Intensive versus standard case management for severe psychotic illness: a randomised trial

Background Case management has increasingly been the recommended approach t o care for severely mentally ill patients since the number of psychiatric b eds has decreased. Despite equivocal results, in the UK and Europe, this ap proach is becoming accepted policy. We assessed the effect of smaller case loads. Methods We randomly assigned 708 psychotic patients in four centres standar d case management (355 patients, case load 30-35 per case manager) or inten sive case management (353 patients, case load 10-15 per case manager). We m easured clinical symptoms and social functioning at baseline, 1 year, and 2 years. The impact of treatment on hospital use was assessed at 2 years by subgroup analyses for Afro-Caribbean and for severely socially disabled pat ients. Analysis was by intention to treat, Findings There was no significant decline in overall hospital use among int ensive-case-management patients (mean 73.5 vs 73.1 days in those who receiv ed standard care [SD 0.4, 95% CI -17.4 to 18.1]), nor were there any signif icant gains in clinical or social functioning. There was no evidence of dif ferential effect in Afro-Caribbean patients or the most socially disabled p atients. Interpretation In well-coordinated mental-health services, a decline in cas e load alone does not improve outcome for these patients. Mental-health pla nners may need to pay more attention to the content of treatment rather tha n changes in service organisation.