Effects of support and follow-up interventions for people with severe mental illness
Systematic review
|Updated
The Norwegian Knowledge Centre for the Health Services has summarized available research on the effect of support and follow-up measures for patients with severe mental illness.
Key message
Many people diagnosed with and treated for severe mental illness are likely to experience relapse at some point during their lives. In addition to beginning and continuing therapeutic and medical treatment, other types of support and follow-up measures may be important for the patients’ health and welfare. Examples of relevant support and follow-up interventions include: patient education and life skills training, structural measures such as supported housing and follow-up monitoring, recreation and leisure activities, and vocational rehabilitation.
The Norwegian Knowledge Centre for the Health Services has summarized available research on the effect of support and follow-up measures for patients with severe mental illness. We included 17 systematic reviews that compared different support and follow-up interventions in addition to treatment as usual compared to treatment as usual. The reviews included people with schizophrenia and schizophrenia-like illnesses, bipolar disorder, severe or major affective disorders, post-traumatic stress disorder, people with both severe mental illness and substance misuse and mixed groups of patients with severe mental illnesses.
The evidence was of moderate to very low quality and the necessary evidence was often lacking. However, based on the available evidence, support and follow-up interventions such as education, exercise and vocational rehabilitation may have beneficial effects on health and health related outcomes such as readmissions and relapse. We also found improvements in adherence to recommended drug use, patient satisfaction and employment.
We could not draw any conclusions about the effects of interventions such as housing and home visits, monitoring of physical health and use of reminders to patients with severe mental illness, supportive relationship building for patients with schizophrenia and bipolar disorder as well as cultural and recreational activities such as sports and games for patients with PTSD. The reason for this was that we did not identify any relevant reviews or that the reviews we found were empty.
Summary
Background
Many people diagnosed and treated for severe mental illness experience relapse at some point. In addition to beginning and continuing therapeutic and medical treatment, other types of support and follow-up measures may be important for the prevention of future problems, as well as general health promotion. There is therefore a need for a systematic review of the evidence that has evaluated the effects of support and follow-up measures to ensure the best possible patient care, and to inform the design of services in practice. Examples of relevant support and follow-up interventions include: patient education and life skills training, structural measures such as supported housing and follow-up monitoring, culture- and leisure activities, and vocational rehabilitation.
Objective
The objective of this report is to systematically review the evidence that has evaluated the effects of support and follow-up measures.
Method
We searched for systematic reviews in relevant databases. The search was done from October 2011 to January 2012. Two people independently assessed all of the titles and summaries. Potentially relevant reviews were retrieved in full text and considered for inclusion or exclusion. All high quality systematic reviews encompassing patients with severe mental illness and who received any support or follow-up measure were included. The quality of the included reviews was assessed with checklists. The quality of the evidence for each outcome was assessed using GRADE. Two researchers reviewed the effects and quality of the evidence for the following outcomes where data were available: health outcomes, quality of life, knowledge and skills, health behaviours (such as follow-up of treatment), patient satisfaction and health care utilization / costs.
Results
Of the 2674 hits that the search generated, we included 17 systematic reviews of high quality, which altogether had 21 comparisons. The reviews included people with schizophrenia and schizophrenia-like illnesses, bipolar disorder, severe or major depression, post-traumatic stress disorder, people with both severe mental illness and substance misuse and mixed groups of patients with severe mental illnesses. The support and follow-up measures were mainly given in addition to conventional treatment or practice as usual, and were compared to conventional treatment or practice as usual. The documentation was of moderate to very low quality and the necessary documentation was often lacking. However, based on the available evidence, we found that:
- Education about one’s own illness and treatment may provide fewer relapses in patients with bipolar disorder and schizophrenia and schizoaffective disorders (evidence of moderate to low quality). Fewer patients (with dual diagnosis) receiving education left the study than those receiving usual practice (evidence of low quality). Patients (with schizophrenia and schizoaffective disorders) receiving education were more satisfied than those receiving usual practice (evidence of low quality).
- Physical health advice for patients with severe mental illness, probably leads to greater uptake of recommended preventive health services (evidence of low quality).
- Education and monitoring by pharmacists possibly improves adherence to antidepressives for patients with major depression (evidence of low quality).
- Exercise for patients with major depression probably improves depression in short term follow-up (evidence of moderate quality).
- Pre-vocational training in addition to hospital care compared with usual hospital care for patients with severe mental illness, possibly leads to more people in any form of employment (evidence of low quality).
- Pre-vocational training in addition to community care compared with community care for patients with severe mental illness, probably leads to a reduction in the number of readmissions to hospital (evidence of moderate quality).
Pre-vocational training with payment for patients with schizophrenia and schizophrenialike illness possibly leads to more people in competitive employment, more participating in the programme and a reduction in readmissions to the hospital compared to pre-vocational training without payment (evidence of low quality).
- Supported employment compared to pre-vocational training for patients with severe mental illness probably leads to more people in competitive employment and less people leaving the study (evidence of moderate quality).
- There was little or insufficient evidence available to make conclusions about the effects of culture and leisure activities and housing and follow-up monitoring interventions, and on outcomes such as mortality, quality of life, knowledge, skills, empowerment, patient satisfaction and costs.
Discussion
Much of the evidence in this report was considered to be of low or very low quality. This is mainly because the included systematic reviews contained few and small studies, but also that those studies had methodological weaknesses or were inadequately reported. Furthermore, the confidence intervals for many of the effect estimates included both potential benefits and harms. This means that there are uncertainties associated with the results for several of the reported outcomes.
Conclusion
Based on the available evidence, support and follow-up interventions such as education, exercise and vocational rehabilitation may have beneficial effects on health and health related outcomes such as readmissions and relapse, and outcomes that may be important for prevention of relapse. We also found improvements in adherence to recommended drug use, patient satisfaction and employments.
There is a need for more studies with larger study populations in order to identify meaningful differences. Also, there is a need for evidence on the effects of interventions such as recreational and leisure activities and supported housing and follow-up measures. Future studies should aim to include mortality quality of life, knowledge, skills, empowerment, patient satisfaction and costs.