Morandi et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:26
DOI 10.1186/s13011-017-0111-8
RESEARCH
Open Access
Intensive Case Management for Addiction
to promote engagement with care of
people with severe mental and substance
use disorders: an observational study
Stéphane Morandi*, Benedetta Silva, Philippe Golay and Charles Bonsack
Abstract
Background: Co-occurring severe mental and substance use disorders are associated with physical, psychological
and social complications such as homelessness and unemployment. People with severe mental and substance use
disorders are difficult to engage with care. The lack of treatment worsens their health and social conditions and
increases treatment costs, as emergency department visits arise. Case management has proved to be effective in
promoting engagement with care of people with severe mental and substance use disorders. However, this impact
seemed mainly related to the case management model. The Intensive Case Management for Addiction (ICMA) aimed
to improve engagement with care of people with severe mental and substance use disorders, insufficiently engaged
with standard treatment. This innovative multidisciplinary mobile team programme combined Assertive Community
Treatment and Critical Time Intervention methodologies. The aim of the study was to observe the impact of ICMA
upon service use, treatment adherence and quality of support networks. Participants’ psychosocial and mental
functioning, and substance use were also assessed throughout the intervention.
Methods: The study was observational. Eligible participants were all the people entering the programme
during the first year of implementation (April 2014–April 2015). Data were collected through structured
questionnaires and medical charts. Assessments were conducted at baseline and at 12 months follow-up
or at the end of the programme if completed earlier. McNemar-Bowker’s Test, General Linear Model
repeated-measures analysis of variance and non-parametric Wilcoxon Signed Rank tests were used for
the analysis.
Results: A total of 30 participants took part in the study. Results showed a significant reduction in the
number of participants visiting the general emergency department compared to baseline. A significantly
decreased number of psychiatric emergency department visits was also registered. Moreover, at follow-up
participants improved significantly their treatment adherence, clinical status, social functioning, and substance
intake and frequency of use.
Conclusions: These promising results highlight the efficacy of the ICMA. The intervention improved
engagement with care and the psychosocial situation of people with severe mental and substance use
disorders, with consequent direct impact on their substance misuse.
Keywords: Assertive community treatment, Critical time intervention, Intensive Case Management, Addiction,
Severe mental disorder, Substance use disorder, Engagement with care
* Correspondence: stephane.morandi@chuv.ch
Department of Psychiatry, Social Psychiatry Section, Community Psychiatry
Service, Lausanne University Hospital (CHUV), Place Chauderon 18, 1003
Lausanne, Switzerland
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Morandi et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:26
Background
Only a minority of people with co-occurring severe
mental and substance use disorders seek help and are
treated for their problems [1–3]. On a personal level,
important identified barriers to treatment are symptoms, lack of awareness of being in need of help,
stigma or social problems such as homelessness or
insufficient financial resources. On a structural level,
the service location and organisation or the unavailability of addiction specialists have been recognised as
care access limitations [4, 5]. Absence of care can
lead to health and social complications and contributes to higher costs of public services as emergency
department visits arise [6]. Different models of case
management have proved to be effective in promoting
engagement with care of people with substance use
disorders in a variety of settings [7–9]. Case management also showed to reduce substance misuse among
homeless people with severe mental illness [10]. However, the impact of these interventions seemed to be
mainly determined by the case management reference
model [11]. Assertive community treatment (ACT)
improved housing stability and was cost-effective for
homeless people with severe mental and substance
use disorders, reducing inpatient and emergency
department visits. Critical Time Intervention (CTI)
showed promise for housing support, psychiatric
symptoms and substance use in this population.
In 2001, an Intensive Case Management (ICM)
programme for people with severe mental disorders (in
French Suivi Intensif dans le milieu-SIM), was developed
and tested in Lausanne, Switzerland, an urban area of
265′000 inhabitants [12]. The intervention combined
the Assertive Community Treatment (ACT) [13, 14] and
the Critical Time Intervention [15] methodologies. As in
the ACT model, case managers and psychiatrists provided home visits when needed. A caseload limited to a
maximum of 20 clients per full-time professional
allowed case managers to spend more time with each
person and to intensify the follow-up during crisis
periods. The multidisciplinarity of the team granted an
approach that was not exclusively focused on the illness.
