From efficacy to effectiveness in community mental health services. PRiSM Psychosis Study. 10.
ABSTRACT The PRiSM Psychosis Study investigated the outcomes of community mental health services for epidemiologically representative cases of psychosis in London.
The results presented in the preceding nine papers are interpreted.
(a) The health and social gains reported in experimental studies of community health services are replicable in ordinary clinical settings, and are more effective than hospital-oriented services which they replace. (b) Dilution does occur--these gains are less pronounced than in experimental (efficacy) studies. (c) Both models of community services produced a range of improved outcomes. (d) Some limited extra advantages (in terms of met needs, improved quality of life, and social networks) were found in the intensive sector. (e) There is no consistent evidence that community-oriented services (which include in-patient beds) fail service users, their families or the wider public. On balance the results weigh slightly in favour of the two-team model (for acute and continuing care) in terms of clinical effectiveness, but the general model is almost as effective and is less expensive.
The evidence supports a community-oriented rather than a hospital-oriented approach and there is little difference between the community mental health team models.
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ABSTRACT: This Editorial addresses the crucial issue of which research methodology is most suited for capturing the complexity of psychosocial interventions conducted in 'real world' mental health settings. It first examines conventional randomized controlled trial (RCT) methodology and critically appraises its strengths and weaknesses. It then considers the specificity of mental health care treatments and defines the term 'complex' intervention and its implications for RCT design. The salient features of pragmatic RCTs aimed at generating evidence of psychosocial intervention effectiveness are then described. Subsequently, the conceptualization of pragmatic RCTs, and of their further developments - which we propose to call 'new generation' pragmatic trials - in the broader routine mental health service context, is explored. Helpful tools for planning pragmatic RCTs, such as the CONSORT extension for pragmatic trials, and the PRECIS tool are also examined. We then discuss some practical challenges that are involved in the design and implementation of pragmatic trials based on our own experience in conducting the GET UP PIANO Trial. Lastly, we speculate on the ways in which current ideas on the purpose, scope and ethics of mental health care research may determine further challenges for clinical research and evidence-based practice.Epidemiology and Psychiatric Sciences 03/2013; · 2.94 Impact Factor
- Epidemiology and Psychiatric Sciences 03/2013; · 2.94 Impact Factor
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ABSTRACT: Due to fragmented mental, somatic, and social healthcare services, it can be hard to engage into care older patients with severe mental illness (SMI). In adult mental health care, assertive community treatment (ACT) is an organizational model of care for treating patients with SMI who are difficult to engage. So far all outcome studies of assertive community treatment have been conducted in adults. In a randomized controlled trial design we compared the effectiveness of ACT for elderly patients with that of treatment as usual (TAU). Sixty-two outpatients (60 years and older) with SMI who were difficult to engage in psychiatric treatment were randomly assigned to the intervention or control group (32 to ACT for elderly patients and 30 to TAU). Primary outcomes included number of patients who had a first treatment contact within 3 months, the number of dropouts (i.e. those discharged from care due to refusing care or those who unintentionally lost contact with the service over a period of at least 3 months); and patients' psychosocial functioning (HoNOS65+ scores) during 18 months follow-up. Secondary outcomes included the number of unmet needs and mental health care use. Analyses were based on intention-to-treat. Of the 62 patients who were randomized, 26 were lost to follow-up (10 patients in ACT for elderly patients and 16 in TAU). Relative to patients with TAU, more patients allocated to ACT had a first contact within three months (96.9 versus 66.7%; X2 (df = 1) = 9.68, p = 0.002). ACT for elderly patients also had fewer dropouts from treatment (18.8% of assertive community treatment for elderly patients versus 50% of TAU patients; X2 (df = 1) = 6.75, p = 0.009). There were no differences in the other primary and secondary outcome variables. These findings suggest that ACT for elderly patients with SMI engaged patients in treatment more successfully.Trial registration: NTR1620.BMC Psychiatry 02/2014; 14(1):42. · 2.23 Impact Factor