compulsory community treatment to reduce readmission to...

Compulsory community treatment to reduce readmission tohospital and increase engagement with community care in

people with mental illness: a systematic review andmeta-analysis

Phoebe Barnett, Hannah Matthews, Brynmor Lloyd-Evans, Euan Mackay, Stephen Pilling, Sonia Johnson

•Makes adherence to treatment a legal requirement for people with mental illness living in the community (Churchill, 2007)

Compulsory Community Treatment (CCT)

Is compulsory community treatment effective in reducing readmission to hospital?

Research Question and methods

Contemporaneous control Pre-post control

Observational/ Non-randomized

RCTs

Results

Patients on compulsory community treatment were significantly less likely to be readmitted to hospital compared to their former selves.

Patients on compulsory community treatment were no less likely to be readmitted to hospital than those released voluntarily.

Results

• Missing data on the outcomes that matter• Glaring omissions in the available data• Specific experiences of certain groups: e.g. women, young people, minority ethnic

groups• Would we need coercion if access to services in the community was improved?

The National Institute for Health Research Lived Experience Working GroupPatrick Nyikavaranda and Karen Machin

Conclusions

• Some evidence for a mechanism of improving treatment provision

• Not demonstrated when considering only RCTs

• Are those on CCT offered more services?

• Insufficient consistent and methodologically robust evidence to justify CCT

Ensuring appropriate community care is provided to patients with severe mental illness, regardless of their legal status and whether they are subject to coercion, is a priority for mental health services.

This presentation presents independent research commissioned and funded by the National Institute for Health Research Policy Research Programme. The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research, the Department of Health and Social Care or its arm's length bodies, and other Government Departments

Psychosocial interventions to reduce compulsory psychiatric admissions: a rapid

evidence synthesis

Jessica Bone25th March 2019After the MHA Review

DIVISION OF PSYCHIATRY

Aim


To conduct a rapid evidence synthesis with wide scope to explore whether there is any evidence for an effect on

compulsory admissions for 15 types of psychosocial intervention

Methods


Participants Anyone with a diagnosis of any mental health disorder, regardless of age

Intervention 15 broad psychosocial intervention types

Comparison Any active treatment or treatment as usual (TAU)

Outcome Compulsory admissions, however measured or reported

Study design Randomised Controlled Trials (RCTs)

Intervention Number of RCTsScreened Eligible Descriptive data Analysis

Acute day units 18 0 - -Adherence or compliance therapy 46 3 2 1Advance statements and crisis plans 22 4 0 4Assertive community treatment 146 2 1 1CBTp 85 4 4 0Community rehabilitation services 20 0 - -Community treatment orders 4 0 0 0Crisis houses 32 1 1 0Crisis resolution teams 45 1 0 1EIS 26 3 0 3Family interventions for psychosis 82 0 - -Housing interventions 73 0 - -Open dialogue 0 - - -Self-management interventions 258 1 0 1Vocational interventions 92 0 - -Total 949 19 8 11

Results


Effective interventions:• Self-management interventions (1 RCT)• Advance statements and crisis plans (4 RCTs)

à Relapse prevention planning

à Identification of early warning signs of relapse

à Plan and share personal coping strategies and desired support

Results


Interventions with mixed evidence:• Early intervention services for psychosis (EIS; 3 RCTs)

à Multidisciplinary community teams

à Provide care to people following a first episode of psychosis

à Relatively intense approach focused on psychological and social recovery

Results


Interventions lacking clear evidence:• Adherence therapy (3 RCTs)• Crisis resolution teams (1 RCT)• Assertive community treatment (2 RCTs)• Cognitive behavioural therapy for psychosis (CBTp; 4 RCTs)• Crisis houses (1 RCT)

Summary


• Less than 2% of trials screened reported compulsory admissions (n=19)

• Crisis planning and self-management interventions most promising

• Early intervention in psychosis may also be effective

Implications


• Should implement and improve access to crisis planning and self-management interventions and EIS teams

• Need more research to make further recommendations for practice, with focus on:• Pre-registration of compulsory admissions as an outcome• Separate reporting of compulsory and voluntary admissions • Observational studies using routine data• What works for whom?

