Better care for less money: cost-effectiveness of integrated care in multi-episode patients with severe psychosis.

OBJECTIVE: To compare cost-effectiveness of integrated care with therapeutic assertive community treatment (IC-TACT) versus standard care (SC) in multiple-episode psychosis. METHOD: Twelve-month IC-TACT in patients with schizophrenia-spectrum and bipolar I disorders were compared with a historical control group. Primary outcomes were entropy-balanced cost-effectiveness based on mental healthcare costs from a payers' perspective and quality-adjusted life years (QALYs) as a measure of health effects during 12-month follow-up. RESULTS: At baseline, patients in IC-TACT (n = 214) had significantly higher illness severity and lower functioning than SC (n = 56). Over 12 months, IC-TACT had significantly lower days in inpatient (10.3 ± 20.5 vs. 28.2 ± 44.9; P = 0.005) and day-clinic care (2.6 ± 16.7 vs. 16.4 ± 33.7; P = 0.004) and correspondingly lower costs (€-55 084). Within outpatient care, IC-TACT displayed a higher number of treatment contacts (116.3 ± 45.3 vs. 15.6 ± 6.3) and higher related costs (€+1417). Both resulted in lower total costs in IC-TACT (mean difference = €-13 248 ± 2975, P < 0.001). Adjusted incremental QALYs were significantly higher for IC-TACT versus SC (+0.10 ± 0.37, P = 0.05). The probability of cost-effectiveness of IC-TACT was constantly higher than 99%. CONCLUSION: IC-TACT was cost-effective compared with SC. The use of prima facies 'costly' TACT teams is highly recommended to improve outcomes and save total cost for patients with severe psychotic disorders.

Early detection and integrated care for adolescents and young adults with psychotic disorders: the ACCESS III study.

OBJECTIVE: The objective of the study was to investigate whether a combined intervention composed of early detection plus integrated care (EDIC) enhances outcomes in patients with early psychosis compared to standard care (SC). METHODS: ACCESS III is a prospective non-randomized historical control design 1-year study examining the efficacy of EDIC (n = 120) vs. SC (n = 105) in patients aged 12-29 years. Primary outcome was the rate of ≥6 months combined symptomatic and functional remission. Additional outcomes comprised the reduction of DUP and course of psychopathology, functioning, quality of life, and satisfaction with care. RESULTS: In observed cases, 48.9% in the EDIC and 15.2% in the SC group reached the primary endpoint. Remission was predicted by EDIC (OR = 6.8, CI: 3.15-14.53, P < 0.001); younger age predicted non-remission (OR = 1.1, CI: 1.01-1.19, P = 0.038). Linear regressions indicated a reduction of DUP in EDIC (P < 0.001), but not in SC (P = 0.41). MMRMs showed significantly larger improvements in PANSS positive (P < 0.001) and GAF (P < 0.01) scores in EDIC vs. SC, and in EDIC over time in CGI-Severity (P < 0.001) and numerically in Q-LES-Q-18 (P = 0.052). CONCLUSIONS: EDIC lead to significantly higher proportions of patients achieving combined remission. Moderating variables included a reduction of DUP and EDIC, offering psychotherapeutic interventions.

[Integrated care for patients with first and multiple episodes of severe psychotic illnesses: 3-year results of the Hamburg model]. / Integrierte Versorgung für erst- und mehrfacherkrankte Patienten mit schweren psychotischen Erkrankungen : 3-Jahres-Ergebnisse des Hamburger Modells.

BACKGROUND: The so-called "Hamburg model" is a designated integrated care model according to § 140 of the Social Code Book (SGB) V for psychosis patients fulfilling the definition of severe mental illness (SMI). OBJECTIVES: Description of the model and evaluation of efficacy of all patients being treated for ≥ 3 years. MATERIALS AND METHODS: Service entry illness status, course of illness, and interventions were assessed within a continuous quality assurance study. One hundred and fifty-eight patients who fulfilled the criterion of being treated for ≥ 3 years were analyzed. RESULTS: At service entry, SMI were among others mirrored by a high level of psychopathology (Brief Psychiatric Rating Scale [BPRS]: 80.3) and severity of illness (Clinical Global Impression Severity [CGI-S]/Clinical Global Impression Bipolar scales [CGI-BP]: 5.8), low functioning level (Global Assessment of Functioning scale [GAF]: 35.9), and high rates of comorbid psychiatric (94.3 %) and somatic (81.6 %) disorders. Only 8 patients (5.1 %) disengaged from the service within the 3-year treatment period. The course of the illness over 3 years showed significant and stable improvements in psychopathology (BPRS: p < 0.001), the severity of illness (CGI-S/CGI-BP: p < 0.001), functioning (GAF: p < 0.001), quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire [Q-LES-Q-18]: p < 0.001), and satisfaction with care (Client Satisfaction Questionnaire [CSQ-8]: 2.0 to 3.3; p = 0.164; nonsignificant because of early improvements). Further, compulsory admissions were reduced and medication adherence in addition to working ability improved (all p < 0.001). Data on interventions showed a continuously high frequency of outpatient interventions over time (on average 112.0 per year), a high percentage of patients in psychotherapy (67 %), and a nearly 90 % reduction in inpatient treatment days from year 1 to year 3. CONCLUSION: Integrated care in severely ill patients with psychotic disorders leads to multidimensional illness improvement and stabilization by offering intensive outpatient care.

