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Crisis resolution and home treatment teams for older people with mental illness

  • Claire Dibben, Humera Saeed, Konstantinos Stagias, Golam Mohammed Khandaker and Judy Sasha Rubinsztein (a1)...
Abstract
Aims and Method

We examined the impact of a crisis resolution and home treatment teams (CRHTT) on hospital admission rates, bed days and treatment satisfaction among older people with mental illness and their carers. We compared these factors in the 6 months before the service started and 6 months after its introduction.

Results

The CRHTT significantly reduced admissions (P<0.001), but there was no significant difference in the length of hospital stay as compared before and after the introduction of this service. There was a trend towards carers, but not patients, being more satisfied with treatment after the introduction of the CRHTT.

Clinical Implications

The CRHTT reduced hospital admissions for older people by 31% and carers preferred the service. Further research on crisis teams in older people with mental illness is needed using randomised controlled methodology.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Cooper, C., Regan, C., Tandy, A. R., et al (2007) Acute mental health care for older people by crisis resolution teams in England. International Journal of Geriatric Psychiatry, 22, 263265.
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Johnson, S., Nolan, F., Pilling, S., et al (2005) Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study. BMJ, 331, 599.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Crisis resolution and home treatment teams for older people with mental illness

  • Claire Dibben, Humera Saeed, Konstantinos Stagias, Golam Mohammed Khandaker and Judy Sasha Rubinsztein (a1)...
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eLetters

Crisis resolution and home treatment teams for older people with mental illness

Anthony J Pelosi, Consultant Psychiatrist
17 September 2008

Dibben et al (2008) have carried out a useful evaluation of a newly established crisis resolution and home treatment service for older people.However, I am afraid they have made a serious error in the interpretation of their results.

They have compared the six month periods before and after the local crisis resolution and home treatment team (CRHTT) extended its remit to include patients aged over 65 years. A crisis was defined as “an event where admission was being considered”. The main findings are as follows: “In the pre-CRHTT period there were 65 crisis events which resulted in 65 admissions. After the introduction of the CRHTT there were 102 crisis events of which only 70 required admissions. Of these, 66 crisis events led to direct hospital admission while four required admission after a brief period of home treatment.” It is impossible to agree with the conclusion that “overall, the CRHTT reduced admissions by 31%”. There was, in fact, a slight increase in admissions and a substantial increase in proposed admissions after this service was made available.

Dibben and her colleagues briefly allude to the likely cause for this. Crisis resolution and home treatment teams act as extra gatekeepersto inpatient care after other mental health clinicians have made the decision that admission is required. I cannot imagine how any experiencedclinician who knows their patients and the local service and who takes pride in their work could find such input from a separate team useful. However, there are times when it could be handy to arrange a bit of extra support for patients whose illness has deteriorated and for distressed people who are experiencing a psychological or social crisis. In those circumstances busy clinicians will simply lower their threshold for the stated intention to admit to hospital and pull in nurses from the crisis team knowing that they will assist the patient in the community for a couple of weeks. Of course, this is not a rational way to use health service resources but it is an inevitable result of the diversion of staffto subspecialist teams with such narrow and largely pointless clinical duties.

The actual data that have been obtained by Dibben and colleagues willbe useful in countering recent suggestions from crisis specialists that their services should be expanded to include older adults (Cooper et al 2007).

Earlier correspondence about this paper from Jha and Boskovic (2008) demonstrates that there are psychiatrists who are thinking very clearly about how best to provide effective, efficient and comprehensive mental health care to older people. I urge policy makers to seek advice on service models from Dr Jha and Dr Boskovic and other experienced old age psychiatry clinicians. They must not repeat the mistakes that have been made with services for working-age adults and foist unnecessary crisis resolution teams on older people with mental disorders.

COOPER, C., REGAN, C., TANDY, A. R., et al (2007) Acute mental healthcare for older people by crisis resolution teams in England. InternationalJournal of Geriatric Psychiatry, 22, 263 -265.

DIBBEN, C., SAEED, H., KONSTANTINOS S., et al (2008) Crisis resolution and home treatment teams for older people with mental illness. Psychiatric Bulletin, 32, 269-270.

