Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care

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1 Improving outcomes for peope in menta heath crisis: a rapid synthesis of the evidence for avaiabe modes of care Fiona Paton, 1 Kath Wright, 1 Nige Ayre, 2 Ceri Dare, 3 Sonia Johnson, 4 Brynmor Loyd-Evans, 4 Aan Simpson, 5 Martin Webber 6 and Nick Meader 1 * 1 Centre for Reviews and Dissemination, University of York, York, UK 2 York Mind, York, UK 3 Department of Heath Sciences, University of York, York, UK 4 Division of Psychiatry, University Coege London, London, UK 5 Schoo of Heath Sciences, City University London, London, UK 6 Department of Socia Poicy and Socia Work, University of York, York, UK *Corresponding author Decared competing interests of authors: none Pubished January 2016 DOI: /hta20030 Scientific summary Improving outcomes for peope in menta heath crisis Heath Technoogy Assessment 2016; Vo. 20: No. 3 DOI: /hta20030 NIHR Journas Library

2 SCIENTIFIC SUMMARY: IMPROVING OUTCOMES FOR PEOPLE IN MENTAL HEALTH CRISIS Scientific summary Background Chaenges of menta heath crisis services It is widey acknowedged that the quaity and accessibiity of care for peope in crisis is highy variabe. Athough many peope in a menta heath crisis experience high-quaity care and support when they need it, there are aso a number of occasions when peope find that services do not respond we to their needs. It is aso often recognised that emergency services reated to menta heath can sometimes compare unfavouraby with those reated to emergency physica heath services. Therefore, it is a priority to improve crisis services for peope with menta heath probems in order to meet the objectives of parity of esteem set out in the NHS Mandate. The NHS mandate for 2014/15 identified severa objectives for menta heath crisis services incuding accessibiity and quaity of emergency menta heath care, improving iaison psychiatric services, and for every community to pan to have sufficient resources avaiabe for crisis care. In addition, NHS panning guidance 2015/16 isted the foowing criteria as essentia for the appropriate support of peope experiencing a menta heath crisis: menta heath support as integra to NHS 111 services; 24/7 crisis care home treatment teams; and enough capacity to prevent chidren, young peope or vunerabe aduts receiving menta heath assessment in poice ces. In response to these issues the Menta Heath Crisis Care Concordat, Improving Outcomes for Peope Experiencing Menta Heath Crisis, was deveoped, which highighted the need for a review of urgent and emergency care, with a focus on modes of care for peope in menta heath crisis. It has ong been recognised that improvements are needed in how heath services, socia services and poice forces work together. Where probems exist, they often happen where these services intersect, concern how the different professiona groups interact with one another and transfer from one service to another. The Menta Heath Crisis Care Concordat aso highighted the disproportionate rate at which some communities reach crisis point or access menta heath services through invovement with the crimina justice system. Back service users were detained at higher rates under the Menta Heath Act 1983 and a higher proportion were admitted to hospita. Athough recent research suggests, when anayses are adjusted for confounding, ethnicity is no onger a predictor of detention under the Menta Heath Act. An independent inquiry into crisis care, carried out by Mind in 2010/11 as part of a Crisis Care Campaign, suggested that peope from some back and ethnic minority (BME) groups seemed to be treated more negectfuy or coercivey in the crisis care system than other peope. The inquiry aso highighted certain barriers that may be faced by different ethnic groups in reation to accessing crisis care: There is variabe access to crisis resoution and home treatment teams (CRHTTs), with owest referra rates identified for Indian, Bangadeshi and Chinese peope. Once assessed by a CRHTT, BME groups are generay more ikey to be admitted to hospita, particuary back Caribbean peope. ii NIHR Journas Library