Each professional could discuss and provide specific help
on a wider range of issues, such as housing or income.
These specificities of ACT are key elements that contribute to clients’ satisfaction and promote their engagement
with care [16]. The ICM programme in Lausanne differed from ACT in three aspects. First, because of a lack
of resources, the team was only available between 8 a.m.
and 6 p.m. During nights and weekends, clients could be
referred to the local psychiatric emergency department
(ED). Second, situations were regularly discussed among
team members, but each client was followed by a specific case manager and by the psychiatrist when no other
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doctor was involved in the situation. Third, the team
members only delivered services that other professionals
could not provide, such as intensive home visits or practical help for time consuming administrative procedures.
This led to a closer collaboration with other members of
the health and social network and made discharge
towards other services easier. The ICM programme borrowed also elements from the critical time intervention
model (CTI) [15]: 1. The intervention was time-limited
to critical or transitional periods; 2. It aimed to engage
clients with other services through a smooth process; 3.
During the programme, it offered a psychological as well
as a practical help adapted to client’s needs; 4. Client’s
resources and limitations were assessed in vivo and
practical solutions proposed.
In Lausanne, the ICM intervention has proved to be effective in promoting engagement with care of people with
severe mental illness and improving both their clinical and
social functioning [17]. These results were in line with
international studies on ICM for severe mental disorders
that have shown to reduce hospitalisations, increase
participants retention in care and improve their social
functioning [18]. Based on the ICM model, in 2014 a pilot
project of Intensive Case Management for Addiction
(ICMA) (in French Suivi Intensif dans le milieu pour les
problèmes d’addiction - SIMA) was developed and implemented in the same area. The programme was tested with
a group of hard-to-reach people with severe mental and
substance use disorders, who have difficulties to engage
with addiction or psychiatric services. This paper presents
findings from the ICMA observational study.
Aims of the study
The main aim of the study was to test whether ICMA
improved engagement with care of people with severe
mental and substance use disorders. Specifically,
expected primary outcomes were: decreased rates of
unplanned service use and involuntary hospitalisations,
improved level of treatment adherence and enhanced
quality of primary (relatives) and secondary (caregivers)
support networks. The secondary objective was to evaluate the programme impact on participants’ well-being
through the measure of their social conditions (housing,
legal status and criminal records), clinical status, social
functioning, and alcohol and other illicit drug use.
Methods
Sample
The ICMA programme was addressed to people with severe mental and substance use disorders hard-to-reach
or refusing traditional addiction or psychiatric treatment.
ICMA participants repeatedly failed to attend outpatient
appointments and/or were involuntarily hospitalised
with no ambulatory care options after discharge. Eligible
Morandi et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:26
study participants were every consecutive person entering the programme during the first year of implementation between April 2014 and April 2015. Inclusion
criteria for the programme were: to be aged between 18
and 65 years and to live in the urban area of Lausanne,
Switzerland. Exclusion criterion for the programme was
the participant’s ability to collaborate with an addiction
treatment or the psychiatric services. Data were collected through structured questionnaires and medical
charts. Assessments were conducted at baseline (T0)
and at 12 months follow-up or at the end of the
programme if completed earlier (T1).
During the first year of implementation, 30 participants entered the programme and were eligible for the
study (Table 1). They were mainly male (73%), single
(63%) and with an average age of 39 years. Half were
Caucasian (50%) while 30% were mixed-race. Only 33%
were native of Switzerland. Ninety-seven percent were
unemployed, although 37% had achieved a secondary or
higher education degree. The primary diagnosis was
mental and behavioural disorder due to psychoactive
substance use (57%), especially alcohol (59%), followed
by schizophrenia, schizotypal and delusional disorders
(20%), affective disorder (13%) and personality disorder
(10%). Eighty-three percent of the participants were hospitalized at least once in their life, the average age of first
admission was 31 years and 57% had at least one involuntary hospitalization. More detailed socio-demographic
and clinical characteristics of the participants were published elsewhere [2].
Intervention description
Two full-time case managers, one nurse and one social
worker, and a 20% psychiatrist were recruited for the
project. Participants were addressed to ICMA
programme by their relatives, or by their health or social
professionals. Programme admission and objectives were
discussed during multidisciplinary team meetings. When
needed, contacts were made with other professionals
already involved in the situation. If inclusion criteria
were met, the situation was assigned to a case manager.
