Intensive case management for the severely mentally ill. Controlled trial. Intellectual functioning and outcome of patients with severe psychotic illness randomised to intensive case management. Report from the UK700 trial. Intensive case management in Australia: a randomized controlled trial. Heavy users of acute psychiatric beds: randomized controlled trial of enhanced community management in an outer London borough. Outcome of case management based on the strengths model compared to standard care. A randomised controlled trial. Randomized trial of general hospital and residential alternative care for patients with severe and persistent mental illness. Family-based intervention for schizophrenic patients in China. A randomised controlled trial. Are day hospitals effective for acutely ill psychiatric patients? A European multicenter randomized controlled trial. Effectiveness of an intervention to reduce sickness absence in patients with emotional distress or minor mental disorders: a randomized controlled effectiveness trial. A trial of problem-solving by community mental health nurses for anxiety, depression and life difficulties among general practice patients. The CPN-GP study. Outcomes of an effectiveness trial of cognitive-behavioural intervention by mental health nurses in schizophrenia. Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial. Exploratory cluster randomised controlled trial of shared care development for long-term mental illness. A comparative trial of home and hospital psychiatric care. One-year follow-up. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Psychoeducation in schizophrenia: 7-year follow-up concerning rehospitalization and days in hospital in the Munich Psychosis Information Project Study. A randomized trial of assertive community treatment for homeless persons with severe mental illness. A randomized, controlled trial of an intensive community nurse-supported discharge program in preventing hospital readmissions of older patients with chronic lung disease. Home-based versus hospital-based care for people with serious mental illness. A whole system study of intermediate care services for older people. Comparative effectiveness of three approaches to serving people with severe mental illness and substance abuse disorders. A randomized controlled trial of a mutual support group for family caregivers of patients with schizophrenia. Advance directives for patients compulsorily admitted to hospital with serious mental illness. Randomised controlled trial. A controlled trial of home-based acute psychiatric services. I: Clinical and social outcome. The effect on hospital admissions of psychiatric case management involving general practitioners: preliminary results. Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Assertive case management in three CMHCs: a controlled study. Psychiatric hospital versus community treatment: the results of a randomised trial. A randomized controlled trial of a community nurse-supported hospital discharge programme in older patients with chronic heart failure.
The aim was to compare the efficacy of intensive clinical case management (ICM) with standard community care in the management of 'hard to treat' patients with a severe mental illness.
                A randomised controlled trial was carried out in East Lambeth, a deprived area of inner London. Seventy people with psychosis designated as 'hard to treat' by referring teams were included; 35 were randomised to ICM (case load eight patients per worker), and 35 to standard care, which offered follow-up by a community psychiatric nursing service (30 patients per worker). Outcome measures were admissions and hospital bed utilisation; contact with services; symptomatology; social behaviour; social functioning; quality of life; patients' satisfaction with care at 9 and 18 months.
                There were no differences in patients' symptoms, social behaviour or social functioning. Quality of life was significantly improved in patients receiving ICM at 9 months. Satisfaction with care was significantly greater among case-managed patients. All ICM patients remained in contact with services throughout the study, while six control patients were refusing all contact with services at 18 months.
                ICM failed to improve the clinical outcome of 'hard to treat' patients. The service was successful in maintaining contact with patients, was greatly appreciated and had a positive effect on their perceived quality of life. Little research has been carried out on the benefits of intensive case management (ICM) for people with borderline IQ and severe mental illness.
                To compare outcome and costs of care of patients with severe psychotic illness with borderline IQ to patients of normal IQ and to assess whether ICM is more beneficial for the former than for the latter.
                The study utilises data from the UK700 multi-centre randomised controlled trial of case management. The main outcome measure was the number of days spent in hospital for psychiatric reasons. Secondary outcomes were costs of care and clinical outcome.
                ICM was significantly more beneficial for borderline-IQ patients than those of normal IQ in terms of reductions in days spent in hospital, hospital admissions, total costs and needs and increased satisfaction.
