Review: limited evidence to support specialist mental health services as alternatives to inpatient care for young people with severe mental health disorders.

Question: Do community based specialist mental health services provide effective alternatives to inpatient mental health care for children and young adults? Outcomes: Disease specific symptoms and general psychological functioning (using various scales including the Global Severity Index (GSI) of brief symptoms, Child Behaviour Checklist (CBC), Family Adaptability and Cohesion Evaluation Scale (FACES)), acceptability and cost. Methods Design: Systematic review. Data sources: Cochrane Effective Practice and Organisation of Care Group Specialised Register (2007), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, the British Nursing Index and RCN database; numerous other electronic resources (including SIGLE, King's Fund); hand search of child mental health journals and bibliographies of retrieved articles. Study selection and analysis: Two independent reviewers assessed studies for inclusion and extracted data. Inclusion criteria: randomised controlled trials, well designed controlled before -- after studies and interrupted time series comparing inpatient care for young people with one or more alternative specialist mental health services (beyond normal outpatient provision); only studies in young people aged 5 -- 18 years with a serious mental health problem requiring more than generic outpatient services. Exclusion criteria: studies where the inpatient group was clinically different at baseline from those admitted to the alternative service; mild mental health disorders; developmental disorders (other than pervasive developmental disorder); inpatient care for chronic physical illness or abuse; trials where the service was not described as alternative to inpatient care; no inpatient control group. Studies were grouped according to intervention type. Standardised mean differences (SMDs) and 95% confidence interval were used for each outcome in terms of the mean change from baseline to follow-up (negative SMDs indicate treatment is favoured); meta-analyses were not performed. Main results Seven single blind randomised controlled trials (n = 783) met inclusion criteria: two evaluating multisystemic therapy (MST) at home; two specialist outpatient service; two intensive home treatment; and one an intensive home based crisis intervention ("Homebuilders" model for crisis intervention). All trials were small (n = 55 to 238). Home based MST for psychosis did not improve functioning (externalising symptoms) at 4 months compared with control in either trial (GSI and CBC). However, young people spent fewer days out of school (one study; SMD -0.47, 95% CI -0.85 to -0.09), drank less alcohol (one study; SMD -0.49, 95% CI -0.87 to -0.11) and had greater satisfaction with their treatment programme than the control group at 4 months (one study; SMD -0.77, 95% CI -1.16 to -0.38). Home based MST for emotionalDSbehavioural difficulties reduced number of days per month spent in out of home placement compared with control (one study; SMD -0.91, 95% CI -1.65 to -0.17) but gave no benefit over control for any other outcome (follow-up complete for only 58% of the MST group and 55% of controls in this trial). Intensive home based crisis intervention gave small, significant improvements compared with control at 6 weeks on the FACES cohesion subscale (one study; SMD -0.56, 95% CI -0.89 to -0.23) and on behaviours that supported social networks (one study; SMD -0.39, 95% CI -0.72 to -0.06); differences were not sustained at the 6 month follow-up. Outcomes following intensive home treatment or specialist outpatient services did not differ from control in any trial. Lack of evidence precluded analysis of cost effectiveness. Conclusions There is limited evidence from the current literature to guide the development of mental health services for young people as alternatives to inpatient care.