The referring relative or professional had to be present
during the first contact with the participant in order to
share their concerns and to explain why the intervention
was requested. If the participant disagreed with the concerns of the referring relative or professional, they were
encouraged to express their own expectations and needs.
The intervention was then focused on the participant’s
agenda. Most of the time, participants identified a social
problem, such as finding a home or a source of income,
as their main concern. This allowed the case managers
or the psychiatrist to provide a practical support and to
develop the therapeutic relationship. This practical help
also gave the opportunity to follow the participant
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Table 1 Baseline characteristics (N = 30)
Characteristics
Demographics
Age (mean ± SD)
38.90 ± 10.50
Sex, % Male (n)
73.3% (22)
Education % (n)
None
23.3% (7)
Compulsory education
40.0% (12)
Secondary education
30.0% (9)
Tertiary education
6.7% (2)
Marital status % (n)
Single
63.3% (19)
Married/Registered partnership
6.7% (2)
Other a
30.0% (9)
Ethnicity % (n)
Caucasian
50.0% (15)
African American
16.7% (5)
Asian
3.3% (1)
Otherb
30% (9)
Origin
% Born in Switzerland (n)
33.3% (10)
Employment status
% Unemployed (n)
96.7% (29)
Clinical history % (n)
Age of first admission (mean ± SD)
30.84 ± 10.32
Hospitalized at least once
83.3% (25)
Hospitalized at least once involuntary
56.7% (17)
Main diagnosis (ICD-10) % (n)
Mental and behavioural disorders due to psychoactive
substance use (F10-F19)
56.7% (17)
Schizophrenia, schizotypal and delusional disorders
(F20-F29)
20.0% (6)
Mood [affective] disorders (F30-F39)
13.3% (4)
Disorders of adult personality and behaviour (F60-F69)
10.0% (3)
Note. a divorced/widowed/separated;
b
person of mixed race
during their daily activities and to assess their resources
and limitations in vivo. Based on these observations, the
participant’s support network and the recovery plan were
progressively developed.
The programme was completed when another
addiction treatment or psychiatric service was permanently in charge of the participant. The decision to
end the ICMA was always taken by the case manager
in accordance with the participants and the other care
providers. The intervention could also end if participants moved out of the catchment area, if they were
lost to follow-up, if they refused to go on with the
programme or in case of death.
Morandi et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:26
Measures
Socio-demographic characteristics, diagnoses and clinical history data were collected at baseline through
structured questionnaires and medical charts. Primary
and secondary outcomes measures were assessed at
baseline (T0) and at 12 months follow-up or at the end
of the programme if completed earlier (T1).
Primary outcomes
The primary outcome measures focused on service use,
treatment adherence and quality of primary (relatives)
and secondary (caregivers) support networks. Service
use data before and during programme were provided
by medical charts. Namely, the researchers assessed
whether or not participants had been hospitalized (voluntary and/or involuntary) in a psychiatric or addiction
treatment unit or had been admitted in the general or
psychiatric ED at least once during the reference period.
The frequency of readmission and contact with the ED,
and the number of inpatient days were also recorded.
Treatment adherence was assessed by case managers
on the basis of two items rating appointment and medication adherence on a visual-analogic scale ranging from
0 (no adherence) to 100 (total adherence). Two other
treatment adherence items assessing psychotropic medication compliance and appointment attendance were incorporated in the Health of the Nation Outcome Scale
(HoNOS) [19], which is routinely assessed by clinicians
at the institutional level. The HoNOS evaluates mental
and social functioning through 12 observer-rated items,
quoted on a Likert – type scale from 0 (no problems
during the reporting period) to 4 (severe to very severe
problem during the reporting period). The French
HoNOS has been shown to have moderate internal
consistency, excellent test-retest reliability and good
inter-rater reliability [20]. The predictive validity of
HoNOS has always been modest and the French version
is no exception. However it has been shown to be suitable for use at the item level for discriminating clinically
meaningful clusters of patients [21].
The quality of primary and secondary support networks
was evaluated by case managers through the Support Network Scale [22], with anchors ranging between 1) adequate
and helpful, and 2) inadequate (gathering the answers:
exhausted and overwhelmed, inactive and unstable, inadequate and incompetent, absent and nonexistent).
