Forty-four relevant studies were identified, including 35 comparisons (n=6,365) of either assertive community treatment or another model of case management with usual treatment. Nine studies directly compared assertive community treatment with another model of case management. Nineteen studies compared assertive community treatment with usual treatment. Sixteen studies compared another model of case management with usual treatment; of these, there was one with a strengths model, one with a rehabilitation model, one with a generalist model, and 13 others that could not be classified further. These models were referred to as 'clinical case management'.
Case management versus usual treatment.
Compared with usual treatment, case management was associated with the following (combined one-tailed p-values given):
a greater improvement in symptoms (weighted mean r 0.16, 95% CI: 0.11, 0.21);
a reduction in the hospital stay (weighted mean r 0.24, 95% CI: 0.21, 0.28, p<0.001);
a smaller proportion of patients hospitalised (weighted mean r 0.10, 95% CI: 0.06, 0.14, p<0.001);
more contacts with mental health services (weighted mean r 0.24, 95% CI: 0.19, 0.28, p<0.001),
more contacts with other services (weighted mean r 0.33, 95% CI: 0.22, 0.43, p<0.001);
lower drop-out rates from mental health services (weighted mean r 0.33, 95% CI: 0.25, 0.41, p<0.001);
a greater improvement in social functioning (weighted mean r 0.15, 95% CI: 0.11, 0.19, p=0.007);
greater patient satisfaction with care (weighted mean r 0.23, 95% CI: 0.17, 0.29, p=0.28);
greater family satisfaction with care (weighted mean r 0.42, 95% CI: 0.29, 0.53, p<0.001); and
less family burden of care (weighted mean r 0.43, 95% CI: 0.23, 0.60, p=0.007).
However, the patients on care management programmes were admitted to hospital more frequently than those receiving usual treatment (weighted mean r -0.10, 95% CI: -0.16, -0.05, p=0.999).
From the fail-safe N, 6 domains could be considered robust against publication bias on the basis of the reported p-values. These were: fewer days hospitalised, a smaller proportion of patients hospitalised, more contacts with mental health services, lower drop-out rates, a greater improvement in social functioning, and increased patient satisfaction. The regression asymmetry test was calculated for each outcome domain with the exception of contacts with other services, family burden of care and family satisfaction, which had sample sizes too small to plot. Three of the remaining 9 domains showed some evidence of publication bias: the proportion of patients hospitalised (p=0.015), contacts with mental health services (p=0.017), and patient satisfaction (p=0.05).
Nine domains had variance greater than would be expected by chance. Four of these 9 measures showed significant differences in outcomes according to the study quality, i.e. high versus low: the number of admissions, the days hospitalised, contacts with mental health services, and level of social functioning. However, the weighted mean r-values for the high-quality group were almost the same as those calculated for the sample as a whole.
Use of measures described in peer-reviewed journals.
The mean weighted effect sizes were significantly higher for the studies that used measures that had been reported in peer-reviewed journals, than for those which did not (i.e. they used non-reported measures). This was true for both domains where comparisons were possible: level of social functioning and client satisfaction.
Assertive community treatment versus clinical case management.
The weighted mean effect size for the days hospitalised was found to be significantly greater for assertive community treatment than for clinical case management (p=0.001). Assertive community treatment was significantly better than clinical case management in reducing the proportion of patients hospitalised (p<0.001), but the number of contacts with mental health services was significantly greater for patients in clinical case management programmes than for those in assertive community treatment programmes (p<0.001).