Lived experience perspective


• Many factors likely to be important for intervention effectiveness:• Implementation quality• Whether it is suitable for individual’s needs• Where in their mental health trajectory individuals receive it• Individuals’ ethnicity, culture, first language, religion

• Compulsory admissions should be an outcome measure for research

Karen Machin, Dr Sarah Markham & Karen Persaud

Thank you


Co-authors:Tayla McCloud, Hannah Scott, Karen Machin, Dr Sarah Markham, Karen Persaud, Professor Sonia Johnson & Dr Brynmor Lloyd-Evans

This presentation presents independent researchcommissioned and funded by the National Institute forHealth Research Policy Research Programme. The viewsexpressed are those of the authors and not necessarilythose of the NHS, the National Institute for HealthResearch, the Department of Health and Social Care or itsarm's length bodies, and other Government Departments.

References (1/3)


Included studies:

Chien, W. T., Mui, J. H. C., Cheung, E. F. C. & Gray, R. Effects of motivational interviewing-based adherence therapy for schizophrenia spectrum disorders: a randomized controlled trial. Trials 16, 1–14 (2015).

Craig, T. K. J. et al. The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. BMJ 329, 1067–1070 (2004).

Fenton, W. S., Mosher, L. R., Herrell, J. M. & Blyler, C. R. Randomized trial of general hospital and residential alternative care for patients with severe and persistent mental illness. Am. J. Psychiatry 155, 516–522 (1998).

Harrison-Read, P. et al. Heavy users of acute psychiatric beds: randomized controlled trial of enhanced community management in an outer London borough. Psychol. Med. 32, 403–416 (2002).

Henderson, C. et al. Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial. BMJ 329, 136 (2004).

Johnson, S. et al. Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study. BMJ 331, 599–602 (2005).

Jolley, S. et al. Cognitive therapy in early psychosis: a pilot randomized controlled trial. Behav. Cogn. Psychother. 31, 473–478 (2003).

Killaspy, H. et al. The REACT study: randomised evaluation of assertive community treatment in north London. Br. Med. J. 332, 815–818 (2006).

Lay, B., Kawohl, W. & Rössler, W. Outcomes of a psycho-education and monitoring programme to prevent compulsory admission to psychiatric inpatient care: a randomised controlled trial. Psychol. Med. 48, 849–860 (2018).

References (1/2)


Included studies:

Morrison, A. P. et al. Antipsychotic drugs versus cognitive behavioural therapy versus a combination of both in people with psychosis: a randomised controlled pilot and feasibility study. The Lancet Psychiatry 5, 411–423 (2018).

Morrison, A. P. et al. Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial. Lancet 383, 1395–1403 (2014).

Øhlenschlæger, J. et al. Effect of integrated treatment on the use of coercive measures in first-episode schizophrenia-spectrum disorder. A randomized clinical trial. Int. J. Law Psychiatry 31, 72–76 (2008).

Papageorgiou, A., King, M., Janmohamed, A., Davidson, O. & Dawson, J. Advance directives for patients compulsorily admitted to hospital with serious mental illness: randomised controlled trial. Br. J. Psychiatry 181, 513–519 (2002).

Priebe, S. et al. Effectiveness of financial incentives to improve adherence to maintenance treatment with antipsychotics: cluster randomised controlled trial. BMJ 347, f5847 (2013).

Ruchlewska, A. et al. Effect of crisis plans on admissions and emergency visits: a randomized controlled trial. PLoS One 9, 1–7 (2014).

Sigrúnarson, V., Gråwe, R. W. & Morken, G. Integrated treatment vs. treatment-as-usual for recent onset schizophrenia; 12 year follow-up on a randomized controlled trial. BMC Psychiatry 13, 200 (2013).

Staring, A. B. P. et al. Treatment adherence therapy in people with psychotic disorders: randomised controlled trial. Br. J. Psychiatry 197, 448–455 (2010).

References (3/3)


Included studies:

Thornicroft, G. et al. Clinical outcomes of Joint Crisis Plans to reduce compulsory treatment for people with psychosis: a randomised controlled trial. Lancet

381, 1634–1641 (2013).

