Education and debate

The home treatment enigma

Home treatmentenigmas and fantasies

The home treatment enigma

M G Smyth, honorary senior lecturer,  J Hoult, consultant. 

Department of Psychiatry, Northern Birmingham Mental Health (NHS) Trust, Birmingham B23 6AL

Correspondence to: M G Smyth

Why is home treatment for acute psychiatric illness generally ignored as an alternative to conventional admission to hospital in the United Kingdom? Despite evidence showing that home treatment is feasible, effective, and generally preferred by patients and relatives, its widespread implementation is still awaited. Furthermore, no study has shown that hospital treatment is better than home treatment for any measure of improvement. In general, patients are denied the option of home treatment as a realistic, less restrictive alternative to formal admission under the Mental Health Act 1983, although the recent white paper Modernising Mental Health Services recommends that it should be provided.¹

In any economic analysis, hospital admission remains the most expensive element of psychiatric care. Although the pressure on acute beds in inner city psychiatric hospitals in the United Kingdom is increasingand it has reached breaking point in some areas ^{2 3} it is claimed that managing these patients outside hospital would be out of the question.⁴ The pressure on hospital beds has been linked indirectly with the practice of discharging psychiatric patients too early and with well publicised reports of official inquiries into "psychiatric scandals." In a recent article that was critical of the current state of British psychiatry, it was alleged that the Department of Health and health authorities had misconstrued research into home treatment and that this had resulted in a reduction in the provision of acute beds.⁴ We aim to examine the issues, real and imagined, that are behind the resistance to treatment at home.

(Credit: SUE SHARPLES)

	What is home treatment?

By home treatment we mean a service for people with serious mental illness who are in crisis and are candidates for admission to hospital. A home treatment team does not stand alone. It is an integral part of the overall provision for psychiatric care and plugs a gap between community mental health teams and inpatient units. The features of an effective home treatment team are set out in the box.

	The research evidence

Home treatment has been shown empirically to be safe, effective, and feasible for up 80% of patients presenting for admission to hospital.^5-12 In these studies patients have been randomised to home or inpatient treatment at the time of admission. Five reviews have endorsed positively the overall findings.^13-17

	Advantages

Research points to the advantages of home treatment. These are set out below.

Reduced admissions and bed use
Studies show that home treatment can reduce admissions to hospital by a mean of 66%.^5-11 The most pessimistic calculation, based on adequately randomised controlled studies only, yields a figure of 55%.¹⁴ Those who advocate this model have never claimed that inpatient beds are no longer necessary. The disadvantages of admission to hospital include: cost, emotional trauma,¹⁸ stigma (still attached by the public to patients who have been admitted to a psychiatric hospital), delay in recognising social problems, increased likelihood of readmission (at worst, leading to the "revolving door syndrome"), and "medicalisation." With regard to this last point, the focus in hospital may be on symptoms and behavioural conformity. Patients in hospital quickly learn that staff are interested in symptoms and this can dominate the discourse and clinical decision making. However, even when a patient is admitted to hospital, the length of stay can be reduced appreciably by home treatment. This has been described as a reduction in the stay of up to 80%¹⁹or a home:hospital bed day ratio of 17:60.¹⁵

Patients' and relatives' preference
We know of no study in which most subjects have preferred hospital admission to a reasonable alternative. When asked by researchers why they did not like hospital, inpatients discussed issues such as deprivation of liberty, lack of autonomy, unsatisfactory surroundings, lack of status and recognition, an emphasis on behavioural conformity, and removal from their family.²⁰

Equal clinical outcomes
Studies mainly involve patients with severe mental illness (functional psychosis accounts for 75% of cases on average). Most reports show that the clinical outcome is similar in patients treated at home or in hospital.

Burden on relatives
Carers are more willing to help the patient at home and avoid the disruption and trauma of admission when they know that immediate help is at hand. Carers witness at first hand the interaction of staff and patients and are better informed about the disorder and the management of eventualities, and of the rationale for different drug treatments. In hospital, carers may never see the medical or nursing staff working directly with the patient.

Better service retention
Higher patient satisfaction should not be dismissed as a "soft" finding. This preference is reflected in significantly higher rates of service retention for home treatment compared with standard hospital treatment. ^{11 17} This issue is central to good psychiatric practice.

