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 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.
PICOs
Plain language summary
Intensive case management for people with severe mental illness
Severe mental illnesses are defined by diagnosis, degree of disability and the presence of some abnormal behaviour. They include schizophrenia and psychosis, severe mood problems and personality disorder, and can cause considerable inconvenience over a long period of time both for the people are affected by them, and for their families and friends.
Until the 1970s it was common for those suffering from these disorders to stay in an institution for most of their lives, but now in most of the countries of the world, they are managed in the community with one of several different styles of intervention. Intensive Case Management (ICM) is one such intervention. It consists of management of the mental health problem and the rehabilitation and social support needs of the person concerned, over an indefinite period of time, by a team of people who have a fairly small group of clients (less than 20). It also offers 24 hour help and sees clients in a non‐clinical setting.
This review compares ICM with non‐Intensive Case Management (non‐ICM; where people receive the same package of care but the professionals have caseloads of more than 20 people) and standard care (where people are seen as outpatients but their support needs are less clearly defined). Thirty‐eight trials were found in the United States, Canada, Europe or Australia involving 7328 people in total.
When ICM was compared to standard care, those in the ICM group were significantly more likely to stay with the service, have improved general functioning, get a job, not be homeless and have shorter stays in hospital (especially when they had had very long stays in hospital previously). There was also a suggestion that it reduced the risk of death and suicide. If ICM was compared to non‐ICM, the only clear difference was that those in the ICM group were more likely to be kept in care. There are no trials comparing non‐ICM with standard care.
One of the drawbacks of this review is that the healthcare and social support systems of these countries are quite different, so it was quite difficult to make valid overall conclusions. In addition, much of the data on quality of life, and patient and carer satisfaction were not able to be used because the trials used many different scales of measuring these things, some of which were not validated. The development of such an overall scale and its validation would be very beneficial in producing services that people liked.
(Plain language summary prepared for this review by Janey Antoniou of RETHINK, UK www.rethink.org)