JHA, A., BOSKOVIC, T. (2008) Crisis resolution and home treatment teams for older people. Psychiatric Bulletin, eletters (accessed September11th 2008).

Competing interests: None
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Conflict of interest: None Declared

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Crisis resolution and home treatment teams for older people

Arun Jha, Consultant Old Age Psychiatrist
21 July 2008

Dibben et al’s (2008) paper on the impact of Crisis resolution and home treatment teams (CRHTT) on hospital admission rate, length of stay and satisfaction among older people with mental illness in West Suffolk ispraise worthy. Although the CRHTTs were unable to reduce the length of hospital stay, they significantly reduced admission rate. Does this study provide enough evidence for developing similar services for older people elsewhere? The answer is both yes and no.

Yes, because, in spite of certain limitations, this study is the first planned study in the UK to provide the much needed evidence for setting up CRHT-type services for older people in line with those originally introduced for working-age adults. But, the answer is ‘No’ because we do not know whether they are necessary and cost effective. It is rather worrying to discover that the CRHTTs in Suffolk were set up following closure of a dementia ward and two day hospitals. What is surprising is that there are five older age community mental health teams (CMHT) for a population of only forty seven thousand older people. In Hertfordshire, which is not far from Suffolk, we have only two CMHTs for asimilar population. We have been managing the service needs reasonably well with limited contribution from the adult CRHTTs in our area. We are curious to know how Suffolk mental health Trust is able to afford more than one CRHTT despite having so many CMHTs for older people. If these services were the knee-jerk products of the unplanned closure of acute assessment ward and day hospitals, the future of those CRHTTs hang in balance. The ever-hanging financial sword may drop on them sooner or later.

Moreover, to develop new services at the cost of well established services may be a short sighted step. Older patients with both functional and organic mental health problems can be managed well by using adequatelyresourced day hospitals and minimum number of hospital beds. We have been doing so quite successfully in the west Hertfordshire for last ten years. We have done so by enabling and encouraging the existing CMHTs to provide assessment and treatment to patients in the community using the principlesof New Ways of working. If we can do that with only two CMHTs for an elderly population of 44,000, why do they need five CMHTs in Suffolk for asimilar population?

The authors describe the CRHTTs in Suffolk as ‘a practitioner-led service which provides short-term assessment and management at the time ofa crisis’. If our guess is correct, by ‘practitioner-led’ they mean ‘non-doctor led’. Specialist mental health teams for older people have traditionally been led, not necessarily managed, by old age psychiatrists.To develop new teams led by non-psychiatrists is a risky initiative. At a time when National Dementia Strategy and quality of care are on the horizon, to see the introduction of practitioner-led teams is very worrying indeed. One of the recommendations of the national dementia strategy is “Good-quality early diagnosis and intervention for all”. Who would provide diagnosis and a treatment plan for an acutely ill patient incrisis? Before one can offer a suitable treatment plan, one needs to know what is wrong with the patient in the first place. Teams which are not letby psychiatrists tend to manage crisis without carrying out thorough assessment and investigations. In elderly population this practice createsa risk of overlooking medical problems and therefore complicating the crises further. By delaying admissions to hospital by providing inadequatehome treatment may be harmful to older patients. Not surprisingly, Craddock et al (2008), in their wake-up call for British psychiatry, warn us that “the accompanying downgrading of medical aspects of care has resulted in services often better suited to offering non-specificpsychosocial support, rather than thorough, broad-based diagnostic assessment leading to specific treatments to optimise well-being and functioning”.

On balance, we are in favour of developing acute community psychiatry services for older people as long as they do not undermine the spirit of multidisciplinary team working of traditional CMHTs and day hospital services, and improve patient care in older population. They should be complementary to each other rather than mutually exclusive.

DIBBEN, C., SAEED, H., KONSTANTNOS S., ET AL (2008) Crisis resolutionand home treatment teams for older people with mental illness. PsychiatricBulletin, 32, 269-270.

CRADDOCK, N., ANTEBI, D., ATTENBURROW, M-J., et al. (2008) Wake-up call for British psychiatry. British Journal of Psychiatry, 193, 6-9.
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Conflict of interest: None Declared

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