Havassy B E, Shopshire M S, Quigley L A
Department of Psychiatry, University of California, School of Medicine, San Francisco 94105, USA.
Psychiatr Serv. 2000 May;51(5):639-44. doi: 10.1176/appi.ps.51.5.639.
The effectiveness of a community-based intensive clinical case management program was compared with that of a hospital-based expanded brokerage case management program for seriously mentally ill adults with and without substance dependence.
The sample of 268 frequently hospitalized psychiatric patients was recruited during acute psychiatric hospitalization. More than half of the sample (53 percent) was diagnosed as having at least one current DSM-III-R substance dependence disorder co-occurring with their primary major mental disorder. Subjects were stratified by substance dependence status and randomly assigned to one of the case management programs. They were interviewed before hospital discharge and at one, two, and six months after discharge to assess psychosocial and drug use variables. Subjects' service use was examined for the six months before and after hospitalization.
The hypothesis that substance-dependent subjects would benefit more from intensive clinical case management was not supported. Substance dependence predicted negative outcomes independent of the case management intervention. The hypothesis that the two case management approaches would be equally effective for subjects not dependent on substances was also not borne out. Intensive clinical case management was the superior treatment for subjects who were not dependent on substances. Fewer of them required psychiatric hospitalization in the six-month postdischarge period than in the six-month period before hospital admission.
The negative outcomes for substance-dependent subjects in both programs suggest that the two case management models were relatively ineffective for these patients. Results suggest that intensive clinical case management can be effective within the first six months for nondependent adults with serious mental illness.
比较基于社区的强化临床病例管理项目与基于医院的扩展经纪病例管理项目对伴有或不伴有物质依赖的重度成年精神病患者的效果。
在急性精神病住院期间招募了268名经常住院的精神病患者样本。超过一半的样本（53%）被诊断为目前至少有一种DSM-III-R物质依赖障碍与其原发性重度精神障碍并发。受试者按物质依赖状况分层，并随机分配到其中一个病例管理项目。在出院前以及出院后1个月、2个月和6个月对他们进行访谈，以评估心理社会和药物使用变量。对受试者住院前后6个月的服务使用情况进行了检查。
物质依赖受试者将从强化临床病例管理中获益更多这一假设未得到支持。物质依赖预示着与病例管理干预无关的负面结果。两种病例管理方法对不依赖物质的受试者同样有效的假设也未得到证实。强化临床病例管理是对不依赖物质的受试者的更佳治疗方法。在出院后的6个月内，他们中需要精神病住院治疗的人数比入院前的6个月要少。
两个项目中物质依赖受试者的负面结果表明，这两种病例管理模式对这些患者相对无效。结果表明，强化临床病例管理在头6个月内对不依赖物质的重度成年精神病患者可能有效。