Other advantages
There are rich descriptive and conceptual studies of the widely differing impact of hospital admission or home treatment on the lives and experience of patients and their families during an acute episode.^21-23 Avoiding admission to hospital provides a critical opportunity to alter for the better the personal set of meanings surrounding mental illness and to impact on the trajectory and personal narrative of the psychiatric patient's experience of his or her illness. These meanings attract powerful emotions and can affect the patient's clinical condition and become inseparable from the individual's life history.²⁴

	Problems of implementation

Since the research evidence points in its favour, why has implementation of home treatment in the United Kingdom been delayed? Mosher believed that early opposition in the United States resulted from resistance to change and a desire to protect vested interests within the medical profession.²⁵ UK research reports which view home treatment positively have commonly been accompanied by critical editorials written by those with no clinical experience in this area. ^{26 27} These critiques reflect the polarised debate around an unhelpful dichotomy between hospital and community care. They highlight issues which are discussed and refuted below.

	Specific criticisms

Burnout among staff
Until recently there has been no research at all on the phenomenon of burnout in members of home treatment teams. This lack of evidence has not, however, stemmed speculation. Minghella et al found low levels of burnout and significantly higher job satisfaction in home treatment teams compared with results from a previous large study of community mental health nurses and ward based staff.¹²

Homicide and suicide
In the 25 years since home treatment became reality, there has been only one reported instance of homicide carried out by a patient who was participating in an experimental home treatment initiative.¹⁰ All the other homicides perpetrated by psychiatric patients over this period occurred while they were being treated by other parts of the mental health service. The most recent meta-analysis concurs with previous reviewsit finds no evidence for higher rates of suicide or deliberate self harm in patients having home treatment compared with hospital care.¹⁷ The risks of suicide and homicide remain a critical issue in the decision to admit patients to hospital when there are other options. However, recommendations for admitting these patients have been advanced in the published reports on home treatment.⁵

Sustainable and generalisable
It has been claimed that home treatment is not generalisable or sustainable. In Madison, Wisconsin, and in Sydney, Australia, model home treatment programmes are still going strong after 20 and 17 years respectively. The Madison model, which included a mental health crisis team, has had a major impact on US psychiatric care. After the Sydney initiative, emergency mobile psychiatric teams were developed in several Australian states. In north Birmingham, the availability of home treatment has expanded so much that it is the first line of response for psychiatric emergencies in a population of over half a million.

	Conclusions

Negative editorial propaganda is not the sole reason for delayed implementation of home treatment in the United Kingdom. We suspect that the rapid developments in community psychiatry involving closure of institutions; cuts in numbers of psychiatric beds; and a high profile culture of blame after tragic, untoward events have created the sort of environment that promotes the more defensive practice of psychiatry. It is worth remembering that these most unfortunate events have occurred even though home treatment is not widely available.

Sophisticated evaluation of the clinical and other factors that determine admission to hospital with acute psychiatric illness remains a neglected area in the United Kingdom compared with the United States. ^{28 29} As clinicians faced with the daily decision to admit or not, we believe that the availability of home treatment allows us to scrutinise the factors influencing this decision in a more refined way. We mostly decide on home treatment as the preferred option to hospital admission, but we also recognise when this is not a safe or feasible alternative. It is our experience that the availability of home treatment in parallel with hospital admission means that beds are readily available (rather than too few) when we need them. This further promotes safe practice. Rapid response alleviates suffering and stems the patient's clinical deterioration and the social escalation that commonly dictate admission to hospital. Finally, while endorsing home treatment in its own right, we also emphasise that its ultimate usefulness is within the context of an integrated comprehensive community strategy that includes assertive outreach provision.

	Footnotes

   Competing interests: None declared.

