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Lonsdale N, Webber M. Practitioner opinions of crisis plans within early intervention in psychosis services: A mixed methods study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:1936-1947. [PMID: 33662171 DOI: 10.1111/hsc.13308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/12/2020] [Accepted: 01/11/2021] [Indexed: 06/12/2023]
Abstract
The efficacy of crisis planning in mental health services is contested. As recovery and self-management are core to Early Intervention in Psychosis (EIP) services and the Care Programme Approach (CPA), the views of EIP practitioners of the most useful aspects of crisis planning can inform this vital aspect of practice. We conducted a mixed methods study using a national cross-sectional survey (n = 70) and semi-structured interviews (n = 12) with EIP practitioners in England in 2019. Data were analysed using non-parametric tests and thematic analysis. A Joint Crisis Plan (JCP) template was used as a benchmark to judge current practice by (Sutherby et al., 1999; Henderson et al., 2004; Thornicroft et al., 2013). The most useful crisis plan themes identified by practitioners included early warning signs, triggers and helpful treatments, although not all elements were considered useful. Additionally, the interviews identified that collaboration with clients, carers and other services; personalisation; and self-management were all considered important in effective crisis planning. The practitioners also identified barriers to effective crisis planning, such as the electronic records system, lack of time and lack of available service provision. The research highlighted the important aspects of EIP and was significant in impacting the service and wider EIP network further. While crisis planning is a significant part of EIP, it does not appear to be consistently applied in practice. Fully implementing collaborative crisis planning in EIP services may require changes to policy, practice and local systems to ensure that crisis planning is as effective as possible.
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Affiliation(s)
- Nikki Lonsdale
- Department of Social Policy and Social Work, University of York, York, UK
| | - Martin Webber
- Department of Social Policy and Social Work, University of York, York, UK
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Soltmann B, Neumann A, March S, Weinhold I, Häckl D, Kliemt R, Baum F, Romanos M, Schwarz J, von Peter S, Ignatyev Y, Arnold K, Swart E, Heinze M, Schmitt J, Pfennig A. Multiperspective and Multimethod Evaluation of Flexible and Integrative Psychiatric Care Models in Germany: Study Protocol of a Prospective, Controlled Multicenter Observational Study (PsychCare). Front Psychiatry 2021; 12:659773. [PMID: 34140902 PMCID: PMC8205541 DOI: 10.3389/fpsyt.2021.659773] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: New cross-sectoral mental health care models have been initiated in Germany to overcome the fragmentation of the German health care system. Starting in 2013, flexible and integrative psychiatric care model projects according to §64b SGB V German Social Law (FIT64b) have been implemented. The study "PsychCare" combines quantitative and qualitative primary data with routine health insurance data for the evaluation of these models. Effects, costs and cost-effectiveness from the perspectives of patients, relatives and care providers are compared with standard care. Additionally, quality indicators for a modern, flexible and integrated care are developed. This article describes the rationale, design and methods of the project. Methods: "PsychCare" is built on a multiperspective and multimethod design. A controlled prospective multicenter cohort study is conducted with three data collection points (baseline assessment, follow-up after 9 and 15 months). A total of 18 hospitals (10 FIT64b model and 8 matched control hospitals) have consecutively recruited in- and outpatients with pre-specified common and/or severe psychiatric disorders. Primary endpoints are differences in change of health-related quality of life and treatment satisfaction. Sociodemographic and service receipt data of the primary data collection are linked with routine health insurance data. A cost-effectiveness analysis, a mixed method, participatory process evaluation by means of qualitative surveys and the development of quality indicators are further elements of "PsychCare." Discussion and Practical Implications: The results based on data from different methodological approaches will provide essential conclusions for the improvement of hospital based mental health care in Germany. This should result in the identification of key FIT64b elements that can be efficiently implemented into standard care in Germany and re-structure the care strongly aligned to patient needs. Clinical Trial Registration: German Clinical Trial Register, identifier DRKS 00022535.
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Affiliation(s)
- Bettina Soltmann
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Anne Neumann
- Center of Evidence-Based Health Care, Medical Faculty Carl Gustav Carus, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Stefanie March
- Department of Social Work, Health and Media, University of Applied Sciences Magdeburg-Stendal, Magdeburg, Germany.,Institute of Social Medicine and Health Systems Research, Medical Faculty, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Ines Weinhold
- WIG2 Scientific Institute for Health Economics and Health System Research Leipzig, Leipzig, Germany
| | - Dennis Häckl
- WIG2 Scientific Institute for Health Economics and Health System Research Leipzig, Leipzig, Germany
| | - Roman Kliemt
- WIG2 Scientific Institute for Health Economics and Health System Research Leipzig, Leipzig, Germany
| | - Fabian Baum
- Center of Evidence-Based Health Care, Medical Faculty Carl Gustav Carus, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Marcel Romanos
- Department of Child and Adolescent Psychiatry, Centre of Mental Health, Psychosomatics and Psychotherapy, University of Würzburg, Würzburg, Germany
| | - Julian Schwarz
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School Theodor Fontane, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - Sebastian von Peter
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School Theodor Fontane, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - Yuriy Ignatyev
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School Theodor Fontane, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - Katrin Arnold
- Center of Evidence-Based Health Care, Medical Faculty Carl Gustav Carus, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Enno Swart
- Institute of Social Medicine and Health Systems Research, Medical Faculty, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Martin Heinze
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School Theodor Fontane, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - Jochen Schmitt
- Center of Evidence-Based Health Care, Medical Faculty Carl Gustav Carus, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Andrea Pfennig
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
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Philip S, Chandran D, Stezin A, Viswanathaiah GC, Gowda GS, Moirangthem S, Kumar CN, Math SB. EAT-PAD: Educating about psychiatric advance directives in India. Int J Soc Psychiatry 2019; 65:207-216. [PMID: 30945582 DOI: 10.1177/0020764019834591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND With India enacting the Mental Health Care Act (MHCA; No. 10 of 2017a), Psychiatric Advance Directives (PADs) have been legalised and have become binding orders for psychiatrists treating patients. There is a paucity of research into acceptability of PADs in Indian mental health care, likely due to a lack of awareness. There are no educational measures about PADs provided for in this Act. Facilitators and facilitation methods have not been elaborated upon as well. AIM The aim of this study is (a) to develop/evaluate the effectiveness of a structured Education-cum-Assessment Tool (EAT) in providing information regarding PADs and (b) to evaluate modes of facilitation required by patients to complete PADs. METHODS A tool was developed as per provisions regarding PADs in the Mental Health Care Bill of 2013. This tool was administered to patients ( n = 100), purposively sampled from the adult psychiatry review out-patient department (OPD). Patients were evaluated on retention of information, completion of PADs, modes of facilitation and time taken to write one. RESULTS Mean years of education was 8.28 (±5.74) years and mean duration of illness was 8.30 (±7.04) years. In all, 65% had Below-Poverty Line (BPL) status. All participants completed valid PADs in an average of 15 minutes. About 93% required facilitation via assistance in writing and reminding. The mean EAT scores implied above 70% retention but did not relate to types of facilitation. CONCLUSIONS EAT scores can be used as an approximate measure of the patient's ability to understand and retain information which is a part of decisional capacity. Types of facilitation can help in understanding patient's ability to communicate their choices. Service providers may find EAT a time-effective tool for uniformly educating service users regarding PADs and indirectly assessing competence.
