Kensington, Chelsea and Westminster Health Authority, London
Forensic Psychiatry Research Unit, St Bartholomew's Hospital, London
Imperial College School of Medicine, Paterson Centre, London
Correspondence: Shaeda Simmonds, Kensington, Chelsea and Westminster Health Authority, 50 Eastborne Terrace, London W2 6LX, UK
See invited commentary, pp.
503-505, this issue.
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ABSTRACT |
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Aims To assess the benefits of community mental health team management in severe mental illness.
Method A systematic review was conducted of community mental health team management compared with other standard approaches.
Results Community mental health team management is associated with fewer deaths by suicide and in suspicious circumstances (odds ratio=0.32, 95% Cl 0.09-1.12), less dissatisfaction with care (odds ratio=0.34, 95% Cl 0.2-0.59) and fewer drop-outs (odds ratio=0.61, 95% Cl 0.45-0.83). Duration of in-patient psychiatric treatment is shorter with community team management and costs of care are less, but there are no gains in clinical symptomatology or social functioning.
Conclusions Community mental health team management is superior to standard care in promoting greater acceptance of treatment, and may also reduce hospital admission and avoid deaths by suicide. This model of care is effective and deserves encouragement.
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INTRODUCTION |
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METHOD |
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Procedure
Two of the authors (S.S. and P.T.), both independently and in parallel,
studied the abstracts, titles and descriptor terms of all downloaded material
from the electronic searches; illegible reports were discarded and the
selected original articles were retained. To check the completeness of the
electronic search, references cited in all included papers were examined and
personal contacts were written to in order to identify any other studies that
might be appropriate. The same authors separately evaluated the acquired
studies and matched them with the inclusion criteria defined above. Agreement
was evaluated by the statistic and if overall agreement was less than
0.75 (the level regarded as excellent by
Cicchetti & Sparrow, 1981)
then the strategy of the selection was reviewed. Where disagreement occurred,
a third reviewer (S.M.) was asked to resolve the dispute. When resolution was
not possible, the study was added to those awaiting assessment and the authors
were contacted for further data.
Outcome measures and analysis
The outcomes measured included:
Dichotomous and continuous data were analysed on an intention-to-treat basis because evaluation of CMHT management is suitable for a pragmatic approach. Because a wide range of instruments is available to measure outcomes in community care, it was decided to include data from instruments that have been published in a peer review journal in which the validity and reliability had been demonstrated to the satisfaction of referees. Because many of the outcomes of community care are not normally distributed, the following standards were applied to all data before they could be combined in meta-analysis: standard deviations and means of reportage in the paper were obtainable from the authors; and standard deviations when multiplied by 2 were less than the mean (otherwise the mean was unlikely to be an appropriate measure of the centre of distribution) (Altman & Bland, 1996; Parmar et al, 1996).
All normally distributed data were entered into the RevMan software (the Cochrane Collaboration Statistical Program), which allowed data to be combined for meta-analysis. The odds ratio (OR) and 95% confidence intervals (CI) were calculated for each study as well as for combined data.
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RESULTS |
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Deaths from all causes
Four out of the five studies had fewer deaths in the standard care group.
Although the small numbers in individual studies seldom provoked comment,
collectively they amounted to a difference that was significant
(Fig. 1): 1.7% of people
treated by CMHTs died during the course of the studies, compared with 3.8% of
the control group. This difference was even greater when deaths by suicide or
suspicious circumstances were compared (OR=0.32; CI 0.09-1.12). Deaths due to
physical causes also were less frequent in the CMHT group, but not to a marked
extent (OR=0.63; CI 0.22-1.82).
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Leaving the study early
All of the five studies provided data. Results relating to the 854 people
showed that a significantly smaller proportion (33%) dropped out of CMHT
management early compared with 45% in those receiving standard care (OR=0.61,
CI 0.45-0.83) (Fig. 2).
Individuals dying of natural causes were excluded from this outcome
measure.