                ICM appears to be a cost-effective strategy for a subgroup of patients with severe psychosis with cognitive deficits. This study compared intensive case management (ICM) with standard clinical case management in a well-resourced community mental health service in Australia. A total of 73 severely disabled clients of an existing clinical service were randomly allocated to either ICM (caseload 10 clients per clinician) or standard case management (caseload up to 30 clients per clinician) and followed up for 12 months. A greater proportion of clients receiving ICM showed improved social functioning, these clients had fewer psychiatric hospital admissions involving police, and were more likely to engage and remain in treatment compared to those who received standard case management. Clients receiving ICM did not show a reduction in hospitalization duration or total number of episodes. It is suggested that future studies of ICM should focus on which aspects of treatment produce positive outcomes, how they can be applied to routine clinical settings, and over what period of time outcomes are sustained. Heavy users of psychiatric services, often defined as the population that uses the most beds, consume a large part of the resources used by the whole service, despite being relatively small in number. Any intervention that reduces heavy use is therefore likely to lead to significant savings, and enhancement of standard care using a form of intensive case management akin to assertive community treatment was thought to be a pragmatic strategy for testing in this group.
                The effectiveness of enhanced community management (ECM) was compared with standard care alone in heavy users, who represented the 10% of patients with the highest number of hospital admissions and occupied bed days over the previous 6.5 years in an outer London borough. One hundred and ninety-three patients were randomly assigned to ECM or standard care and their use of services was determined after 1 and 2 years, with assessments of costs, clinical symptoms, needs, and social function made before entry into the study and after 1 and 2 years.
                Despite a 24 fold increase in community contacts in the study group, there were no significant differences between the two groups in any of the main outcome measures. Small savings on in-patient and day-hospital service costs were counterbalanced by the increased costs of outpatient and community care for the subjects assigned to ECM. Clinical outcome data derived from interviews in two-thirds of the subjects were similar in both groups.
                Providing additional intensive community focused care to a group of heavy users of psychiatric in-patient services in an outer London borough does not lead to any important clinical gains or reduced costs of psychiatric care. The outcome of less intensive case management services, such as the strengths model, is still inconclusive, which suggests a need for more controlled studies. The aim of the present study was to investigate the outcome of a strengths model of case management service (SCM) compared to standard care.
                Seventy-seven clients with a mental illness and a serious impairment in functioning in social contacts, housing or work situation were randomly allocated to SCM or standard care. Outcome was assessed with regard to use of psychiatric services, changes in symptomatology, psychosocial functioning, social network, needs for care, quality of life and client satisfaction with care. The follow-up period was 36 months.
                The results showed a greater reduction in needs for care in clients receiving SCM. No differences in clinical or social outcome were shown. Clients receiving SCM also used significantly less days in psychiatric inpatient services and were generally more satisfied with the psychiatric services offered.
                SCM failed to improve clinical and social outcome compared to standard care, but was more successful in reducing days spent in hospital, and the clients were also more satisfied with the service compared to standard care. Severe and persistent mental illnesses are often lifelong and characterized by intermittent exacerbations requiring hospitalization. Providing needed care within budgetary constraints to this largely publicly subsidized population requires technologies that reduce costly inpatient episodes. The authors report a prospective randomized trial to test the clinical effectiveness of a model of acute residential alternative treatment for patients with persistent mental illness requiring hospital-level care.
                Patients enrolled in the Montgomery County, Md., public mental health system who experienced an illness exacerbation and were willing to accept voluntary treatment were randomly assigned to the acute psychiatric ward of a general hospital or a community residential alternative. There were no psychopathology-based exclusion criteria. Treatment episode symptom improvement, satisfaction, discharge status, and 6-month pre- and postepisode acute care utilization, psychosocial functioning, and patient satisfaction were assessed.
                Of 185 patients, 119 (64%) were successfully placed at their assigned treatment site. Case mix data indicated that patients treated in the hospital (N = 50) and the alternative (N = 69) were comparably ill. Treatment episode symptom reduction and patient satisfaction were comparable for the two settings. Nine (13%) of 69 patients randomly assigned to the alternative required transfer to a hospital unit; two (4%) of 50 patients randomly assigned to the hospital could not be stabilized and required transfer to another facility. Psychosocial functioning, satisfaction, and acute care use in the 6 months following admission were comparable for patients treated in the two settings and did not differ significantly from functioning before the acute episode.
                Hospitalization is a frequent and high-cost consequence of severe mental illness. For patients who do not require intensive general medical intervention and are willing to accept voluntary treatment, the alternative program model studied provides outcomes comparable to those of hospital care. We developed and evaluated a comprehensive, ongoing intervention for families of schizophrenic patients appropriate for China's complex family relationships and unique social environment.
