Case management for schizophrenic patients at risk for rehospitalization: a case control study

Overview of post-discharge predictors for psychiatric re-hospitalisations: a systematic review of the literature

BACKGROUND

High levels of hospital readmission (rehospitalisation rates) is widely used as indicator of a poor quality of care. This is sometimes also referred to as recidivism or heavy utilization. Previous studies have examined a number of factors likely to influence readmission, although a systematic review of research on post-discharge factors and readmissions has not been conducted so far. The main objective of this review was to identify frequently reported post-discharge factors and their effects on readmission rates.

METHODS

Studies on the association between post-discharge variables and readmission after an index discharge with a main psychiatric diagnosis were searched in the bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management, OpenGrey and Google Scholar. Relevant articles published between January 1990 and June 2014 were included. A systematic approach was used to extract and organize in categories the information about post-discharge factors associated with readmission rates.

RESULTS

Of the 760 articles identified by the initial search, 80 were selected for this review which included a total number of 59 different predictors of psychiatric readmission. Subsequently these were grouped into four categories: 1) individual vulnerability factors, 2) aftercare related factors, 3) community care and service responsiveness, and 4) contextual factors and social support. Individual factors were addressed in 58 papers and were found to be significant in 37 of these, aftercare factors were significant in 30 out of the 45 papers, community care and social support factors were significant in 21 out of 31 papers addressing these while contextual factors and social support were significant in all seven papers which studied them.

CONCLUSIONS

This review represents a first attempt at providing an overview of post-discharge factors previously studied in association with readmission. Hence, by mapping out the current research in the area, it highlights the gaps in research and it provides guidance future studies in the area.

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.

Psychiatric readmissions and their association with environmental and health system characteristics: a systematic review of the literature

BACKGROUND

Psychiatric readmissions have been studied at length. However, knowledge about how environmental and health system characteristics affect readmission rates is scarce. This paper systemically reviews and discusses the impact of health and social systems as well as environmental characteristics for readmission after discharge from inpatient care for patients with a psychiatric diagnosis.

METHODS

Comprehensive literature searches were conducted in the electronic bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. In addition, Google Scholar was utilised. Relevant publications published between January 1990 and June 2014 were included. No restrictions regarding language or publication status were imposed. A qualitative synthesis of the included studies was performed. Variables describing system and environmental characteristics were grouped into three groups: those capturing regulation, financing system and governance; those capturing capacity, organisation and structure; and those capturing environmental variables.

RESULTS

Of the 734 unique articles identified in the original search, 35 were included in the study. There is a limited number of studies on psychiatric readmissions and their association with environmental and health system characteristics. Even though the review reveals an extensive list of characteristics studied, most characteristics appear in a very limited number of articles. The most frequently studied characteristics are related to location (local area, district/region/country). In most cases area differences were found, providing strong indication that the risk of readmission not only relates to patient characteristics but also to system and/or environmental factors that vary between areas. The literature also points in the direction of a negative association of institutional length of stay and community aftercare with readmission for psychiatric patients.

CONCLUSION

This review shows that analyses of system level variables are scarce. Furthermore they differ with respect to purpose, choice of system characteristics and the way these characteristics are measured. The lack of studies looking at the relationship between readmissions and provider payment models is striking. Without the link to provider payment models and other health system characteristics related to regulation, financing system and governance structure it becomes more difficult to draw policy implications from these analyses.

[Case management for moderate-need patients and recovery: what can we learn from experimental and quasi-experimental studies?]

How should case management be organized for people who have severe mental illness, but do not need Assertive Community Treatment or similar high-intensity programs? To address this question, the authors conducted a systematic review of studies published in English between 1980 and 2010. Five main case management models were identified: broker, clinical case management, rehabilitation, strengths and intensive case management. In all, 11 experimental and 13 quasi-experimental studies evaluating case management programs not targeted at a typical ACT clientele were identified. These studies suggest that the strengths model, which can be viewed as a way of structuring intensive case management for a moderate-need population, is the best supported by evidence if one desires to see effects not only on hospital days, but also on other domains such as symptoms, quality of life and social functioning. It is also compatible with a recovery orientation. The evidence in its favor, however, remains modest.

WITHDRAWN: Assertive community treatment for people with severe mental disorders

BACKGROUND

Assertive Community Treatment (ACT) was developed in the early 1970s as a response to the closing down of psychiatric hospitals. ACT is a team-based approach aiming at keeping ill people in contact with services, reducing hospital admissions and improving outcome, especially social functioning and quality of life.

