Background:Adolescents experiencing psychiatric emergencies often require intensive interventions to prevent hospitalisation and support their return to education, employment or training. Intensive Community Care Services aim to provide an alternative to inpatient care. Aims:To evaluate the effectiveness of Intensive Community Care Services compared to treatment as usual in reducing the time to start or return to education, employment or training for young people with psychiatric emergencies. Method:A multicentre, parallel-group, single-blinded, randomised controlled trial, including an internal feasibility phase, across seven NHS trusts in the United Kingdom. Adolescents aged 12-17 were randomised to receive either Intensive Community Care Services or treatment as usual. The primary outcome was the time to start or return to education, employment or training within a 6-month observation period. Secondary outcomes included clinical symptoms, functioning and service satisfaction. Process evaluation used semistructured visual interviews followed by thematic decomposition analysis. The impact of COVID-19 and the importance of continuity of care were explored in a series of cohort studies based in emergency departments. A consensus meeting was held to define the features of Intensive Community Care Services. Results:Of the approximately 977 adolescents screened, 36 were randomised in a 1 : 1 ratio using a web-based randomisation system stratified by the NHS trust using variable block sizes to receive either Intensive Community Care Services or treatment as usual. A key reason for poor recruitment was the absence of an alternative to Intensive Community Care Services. The recruitment rate did not meet pre-specified progression criteria (n = 55 by the first 6 months of recruitment), and conducting a full evaluation trial was deemed not feasible. Thirty participants from the pilot sample (83.3%) returned to education, employment or training during the 6-month follow-up period, with a median time to education, employment or training of 9 days (interquartile range 1-49). The median time to education, employment or training was lower in the Intensive Community Care Services group (6 days) compared to the treatment-as-usual group (12 days), with a hazard ratio of 1.34 (95% confidence interval 0.63 to 2.86). Estimated effect sizes for secondary outcomes were also in the direction of a benefit under Intensive Community Care Services, with higher satisfaction with services and improvements in clinical symptoms and functioning. There was a greater total average cost for the treatment-as-usual group at £15,155 (standard deviation 31,560), compared to £7063 (standard deviation 10,605) for Intensive Community Care Services. Due to the small sample size, no inferences regarding Intensive Community Care Services effectiveness or cost-effectiveness can be drawn. Fourteen young people participated in the process evaluation. Inpatient care received both praise for effective diagnoses and therapeutic interventions and criticism for a sterile approach and inadequate staff attention. Intensive Community Care Services was valued for the personalised approach, exemplified by beneficial home visits. During COVID-19, there was a significant reduction in emergency presentations of young people, followed by a significant increase post pandemic. The follow-up attendance rate increased by more than three times if the follow-up appointment was offered by the same clinician who saw the young person in an emergency room (odds ratio 3.66, 95% confidence interval 1.65 to 8.13). Intensive Community Care Services teams should use the modified Dartmouth Assertive Community Treatment Fidelity Scale to assess their quality. Recruitment to a randomised controlled trial of this kind can be improved if all new Intensive Community Care Services teams are considered to be experimental services and an equipoise between Intensive Community Care Services and existing services acknowledged. Future work:Rigorous post-implementation research is warranted for those areas that choose to implement Intensive Community Care Services. An adequately powered randomised controlled trial is needed to confirm the pilot findings of the IVY study and explore the full potential of Intensive Community Care Services as an alternative to inpatient and other community-based services for young people with severe mental health needs. Clinicians' experience delivering Intensive Community Care Services should be explored in further qualitative studies. Limitations:The most significant limitation of this pilot study is the very small sample size, which was a direct result of recruitment difficulties. As a result, we were unable to draw any inferences about the effectiveness or cost-effectiveness of Intensive Community Care Services relative to treatment as usual. It was not possible to blind participants to the intervention they were receiving. The 6-month follow-up period may have been insufficient to capture important long-term outcomes. Conclusions:No definitive conclusions can be drawn from this study. Preliminary results suggest that Intensive Community Care Services may support a faster return to education, employment or training than treatment as usual. Intensive Community Care Services may be cost-effective compared to treatment as usual. Additional mental health professionals should be deployed to Intensive Community Care Services during future lockdowns. The same Intensive Community Care Services professionals should offer assessments in emergency departments and provide community follow-up. Research with a larger sample is warranted to confirm these findings. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR127408.
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