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Evidence summaries

Intensive Case Management for Severe Mental Illness

Intensive case management (ICM) appears to reduce hospitalisation, increase retention in care and improve social functioning in severe mental illness compared to standard care, although its effect on mental state and quality of life remains unclear. However, its benefit on top of a less formal non-ICM approach appears not to be clear. Level of evidence: "B"

A Cochrane review [Abstract] 1 included 40 RCTs with a total of 7524 patients with severe mental illness. Severe mental illness included schizophrenic, affective and personality disorders. The patients were treated in the community-care setting, where intensive case management (ICM), non-ICM or standard care were compared. The majority of studies had over one year of follow-up time.

1. ICM vs standard care

  • Length of hospitalization was shorter with ICM (MD -0.86, CI -1.37 to -0.34; 24 RCTs, n=3595). Participants in the ICM group were less likely to be lost to psychiatric services (RR 0.43, CI 0.30 to 0.61; 9 RCTs, n=1633).
  • ICM reduced the number of people leaving the trial early (RR 0.68, 95% CI 0.58 to 0.79; 13 RCTs, n = 1798)
  • Global Assessment of Functioning (GAF) Scale showed an improvement with ICM (MD 3.41, CI 1.66 to 5.16; 5 RCTs, n=818).
  • No differences in mortality between ICM and standard care groups was found either due to 'all causes' (RR 0.84, CI 0.48 to 1.47; 9 RCTs, n=1456) or to 'suicide' (RR 0.68, CI 0.31 to 1.51; 9 RCTs, n=1456).
  • Social functioning results varied, significant improvement in accommodation status was found. Also, the incidence of not living independently was lower in the ICM group (RR 0.65, CI 0.49 to 0.88; 4 RCTs, n=1185).
  • Quality of life data found no significant difference between groups, but data were weak. Client Satisfaction Questionnaire (CSQ) scores showed a greater participant satisfaction in the ICM group (MD 3.23, CI 2.31 to 4.14; 2 RCTs, n=423).

2. ICM versus non-ICM

  • ICM makes little or no difference in the average number of days in hospital per month (MD -0.08, 95% CI -0.37 to 0.21; 21 RCTs, n = 2220) or in the average number of admissions (MD -0.18, 95% CI -0.41 to 0.05; 1 RCT, n = 678).
  • ICM reduced the number of participants leaving the intervention early (RR 0.70, 95% CI 0.52 to 0.95; 7 RCTs, n = 1970).
  • ICM reduced the rate of lost to follow-up (RR 0.72, CI 0.52 to 0.99; 9 RCTs, n=2195).
  • There is little or no difference in reducing death by suicide (RR 0.88, 95% CI 0.27 to 2.84; 3 RCTs, n = 1152).
  • Regarding social functioning, there was uncertainty about the effect of ICM on unemployment vs. non-ICM (RR 1.46, 95% CI 0.45 to 4.74; 1 RCT, n = 73).

Comment: The quality of the evidence is downgraded by study quality (inadequate allocation concealment).

    References

    • Dieterich M, Irving CB, Bergman H et al. Intensive case management for severe mental illness. Cochrane Database Syst Rev 2017;1():CD007906. [PubMed]

Primary/Secondary Keywords