The full-text may be used and/or reproduced, and given to third parties in any format or medium, without prior permission or charge, for personal research or study, educational, or not-for-pro t purposes provided that: • a full bibliographic reference is made to the original source • a link is made to the metadata record in DRO • the full-text is not changed in any way The full-text must not be sold in any format or medium without the formal permission of the copyright holders. Please consult the full DRO policy for further details.

To identify factors that women who have recovered from postnatal depression consider to be important in the recovery process and to measure the consensus among recovered women regarding the importance of those factors. A two-panel, three-round adapted Delphi exercise supplemented by a user-led interpretation work-shop. Panel one consisted of ten women who had been treated by a health visitor for and recovered from postnatal depression. Panel two consisted of 158 women who had recovered from postnatal depression who were London based members of a national support group for postnatal depression. There was a strong consensus among the participants about the 37 success factors that were identified. Factors that were identified as 'essential' in recovery from postnatal depression included: emotional support from partner; sleep; improved communication with partner; the diagnosis; practical support from partner; emotional support from friends; time to bond with the new baby; and prompt assessment by a health visitor. An interpretation group, made up of seven women who had recovered from postnatal depression, condensed the 37 factors into seven categories: diagnosis; positive action (or reaction) to intervene in the recognized problem; provision of support by people you know; professional or outside agency input; relationship between mother and baby; returning to work and continuity of care. There was a strong level of consensus among recovered women regarding a wide range of recovery factors. While all of the factors were considered to be, at least, 'important', social support from family and friends was generally rated more highly than support from health care professionals.

BackgroundA limited case-load size is considered crucial for some forms of intensive case management and many countries have undertaken extensive reorganisation of mental health services to achieve this. However, there has been limited empirical work to explore this specifically.AimsTo test whether there is a discrete threshold for changes in intensive case management practice determined by case-load size.Method‘Virtual’ case-load sizes were calculated for patients from their actual contacts over a 2-year period and were compared with the proportions of contacts devoted to medical and non-medical care (as a proxy for a more comprehensive service model).ResultsThere were 39 025 recordings for 545 patients over 2 years, with a mean rate of contacts per full-time case manager per month of 48 (range 35–60). There was no variation in the proportion of non-medical contacts when case-load sizes were over 1:20 but there was a convincing linear relationship when sizes were between 1:10 and 1:20.ConclusionsCase-load size between 1:10 and 1:20 does affect the practice of case management. However, there is no support for a paradigm shift in practice at a discrete level.

PURPOSE:Data on the process of mental health care is scant. Most studies focus on services at their inception when activity may be atypical and then usually present data only mean values for the reported variables over the whole study period. We aimed to test whether care delivery changes over time, and to describe any changes at the individual patient and team levels.METHODS:Process data on 272 patients in three new intensive case management (ICM) teams were collected over 2 years. Interventions were prospectively recorded using clinician-derived categories. Changes over time are described at both patient and team level.RESULTS:The number of contacts and the proportion of face-to-face activity were remarkably constant after the first month at the patient level. The proportion of 'psychiatric' interventions (main focus on medication or a specific 'mental health' intervention performed) increased greatly after the first 6 months. The care activity received by individual patients varied considerably. Overall, teams varied significantly in the extent to which their activity rates were sustained over time.CONCLUSIONS:New ICM teams deliver highly individualised care with more marked differences in treatment patterns between patients in the same team than mean differences between teams. The early 'engagement' period is marked by a greater focus on social care. There is evidence of differences in sustainability of the services by site.

Background Early intervention teams attempt to improve outcome in schizophrenia through earlier detection and the provision of phase-specific treatments. Whilst the number of early intervention teams is growing, there is a lack of clarity over their essential structural and functional elements. Methods A 'Delphi' exercise was carried out to identify how far there was consensus on the essential elements of early intervention teams in a group of 21 UK expert clinicians. Using published guidelines, an initial list was constructed containing 151 elements from ten categories of team structure and function. Results Overall there was expert consensus on the importance of 136 (90%) of these elements. Of the items on which there was consensus, 106 (70.2%) were rated essential, meaning that in their absence the functioning of the team would be severely impaired. Conclusion This degree of consensus over essential elements suggests that it is reasonable to define a model for UK early intervention teams, from which a measure of fidelity could be derived.

Objective: To compare patterns of clinical activity amongst existing staff in two inner-city community mental health teams before and after their enhancement with extra resources using a new activity schedule containing 11 comprehensive and mutually exclusive practice categories.Method: Patterns of clinical activity amongst existing members of two inner-London community mental health teams were compared before and after the addition of extra resources.Results: The amount of time spent in face-to-face contact with patients and carers showed no meaningful change following team enhancement. Patterns of clinical activity amongst team members remained relatively static.Conclusion: Adding resources to community mental teams without considering how to target the time released amongst existing staff may reduce their capacity to work more innovatively.

