Twenty-four hour care for schizophrenia

Schizophrenia is a long-term, chronic, illness with a worldwide lifetime prevalence of about one per cent. It has a high disability rate and the cost to individuals, their carers and health services is substantial. Although the majority of people with schizophrenia learn to cope in the community, there are some people who need help and reminders if they are to manage self-care and other aspects of day-to-day living. In many countries these people end up as long stay patients on hospital wards. This review aims to look at the economic costs and quality of life of people in 24 hour non-hospital care compared to those still in hospital. Only one trial of 22 people and lasting two years was identified, and it took place in the UK. Most of the participants but not all had schizophrenia. Half were assigned to live in a house staffed by a psychologist, and enough nurses and nursing assistants to provide 24 hour care. The staff were expected to help prepare and share meals with the residents and the residents had a programme of domestic work and some self-care tasks. The psychologist worked with each individual to improve social interaction and behaviour. The control group had normal hospital care with access to occupational therapy, industrial therapy and recreational facilities. They were also allowed home on leave and were counted as part of the group if they were discharged, transferred to hostels or in prison. The majority of the data were difficult to interpret because the numbers needed to make statistical comparisons were not given. Three people from the house had to be readmitted to the hospital and several of the others had short stays there. Those people who were resident in the house were reported to be significantly more likely to use social facilities and spent more time in socially constructive activities (self-care, eating with the group). All other measures reported were not significantly different between the groups. The costs for each group were similar, however if cost was calculated for those in the house who did not use the hospital at all, it was slightly less expensive. This was a small study which was not designed well. A larger, well-designed trial would answer the question of whether 24 hour care would benefit this group of people.

(Plain language summary prepared for this review by Janey Antoniou of RETHINK, UK www.rethink.org).

Authors' conclusions: 

From the single, small and ill-reported, included study, the hostel ward type of facility appeared cheaper and positively effective. Currently, the value of this way of supporting people - which could be considerable - is unclear. Trials are needed. Any 24 hour care 'ward-in-a-house' is likely to be oversubscribed. We argue that the only equitable way of providing care in this way is to draw lots as to who is allocated a place from the eligible group of people with serious mental illness. With follow-up of all eligible for the placements - those who were lucky enough to be allocated a place as well as people in more standard type of care - real-world evaluation could take place. In the UK further randomised control trials are probably impossible, as many of these types of facilities have closed. The broader lesson of this review is to ensure early and rigorous evaluation of fashionable innovations before they are superseded by new approaches.

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Background: 

Despite modern treatment approaches and a focus on community care, there remains a group of people who cannot easily be discharged from psychiatric hospital directly into the community. Twenty-four hour residential rehabilitation (a 'ward-in-a-house') is one model of care that has evolved in association with psychiatric hospital closure programmes.

Objectives: 

To determine the effects of 24 hour residential rehabilitation compared with standard treatment within a hospital setting.

Search strategy: 

We searched the Cochrane Schizophrenia Group Trials Register (May 2002 and February 2004).

Selection criteria: 

We included all randomised or quasi-randomised trials that compared 24 hour residential rehabilitation with standard care for people with severe mental illness.

Data collection and analysis: 

Studies were reliably selected, quality assessed and data extracted. Data were excluded where more than 50% of participants in any group were lost to follow-up. For binary outcomes we calculated the relative risk and its 95% confidence interval.

Main results: 

We identified and included one study with 22 participants with important methodological shortcomings and limitations of reporting. The two-year controlled study evaluated "new long stay patients" in a hostel ward in the UK. One outcome 'unable to manage in the placement' provided usable data (n=22, RR 7.0 CI 0.4 to 121.4). The trial reported that hostel ward residents developed superior domestic skills, used more facilities in the community and were more likely to engage in constructive activities than those in hospital - although usable numerical data were not reported. These potential advantages were not purchased at a price. The limited economic data was not good but the cost of providing 24 hour care did not seem clearly different from the standard care provided by the hospital - and it may have been less.

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