Secondary outcomes
Secondary outcome measures combined data on participants’ housing conditions (stable housing vs. homeless),
legal status (legal guardianship, involuntary hospitalization
and/or penal measures underway), criminal records (number of participants with at least one crime, infraction and/
or victimisation occurred during the previous 12 months),
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psychosocial and mental functioning, and alcohol and
other illicit drug use in the previous 30 days.
To assess participants’ psychosocial and mental functioning several validated and widely used scales were deployed. The 12 observer-rated items of the HoNOS [19]
were assessed. Item-level scores rather than composite
scores were used in the analysis [21]. The Crisis Triage
Rating Scale (CTRS) assess participants’ dangerousness,
ability to cooperate and support system on the basis of
three Likert – type subscales ranging from 0 (no problems
during the reporting period) to 4 (severe to very severe
problem during the reporting period) [23, 24]. The
subscales Ability to cooperate and Support system were
also analysed as primary outcome measures of treatment
adherence and quality of primary and secondary support
networks. The CTRS has been validated in English,
showing good reliability and validity [23, 24]. The French
version has been shown to be sensible to change in assertive community treatment settings [17].
The Global Assessment of Functioning Scale (GAF)
rates the participants’ social, occupational and psychological functioning on a numeric scale from 1 to 100
[25]. The Clinical Global Impression – Severity scale
(CGI-S) evaluates illness severity at the time of assessment on a 7-point scale quoting from 1 (normal) to 7
(among the most extremely ill) [26]. The GAF (which is
the DSM-IV fifth axis) and CGI-S are clinical global impression scales for which inter-rater reliability has been
shown to be satisfactory to excellent [27, 28].
Alcohol and other illicit drug use in the previous
30 days were self-reported. A structured questionnaire
was administered by case managers to assess whether or
not participants had been using alcohol and/or other
illicit drug at least once during the last month. Namely,
the case managers aimed at assessing the alcohol and
other illicit drug use frequency, the average number of
alcohol units consumed per drinking day and if the
participants had been part at least one time of a heavy
alcohol use episode (> than 10 alcohol units).
Statistical analysis
Primary and secondary dichotomous outcomes were analysed using McNemar-Bowker’s exact test. General Linear
Model repeated-measures analysis of variance was performed for continuous and ordinal variables. Highly
skewed continuous and ordinal variables were analysed
using non-parametric Wilcoxon Signed Rank tests.
Baseline data were compared with 12 months followup measures or with final assessment if the programme
was completed earlier.
In order to verify whether longer engagement in the
programme impacted outcomes at T1, the relationship between programme duration and the outcomes’ variations
(T0 vs. T1) was tested using Spearman’s rank correlation
Morandi et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:26
coefficient. These analyses revealed no impact of the
programme duration on the outcomes.
Services use data, before and during programme, were
compared over the same time span (i.e.: 6 months before
vs. 6 months during programme; 8 months vs. 8 months;
etc.) based on each individual programme length, but no
longer than the 12 months evaluation point.
Assuming a sample size of 30 and interest in moderate
sized effects (i.e., Cohen’s d ≥ 0.5; described as observable
and noticeable to the eye of the beholder) and using a
conservative estimate of the correlation between time 1
and time 2 measurements, 72% power for the comparison
of pre- and post-measurements could be achieved adjusting for the use of the Wilcoxon test. Assuming even a reasonable correlation between the first and the second
measurements (r = 0.7), the power becomes 90.8% which
could be considered as more than adequate. Deviations
from normality would further increase power.
All statistical tests were two-tailed and significance
level was set at .05. Statistical analyses were performed
with the IBM SPSS statistical package version 23.
Results
Out of 30 participants enrolled at the baseline, 17 were
still undergoing the programme after 12 months while
13 had completed it. At the end of ICMA intervention,
2 participants were transferred to other services of the
Department of psychiatry, 2 to the alcohology service, 2
to private psychiatrists, 3 to other psychosocial services
and 3 were not referred to any service (one improved
sufficiently, one moved and the last one refused to be referred to another service). One 50 years old participant
died during the programme. The cause of the death was
undetermined. The mean programme duration was
10.00 ± 2.83 months. During the first year of implementation, each participant had on average 1.25 contacts per
week with the case manager (1.07 h per week).
