Max Marshall

Helping people with severe mental illness to obtain work: systematic review

Abstract Objective: To determine the most effective way of helping people with severe mental illness to obtain competitive employment—that is, a job paid at the market rate, and for which anyone can apply. Design: Systematic review. Participants: Eligible studies were randomised controlled trials comparing prevocational training or supported employment (for people with severe mental illness) with each other or with standard community care. Outcome measures: The primary outcome was number of subjects in competitive employment. Secondary outcomes were other employment outcomes, clinical outcomes, and costs. Results: Eleven trials met the inclusion criteria. Five (1204 subjects) compared prevocational training with standard community care, one (256 subjects) compared supported employment with standard community care, and five (484 subjects) compared supported employment with prevocational training. Subjects in supported employment were more likely to be in competitive employment than those who received prevocational training at 4, 6, 9, 12, 15, and 18 months (for example, 34% v 12% at 12 months; number needed to treat 4.45, 95% confidence interval 3.37 to 6.59). This effect was still present, although at a reduced level, after a sensitivity analysis that retained only the highest quality trials (31% v 12%; 5.3, 3.6 to 10.4). People in supported employment earned more and worked more hours per month than those who had had prevocational training. Conclusion: Supported employment is more effective than prevocational training at helping people with severe mental illness obtain competitive employment.

Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression

Objectives To explain why clinical trials of intensive case management for people with severe mental illness show such inconsistent effects on the use of hospital care. Design Systematic review with meta-regression techniques applied to data from randomised controlled trials. Data Sources Cochrane central register of controlled trials, CINAHL, Embase, Medline, and PsychINFO databases from inception to January 2007. Additional anonymised data on patients were obtained for multicentre trials. Review methods Included trials examined intensive case management compared with standard care or low intensity case management for people with severe mental illness living in the community. We used a fidelity scale to rate adherence to the model of assertive community treatment. Multicentre trials were disaggregated into individual centres with fidelity data specific for each centre. A multivariate meta-regression used mean days per month in hospital as the dependent variable. Results We identified 1335 abstracts with a total of 5961 participants. Of these, 49 were eligible and 29 provided appropriate data. Trials with high hospital use at baseline (before the trial) or in the control group were more likely to find that intensive case management reduced the use of hospital care (coefficient −0.23, 95% confidence interval −0.36 to −0.09, for hospital use at baseline; −0.44, −0.57 to −0.31, for hospital use in control groups). Case management teams organised according to the model of assertive community treatment were more likely to reduce the use of hospital care (coefficient −0.31, −0.59 to −0.03), but this finding was less robust in sensitivity analyses and was not found for staffing levels recommended for assertive community treatment. Conclusions Intensive case management works best when participants tend to use a lot of hospital care and less well when they do not. When hospital use is high, intensive case management can reduce it, but it is less successful when hospital use is already low. The benefits of intensive case management might be marginal in settings that have already achieved low rates of bed use, and team organisation is more important than the details of staffing. It might not be necessary to apply the full model of assertive community treatment to achieve reductions in inpatient care.

Early Intervention for Psychosis

Proponents of early intervention have argued that outcomes might be improved if more therapeutic efforts were focused on the early stages of schizophrenia or on people with prodromal symptoms. Early intervention in schizophrenia has 2 elements that are distinct from standard care: early detection and phase-specific treatment (phase-specific treatment is a psychological, social, or physical treatment developed, or modified, specifically for use with people at an early stage of the illness). Early detection and phase-specific treatment may both be offered as supplements to standard care or may be provided through a specialized early intervention team. Early intervention is now well established as a therapeutic approach in America, Europe, and Australasia.

Duration of untreated psychosis and negative symptoms ? A systematic review and meta-analysis of individual patient data

BACKGROUND Longer duration of untreated psychosis (DUP) is associated with poorer outcome in terms of positive symptoms, relapse rate, and time to remission. In contrast, the association with negative symptoms is less consistent. AIMS The study had three aims. First, to arrive at a more precise estimate of the correlation between DUP and negative symptoms than previous reviews, by substantially increasing the amount of available data. Second, to see whether the strength of this correlation attenuated over longer follow-up intervals. Third, to determine whether there is a relationship between DUP and changes in negative symptoms. METHOD Relevant databases were searched for studies published between December 1992 and March 2009 that reported data on DUP and negative symptoms. We obtained individual patient data where possible and calculated summary correlations between DUP and negative symptoms for each study at baseline, short and long-term follow-up. We used multilevel regression analysis to examine whether the effect of DUP on negative symptoms was the greatest in the early stages of illness. RESULTS We included 28 non-overlapping studies from the 402 papers detected by the search strategy. After contacting the authors we obtained individual patient data from 16 of these studies involving 3339 participants. The mean DUP was 61.4 weeks (SD=132.7, median DUP=12.0). Shorter DUP was significantly associated with less severe negative symptoms at baseline and also at short (1-2 years) and longer term follow-up (5-8 years) (r=0.117, 0.180 and 0.202 respectively, p<0.001). The relationship between improvement in negative symptoms and DUP was found to be non-linear: people with a DUP shorter than 9 months showed substantially greater negative symptom reduction than those with a DUP of greater than 9 months. CONCLUSIONS Shorter DUP is associated with less severe negative symptoms at short and long-term follow up, especially when the DUP is less than 9 months. Since there is no effective treatment for negative symptoms, reducing DUP to less than 9 months may be the best way to ameliorate them.