                Sixty-three DSM-III-R schizophrenic patients living with family members were enrolled when admitted to hospital and randomly assigned to receive standard care or a family-based intervention that included monthly 45-minute counselling sessions focused on the management of social and occupational problems, medication management, family education, family group meetings, and crisis intervention.
                At 6, 12, and 18-month follow-ups by blind evaluators, the proportion of subjects rehospitalised was lower, the duration of rehospitalisation was shorter, and the duration of employment was longer in the experimental group than in the control group; these differences were statistically significant at the 12 and 18-month follow-ups and were not explained by differences in drug compliance. Family intervention was associated with significantly lower levels of family burden.
                This intervention is less costly than standard treatment, is suitable for urban families of schizophrenic patients in China and feasible given the constraints of the Chinese mental health system. Acute psychiatric day care has been proposed as an alternative to conventional inpatient care, yet the evidence of its effectiveness is inconsistent and based only on single-site studies in 3 countries. The aim of this multicenter randomized controlled trial was to establish the effectiveness of acute day hospital care in a large sample across a range of mental health care systems.
                The trial was conducted from December 2000 to September 2003 in 5 European countries, with a sample of 1117 voluntarily admitted patients. Immediately before or very shortly after admission to the participating psychiatric facilities, patients were randomly allocated to treatment in a day hospital or an inpatient ward. Psychopathology, treatment satisfaction, subjective quality of life, and social disabilities were assessed at admission, at discharge, and 3 and 12 months after discharge. An intention-to-treat analysis was conducted using fixed-effects linear models with structured error covariance matrices and covariates.
                Day hospital care was as effective as conventional inpatient care with respect to psychopathologic symptoms, treatment satisfaction, and quality of life. It was more effective on social functioning at discharge and at the 3- and 12-month follow-up assessments.
                This study, which has more than doubled the existing evidence base, has shown that day hospital care is as effective on clinical outcomes as conventional inpatient care and more effective on social outcomes.
                ClinicalTrials.gov identifier NCT00153959. The purpose of this study was to evaluate the effectiveness of an activating intervention designed to reduce sick leave duration in patients with emotional distress or minor mental disorders.
                In a 1.5-year randomized controlled trial, 194 patients with minor mental disorders received either an experimental intervention by social workers or general practitioners' usual care. The intervention focused on understanding causes, developing and implementing problem-solving strategies and promoting early work resumption. Outcome measures were sick leave duration, mental health and physical health (questionnaires included the Hospital Anxiety and Depression Scale, the Four-Dimensional Symptom Questionnaire and SF-36), all measured at baseline at and 3, 6 and 18 months later. Multilevel analyses were used to evaluate differences between groups.
                The groups did not differ significantly on any of the outcome measures, except that the experimental group reported higher satisfaction with treatment.
                Although the intervention has benefits, it was not successful at its primary goal (i.e., to reduce sick leave duration in patients with emotional distress or minor mental disorders). Programs aimed at the reduction of sick leave duration may yield better results if targeted at patients with more severe emotional problems than at those with exclusively emotional distress or minor mental disorders, or if delivered by caregivers who are closer to the work environment than are social workers, such as occupational physicians. To compare the effectiveness of community mental health nurse (CMHN) problem-solving and generic CMHN care, against usual general practitioner (GP) care in reducing symptoms, alleviating problems, and improving social functioning and quality of life for people living in the community with common mental disorders; and to undertake a cost comparison of each CMHN treatment compared with usual GP care.
                A pragmatic, randomised controlled trial with three arms: CMHN problem-solving, generic CMHN care and usual GP care.
                General practices in two southern English counties were included in the study. CMHNs were employed by local NHS trusts providing community mental health services.
                Participants were GP patients aged 18--65 years with a new episode of anxiety, depression or reaction to life difficulties and had to score at least 3 points on the General Health Questionnaire-12 screening tool. Symptoms had to be present for a minimum of 4 weeks but no longer than 6 months.
                Patients were randomised to one of three groups: (1) CMHN problem-solving treatment, (2) generic CMHN treatment, or (3) usual GP care. All three groups of patients remained free to consult their GPs throughout the course of the study, and could be prescribed psychotropic drug treatments.
                Patients were assessed at baseline, and 8 weeks and 26 weeks after randomisation. The primary outcome measure was psychological symptoms measured on the Clinical Interview Schedule -- Revised. Other measures included social functioning, health-related quality of life, problem severity and satisfaction. The economic outcomes were evaluated with a cost--utility analysis.
