Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial
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《英国医生杂志》
1 Health Services Research Department, Institute of Psychiatry, King's College London, London SE5 8AF, 2 South London and Maudsley NHS Trust, Croydon CR0 1XT, 3 Institute of Psychiatry, King's College London, London
Correspondence to: C Henderson hendersc@nypdrat.cpmc.columbia.edu
Abstract
For patients receiving psychiatric treatment a joint crisis plan aims to empower the holder and to facilitate detection and treatment of relapse.1 It is developed by a patient together with mental health staff. Held by the patient, it contains his or her choice of information, which can include an advance agreement for treatment preferences for any future emergency, when he or she might be too unwell to express coherent views.
The format was developed after consultation with national user groups, interviews with organisations and individuals using crisis cards,2 and detailed development work with service users in south London. The results of the pilot study1 showed that (at 6-12 month follow up) 57% of participating patients felt more involved in their care, 60% felt more positive about their situation, 51% felt more in control of their mental health problem, and 41% were more likely to continue treatment.1 The plan may have direct and indirect effects: family doctors and carers may be able to react earlier to a relapse, while emergency department staff may make better decisions. Negotiating the content may clarify treatment issues and build consensus between patients and staff, potentially reducing future compulsory treatment and care.
Use of the Mental Health Act has increased in English mental health services. Data returned to the Department of Health3 show a 57% increase in civil cases of compulsory detention under the Mental Health Act 1983 between 1988 and 1998.3 Legal detention can have serious negative consequences for patients, including restricted access to travel visas and financial services. Current policy in England is towards greater involvement of patients as partners in care.4 5 In the review of the Mental Health Act 1983, the Legislation Scoping Study Committee referred to the desirability of reducing compulsory treatment through the use of advance agreements; in the context of new mental health legislation to be introduced "the creation and recognition of advance agreements about care would greatly assist in the promotion of informal and consensual care."6
We evaluated the effectiveness of joint crisis plans at reducing use of inpatient services and objective coercion at and during admission.
Methods
Participants
We assessed 466 sets of case notes for eligibility using OPCRIT 5 (figure).7 There were no significant differences for age, sex, or length of service contact between eligible patients who were or were not recruited. Information on hospital admission was available for all participants. Bed days were available for all except one known admission. Information on use of the Mental Health Act was available for 77/80 of each group (total 154/160 = 96%) (figure). Of the 31 participants known to have been compulsorily admitted or treated, we knew the duration for each patient. One participant in the intervention group died from a longstanding cardiac condition. Table 1 shows other adverse events during follow up. Table 2 shows that the sociodemographic and clinical features of the two groups were similar.
Trial profile: participant flow and follow up
Table 1 Adverse events in psychiatric patients randomised to receive joint crisis plan (intervention) or standard treatment (control). Figures are numbers (percentages) of patients
Table 2 Baseline demographic and clinical characteristics of participant groups. Figures are numbers (percentages) unless stated otherwise
Hospital admissions
Table 3 shows that a smaller proportion of the intervention group were admitted (30% 44%, risk ratio 0.69, 95% confidence interval 0.45 to 1.04, 2 = 3.25, P = 0.07). There was no significant difference in mean bed days (difference 4, -18 to 26, P = 0.15, for the whole sample; difference -24, -72 to 24, P = 0.39, for those admitted). Overall about a quarter of patients were admitted for more than one month (23% in the intervention group and 29% in the control group).
Table 3 Hospital admission and use of the Mental Health Act 1983
Use of the Mental Health Act
Compulsory admission and treatment were significantly less common in the intervention group (13% 27%, risk ratio 0.48, 0.24 to 0.95, 2 = 4.84, P = 0.03, table 3). Sensitivity analyses did not alter this conclusion. The mean number of days of detention for the intervention group was 14 compared with 31 for the control group (difference 17, 0 to 36, P = 0.04). For those admitted on a section, the mean number of days on a section was similar in the two groups (difference 3, -61 to 67, P = 0.98).
The pattern of types of section was similar in both groups (table 4), but those in the intervention group were less likely to be put on a section (table 4) and more often had their sections terminated early (table 5).