[Remission and recovery: new hopes--realistic aims in the therapy for schizophrenia]. / Remission und Recovery: Neue Hoffnung--realistische Ziele in der Schizophrenietherapie.

The present review critically appraises the various different definitions of and the ongoing discussions about the terms remission and recovery, which represent important aspects for describing the disease course, therapy planning and the setting of therapeutic targets for the patient, relatives and the professional care-giver. A symptomatic remission is well defined and is reached by about 30-60% of the first-time patients. However, this is not to be equated with functional, social and subjective remission. The term recovery has various definitions and has as yet only been studied in a relatively unempirical manner but represents an important supplement to the often strictly formulated therapeutic targets that need to be complemented by subjective and objective as well as personal and clinical perspectives. To inspire and maintain hope is thus an essential factor that extends beyond the therapeutic target of an often rather resigning symptomatic therapy. Even so, the provision of hope remains a balancing act. Too little hope can induce pessimism which in turn may have considerable negative therapeutic and personal consequences. On the other hand an uncritical attitude to hope may lead to unrealistic expectations--inevitably to be followed by frustration and resignation again.

Differences between first episode schizophrenia and schizoaffective disorder.

BACKGROUND: The diagnostic and clinical overlap between schizophrenia and schizoaffective disorder is an important nosological issue in psychiatry that is yet to be resolved. The aim of this study was to compare the clinical and functional characteristics of an epidemiological treated cohort of first episode patients with an 18-month discharge diagnosis of schizophrenia (FES) or schizoaffective disorder (FESA). METHODS: This study was part of the larger First Episode Psychosis Outcome Study (FEPOS) which involved a medical file audit study of all 786 patients treated at the Early Psychosis Prevention and Intervention Centre between 1998 and 2000. Of this cohort, 283 patients had an 18-month discharge diagnosis of FES and 64 had a diagnosis of FESA. DSM-IV diagnoses and clinical and functional ratings were derived and validated by two consultant psychiatrists. RESULTS: Compared to FES patients, those with FESA were significantly more likely to have a later age of onset (p=.004), longer prodrome (p=.020), and a longer duration of untreated psychosis (p<.001). At service entry, FESA patients presented with a higher illness severity (p=.020), largely due to the presence of more severe manic symptoms (p<.001). FESA patients also had a greater number of subsequent inpatient admissions (p=.017), had more severe depressive symptoms (p=.011), and higher levels of functioning at discharge. DISCUSSION: The findings support the notion that these might be considered two discernable disorders; however, further research is required to ascertain the ways and extent to which these disorders are discriminable at presentation and over time.

Remitted but still impaired? Symptomatic versus functional remission in patients with schizophrenia.

INTRODUCTION: Studies reported close associations between functional outcome and symptomatic remission as defined by the Remission in Schizophrenia Working Group. This observational study was aimed at the investigation of deficits in daily functioning, symptoms and subjective well-being in remitted and non-remitted patients with schizophrenia. METHODS: Symptoms (PANSS), functional outcome (FROGS, GAF), subjective well-being (SWN-K) and other characteristics were assessed in 131 patients with schizophrenia (DSM-IV) within the European Group on Functional Outcomes and Remission in Schizophrenia (EGOFORS) project. RESULTS: A significant better level of functioning was measured for remitted versus non-remitted patients, though remitted patients still showed areas with an inadequate level of functioning. Functional deficits were most often seen in social relations (40%), work (29%) and daily life activities (17%). Best functioning was assessed for self-care, self-control, health management and medical treatment. A moderate to severe level of disorganization and emotional distress was observed in 38% and impaired subjective well-being in 29% of patients defined as being in symptomatic remission. DISCUSSION: The results confirm a close association between symptomatic remission and functional outcome. However, deficits in different areas of functioning, symptoms and well-being underline the need for combined outcome criteria for patients with schizophrenia.

Applicability of the Clinical Global Impressions-Aggression (CGI-A) scale for use in file audit trials.

The aim of this study was to evaluate the applicability and validity of a clinical global impressions-aggression (CGI-A) scale in retrospective trials. CGI-A scores were derived from clinical records, BPRS scores were assessed prospectively in 101 patients with first-episode psychosis. CGI-A showed highly significant correlations to the brief psychiatric rating scale (BPRS) excited component (BPRS-EC; r=0.32; p=0.001) and BPRS resistance (r=0.25; p=0.011), to aggression at admission (r=0.70; p<0.001) and to involuntary treatment (r=0.55; p<0.001). The CGI-A retains high construct and face validity in retrospective trials.