                Twenty-four CMHNs were trained to provide problem-solving under supervision, and another 29 were referred patients for generic support. In total, 247 patients were randomised to the three arms of the study, referred by 98 GPs in 62 practices. All three groups of patients were greatly improved by the 8-week follow-up. No significant differences were found between the groups at 8 weeks or 26 weeks in symptoms, social functioning or quality of life. Greater satisfaction with treatment was found in the CMHN groups. CMHN care represented a significant additional health service cost and there were no savings in sickness absence.
                The study found that specialist mental health nurse support is no better than support from GPs for patients with anxiety, depression and reactions to life difficulties. The results suggest that healthcare providers could consider adopting policies of restricting referrals of unselected patients with common mental disorders to specialist CMHNs, although there may be other roles in primary care that CMHNs could play effectively. Further research should address the predictors of chronicity in common mental disorders and target extra treatment. More research is also needed into the effectiveness and cost-effectiveness of problem-solving treatment for other disorders, of facilitated self-help treatments for common mental disorders and of CMHN care for people with severe and enduring mental illnesses, as well as the prevention of mental disorders. Little is known about the medium-term durability of cognitive-behavioural therapy (CBT) in a community sample of people with schizophrenia.
                To investigate whether brief CBT produces clinically important outcomes in relation to recovery, symptom burden and readmission to hospital in people with schizophrenia at 1-year follow-up.
                Participants (336 of 422 randomised at baseline) were followed up at a mean of 388 days (s.d. = 53) by raters masked to treatment allocation (CBT or usual care).
                At 1-year follow-up, participants who received CBT had significantly more insight (P = 0.021) and significantly fewer negative symptoms (P = 0.002). Brief therapy protected against depression with improving insight and against relapse; significantly reduced time spent in hospital for those who did relapse and delayed time to admission. It did not improve psychotic symptoms or occupational recovery, nor have a lasting effect on overall symptoms or depression at follow-up.
                Mental health nurses should be trained in brief CBT for schizophrenia to supplement case management, family interventions and expert therapy for treatment resistance. To investigate whether a form of advance agreement for people with severe mental illness can reduce the use of inpatient services and compulsory admission or treatment.
                Single blind randomised controlled trial, with randomisation of individual patients. The investigator was blind to allocation.
                Eight community mental health teams in southern England.
                160 people with an operational diagnosis of psychotic illness or non-psychotic bipolar disorder who had experienced a hospital admission within the previous two years.
                The joint crisis plan was formulated by the patient, care coordinator, psychiatrist, and project worker and contained contact information, details of mental and physical illnesses, treatments, indicators for relapse, and advance statements of preferences for care in the event of future relapse.
                Admission to hospital, bed days, and use of the Mental Health Act over 15 month follow up.
                Use of the Mental Health Act was significantly reduced for the intervention group, 13% (10/80) of whom experienced compulsory admission or treatment compared with 27% (21/80) of the control group (risk ratio 0.48, 95% confidence interval 0.24 to 0.95, P = 0.028). As a consequence, the mean number of days of detention (days spent as an inpatient while under a section of the Mental Health Act) for the whole intervention group was 14 compared with 31 for the control group (difference 16, 0 to 36, P = 0.04). For those admitted under a section of the Mental Health Act, the number of days of detention was similar in the two groups (means 114 and 117, difference 3, -61 to 67, P = 0.98). The intervention group had fewer admissions (risk ratio 0.69, 0.45 to 1.04, P = 0.07). There was no evidence for differences in bed days (total number of days spent as an inpatient) (means 32 and 36, difference 4, -18 to 26, P = 0.15 for the whole sample; means 107 and 83, difference -24, -72 to 24, P = 0.39 for those admitted).
                Use of joint crisis plans reduced compulsory admissions and treatment in patients with severe mental illness. The reduction in overall admission was less. This is the first structured clinical intervention that seems to reduce compulsory admission and treatment in mental health services. Primary care clinicians have a considerable amount of contact with patients suffering from long-term mental illness. The United Kingdom's National Health Service now requires general practices to contribute more systematically to care for this group of patients.
                To determine the effects of Mental Health Link, a facilitation-based quality improvement programme designed to improve communication between the teams and systems of care within general practice. Design of study: Exploratory cluster randomised controlled trial.
                Twenty-three urban general practices and associated community mental health teams.