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Hospitalisation
The mean duration of psychiatric hospital admissions showed that less time
was spent in hospital following CMHT management
(Table 2) but the data were not
homogeneous (2=21.3, d.f.=3, P < 0.001). This is
mainly because one study (Hoult &
Reynolds, 1984) randomised patients at the point of admission to
hospital and, as there were no special provisions to prevent admissions in the
standard care group, 56 of the 58 patients concerned were admitted. However,
the duration of hospital treatment was also significantly less in patients
from CMHT management in other settings and, despite the skewed data, it is
reasonable to conclude that such management reduces hospital stay.
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Clinical psychopathology and social functioning
The results of the five studies are shown in
Table 3. Because studies used
different rating scales and these showed larger than acceptable standard
deviations, it was not possible to combine these in a meta-analysis. However,
the data taken separately suggest no convincing differences in favour of
either form of management for clinical symptoms or social functioning.
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Costs
In all five studies the total cost of care was less for those treated with
CHMT management (Table 4).
Because of the gross skewing of data it was not possible to use meta-analysis
to combine the data, but all studies reported lower costs with CMHT
management, with differences of between 12 and 53% across the five studies.
Because these differences are substantial, it is fair to conclude that the
published studies showed clear evidence of CMHT management being cheaper than
standard care, even allowing for the limitations of the data across a span of
17 years.
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DISCUSSION |
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Before discussing the implications of these positive conclusions, it needs to be acknowledged that the studies do not necessarily reflect the exercise of both of these models of care in practice. The Australian study had a specific research focus, and in all studies there was a level of enthusiasm for community care in the mental health teams that could well be greater than the average for such services. However, there is no evidence that enthusiasm alone has any significant impact on the care of patients with severe mental illness, and the inclusion of patients in any research study tends to be associated with a Hawthorne effect that applies across all treatment arms. In recent years the practices employed by the CMHTs in this study have been more widely spread and are generally becoming the norm.
Effects on psychiatric bed use
The evidence that duration of psychiatric care is reduced with CMHT
management is strong but not overwhelming. The figures lie between those
studies, mainly published in the USA, that suggest that the ACT model has a
major impact on reducing admissions
(Marshall et al,
1999) and formal case management (allocation to a formal process
of regular assessment and review), which creates the opposite effect with
greater hospital admissions (Tyrer et
al, 1995; Marshall et
al, 1998). The results also need to be tempered with some
caution. The findings apply only when sufficient beds are available for
admission. When there is a significant shortage of beds, as in the later study
(Tyrer et al, 1998), admissions were still reduced but the duration of hospital admissions may
become longer because of the disruption created by transfer of patients to
distant hospitals. The lower rate of drop-out from care with CHMT management
supports the findings of case management
(Marshall et al,
1998) and assertive approaches
(Marshall et al,
1999) and is perhaps partly expected, because one of the main
functions of such teams is to maintain contact with patients and to see them
in settings that are most appropriate for their care, including home
treatment.
Cost-effectiveness and reduced deaths
The lower use of in-patient services is probably the main reason for the
reduced cost of CMHT treatment (Table
4). Indeed, the savings here are substantial because a very large
amount of money is saved by preventing relatively few admissions and it is
perhaps this reason that has led to much of the savings created by the closure
of mental hospitals not being transferred to acute services, where they appear
to be most needed (Lelliott et
al, 1993). The finding that CMHT management may reduce
suicide and deaths under suspicious circumstances is of particular interest in
view of the perceived failings of community care in some parts of the world,
in particular the UK, where its failure has been stated clearly by government
(Department of Health, 1998). Largely because of incorrect and tendentious reporting by the media, the
policy of care in the community for people with severe mental
illness has become associated in the public mind with professional neglect and
increased rates of homicide and suicide. It appears from our data that good
CMHTs have the opposite effect and that if we are able to provide adequate
resources then these serious adverse consequences arise rather less often than
in other settings.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication July 11, 2000. Revision received January 5, 2001. Accepted for publication January 9, 2001.
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