Variations in structures, processes and outcomes of community mental health teams for older people: a systematic review of the literature

Authors:
ABENDSTERN M., et al
Journal article citation:
Aging and Mental Health, 16(7), September 2012, pp.861-873.
Publisher:
Taylor and Francis

Specialist community mental health teams (CMHTs) are central to the provision of comprehensive services for older people with mental ill health. Recent guidance documents suggest a core set of attributes that such teams should encompass. This literature review explored existing evidence regarding the structures and processes of CMHTs for older people and to evaluate evidence linking approaches to effectiveness. Searches were limited to the UK for descriptions of organisation and practice. Forty-five studies met inclusion criteria of which seven provided comparative outcome data. Limited evidence was found regarding the effectiveness of many of the core attributes recommended in policy directives although their presence was reported in much of the literature. The contrast between presentation and evaluation of attributes is stark. Whilst some gaps can be filled from related fields, further research is required to evaluate the impact of team design on service user outcomes in order to inform future guidance.

Extended abstract:
Author

ABENDSTERN M.; et al.;

Title

Variations in structures, processes and outcomes of community mental health teams for older people: a systematic review of the literature.

Journal citation/publication details

Aging and Mental Health, 16(7), March 2012, pp.861-873.

Summary

Forty-seven studies, all but one set in the UK, were included in this systematic review. Most of the evidence focuses on describing the range of key attributes identified in policy and practice guidance; seven studies reported on evidence of effectiveness related to key attributes such as open referral systems, assessment, and intensive care management. The inconclusive nature of the evidence and the limited evidence base lead the authors to call for a greater focus on research into the effectiveness of different attributes.

Context

In the UK the provision of mental health services for older people is through multidisciplinary community health teams CMHTOP, of which there are now more than 400 operating in England alone. Guidance on service specification has been published in a number of documents but a specific model of working has not been stipulated, although there is a degree of agreement on a core set of attributes that a CMHTOP should possess. Also, much of the guidance is based on good practice rather than good evidence. This systematic review is based on two objectives: ‘to establish the nature and extent of variation in structures and processes of CMHTOPs in the UK over time’, and to evaluate the international evidence linking variations in team approaches to service user, staff and service outcomes’.

Methods

What sources were searched?
The electronic databases EMBASE, Medline, PsycINFO, and Web of Science were searched in October 2008. Additional searches were conducted in search engines and on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Effectiveness and Health Technology Assessment. The reference lists of all included documents, and the three most commonly cited journals, were hand searched and experts in the field were asked to identify studies that might have been missed.  

What search terms/strategies were used?
Search terms for service, such as geriatric psychiatry, mental health team or community mental health, were combined with terms to describe the service user group, team characteristics, and processes. Further details are available from the authors.

What criteria were used to decide on which studies to include?
Empirical studies set in the UK describing at least one aspect of a team’s structure, organisation or operation were eligible for inclusion of the review with objective one. Documents could be peer-reviewed articles published from 1989, or nationally or regionally representative non peer-reviewed studies and reports published after 1998. For objective two, studies had to compare at least one aspect of a team’s structure, organisation or operation with the same feature in a different team approach in empirical peer-reviewed articles published in English in or after 1989. Studies of therapeutic interventions, and single discipline teams were excluded unless they provided contextual information relevant to objective one. 

Who decided on their relevance and quality?
Titles were screened by the first author with 10% being independently screened by another author to ensure consistency. Two named authors then jointly screened abstracts against the inclusion criteria. Full articles were read by one of two reviewers and decisions on inclusion were made through discussion. The same two reviewers assessed the quality of relevant studies using the method described by Zaza, 2000.

How many studies were included and where were they from?
The database searches produced a total of 3,331 articles 91% of which were excluded at first screening; 82 of the remaining 318 documents were retained for more detailed evaluation. The final total of articles included in the review was 45 including 18 additional publications identified through other sources; 44 were relevant to objective one and seven were relevant to objective two. All but one study from Australia were set in the UK.

How were the study findings combined?
Data was extracted by two reviewers using a standardised electronic form; the first 10 studies were coded jointly to ensure consistency. A narrative synthesis was undertaken as the literature was heterogeneous in nature. The results are divided into descriptive data on variations in team structures and processes, related to objective one, and evaluations of linkages between team approaches and service user outcomes related to objective two.

Findings of the review

Most of the descriptive papers were observational studies collecting quantitative data. Thirty-three studies reporting data on 56 individual CMHTOPs had a local focus with much of the evidence coming from exemplar teams. The number of papers reporting on individual key attributes identified in policy and practice guidance, a summary description of attribute development in the literature, and the existence of evidence of effectiveness, are presented in Table 2. The most commonly reported key attributes were: multidisciplinary membership, 30 publications; open referral systems and single point of access, 17 papers, and; domiciliary assessment, 13 papers.

All seven studies presenting evaluative data were local studies, four of which focused on the exemplary teams in Lewisham. The attributes considered were aspects of referral, assessment, post assessment decisions, and the consequences of intensive care management for people with dementia. The most robust evidence was from research based on a small number of exemplar teams in a single area, which may not be translated to other areas.

Authors' conclusions

This review demonstrates the lack of comparison of different community mental health team approaches to steer best practice. The emphasis over the past 30 years has been on growth: “how many teams and what do they consist of. It is now time to move beyond this and to focus on the effectiveness of different attributes”.

Implications for policy or practice

None are discussed.

Subject terms:
mental health, older people, social policy, community mental health teams;
Content type:
systematic review
Location(s):
United Kingdom
Link:
Journal home page
ISSN online:
1364-6915
ISSN print:
1360-7863

Key to icons

  • Free resource Free resource
  • Journal article Journal article
  • Book Book
  • Digital media Digital media
  • Journal Journal

Give us your feedback

Social Care Online continues to be developed in response to user feedback.

Contact us with your comments and for any problems using the website.

Sign up/login for more

Register/login to access resource links, advanced search and email alerts