                Practices were randomised to service development as usual or to the Mental Health Link programme. Questionnaires and an audit of notes assessed 335 patients' satisfaction, unmet need, mental health status, processes of mental and physical care, and general practitioners' satisfaction with services and beliefs about service development. Service use and intervention costs were also measured.
                There were no significant differences in patients' perception of their unmet need, satisfaction or general health. Intervention patients had fewer psychiatric relapses than control patients (mean = 0.39 versus 0.71, respectively, P = 0.02) but there were no differences in documented processes of care. Intervention practitioners were more satisfied and services improved significantly for intervention practices. There was an additional mean direct cost of pound 63 per patient with long-term mental illness for the intervention compared with the control.
                Significant differences were seen in relapse rates and practitioner satisfaction. Improvements in service development did not translate into documented improvements in care. This could be explained by the intervention working via the improvements in informal shared care developed through better link working. This type of facilitated intervention tailored to context has the potential to improve care and interface working. The effectiveness of community-based treatment stressing home care was compared with hospital-based psychiatric care. One hundred and fifty-five patients destined for inpatient psychiatric care were randomly assigned to Home Care (76 patients) and to Hospital Care (79 patients). Symptoms, role functioning, and psychosocial burden on the family were similar at admission, one month, three months, six months, and one year. The mean in-hospital stay of Hospital Care patients was 41.7 days compared with a mean stay of 14.5 days for Home Care patients. The difference in the amount of ambulatory care received by patients in the two groups was not significant. The evidence is consistent: community-based psychiatric care is an effective alternative to hospital-based care for many but not all severely disabled patients. The active ingredients of successful community treatment are known, yet the lag in implementing these programs persists. This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder.
                Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables.
                Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization.
                Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required. According to most of the relevant guidelines, psychoeducation is considered a basic part of routine therapy for patients with schizophrenia; scientific proofs of its efficacy are based mainly on the results of 1- and 2-year follow-ups. Therefore, the long-term effects of psychoeducation over a period of 7 years were investigated in regard to rehospitalization rates and hospital days.
                Of 101 patients with DSM-III-R or ICD-9 schizophrenia randomly allocated to either an intervention group or a control group between 1990 and 1994, 48 patients were available for follow-up after 7 years. During their index stay, the 24 patients of the intervention group and their key relatives each received a separate psychoeducational group therapy. The 24 patients of the control group received the usual treatment. After index discharge, all 48 patients received a comparable outpatient treatment. Main outcome measures were rehospitalization rate, number of intervening hospital days, compliance, and mean number of consumed chlorpromazine (CPZ) units.
                Seven years after index discharge, the rate of rehospitalization was 54% in the intervention group and 88% in the control group. The rate of rehospitalization per patient was 1.5 in the intervention group and 2.9 in the control group (p < .05). In the intervening period, the mean number of hospital days spent in a psychiatric hospital was 75 in the intervention group and 225 days in the control group. (p < .05). The mean number of consumed CPZ units after 7 years was 354 in the intervention and 267 in the control group.
                Seven years after psychoeducational group therapy, significant effects on the long-term course of the illness can be found. Therefore, the integration of psychoeducation into standard therapy for schizophrenia should become obligatory. This experiment evaluated the effectiveness of an innovative program of assertive community treatment (ACT) for homeless persons with severe and persistent mental illnesses.
                One hundred fifty-two homeless persons with severe and persistent mental illness were randomized to either the experimental ACT program or to usual community services. Baseline assessments included the Structured Clinical Interview for DSM-III-R, Quality-of-Life Interview, Colorado Symptom Index, and the Medical Outcomes Study 36-Item Short Form Health Survey. All assessments (except the Structured Clinical Interview) were repeated at the 2-, 6-, and 12-month follow-up evaluations.
                Subjects in the ACT program used significantly fewer psychiatric inpatient days, fewer emergency department visits, and more psychiatric outpatient visits than the comparison subjects. The ACT subjects also spent significantly more days in stable community housing, and they experienced significantly greater improvements in symptoms, life satisfaction, and perceived health status.
                Relative to usual community care, the ACT program for homeless persons with severe and persistent mental illness shifts the locus of care from crisis-oriented services to ongoing outpatient care and produces better housing, clinical, and life satisfaction outcomes. To evaluate the effectiveness of an intensive community nurse (CN)-supported discharge program in preventing hospital readmissions of older patients with chronic lung disease (CLD).
                Randomized, controlled trial.
                Two acute hospitals in the same health region in Hong Kong.
