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
Our objectives are to review the effects of a crisis intervention model for anyone with serious mental illness experiencing an acute episode, compared with 'standard care'.
Search methods
We updated the 1998 and 2003 searches with a search of the Cochrane Schizophrenia Group's Register of trials (January 2006).
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
Working independently, we selected and critically appraised studies, extracted data and analysed on an intention‐to‐treat basis. Where possible and appropriate we calculated relative risk ratios (RR) and their 95% confidence intervals (CI), with the number needed to treat (NNT). We calculated Weighted Mean Differences (WMD) for continuous data.
Main results
Several home‐care studies have been carried out recently but none of these met the inclusion criteria for this review. For the 2006 update we excluded four more studies (total excluded 25). Two other recent studies await assessment; we found no new studies to add to the five studies already included in this review. None of these included studies purely investigated crisis intervention; all used a form of home care for acutely ill people, which included elements of crisis intervention. Forty five percent 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 RCTs, 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 RCTs, 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 RCT, 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 numerical data were either skewed or unusable. No data on staff satisfaction, carer input, compliance with medication or 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 still needed.
PICOs
Plain language summary
Crisis intervention for people with severe mental illnesses
Over the past three decades mental health care of people in crisis has moved from predominantly hospital‐based to being largely community based. We sought evidence for the effectiveness of a specific home‐care package for people in crisis; crisis intervention. It was difficult to find trials specifically randomising crisis intervention with hospital care as 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 be admitted to hospital. The crisis/home care package, however, may help avoid repeat admissions (although data are not strong and are overly influenced by one very positive study).
Crisis/home care does reduce the number of people leaving the study early and the burden on the family. It also seems to be a more satisfactory form of care for both people with severe mental illnesses and their families and may be less expensive than standard care. Several reports specifically mentioned that the burden on the teams was considerable and that the crisis/home care does not clearly affect a person's mental state. Management of a crisis at home is now widely incorporated into other care packages. More data from existing studies may help clarify if this is a prudent use of resources.
