Observations from community care for serious mental illness during a controlled study

Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality

BACKGROUND

Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favour of providing care in a variety of non-hospital settings, underpins the rationale behind care in the community. A major thrust towards community care has been the development of community mental health teams (CMHT).

OBJECTIVES

To evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness compared with standard non-team management.

SEARCH STRATEGY

We searched The Cochrane Schizophrenia Group Trials Register (March 2006). We manually searched the Journal of Personality Disorders, and contacted colleagues at ENMESH, ISSPD and in forensic psychiatry.

SELECTION CRITERIA

We included all randomised controlled trials of CMHT management versus non-team standard care.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (WMD) again based on a fixed effects model.

MAIN RESULTS

CMHT management did not reveal any statistically significant difference in death by suicide and in suspicious circumstances (n=587, 3 RCTs, RR 0.49 CI 0.1 to 2.2) although overall, fewer deaths occurred in the CMHT group. We found no significant differences in the number of people leaving the studies early (n=253, 2 RCTs, RR 1.10 CI 0.7 to 1.8). Significantly fewer people in the CMHT group were not satisfied with services compared with those receiving standard care (n=87, RR 0.37 CI 0.2 to 0.8, NNT 4 CI 3 to 11). Also, hospital admission rates were significantly lower in the CMHT group (n=587, 3 RCTs, RR 0.81 CI 0.7 to 1.0, NNT 17 CI 10 to 104) compared with standard care. Admittance to accident and emergency services, contact with primary care, and contact with social services did not reveal any statistical difference between comparison groups.

AUTHORS' CONCLUSIONS

Community mental health team management is not inferior to non-team standard care in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide. The evidence for CMHT based care is insubstantial considering the massive impact the drive toward community care has on patients, carers, clinicians and the community at large.

Assertive outreach teams in London: staff experiences and perceptions. Pan-London Assertive Outreach Study, part 2

BACKGROUND

The job satisfaction, burn-out and work experiences of assertive outreach team staff are likely to be important to the model's sustainability.

AIMS

To describe self-reported views and work experiences of staff in London's 24 assertive outreach teams and to compare these with staff in community mental health teams (CMHTs) and between different types of assertive outreach team.

METHOD

Confidential staff questionnaires in London's assertive outreach teams (n=187, response rate=89%) and nine randomly selected CMHTs (n=114, response rate=75%).

RESULTS

Staff in assertive outreach teams and CMHTs were moderately satisfied with their jobs, with similar sources of satisfaction and stress. Mean scores were low or average for all sub-scales of the Maslach Burnout Inventory for the assertive outreach team and the CMHT staff, with some differences suggesting less burn-out in the assertive outreach teams. Nine of the 24 assertive outreach teams had team means in the high range for emotional exhaustion and there were significant differences between types of assertive outreach team in some components of burn-out and satisfaction.

CONCLUSIONS

These findings are encouraging, but repeated investigation is needed when assertive outreach teams have been established for longer.

Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality

BACKGROUND

Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favour of providing care in a variety of non-hospital settings underpins the rationale behind care in the community. A major thrust towards community care has been the development of community mental health teams (CMHT).

OBJECTIVES

To evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1997), the Cochrane Library (1998, Issue 2), EMBASE (1980-1997), MEDLINE (1966-1997), PsycLIT (1974-1997) and SCISEARCH (1997) were undertaken. The Journal of Personality Disorders was hand searched, and contact was made with colleagues at ENMESH, ISSPD and in forensic psychiatry.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of CMHT management versus non-team standard care.

DATA COLLECTION AND ANALYSIS

The selection of trials, assessment of quality and data extraction was undertaken independently and in parallel by two reviewers. Where possible the data were entered into RevMan and an intention-to-treat analysis undertaken. Tests of heterogeneity were undertaken.

MAIN RESULTS

CMHT management may be associated with fewer deaths by suicide and in suspicious circumstances (OR 0.32 CI 0.09-1.12). It causes less people to be dissatisfied with their care (OR 0.34 CI 0.2-0.59) and to leave the studies early (OR 0.61 CI 0.45-0.83). No clear difference was found in admission rates, overall clinical outcomes and duration of in-patient hospital treatment, although this was partly a consequence of poorly presented data.

REVIEWER'S CONCLUSIONS

Community mental health team management is not inferior to non-team standard care in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide.

[Economic perspectives in the care and treatment of patients diagnosed with schizophrenia]

OBJECTIVE

To consider the main problems associated with care and treatment of patients with diagnosis of schizophrenia in the light of the more recent literature of the economic aspects of this pathology.

METHOD

An analysis of the literature related to the social costs of schizophrenia, the economic analysis of different health-care models, and the evaluation of the costs of antipsychotic treatments has been carried out.

RESULTS

Schizophrenia is a pathology creating huge social costs. The health costs associated with the care of schizophrenia take up a significant amount of the resources of healthcare systems in the principal industrialised countries. Indirect costs, due mainly to the patients' exclusion from work, exceed the direct costs of treatment. In those countries where community care has been supported by a real organisational effort to create community and residential services, it has proved to be a cost-effective solution compared with psychiatric hospital-based care and provides patients and family members with better results. The introduction of new antipsychotic drugs and the development of psychosocial support could represent the means of encouraging new healthcare strategies.

CONCLUSIONS

From an economic perspective, the organisation, technological means, and strategies which would allow the available resources to be invested in a rational way must be considered. Consideration of these issues appears to be unavoidable today, not only for the administrators and the policy makers but also for mental health service professionals.

Home-based versus hospital-based care for serious mental illness. Controlled cost-effectiveness study over four years

BACKGROUND

The Daily Living Programme (DLP) offered intensive home-based care with problem-centred case management for seriously mentally ill people facing crisis admission to the Maudsley Hospital, London. The cost-effectiveness of the DLP was examined over four years.

METHOD

A randomised controlled study examined cost-effectiveness of DLP versus standard in/out-patient hospital care over 20 months, followed by a randomised controlled withdrawal of half the DLP patients into standard care. Three patient groups were compared over 45 months: DLP throughout the period, DLP for 20 months followed by standard care, and standard care throughout. Bivariate and multivariate analyses were conducted (the latter to standardise for possible inter-sample differences stemming from sample attrition and to explore sources of within-sample variation).

RESULTS

The DLP was more cost-effective than control care over months 1-20, and also over the full 45-month period, but the difference between groups may have disappeared by the end of month 45.

CONCLUSIONS

The reduction of the cost-effectiveness advantage for home-based care was perhaps partly due to the attenuation of DLP care, although sample attrition left some comparisons under-powered.

Perceived sources of work stress and satisfaction among hospital and community mental health staff, and their relation to mental health, burnout and job satisfaction

This questionnaire study examined perceived sources of stress and satisfaction at work among 121 mental health staff members. Five factors were derived from principal component analysis of sources of work stress items (stress from: role, poor support, clients, future, and overload), and accounted for 70% of the total variance. Four factors were derived from the items related to sources of job satisfaction (satisfaction from: career, working with people, management, and money), accounting for 68% of the variance. The associations of these factors with sociodemographic and job characteristics were examined, and they were entered as explanatory variables into regression models predicting mental health, burnout, and job satisfaction. Stress from "overload" was associated with being based outside an in-patient ward, and with emotional exhaustion and worse mental health. Stress related to the "future" was associated with not being white. Stress from "clients" was associated with the "depersonalization" component of burnout. Higher job satisfaction was associated with "management" and "working with people" as sources of satisfaction, whereas emotional exhaustion and poorer mental health were associated with less "career" satisfaction.