Models of community treatments inschizophrenia: do they travel?

Burns T. Models of community treatments in schizophrenia: do theytravel?Acta Psychiatr Scand 2000: 102(Suppl. 407): 11±14. # Munksgaard2000.

Objective: To explore the stability of conclusions from mental healthservices research across differing care systems. Contradictory results indifferent countries for similar studies of programmes for patients withschizophrenia have usually been attributed to poor replication. Thispaper explores whether these differing results can illuminate aspects ofschizophrenia by examining the interaction of the disorder with the carecontext as an alternative explanation.Method: The ®ndings of a large UK random controlled trial of intensivecase management with such patients is compared to previous UK andUS studies.Results: Reduction of case-load size of psychotic patients did notsigni®cantly reduce their need for hospitalization in the context of locallyavailable co-ordinated care.Conclusion: There is more to be gained in understanding complexdisorders such as schizophrenia by interpreting the impact of context ontreatment study outcomes than by simply dismissing contradictory®ndings as failures of implementation of either research or clinicalpractice.

Tom Burns

Department of Community Psychiatry, St George's

Hospital Medical School, London, UK

Key words: schizophrenia; case management

Prof. Tom Burns, Community Psychiatry, Department of

General Psychiatry, St George's Hospital Medical

School, Jenner Wing, Cranmer Terrace, London SW17

0RE, UK

Introduction

The perspective of a clinician and a mental healthservices researcher could be thought to have little toadd to the understanding of schizophrenia, and inparticular its psychosocial basis. However, there isgood reason to believe that treatments can some-times be as useful as starting points for investiga-tions as they are, hopefully, the endpoint of goodscience. The turn of the century is an appropriatetime to examine long-term and complex treatmentprogrammes. The pressure on health services in thedeveloped world, where the `epidemiological tran-sition' has occurred (1) is from chronic diseases.This is equally so within mental health services

where the management of long-term disabilityoccupies an increasing proportion of activity.

Routes to investigate schizophrenia

Traditionally, schizophrenia has been studiedthrough a number of routes. An important recentroute into the enigma of schizophrenia is byworking backwards from treatments which arecurrently in use.

Approaches to investigate schizophrenia

' Biological: genetics, structural and functionalimaging.

' Psychological: psychopathological, de®cits,testing.

' Social: interactions, networks.' Backtracking from treatments.

This paper was read in a preliminary version at the 1st International

Zurich Conference on Clinical and Social Psychiatry, Zurich,

September 9±12, 1999. The conference and this publication were

sponsored by Eli Lilly Suisse.

Acta Psychiatr Scand 2000: 102(Suppl. 407): 11±14Printed in UK. All rights reserved

Copyright # Munksgaard 2000

ACTA PSYCHIATRICASCANDINAVICAISSN 0065-1591

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There is a long medical (not simply psychiatric)tradition of successful pragmatic treatments (e.g.digoxin for heart failure, chlorpromazine forschizophrenia) leading to better understanding ofillnesses rather than the other way around. Overtime, theories subsequently developed to explaintheir ef®cacy and from this to understand theillness. Some treatments have been consciouslyderived from theories, which subsequently havebeen disproved, yet the treatment has continued tobe used because it works. Examples in psychiatryare ECT and `Training in Community Living'introduced by Stein and Test in the late 1970s (2).Alternative theories have grown up to try to explaintheir effects. Training in Community Living wasrapidly relaunched as `Assertive CommunityTreatment' (ACT). Psychoanalysis continues to bein¯uential and an effective aspect of mental healthcare although rarely for the reasons for which it wasintroduced.

The assertive community treatment/intensive casemanagement controversy

Most effective treatments for individuals sufferingfrom schizophrenia are complex in themselves andtheir effects are modi®ed and in¯uenced by the caresystem in which they are embedded. Ostensiblyidentical interventions can produce substantiallydiffering outcomes in different contexts (countries)(3). The academic community is currently vexedover the question of the different experiences ofEuropeans and North Americans with ACT andIntensive Case Management (ICM) (4, 5). ACT is asystem of care that depends on a high staff topatient ratio (1:10) to follow-up psychotic patientsclosely in their own environments. This closefollow-up allows careful monitoring and deliveryof care from a small multiprofessional team. Theemphasis is on ensuring maintenance medication,supporting stable accommodation and structureddaily activity and on providing rapid crisis inter-vention. Despite being probably the most exhaus-tively researched psychosocial intervention forpsychotic patients, there is no unity on how tointerpret the ®ndings. A Cochrane meta-analysis ofACT (6) demonstrates unequivocal advantages andone of ICM (7) no advantage, but the contributionof individual factors is unclear. Is ACT quitedistinct from ICM or is one the American andone the European term for essentially the sameservice? Indeed, is there still a clear difference inoutcome? The Cochrane review derives much of itspower from the two early studies by Stein and Test(7) and by Bond (8), conducted over 15 years ago.Repeated RCTs of ICM head-to-head with `stan-