BackgroundThe significant reductions in hospital admission demonstrated in US assertive community treatment (ACT) studies have not been replicated in the UK. Explanations cite poor UK ‘model fidelity’ and/or better UK standard care. No international model-fidelity comparisons exist.AimsTo compare high-fidelity US ACT teams with a UK team.MethodThe UK700's ACT team (n=97) was compared with high-fidelity US ACT teams (n=73) by using two measures: a forerunner of the Dartmouth Assertive Community Treatment schedule (to assess adherence to ACT principles) and 2-year prospective activity data.ResultsThe UK and US teams had similar high-fidelity scores. Although significant differences were found in the amount and type of activity, practice differences in areas central to ACT were not great.ConclusionsThe failure of UK ACT studies to demonstrate the outcome differences of early US studies cannot be attributed entirely to the lack of ACT fidelity.

OBJECTIVE: Relatives play a vital role in caring for patients with severe mental illness but receive inadequate support from psychiatric services. Evidence suggests that although intensive case management is directed primarily at patients, relatives may benefit as well. This study examined whether relatives of patients who were receiving intensive case management had more contact with mental health professionals than relatives of patients who were receiving standard case management. It also examined whether relatives of patients receiving intensive case management appraised caregiving less negatively and experienced less psychological distress than relatives of patients receiving standard case management. METHODS: The sample was drawn from the pool of patients participating in the UK700 randomized controlled trial of intensive case management. Prospective data on contact between case managers and the relatives of 146 patients were collected over a two-year period. At a two-year follow-up assessment, relatives of 116 patients were interviewed with the Experience of Caregiving Inventory and the 12-item General Health Questionnaire. RESULTS: Considerably more relatives of patients receiving intensive case management had contact with a case manager during the study period than relatives of patients receiving standard case management (70 percent compared with 45 percent). However, relatives of patients receiving intensive case management did not appraise caregiving less negatively or experience less psychological distress than relatives of patients who were receiving standard case management. CONCLUSIONS: Reducing case managers' caseloads alone will not guarantee adequate support for relatives. Instead, providing more support will need to be an explicit aim, and staff will require specific additional training to achieve it.

Conclusions Case-loadreduction is not in itself enoughto reduce theneed for hospital care inpsychosis.Baseline patient characteristics (inparticular length of previous hospitalisation andrecruitment fromin-patientcare) have a significant influence and should be allowed for in powercalculations.Identifying the optimal clinicalprofile for patients likely to benefit fromintensivecasemanagementremains a pressingneed for further studies.

BACKGROUND:Trials in community psychiatry must balance rigour with generalisability. The UK700 trial failed to find a significant effect on hospitalisation, but its sample population contained significant heterogeneity of exposure to case management in the two groups.AIMS:To test whether patients successfully exposed to a minimum of 12 months' intensive case management over the 2-year follow-up period achieved reduced hospitalisation.METHOD:Of 679 participants with hospitalisation data, 84 were identified as having < 12 months' exposure owing to prolonged hospitalisation, imprisonment or a combination of the two. These patients were excluded and outcomes tested for the remaining 595 patients.RESULTS:Overall reduced case-load size did not reduce hospitalisation or treatment costs over 2 years despite elimination of outliers. Age, previous hospitalisation and source of recruitment to the study all correlated with outcome.CONCLUSIONS:Case-load reduction is not in itself enough to reduce the need for hospital care in psychosis. Baseline patient characteristics (in particular length of previous hospitalisation and recruitment from in-patient care) have a significant influence and should be allowed for in power calculations. Identifying the optimal clinical profile for patients likely to benefit from intensive case management remains a pressing need for further studies.

BACKGROUND:Many factors influence the type and quantity of services received by patients and, thus, the total cost of care. Knowledge of these factors can aid budgetary and service-planning decisions.AIMS:To investigate factors that influence the cost of caring for patients with severe psychotic illness.METHOD:Univariate and multivariate analyses were used to examine associations between baseline characteristics and subsequent 2-year total direct costs in 667 patients from the UK 700 case management trial.RESULTS:Significantly more money was spent on younger patients, those with longer duration of illness, those who had spent less time living independently and those who had spent longer in hospital for psychiatric reasons.CONCLUSIONS:Total costs of caring for patients with severe psychotic illness appear to be influenced to a large extent by age, duration of illness and past levels of dependence on statutory services. The strength of these relationships is greater than the impact of illness severity.

An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

An abstract is not available for this content. As you have access to this content, full HTML content is provided on this page. A PDF of this content is also available in through the ‘Save PDF’ action button.

