A randomized-controlled trial of intensive case management emphasizing the recovery model among patients with severe and enduring mental illness

Abstract

Background

There is increasing interest in the application of recovery principles in mental health services.

Aims

We studied the implementation of a programme of intensive case management (ICM) emphasizing recovery principles in a community mental health service in Ireland.

Methods

Eighty service attenders with severe and enduring illness characterized by significant ongoing disability were randomized into (1) a group receiving a programme of ICM and (2) a group receiving treatment as usual (TAU). Groups were compared before and after the programme for general psychopathology using the Brief Psychiatric Rating Scale (BPRS) (clinician rated) and How are You? scale (self-rated). The Functional Analysis of Care Environments (FACE) scale provided assessment of multiple functional domains.

Results

The overall group (mean age 44.5 ± 13.2 years; 60% male) had mean total Health of the Nation Outcome Scale (HoNOS) scale scores of 10.5 ± 4.6, with problems in social functioning especially prominent (mean social subscale score 5.0 ± 2.7). The ICM group were younger (p < 0.01) with higher baseline scores on the HoNOS social subscale and BPRS (p < 0.05). An analysis of covariance, controlling for these baseline differences, indicated greater improvement in BPRS scores (p = 0.001), How are You? scores (p = 0.02) and FACE domains for cognition, symptoms and interpersonal relationships (all p < 0.001) in the ICM group. The ICM group underwent greater changes in structured daily activities that were linked to improved BPRS scores (p = 0.01).

Conclusions

A programme of ICM emphasizing recovery principles resulted in significant improvement across psychopathological and functional domains. Improvements were linked to enhanced engagement with structured daily activities. Recovery-oriented practices can be integrated into existing mental health services and provided alongside traditional models of care.

Appendix

Box 1. Recovery principles [6]

• Participation

• Autonomy

• Strengths-based assessment

• Self-management/responsibility

• Person-centred service

• Empowerment

• Small goals and achievable steps

Box 2. Description of Recovery/ICM meetings

The weekly ICM/Recovery programme meeting was scheduled for Wednesday mornings immediately after the routine multidisciplinary team meeting and attended by the full team (including case managers).

The meetings included minutes of attendance and proceedings with a rotating chair.

A ‘psychological bell’ was used to prevent excessive discussion of medical matters that could be more appropriately addressed within usual service activities such as clinic attendances.

Meetings involved discussion of cases focusing initially on devising care plans based on clinical assessments and collaborative discussions with patients to prioritize needs and identify appropriate supports, both within the service and involving engagement with other community-based services (e.g. rehabilitative programmes, patient and carer support agencies, patient advocacy services, self-help groups, etc.).

Selected external agencies were invited to participate in sessions to explore ways of facilitating complementary interaction.

Patient, carer and case manager experiences of the process were discussed with particular focus where there was any disparity between these groups in relation to the ICM process and identified needs/goals.

The meetings were used to explore creative solutions for challenging cases and positive examples were used to generate ideas (e.g. identification of useful resources, opportunities to engage with community-based agencies, etc.).