Trower, P. et al. Cognitive therapy for command hallucinations: randomised controlled trial. Br. J. Psychiatry 184, 312–320 (2004).

Original systematic review:

De Jong, M. H. et al. Interventions to reduce compulsory psychiatric admissions a systematic review and meta-analysis. JAMA Psychiatry 73, 657–664 (2016).

Included interventions


• Acute day units

• Adherence or compliance therapy

• Advance statements and crisis plans

• Assertive community treatment

• Cognitive behavioural therapy for psychosis

• Community rehabilitation services

• Community treatment orders

• Crisis houses

• Crisis resolution teams

• Early intervention services for psychosis

• Family interventions for psychosis

• Housing interventions

• Open Dialogue

• Self-management interventions

• Vocational interventions

Search strategy


1) Systematic reviews of each intervention: 2) RCTs of each intervention:

Discussion


• Broad search strategy• Rapid evidence synthesis

• No quantitative synthesis due to high heterogeneity• May have missed studies not clearly reporting compulsory admissions• Some clinical groups may have been under-represented

Do crisis planning interventions reduce the risk of compulsory admissions?

Systematic review and meta-analysesEmma Molyneaux, Amelia Turner, Bridget Candy,

Sabine Landau, Sonia Johnson and Brynmor Lloyd-Evans

“Crisis planning”

• Enabling people to be involved in planning their care, including in the event of a future mental health crisis•Multiple types exist and vary in terminology, content and legal

enforceability: Advance decisions, advance statements, joint crisis plans, advance directives • Some evidence that these interventions are effective in reducing

compulsory admissions (De Jong et al 2016)

MethodsSystematic review of:• RCTs• Any form of crisis planning intervention vs. treatment as usual• Adults with a diagnosis of a psychotic illness or bipolar disorder (or a

majority of the sample from these groups)• No exclusion criteria based on language or date of publication

Searches included online databases, clinical trials registry, conference proceedings, and forward and backward citation tracking

Outcomes of interest

Primary outcome: compulsory psychiatric admission

Secondary outcomes: 1) voluntary hospital admission for psychiatric care, 2) any hospital admission for psychiatric care, 3) duration of inpatient psychiatric treatment, 4) global and specific psychiatric symptoms, 5) psychiatric functioning, 6) quality of life, 7) therapeutic alliance, 8) service engagement, 9) perceived coercion, 10) adverse effects and 11) cost effectiveness.

Authors Setting N randomised Intervention typePapageorgiou et al. 2002 England 161 Advance Statement

Henderson et al. 2004 England 160 Joint Crisis PlanThornicroft et al. 2013 England 569 Joint Crisis PlanRuchlewska et al. 2014 The Netherlands 212 Joint Crisis PlanLay et al. 2017 Switzerland 238 Crisis plan with

intensive monitoring

Included studies

Compulsory admissions

Voluntary admissions

Overall admissions

• Based on the five eligible RCTs, there appears to be approximately a 25% reduction in risk of compulsory admissions among those receiving crisis planning interventions compared with usual care • In contrast, there was no evidence that crisis planning interventions

reduce the overall number of psychiatric admissions or the number of voluntary admissions• More research is needed about the best models of crisis planning

interventions and how to effectively implement these in routine clinical practice.

Conclusions

• The lack of effect on overall and voluntary admissions also matter: voluntary admissions are often de facto detentions - “Come in voluntarily or we will section you” - lacking legal safeguards• Review limited by focus on psychosis and bipolar disorder, and few

included studies break down results by race• The three English studies largely predate austerity – compulsory

admissions often relate to lack of resources. • Any economic savings should be invested in better and radical crisis

support intervention

Commentary: Patrick Nyikavaranda and Rachel Rowan Olive from the Lived Experience Working Group

Acknowledgements:

This presentation presents independent research commissioned and funded by the National Institute for Health Research Policy Research Programme. The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research, the Department of Health and Social Care or its arm's length bodies, and other Government Departments

compulsory community treatment to reduce readmission to...

Documents