Crisis intervention for people with severe mental illnesses
Abstract
Background
A particularly difficult challenge for community treatment of people with serious mental illnesses is the delivery of an acceptable level of care during the acute phases of severe mental illness. Crisis intervention models of care were developed as a possible solution.
Objectives
To review the effects of crisis intervention models for anyone with serious mental illness experiencing an acute episode, compared with 'standard care'.
Search methods
We updated the 1998, 2003 and 2006 searches with a search of the Cochrane Schizophrenia Group's Register of trials (2010) which is based on regular searches of CINAHL, EMBASE, MEDLINE, and PsycINFO.
Selection criteria
We included all randomised controlled trials of crisis intervention models versus standard care for people with severe mental illnesses.
Data collection and analysis
We independently extracted data from these trials and we estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CI). We assumed that people who left early from a trial had no improvement.
Main results
Three new studies have been found since the last review in 2006 to add to the five studies already included in this review. None of the previously included studies investigated crisis intervention alone; all used a form of home care for acutely ill people, which included elements of crisis intervention. However, one of the new studies focuses purely on crisis intervention as provided by Crisis Resolution Home Teams within the UK; the two other new studies investigated crisis houses i.e. residential alternatives to hospitalisation providing home‐like environments.
Crisis intervention appears to reduce repeat admissions to hospital after the initial 'index' crises investigated in the included studies, this was particularly so for mobile crisis teams supporting patients in their own homes.
Crisis intervention reduces the number of people leaving the study early, reduces family burden, is a more satisfactory form of care for both patients and families and at three months after crisis, mental state is superior to standard care. We found no differences in death outcomes. Some studies found crisis interventions to be more cost effective than hospital care but all numerical data were either skewed or unusable. No data on staff satisfaction, carer input, complications with medication or number of relapses were available.
Authors' conclusions
Care based on crisis intervention principles, with or without an ongoing home care package, appears to be a viable and acceptable way of treating people with serious mental illnesses. If this approach is to be widely implemented it would seem that more evaluative studies are still needed.
PICOs
Plain language summary
Crisis intervention for people with severe mental illnesses
The move from hospital to community‐based care can be a frightening and difficult experience for people with severe mental illness (SMI). People with mental health problems may not have networks of support such as family, friends and carers. They often have no one they know personally to help them when they go home. To complicate matters, people with SMI can have critical downturns in their mental health creating a revolving‐door of care, where service users are discharged from hospital when considered stable and well, only to go back into hospital again when their mental health becomes worse during an acute episode or crisis. Crisis intervention and home‐care packages have been developed as a possible solution to these problems.
Crisis care, where support is provided during a crisis for service users, either in their home or a community setting, was found by this review to provide a package of support that was worthwhile, acceptable and less expensive than standard care. Furthermore, crisis care avoided repeat admission to hospital (at three and six months after crisis, in some cases by 50%); improved the mental state of services users more than standard care (at three months after crisis); was more acceptable and satisfactory to service users, their families and carers; placed less burden on families and carers; and reduced the stigma of hospitalisation. Burden (such as disruption to daily routine, social life and susceptibility to physical illness) was also reduced for service users, their families and carers. There were no differences in death rates between crisis and standard care.
The review, however, looks at only six studies with a total of 984 people. The methods of these six studies were considered poor and there was no definitive description of crisis intervention or crisis care, meaning there was a lack of focus on crisis care in its pure form. Most studies excluded service users with alcohol or drug misuse, and those who were a danger of being harmful to themselves or others. The authors of the review suggest more studies are needed to create a stronger evidence base. Crisis care may be currently delivered without sound and good evidence. For example, no data or information were available on carer input, concordance or the willingness of service users to take medication and the number of relapses experienced by service users. Finally despite reports of staff 'burn‐out', staff satisfaction with crisis care was not assessed.
This plain language summary has been prepared by Ben Gray of Rethink Mental Illness: Benjamin Gray, Service User and Service User Expert, Rethink Mental Illness. Email: [email protected].