3 HEALTH TECHNOLOGY ASSESSMENT 2016 VOL. 20 NO. 3 (SCIENTIFIC SUMMARY) Crisis care pathway The Crisis Concordat proposed four key stages of the menta heath crisis care pathway: 1. Access to support before crisis point: the provision of readiy accessibe support 24 hours a day and 7 days a week. This is for peope who are cose to crisis and need quick access to support that may hep prevent escaation of their probems. 2. Urgent and emergency access to crisis care: when peope need emergency hep reated to their menta heath needs when in crisis. The emphasis is on treatment being accessed urgenty and with respect in a simiar manner to a physica heath emergency. 3. Quaity of treatment and care when in crisis: the provision of support and treatment for peope in menta heath crisis. Effective treatment is provided by competent practitioners, who focus on the service user s recovery, and is provided in a setting that best suits their needs. 4. Promoting recovery/preventing future crises: the provision of services that wi support the process of recovery for peope with menta heath probems and hep them stay we. Objectives The aim of the Crisis Concordat is to improve the quaity and accessibiity of services for the four key stages of the menta heath crisis pathway. Therefore, our review aims to conduct a rapid evidence synthesis evauating the cinica effectiveness and cost-effectiveness of modes of care at each of the four stages identified by the Crisis Concordat. We hope this wi hep inform the provision of effective menta heath crisis services in Engand and highight key uncertainties regarding effectiveness of modes of care where future research is a priority. Methods Eectronic databases were searched for guideines, reviews and, where necessary, primary studies. The searches were performed on 25 and 26 June 2014 for NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, NHS Economic Evauation Database, and the Heath Technoogy Assessment (HTA) and PROSPERO databases, and on 11 November 2014 for MEDLINE, PsycINFO and the Crimina Justice Abstracts database. Reevant reports and reference ists of retrieved artices were scanned to identify additiona studies. Reevant evidence was incuded in the synthesis according to the foowing hierarchy [with preference given in ascending order (1 4)]: 1. Guideines: guideines produced or accredited by the Nationa Institute for Heath and Care Exceence (NICE). This incuded UK guideines produced by NICE or by UK bodies accredited by NICE such as the Roya Coege of Physicians. It aso incuded guideines produced in Engish by non-uk guidance producers who had received NICE accreditation. 2. Systematic reviews of reviews. 3. Systematic reviews of primary studies and economic evauations. 4. Good-quaity primary studies: when no reevant guideines, reviews of reviews, or systematic reviews of primary studies were avaiabe, we incuded primary studies (both randomised and non-randomised controed trias). Queen s Printer and Controer of HMSO This work was produced by Paton et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. iii

4 SCIENTIFIC SUMMARY: IMPROVING OUTCOMES FOR PEOPLE IN MENTAL HEALTH CRISIS Resuts Access to support before crisis point Studies across a range of disorders suggest teephone support and triage appear to resut in quick access, acceptabe referra decisions and minima harm. However, at present there are very few data in reation to the use of teephone support and triage for providing support to peope before the point of menta heath crisis. In addition, studies that have assessed the benefits of training and supporting primary care and community-based staff have not identified any modes that ceary benefit service user outcomes. Recommendations by NICE on access to support before crisis point are derived mainy from expert consensus and overap argey with recommendations from the Crisis Concordat and the London Strategic Network commissioning guide. These incude the importance of receiving care with a minimum of deay, the importance of quick referra (either through sef-referra or buiding inks between menta heath services, primary care and third-sector organisations) and equaity of access. Urgent and emergency access to crisis care There is imited quantitative evidence on the cinica effectiveness of interventions to improve urgent and emergency access to crisis care. Most studies were on iaison psychiatry modes that were associated with reduced readmission rates, reduced waiting times (in most studies) and improved service user satisfaction. However, there was a ack of high-quaity we-controed trias and, for most studies, it was not possibe to rue out the potentia for confounding. There was ess evidence on the benefits of providing menta heath training to emergency department staff. The evidence was even more imited regarding the provision of support from menta heath professionas to poice officers, either through training programmes, street triage or teephone triage. Street triage and training of poice officers both appeared to reduce poice time at the scene of menta heath-reated incidents. Street triage may aso potentiay improve service user engagement with outpatient treatment services. Poice officers with menta heath training were more ikey to transport peope to a heath-care setting and ess ikey to arrest peope with potentia menta heath probems. However, there was no evidence that either street triage or menta heath training reduced eve of force used by poice officers in menta heath-reated cas. Quaity treatment and care in crisis Crisis resoution and home treatment teams were found to be both cinicay effective and cost-effective with benefits incuding substantia reductions in the probabiity of hospita admission and greater service user satisfaction compared with inpatient treatment. However, the quaity of evidence was rated ow because of the sma number of studies, a high risk of bias in incuded studies and high heterogeneity. Reviews of factors affecting cinica effectiveness and cost-effectiveness of CRHTTs found a great dea of variabiity when impementing these interventions. Athough there were exampes of good practice in the UK regarding various eements of CRHTT care it appears that few teams were exhibiting good practice across a comprehensive range of criteria. Crisis houses and acute day hospitas were not found to be more cinicay effective than inpatient treatment. However, it shoud be noted that there is no evidence that crisis houses and acute day hospitas are associated with greater readmissions and are recommended by NICE as viabe aternatives to inpatient treatment. In addition, there is evidence that crisis houses are associated with greater service user satisfaction in both quantitative and quaitative studies. iv NIHR Journas Library