Background: 'Relapse' is a common outcome indicator in intervention studies in schizophrenia. in community studies it is frequently equated with hospitalisation and in psychopharmacological studies with predetermined symptom scores. Its clinical meaning, however, remains undefined.Method: Consensus on the defining features of 'relapse' in schizophrenia used by academic and clinical schizophrenia experts in the UK, was investigated using a four stage Delphi process. A two panel, four stage, Delphi based methodology was used to investigate the implicit meanings of 'relapse' in clinical practice. A multidisciplinary panel of twelve members each listed anonymously ten indicators of relapse. A second panel, of ten experienced psychiatrists, rated the 188 submitted indicators from essential-unimportant (1-5). This panel completed a one day workshop during the remaining Delphi rounds ending with a structured discussion of the results.Results: Very strong consensus was achieved on the relative importance of potential relapse indicators. There was complete agreement about some aspects of a definition of relapse (such as recurrence of positive symptoms) and a number of the complex issues underlying the concept were clearly articulated.Conclusions: This four stage Delphi process achieved consensus on core features of relapse. The elucidation of the "softer" features at the threshold between normal fluctuations in functioning and the start of relapse require continuing investigations.

BackgroundIntensive case management is commonly advocated for the care of the severely mentally ill, but evidence of its cost-effectiveness is lacking.AimsTo investigate the cost-effectiveness of intensive compared with standard case management for patients with severe psychosis.Method708 patients with psychosis and a history of repeated hospital admissions were randomly allocated to standard (case-loads 30–35) or intensive (case-loads 10–15) case management. Clinical and resource use data were assessed over two years.ResultsNo statistically significant difference was found between intensive and standard case management in the total two-year costs of care per patient (means £24 550 and £22 700, respectively, difference £1850, 95% Cl – £1600 to £5300). There was no evidence of differential effects in African–Caribbean patients or in the most disabled. Psychiatric in-patient hospital stay accounted for 47% of the total costs, but neither such hospitalisation nor other clinical outcomes differed between the randomised groups.ConclusionReduced case-loads have no clear beneficial effect on costs, clinical outcome or cost-effectiveness. The policy of advocating intensive case management for patients with severe psychosis is not supported by these results.

BACKGROUND:Studies of intensive case management (ICM) for patients with psychotic illnesses have produced conflicting results in terms of outcome. Negative results have sometimes been attributed to a failure to deliver differing patterns of care.AIMS:To test whether the actual care delivered in a randomised clinical trial of ICM v. standard case management (the UK700 trial) differed significantly.METHOD:Data on 545 patients' care were collected over 2 years. All patient contacts and all other patient-centred interventions (e.g. telephone calls, carer contacts) of over 15 minutes were prospectively recorded. Rates and distributions of these interventions were compared.RESULTS:Contact frequency was more than doubled in the ICM group. There were proportionately more failed contacts and carer contacts but there was no difference in the average length of individual contacts or the proportion of contacts in the patients' homes.CONCLUSIONS:The failure to demonstrate outcome differences in the UK700 study is not due to a failure to vary the treatment process. UK standard care contains many of the characteristics of assertive outreach services and differences in outcome may require that greater attention be paid to delivering evidence-based interventions.

OBJECTIVE:The activities of mental health practitioners are poorly understood and described because of a lack of generally accepted and understandable categories. Greater precision is needed for accountability, planning, and evaluation. The objective of this study was to identify a valid and reliable set of categories to describe the clinical work practices of intensive case managers in the United Kingdom.METHODS:Eight intensive case managers participated in a Delphi process to produce a set of categories that described their clinical work practices. They each completed three questionnaires and participated in a final group discussion.RESULTS:The initial open questionnaire generated 38 potential categories after exact duplicates were removed. In round 2, the intensive case managers each rated the 38 categories from 1 to 5 (essential to unimportant). A high degree of consensus on the relative importance of the 38 suggested practice categories was rapidly achieved. In round 3, they re-rated the categories in the light of group medians and their own round 2 ratings. In a structured face-to-face discussion group, the intensive case managers then reduced the 38 potential categories to ten comprehensive and mutually exclusive categories that were judged to adequately and accurately reflect work practices. They were housing, finance, daily living skills, criminal justice system, occupation and leisure, engagement, physical health, caregivers and significant others, specific mental health intervention or assessment, and medication.CONCLUSIONS:Delphi methods were effective and relatively straightforward in producing an agreed-on set of categories with which to record clinical activity and inform care planning.

An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

Other than medication and access to in‐patient care, there is little published consensus on the essential components of schizophrenia care. This paper reports a Delphi approach to the identification of these components. This approach identifies and measures the degree of consensus, using a structured iterative series of questionnaires by a group of experienced UK and Irish psychiatrists (n= 15) on the essential components. Pharmacotherapy, in‐patient care and community mental health team (CMHT) staffing were explicitly excluded from the study. In total, 106 components were identified and their importance was rated twice. There was consensus on 92% of the components and strong consensus on 64%. The Delphi results were refined by the participants to produce 10 essential components of care.