                One hundred fifty-seven hospitalized patients aged 60 and older with a primary diagnosis of CLD and at least one hospital admission in the previous 6 months.
                CNs made home visits within 7 days of discharge, then weekly for 4 weeks and monthly until 6 months. CNs coordinated closely with a geriatric or respiratory specialist in hospital. Subjects had telephone access to CNs during normal working hours from Monday to Saturday.
                The primary outcome was the rate of unplanned readmission within 6 months. The secondary outcomes were the rate of unplanned readmission within 28 days, number of unplanned readmissions, hospital bed days, accident and emergency room attendance, functional and psychosocial status, and caregiver burden.
                One hundred forty hospitalized patients completed the trial. Intervention group subjects had a higher rate of unplanned readmission within 6 months than control group subjects (76% vs 62%, P=.080, chi2 test). There was no significant group difference in any of the secondary outcomes except that intervention group subjects did better on social handicap scores.
                There was no evidence that an intensive CN-supported discharge program can prevent hospital readmissions in older patients with CLD. A controlled study tested whether the superior outcome of community care for serious mental illness (SMI) in Madison and in Sydney would also be found in inner London.
                Patients from an inner London catchment area who faced emergency admission for SMI (many were violent or suicidal) were randomised to 20 months or more of either home-based care (Daily Living Programme, DLP; n = 92), or standard in-patient and later out-patient care (controls, n = 97). Most DLP patients had brief in-patient stays at some time. Measures included number and duration of in-patient admissions, independent ratings of clinical and social function, and patients' and relatives' satisfaction.
                Outcome was superior with home-based care. Until month 20, DLP care improved symptoms and social adjustment slightly more, and enhanced patients' and relatives' satisfaction. From 3 to 18 months DLP care greatly reduced the number of in-patient bed days as long as the DLP team was responsible for any in-patient phase its patients had. Cost was less. DLP care did not reduce the number of admissions, nor of deaths from self-harm (3 DLP, 2 control). One DLP patient killed a child. Even at 20 months many DLP and control patients still had severe symptoms, poor social adjustment, no job, and need for assertive follow-up and heavy staff input. (Beyond 20 months most gains were lost apart from satisfaction.)
                It is unclear how much the gain until 20 months from home-based care was due to its site of care, its being problem-centred, its teaching of daily living skills, its assertive follow-up, the home care team's keeping responsibility for any in-patient phase, its coordination of total care (case management), or to other care components. Home-based care is hard to organise and vulnerable to many factors, and needs careful training and clinical audit if gains are to be sustained. Intermediate care (IC) services have been widely introduced in England and have the strategic objectives of reducing hospital and long-term care use. There is uncertainty about the clinical outcomes of these services and whether their strategic aims will be realised.
                A metropolitan city in northern England.
                A quasi-experimental study comparing a group of older people before and after the introduction of an IC service. A quota sampling method was used to match the groups.
                Patients presenting as emergency admissions to two elderly care departments with falls, confusion, incontinence or immobility. Intervention: a city-wide service in which a joint care management team (multi-agency, multi-disciplinary) assessed patient need and purchased support and rehabilitation from sector-based IC teams.
                Nottingham Extended Activities of Daily Living score, Barthel Index, Hospital Anxiety and Depression score, mortality, readmission to hospital, and new institutional care placement at 3, 6 and 12 months post-recruitment.
                There were 800 and 848 patients, respectively, in the control and intervention groups. Clinical outcomes, hospital and long-term care use were similar between the groups. Uptake of IC was lower than anticipated at 29%. An embedded case-control study comparing the 246 patients who received IC with a matched sample from the control group demonstrated similar clinical outcomes but increased hospital bed days used over 12 months (mean +8 days; 95% CI 3.1-13.0).
