Author:

Abstract

Introduction

Case management (CM) as a model of community intervention in people with severe mental illness and with pharmacological and psychosocial integrated care have been suggested as a way to improve treatment adherence and to prevent hospital admissions among people with severe schizophrenia compared with standard treatment.

The objectives of this study were to know the treatment adherence and the psychiatric hospitalizations of patients with severe schizophrenia before (standard treatment in mental health units) and during treatment in an integrated, community based, intensive case managed program.

The program for people with severe mental illness in Gijón (Spain) is based on the principles of community care with intensive case management and with a multidiscipli-nary team intervention. Nurses as case managers and integrated psychological and pharmacological treatment, social skills training, psychoeducation, vocational interven-tion and home support are provided.

Methods

Observational study, mirror image, of ten years of follow-up and ten retrospectives (pretreatment), of patients with severe schizophrenia in a community based program, with integrated pharmacological and psychosocial treatment and  intensive case management (N=344). Reasons for the Program discharge and psychiatric hospital admissions were recorded ten years before and during treatment.

Results              

After 10 years only 12.2% of the patients were voluntary discharges (In previous standard treatment: 84.3%). CGI-S at baseline was 5.9(0.7). After ten years 51.7% of patients continued under treatment (CGI-S= 3.9(0.9); p<0.01); 19.3% were medical discharged (CGI-S=3.4(1.5); p<0.001). The percentage of patients with hospital admissions, and the number of admissions due to relapses decreased drastically after entering the Program (p <0.0001), and as well the involuntary ones (p <0.001).

Discussion

Given the high rates of non-compliance among patients with schizophrenia, and especially in those with greater severity, and their association with psychiatric hospitalizations, the findings of this study shows how specific strategies focused to increase adherence, such as community programs with integrated pharmacological and psychosocial interventions and intensive case management, decrease relapses and hospitalizations. In short, the results support the effectiveness of integrated treatment and case management approach in terms of improving adherence and diminishing hospitalizations compared to standard treatment.

Conclusions

The incorporation of patients with severe schizophrenia into a comprehensive, community-based program, with integrated pharmacological and psychosocial treatment and intensive case management achieved high treatment retention, and was effective in drastically reducing psychiatric hospitalizations compared to the previous standard treatment.

Lessons learned

The widespread implementation of comprehensive community programs,   with pharmacological and psychosocial  integrated care and intensive case management should be considered as the choice for people with severe schizophrenia.

Limitations

We have designed an open, non-randomized study under conditions of usual, pragmatic practice. There is therefore no control group and there is no active comparator during the course of this investigation.

All patients are classified as seriously ill at the beginning of the study. Because of this, the results presented here cannot be generalized to populations that are not severely ill.

Suggestions for future research

Further researches with naturalistic approach and even randomized clinical trials should be made to confirm these findings.