Collaborative care approaches for people with severe mental illness

Collaborative care aims to improve the physical and mental health of people with severe mental illness (SMI). Common to all definitions is that collaborative care aims to develop closer working relationships between primary care (family doctors or GPs and practice nurses) and specialist health care (such as Community Mental Health Teams). There are different ways in which this can be achieved, making collaborative care very complex. Integrating or joining-up primary care and mental health services, so that they work better together, is intended to increase communication and joint working between health professionals (e.g. GPs, psychiatrists, nurses, pharmacists, psychologists). This is meant to provide a person with severe mental illness with better care, based in the community, which is often a less stigmatised setting than hospital, and that promotion of good practice helps consumers maintain contact with services. A major issue is that many GPs still feel that physical health problems (such as diabetes, heart disease, smoking cessation) are more their concern and see treatment of severe mental illness as the job of psychiatrists and other mental health professionals. Collaborative care aims to improve overall quality of care by ensuring that healthcare professionals work together, trying to meet the physical and mental health needs of people. The aim of the review was to assess the effectiveness of collaborative care in comparison to standard or usual care. An electronic search for trials was carried out in April 2011. The primary focus of interest was admissions to hospital. According to the one included study in this review, collaborative care may be effective in reducing going into hospital (less psychiatric admissions and other admissions). It also helps improve people’s quality of life and mental health. However, all evidence was either low or very low quality and further research is needed to determine whether collaborative care is good for people with SMI in terms of clinical outcomes or helping people feel better as well as its cost effectiveness.

This summary has been written by a consumer Ben Gray (Service User and Service User Expert, Rethink Mental Illness).

Authors' conclusions: 

The review did not identify any studies relevant to care of people with schizophrenia and hence there is no evidence available to determine if collaborative care is effective for people suffering from schizophrenia or schizophreniform disorders. There was however one trial at high risk of bias that suggests that collaborative care for US veterans with bipolar disorder may reduce psychiatric admissions at two years and improves quality of life (mental health component) at three years, however, on its own it is not sufficient for us to make any recommendations regarding its effectiveness. More large, well designed, conducted and reported trials are required before any clinical or policy making decisions can be made.

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Background: 

Collaborative care for severe mental illness (SMI) is a community-based intervention, which typically consists of a number of components. The intervention aims to improve the physical and/or mental health care of individuals with SMI.

Objectives: 

To assess the effectiveness of collaborative care approaches in comparison with standard care for people with SMI who are living in the community. The primary outcome of interest was psychiatric admissions.

Search strategy: 

We searched the Cochrane Schizophrenia Group Specialised register in April 2011. The register is compiled from systematic searches of major databases, handsearches of relevant journals and conference proceedings. We also contacted 51 experts in the field of SMI and collaborative care.

Selection criteria: 

Randomised controlled trials (RCTs) described as collaborative care by the trialists comparing any form of collaborative care with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI, defined as schizophrenia or other types of schizophrenia-like psychosis (e.g. schizophreniform and schizoaffective disorders), bipolar affective disorder or other types of psychosis.

Data collection and analysis: 

Two review authors worked independently to extract and quality assess data. For dichotomous data, we calculated the risk ratio (RR) with 95% confidence intervals (CIs) and we calculated mean differences (MD) with 95% CIs for continuous data. Risk of bias was assessed.

Main results: 

We included one RCT (306 participants; US veterans with bipolar disorder I or II) in this review. We did not find any trials meeting our inclusion criteria that included people with schizophrenia. The trial provided data for one comparison: collaborative care versus standard care. All results are 'low or very low quality evidence'.

Data indicated that collaborative care reduced psychiatric admissions at year two in comparison to standard care (n = 306, 1 RCT, RR 0.75, 95% CI 0.57 to 0.99).

The sensitivity analysis showed that the proportion of participants psychiatrically hospitalised was lower in the intervention group than the standard care group in year three: 28% compared to 38% (n = 330, 1 RCT, RR 0.72, 95% CI 0.53 to 0.99).

In comparison to the standard care group, collaborative care significantly improved the Mental Health Component (MHC) of quality of life at the three-year follow-up, (n = 306, 1 RCT, MD 3.50, 95% CI 1.80 to 5.20). The Physical Health Component (PHC) of the quality of life measure at the three-year follow-up did not differ significantly between groups (n = 306, 1 RCT, MD 0.50, 95% CI 0.91 to 1.91).

Direct intervention (all-treatment) costs of collaborative care at the three-year follow-up did not differ significantly from standard care (n = 306, 1 RCT, MD -$2981.00, 95% CI $16934.93 to $10972.93). The proportion of participants leaving the study early did not differ significantly between groups (n = 306, 1 RCT, RR 1.71, 95% CI 0.77 to 3.79). There is no trial-based information regarding the effect of collaborative care for people with schizophrenia.

No statistically significant differences were found between groups for number of deaths by suicide at three years (n = 330, 1 RCT, RR 0.34, 95% CI 0.01 to 8.32), or the number of participants that died from all other causes at three years (n = 330, 1 RCT, RR 1.54, 95% CI 0.65 to 3.66).

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