Intensive case management for severe mental illness

Abstract

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 methods 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 ...

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“…Our results confirm earlier reports in that total inpatient days were reduced during ACT, but without significant reduction in the number of admissions [ 9 ]. The reduction in total and involuntary inpatient days amongst participants with problematic substance use occurred despite on-going substance use.…”

Hospitalisation of severely mentally ill patients with and without problematic substance use before and during Assertive Community Treatment: an observational cohort study

“…Our results confirm earlier reports in that total inpatient days were reduced during ACT, but without significant reduction in the number of admissions [ 9 ]. The reduction in total and involuntary inpatient days amongst participants with problematic substance use occurred despite on-going substance use.…”

A Meta-Analysis of the Efficacy of Case Management for Substance Use Disorders: A Recovery Perspective

“…Similar results were found in meta-analyses of case management with other mental health populations (21, 67, 68). Given the primary goals of case management (to help individuals identify needed services, facilitate linking with these services, monitor treatment participation and retention, coordinate service provision, and advocate on clients' behalf) (31, 69), its greater effect on treatment tasks is not surprising.…”

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“…Comparing this study’s findings with those of other studies on similar subjects and approaches [ 1 , 5 , 6 , 7 ] reveals that the reasons that CMP is significantly more effective than the MHU treatment (e.g., seven times fewer treatment discontinuations when LAIs were used only twice as often as OAPs) are possibly linked not only to closer and more intensive contact with patients but also to the integrated psychosocial and pharmacological treatment provided [ 3 , 4 ].…”

Hospitalisation of severely mentally ill patients with and without problematic substance use before and during Assertive Community Treatment: an observational cohort study

“…Our results confirm earlier reports in that total inpatient days were reduced during ACT, but without significant reduction in the number of admissions [ 9 ]. The reduction in total and involuntary inpatient days amongst participants with problematic substance use occurred despite on-going substance use.…”

A Meta-Analysis of the Efficacy of Case Management for Substance Use Disorders: A Recovery Perspective

“…Similar results were found in meta-analyses of case management with other mental health populations (21, 67, 68). Given the primary goals of case management (to help individuals identify needed services, facilitate linking with these services, monitor treatment participation and retention, coordinate service provision, and advocate on clients' behalf) (31, 69), its greater effect on treatment tasks is not surprising.…”

Effectiveness of More Personalized, Case-Managed, and Multicomponent Treatment for Patients with Severe Schizophrenia Compared to the Standard Treatment: A Ten-Year Follow-Up

“…Comparing this study’s findings with those of other studies on similar subjects and approaches [ 1 , 5 , 6 , 7 ] reveals that the reasons that CMP is significantly more effective than the MHU treatment (e.g., seven times fewer treatment discontinuations when LAIs were used only twice as often as OAPs) are possibly linked not only to closer and more intensive contact with patients but also to the integrated psychosocial and pharmacological treatment provided [ 3 , 4 ].…”

Hospitalisation of severely mentally ill patients with and without problematic substance use before and during Assertive Community Treatment: an observational cohort study

“…Our results confirm earlier reports in that total inpatient days were reduced during ACT, but without significant reduction in the number of admissions [ 9 ]. The reduction in total and involuntary inpatient days amongst participants with problematic substance use occurred despite on-going substance use.…”

A Meta-Analysis of the Efficacy of Case Management for Substance Use Disorders: A Recovery Perspective

“…Similar results were found in meta-analyses of case management with other mental health populations (21, 67, 68). Given the primary goals of case management (to help individuals identify needed services, facilitate linking with these services, monitor treatment participation and retention, coordinate service provision, and advocate on clients' behalf) (31, 69), its greater effect on treatment tasks is not surprising.…”

Effectiveness of More Personalized, Case-Managed, and Multicomponent Treatment for Patients with Severe Schizophrenia Compared to the Standard Treatment: A Ten-Year Follow-Up

“…Comparing this study’s findings with those of other studies on similar subjects and approaches [ 1 , 5 , 6 , 7 ] reveals that the reasons that CMP is significantly more effective than the MHU treatment (e.g., seven times fewer treatment discontinuations when LAIs were used only twice as often as OAPs) are possibly linked not only to closer and more intensive contact with patients but also to the integrated psychosocial and pharmacological treatment provided [ 3 , 4 ].…”