OBJECTIVES

To determine the effectiveness of Assertive Community Treatment (ACT) as an alternative to i. standard community care, ii. traditional hospital-based rehabilitation, and iii. case management. For each of the three comparisons the main outcome indices were i. remaining in contact with the psychiatric services, ii. extent of psychiatric hospital admissions, iii. clinical and social outcome and iv. costs.

SEARCH STRATEGY

Electronic searches of CINAHL (1982-1997), the Cochrane Schizophrenia Group's Register of trials (1997), EMBASE (1980-1997), MEDLINE (1966-1997), PsycLIT (1974-1997) and SCISEARCH (1997) were undertaken. References of all identified studies were searched for further trial citations.

SELECTION CRITERIA

The inclusion criteria were that studies should i. be randomised controlled trials, ii. have compared ACT to standard community care, hospital-based rehabilitation, or case management and iii. have been carried out on people with severe mental disorder the majority of whom were aged from 18 to 65. Studies of ACT were defined as those in which the investigators described the intervention as "Assertive Community Treatment" or one of its synonyms. Studies of ACT as an alternative to hospital admission, hospital diversion programmes, for those in crisis, were excluded. The reliability of the inclusion criteria were evaluated.

DATA COLLECTION AND ANALYSIS

Three types of outcome data were available: i. categorical data, ii. numerical data based on counts of real life events (count data) and iii. numerical data collected by standardised instruments (scale data). Categorical data were extracted twice and then cross-checked. Peto Odds Ratios and the number needed to treat (NNT) were calculated. Numerical count data were extracted twice and cross-checked. Count data could not be combined across studies for technical reasons (the data were skewed) but all relevant observations based on count data were reported in the review. Numerical scale data were subject to a quality assessment. The validity of the quality assessment was itself assessed. Numerical scale data of suitable quality were combined using the standardised mean difference statistic where possible, otherwise the data were reported in the text or 'Other data tables' of the review.

MAIN RESULTS

ACT versus standard community care Those receiving ACT were more likely to remain in contact with services than people receiving standard community care (OR 0.51, 99%CI 0.37-0.70). People allocated to ACT were less likely to be admitted to hospital than those receiving standard community care (OR 0.59, 99%CI 0.41-0.85) and spent less time in hospital. In terms of clinical and social outcome, significant and robust differences between ACT and standard community care were found on i. accommodation status, ii. employment and iii. patient satisfaction. There were no differences between ACT and control treatments on mental state or social functioning. ACT invariably reduced the cost of hospital care, but did not have a clear cut advantage over standard care when other costs were taken into account.ACT versus hospital-based rehabilitation services Those receiving ACT were no more likely to remain in contact with services than those receiving hospital-based rehabilitation, but confidence intervals for the odds ratio were wide. People getting ACT were significantly less likely to be admitted to hospital than those receiving hospital-based rehabilitation (OR 0.2, 99%CI 0.09-0.46) and spent less time in hospital. Those allocated to ACT were significantly more likely to be living independently (OR (for not living independently) 0.19, 99%CI 0.06-0.54), but there were no other significant and robust differences in clinical or social outcome. There was insufficient data on costs to permit comparison.ACT versus case management There were no data on numbers remaining in contact with the psychiatric services or on numbers admitted to hospital. People allocated to ACT consistently spent fewer days in hospital than those given case management. There was insufficient data to permit robust comparisons of clinical or social outcome. The cost of hospital care was consistently less for those allocated to ACT, but ACT did not have a clear cut advantage over case management when other costs were taken into account.

AUTHORS' CONCLUSIONS

ACT is a clinically effective approach to managing the care of severely mentally ill people in the community. ACT, if correctly targeted on high users of in-patient care, can substantially reduce the costs of hospital care whilst improving outcome and patient satisfaction. Policy makers, clinicians, and consumers should support the setting up of ACT teams.

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. ICM evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (less than 20) and high intensity input.

OBJECTIVES

To assess the effects of Intensive Case Management (caseload <20) in comparison with non-Intensive Case Management (caseload > 20) and with standard community care in people with severe mental illness. To evaluate whether the effect of ICM on hospitalisation depends on its fidelity to the ACT model and on the setting.

SEARCH STRATEGY

For the current update of this review we searched the Cochrane Schizophrenia Group Trials Register (February 2009), which is compiled by systematic searches of major databases, hand searches and conference proceedings.

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 Intensive Case Management, non-Intensive Case Management or standard care were compared. Outcomes such as service use, adverse effects, global state, social functioning, mental state, behaviour, quality of life, satisfaction and costs were sought.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes we calculated relative risk (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% confidence interval (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.

