Elsevier

The Lancet Psychiatry

Volume 2, Issue 1, January 2015, Pages 29-37
The Lancet Psychiatry

Articles
Intensive case management for high-risk patients with first-episode psychosis: service model and outcomes

https://doi.org/10.1016/S2215-0366(14)00127-8Get rights and content

Summary

Background

The first episode of psychosis is a crucial period when early intervention can alter the trajectory of the young person's ongoing mental health and general functioning. After an investigation into completed suicides in the Early Psychosis Prevention and Intervention Centre (EPPIC) programme, the intensive case management subprogramme was developed in 2003 to provide assertive outreach to young people having a first episode of psychosis who are at high risk owing to risk to self or others, disengagement, or suboptimal recovery. We report intensive case management model development, characterise the target cohort, and report on outcomes compared with EPPIC treatment as usual.

Methods

Inclusion criteria, staff support, referral pathways, clinical review processes, models of engagement and care, and risk management protocols are described. We compared 120 consecutive referrals with 50 EPPIC treatment as usual patients (age 15–24 years) in a naturalistic stratified quasi-experimental real-world design. Key performance indicators of service use plus engagement and suicide attempts were compared between EPPIC treatment as usual and intensive case management, and psychosocial and clinical measures were compared between intensive case management referral and discharge.

Findings

Referrals were predominately unemployed males with low levels of functioning and educational attainment. They were characterised by a family history of mental illness, migration and early separation, with substantial trauma, history of violence, and forensic attention. Intensive case management improved psychopathology and psychosocial outcomes in high-risk patients and reduced risk ratings, admissions, bed days, and crisis contacts.

Interpretation

Characterisation of intensive case management patients validated the clinical research focus and identified a first episode of psychosis high-risk subgroup. In a real-world study, implementation of an intensive case management stream within a well-established first episode of psychosis service showed significant improvement in key service outcomes. Further analysis is needed to determine cost savings and effects on psychosocial outcomes. Targeting intensive case management services to high-risk patients with unmet needs should reduce the distress associated with pathways to care for patients, their families, and the community.

Funding

National Health & Medical Research Council and the Colonial Foundation.

Introduction

The rationale for early intervention in the first episode of psychosis (FEP) is well described and has resulted in an international network of services.1 Although this network has facilitated the development of multicomponent, phase-specific models of care, clusters of unmet need within FEP services remain.2 One of the most compelling subgroups is the difficult-to-engage cohort with multiple risks. The sequelae of disengagement are well known and include poorer remission from positive and negative symptoms, poorer social functioning and lowered quality of life, and heightened risk of relapse with repeated hospitalisations.3, 4, 5 Untreated, psychosis can permanently interrupt educational and vocational achievement leading to lifelong disability.6 More compelling sequelae include suicide, serious assault, and homicide. Suicide constitutes a leading cause of premature death in the FEP population,7, 8 with lifetime risk of 2–7% and self-harm rates of 25–50%.9, 10, 11

The Early Psychosis Prevention and Intervention Centre (EPPIC) was established in Melbourne, Australia in 1992 and is a cornerstone in the development of international FEP services.3 EPPIC provides enriched, comprehensive, phase-specific treatment focusing on early detection, recovery and relapse prevention, and aims to minimise disability and secondary comorbidity. Implementation of the EPPIC programme resulted in a reduced incidence of suicide from 4·25% in the historic generic service (1991) to 0·4% (1995–2000).12, 13 A specific cognitive behavioural treatment package (LifeSPAN) and risk monitoring system were subsequently introduced,12, 13, 14 resulting in further reduction in suicidality. Investigation into those who completed suicide despite the introduction of LifeSPAN showed a gap in service provision to disengaged high-risk patients who lacked social support, had dropped out of treatment prematurely, or were having an inadequate treatment response.15 It was also found by internal review that the effectiveness of existing EPPIC case managers in meeting the needs of these patients was compromised by high case loads. The investigation revealed the following subgroup profile: reluctance to engage in treatment; restricted psychosocial support; persistent positive or negative symptoms; high or unassessable risk of suicide; young males; frequent relapse; high-risk behaviours including violence; deteriorating mental status; and poor compliance. This profile showed the need for a tailored intensive treatment model to ameliorate suicide and other adverse outcomes in this subgroup.15

