Community mental health teams (CMHTs) for people with severe mental illnesses and disordered personality

 

Abstract

Background

Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favour of providing care in a variety of non-hospital settings, underpins the rationale behind care in the community. A major thrust towards community care has been the development of community mental health teams (CMHT).

Objectives

To evaluate the effects of community mental health team (CMHT) treatment for anyone with serious mental illness compared with standard non-team management.

Search methods

We searched The Cochrane Schizophrenia Group Trials Register (March 2006). We manually searched the Journal of Personality Disorders, and contacted colleagues at ENMESH, ISSPD and in forensic psychiatry.

Selection criteria

We included all randomised controlled trials of CMHT management versus non-team standard care.

Data collection and analysis

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed effects model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (WMD) again based on a fixed effects model.

Main results

CMHT management did not reveal any statistically significant difference in death by suicide and in suspicious circumstances (n=587, 3 RCTs, RR 0.49 CI 0.1 to 2.2) although overall, fewer deaths occurred in the CMHT group. We found no significant differences in the number of people leaving the studies early (n=253, 2 RCTs, RR 1.10 CI 0.7 to 1.8). Significantly fewer people in the CMHT group were not satisfied with services compared with those receiving standard care (n=87, RR 0.37 CI 0.2 to 0.8, NNT 4 CI 3 to 11). Also, hospital admission rates were significantly lower in the CMHT group (n=587, 3 RCTs, RR 0.81 CI 0.7 to 1.0, NNT 17 CI 10 to 104) compared with standard care. Admittance to accident and emergency services, contact with primary care, and contact with social services did not reveal any statistical difference between comparison groups.

Authors' conclusions

Community mental health team management is not inferior to non-team standard care in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide. The evidence for CMHT based care is insubstantial considering the massive impact the drive toward community care has on patients, carers, clinicians and the community at large.

 

Plain language summary

Community mental health teams for people with severe mental illnesses and disordered personality

Since the 1950s there has been a trend to close institutions of care for people who are mentally unwell. In addition, government policy has sought to reduce the number of hospital beds available in favour of care being provided in the community to enable people to live more independent lives. The aim of Community Mental Health Teams (CMHTs) is to bring a specialist care package to people in the community. We reviewed the available evidence on CMHTs compared with standard non-team community care. We found only three trials which indicated some benefit in terms of acceptability of treatment, but overall the evidence for CMHTs is inadequate and further trials are needed to determine its effectiveness.

 

摘要

背景

對嚴重精神疾病及人格疾患服務的社區精神衛生小組(CMHTs)

關閉收容精神疾患的收容所和機構，加上政策上縮減住院床數，提供多樣的非住院環境，而支持的理由是由社區照顧來取代。對社區照顧的主要重點是社區精神衛生小組(CMHT)的發展

目標

比較在治療嚴重精神疾患上，使用社區精神衛生小組及非團隊治療的效果

搜尋策略

我們搜尋The Cochrane Schizophrenia Group Trials Register(2006年,3月)，也搜尋the Journal of Personality Disorders,同時也和 ENMESH, ISSPD，及負責司法精神醫學的同事接觸

選擇標準

我們納入所有有關 CMHT 管理及非團隊照顧的隨機對照試驗

資料收集與分析

我們分別抽取資料，對於二分法的變項，根據固定效果模式計來計算相對危險性(RR)和95% 的信賴區間(CI)。我們計算(NNT/NNH)。對於連續變項，根據固定效果模式計算加權平均數(WMD)

主要結論

整體而言在CMHT 的管理下較少死亡事件，但是CMHT 管理在自殺的死亡及猜疑的環境中，在統計上並沒有顯示任何統計上的顯著差異(n = 587, 3 RCTs, RR 0.49 CI 0.1 to 2.2)。退出率也沒有達到的顯著差異(n = 253, 2 RCTs, RR 1.10 CI 0.7 to 1.8). 有意義的是，比起一般標準照護組，參與 CMHT 的人通常有比較高的滿意度(n = 87, RR 0.37 CI 0.2 to 0.8, NNT 4 CI 3 to 11).同樣的，比起一般標準照護組，CMHT組的再住院率也顯著的較低(n = 587, 3 RCTs, RR 0.81 CI 0.7 to 1.0, NNT 17 CI 10 to 104) 。兩組的比較在意外、使用急診、使用門診、使用其他社會服務上並沒有達到統計的顯著差異

作者結論

比起標準照護來說，社區精神衛生小組在各種重要的層面來說並沒有比較不好，相反的會提高對於治療的接受度，也能降低再住院率及避免自殺死亡。以CMHT為基礎的照顧證據初步顯示對病人、照顧者、臨床者和一般社區民眾有產生重要影響

翻譯人

本摘要由彰化基督教醫院胡淑惠翻譯

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

從1950年代開始，開始有一個趨勢慢慢的關閉了照顧精神疾患的機構。此外，政策上也開始縮減住院床數，態度上較傾向於提供社區照顧，使得人們可以過著較獨立的生活。而社區精神衛生小組(CMHTs)的目標是在社區中由一個專家帶領團隊來照顧病人。我們回顧了所有有關社區精神衛生小組和非團隊照護的社區服務的證據，發現只有3個試驗指出，基於對這樣的治療的接受度而言，只呈現一些優點，而且對於是否支持CMHTs 的證據並不充足，未來仍需更多試驗來驗證它的效果