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Affiliation(s)
- Sharad Philip
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Dhanya Chandran
- 2 Neuropsychology Unit, Department of Clinical Psychology, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Albert Stezin
- 3 Department of Clinical Neurosciences, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Geetha C Viswanathaiah
- 4 Center for Addiction Medicine, Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Guru S Gowda
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Sydney Moirangthem
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Channaveerachari Naveen Kumar
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Suresh Bada Math
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
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Bainbridge E, Hallahan B, McGuinness D, Gunning P, Newell J, Higgins A, Murphy K, McDonald C. Predictors of involuntary patients' satisfaction with care: prospective study. BJPsych Open 2018; 4:492-500. [PMID: 30564445 PMCID: PMC6293452 DOI: 10.1192/bjo.2018.65] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 09/12/2018] [Accepted: 10/07/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Involuntary admission can be traumatic and is associated with negative attitudes that persist after the episode of illness has abated. AIMS We aimed to prospectively assess satisfaction with care at the points of involuntary admission and symptomatic recovery, and identify their sociodemographic, clinical and service experience predictors. METHOD Levels of satisfaction with care, and clinical and sociodemographic variables were obtained from a representative cohort of 263 patients at the point of involuntary admission and from 155 of these patients 3 months after termination of the involuntary admission. Data were analysed with multiple linear regression modelling. RESULTS Higher baseline awareness of illness (B = 0.19, P < 0.001) and older age (B = 0.05, P = 0.001) were associated with more satisfaction with care at baseline and follow-up. Transition to greater satisfaction with care was associated with improvements in awareness of illness (B = 0.13, P < 0.001) and in symptoms (B = 0.05, P = 0.02), as well as older age (B = 0.04, P = 0.01). Objective coercive experiences were not associated with variation in satisfaction with care. CONCLUSIONS There is wide variation in satisfaction with coercive care. Greater satisfaction with care is positively associated with clinical variables such as increased awareness of illness. DECLARATION OF INTEREST None.
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Affiliation(s)
- Emma Bainbridge
- Honorary Clinical Fellow, College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Ireland
| | - Brian Hallahan
- Senior Lecturer in Psychiatry, College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Ireland
| | - David McGuinness
- Research Nurse, College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Ireland
| | - Patricia Gunning
- Clinical Research Biostatistician, HRB Clinical Research Facility, National University of Ireland Galway, Ireland
| | - John Newell
- Professor of Biostatistics, HRB Clinical Research Facility, National University of Ireland Galway and School of Mathematics, Statistics and Applied Mathematics, National University of Ireland Galway, Ireland
| | - Agnes Higgins
- Professor in Mental Health, School of Nursing and Midwifery, Trinity College Dublin, Ireland
| | - Kathy Murphy
- Professor of Nursing, School of Nursing and Midwifery, National University of Ireland Galway, Ireland
| | - Colm McDonald
- Professor of Psychiatry, College of Medicine, Nursing and Health Sciences, National University of Ireland Galway and HRB Clinical Research Facility, National University of Ireland Galway, Ireland
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Henderson C, Farrelly S, Flach C, Borschmann R, Birchwood M, Thornicroft G, Waheed W, Szmukler G. Informed, advance refusals of treatment by people with severe mental illness in a randomised controlled trial of joint crisis plans: demand, content and correlates. BMC Psychiatry 2017; 17:376. [PMID: 29178895 PMCID: PMC5702102 DOI: 10.1186/s12888-017-1542-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 11/13/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In the UK, crisis planning for mental health care should acknowledge the right to make an informed advance treatment refusal under the Mental Capacity Act 2005. Our aims were to estimate the demand for such treatment refusals within a sample of service users who had had a recent hospital admission for psychosis or bipolar disorder, and to examine the relationship between refusals, and service user characteristics. METHODS To identify refusals we conducted content analysis of Joint Crisis Plans, which are plans formulated by service users and their clinical team with involvement from an external facilitator, and routine care plans in sub-samples from a multi-centre randomised controlled trial of Joint Crisis Plans (plus routine mental health care) versus routine care alone (CRIMSON) in England. Factors hypothesised to be associated with refusals were identified using the trial data collected through baseline interviews of service users and clinicians and collection of routine clinical data. RESULTS Ninety-nine of 221 (45%) of the Joint Crisis Plans contained a treatment refusal compared to 10 of 424 (2.4%) baseline routine care plans. No Joint Crisis Plans recorded disagreement with refusals on the part of clinicians. Among those with completed Joint Crisis Plans, adjusted analyses indicated a significant association between treatment refusals and perceived coercion at baseline (odds ratio = 1.21, 95% CI 1.02-1.43), but not with baseline working alliance or a past history of involuntary admission. CONCLUSIONS We demonstrated significant demand for written treatment refusals in line with the Mental Capacity Act 2005, which had not previously been elicited by the process of treatment planning. Future treatment/crisis plans should incorporate the opportunity for service users to record a treatment refusal during the drafting of such plans. TRIAL REGISTRATION ISRCTN11501328 Registered 13th March 2008.
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Affiliation(s)
- Claire Henderson
- Health Service and Population Research Department, David Goldberg Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK.
| | - Simone Farrelly
- 0000 0001 2322 6764grid.13097.3cHealth Service and Population Research Department, David Goldberg Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AF UK
| | - Clare Flach
- 0000 0001 2322 6764grid.13097.3cMedical Statistics Unit, Health and Social Care Research, King’s College London, London, UK
| | - Rohan Borschmann
- 0000 0001 2322 6764grid.13097.3cHealth Service and Population Research Department, David Goldberg Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AF UK ,0000 0004 0614 0346grid.416107.5Centre for Adolescent Health, Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, Australia ,0000 0001 2179 088Xgrid.1008.9Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia ,0000 0001 2179 088Xgrid.1008.9Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Max Birchwood
- 0000 0004 1936 7486grid.6572.6School of Psychology, University of Birmingham, Birmingham, UK
| | - Graham Thornicroft
- 0000 0001 2322 6764grid.13097.3cHealth Service and Population Research Department, David Goldberg Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AF UK
| | - Waquas Waheed
- 0000000121662407grid.5379.8Division of Psychiatry, School of Medicine, University of Manchester, Manchester, UK
| | - George Szmukler
- 0000 0001 2322 6764grid.13097.3cHealth Service and Population Research Department, David Goldberg Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AF UK
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Manuševa N, Arsova S, Markovska-Simoska S, Novotni A, Stefanovski B, Raleva M. Mental Health Legislation and Involuntary Hospitalization in the Republic of Macedonia. Open Access Maced J Med Sci 2016; 4:458-460. [PMID: 27703575 PMCID: PMC5042635 DOI: 10.3889/oamjms.2016.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 08/15/2016] [Accepted: 08/16/2016] [Indexed: 11/05/2022] Open
Abstract
As psychiatrists, we are often obliged to provide non-consensual treatment. This institute comprises the rights of the patients with mental health disorders. The aim of this paper is to explain the contemporary mental health legislation in our country the Republic of Macedonia and the problems with the implementation of involuntary hospitalisation. This could be overcome with close cooperation between the judicial and health care system.