dard care' in the United Kingdom have thrown nolight on the controversy (9, 10) and are unlikely to.The research methodology to resolve these con¯ictsneeds to be much sharper, with more attention paidto potential confounders.

The UK700 Study

Our approach was to mount a pragmatic RCT ofcase management varying only one isolated com-ponent Ð case management size. Our reasons forconducting the trial were the con¯icting researchresults, and a wish to deconstruct a complexintervention (11). From a purely parochial pointof view we needed the local service context to berecognized Ð highly developed primary care (nevermentioned in any of the major ACT trials),established multidisciplinary generic CommunityMental Health Teams and a focus on severe mentalillness. We powered the study on a primary outcomeof hospitalization over 2 years because it remainsthe most frequently reported outcome in theliterature, and in the current UK situation of bedshortages it is not a bad proxy for relapse. We chosemean hospitalization rather than the medianbecause we anticipated a reduction in longeradmissions and also because the mean permitscalculations about service requirements (Table 1).

Why a local study?

' Highly developed primary care.' Sectorized services: generic teams.' Concept of SMI: `Severe and Enduring Mental

Illness'.' Results increasingly inconclusive.' Geographical bias.' Complex intervention.

Patient characteristics

' Psychotic illness.' Minimum of two admissions.' Last admission within 2 years.' Age 18±65.' Not primary substance abuse/organic.' 25% African-Caribbean.' 50% from in-patient discharge.

The study involved 708 patients recruited fromfour centres (12). We targeted patients withpsychosis, with a minimum of two admissions(the last within the preceding 2 years), aged 18±65(to re¯ect standard service con®gurations) and noprimary diagnosis of substance abuse or braindamage. We strati®ed for discharge and disabilityand aimed for 25% black Afro-Caribbean patients

Burns

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because they are generally thought to be poorlyserved by our services. Our results have beenpublished and they show a remarkable absence ofimpact of case-load size on hospitalization (13).This result is non-signi®cant but compatible witheither an increase or decrease of in-patient care of 17days per patient. There is no effect of level ofdisability or ethnicity. Social and clinical outcomeswere also remarkably similar. The hospitalizationmeans over-simplify somewhat, as the ICM patientshad slightly more short admissions (<1 month) andmore long admissions (>6 months). Twenty-threepatients were in hospital or prison for over 12months and probably cannot be considered to havereceived either treatment. Their care exerts adisproportionate effect on the results, but this is alarge and adequately powered study.

It was a pragmatic study and there were certainlydifferences in practice between the four sites.Detailed prospective process recording was con-ducted and is currently being analysed. This holdsout the possibility of determining further hypothesesto be tested from this database. For example, our StGeorge's service had signi®cantly higher contactfrequencies than the other three sites but there wasstill no difference in outcome (73 days ICM, 63 daysSCM). However this subsample contained a remar-kable concentration of stuck patients. Most weredetained in hospital for reasons not amenable toclinical decision-making (two homicides, two severearson attempts, etc.). Duration of hospitalizationdemonstrates a fairly convincing discontinuity and itis worth exploring what happens if this `forensic'group of patients is excluded. If they are, then ICMmean hospitalization falls to 30 days and that in

SCM 60 days, yielding a signi®cant (although nothighly signi®cant) difference, P=0.02.

Discussion

Professor RoÈssler's recent symposium on Europeancase management research at the 1999 WorldPsychiatric Association in Hamburg was illustra-tive. This symposium explored both a wide range ofmental health-care contexts and an equally widerange of research questions. Italians, Germans,Swedes and the British wanted to know differentthings and used differing research methodologies toapproach these questions. There was strong criti-cism from the ¯oor for a failure to repeat slavishlythe landmark ACT vs. Hospital Care studies. This isa call we should resist Ð it is both sterile anddivorced from current clinical issues.

