Joint Crisis Plans reduce coercive treatment

Background

To investigate whether a form of advance agreement for people with severe mental illness can reduce the use of inpatient services and compulsory admission.

Methods

Design: Single blind randomized controlled trial. Setting: Eight community mental health teams in southern England. Participants: 160 people with psychotic or bipolar disorder who had had 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.

Results

Over 15 month follow up, 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). 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). Fewer episodes of violence (3/74 episodes versus 11/76, p = 0.046) and self harm (1/74 episodes versus 7/76, p = 0.063) occurred in the active intervention group.

Conclusion

This is the first structured clinical intervention that seems to reduce compulsory admission and treatment in mental health services [1, 2]. The reduction in overall admission was less. Joint crisis plans may also reduce violence to others and self-harm associated with relapse of mental illness but the mechanism requires further investigation.