5 HEALTH TECHNOLOGY ASSESSMENT 2016 VOL. 20 NO. 3 (SCIENTIFIC SUMMARY) In terms of confict and containment in inpatient menta heath services, the evidence was argey based on descriptive studies with few controed trias. The Safewards mode has been suggested as a foundation for future research on inpatient treatment. They propose six factors that infuence confict and containment: (1) staff team; (2) physica environment; (3) outside hospita; (4) patient community; (5) patient characteristics; and (6) reguatory framework. A recent custer randomised tria has been competed based on the Safewards mode and found reductions in confict and containment versus contros. Promoting recovery/preventing future crises Promoting recovery and staying we covers a arge and diverse iterature. We have sought to review this iterature primariy by drawing on systematic reviews of interventions recommended by NICE menta heath guideines. For a other stages of the care pathway we ony incuded service modes. However, we aso incuded individua-eve interventions on promoting recovery to refect the emphasis of these interventions in the Crisis Care Concordat and aso feedback provided by service user members of the advisory group. There are a arge number of effective interventions for promoting recovery and preventing reapse recommended by NICE. These incude service modes [e.g. eary intervention services (EISs)], pharmacoogica interventions (e.g. antidepressants for peope with depression and antipsychotics for peope with psychosis), individua-eve interventions to prevent reapse of menta heath conditions [e.g. cognitive behavioura therapy (CBT) for peope with psychosis, famiy intervention for peope with psychosis, diaectica behaviour therapy (DBT) for peope with borderine personaity disorder (BPD)] and strengths-based interventions to promote recovery (e.g. sef-management and supported empoyment). Limitations A common imitation across a four major eements of the care pathway was a genera ack of rigorous randomised and custer randomised trias evauating modes of menta heath crisis care. Further high-quaity trias conducted in the UK woud have a considerabe impact on reducing uncertainty regarding what are the most effective modes of care for peope experiencing menta heath crisis. Concusions Impications for practice Access to support before crisis point Services shoud ensure that peope at risk of menta heath crisis receive care with minimum deay, receive quick referra (either through sef-referra or buiding inks between services) and that there is equaity of access to such care. Urgent and emergency access to crisis care Athough there is evidence of benefits for iaison psychiatry teams in improving waiting times and reducing readmission this is argey based on uncontroed studies and a ack of data from the UK. Queen s Printer and Controer of HMSO This work was produced by Paton et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. v

6 SCIENTIFIC SUMMARY: IMPROVING OUTCOMES FOR PEOPLE IN MENTAL HEALTH CRISIS Quaity treatment and care in crisis Crisis resoution teams (CRTs) are more effective than inpatient care for a range of outcomes, athough impementation of this mode of care varies across the UK with few teams meeting a evidence-based criteria for good practice. Crisis houses and acute day hospitas appear as cinicay effective as inpatient treatment but are associated with greater service user satisfaction. Promoting recovery Effective service modes incude EISs for peope with psychosis and other serious menta inesses, and coaborative care for depression (particuary for peope with chronic physica heath probems). Effective pharmacoogica interventions incude antidepressants for peope with depression, ithium for peope with bipoar disorder and antipsychotics for peope with psychosis. Effective individua-eve strengths-based interventions incude sef-management and supported empoyment. There is aso some evidence for benefit for peer support (but this needs further high-quaity research to vaidate these findings). Individua-eve interventions with evidence of benefit incude for peope: with psychosis CBT, famiy interventions with bipoar disorder psychoogica interventions who sef-harm psychoogica interventions with BPD DBT and mentaisation-based therapy with depression CBT (particuary mindfuness-based cognitive therapy). Crisis panning is currenty recommended by NICE, athough more recent research has raised questions regarding the cinica effectiveness of this intervention; therefore, further research is needed on whether or not this is an effective approach to promoting recovery. Recommendations for research Access to support before crisis point Most current recommendations and service deveopments are based on expert opinion with imited research in this area. Rigorous evauation of current service deveopments are needed to ensure evidence-based and effective support for service users. Urgent and emergency access to crisis care Potentia benefits of iaison psychiatry teams are based on imited evidence; therefore, confirmation of the cinica effectiveness of these modes of care in high-quaity trias (e.g. custer randomised trias) is needed. Data on cinica effectiveness and cost-effectiveness of menta heath training of poice officers, street triage and teephone triage to assist poice officers with potentiay menta heath-reated incidents is very imited and requires rigorous high-quaity evauation. Quaity treatment and care in crisis Current work from the Crisis resoution team Optimisation and REapse prevention study aims to improve impementation of good practice in CRTs and is an important component of improving the quaity of treatment for peope in crisis. Further work is needed to examine the cinica effectiveness and cost-effectiveness of various aspects of inpatient care on service user outcomes. vi NIHR Journas Library

7 HEALTH TECHNOLOGY ASSESSMENT 2016 VOL. 20 NO. 3 (SCIENTIFIC SUMMARY) Promoting recovery Many of the key service modes to provide ong-term management and treatment of menta heath probems ack a cear evidence base (e.g. Community Menta Heath Teams, intensive case management); therefore, further deveopments are needed. There is a key need to deveop modes of care that reduce sef-harm, suicide and reapse after discharge from crisis services and inpatient treatment. Large-scae studies are currenty under way to investigate the effectiveness of peer support, which is a key area of uncertainty. Interventions on improving socia networks and socia capita are aso important deveopments currenty being evauated in the UK. Interventions to promote equaity of access to menta heath services for BME popuations are needed. Study registration This study is registered as PROSPERO CRD Funding The Nationa Institute for Heath Research HTA programme. Queen s Printer and Controer of HMSO This work was produced by Paton et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. vii

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