MAIN RESULTS

We included 38 trials (7328 participants) in this review. The trials provided data for two comparisons: 1. ICM versus standard care, 2. ICM versus non-ICM.1. ICM versus standard care Twenty-four trials provided data on length of hospitalisation, and results favoured Intensive Case Management (n=3595, 24 RCTs, MD -0.86 CI -1.37 to -0.34). There was a high level of heterogeneity, but this significance still remained when the outlier studies were excluded from the analysis (n=3143, 20 RCTs, MD -0.62 CI -1.00 to -0.23). Nine studies found participants in the ICM group were less likely to be lost to psychiatric services (n=1633, 9 RCTs, RR 0.43 CI 0.30 to 0.61, I²=49%, p=0.05).One global state scale did show an Improvement in global state for those receiving ICM, the GAF scale (n=818, 5 RCTs, MD 3.41 CI 1.66 to 5.16). Results for mental state as measured through various rating scales, however, were equivocal, with no compelling evidence that ICM was really any better than standard care in improving mental state. No differences in mortality between ICM and standard care groups occurred, either due to 'all causes' (n=1456, 9 RCTs, RR 0.84 CI 0.48 to 1.47) or to 'suicide' (n=1456, 9 RCTs, RR 0.68 CI 0.31 to 1.51).Social functioning results varied, no differences were found in terms of contact with the legal system and with employment status, whereas significant improvement in accommodation status was found, as was the incidence of not living independently, which was lower in the ICM group (n=1185, 4 RCTs, RR 0.65 CI 0.49 to 0.88).Quality of life data found no significant difference between groups, but data were weak. CSQ scores showed a greater participant satisfaction in the ICM group (n=423, 2 RCTs, MD 3.23 CI 2.31 to 4.14).2. ICM versus non-ICM The included studies failed to show a significant advantage of ICM in reducing the average length of hospitalisation (n=2220, 21 RCTs, MD -0.08 CI -0.37 to 0.21). They did find ICM to be more advantageous than non-ICM in reducing rate of lost to follow-up (n=2195, 9 RCTs, RR 0.72 CI 0.52 to 0.99), although data showed a substantial level of heterogeneity (I²=59%, p=0.01). Overall, no significant differences were found in the effects of ICM compared to non-ICM for broad outcomes such as service use, mortality, social functioning, mental state, behaviour, quality of life, satisfaction and costs.3. Fidelity to ACT Within 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 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 CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but 'baseline hospital use' result is still significantly influencing time in hospital (regression coefficient -0.18 CI -0.29 to -0.07, p=0.0027).

AUTHORS' CONCLUSIONS

ICM was found effective in ameliorating many outcomes relevant to people with severe mental illnesses. Compared to standard care ICM was shown to 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. ICM is of value at least to people with severe mental illnesses who are in the sub-group of those with a high level of hospitalisation (about 4 days/month in past 2 years) and the intervention should be performed close to the original model.It is not clear, however, what 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, but currently we know of no review comparing non-ICM with standard care and this should be undertaken.

Co-occurring depressive symptoms in the older patient with schizophrenia

Clinicians treating older patients with schizophrenia are often challenged by patients presenting with both depressive and psychotic features. The presence of co-morbid depression impacts negatively on quality of life, functioning, overall psychopathology and the severity of co-morbid medical conditions. Depressive symptoms in patients with schizophrenia include major depressive episodes (MDEs) that do not meet criteria for schizoaffective disorder, MDEs that occur in the context of schizoaffective disorder and subthreshold depressive symptoms that do not meet criteria for MDE. Pharmacological treatment of patients with schizophrenia and depression involves augmenting antipsychotic medications with antidepressants. Recent surveys suggest that clinicians prescribe antidepressants to 30% of inpatients and 43% of outpatients with schizophrenia and depression at all ages. Recent trials addressing the efficacy of this practice have evaluated selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, fluvoxamine and citalopram. These trials have included only a small number of subjects and few older subjects participated; furthermore, the efficacy results have been mixed. Although no published controlled psychotherapeutic studies have specifically targeted major depression or depressive symptoms in older patients with schizophrenia, psychosocial interventions likely play a role in any comprehensive management plan in this population of patients.Our recommendations for treating the older patient with schizophrenia and major depression involve a stepwise approach. First, a careful diagnostic assessment to rule out medical or medication causes is important as well as checking whether patients are adherent to treatments. Clinicians should also consider switching patients to an atypical antipsychotic if they are not taking one already. In addition, dose optimization needs to be targeted towards depressive as well as positive and negative psychotic symptoms. If major depression persists, adding an SSRI is a reasonable next step; one needs to start with a low dose and then cautiously titrate upward to reduce depressive symptoms. If remission is not achieved after an adequate treatment duration (8-12 weeks) or with an adequate dose (similar to that used for major depression without schizophrenia), switching to another agent or adding augmenting therapy is recommended.We recommend treating an acute first episode of depression for at least 6-9 months and consideration of longer treatment for patients with residual symptoms, very severe or highly co-morbid major depression, ongoing episodes or recurrent episodes. Psychosocial interventions aimed at improving adherence, quality of life and function are also recommended. For patients with schizophrenia and subsyndromal depression, a similar approach is recommended.Psychosis accompanying major depression in patients without schizophrenia is common in elderly patients and is considered a primary mood disorder; for these reasons, it is an important syndrome to consider in the differential diagnosis of older patients with mood and thought disturbance. Treatment for this condition has involved electroconvulsive therapy (ECT) as well as combinations of antidepressant and antipsychotic medications. Recent evidence suggests that combination treatment may not be any more effective than antidepressant treatment alone and ECT may be more efficacious overall.

