring intervention with two intertwined sessions administered at hospital discharge and 3 months thereafter. Outcomes were assessed at four measurement points during a period of 18 months following discharge.

RESULTS

Intention-to-treat analyses showed no effect of the intervention on primary or secondary outcomes.

CONCLUSIONS

Process evaluation pending, the intervention cannot be recommended for implementation in routine care. Other approaches, e.g. team-based community care, might be more beneficial for people with persistent and severe mental illness.

Usual and unusual care: existing practice control groups in randomized controlled trials of behavioral interventions

OBJECTIVE

To evaluate the use of existing practice control groups in randomized controlled trials of behavioral interventions and the role of extrinsic health care services in the design and conduct of behavioral trials.

METHOD

Selective qualitative review.

RESULTS

Extrinsic health care services, also known as nonstudy care, have important but under-recognized effects on the design and conduct of behavioral trials. Usual care, treatment-as-usual, standard of care, and other existing practice control groups pose a variety of methodological and ethical challenges, but they play a vital role in behavioral intervention research.

CONCLUSIONS

This review highlights the need for a scientific consensus statement on control groups in behavioral trials.

The effects of centralised and specialised combined pharmacological and psychological intervention compared with decentralised and non-specialised treatment in the early course of severe unipolar and bipolar affective disorders--design of two randomised clinical trials

Background

In unipolar, and bipolar affective disorders, there is a high risk of relapse that increases as the number of episodes increases. Naturalistic follow-up studies suggest that the progressive development of the diseases is not prevented with the present treatment modalities. It is not known whether centralised and specialised secondary care intervention initiated early after the onset of the diseases can prevent the progression and thereby improve the prognosis.

Methods

Two randomised clinical multi-centre trials comparing a centralised and specialised outpatient intervention program consisting of combined pharmacological and psychological intervention with standard decentralised psychiatric treatment. Patients discharged from their first, second, or third hospitalisation due to a manic episode or bipolar disorder (trial 1) or to a single depressive episode or recurrent depressive disorder (trial 2) were randomised. Central randomisations for both trials were stratified for the number of hospitalisations and treatment centre. The primary outcome measure for the two trials is time to re-hospitalisation with an affective episode.

Discussion

These trials are the first to evaluate the effect of a centralised and specialised intervention in patients with early severe affective disorders. The trials used a pragmatic design comparing a specialised mood disorder clinic intervention with decentralised, non-specialised standard psychiatric treatment.

Trial Registration

ClinicalTrials.gov: NCT00253071

Where the wicked problems are: the case of mental health

OBJECTIVE

To use system ideas and the concept of 'wicked problems' to frame examination of a decade-and-a-half of UK mental health policy.

METHODS

Theoretically informed policy analysis.

RESULTS

Modern health care is complex, and mental health care particularly so. In the UK the mental health system has also become a policymaking priority. Features of this system mean that many of the problems policymakers face are of the 'wicked' variety. Wicked problems are resistant. Problem formulations and their solutions are contestable. Solutions which have 'worked' in one setting may not 'work' in another, and evidence to guide change is open to challenge. Actions trigger waves with widespread system consequences. In the case of the UK's mental health field significant shifts have taken place in formulations of 'the problem' to which actions have been directed. These have included assessments of community care failure, formulations emphasising problems with the professions and, most recently, the need for action to promote mental health and wellbeing.

CONCLUSIONS

In their efforts to secure improvement in a neglected field UK policymakers have unleashed a torrent of top-down actions. Attention needs to be paid to constructing strong, system-wide, partnerships and to examining the cumulative impact of policy actions.

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.

Assessing the efficacy of a modified assertive community-based treatment programme in a developing country

BACKGROUND

A number of recently published randomized controlled trials conducted in developed countries have reported no advantage for assertive interventions over standard care models. One possible explanation could be that so-called "standard care" has become more comprehensive in recent years, incorporating some of the salient aspects of assertive models in its modus operandi. Our study represents the first randomised controlled trial assessing the effect of a modified assertive treatment service on readmission rates and other measures of outcome in a developing country.

METHODS

High frequency service users were randomized into an intervention (n = 34) and a control (n = 26) group. The control group received standard community care and the active group an assertive intervention based on a modified version of the international model of assertive community treatment. Study visits were conducted at baseline and 12 months with demographic and illness information collected at visit 1 and readmission rates documented at study end. Symptomatology and functioning were measured at both visits using the PANSS, CDSS, ESRS, WHO-QOL and SOFAS.

RESULTS

At 12 month follow-up subjects receiving the assertive intervention had significantly lower total PANSS (p = 0.02) as well as positive (p < 0.01) and general psychopathology (p = 0.01) subscales' scores. The mean SOFAS score was also significantly higher (p = 0.02) and the mean number of psychiatric admissions significantly lower (p < 0.01) in the intervention group.

CONCLUSIONS

Our results indicate that assertive interventions in a developing setting where standard community mental services are often under resourced can produce significant outcomes. Furthermore, these interventions need not be as expensive and comprehensive as international, first-world models in order to reduce inpatient days, improve psychopathology and overall levels of functioning in patients with severe mental illness.

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.