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Affiliation(s)
- Nensi Manuševa
- University Psychiatry Clinic, Psychophysiology, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Slavica Arsova
- University Psychiatry Clinic, Psychophysiology, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Silvana Markovska-Simoska
- Division of Neuroinformatics, Research Center for Energy, Informatics and Materials, Macedonian Academy of Sciences and Arts, Skopje, Republic of Macedonia
| | - Antoni Novotni
- University Psychiatry Clinic, Psychophysiology, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Branislav Stefanovski
- University Psychiatry Clinic, Psychophysiology, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Marija Raleva
- University Psychiatry Clinic, Psychophysiology, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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Preventing compulsory admission to psychiatric inpatient care using psycho-education and monitoring: feasibility and outcomes after 12 months. Eur Arch Psychiatry Clin Neurosci 2015; 265:209-17. [PMID: 25361537 DOI: 10.1007/s00406-014-0553-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 10/11/2014] [Indexed: 10/24/2022]
Abstract
The aim of this study was to evaluate an intervention programme for people with severe mental illness that targets the reduction in compulsory psychiatric admissions. In the current study, we examine the feasibility of retaining patients in this programme and compare outcomes over the first 12 months to those after treatment as usual (TAU). Study participants were recruited in four psychiatric hospitals in the Canton of Zurich, Switzerland. Patients were eligible if they had at least one compulsory admission during the past 24 months. Participants were assigned at random to the intervention or to the TAU group. The intervention programme consists of individualised psycho-education focusing on behaviours prior to illness-related crisis, crisis cards and, after discharge from the psychiatric hospital, a 24-month preventive monitoring. In total, 238 (of 756 approached) inpatients were included in the trial. After 12 months, 80 (67.2%) in the intervention group and 102 (85.7%) in the TAU group were still participating in the trial. Of these, 22.5% in the intervention group (35.3% TAU) had been compulsorily readmitted to psychiatry; results suggest a significantly lower number of compulsory readmissions per patient (0.3 intervention; 0.7 TAU). Dropouts are characterised by younger age and unemployment. This interim analysis suggests beneficial effects of this intervention for targeted psychiatric patients.
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Farrelly S, Brown G, Szmukler G, Rose D, Birchwood M, Marshall M, Waheed W, Thornicroft G. Can the therapeutic relationship predict 18 month outcomes for individuals with psychosis? Psychiatry Res 2014; 220:585-91. [PMID: 25113923 DOI: 10.1016/j.psychres.2014.07.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 07/14/2014] [Accepted: 07/16/2014] [Indexed: 01/02/2023]
Abstract
Therapeutic relationships (TRs) are considered a key component of good psychiatric care, yet its association with outcomes for individuals with psychosis remains unclear. Five hundred and sixty-nine service users with psychotic disorders and care coordinators in community settings rated their therapeutic relationship; outcomes were assessed 18 months later. In multivariate analyses, a small but significant association was found between service user ratings and instances of psychiatric hospital admissions, self harm and suicide attempts over an 18 month period. Care coordinator ratings were associated with instances of psychiatric hospital admissions and harm to others over the 18 months and level of functioning at 18 months. The differential findings and small effect size suggests that the therapeutic relationship needs further definition for this patient group in this setting. Nevertheless, clinicians should prioritise interactions that strengthen therapeutic relationships.
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Affiliation(s)
- Simone Farrelly
- Health Service and Population Research Department, King׳s College London, Institute of Psychiatry, UK.
| | - Gill Brown
- Division of Psychiatry, School of Medicine, University of Manchester, Manchester, UK
| | - George Szmukler
- Health Service and Population Research Department, King׳s College London, Institute of Psychiatry, UK
| | - Diana Rose
- Health Service and Population Research Department, King׳s College London, Institute of Psychiatry, UK
| | - Max Birchwood
- Division of Health and Wellbeing, Warwick Medical School, University of Warwick, UK
| | - Max Marshall
- Division of Psychiatry, School of Medicine, University of Manchester, Manchester, UK
| | - Waquas Waheed
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Graham Thornicroft
- Health Service and Population Research Department, King׳s College London, Institute of Psychiatry, UK
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Weich S, McBride O, Twigg L, Keown P, Cyhlarova E, Crepaz-Keay D, Parsons H, Scott J, Bhui K. Variation in compulsory psychiatric inpatient admission in England: a cross-sectional, multilevel analysis. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02490] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundRates of compulsory admission have increased in England in recent decades, and this trend is accelerating. Studying variation in rates between people and places can help identify modifiable causes.ObjectivesTo quantify and model variances in the rate of compulsory admission in England at different spatial levels and to assess the extent to which this was explained by characteristics of people and places.DesignCross-sectional analysis using multilevel statistical modelling.SettingEngland, including 98% of Census lower layer super output areas (LSOAs), 95% of primary care trusts (PCTs), 93% of general practices and all 69 NHS providers of specialist mental health services.Participants1,287,730 patients.Main outcome measureThe study outcome was compulsory admission, defined as time spent in an inpatient mental illness bed subject to the Mental Health Act (2007) in 2010/11. We excluded patients detained under sections applying to emergency assessment only (including those in places of safety), guardianship or supervision of community treatment. The control group comprised all other users of specialist mental health services during the same period.Data sourcesThe Mental Health Minimum Data Set (MHMDS). Data on explanatory variables, characterising each of the spatial levels in the data set, were obtained from a wide range of sources, and were linked using MHMDS identifiers.ResultsA total of 3.5% of patients had at least one compulsory admission in 2010/11. Of (unexplained) variance in the null model, 84.5% occurred between individuals. Statistically significant variance occurred between LSOAs [6.7%, 95% confidence interval (CI) 6.2% to 7.2%] and provider trusts (6.9%, 95% CI 4.3% to 9.5%). Variances at these higher levels remained statistically significant even after adjusting for a large number of explanatory variables, which together explained only 10.2% of variance in the study outcome. The number of provider trusts whose observed rate of compulsory admission differed from the model average to a statistically significant extent fell from 45 in the null model to 20 in the fully adjusted model. We found statistically significant associations between compulsory admission and age, gender, ethnicity, local area deprivation and ethnic density. There was a small but statistically significant association between (higher) bed occupancy and compulsory admission, but this was subsequently confounded by other covariates. Adjusting for PCT investment in mental health services did not improve model fit in the fully adjusted models.ConclusionsThis was the largest study of compulsory admissions in England. While 85% of the variance in this outcome occurred between individuals, statistically significant variance (around 7% each) occurred between places (LSOAs) and provider trusts. This higher-level variance in compulsory admission remained largely unchanged even after adjusting for a large number of explanatory variables. We were constrained by data available to us, and therefore our results must be interpreted with caution. We were also unable to consider many hypotheses suggested by the service users, carers and professionals who we consulted. There is an imperative to develop and evaluate interventions to reduce compulsory admission rates. This requires further research to extend our understanding of the reasons why these rates remain so high.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Scott Weich
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Orla McBride
- School of Psychology, University of Ulster, Londonderry, UK
| | - Liz Twigg
- Department of Geography, University of Portsmouth, Portsmouth, UK
| | - Patrick Keown
- Academic Psychiatry, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jan Scott
- Academic Psychiatry, Newcastle University, Newcastle upon Tyne, UK
| | - Kamaldeep Bhui
- Centre for Psychiatry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Abstract
Background. In England, people with a serious mental illness are offered a standardized care plan under the Care Programme Approach (CPA). A crisis plan is a mandatory part of this standard; however, the quality and in particular the level of individualisation of these crisis plans are unknown. In this context, the aim of this study was to assess the quality of crisis planning and the impact of exposure to a specialized crisis planning intervention. Method. The crisis plans of 424 participants were assessed, before and after exposure to the Joint Crisis Plan (JCP) intervention, for 'individualisation' (i.e., at least one item of specific and identifiable information about an individual). Associations of individualisation were investigated. Results. A total of 15% of crisis plans were individualised at baseline. There was little or no improvement following exposure to the JCP. Individualised crisis plans were not associated with a history of prior crises or incidences of harm to self and others. Conclusions. Routine crisis planning for individuals with serious mental illness is not influenced by clinical risk profiles. 'Top down' implementation of the policy is unlikely to generate the best practice and compliance if clinicians do not perceive the clinical value in the process.
