Pathways of care of women in secure hospitals: which women go where and why.

BACKGROUND: Care pathways for women needing expensive, secure hospital care are poorly understood. AIMS: To characterise women in low and medium security hospitals in England and Wales and to compare populations by security and service provider type. METHOD: Census data from all specialist commissioning areas. Sociodemographic, clinical, medico-legal, criminological and placement needs data were requested on all women in low and medium secure hospital beds. Parametric tests were used for continuous data and chi-square or Fisher's exact tests for categorical data. Thematic analysis was used for free text data. RESULTS: The independent sector is the main service provider. A third of all women (n = 1149) were placed outside their home region despite spare local National Health Service (NHS) capacity. The independent sector provides for women with relatively rare disorders, including intellectual disability. The NHS admits most serious offenders. One in 20 are detained because of self-harm alone. CONCLUSIONS: Patient-specific factors (notably the diagnosis of personality disorder) and organisational inadequacy (commissioner and service provider) contribute to placements that compromise rehabilitation. Responses should include local solutions for women whose main risk is self-harm and a national approach to women with highly specialist needs.

Recovery from postnatal depression: a consumer's perspective.

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.

Essential elements of an early intervention service for psychosis: the opinions of expert clinicians.

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.

The effect of intensive case management on the relatives of patients with severe mental illness.

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.

Using activity data to explore the influence of case-load size on care patterns.

BACKGROUND: A 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. AIMS: To 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). RESULTS: There 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. CONCLUSIONS: Case-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.

Assertive community treatment across the Atlantic: comparison of model fidelity in the UK and USA.

BACKGROUND: The 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. AIMS: To compare high-fidelity US ACT teams with a UK team. METHOD: The UK 700'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. RESULTS: The 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. CONCLUSIONS: The failure of UK ACT studies to demonstrate the outcome differences of early US studies cannot be attributed entirely to the lack of ACT fidelity.

Exposure to case management: relationships to patient characteristics and outcome. Report from the UK700 trial.

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.