From efficacy to effectiveness in community mental health services. PRiSM Psychosis Study. 10

Article (PDF Available)inThe British Journal of Psychiatry 173(5):423-7 · December 1998with43 Reads
DOI: 10.1192/bjp.173.5.423 · Source: PubMed
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.
    • "By showing better engagement but no effects on psychosocial functioning, these results are in line with studies on the effects of ACT in adults333435. 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]. "
    [Show abstract] [Hide abstract] 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.
    Full-text · Article · Feb 2014
    • "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. "
    Full-text · Article · Mar 2013
    • "" Complex patients " belong to the following diagnostic categories: schizophrenia spectrum disorder, bipolar disorders and severe personality disorders. In this case we can realize an intensive case management to prevent admission and to follow the patient at home345. In the Province of Siena, the University, the Local Hospital and the USL 7 set up a programme in 2010 by creating a joint department of Mental Health Care in order to get the University involved in the direct management of mental health problems. "
    [Show abstract] [Hide abstract] ABSTRACT: We describe the construction of a Joint Department of Mental Health in the Province of Siena (Italy), among a population of 272,000 residents. Three institutions took part in the project: the University and the Hospital of Siena, the USL 7 (the Local Health District). In this paper we report the articulations of services for adults and present the first results of the work relating to the low rate of hospital adimissions and the high numerber of patients who uderwent the treatment. This model represents and update with respect to the 1978 Italian Health Care Reform, with the involvement of the University in the overall project of Community Mental Health Service.
    Full-text · Article · Nov 2012 · Epidemiology and Psychiatric Sciences
Show more