Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial.
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OBJECTIVE: To investigate whether a form of advance agreement for people with severe mental illness can reduce the use of inpatient services and compulsory admission or treatment. DESIGN: Single blind randomised controlled trial, with randomisation of individual patients. The investigator was blind to allocation. SETTING: Eight community mental health teams in southern England. PARTICIPANTS: 160 people with an operational diagnosis of psychotic illness or non-psychotic bipolar disorder who had experienced a hospital admission within the previous two years. INTERVENTION: The joint crisis plan was formulated by the patient, care coordinator, psychiatrist, and project worker and contained contact information, details of mental and physical illnesses, treatments, indicators for relapse, and advance statements of preferences for care in the event of future relapse. MAIN OUTCOME MEASURES: Admission to hospital, bed days, and use of the Mental Health Act over 15 month follow up. RESULTS: Use of the Mental Health Act was significantly reduced for the intervention group, 13% (10/80) of whom experienced compulsory admission or treatment compared with 27% (21/80) of the control group (risk ratio 0.48, 95% confidence interval 0.24 to 0.95, P = 0.028). As a consequence, the mean number of days of detention (days spent as an inpatient while under a section of the Mental Health Act) for the whole intervention group was 14 compared with 31 for the control group (difference 16, 0 to 36, P = 0.04). For those admitted under a section of the Mental Health Act, the number of days of detention was similar in the two groups (means 114 and 117, difference 3, -61 to 67, P = 0.98). The intervention group had fewer admissions (risk ratio 0.69, 0.45 to 1.04, P = 0.07). There was no evidence for differences in bed days (total number of days spent as an inpatient) (means 32 and 36, difference 4, -18 to 26, P = 0.15 for the whole sample; means 107 and 83, difference -24, -72 to 24, P = 0.39 for those admitted). CONCLUSIONS: Use of joint crisis plans reduced compulsory admissions and treatment in patients with severe mental illness. The reduction in overall admission was less. This is the first structured clinical intervention that seems to reduce compulsory admission and treatment in mental health services. (+info)
A prospective cohort study of the effectiveness of employer-sponsored crisis interventions after a major disaster.
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Postdisaster crisis interventions have been viewed by many as the appropriate and immediate approach to enhance psychological well-being among persons affected by large-scale traumatic events. Yet, studies and systematic reviews have challenged the effectiveness of these efforts. This article provides the first rigorous scientific evidence to suggest that postdisaster crisis interventions in the workplace significantly reduced mental health disorders and symptoms up to 2 years after the initial interventions. Until now, studies have neither focused on the effectiveness and safety of brief mental health services following disasters, or traumatic events generally, nor examined the long-term impact of these interventions across a spectrum of outcomes using a rigorous research design. The focus of this study was to examine the impact of brief mental health crisis interventions received at the worksite following the World Trade Center disaster (WTCD) among a random sample of New York adults. The data for the present study come from a prospective cohort study of 1,681 adults interviewed by telephone at 1 year and 2 years after this event. Results indicate that worksite crisis interventions offered by employers following the WTCD had a beneficial impact across a spectrum of outcomes, including reduced risks for binge drinking, alcohol dependence, PTSD symptoms, major depression, somatization, anxiety, and global impairment, compared with individuals who did not receive these interventions. In addition, it appeared that 2-3 brief sessions achieved the maximum benefit for most outcomes examined. Implications for postdisaster crisis interventions efforts are discussed. (+info)
Crisis management during anaesthesia: recovering from a crisis.
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Preventing harm to the patient is the priority during a crisis. After a major incident, and especially when a patient has been harmed, there are a number of matters to be addressed: the ongoing care of the patient; documentation of the incident; investigation of the root causes; completion of reports; interviews with the patient and/or the next of kin, together with apologies and expression of regret; updates and ongoing support for friends and relatives; a word of thanks to the staff involved for their assistance; formal debriefing of staff for quality assurance and possibly ongoing support and a separate debriefing for psychological purposes; ensuring that the recommendations of the root cause analysis are carried out; or, failing that, that the issues are logged on a risk register. The extent and depth of the follow up protocol depends on what, if any, harm may have been done. This may constitute completion of an incident report; notification of an equipment failure to a federal regulatory authority; arranging consultations with a mental health professional to manage psychological sequelae (especially following an awareness episode); follow up during weeks of intensive care treatment; or, when a death has occurred, a full medico-legal and/or coronial set of procedures. A precis is appended in an action card format. (+info)
Outcomes of crises before and after introduction of a crisis resolution team.
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BACKGROUND: Crisis resolution teams (CRTs) are being introduced throughout England, but their evidence base is limited. AIMS: To compare outcomes of crises before and after introduction of a CRT. METHOD: A new methodology was developed for identification and operational definition of crises. A quasi-experimental design was used to compare cohorts presenting just before and just after a CRT was established. RESULTS: Following introduction of the CRT, the admission rate in the 6 weeks after a crisis fell from 71% to 49% (OR 0.38, 95% CI 0.21-0.70). A difference of 5.6 points (95% CI 2.0-8.3) on mean Client Satisfaction Questionnaire (CSQ-8) score favoured the CRT. These findings remained significant after adjustment for baseline differences. No clear difference emerged in involuntary hospitalisations, symptoms, social functioning or quality of life. CONCLUSIONS: CRTs may prevent some admissions and patients prefer them, although other outcomes appear unchanged in the short term. (+info)
Crisis card following self-harm: 12-month follow-up of a randomised controlled trial.
