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 a crisis intervention model for anyone with serious mental illness experiencing an acute episode, compared to 'standard care'.
Search methods
Searches of 1998 were updated with a search of the Cochrane Schizophrenia Group's Register of trials (July 2003).
Selection criteria
All randomised controlled trials of crisis intervention models versus standard care for people with severe mental illnesses.
Data collection and analysis
Working independently, reviewers selected and critically appraised studies, extracted data and analysed on an intention‐to‐treat basis. Where possible and appropriate we calculated risk ratios (RR) and their 95% confidence intervals (CI), with the number needed to treat (NNT). For continuous data Weighted Mean Differences (WMD) were calculated.
Main results
This 2003 update includes no new studies. Five studies, none purely investigating crisis intervention, are included and 21 excluded. All included trials used a form of home care for acutely ill people, which included elements of crisis intervention. 45% of the crisis/home care group were unable to avoid hospital admission during their treatment period. Home care, however, may help avoid repeat admissions (n = 465, 3 randomised controlled trials, RR 0.72 CI 0.54 to 0.92, NNT 11 CI 6 to 97), but these data are heterogeneous (I‐squared 86%).
Crisis/home care reduces the number of people leaving the study early (n = 594, 4 randomised controlled trials, RR lost at 12 months 0.74 CI 0.56 to 0.98, NNT 13 CI 7 to 130), reduces family burden (n = 120, 1 randomised controlled trial, RR 0.34 CI 0.20 to 0.59, NNT 3 CI 2 to 4), and is a more satisfactory form of care for both patients and families. We found no differences in death or mental state outcomes. All studies found home care to be more cost effective than hospital care but all data were either skewed or unusable. No data on staff satisfaction, carer input, compliance with medication and number of relapses were available.
Authors' conclusions
Home care crisis treatment, coupled with an ongoing home care package, is 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 needed.
PICOs
Plain language summary
Over the past two decades mental health care of people in crisis has moved from a predominantly hospital‐based care package to one where, if possible, people can be treated in the community. This review sought evidence for the effectiveness of a specific care package for those in crisis ‐ crisis intervention. It was difficult to find trials specifically randomising crisis intervention with hospital care, all crisis interventions were coupled with a broader home‐based package. Overall, nearly half of the people in crisis allocated to home care eventually needed to come into hospital. The crisis/home care package, however, may help avoid repeat admissions (although data are not strong and overly influenced by one very positive study). Crisis/home care does reduce the number of people leaving the study early, family burden and seems to be a more satisfactory form of care for both patients and families. Several reports specifically mentioned the burden on the teams to be considerable. The crisis/home care does not clearly affect a person's mental state.
Management of a crisis at home is now widely incorporated in other packages of care. More data from existing studies may help clarify whether this is a prudent use of resources.