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Farrelly S, Brown G, Rose D, Doherty E, Henderson RC, Birchwood M, Marshall M, Waheed W, Szmukler G, Thornicroft G. What service users with psychotic disorders want in a mental health crisis or relapse: thematic analysis of joint crisis plans. Soc Psychiatry Psychiatr Epidemiol 2014; 49:1609-17. [PMID: 24691492 PMCID: PMC4165869 DOI: 10.1007/s00127-014-0869-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 03/16/2014] [Indexed: 01/05/2023]
Abstract
PURPOSE Recent legislation and guidance in England emphasises the importance of service user choice in care planning. However, it is not obvious how best to facilitate choices in care planning, and some clinicians are concerned that service users may make 'unwise' decisions. This study aimed to examine mental health service users' preferences and priorities in the event of a future mental health crisis or relapse. METHOD Thematic analysis of 221 joint crisis plans (JCP) developed by service users and their clinical team as part of the CRIMSON randomised controlled trial. Participants had a diagnosis of a psychotic disorder, at least one psychiatric admission in the past 2 years, contact with a community mental health team, and complex care needs. RESULTS Two major categories of preferences were identified: first the manner in which crisis care would be delivered; and second, specific treatment interventions. Most service users requested full involvement in decisions about their care, clear and consistent treatment plans, access to familiar clinicians who knew them well, and to be treated with respect and compassion. Some service users requested hospitalisation, but the majority preferred alternatives. The most frequently preferred intervention was care by a home treatment team. Just under half made a treatment refusal, the majority being for specific medications, alternatives were offered. CONCLUSIONS Joint crisis planning resulted in service users making choices that were clinically reasonable. The technique employed by JCPs appeared to empower service users by engaging them in a productive dialogue with their clinicians.
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Affiliation(s)
- Simone Farrelly
- Section of Community Mental Health, Box PO29, Health Service and Population Research Department, Institute of Psychiatry, King's College London, De Crespigny Park, London, SE5 8AF, UK,
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Users' and health professionals' values in relation to a psychiatric intervention: the case of psychiatric advance directives. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2014; 42:384-93. [PMID: 25091050 DOI: 10.1007/s10488-014-0580-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Although clinical and organisational benefits have been expected from Psychiatric Advance Directives (PADs), their take-up rates remain low and their evaluation disappointing. The endorsement of PADs by stakeholders is decisive for their use and understanding stakeholders' preferences for implementation is crucial. A Multinomial Discrete Choice analysis was carried out of options for designing, completing, and honouring PADs, with a view to enhancing user autonomy, therapeutic alliance, care coordination, and feasibility. Although autonomy underlies the whole process, the criteria determining options varied with the stage of the intervention. These criteria should be taken into account in future PAD intervention and evaluation processes.
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Recruiting South Asians into a UK Mental Health Randomised Controlled Trial: Experiences of Field Researchers. J Racial Ethn Health Disparities 2014. [DOI: 10.1007/s40615-014-0024-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Khazaal Y, Manghi R, Delahaye M, Machado A, Penzenstadler L, Molodynski A. Psychiatric advance directives, a possible way to overcome coercion and promote empowerment. Front Public Health 2014; 2:37. [PMID: 24809041 PMCID: PMC4010761 DOI: 10.3389/fpubh.2014.00037] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 04/14/2014] [Indexed: 11/13/2022] Open
Abstract
Psychiatric advance directives (ADs) allow an individual to state their preferences for future treatment at times when they may be unable to make considered decisions. There are differences in their form and legal value and the process associated with their use and completion. Several studies have now been completed to assess the impact of ADs on service use and coercion. Their results give a mixed picture but directives nevertheless have the potential to support the empowerment process, minimize experienced coercion, and improve coping strategies. These may in turn reduce the frequency of in-patient service use. Further studies on the different processes of facilitation involved and on different populations are necessary to improve our knowledge and use of these potentially powerful interventions.