Assertive case management derives from assertive community treatment16 and is distinguished from generic case management models by smaller case loads, interventions that address many domains, the co-ordination of many services, and an emphasis on outreach and the team providing services in-house.17, 18, 19, 20, 21 Considerable evidence supports the benefits of assertive community treatment in the management of serious mental illness,19, 22, 23 although these findings are not universal24, 25 and appear more robust when the comparison intervention does not share key elements of assertive community treatment26 and when it is tailored to the needs of the highest service use.27 All FEP services follow an assertive community treatment model delivering phase-oriented treatment focusing on early detection, recovery and relapse prevention, and minimising disability and secondary comorbidity.28 FEP services are effective in reducing hospitalisations, bed days, and in improving engagement;29, 30, 31 however, they vary widely in their fidelity to the essential features of assertive community treatment and it is has been shown that the closer the model approximates to its original definition the better the outcomes,32, 33 although contrary findings have been reported.34

The term intensive case management was originally used to describe models of assertive community treatment designed to meet the needs of high service users, using low case loads and assertive outreach in the patient's own environment.19 In the last decade, the term has broadened to encompass any approach involving low case loads, ranging from standard case management35, 36 to assertive outreach. Intensive case management appears particularly beneficial for reducing admissions and bed days for high-risk and revolving-door patients, and managing patients with comorbidity or who are difficult to engage in traditional office-based settings.15, 27, 35, 36, 37 Its effect on symptom severity, social functioning, quality of life, life skills, and risk remains difficult to interpret.23 Since FEP services already provide some features of assertive community treatment, the development of additional intensive case management services to high-risk FEP patients implies a more intensive approach.

FEP services affect suicidality. The Danish OPUS study, a randomised controlled trial of integrated treatment (enriched case management within a multidisciplinary team) compared with standard treatment among patients with FEP, found non-significant reductions in completed suicides, suicidal attempts, and suicidal plans, but not suicidal thoughts at 1 year with assertive community treatment compared with standard case management.38 It was hypothesised that developing an intensive case management team focusing on reducing risk would further reduce suicides and other risk behaviours among those referred, while improving a raft of outcome measures. Although we were unable to implement the gold standard randomised controlled trial, there are important restrictions to the external validity of randomised controlled trials for public health interventions, especially those involving complex causal pathways or where those pathways can be affected by many characteristics of the population, health system, or environment.39 The effectiveness of an intervention is defined as its effect under normal conditions in field settings. Measuring outcomes in a real-world setting helps overcome some of the limitations of randomised controlled trials,40, 41 aiming for clinical realism by the inclusion of heterogeneous samples of consumers treated under routine clinical conditions.42 Therefore, the purpose of this study was to assess key service usage and symptomatic and psychosocial outcomes in a pilot intensive case management service at EPPIC compared with treatment as usual with a naturalistic stratified quasi-experimental design.

In 2002, a reduction in the upper limit of the EPPIC target age range from 30 to 25 years provided the budgetary opportunity to develop a pilot intensive case management team. The aim was to target and treat young people having a FEP who were at high risk owing to risk to self or others, disengagement or suboptimal recovery while drawing on minimal resources, and showing a substantial effect relative to EPPIC treatment as usual. No studies report the efficacy of intensive case management services in FEP. The service development model is described in the appendix.

Section snippets

Participants

The sample comprised the first 120 patients aged 15–24 years consecutively referred to the intensive case management service between 2003 and 2008. Referrals were triaged by the treatment-resistant early assessment team (TREAT). In effect, there were three groups of increasing risk within EPPIC: group 1, EPPIC patients; group 2, EPPIC patients unwell enough to be referred to the TREAT; and group 3, EPPIC patients referred by TREAT to intensive case management. During this period, 1226 patients

Results

We conducted a pilot assessment of the first 41 consecutive referrals to validate the clinical characteristics of the target cohort (appendix). The cohort was predominately unemployed and male with parental migration and restricted education. Over half had a family history of mental illness, with high levels of family break-up at a young age. Their backgrounds were characterised by substantial levels of abuse, forensic history (as evidenced by a formal police record), and a history of violence

Discussion

This is the first report of the effect of an intensive case management team in a FEP service targeting a difficult subgroup of high-risk patients. Evolution of FEP services has allowed the identification of subgroups of patients who need a more intensive approach. Characterisation of the first 41 intensive case management patients validated the target group, revealing a cohort of low functioning, unemployed males with little education. They had a family history of mental illness, migration and

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