Frequency and effects of psychosocial interventions additional to olanzapine treatment in routine care of schizophrenic patients

BACKGROUND

Guidelines for the treatment of schizophrenia recommend the combination of pharmacologic and psychosocial interventions. There is a lack of data on the utilization and effects of psychosocial interventions additional to neuroleptic treatment in routine care of schizophrenic patients.

METHOD

In a drug utilization study 495 psychiatrists documented patient and disease characteristics of 1,711 schizophrenic outpatients treated with olanzapine. Data were recorded at five visits during an observation period of 6 months.

RESULTS

Psychosocial interventions were reported in 30% of all patients. Compared to patients who were treated with olanzapine alone (nPSI), patients receiving psychosocial interventions (PSI) were more likely to be unmarried and unemployed, and showed significantly higher impairment on relevant psychopathological and psychosocial parameters (e.g. PANSS, GAF, LQLP). After 6 months of treatment with olanzapine patients improved significantly in respect to their schizophrenic symptoms, psychosocial functioning, and quality of life. Patients receiving psychoeducation showed a higher degree of improvement than the other patients. They were more ill at the beginning of the study, but less ill at the end of the study. Patients receiving psychoeducation showed a trend to better medication compliance.

CONCLUSIONS

The data suggest that psychosocial interventions are a frequently used mode of treatment especially for severe cases of schizophrenia Psychoeducation appears to be especially effective for this patient group with a positive impact not only on psychosocial but also on psychopathological criteria of outcome.

Assertive community treatment for people with severe mental disorders

BACKGROUND

Assertive Community Treatment (ACT) was developed in the early 1970s as a response to the closing down of psychiatric hospitals. ACT is a team-based approach aiming at keeping ill people in contact with services, reducing hospital admissions and improving outcome, especially social functioning and quality of life.

OBJECTIVES

To determine the effectiveness of Assertive Community Treatment (ACT) as an alternative to i. standard community care, ii. traditional hospital-based rehabilitation, and iii. case management. For each of the three comparisons the main outcome indices were i. remaining in contact with the psychiatric services, ii. extent of psychiatric hospital admissions, iii. clinical and social outcome and iv. costs.

SEARCH STRATEGY

Electronic searches of CINAHL (1982-1997), the Cochrane Schizophrenia Group's Register of trials (1997), EMBASE (1980-1997), MEDLINE (1966-1997), PsycLIT (1974-1997) and SCISEARCH (1997) were undertaken. References of all identified studies were searched for further trial citations.

SELECTION CRITERIA

The inclusion criteria were that studies should i. be randomised controlled trials, ii. have compared ACT to standard community care, hospital-based rehabilitation, or case management and iii. have been carried out on people with severe mental disorder the majority of whom were aged from 18 to 65. Studies of ACT were defined as those in which the investigators described the intervention as "Assertive Community Treatment" or one of its synonyms. Studies of ACT as an alternative to hospital admission, hospital diversion programmes, for those in crisis, were excluded. The reliability of the inclusion criteria were evaluated.

DATA COLLECTION AND ANALYSIS

Three types of outcome data were available: i. categorical data, ii. numerical data based on counts of real life events (count data) and iii. numerical data collected by standardised instruments (scale data). Categorical data were extracted twice and then cross-checked. Peto Odds Ratios and the number needed to treat (NNT) were calculated. Numerical count data were extracted twice and cross-checked. Count data could not be combined across studies for technical reasons (the data were skewed) but all relevant observations based on count data were reported in the review. Numerical scale data were subject to a quality assessment. The validity of the quality assessment was itself assessed. Numerical scale data of suitable quality were combined using the standardised mean difference statistic where possible, otherwise the data were reported in the text or 'Other data tables' of the review.