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Affiliation(s)
- Yasser Khazaal
- Geneva University Hospitals , Geneva , Switzerland ; Geneva University , Geneva , Switzerland
| | - Rita Manghi
- Geneva University Hospitals , Geneva , Switzerland
| | | | | | | | - Andrew Molodynski
- Oxford Health NHS Foundation Trust , Oxford , UK ; Department of Psychiatry, Oxford University , Oxford , UK
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Barrett B, Waheed W, Farrelly S, Birchwood M, Dunn G, Flach C, Henderson C, Leese M, Lester H, Marshall M, Rose D, Sutherby K, Szmukler G, Thornicroft G, Byford S. Randomised controlled trial of joint crisis plans to reduce compulsory treatment for people with psychosis: economic outcomes. PLoS One 2013; 8:e74210. [PMID: 24282495 PMCID: PMC3839936 DOI: 10.1371/journal.pone.0074210] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 11/02/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Compulsory admission to psychiatric hospitals may be distressing, disruptive to patients and families, and associated with considerable cost to the health service. Improved patient experience and cost reductions could be realised by providing cost-effective crisis planning services. METHODS Economic evaluation within a multi-centre randomised controlled trial comparing Joint Crisis Plans (JCP) plus treatment as usual (TAU) to TAU alone for patients aged over 16, with at least one psychiatric hospital admission in the previous two years and on the Enhanced Care Programme Approach register. JCPs, containing the patient's treatment preferences for any future psychiatric emergency, are a form of crisis intervention that aim to mitigate the negative consequences of relapse, including hospital admission and use of coercion. Data were collected at baseline and 18-months after randomisation. The primary outcome was admission to hospital under the Mental Health Act. The economic evaluation took a service perspective (health, social care and criminal justice services) and a societal perspective (additionally including criminal activity and productivity losses). FINDINGS The addition of JCPs to TAU had no significant effect on compulsory admissions or total societal cost per participant over 18-months follow-up. From the service cost perspective, however, evidence suggests a higher probability (80%) of JCPs being the more cost-effective option. Exploration by ethnic group highlights distinct patterns of costs and effects. Whilst the evidence does not support the cost-effectiveness of JCPs for White or Asian ethnic groups, there is at least a 90% probability of the JCP intervention being the more cost-effective option in the Black ethnic group. INTERPRETATION The results by ethnic group are sufficiently striking to warrant further investigation into the potential for patient gain from JCPs among black patient groups. TRIAL REGISTRATION Current Controlled Trials ISRCTN11501328.
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Affiliation(s)
- Barbara Barrett
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Waquas Waheed
- Division of Psychiatry, School of Medicine, University of Manchester, Manchester, United Kingdom
| | - Simone Farrelly
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Max Birchwood
- Department of Psychology, University of Birmingham, Birmingham, United Kingdom
| | - Graham Dunn
- Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Clare Flach
- Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Claire Henderson
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Morven Leese
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Helen Lester
- School of Health and Population Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Max Marshall
- Division of Psychiatry, School of Medicine, University of Manchester, Manchester, United Kingdom
| | - Diana Rose
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Kim Sutherby
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - George Szmukler
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Graham Thornicroft
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Sarah Byford
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, United Kingdom
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Farrelly S, Brown GE, Flach C, Barley E, Laugharne R, Henderson C. User-held personalised information for routine care of people with severe mental illness. Cochrane Database Syst Rev 2013; 2013:CD001711. [PMID: 24096715 PMCID: PMC8078447 DOI: 10.1002/14651858.cd001711.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND It is important to seek cost-effective methods of improving the care and outcome of those with serious mental illnesses. User-held records, where the person with the illness holds all or some personal information relating to the course and care of their illness, are now the norm in some clinical settings. Their value for those with severe mental illnesses is unknown. OBJECTIVES To evaluate the effects of personalised, accessible, user-held clinical information for people with a severe mental illness (defined as psychotic illnesses). SEARCH METHODS We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register in August 2011. This register is compiled by systematic searches of major databases, and handsearches of journals and conference proceedings. SELECTION CRITERIA We included all relevant randomised controlled trials (RCTs) that:i. have recruited adult participants with a diagnosis of a severe mental illness (specifically psychotic illnesses and severe mood disorders such as bipolar and depression with psychotic features); andii. compared any personalised and accessible clinical information held by the user beyond standard care to standard information routinely held such as appointment cards and generic information on diagnosis, treatment or services available. DATA COLLECTION AND ANALYSIS Study selection and data extraction were undertaken independently by two authors and confirmed and checked by a third. We contacted authors of trials for additional and missing data. Where possible, we calculated risk ratios (RR) and 95% confidence intervals (CI). We used a random-effects model. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE. MAIN RESULTS Four RCTs (n = 607) of user-held records versus treatment as usual met the inclusion criteria. When the effect of user-held records on psychiatric hospital admissions was compared with treatment as usual in four studies, the pooled treatment effect showed no significant impact of the intervention and was of very low magnitude (n = 597, 4 RCTs, RR 0.99 CI 0.71 to 1.38, moderate quality evidence). Similarly, there was no significant effect of the intervention in three studies which investigated compulsory psychiatric hospital admissions (n = 507, 4 RCTs, RR 0.64 CI 0.37 to 1.10, moderate quality evidence). Other outcomes including satisfaction and mental state were investigated but pooled estimates were not obtainable due to skewed or poorly reported data, or only being investigated by one study. Two outcomes (violence and death) were not investigated by the included studies. Two important randomised studies are ongoing. AUTHORS' CONCLUSIONS The evidence gap remains regarding user-held, personalised, accessible clinical information for people with psychotic illnesses for many of the outcomes of interest. However, based on moderate quality evidence, this review suggests that there is no effect of the intervention on hospital or outpatient appointment use for individuals with psychotic disorders. The number of studies is low, however, and further evidence is required to ascertain whether these results are mediated by the type of intervention, such as involvement of a clinical team or the type of information included.
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Affiliation(s)
- Simone Farrelly
- Institute of PsychiatryHealth Service and Population Research DepartmentKing's College LondonDe Crespigney ParkLondonUKSE5 8AF
| | - Gill E Brown
- Edge Hill UniversityFaculty of Health and Social CareSt Helen's RoadOrmskirkLancashireUKL39 4QP
| | - Clare Flach
- University of ManchesterBiostatistics, Health Sciences‐MethodologySchool of Community Based MedicineJean McFarlane Building, Oxford RoadManchesterUKM13 9PL
| | - Elizabeth Barley
- King's College LondonFlorence Nightingale School of Nursing and Midwifery2.25, James Clerk Maxwell Building57 Waterloo RoadLondonUKSE1 8WA
| | - Richard Laugharne
- Cornwall Partnership NHS Foundation Trust and Peninsula College of Medicine and DentistryMental Health Research GroupVeysey BuildingExeterUK
| | - Claire Henderson
- King's College LondonHealth Service and Population Research Department, Institute of PsychiatryDe Crespigny ParkDenmark HillLondonUKSE5 8AF
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Thornicroft G, Farrelly S, Szmukler G, Birchwood M, Waheed W, Flach C, Barrett B, Byford S, Henderson C, Sutherby K, Lester H, Rose D, Dunn G, Leese M, Marshall M. Clinical outcomes of Joint Crisis Plans to reduce compulsory treatment for people with psychosis: a randomised controlled trial. Lancet 2013; 381:1634-41. [PMID: 23537606 DOI: 10.1016/s0140-6736(13)60105-1] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The CRIMSON (CRisis plan IMpact: Subjective and Objective coercion and eNgagement) study is an individual level, randomised controlled trial that compared the effectiveness of Joint Crisis Plans (JCPs) with treatment as usual for people with severe mental illness. The JCP is a negotiated statement by a patient of treatment preferences for any future psychiatric emergency, when he or she might be unable to express clear views. We assessed whether the additional use of JCPs improved patient outcomes compared with treatment as usual. METHODS Patients were eligible if they had at least one psychiatric admission in the previous 2 years and were on the Enhanced Care Programme Approach register. The study was done with 64 generic and specialist community mental health teams in four English mental health care provider organisations (trusts). Hypotheses tested were that, compared with the control group, the intervention group would experience: fewer compulsory admissions (primary outcome); fewer psychiatric admissions; shorter psychiatric stays; lower perceived coercion; improved therapeutic relationships; and improved engagement. We stratified participants by centre. The research team but not participants nor clinical staff were masked to allocation. This study is registered with ClinicalTrials.gov, number ISRCTN11501328. FINDINGS 569 participants were randomly assigned (285 to the intervention group and 284 to the control group). No significant treatment effect was seen for the primary outcome (56 [20%] sectioned in the control group and 49 [18%] in the JCP group; odds ratio 0·90 [95% CI 0·58-1·39, p=0·63]) or any secondary outcomes, with the exception of an improved secondary outcome of therapeutic relationships (17·3 [7·6] vs 16·0 [7·1]; adjusted difference -1·28 [95% CI -2·56 to -0·01, p=0·049]). Qualitative data supported this finding. INTERPRETATION Our findings are inconsistent with two earlier JCP studies, and show that the JCP is not significantly more effective than treatment as usual. There is evidence to suggest the JCPs were not fully implemented in all study sites, and were combined with routine clinical review meetings which did not actively incorporate patients' preferences. The study therefore raises important questions about implementing new interventions in routine clinical practice. FUNDING Medical Research Council UK and the National Institute for Health Research.
