From efficacy to effectiveness in community mental health services. PRiSM Psychosis Study 10. British Journal of Psychiatry, 173, 423-427

London Research Institute, Londinium, England, United Kingdom
The British Journal of Psychiatry (Impact Factor: 7.99). 12/1998; 173(5):423-7. DOI: 10.1192/bjp.173.5.423
Source: PubMed


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.


Available from: Til Wykes, Jul 03, 2014
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    • "By showing better engagement but no effects on psychosocial functioning, these results are in line with studies on the effects of ACT in adults [33-35]. Some studies explained the lack of added value of ACT due to the high quality of TAU teams [12,14,36] or due to a lack of implementation of evidence based modules in ACT teams [33]. In their study, Killaspy et al. explained that better engagement in ACT was associated with a smaller caseload in ACT than in TAU, and with the team approach (shared caseload) [10]. "
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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. DOI:10.1186/1471-244X-14-42 · 2.21 Impact Factor
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    • "The choice of control intervention is a critical issue for pragmatic RCTs testing psychosocial interventions in routine settings. For example, trials evaluating the effectiveness of assertive community treatment (ACT) in the UK (Thornicroft et al. 1998; Burns et al. 1999) showed minimal advantages over TAU. Burns (2008) commented on these findings by suggesting that the observed lack of effect could have been due to the control condition being 'too good' or 'too similar' to the experimental intervention. "

    Epidemiology and Psychiatric Sciences 03/2013; 22(2):1-3. DOI:10.1017/S2045796013000115 · 3.91 Impact Factor
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    • "Sin embargo, y a pesar de la contundencia de estos datos, su superioridad frente a otros modelos de gestión de pacientes graves está sometida actualmente a debate. En concreto, los estudios Prism y UK700 (Thornicroft, et al., 1998; UK700 Group, 1999, 2000) realizados en el Reino Unido, y de incuestionable calidad metodológica, no son concluyentes a la hora de mostrar una superioridad de un modelo de gestión de casos intensivo o asertivo comunitario frente a la atención ambulatoria estándar de los equipos de salud mental comunitarios (es importante resaltar que estos equipos del Reino Unido ofrecen un modelo intensivo e integral de gestión de casos; Departament of Health, 2002). Estos resultados han sido interpretados en dos sentidos. "

    Revista de Psicopatología y Psicología Clínica 04/2012; 17(1):1. DOI:10.5944/rppc.vol.17.num.1.2012.10365 · 0.23 Impact Factor
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