                This city-wide IC service was associated with similar clinical outcomes but did not achieve its strategic objectives of reducing long-term care and hospital use. This study examines the rationale for and relative effectiveness of three intervention models for treating people with severe mental illness and substance abuse disorders: Twelve Step recovery, behavioral skills training, and intensive case management. Using clinical trial methods, 132 dually diagnosed clients were assigned to three service approaches. Changes in client psychosocial outcomes, and psychiatric and substance abuse symptomatology were tracked over a 24-month period. Differential effectiveness was evident, with clients in the behavioral skills group demonstrating the most positive and significant differences in psychosocial functioning and symptomatology, compared with the Twelve Step recovery approach. However, the case management intervention also resulted in several positive and important differences compared with the Twelve Step recovery approach. We also found significant changes over time, not only at 6 months but increasingly positive changes in psychosocial functioning at 12 and 18 months as well. These results underscore the need for clinical trials to further examine the relative cost effectiveness of treatment approaches for dually disordered clients and to incorporate means of assessing subgroup differences so that the interventions being tested can be further refined and targeted to a broad set of needs among the dually diagnosed. This randomized controlled trial examined the effectiveness of a 12-session mutual support group conducted over 3-months for Chinese family caregivers of a relative with schizophrenia compared with routine family support services in Hong Kong. Forty-eight family caregivers from two psychiatric outpatient clinics were allocated randomly to an experimental (mutual support and usual outpatient care) group (n = 24) or a control (usual outpatient care only) group (n = 24). Data were collected prior to, 1 week and 3 months after the intervention. Families allocated to the mutual support group experienced decreased levels of family burden and increased family functioning and these changes were significantly greater than those of the controls at both post-intervention time points. The experimental group also showed a significant decrease in the duration of patient re-hospitalization (the total number of days of psychiatric hospitalization) at 3 months compared with the control group. This suggests that the mutual support group provided a more responsive service for patients than standard care. However, there was no significant difference in family service utilization between the two groups. The findings indicate that a mutual support group can provide benefits for family caregivers of people with schizophrenia that go beyond those provided by routine family support.
                Copyright 2004 Elsevier Ltd. An advance directive is a statement of a person's preferences for treatment, should he or she lose capacity to make treatment decisions in the future.
                To evaluate whether use of advance directives by patients with mental illness leads to lower rates of compulsory readmission to hospital.
                In a randomised controlled trial in two psychiatric services in inner London, 156 in-patients about to be discharged from compulsory treatment under the Mental Health Act were recruited. The trial compared usual psychiatric care with usual care plus the completion of an advance directive. The primary outcome was the rate of compulsory readmission.
                Fifteen patients (19%) in the intervention group and 16 (21%) in the control group were readmitted compulsorily within 1 year of discharge. There was no difference in the numbers of compulsory readmissions, numbers of patients readmitted voluntarily, days spent in hospital or satisfaction with psychiatric services.
                Users' advance instruction directives had little observable impact on the outcome of care at 12 months. While research has shown community-based psychiatric care to be as good as, or better than, hospital-based care, generalisation to clinical practice has been difficult. This prospective, randomised controlled study examined a community-based approach feasible within NHS conditions. Ninety-four patients were randomly allocated to experimental and 78 to control treatments and followed for one year. The groups were well matched apart from an excess of psychotic control patients. No differences in clinical or social functioning outcome were found. Both groups improved substantially on clinical measures in the first six weeks, with some slow consolidation thereafter. There were three suicides in the control group and one in the experimental group. Access to care was better in the experimental group (93% attended assessment) than in the control group (75% attended assessment). A two year follow-up of two matched groups of subjects with chronic severe mental illness was performed in order to evaluate a new psychiatric case management system. One group (n = 59) received care through psychiatric case management, using an assertive community treatment model that directly involved general practitioners. The other group, matched for age, sex, diagnostic group and number of hospital admissions, received standard outpatient care. Comparing the two years before and after case management, the experimental group showed a dramatic fall in inpatient admission days while the control group admission days remained the same (median difference in admission days across matched subject pairs = 64.5, 95% C.I. from 134.5 to 16). The experimental group remained out of hospital longer before first readmission (Kaplan-Meier survival analysis, P = 0.002). This type of case management programme can shorten or prevent admissions to psychiatric hospitals of patients with chronic mental illness, and increase their time before readmission. Depression and anxiety disorders are common mental disorders worldwide. The MANAS trial aimed to test the effectiveness of an intervention led by lay health counsellors in primary care settings to improve outcomes of people with these disorders.
                In this cluster randomised trial, primary care facilities in Goa, India, were assigned (1:1) by computer-generated randomised sequence to intervention or control (enhanced usual care) groups. All adults who screened positive for common mental disorders were eligible. The collaborative stepped-care intervention offered case management and psychosocial interventions, provided by a trained lay health counsellor, supplemented by antidepressant drugs by the primary care physician and supervision by a mental health specialist. The research assessor was masked. The primary outcome was recovery from common mental disorders as defined by the International Statistical Classification of Diseases and Related Health Problems-10th revision (ICD-10) at 6 months. This study is registered with ClinicalTrials.gov, number NCT00446407.