	References

1.	Department of Health. Modernising mental health services. London: Stationery Office, 1998.
2.	Monitoring Inner London Mental Illness Services Project Group. Monitoring inner London mental illness services. Psychiatr Bull 1995; 19: 276-280[Abstract/Free Full Text].
3.	Marshall M. London's mental health service in crisis. BMJ 1997; 314: 246[Free Full Text].
4.	Deahl M, Turner T. General psychiatry in no man's land. Br J Psychiatry 1997; 171: 6-8[Free Full Text].
5.	Stein LI, Test MA. Alternative to mental hospital treatment. Conceptual model, treatment program, and clinical evaluation. Arch Gen Psychiatry 1980; 37: 392-397[Abstract].
6.	Fenton FR, Tessier L, Struening ELA. A comparative trial of home and psychiatric hospital care; one year follow up. Arch Gen Psychiatry 1979; 36: 1073-1079[Abstract].
7.	Pasaminick B, Scarpetti FR, Dinitz S. Schizophrenia in the community: an experimental model in the prevention of hospitalisation. New York: Appleton Century Crofts, 1967.
8.	Hoult J. Community care of the acutely mentally ill. Br J Psychiatry 1986; 149: 137-144[Free Full Text].
9.	Polak PR, Kirby MW. A model to replace psychiatric hospitals. J Nerv Ment Dis 1976; 162: 13-22[Medline].
10.	Muijen M, Marks IM, Connolly J, Audini B. Home-based care versus standard hospital-based care with severe mental illness: a randomised controlled trial. BMJ 1992; 304: 749-754.
11.	Dean C, Phillips J, Gadd EM, Joseph M, England S. Comparison of community based service with hospital based service for people with acute, severe psychiatric illness. BMJ 1993; 307: 473-476.
12.	Minghella E, Ford R, Freeman T, Hoult J, McGlynn P, O'Halloran P. Open all hours. 24-hour response for people with mental health emergencies. London: Sainsbury Centre for Mental Health, 1998.
13.	Braun P, Kochansky G, Shapiro R, Greenberg S, Gudeman J, Johnson S, et al. Overview: deinstitutionalisation of psychiatric patients; a critical review of outcome studies. Am J Psychiatry 1981; 138: 736-749[Abstract/Free Full Text].
14.	Kiesler CA. Mental hospitals and alternative care. Am Psychol 1982; 37: 349-360[CrossRef][Medline].
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16.	Szmukler GI. Alternatives to hospital treatment. Curr Opinion Psychiatry 1990; 3: 273-277.
17.	Joy CB, Adams CE, Rice K. Crisis intervention for severe mental illness. In: Cochrane Collaboration. In: Cochrane Library. Issue 4. Oxford: Update Software, 1998.
18.	Scott RD. A family orientated psychiatric service to the London Borough of Barnet. Health Trends 1980; 12: 65-68.
19.	Audini B, Marks IM, Lawrence RE, Connolly J, Watts V. Home-based versus out-patient/in-patient care for people with serious mental illness. Phase II of a controlled study. Br J Psychiatry 1994; 165: 204-210[Abstract/Free Full Text].
20.	Young L, Reynolds I. Evaluation of selected psychiatric admission wards. Report for the New South Wales Health Commission. Sydney: NSW Department of Health, 1980.
21.	Polak P. The crisis of admission. Soc Psychiatry 1967; 2: 150-157.
22.	Querido A. The shaping of community health care. Br J Psychiatry 1968; 114: 293-302[Free Full Text].
23.	Smyth M, Bracken P. Senior registrar training and home treatment. Psychiatr Bull 1994; 18: 408-409[Abstract/Free Full Text].
24.	Kleinman A. The illness narratives. New York: Basic Books, 1988.
25.	Mosher LR. Alternatives to psychiatric hospitalisation. Why has research failed to be translated into practice? N Engl J Med 1983; 309: 1579-1580[Medline].
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27.	Dedman P. Home treatment for psychiatric disorder. BMJ 1993; 306: 1359-1360.
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(Accepted 22 March 1999)

Home treatmentenigmas and fantasies

Anthony J Pelosi, consultant psychiatrist, ^a Graham A Jackson, consultant psychiatrist. ^b

^a Lanarkshire Primary Care NHS Trust, East Kilbride G75 8RG, ^b Greater Glasgow Primary Care NHS Trust, Leverndale Hospital, Glasgow G52 7TU

Correspondence to: A Pelosi anthonypelosi{at}compuserve.com

It is vital to be clear about what Smyth and Hoult are not considering in their review. Politicians and health service managers are under pressure to establish comprehensive, 24 hour psychiatric crisis intervention services and telephone help lines. They are being lobbied by enthusiasts for crisis theory, who advocate that short term psychiatric input should be given to people experiencing serious life stresses in order to help them develop greater psychological strength for the future.¹ Some inexperienced clinicians have bowed to this pressure and established crisis services that are as unsuccessful now as they were during the 1960s and 1970s. With a few exceptions, evaluations are not published, probably because failures of these teams are so embarrassing. This is compounded by the political difficulty of closing down a service once it is establishedso the waste of time, for patients as well as staff, and public money continues. Our local trust managers established an out of hours crisis team, but fortunately conducted a pilot study before committing themselves to longer term funding. Not surprisingly, assistance was not requested by or for mentally ill people and the team became involved with emotional and social problems. It cost an average of £1500 for each call out (internal report available from AJP on request).

Consultant psychiatrists see it as their duty to resist any diversion of resources from those people with the most severe psychiatric and neuropsychiatric illnesses. In spite of Smyth and Hoult's apparent approval of crisis intervention theory,² they seem to have focused fairly successfully on people with serious and enduring mental illnesses.³ Why then do most UK psychiatrists remain opposed to the introduction of these emergency home treatment teams?

