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Suicide under crisis resolution home treatment – a key setting for patient safety

  • Isabelle M. Hunt (a1), Louis Appleby (a1) and Nav Kapur (a1)
Summary

Recent years have seen a substantial increase in the use of crisis resolution home treatment (CRHT) teams as an alternative to psychiatric in-patient admission. We discuss the functions of these services and their effectiveness. Our research suggests high rates of suicide in patients under CRHT. Specific strategies need to be developed to improve patient safety in this setting.

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Copyright
This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence to Isabelle M. Hunt (isabelle.m.hunt@manchester.ac.uk)
Footnotes
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Declaration of interest

L.A. chairs the Suicide Prevention Advisory Group at the Department of Health and is a non-executive Director for the Care Quality Commission. N.K. is a member of the Suicide Prevention Advisory Group.

Footnotes
References
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1 Department of Health. The NHS Plan: A Plan for Investment, A Plan for Reform. Department of Health, 2000.
2 Johnson, S. Crisis resolution and home treatment teams: an evolving model. Adv Psychiatr Treat 2013; 19: 115–23.
3 Department of Health. Mental Health Policy Implementation Guide. Department of Health, 2001.
4 National Audit Office. Crisis Resolution and Home Treatment: The Service User and Carer Experience. NAO, 2008.
5 Joy, CB, Adams, CE, Rice, K. Crisis Intervention for People with Severe Mental Illnesses. Cochrane Collaboration, 2006.
6 Morgan, S, Hunte, K. One Foot in the Door. Mental Health Today, 2008.
7 Winness, MG, Borg, M, Kim, SK. Service users' experiences with help and support from crisis resolution teams. J Ment Health 2010; 19: 7587.
8 Jethwa, K, Galappathie, N, Hewson, P. Effects of a crisis resolution and home treatment team on in-patient admissions. Psychiatr Bull 2007; 31: 170–2.
9 Jacobs, R, Barrenho, E. Impact of crisis resolution and home treatment teams on psychiatric admissions in England. Br J Psychiatry 2011; 199: 71–6.
10 Johnson, S, Nolan, F, Pilling, S, Sandor, A, Hoult, J, Mckenzie, N, et al. Randomised controlled trial of acute mental health care by a crisis resolution team: the North Islington Crisis Study. BMJ 2005; 331: 599.
11 Wheeler, C, Lloyd-Evans, B, Churchard, A, Fitzgerald, C, Fullarton, K, Mosse, L, et al. Implementation of the crisis resolution team model in adult mental health settings: a systematic review. BMC Psychiatry 2015; 15: 74.
12 Onyett, S, Linde, K, Glover, G, Floyd, S, Bradley, S, Middleton, H. A National Survey of Crisis Resolution Teams in England. Care Services Improvement Partnership, Department of Health & University of the West of England, 2006.
13 Morgan, S. Are Crisis Resolution and Home Treatment Services Seeing the Patients they are Supposed to See? Report on Behalf of the National Audit Office. National Audit Office, 2007.
14 Kapur, N, Hunt, IM, Windfuhr, K, Rodway, C, Webb, R, Rahman, MS, et al. Psychiatric in-patient care and suicide in England, 1997–2008: a longitudinal study. Psychol Med 2013; 43: 6171.
15 National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Annual Report: England, Northern Ireland, Scotland and Wales. University of Manchester, 2015.
16 Hunt, IM, Rahman, MS, While, D, Windfuhr, K, Shaw, J, Appleby, L, et al. Safety in crisis resolution home treatment services in England: an investigation of suicide trends 2003–2011. Lancet Psychiatry 2014; 1: 135–41.
17 While, D, Bickley, H, Roscoe, A, Windfuhr, K, Rahman, S, Shaw, J, et al. Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study. Lancet 2012; 379: 1105–12.
18 Bickley, H, Hunt, IM, Windfuhr, K, Shaw, J, Appleby, L, Kapur, N. Suicide within two weeks of discharge from psychiatric in-patient care: a case-control study. Psychiatr Serv 2013; 64: 653–59.
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BJPsych Bulletin
  • ISSN: 2056-4694
  • EISSN: 2056-4708
  • URL: /core/journals/bjpsych-bulletin
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Suicide under crisis resolution home treatment – a key setting for patient safety

  • Isabelle M. Hunt (a1), Louis Appleby (a1) and Nav Kapur (a1)
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eLetters

Alternatives for acute in-patient care: safety and efficacy

Frank Röhricht, MD FRCPsych, Consultant Psychiatrist and Associate Medical Director, East London NHS Foundation Trust
10 August 2016

Hunt et al (1) discuss implications of recent findings regarding high rates of suicide in patients under crisis resolution home treatment. Their obvious conclusion points towards improving safety in this setting. There is, however, in my opinion, another important consequence, i.e. reconsidering other evidence-based models that provide treatment as an alternative for in-patient admission at times of acute mental health crisis. The NHS Plan policy mandate appears to have been too one-sided in favouring one model of care over other evidence-based services.

The Acute Day Hospital (ADH) model – somewhat out of fashion, partially because most services provide step-down day care rather than acute crisis care – is an interesting alternative model worth considering because of its established safety track record and hence relevance to this debate. In contrast to the home treatment team model, ADH (‘virtual community ward’) provides individuals who experience an acute mental health crisis with an intensive group therapy programme (including psychological therapies and social activities), as well as multidisciplinary daily monitoring of their mental state and associated risks.

According to a Cochrane review 25–40% of all voluntary patients can be treated in an acute day hospital with significant cost reductions (2) and the treatment is associated with higher patient satisfaction and better efficacy in reducing psychopathology (3). Most importantly, suicide incident rates were reported as being low (4). Furthermore, unpublished data from the East London ADH indicates an average length of stay close to that of in-patient wards.

There appears to be renewed interest in alternative models for in-patient care in the context of financial constraints and it might be worth comparing the various models directly in terms of their clinical efficacy and cost-effectiveness.

References

1 Hunt IM, Appleby L, Kapur N. Suicide under crisis resolution home treatment – a key setting for patient safety BJPsych Bull 2016; 40:172–4.

2 Marshall M, Crowther R, Almaraz-Serrano A, Creed F, Sledge W, Kluiter H, et al. Day hospital versus admission for acute psychiatric disorders. Cochrane Database Syst Rev 2003; 1: CD004026.

3 Priebe S, Jones G, McCabe R, Briscoe J, Wright D, Sleed M, et al. Effectiveness and costs of acute day hospital treatment compared with conventional in-patient care. Br J Psychiatry 2006; 188: 243–9.

4 Jones G, Gavrilovic J, McCabe R, Becktas C, Priebe S. Treating suicidal patients in an acute psychiatric day hospital: a challenge to assumptions about risk and overnight care. J Ment Health 2008 17:375–387.

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