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Affiliation(s)
- Graham Thornicroft
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, UK.
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Ramsay H, Roche E, O'Donoghue B. Five years after implementation: a review of the Irish Mental Health Act 2001. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2013; 36:83-91. [PMID: 23274178 DOI: 10.1016/j.ijlp.2012.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES The Mental Health Act 2001 (MHA 2001) was implemented in November 2006. Since that time, there has been considerable research into its impact, including the impact on service provision, use of coercive practices and the perceptions by key stakeholders. Our objective is to present a summary of research into the MHA 2001 since its implementation in the Irish state in the context of international standards and practice. METHODS We reviewed the literature presented on Medline and Google Scholar, directly assessed relevant journals and sought abstract information from the College of Psychiatry of Ireland. RESULTS There has been a small decrease in the rate of involuntary admission since implementation but there has been no change in the representativeness of diagnoses of individuals admitted involuntarily. Mental Health Tribunals were held for 57% of those admitted involuntarily and 46% of service users found that the Mental Health Tribunal made the involuntary admission easier to accept. One year after discharge, 60% of service users reflected that their involuntary admission had been necessary. Professional groups have expressed concerns regarding workload, training time for junior doctors and paperwork. CONCLUSIONS The MHA 2001 has brought the practice of involuntary admission further into line with international standards. However, five years after the implementation of the Act international guidelines and practice have highlighted areas in need of further reform, including capacity legislation and consideration of advance directives and community treatment orders. Further research is also lacking on caregivers' or family members' perceptions of the MHA 2001.
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Affiliation(s)
- Hugh Ramsay
- Lucena Clinic, Orwell Road, Rathgar, Dublin 6, Ireland.
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Lay B, Salize HJ, Dressing H, Rüsch N, Schönenberger T, Bühlmann M, Bleiker M, Lengler S, Korinth L, Rössler W. Preventing compulsory admission to psychiatric inpatient care through psycho-education and crisis focused monitoring. BMC Psychiatry 2012; 12:136. [PMID: 22946957 PMCID: PMC3532124 DOI: 10.1186/1471-244x-12-136] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 08/31/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The high number of involuntary placements of people with mental disorders in Switzerland and other European countries constitutes a major public health issue. In view of the ethical and personal relevance of compulsory admission for the patients concerned and given the far-reaching effects in terms of health care costs, innovative interventions to improve the current situation are much needed. A number of promising approaches to prevent involuntary placements have been proposed that target continuity of care by increasing self-management skills of patients. However, the effectiveness of such interventions in terms of more robust criteria (e.g., admission rates) has not been sufficiently analysed in larger study samples. The current study aims to evaluate an intervention programme for patients at high risk of compulsory admission to psychiatric hospitals. Effectiveness will be assessed in terms of a reduced number of psychiatric hospitalisations and days of inpatient care in connection with involuntary psychiatric admissions as well as in terms of cost-containment in inpatient mental health care. The intervention furthermore intends to reduce the degree of patients' perceived coercion and to increase patient satisfaction, their quality of life and empowerment. METHODS/DESIGN This paper describes the design of a randomised controlled intervention study conducted currently at four psychiatric hospitals in the Canton of Zurich. The intervention programme consists of individualised psycho-education focusing on behaviours prior to and during illness-related crisis, the distribution of a crisis card and, after inpatient admission, a 24-month preventive monitoring of individual risk factors for compulsory re-admission to hospital. All measures are provided by a mental health care worker who maintains permanent contact to the patient over the course of the study. In order to prove its effectiveness the intervention programme will be compared with standard care procedures (control group). 200 patients each will be assigned to the intervention group or to the control group. Detailed follow-up assessments of service use, psychopathology and patient perceptions are scheduled 12 and 24 months after discharge. DISCUSSION Innovative interventions have to be established to prevent patients with mental disorders from undergoing the experience of compulsory admission and, with regard to society as a whole, to reduce the costs of health care (and detention). The current study will allow for a prospective analysis of the effectiveness of an intervention programme, providing insight into processes and factors that determine involuntary placement.
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Affiliation(s)
- Barbara Lay
- Psychiatric University Hospital Zurich, Zurich, Switzerland.