	A cause for concern

Firstly, enthusiastic reports of treating patients undergoing severe psychotic relapses outside hospital are a cause for concern. Here is an example. "Mark, a 20 year old schizophrenic ... began hallucinating and hearing voices earlier this year. In the middle of an acute attack in which he was threatening to kill people, his father took him to Highcroft Hospital in north Birmingham. Mark was on the brink of being admitted as a psychiatric inpatient when a unique team of mental health professionals stepped in and took him home, saving him from what can often be a disruptive and frightening experience ... [The] 24 hour crisis service ... visited Mark up to three times a day until he was well enough to be transferred to a key worker."⁴

We are keen exponents of community care, but we are not heroic clinicians. If Mark lived in our area he would have had a permanent key worker who would be trying to prevent this situation. If this failed, the key worker would decidein collaboration with Mark, his family, the consultant, and the general practitionerwhen admission to hospital was necessary. Mark would be admitted to hospital until the ward and community multidisciplinary teams could advise his consultant, who would make the final decision on a discharge date. Hoult's other tales of "derring-do," such as driving around on home visits accompanied by an acutely psychotic patient who had relapsed, fail similarly to impress.²

	Lack of professional respect

Secondly, devotion to this model of care seems to have led to a lack of respect for other clinicians. Psychiatrists in Birmingham or Sydney or Wisconsin face different challenges from, for example, colleagues in the West of Scotland, where so many referrals for admission are related to alcohol or drugs. Smyth and Hoult are particularly unfair to imply criticism of psychiatrists in central London who are trying to cope with the extremes of inner city psychiatry (see their reference 4). Even Smyth and Hoult will surely accept that it is difficult to be enthusiastic about emergency home treatment when many patients do not have a home.

	Outdated

Thirdly, the research cited in favour of home treatment teams is out of date since it compared a package of assertive community treatment with old fashioned asylum care. Nowadays, community mental health teams provide long term assistance to people with major mental disorders throughout their relapses and remissions. Smyth and Hoult concentrate on incident referrals or rereferrals and do not seem to appreciate what it is like to work with patients with incurable conditions over many years. No keyworker would wish to transfer care in the community to another team just when a patient whom they have known for years is going through a personal crisis or a relapse of their illness.

	Ignoring general practice

This issue of continuity of care brings us to the most important flaw in Smyth and Hoult's home treatment model, at least as it applies to the United Kingdom. They ignore the role of general practitioners who have known their mentally ill patients for years, and sometimes for decades. Smyth and Hoult's summary of an effective home treatment team emphasises practical assistance, counselling, use of medication, knowledge of underlying social issues, involvement with patients and carers for as long as necessary, and 24 hour availability seven days per week. This describes the primary care system in Britain. General practitioners cannot carry out the most labour intensive parts of treatment, but unlike the staff of home treatment teams they are properly trained as gatekeepers to appropriate secondary care and they carry out this function more effectively than other health professionals.⁵

	Accepting the advantages of community care

In the end, disagreement about the desirability of emergency home treatment teams (and crisis intervention services) boils down to whether or not one accepts the advantages for patients of continuity of care from general practitioners and specialists. We accept that some people with chronic psychotic illnesses fall through the safety net of community care and that general practitioners cannot always give enough time to patients when they are facing health or social crises. We know that communication between community mental health teams, general practitioners, and inpatient units could be improved, and we are only too well aware that staffing levels and facilities in some psychiatric wards are inadequate. However, clinicians and health service managers should be doing everything in their power to tackle these shortcomings. Their efforts can only be hampered by costly, short term psychiatric treatment teams that are totally unnecessary within the health care system of the United Kingdom.

	References

1.	Caplan G. Principles of preventive psychiatry. New York: Basic Books, 1964.
2.	Hoult J. Management of acute psychiatric problems in the community with crisis intervention. In: Rao Punokollu N, ed. Recent advances in crisis intervention. , Vol 1 Huddersfield: International Institute of Crisis Intervention and Community Psychiatry Publications, 1990:45-57.
3.	Minghella E, Ford R, Freeman T, Hoult J, McGlynn P, O'Halloran P. Open all hours. 24-hour response for people with mental health emergencies. London: Sainsbury Centre for Mental Health, 1999.
4.	Catherall S. Crisis service helps patients back home. Hospital Doctor 1996; 7 Nov: 43.
5.	Dale J, Lang H, Roberts JA, Green J, Glucksman E. Cost effectiveness of treating primary care patients in accident and emergency: a comparison between general practitioners, senior house officers, and registrars. BMJ 1996; 312: 1340-1344[Abstract/Free Full Text].

	Footnotes

   Competing interests: None declared.