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: There is increasing interest in the application of recovery principles in mental health services. We studied the implementation of a programme of intensive case management (ICM) emphasizing recovery principles in a community mental health service in Ireland. Eighty service attenders with severe and enduring illness characterized by significant ongoing disability were randomized into (1) a group receiving a programme of ICM and (2) a group receiving treatment as usual (TAU). Groups were compared before and after the programme for general psychopathology using the Brief Psychiatric Rating Scale (BPRS) (clinician rated) and How are You? scale (self-rated). The Functional Analysis of Care Environments (FACE) scale provided assessment of multiple functional domains. The overall group (mean age 44.5 ± 13.2 years; 60% male) had mean total Health of the Nation Outcome Scale (HoNOS) scale scores of 10.5 ± 4.6, with problems in social functioning especially prominent (mean social subscale score 5.0 ± 2.7). The ICM group were younger (p < 0.01) with higher baseline scores on the HoNOS social subscale and BPRS (p < 0.05). An analysis of covariance, controlling for these baseline differences, indicated greater improvement in BPRS scores (p = 0.001), How are You? scores (p = 0.02) and FACE domains for cognition, symptoms and interpersonal relationships (all p < 0.001) in the ICM group. The ICM group underwent greater changes in structured daily activities that were linked to improved BPRS scores (p = 0.01). A programme of ICM emphasizing recovery principles resulted in significant improvement across psychopathological and functional domains. Improvements were linked to enhanced engagement with structured daily activities. Recovery-oriented practices can be integrated into existing mental health services and provided alongside traditional models of care.Irish Journal of Medical Science 01/2012; 181(3):301-8. · 0.51 Impact Factor
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ABSTRACT: BACKGROUND: For too long there have been heated debates between those who believe that mental health care should be largely or solely provided from hospitals and those who adhere to the view that community care should fully replace hospitals. The aim of this study was to propose a conceptual model relevant for mental health service development in low-, medium- and high-resource settings worldwide. Method We conducted a review of the relevant peer-reviewed evidence and a series of surveys including more than 170 individual experts with direct experience of mental health system change worldwide. We integrated data from these multiple sources to develop the balanced care model (BCM), framed in three sequential steps relevant to different resource settings. RESULTS: Low-resource settings need to focus on improving the recognition and treatment of people with mental illnesses in primary care. Medium-resource settings in addition can develop 'general adult mental health services', namely (i) out-patient clinics, (ii) community mental health teams (CMHTs), (iii) acute in-patient services, (iv) community residential care and (v) work/occupation. High-resource settings, in addition to primary care and general adult mental health services, can also provide specialized services in these same five categories. CONCLUSIONS: The BCM refers both to a balance between hospital and community care and to a balance between all of the service components (e.g. clinical teams) that are present in any system, whether this is in low-, medium- or high-resource settings. The BCM therefore indicates that a comprehensive mental health system includes both community- and hospital-based components of care.Psychological Medicine 07/2012; · 5.59 Impact Factor
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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