| | | | | | - Nicolas Rüsch
- Psychiatric University Hospital Zurich, Zurich, Switzerland
| | | | | | - Marco Bleiker
- Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Silke Lengler
- Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Lena Korinth
- Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Wulf Rössler
- Psychiatric University Hospital Zurich, Zurich, Switzerland
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Borschmann R, Henderson C, Hogg J, Phillips R, Moran P. Crisis interventions for people with borderline personality disorder. Cochrane Database Syst Rev 2012:CD009353. [PMID: 22696385 DOI: 10.1002/14651858.cd009353.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND People with borderline personality disorder (BPD) frequently present to health services in crisis, often involving suicidal thoughts or actions. Despite this, little is known about what constitutes effective management of acute crises in this population. OBJECTIVES To review the evidence for the effectiveness of crisis interventions for adults with BPD in any setting. For the purposes of the review, we defined crisis intervention as 'an immediate response by one or more individuals to the acute distress experienced by another individual, which is designed to ensure safety and recovery and lasts no longer than one month.' SEARCH METHODS We searched the following databases in September 2011: CENTRAL (The Cochrane Library 2011, Issue 3), MEDLINE (1948 to August Week 5 2011), MEDLINE In Process & Other Non-indexed Citations (8 September 2011), EMBASE (1980 to Week 36 2011), PsycINFO (1806 to September Week 1 2011), CINAHL (1937 to current), Social Services Abstracts (1979 to current), Social Care Online (12 September 2011), Science Citation Index (1970 to current), Social Science Citation Index (1970 to current), Conference Proceedings Citation Index - Science (1990 to current), Conference Proceedings Citation Index - Social Science and Humanities (1990 to current) and ZETOC Conference proceedings (12 September 2011). We searched for dissertations in WorldCat (12 September 2011), Australasian Digital Theses Program (ADTP; 12 September 2011), Networked Digital Library of Theses and Dissertations (NDLTD), 12 September 2011 and Theses Canada Portal (12 September 2011). We searched for trials in the International Clinical Trials Registry Platform (ICTRP) and searched reference lists from relevant literature. We contacted the 10 most published researchers in the field of BPD (as indexed by BioMed Experts), in addition to contacting topic experts, Marsha Linehan, Arnoud Arntz and Paul Links, about ongoing trials and unpublished data. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing crisis interventions with usual care or no intervention or a waiting list control for adults of any age with BPD. DATA COLLECTION AND ANALYSIS Two authors independently screened titles, abstracts and full-text articles and assessed these against the inclusion criteria. MAIN RESULTS The search identified 15 studies, 13 of which we excluded. Reasons for exclusion were: lack of randomisation (N = 8); retrospective design (N = 2); or the intervention was a complex psychological therapy lasting longer than one month (N = 3). We identified two ongoing RCTs that met the inclusion criteria, with a combined predicted sample size of 688. These trials are ongoing and the results are therefore not included in the review, although they will be incorporated into future updates. AUTHORS' CONCLUSIONS A comprehensive search of the literature showed that currently there is no RCT-based evidence for the management of acute crises in people with BPD and therefore we could not reach any conclusions about the effectiveness of any single crisis intervention. High-quality, large-scale, adequately powered RCTs in this area are urgently needed.
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Affiliation(s)
- Rohan Borschmann
- Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK.
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Altman DG, Hrynaszkiewicz I, Furberg CD, Grimshaw JM, Rothwell PM. Five years of Trials. Trials 2011; 12:248. [PMID: 22112799 PMCID: PMC3254076 DOI: 10.1186/1745-6215-12-248] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 11/23/2011] [Indexed: 11/16/2022] Open
Abstract
This editorial marks the launch of a special collection of articles highlighting 'Five years of Trials' (http://www.trialsjournal.com/series/5years). The journal's achievements on its objectives since 2006 are described and some of the challenges still ahead are outlined - in particular further innovating in the reporting of trials and the publication of negative results. The other articles in this series are examples of where Trials has demonstrated progress on its objectives. These include the publication of raw data, extended versions of previously published trial-related articles, descriptions of 'lessons learned', negative results, and educational articles regarding ethics and reporting bias.
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Affiliation(s)
- Douglas G Altman
- Centre for Statistics in Medicine, Wolfson College Annexe, Linton Road, Oxford OX2 6UD, UK
| | | | - Curt D Furberg
- Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1063, USA
| | - Jeremy M Grimshaw
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, and Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa ON K1H 8L6, Canada
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences Level 6, West Wing John Radcliffe Hospital Headington Oxford OX3 9DU, UK
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Kisely SR, Campbell LA, Preston NJ. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev 2011:CD004408. [PMID: 21328267 PMCID: PMC4164937 DOI: 10.1002/14651858.cd004408.pub3] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND There is controversy as to whether compulsory community treatment for people with severe mental illnesses reduces health service use, or improves clinical outcome and social functioning. Given the widespread use of such powers it is important to assess the effects of this type of legislation. OBJECTIVES To examine the clinical and cost effectiveness of compulsory community treatment for people with severe mental illness. SEARCH STRATEGY We undertook searches of the Cochrane Schizophrenia Group Register 2003, 2008, and Science Citation Index. We obtained all references of identified studies and contacted authors of each included study. SELECTION CRITERIA All relevant randomised controlled clinical trials of compulsory community treatment compared with standard care for people with severe mental illness. DATA COLLECTION AND ANALYSIS We reliably selected and quality assessed studies and extracted data. For binary outcomes, we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and, where possible, the weighted number needed to treat/harm statistic (NNT/H). MAIN RESULTS We identified two randomised clinical trials (total n = 416) of court-ordered 'Outpatient Commitment' (OPC) from the USA. We found little evidence that compulsory community treatment was effective in any of the main outcome indices: health service use (2 RCTs, n = 416, RR for readmission to hospital by 11-12 months 0.98 CI 0.79 to 1.2); social functioning (2 RCTs, n = 416, RR for arrested at least once by 11-12 months 0.97 CI 0.62 to 1.52); mental state; quality of life (2 RCTs, n = 416, RR for homelessness 0.67 CI 0.39 to 1.15) or satisfaction with care (2 RCTs, n = 416, RR for perceived coercion 1.36 CI 0.97 to 1.89). However, risk of victimisation may decrease with OPC (1 RCT, n = 264, RR 0.5 CI 0.31 to 0.8). In terms of numbers needed to treat (NNT), it would take 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent one arrest. The NNT for the reduction of victimisation was lower at six (CI 6 to 6.5). A new search for trials in 2008 did not find any new trials that were relevant to this review. AUTHORS' CONCLUSIONS Compulsory community treatment results in no significant difference in service use, social functioning or quality of life compared with standard care. People receiving compulsory community treatment were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Evaluation of a wide range of outcomes should be considered when this type of legislation is introduced.