Table 4 Sections of Mental Health Act used for intervention and control groups
Table 5 Outcomes of sections 2 and 3 of the Mental Health Act
Discussion
Sutherby K, Szmukler GI, Halpern A, Alexander M, Thornicroft G, Johnson C, et al. A study of "crisis cards" in a community psychiatric service. Acta Psychiatr Scand 1999;100: 56-61.
Sutherby K, Szmukler GI. Crisis cards and self-help crisis initiatives. Psychiatric Bulletin 1998;22: 4-7.
Department of Health. Inpatients formally detained in hospitals under the Mental Health Act 1983 and other legislation, England: 1988-89 to 1998-99. London: Government Statistical Service, 1999.
Department of Health. The national service framework for mental health. Modern standards and service models. London: Department of Health, 1999.
Department of Health. The NHS plan. London: Department of Health, 2000.
Department of Health. Report of the expert committee. Review of the Mental Health Act 1983. London: Stationery Office, 1999.
McGuffin P, Farmer A, Harvery I. A polydiagnostic application of operational criteria in studies of psychotic illness. Development and reliability of the OPCRIT System. Arch Gen Psychiatry 1991;48: 764-70.
Department of Health. Effective care co-ordination in mental health services. Modernising the care programme approach. A policy booklet. London: Department of Health, 2000.
Kemp RA, Lambert TJ. Insight in schizophrenia and its relationship to psychopathology. Schizophr Res 1995;18: 21-8.
Papageorgiou A, King M, Janmohamed A, Davidson O, Dawson J. Advance directives for patients compulsorily admitted to hospital with serious mental illness: randomised controlled trial. Br J Psychiatry 2002;181: 513-9.
Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, et al. Framework for design and evaluation of complex interventions to improve health. BMJ 2000;321: 694-7.
Medical Research Council. A framework for development and evaluation of RCTs for complex interventions to improve health. London: Medical Research Council, Health Services and Public Health Research Board, 2000.
Pawson R, Tilley N. Realistic evaluation. London: Sage Publications, 1997.
Thomas P. How should advance statements be implemented? (letter). Br J Psychiatry 2003;182: 548-9.
Bracken P, Thomas P. Postpsychiatry: a new direction for mental health. BMJ 2001;322: 724-7.(Claire Henderson, MRC spe)
Correspondence to: C Henderson hendersc@nypdrat.cpmc.columbia.edu
Abstract
For patients receiving psychiatric treatment a joint crisis plan aims to empower the holder and to facilitate detection and treatment of relapse.1 It is developed by a patient together with mental health staff. Held by the patient, it contains his or her choice of information, which can include an advance agreement for treatment preferences for any future emergency, when he or she might be too unwell to express coherent views.
The format was developed after consultation with national user groups, interviews with organisations and individuals using crisis cards,2 and detailed development work with service users in south London. The results of the pilot study1 showed that (at 6-12 month follow up) 57% of participating patients felt more involved in their care, 60% felt more positive about their situation, 51% felt more in control of their mental health problem, and 41% were more likely to continue treatment.1 The plan may have direct and indirect effects: family doctors and carers may be able to react earlier to a relapse, while emergency department staff may make better decisions. Negotiating the content may clarify treatment issues and build consensus between patients and staff, potentially reducing future compulsory treatment and care.
Use of the Mental Health Act has increased in English mental health services. Data returned to the Department of Health3 show a 57% increase in civil cases of compulsory detention under the Mental Health Act 1983 between 1988 and 1998.3 Legal detention can have serious negative consequences for patients, including restricted access to travel visas and financial services. Current policy in England is towards greater involvement of patients as partners in care.4 5 In the review of the Mental Health Act 1983, the Legislation Scoping Study Committee referred to the desirability of reducing compulsory treatment through the use of advance agreements; in the context of new mental health legislation to be introduced "the creation and recognition of advance agreements about care would greatly assist in the promotion of informal and consensual care."6
We evaluated the effectiveness of joint crisis plans at reducing use of inpatient services and objective coercion at and during admission.
