Holloway F, Carson J
Maudsley Hospital, London.
Br J Psychiatry. 1998 Jan;172:19-22. doi: 10.1192/bjp.172.1.19.
The aim was to compare the efficacy of intensive clinical case management (ICM) with standard community care in the management of 'hard to treat' patients with a severe mental illness.
A randomised controlled trial was carried out in East Lambeth, a deprived area of inner London. Seventy people with psychosis designated as 'hard to treat' by referring teams were included; 35 were randomised to ICM (case load eight patients per worker), and 35 to standard care, which offered follow-up by a community psychiatric nursing service (30 patients per worker). Outcome measures were admissions and hospital bed utilisation; contact with services; symptomatology; social behaviour; social functioning; quality of life; patients' satisfaction with care at 9 and 18 months.
There were no differences in patients' symptoms, social behaviour or social functioning. Quality of life was significantly improved in patients receiving ICM at 9 months. Satisfaction with care was significantly greater among case-managed patients. All ICM patients remained in contact with services throughout the study, while six control patients were refusing all contact with services at 18 months.
ICM failed to improve the clinical outcome of 'hard to treat' patients. The service was successful in maintaining contact with patients, was greatly appreciated and had a positive effect on their perceived quality of life.
目的是比较强化临床病例管理（ICM）与标准社区护理在治疗“难治性”重度精神疾病患者方面的疗效。
在伦敦市中心贫困地区东兰贝斯进行了一项随机对照试验。纳入了70名被转诊团队认定为“难治性”的精神病患者；35人被随机分配到ICM组（每位工作人员负责8名患者），35人被分配到标准护理组，由社区精神科护理服务进行随访（每位工作人员负责30名患者）。结局指标包括住院情况和病床使用情况；与服务机构的接触；症状表现；社会行为；社会功能；生活质量；患者在9个月和18个月时对护理的满意度。
患者的症状、社会行为或社会功能没有差异。接受ICM治疗的患者在9个月时生活质量有显著改善。病例管理患者对护理的满意度明显更高。在整个研究过程中，所有ICM患者都与服务机构保持联系，而在18个月时，6名对照患者拒绝与服务机构进行任何接触。
ICM未能改善“难治性”患者的临床结局。该服务成功地与患者保持了联系，深受患者感激，并对他们感知到的生活质量产生了积极影响。