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Affiliation(s)
- Steve R Kisely
- School of Population Health, The University of Queensland, Brisbane, Australia
| | | | - Neil J Preston
- Mental Health Directorate, Fremantle Hospital and Health Service, Fremantle, Australia
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Abstract
BACKGROUND Intensive Case Management (ICM) is a community based package of care, aiming to provide long term care for severely mentally ill people who do not require immediate admission. ICM evolved from two original community models of care, Assertive Community Treatment (ACT) and Case Management (CM), where ICM emphasises the importance of small caseload (less than 20) and high intensity input. OBJECTIVES To assess the effects of Intensive Case Management (caseload <20) in comparison with non-Intensive Case Management (caseload > 20) and with standard community care in people with severe mental illness. To evaluate whether the effect of ICM on hospitalisation depends on its fidelity to the ACT model and on the setting. SEARCH STRATEGY For the current update of this review we searched the Cochrane Schizophrenia Group Trials Register (February 2009), which is compiled by systematic searches of major databases, hand searches and conference proceedings. SELECTION CRITERIA All relevant randomised clinical trials focusing on people with severe mental illness, aged 18 to 65 years and treated in the community-care setting, where Intensive Case Management, non-Intensive Case Management or standard care were compared. Outcomes such as service use, adverse effects, global state, social functioning, mental state, behaviour, quality of life, satisfaction and costs were sought. DATA COLLECTION AND ANALYSIS We extracted data independently. For binary outcomes we calculated relative risk (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data we estimated mean difference (MD) between groups and its 95% confidence interval (CI). We employed a random-effects model for analyses.We performed a random-effects meta-regression analysis to examine the association of the intervention's fidelity to the ACT model and the rate of hospital use in the setting where the trial was conducted with the treatment effect. MAIN RESULTS We included 38 trials (7328 participants) in this review. The trials provided data for two comparisons: 1. ICM versus standard care, 2. ICM versus non-ICM.1. ICM versus standard care Twenty-four trials provided data on length of hospitalisation, and results favoured Intensive Case Management (n=3595, 24 RCTs, MD -0.86 CI -1.37 to -0.34). There was a high level of heterogeneity, but this significance still remained when the outlier studies were excluded from the analysis (n=3143, 20 RCTs, MD -0.62 CI -1.00 to -0.23). Nine studies found participants in the ICM group were less likely to be lost to psychiatric services (n=1633, 9 RCTs, RR 0.43 CI 0.30 to 0.61, I²=49%, p=0.05).One global state scale did show an Improvement in global state for those receiving ICM, the GAF scale (n=818, 5 RCTs, MD 3.41 CI 1.66 to 5.16). Results for mental state as measured through various rating scales, however, were equivocal, with no compelling evidence that ICM was really any better than standard care in improving mental state. No differences in mortality between ICM and standard care groups occurred, either due to 'all causes' (n=1456, 9 RCTs, RR 0.84 CI 0.48 to 1.47) or to 'suicide' (n=1456, 9 RCTs, RR 0.68 CI 0.31 to 1.51).Social functioning results varied, no differences were found in terms of contact with the legal system and with employment status, whereas significant improvement in accommodation status was found, as was the incidence of not living independently, which was lower in the ICM group (n=1185, 4 RCTs, RR 0.65 CI 0.49 to 0.88).Quality of life data found no significant difference between groups, but data were weak. CSQ scores showed a greater participant satisfaction in the ICM group (n=423, 2 RCTs, MD 3.23 CI 2.31 to 4.14).2. ICM versus non-ICM The included studies failed to show a significant advantage of ICM in reducing the average length of hospitalisation (n=2220, 21 RCTs, MD -0.08 CI -0.37 to 0.21). They did find ICM to be more advantageous than non-ICM in reducing rate of lost to follow-up (n=2195, 9 RCTs, RR 0.72 CI 0.52 to 0.99), although data showed a substantial level of heterogeneity (I²=59%, p=0.01). Overall, no significant differences were found in the effects of ICM compared to non-ICM for broad outcomes such as service use, mortality, social functioning, mental state, behaviour, quality of life, satisfaction and costs.3. Fidelity to ACT Within the meta-regression we found that i. the more ICM is adherent to the ACT model, the better it is at decreasing time in hospital ('organisation fidelity' variable coefficient -0.36 CI -0.66 to -0.07); and ii. the higher the baseline hospital use in the population, the better ICM is at decreasing time in hospital ('baseline hospital use' variable coefficient -0.20 CI -0.32 to -0.10). Combining both these variables within the model, 'organisation fidelity' is no longer significant, but 'baseline hospital use' result is still significantly influencing time in hospital (regression coefficient -0.18 CI -0.29 to -0.07, p=0.0027). AUTHORS' CONCLUSIONS ICM was found effective in ameliorating many outcomes relevant to people with severe mental illnesses. Compared to standard care ICM was shown to reduce hospitalisation and increase retention in care. It also globally improved social functioning, although ICM's effect on mental state and quality of life remains unclear. ICM is of value at least to people with severe mental illnesses who are in the sub-group of those with a high level of hospitalisation (about 4 days/month in past 2 years) and the intervention should be performed close to the original model.It is not clear, however, what gain ICM provides on top of a less formal non-ICM approach.We do not think that more trials comparing current ICM with standard care or non-ICM are justified, but currently we know of no review comparing non-ICM with standard care and this should be undertaken.
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Affiliation(s)
- Marina Dieterich
- Department of Mental Health, Azienda USL 6 Livorno, Livorno, Italy
| | - Claire B Irving
- Cochrane Schizophrenia Group, The University of Nottingham, Nottingham, UK
| | - Bert Park
- The University of Nottingham, Nottingham, UK
| | - Max Marshall
- University of Manchester, The Lantern Centre, Preston., UK
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Abstract
BACKGROUND An advance directive is a document specifying a person's preferences for treatment, should he or she lose capacity to make such decisions in the future. They have been used in end-of-life settings to direct care but should be well suited to the mental health setting. OBJECTIVES To examine the effects of advance treatment directives for people with severe mental illness. SEARCH STRATEGY We searched the Cochrane Schizophrenia Group's Register (February 2008), the Cochrane Library (Issue 1 2008), BIOSIS (1985 to February 2008), CINAHL (1982 to February 2008), EMBASE (1980 to February 2008), MEDLINE (1966 to February 2008), PsycINFO (1872 to February 2008), as well as SCISEARCH and Google - Internet search engine (February 2008). We inspected relevant references and contacted first authors of included studies. SELECTION CRITERIA We included all randomised controlled trials (RCTs), involving adults with severe mental illness, comparing any form of advance directive with standard care for health service and clinical outcomes. DATA COLLECTION AND ANALYSIS We extracted data independently. For homogenous dichotomous data we calculated fixed-effect relative risk (RR) and 95% confidence intervals (CI) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD) and their 95% confidence interval again using a fixed-effect model. MAIN RESULTS We were able to include two trials involving 321 people with severe mental illnesses. There was no significant difference in hospital admission (n=160, 1 RCT, RR 0.69 0.5 to 1.0), or number of psychiatric outpatient attendances between participants given advanced treatment directives or usual care. Similarly, no significant differences were found for compliance with treatment, self harm or number of arrests. Participants given advanced treatment directives needed less use of social workers time (n=160, 1 RCT, WMD -106.00 CI -156.2 to -55.8) than the usual care group, and violent acts were also lower in the advanced directives group (n=160, 1 RCT, RR 0.27 CI 0.1 to 0.9, NNT 8 CI 6 to 92). The number of people leaving the study early were not different between groups (n=321, 2 RCTs, RR 0.92 CI 0.6 to 1.6). AUTHORS' CONCLUSIONS There are too few data available to make definitive recommendations. More intensive forms of advance directive appear to show promise, but currently practice must be guided by evidence other than that derived from randomised trials. More trials are indicated to determine whether higher intensity interventions, such as joint crisis planning, have an effect on outcomes of clinical relevance.
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Affiliation(s)
- Leslie Anne Campbell
- Health Outcomes Research Unit, Capital Health District Authority, Centre for Clinical Research, West Annexe, Mackenzie Building, 5790 University Avenue, Halifax, Nova Scotia, Canada, B3H 2E2.
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