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Primary outcomes
No significant influence of the programme duration on
the primary outcomes’ variations was found.
Longitudinal analysis comparing service use over
the same time span before and during programme
(Table 2) showed a significant decreased rate of
general ED contacts (73% to 50%; p = .039). The decrease in the number of contacts with the psychiatric
ED (Wilcoxon z = −1.997; p = .046; r = −.36) was
also significant, with on average 0.60 ± 1.22
(Mdn = 0.0; IQR = 1) contacts before starting the
programme and 0.20 ± 0.55 (Mdn = 0.0; IQR = 0)
during the following period. No significant differences
were found for the number of voluntary and involuntary psychiatric hospitalisations, the number of general ED visits and the number of total inpatient days.
The decreased rate of involuntary hospitalizations
(33% to 13%) did not reach statistical significance.
Participants’ treatment adherence improved significantly during the programme (Table 3). At T1, participants scored significantly better on medication
adherence (F(1,23) = 15.754, p = .001, ƞ2p = .407) and appointment adherence (F(1,29) = 9.604, p = .004, ƞ2p = .249).
Besides, the severity scores on the two additional HoNOSbased items testing participants’ appointment attendance
(F(1,27) = 12.911, p = .001, ƞ2p = .323) and psychotropic
medication compliance (F(1,23) = 10.827, p = .003, ƞ2p
= .320) decreased significantly. The enhanced participants’
compliance was also confirmed by the reduced score
achieved at T1 on the CTRS Ability to Cooperate subscale
(F(1,28) =16.605, p < .001, ƞ2p = .372).
Finally, the support network quality improved significantly. Sixty-seven percent of the participants’ primary
(relatives) and secondary (professionals) networks were
described by case managers as “adequate and helpful” at
T1 versus only 10% at baseline (p < .001). A significant
improvement was also achieved on the CTRS Support
System subscale (F(1,27) = 12.680, p = .001, ƞ2p = .320).
Table 2 Longitudinal analysis comparing services use over the same time span before and after programme enrolment
Services use
Before (N = 30)
After (N = 30)
Test
p-value
Psychiatric hospitalisation % (n)
63.3% (19)
53.3% (16)
a
.508
.070
Involuntary hospitalisation % (n)
33.3% (10)
13.3% (4)
a
Psychiatric ED visit % (n)
30.0% (9)
13.3% (4)
a
.125
.039
General ED visit % (n)
73.3% (22)
50.0% (15)
a
Number of psychiatric hospitalisations Mdn (IQR)
1.0 (2)
1.0 (2)
z = −0.354b
.723
b
Number of involuntary hospitalisations Mdn (IQR)
0.0 (1)
0.0 (0)
z = −1.327
.185
Number of psychiatric ED visits Mdn (IQR)
0.0 (1)
0.0 (0)
z = −1.997b
.046
b
Number of general ED visits Mdn (IQR)
2.0 (3)
0.5 (2)
z = −1.573
.116
Number of inpatient days Mdn (IQR)
22.0 (45)
6.5 (49)
z = −0.503b
.615
Note. a McNemar-Bowker’s Test; b Wilcoxon Signed Rank test; Mdn median, IQR interquartile range
Morandi et al. Substance Abuse Treatment, Prevention, and Policy (2017) 12:26
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Table 3 Clinical and social within-group changes at 12 months follow-up or at the end of the programme if completed earlier (T1)
compared to baseline (T0)
T0 (N = 30)
T1 (N = 30)
p-value
24.1% (7)
6.9% (2)
.125a
Legal guardianship underway
63.3% (19)
73.3% (22)
.375a
Involuntary hospitalization underway
30.0% (9)
23.3% (7)
.687a
Penal measure underway
13.3% (4)
16.7% (4)
1.000a
Crime or infraction
47.1% (8)
35.3% (6)
.688a
Victimisation
35.3% (6)
5.9% (1)
.063a
Medication adherence
52.92 ± 32.36
78.75 ± 29.68
.001b
Appointments adherence
52.10 ± 34.22
74.50 ± 26.37
.004b
Adequate and helpful
10.0% (3)
66.7% (20)
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