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Critical Time Intervention for serious mental illness

Adult Mental Health: Serious Mental Illness
Benefit-cost estimates updated May 2017.  Literature review updated September 2016.
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Critical time intervention is a short-term program which supports particularly vulnerable patients transitioning from inpatient psychiatric treatment to outpatient care. This is done by providing them with a social worker, peer mentor or other system of support to help them at the beginning of the integration process. Critical time intervention is provided in conjunction with other kinds of treatment and is designed to increase treatment adherence and reduce recidivism, homelessness, and re-hospitalization. Critical Time Intervention has been used to treat a wide variety of vulnerable patients; however, we explore the impact of Critical Time Intervention on treatment of subjects with severe psychosis.
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $2,253 Benefits minus costs ($4,831)
Participants $31 Benefit to cost ratio $0.17
Others $507 Chance the program will produce
Indirect ($1,785) benefits greater than the costs 14 %
Total benefits $1,006
Net program cost ($5,837)
Benefits minus cost ($4,831)
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Health care associated with psychiatric hospitalization $2,253 $31 $507 $1,126 $3,916
Adjustment for deadweight cost of program $0 $0 $0 ($2,911) ($2,911)
Totals $2,253 $31 $507 ($1,785) $1,006
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $3,769 1992 Present value of net program costs (in 2016 dollars) ($5,837)
Comparison costs $0 1992 Cost range (+ or -) 10 %
Per-participant costs for critical time intervention is based on the figures published in Jones, K., Colson, P. W., Holter, M. C., Lin, S., Valencia, E., Susser, E., & Wyatt, R.J. (2003). Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness. Psychiatric Services, 54(6), 884-90.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

^WSIPP’s benefit-cost model does not monetize this outcome.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Homelessness^ 2 125 -1.059 0.249 39 0.000 0.118 40 -1.059 0.001
Hospitalization (psychiatric) 1 77 -1.331 0.670 39 0.000 0.118 40 -1.331 0.047
Psychiatric symptoms^ 1 38 -0.320 0.231 39 0.000 0.118 40 -0.320 0.166
Psychosis symptoms (negative)^ 1 38 -0.572 0.234 39 0.000 0.118 40 -0.572 0.014
Psychosis symptoms (positive)^ 1 38 0.091 0.230 39 0.000 0.118 40 0.091 0.691

Citations Used in the Meta-Analysis

Herman, D., Opler, L., Felix, A., Valencia, E., Wyatt, R. J., & Susser, E. (2000). A critical time intervention with mentally ill homeless men: impact on psychiatric symptoms. The Journal of Nervous and Mental Disease, 188(3), 135-140.

Herman, D.B., Conover, S., Gorroochurn, P., Hinterland, K., Hoepner, L., & Susser, E.S. (2011). Randomized trial of critical time intervention to prevent homelessness after hospital discharge. Psychiatric Services, 62(7), 713-719.

Susser, E., Valencia, E., Conover, S., Felix, A., Tsai, W.Y., & Wyatt, R.J. (1997). Preventing recurrent homelessness among mentally ill men: A 'critical time' intervention after discharge from a shelter. American Journal of Public Health, 87(2), 256-262.

Tomita, A., & Herman, D.B. (2012). The impact of critical time intervention in reducing psychiatric rehospitalization after hospital discharge. Psychiatric Services, 63(9), 935-937.

For more information on the methods
used please see our Technical Documentation.
360.664.9800
institute@wsipp.wa.gov