Methods
Participants
We assessed 466 sets of case notes for eligibility using OPCRIT 5 (figure).7 There were no significant differences for age, sex, or length of service contact between eligible patients who were or were not recruited. Information on hospital admission was available for all participants. Bed days were available for all except one known admission. Information on use of the Mental Health Act was available for 77/80 of each group (total 154/160 = 96%) (figure). Of the 31 participants known to have been compulsorily admitted or treated, we knew the duration for each patient. One participant in the intervention group died from a longstanding cardiac condition. Table 1 shows other adverse events during follow up. Table 2 shows that the sociodemographic and clinical features of the two groups were similar.
Trial profile: participant flow and follow up
Table 1 Adverse events in psychiatric patients randomised to receive joint crisis plan (intervention) or standard treatment (control). Figures are numbers (percentages) of patients
Table 2 Baseline demographic and clinical characteristics of participant groups. Figures are numbers (percentages) unless stated otherwise
Hospital admissions
Table 3 shows that a smaller proportion of the intervention group were admitted (30% 44%, risk ratio 0.69, 95% confidence interval 0.45 to 1.04, 2 = 3.25, P = 0.07). There was no significant difference in mean bed days (difference 4, -18 to 26, P = 0.15, for the whole sample; difference -24, -72 to 24, P = 0.39, for those admitted). Overall about a quarter of patients were admitted for more than one month (23% in the intervention group and 29% in the control group).
Table 3 Hospital admission and use of the Mental Health Act 1983
Use of the Mental Health Act
Compulsory admission and treatment were significantly less common in the intervention group (13% 27%, risk ratio 0.48, 0.24 to 0.95, 2 = 4.84, P = 0.03, table 3). Sensitivity analyses did not alter this conclusion. The mean number of days of detention for the intervention group was 14 compared with 31 for the control group (difference 17, 0 to 36, P = 0.04). For those admitted on a section, the mean number of days on a section was similar in the two groups (difference 3, -61 to 67, P = 0.98).
The pattern of types of section was similar in both groups (table 4), but those in the intervention group were less likely to be put on a section (table 4) and more often had their sections terminated early (table 5).
Table 4 Sections of Mental Health Act used for intervention and control groups
Table 5 Outcomes of sections 2 and 3 of the Mental Health Act
Discussion
Sutherby K, Szmukler GI, Halpern A, Alexander M, Thornicroft G, Johnson C, et al. A study of "crisis cards" in a community psychiatric service. Acta Psychiatr Scand 1999;100: 56-61.
Sutherby K, Szmukler GI. Crisis cards and self-help crisis initiatives. Psychiatric Bulletin 1998;22: 4-7.
Department of Health. Inpatients formally detained in hospitals under the Mental Health Act 1983 and other legislation, England: 1988-89 to 1998-99. London: Government Statistical Service, 1999.
Department of Health. The national service framework for mental health. Modern standards and service models. London: Department of Health, 1999.
Department of Health. The NHS plan. London: Department of Health, 2000.
Department of Health. Report of the expert committee. Review of the Mental Health Act 1983. London: Stationery Office, 1999.
McGuffin P, Farmer A, Harvery I. A polydiagnostic application of operational criteria in studies of psychotic illness. Development and reliability of the OPCRIT System. Arch Gen Psychiatry 1991;48: 764-70.
Department of Health. Effective care co-ordination in mental health services. Modernising the care programme approach. A policy booklet. London: Department of Health, 2000.
Kemp RA, Lambert TJ. Insight in schizophrenia and its relationship to psychopathology. Schizophr Res 1995;18: 21-8.
Papageorgiou A, King M, Janmohamed A, Davidson O, Dawson J. Advance directives for patients compulsorily admitted to hospital with serious mental illness: randomised controlled trial. Br J Psychiatry 2002;181: 513-9.
Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, et al. Framework for design and evaluation of complex interventions to improve health. BMJ 2000;321: 694-7.
Medical Research Council. A framework for development and evaluation of RCTs for complex interventions to improve health. London: Medical Research Council, Health Services and Public Health Research Board, 2000.
Pawson R, Tilley N. Realistic evaluation. London: Sage Publications, 1997.
Thomas P. How should advance statements be implemented? (letter). Br J Psychiatry 2003;182: 548-9.
Bracken P, Thomas P. Postpsychiatry: a new direction for mental health. BMJ 2001;322: 724-7.(Claire Henderson, MRC spe)