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No intervention has been shown to be effective in preventing repetition of self-harm. In the 6-month follow-up of a large randomised controlled trial, we previously reported no effectiveness of the provision of a card offering 24-h crisis telephone consultation on repetition of self-harm. However, there was a possible benefit among those presenting following a first episode (OR=0.64, 95% CI 0.34-1.22). Here we report the 12-month follow-up of the trial. The results confirm no overall benefit of the intervention (OR=1.19, 95% CI 0.85-1.67). Among those with a first episode of self-harm, the possible benefit of the intervention had diminished (OR=0.89, 95% CI 0.52-1.52), although a modest effect cannot be excluded. (+info)
Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study.
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OBJECTIVE: To evaluate the effectiveness of a crisis resolution team. DESIGN: Randomised controlled trial. PARTICIPANTS: 260 residents of the inner London Borough of Islington who were experiencing crises severe enough for hospital admission to be considered. INTERVENTIONS: Acute care including a 24 hour crisis resolution team (experimental group), compared with standard care from inpatient services and community mental health teams (control group). MAIN OUTCOME MEASURES: Hospital admission and patients' satisfaction. RESULTS: Patients in the experimental group were less likely to be admitted to hospital in the eight weeks after the crisis (odds ratio 0.19, 95% confidence interval 0.11 to 0.32), though compulsory admission was not significantly reduced. A difference of 1.6 points in the mean score on the client satisfaction questionnaire (CSQ-8) was not quite significant (P = 0.07), although it became so after adjustment for baseline characteristics (P = 0.002). CONCLUSION: Crisis resolution teams can reduce hospital admissions in mental health crises. They may also increase satisfaction in patients, but this was an equivocal finding. (+info)
Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol.
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BACKGROUND: People who are homeless and chronically alcoholic have increased health problems, use of emergency services and police contact, with a low likelihood of rehabilitation. Harm reduction is a policy to decrease the adverse consequences of substance use without requiring abstinence. The shelter-based Managed Alcohol Project (MAP) was created to deliver health care to homeless adults with alcoholism and to minimize harm; its effect upon consumption of alcohol and use of crisis services is described as proof of principle. METHODS: Subjects enrolled in MAP were dispensed alcohol on an hourly basis. Hospital charts were reviewed for all emergency department (ED) visits and admissions during the 3 years before and up to 2 years after program enrollment, and the police database was accessed for all encounters during the same periods. The results of blood tests were analyzed for trends. A questionnaire was administered to MAP participants and staff about alcohol use, health and activities of daily living before and during the program. Direct program costs were also recorded. RESULTS: Seventeen adults with an average age of 51 years and a mean duration of alcoholism of 35 years were enrolled in MAP for an average of 16 months. Their monthly mean group total of ED visits decreased from 13.5 to 8 (p = 0.004); police encounters, from 18.1 to 8.8 (p = 0.018). Changes in blood test findings were nonsignificant. All program participants reported less alcohol consumption during MAP, and subjects and staff alike reported improved hygiene, compliance with medical care and health. INTERPRETATION: A managed alcohol program for homeless people with chronic alcoholism can stabilize alcohol intake and significantly decrease ED visits and police encounters. (+info)
A propensity score analysis of brief worksite crisis interventions after the World Trade Center disaster: implications for intervention and research.
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BACKGROUND: Postdisaster crisis interventions have been viewed by some as appropriate to enhance the mental health status of persons affected by large-scale traumatic events. However, studies and systematic reviews have challenged the effectiveness of these efforts. OBJECTIVES: The focus of this study was to examine the impact of brief mental health interventions received by employees at the worksite after the World Trade Center disaster (WTCD) among workers in New York City (NYC). RESEARCH DESIGN: The data for the present study come from a prospective cohort study of 1121 employed adults interviewed by telephone in a household survey 1 year and 2 years after the WTCD. All study participants were living in NYC at the time of the attacks. For the current study, we used propensity scores to match intervention cases (n = 150) to nonintervention controls (n = 971) using a 1:5 matching ratio based on a bias-corrected nearest-neighbor algorithm. RESULTS: Approximately 7% of NYC adults (approximately 425,000 persons) reported receiving employer-sponsored, worksite crisis interventions related to the WTCD provided by mental health professionals. In addition, analyses indicated that attending 1 to 3 brief worksite sessions was associated with positive outcomes up to 2 years after the WTCD across a spectrum of results, including reduced alcohol dependence, binge drinking, depression, PTSD severity, and reduced anxiety symptoms. CONCLUSIONS: Although our study had limitations, it is one of the few to suggest that brief postdisaster crisis interventions may be effective for employees after mass exposure to psychologically traumatic events. The reasons for the effectiveness of these interventions are unclear at this time and warrant further investigation. (+info)