                24 study clusters, with an equal proportion of public and private facilities, were randomised equally between groups. 1160 of 1360 (85%) patients in the intervention group and 1269 of 1436 (88%) in the control group completed the outcome assessment. Patients with ICD-10-confirmed common mental disorders in the intervention group were more likely to have recovered at 6 months than were those in the control group (n=620 [65·0%] vs 553 [52·9%]; risk ratio 1·22, 95% CI 1·00-1·47; risk difference=12·1%, 95% CI 1·6%-22·5%). The intervention had strong evidence of an effect in public facility attenders (369 [65·9%] vs 267 [42·5%], risk ratio 1·55, 95% CI 1·02-2·35) but no evidence for an effect in private facility attenders (251 [64·1%] vs 286 [65·9%], risk ratio 0·95, 0·74-1·22). There were three deaths and four suicide attempts in the collaborative stepped-care group and six deaths and six suicide attempts in the enhanced usual care group. None of the deaths were from suicide.
                A trained lay counsellor-led collaborative care intervention can lead to an improvement in recovery from CMD among patients attending public primary care facilities.
                The Wellcome Trust.
                Copyright © 2010 Elsevier Ltd. All rights reserved. At three community mental health centers (CMHCs) in Indiana, 167 clients at risk for rehospitalization were randomly assigned to experimental groups receiving assertive case management (ACM) or to control groups eligible to receive all other aftercare services at the centers. During a six-month follow-up period, experimental clients received an average of one visit a week from the ACM team, usually in the client's home or in community settings. Overall, ACM clients were rehospitalized an average of 9.2 days, significantly less than the 30.8 days for controls. In two of the three centers, significant rehospitalization differences were also found between ACM and control groups. No differences were found between groups in quality of life, medication compliance, involvement in CMHC programs, or contacts with the legal system in any of the centers. The most cost-effective center had savings of about +5,500 for each ACM client. One hundred and twenty patients presenting for admission were randomly allocated into two groups. Controls received standard hospital care and after-care. Projects were not admitted if this could be avoided; instead they and their relatives were provided with comprehensive community treatment and a 24-hour crisis service. Patients with a primary diagnosis of alcohol or drug dependence, organic brain disorder or mental retardation were excluded. During the 12 months study period, 96% of controls were admitted, 51% more than once. Of the projects, 60% were not admitted at all and only 8% were admitted more than once. Controls spent an average of 53.5 days in psychiatric hospitals; projects spent an average of 8.4 days. Community treatment did not increase the burden upon the community, was considered to be significantly more satisfactory and helpful by patients and their relatives, achieved a clinically superior outcome, and cost less than standard care and after-care. To evaluate the effectiveness and cost-effectiveness of a community nurse-supported hospital discharge programme in preventing hospital re-admissions, improving functional status and handicap of older patients with chronic heart failure.
                Randomized controlled trial; 105 hospitalized patients aged 60 years or over with chronic heart failure and history of hospital admission(s) in previous year were randomly assigned into intervention group (n = 49) and control group (n = 56) for six months. Intervention group subjects received community nurse visits before discharge, within seven days of discharge, weekly for four weeks, then monthly. Community nurse liaised closely with a designated specialist in hospital and were accessible to subjects during normal working hours. Control and intervention group subjects were followed up in the same specialist medical clinics. Primary outcome was the rate of unplanned re-admission at six months. Secondary outcomes were number of unplanned re-admissions, six-minute walking distance, London Handicap Scale and public health care and personal care costs.
                At sixth months, the re-admission rates were not significantly different (46 vs. 57% in control subjects, p = 0.233, Chi-square test). But the median number of re-admissions tended to lower in the intervention group (0 vs. 1 in control group, p = 0.057, Mann Whitney test). Intervention group subjects had less handicap in independence (median change 0 vs. 0.5 in control subjects, p = 0.002, Mann Whitney test), but there was no difference in six-minute walking distance. There was no significant group difference in median total public health care and personal care costs.
                Community nurse-supported post-discharge programme was effective in preserving independence and was probably effective in reducing the number of unplanned re-admissions. The cost benefits to public health care were not significant.
                Older chronic heart failure patients are likely to benefit from post-discharge community nurse intervention programmes. More comprehensive health economic evaluation needs to be undertaken.
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.