ArticlesIntensive versus standard case management for severe psychotic illness: a randomised trial*
Introduction
Effective systems of care in the community for people with serious mental illness have become a priority, since the number of psychiatric beds has been decreased by more than two-thirds in the past 40 years. Severely mentally ill patients are at particular risk of neglect in large cities, and case management has been proposed for their care. Case management is a form of care in which a trained mental-health professional (eg, nurse, social worker, or psychologist) is responsible for direct care of the patient and for coordinating the wide range of health and social inputs that are required by individuals with severe mental illness to cope outside hospital. The form of intensive case management favoured in the USA—assertive community treatment—has been shown in several controlled trials to lower hospital admissions and to improve the outcome of such patients, and its provision is now a federal requirement1, 2, 3 Studies in the UK and Europe have not shown the same benefits, and the model most commonly chosen—intensive case management—may be associated with increased hospital admission and no improvement in clinical and social functioning outcomes.4, 5, 6, 7, 8, 9
The difference between the two methods may be explained by the inability to replicate in the UK those features of US services responsible for improved outcome; intensive and assertive features have not been precisely defined.10, 11 This difference could also be explained by the absence of coordinated care in US standard practice. The effective parts of the early US case-management services are already well established in routine practice in Europe.4, 10, 11 We aimed to assess the effect of intensive case management (defined as smaller case-load size) in patients with serious mental illness in four inner-city mental-health services. We did a randomised trial to test the hypotheses that psychotic patients with a history of frequent admissions treated with intensive case management have shorter periods of inpatient hospital treatment, that this effect is greater for Afro-Caribbean patients (who are harder to keep in treatment and are poorly served in current services) and for severely rather than moderately socially disabled patients, and that intensive case management lowers costs, increases the meeting of needs, and improves symptoms and social function. The economic evaluation will be the subject of a separate paper.
Section snippets
Study participants
Our study took place in four inner-city mental-health services— three in London (St George's Hospital, St Mary's Hospital, King's College Hospital) and one in Manchester (Manchester Royal Infirmary).12 All four hospitals serve populations with substantial social deprivation (total population 467 500). We included patients if they were aged 18–65 years (to reflect the current age range for general adult services) and had had psychotic illness for at least 2 years. Diagnosis was by a structured
Results
708 patients were recruited from the four centres (figure 1). Baseline characteristics were similar in the two groups (table 2). More than half the patients were young men with long histories of illness (median 10 years; median 2 months in hospital in the preceding 2 years). Most patients had schizophrenia and schizoaffective disorders. 28% of patients were Afro-Caribbean. Mean CPRS and DAS scores indicated that patients were moderately to severely ill. 35 (10%) patients in the intensive group
Discussion
Our results do not support our hypotheses. Mean duration in hospital was the same in the two groups, although the 95% CI was consistent with a difference of 18 days between groups.
We chose mean duration in hospital as our primary outcome measure because studies have shown a decrease in duration of hospital stay, despite unchanged or slightly increased rates of admission.1, 2, 3 We expected that lower case loads, with more intensive support and contact, would lead to earlier discharge, even if
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