MAIN RESULTS

ACT versus standard community care Those receiving ACT were more likely to remain in contact with services than people receiving standard community care (OR 0.51, 99%CI 0.37-0.70). People allocated to ACT were less likely to be admitted to hospital than those receiving standard community care (OR 0.59, 99%CI 0.41-0.85) and spent less time in hospital. In terms of clinical and social outcome, significant and robust differences between ACT and standard community care were found on i. accommodation status, ii. employment and iii. patient satisfaction. There were no differences between ACT and control treatments on mental state or social functioning. ACT invariably reduced the cost of hospital care, but did not have a clear cut advantage over standard care when other costs were taken into account. ACT versus hospital-based rehabilitation services Those receiving ACT were no more likely to remain in contact with services than those receiving hospital-based rehabilitation, but confidence intervals for the odds ratio were wide. People getting ACT were significantly less likely to be admitted to hospital than those receiving hospital-based rehabilitation (OR 0.2, 99%CI 0.09-0.46) and spent less time in hospital. Those allocated to ACT were significantly more likely to be living independently (OR (for not living independently) 0.19, 99%CI 0.06-0. (A

Case management for people with severe mental disorders

BACKGROUND

Since the 1960s, in many parts of the world, large psychiatric were closed down and people were treated in outpatient clinics, day centres or community mental health centres. Rising readmission rates suggested that this type of community care may be less effective than anticipated. In the 1970s case management arose as a means of co-ordinating the care of severely mentally ill people in the community.

OBJECTIVES

To determine the effects of case management as an approach to caring for severely mentally ill people in the community. Case management was compared against standard care on four main indices: (i) numbers remaining in contact with the psychiatric services; (ii) extent of psychiatric hospital admissions; (iii) clinical and social outcome; and (iv) costs.

SEARCH STRATEGY

Electronic searches of CINAHL (1997), the Cochrane Schizophrenia Group's Register of trials (1997), EMBASE (1980-1995), MEDLINE (1966-1995), PsycLIT (1974-1995) and SCISEARCH (1997) were undertaken. References of all identified studies were searched for further trial citations.

SELECTION CRITERIA

The inclusion criteria were that studies should be randomised controlled trials that (i) had compared case management to standard community care; and (ii) had involved people with severe mental disorder mainly between the ages of 18-65. Studies of case management were defined as those in which the investigators described the intervention as 'case' or 'care' management rather than 'Assertive Community Treatment' or 'ACT'.

DATA COLLECTION AND ANALYSIS

A study was carried out to test the reliability of the inclusion criteria. Categorical data were extracted twice and then cross-checked, any disagreements being resolved by discussion. Odds ratios and the number needed to treat were estimated. Continuous data collected by a measuring instrument was only included if the instrument (i) had been described in a peer-reviewed journal; (ii) was a self-report or had been completed by an independent rater; and (iii) provided a summary score for a broad area of functioning. Normally distributed continuous data were included if means and standard deviations were available. Non-normal data were included if analysed either after transformation or using non-parametric methods. Tests for heterogeneity were conducted.

MAIN RESULTS

Case management increased the numbers remaining in contact with services (for case management odds ratio = 0.70; 99%CI 0.50-0. 98; n=1210). Case management approximately doubled the numbers admitted to psychiatric hospital (OR 1.84; 99% CI 1.33-2.57; n=1300). Except for a positive finding on compliance, from one study, case management showed no significant advantages over standard care on any psychiatric or social variable. Cost data did not favour case management but insufficient information was available to permit definitive conclusions.

REVIEWER'S CONCLUSIONS

Case management ensures that more people remain in contact with psychiatric services (one extra person remains in contact for every 15 people who receive case management), but it also increases hospital admission rates. Present evidence suggests that case management also increases duration of hospital admissions, but this is not certain. Whilst there is some evidence that case management improves compliance, it does not produce clinically significant improvement in mental state, social functioning, or quality of life. There is no evidence that case management improves outcome on any other clinical or social variables. Present evidence suggests that case management increases health care costs, perhaps substantially, although this is not certain. In summary, therefore, case management is an intervention of questionable value, to the extent that it is doubtful whether it should be offered by community psychiatric services. It is hard to see how policy makers who subscribe to an evidence-based approach can justify retaining case management as 'the cornerstone' of community mental hea