Crisis intervention for people with severe mental illnesses

Abstract

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. 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'. We updated the 1998 and 2003 searches with a search of the Cochrane Schizophrenia Group's Register of trials (January 2006). We included all randomised controlled trials of crisis intervention models versus standard care for people with severe mental illnesses. 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. 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. 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.