Modernising mental health services

In Modernising Mental Health Services , the new national mental health strategy for England announced in December, 1 2 the government lays out detailed plans for reforming general psychiatric services, and places them in the context of its wider NHS reforms. The document asserts that “community care has failed” and blames underfunding, inadequate services, overburdening of families, problems in recruiting and retaining staff, and an outdated legal framework. It then describes a strategy for providing a service “in which patients, carers and the public are safe and where security and support is provided to all.” This strategy has two key elements: increased investment and increased control (over patients and clinicians). The increased investment consists of =A3700m spread over three years. These extra funds will provide more beds (in hostels and secure units); outreach teams and 24 hour access; new treatments, including atypical neuroleptics; and staff training. Increased control of patients will be achieved by “modernising” mental …

REDUCING DURATION OF UNTREATED PSYCHOSIS: CARE PATHWAYS TO EARLY INTERVENTION IN PSYCHOSIS SERVICES

BACKGROUND Interventions to reduce treatment delay in first-episode psychosis have met with mixed results. Systematic reviews highlight the need for greater understanding of delays within the care pathway if successful strategies are to be developed. AIMS To document the care-pathway components of duration of untreated psychosis (DUP) and their link with delays in accessing specialised early intervention services (EIS). To model the likely impact on efforts to reduce DUP of targeted changes in the care pathway. METHOD Data for 343 individuals from the Birmingham, UK, lead site of the National EDEN cohort study were analysed. RESULTS A third of the cohort had a DUP exceeding 6 months. The greatest contribution to DUP for the whole cohort came from delays within mental health services, followed by help-seeking delays. It was found that delay in reaching EIS was strongly correlated with longer DUP. CONCLUSIONS Community education and awareness campaigns to reduce DUP may be constrained by later delays within mental health services, especially access to EIS. Our methodology, based on analysis of care pathways, will have international application when devising strategies to reduce DUP.

Case management: a dubious practice

American psychiatrists visiting Britain will experience a sense of deja vu when they encounter the recent clutch of community care “initiatives.” They will soon spot that “care management” and the “care programme approach” are no more than a rehash of “case management,” an old American idea. From politeness they will probably refrain from telling their hosts that there is little reason to believe that case management works. Case management arose in the United States in response to the dispersal of psychiatric and social care that followed the closure of large mental hospitals. The basic idea was that a designated person, the “case manager,” would take special responsibility for a “client” in the community. The case manager would assess the clients needs and ensure, through a care plan, that suitable services were provided to meet them. The case manager would also monitor the provision of these services and maintain contact with the client.1 From the beginning the literature on “case management” has been bedevilled by a tendency to …

Views of Young People in Early Intervention Services for First-Episode Psychosis in England

OBJECTIVE This study described the views over time of young people referred to early intervention services (EIS), particularly as they relate to the importance of relationships. METHODS A cohort of people aged 14 to 35 enrolled in a large multisite study of EIS for psychosis in the United Kingdom were recruited for a qualitative, longitudinal study in which they were interviewed within six months of admission to EIS and 12 months later. Transcripts of the interviews were analyzed using Charmazs constructivist grounded-theory methodology. RESULTS A total of 63 individuals were interviewed during the six months after their first service contact, and 36 (57%) were interviewed 12 months later. Service users generally viewed IES key workers as supportive and youth sensitive, but up to one-third felt that the three years of sustained engagement expected was too intensive. Family support was highly valued by service users, and key workers and families worked well together to support the young people as they recovered. A significant minority of service users, however, reported feeling the emergence of a new self-identity, often associated with a sense of loss of the person they had felt themselves to be before becoming ill. CONCLUSIONS EIS for young people should provide not only the right type of engagement but also the right amount, recognize the very important role of families in giving both practical and emotional support and in liaising with key workers, and take into account the relatively rapid change in perceptions of personal identity that accompany illness.

Reliability of the Salford Needs Assessment Schedule for Adolescents

BACKGROUND For adolescents, there is no specific needs assessment instrument that assesses significant problems that can benefit from specified interventions. A new instrument (S.NASA) was developed by incorporating and adapting three well established adult needs assessment instruments. The S.NASA covers 21 areas of functioning including social, psychiatric, educational and life skills. METHOD Client and carer interviews were conducted by different researchers. A week later the interviews were repeated using a crossover design. Significant (cardinal) problems were generated from the clinical interviews using a pre-defined algorithm. Final need status (three categories) was made by clinicians assessing the cardinal problems against defined interventions. The interventions were generated from discussions with clinicians and a survey of appropriate professionals working with adolescents. RESULTS. Pre-piloting led to the final version being administered to 40 adolescents from secure units, forensic psychiatric and adolescent psychiatric services. There were 25 males and 15 females, mean age 15.5 years. Overall there were moderate to good inter-rater and test-retest reliability coefficients, the test-retest reliability coefficients for the total scores on the needs assessment interviews ranged from 0.73 to 0.85. Consensual and face validity was good, the adolescents and staff finding the instrument useful and helpful. CONCLUSIONS This new needs assessment instrument shows acceptable psychometric properties. It should be of use in research projects assessing the needs and the provision of services for adolescents with complex and chronic problems.

The UK national evaluation of the development and impact of Early Intervention Services (the National EDEN studies): study rationale, design and baseline characteristics

National EDEN aims to evaluate the implementation and impact on key outcomes of somewhat differently configured Early Intervention Services (EIS) across sites in England and to develop a model of variance in patient outcomes that includes key variables of duration of untreated psychosis (DUP), fidelity to the EIS model and service engagement. The cohort is being followed up for two further years as patients are discharged, to observe the stability of change and the impact of the discharge settings.