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Intensive case management decreased hospital resource use in psychotic patients with borderline intelligence quotient
  1. Ben Thomas, MSc RMN, RGN, RNT, FRCN
  1. NHS and Social Care Trust Bridgwater, UK

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QUESTION: Do psychotic patients of borderline intelligence quotient (IQ) benefit more from intensive case management (ICM) than patients of normal IQ?


Subgroup analysis of a randomised {allocation concealed*}, unblinded*, controlled trial with 2 years of follow up.


4 hospital centres in the UK.


{708 patients who were 18–65 years of age (mean age 38 y, 57% men) with a psychotic illness for ≥ 2 years. Exclusion criteria were organic brain damage or a primary diagnosis of substance abuse}. Patients were stratified for IQ by their score (range 0–50) on the National Adult Reading Test (NART) (error score ≥ 40= borderline IQ, <40= normal IQ). 586 patients took the NART and 104 (17.7%) were classified as borderline IQ. Follow up was 96% for the main outcome measure.


Patients were allocated to ICM (10–15 patients per case manager) (n=50 borderline and 237 normal IQ) or SCM (30–35 patients per case manager) (n=54 borderline and 245 normal IQ).

Main outcome measures

Days spent in hospital for psychiatric reasons. Number of hospital admissions and resource use were also assessed.

Main results

Borderline and normal IQ patients did not differ for mean number of days in hospital (78 v 75 d, p=0.84), mean number of hospital admissions (1.05 v 1.19 admissions, p=0.43), or mean total costs (£26 551 v £23 265, p=0.20). ICM had a statistically significant effect on borderline IQ patients: borderline IQ patients receiving ICM spent fewer days in hospital than patients receiving SCM and had fewer hospital admissions; the same differences were not seen among normal IQ patients (p=0.003 and p=0.004, respectively) (table). After adjustment, the total costs were less for ICM among borderline IQ patients than for SCM, while ICM increased costs among normal IQ patients (adjusted p=0.04) (table).

Intensive case management (ICM) v standard case management (SCM) for psychotic patients with borderline and normal IQ at 2 years‡


Intensive case management decreased hospital use in psychotic patients of borderline intelligence quotient (IQ) more than in patients of normal IQ.


From a UK perspective, the study by Hassiotis et al is both timely and clinically relevant in its focus and demonstration of the benefits of ICM for patients with a mild or moderate learning disability compared with patients of normal IQ. Many current services are poorly coordinated and fail to meet the substantial healthcare needs of people with a mild or moderate learning disability, of whom about 1.2 million live in England alone.1 This lack of support is most evident among people with coexistent severe mental illness and mild learning disability or borderline intellectual functioning.

The results show that not only were duration and frequency of hospital admissions reduced for patients with psychosis and mild learning disability, but total costs were also lower. In addition, patients showed more satisfaction with services and reported fewer needs.

Like all groups of patients with a dual diagnosis, a high risk exists of people with a moderate learning disability and severe mental illness “falling through the net” between various specialist agencies. The UK government objective is to enable people with learning disabilities to have access to health services designed to meet individual needs with fast and convenient care delivered to a consistently high standard and with all the necessary support. To achieve this goal, learning disability services must work in true partnership with specialist mental health services and deliver coordinated care. Hassiotis et al identify the multidimensional and intensive focus of ICM as having beneficial effects for this vulnerable group of patients. Service planners should bear in mind, however, that the findings need to be confirmed by further research.


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Review history and Supplementary material

  • See also:

    Intensive case management was not more cost-effective than standard case management for severe psychosis. Evidence-Based Mental Health 2001;4:64.

    Review: assertive community treatment reduced hospital use and was cost effective when used for severely mental ill patients with previous hospital use of 50 days yearly. Evidence-Based Mental Health 2001;3:94.

    Intensive case management was as effective as standard case management in severe psychotic illness. Evidence-Based Mental Health 2001;3:11.

    Assertive community treatment for high users of inpatient services had different outcomes at different types of hospitals. Evidence-Based Mental Health 2001;1:128.


  • * See glossary.

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  • Sources of funding: UK Department of Health and NHS Research and Development Programme.

  • For correspondence: Dr A Hassiotis, Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, Wolfson Building, 48 Riding House Street, London W1N 8AA, UK. Fax +44 (0)20 7 679 9426.

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