A less competitive approach to the current debateabout the status of case management could use therich mosaic of differing outcomes and trials to beginthe process of distinguishing essential from non-essential components of care. Rather than remain-ing stuck at simply observing the differences inresults of the UK700 and PRiSM studies, from theoriginal Stein and Test study, we can try to see whatwe can learn from this difference. Triangulating theUK700 and the PRiSM studies with Stein andTest's original work (2) can be read to support thevalue of a consistent and ¯exible but non-intensetherapeutic relationship as protective in schizo-phrenia. What we still have to determine is theoptimal intensity of this contact (initially probablyusing case-load size as a proxy).

Table 1. Days in hospital over 2 years for patients in UK700 study of intensive case management

Intensive StandardDifference (Intensive±Standard)

n=353 n=355 Estimate 95% CI P-value

Missing data 15 (4.3%) 14 (3.9%)

Mean days in hospital (SD) 73.5 (124.2) 73.1 (111.2) 0.4 x17.4 18.1 0.97

Centre

St George's (n=189) 73.9 63.4 10.5 x22.3 43.3

Manchester (n=151) 78.9 59.4 19.5 x19.6 58.7

St Mary's (n=189) 65.7 90.9 x25.3 x59.5 9.0

King's (n=150) 76.7 75.8 0.9 x36.9 38.7

Ethnicity

Afro-Caribbean (n=194) 72.3 72.3 x0.1 x30.6 30.5

Other (n=485) 74.0 73.4 0.6 x21.2 22.3

Severity (DAS total)

<1 (moderate) (n=306) 67.9 66.9 1.0 x25.9 27.9

o1 (severe) (n=363) 75.1 81.0 x5.9 x30.1 18.3

Median days in hospital 17.5 28.0 10.5 x22.0 2.0 0.16

Any time in hospital 210 (62.1%) 228 (66.9%) x4.7% x11.9% 2.5% 0.20

Source: Tom Burns, Francis Creed, Tom Fahy, Simon Thompson, Peter Tyrer, Ian White for the UK700 Group. Intensive versus standard case management for severe psychoticillness: a randomized trial. # The Lancet Ltd 1999;353:2185±2189.

Do community treatments travel?

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The lesson to take from the inconclusive inter-national results of case management research is thatthey are a window of opportunity, not a strangefailure to be explained away. Adopting a richerresearch agenda may provide a better understan-ding of the effective ingredients of these treatments.More importantly, by evaluating their acceptabilityto, and impact on, individuals with schizophreniathemselves, we may gain a greater understanding ofwhat schizophrenia is: not necessarily about whatcauses it, but what it is to live it and to live with it.

References

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3. BURNS T, PRIEBE S. Mental health care systems and theircharacteristics: a proposal. Acta Psychiatr Scand 1996;94:381±385.

4. BURNS T. Case management two nations still divided. Psych-iatr Serv 1996;47:793.

5. HOLLOWAY F, OLIVER N, COLLINS E, CARSON J. Case

management a critical review of the outcome literature.Eur Psychiatry 1995;10:113±128.

6. MARSHALL M, LOCKWOOD A.Assertive Community Treatmentfor people with severe mental disorsers (Cochrane Review).The Cochrane Library (3): Oxford: Update Software, 1998.

7. MARSHALL M, GRAY A, LOCKWOOD A, GREEN R. Casemanagement for severe mental disorders. The CochraneCollaboration (2): Oxford: Update Software, 1997.

8. BOND GR, MILLER LD, KRUMWIED RD, WARD RS. Assertivecase management in three CMHC's: a controlled study.Hosp Commun Psychiatry 1988;39:411±418.

9. HOLLOWAY F, CARSON J. Intensive case management for theseverely mentally ill: controlled trial. Br J Psychiatry1998;172:19±22.

10. THORNICROFT G, STRATHDEE G, PHELAN M et al. Rationaleand design. PriSM Psychosis Study 1. Br J Psychiatry1998;173:363±370.

11. UK700 Group: CREED F, BURNS T, BUTLER T et al.Comparison of intensive and standard case managementfor patients with psychosis. Rationale of the trial. Br JPsychiatry 1999;174:74±78.

12. UK700 Group: FAHY T, KENT A, TATTAN T, VAN HORN, WHITE

E. Predictors of quality of life in people with severe mentalillness; Study methodology with baseline analysis in theUK700 trial. Br J Psychiatry 1999;175: 426±432.

13. UK700 Group: BURNS T, CREED F, FAHY T, THOMPSON S,TYRER P, WHITE I. Intensive versus standard case manage-ment for severe psychotic illness: a randomised trial. Lancet1999;353:2185±2189.

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