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ISBN 10: 0198516150

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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 ]. However it has been shown to be suitable for use at the item level for discriminating clinically meaningful clusters of patients [ 21 ].

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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. The 12 observer-rated items of the HoNOS [ 19 ] were assessed.

Special order items

Item-level scores rather than composite scores were used in the analysis [ 21 ]. 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 French version has been shown to be sensible to change in assertive community treatment settings [ 17 ]. 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 ].

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. These analyses revealed no impact of the programme duration on the outcomes.

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Services use data, before and during programme, were compared over the same time span i. Assuming a sample size of 30 and interest in moderate sized effects i. Deviations from normality would further increase power. All statistical tests were two-tailed and significance level was set at. 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.

The cause of the death was undetermined. The mean programme duration was During the first year of implementation, each participant had on average 1. 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.

Longitudinal analysis comparing services use over the same time span before and after programme enrolment.

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Finally, the support network quality improved significantly. Nevertheless, the average number of alcohol units consumed per drinking day decreased significantly, from Moreover, at follow-up participants showed significant improvements in their treatment adherence, clinical status, social functioning and the rates and frequency of alcohol and other illicit drug use. These findings were in line with previous studies on the effectiveness of ICM in population with severe mental and substance use disorders [ 18 , 29 ]. However, the long term programme cost-effectiveness should be assessed in the future.

The ICMA intervention was able to overcome barriers to care access on both the personal and the structural level. The experience of a positive therapeutic relationship erased the memory of bad previous experiences with care services such as coercion, and overcame the addiction behaviours. Appointment attendance and medication compliance increased during the intervention. However, no significant impact was found on the number of people admitted to the psychiatric hospital. This could be explained by the heterogeneity of the sample.

Before the intervention, some participants were regularly hospitalised or had had long inpatient stays. In these situations, the ICMA allowed a prompt discharge and return into the community. Other participants had had no contact with care services for long periods before the enrolment.

Therefore, once in the programme, their highly decayed health status required immediate inpatient care. If the rate and the number of psychiatric admissions did not decrease, the use of compulsion seemed positively, but not significantly, reduced. The quality of the support network was greatly improved by the ICMA intervention. Moreover, case managers weekly attended other services team meetings. On a clinical level, regular contacts with each member of the network were constantly fostered.

Most clinical and social outcomes improved during the intervention. If the social functioning improvements can easily be explained by the fact that case managers and the psychiatrist provided practical help and supported the participants during social procedures, their clinical evolution needs to be further discussed.

Clinical improvements may be explained by three factors. Secondly, ICMA may have broken the vicious circle in which this population is often trapped.

Stigma of mental illness - Alastair Campbell

In fact, severe substance use disorders are associated with social dropout and inappropriate medical care. Help is often provided only during crisis periods and mainly through compulsion involuntary admission or guardianship [ 32 , 33 ]. The use of coercion can lead to increased anxiety, loss of self-esteem and mood disorders, with a consequent intensification of alcohol and other illicit drug consumption [ 34 ].

This may have positively influenced the number of ED visits. While in need for further experimentation on a larger sample, the intervention seemed to positively influence the rates of homelessness and victimisation in this highly vulnerable population during the follow-up period. This former finding confirmed the positive impact of ACT and CTI in improving housing stability and reducing the rate of homelessness among people with severe mental and substance use disorders [ 11 ]. The latter finding pointed at the ICMA as an excellent approach to reduce victimisation among this highly vulnerable population which gathers several risk factors such as severe mental and substance use disorders, homelessness, and absence of contact with psychiatric services [ 35 , 36 ].

Regarding the strengths, this was a prospective exploratory study. Despite the difficult-to-engage target population, none of the participants refused to take part in the research project. Two main methodological limitations were the absence of a control group and the modest sample size. Generalizability of the results may thus be restricted. Besides, some measures were self-reported while others were rated by the case managers.

Despite the limited scale of this observational project, the results are promising, highlighting the efficacy of ICMA methodology to improve engagement with care and the psychosocial situation of this hard-to-reach population, with consequent direct impact on substance problems.

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Further research is needed to confirm the programme effectiveness. However, the high-risk profile of these participants and the dangers related to the lack of an adapted care could represent an ethical and actual obstacle to the assessment of this issue in a randomised controlled trial setting. The ICMA does not replace other addiction treatment services. We wish to thank the case managers for their work and we also express our gratitude to all clients for their participation. SM contributed to the conception and design of the study.

SM and BS contributed to the acquisition of the data. BS and PG undertook the data analysis. SM and BS contributed to the interpretation of the data and drafted the manuscript. PG and CB were involved in the critical revision of the manuscript. All authors read and approved the final manuscript. No explicit consent was required since data were collected as part of a routine outcome monitoring procedure. However, participants were informed about the research and the possibility of being excluded if they wished so. All participants agreed to take part in the study.

Benedetta Silva, Email: hc. Philippe Golay, Email: hc. Charles Bonsack, Email: hc. National Center for Biotechnology Information , U. Subst Abuse Treat Prev Policy.

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