Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Effectiveness of joint crisis plans in psychiatry.
- Dr. Naseem A. Qureshi MD, IMAPA, LMIPS (17 July 2004)
-
Joint crisis plans: how do they reduce compulsory admission?
- Robert H Chaplin (28 July 2004)
-
Advance planning in mental health
- Jacqueline M Atkinson (30 July 2004)
|
|
|||
|
Dr. Naseem A. Qureshi MD, IMAPA, LMIPS, Locum Psychiatry POBox.64399, SBAHC,Riyadh,KSA.
Send response to journal:
|
Sir: The natural course of serious mental disorders such as group of schizophrenic psychoses, delusional disorders, mood disorders of psychotic proportions, some personality disorders, and dual diagnoses (psychosis co- morbid with drug addictions) is characterized by relapses and remissions. Impending relapses if not controlled promptly, though often well recognized not only by experienced mental health professionals but also by key cares, frequently lead to hospitalization of patients with overstay in the hospital coupled with increased health costs. Moreover, a variety of symptoms heralding dangerousness of patient during relapse guide health providers to use compulsory measures to ensure safety both of the patient and the public at large. There are several effective methods of managing "crisis arising from imminent relapse" of psychosis. Although governmental legislations are known to have positive as well as negative points, Mental Health Act [MHA] of the UK is helpful in subserving some important functions related to relapse crisis. However, a possibility always exists that it may be abused in some mental patients. This pilot controlled study uses innovative "joint crisis plans" to manage patients with psychotic relapses in best possible manner and within the shortest period of time. The encouraging results were in favour of the intervention group: overall reduced use of the Mental Health Act; significant reduction in compulsory admission and treatment of intervention group; and reduction in the mean number of days of detention (inpatient) under a section of the Mental Health Act. Finally, if the MHA is used judiciously, besides circumventing many ethical problems it will tremendously help mental health staff in managing cost-effectively patients with impending crisis coupled with psychotic relapse. Reference: Claire Henderson, Chris Flood, Morven Leese, Graham Thornicroft, Kim Sutherby, and George Szmukler. Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial BMJ 2004; 329: 136-0 Competing interests: Supportor of crisis intervention in psychiatry |
|||
|
|
|||
|
Robert H Chaplin, Consultant Psychiatrist Littlemore Hospital, Oxford, OX4 4XN
Send response to journal:
|
EDITOR: Henderson et al (1) reported on the use of joint crisis plans and the subsequent need for compulsory psychiatric treatment. They reported their success as "the first structured clinical intrervention that seems to reduce compulsory admission and treatment in mental health services." This was based on significant reductions in the numbers of patients experiencing compulsory admission and the number of days they were detained in those who made joint crisis plans. Thomas and Cahill (2) in their editorial reach a rather different interpretation of their findings based on a 66% refusal rate to enter the study and state "liberation cannot be handed to the oppressed by the oppressor." The truth lies somewhere between the two statements. Indeed joint crisis care planning seems to be a successful intervention for a substantial mimority of individuals. This study included very broad criteria for eligibility, at least one admission in the last two years. Patients experiencing only one episode of hospitalisation could realistically expect not to be admitted in an emergency again and see the study as not relevant. If the study had targetted a group with long term mental health needs, the recruitment rate could have been higher. Joint crisis planning appears not to be an effective intervention for all patients with at least a single hospital admission for psychosis or bipolar affective disorder. This makes clinical sense as there is seldom a single overall intervention that would be expected to benefit all patients with a variety of conditions. The question is therefore, who benefits from joint crisis planning? This study seems to indicate that it is likely to be those individuals who are prepared to engage in the process. The other interesting point that the study could have made is, how does joint crisis planning have its effect on reduced compulsory admission? Is it a non-specific effect of the collaborative process whereby individuals are more likely to engage with services in the emergency situation, or is it due to the plans actually being followed? Patients are more likely to engage in the process if it could be demonstrated that their wishes were being acceded to rather than overridden. Evidence of how joint crisis plans actually influenced the course of an individual's emergency care could be gathered qualitatively to answer two important clinical questions. Firstly, how did the plan influence help seeking behaviour and was the plan followed? Secondly, for those admitted agaist their will, how did the plans fail to prevent this? Exploration of the complex interaction between patient, care-coordinator and emergency care services will shed further light on the acceptability and effectiveness of joint crisis planning. 1. Henderson C, Flood C, Leese M, Thornicroft G, Sutherby K, & Szmuckler G. Effect of joint crisis plans on the use of compulsory treatment in psychiatry: a single blind randomised controlled trial. BMJ 2004;329:136-8 2. Thomas P & Cahill AB. Compulsion and psychiatry - the role of advance statements. BMJ 2004;329:122-3. Competing interests: None declared |
|||
|
|
|||
|
Jacqueline M Atkinson, senior lecturer Public Health and Health Policy, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ
Send response to journal:
|
Sir Advance planning in mental health involving users in the planning is to be welcomed. The reduction in compulsory admission and treatment under the Mental Health Act 1983 by the use of joint crisis plans as reported by Henderson et at (BMJ 17/7/04 329 136-8) is impressive. Both the authors of this paper and the editorial (Thomas and Cahill 17/7/04 122-123), however, point to the low uptake and suggest reasons. I would like to add other possible reasons, some of which might be directly related to the type of advance planning, in this case joint crisis plan, used. The article does not indicate what was in the plans, or when and how they were invoked. Was it when the patient became ill but before they reached the criteria for detention or compulsory treatment? Where they only used in place of detention? Were they only used when capacity has been lost, or to invoke treatment plans which were being refused before this point? These are potentially important issues for patients who might be concerned that interventions will be started before they are ready for them. Without further information we assume that the crisis plan is largely an‘opt-in’ agreement, or agreement to accept treatment. Against popular conceptions there are substantial numbers of patients who have a good relationship with their psychiatrist, are satisfied with interventions when they become unwell and are happy to leave the decisions in the hands of people they trust. Other people want to make decisions about their treatment independent of the service they are in or want to make decisions with which staff do not agree. Some patients would like to make ‘opt-out’ advance statements, or refuse treatment, and it should be remembered that anyone is currently entitled to make an advance directive refusing treatment. While the Mental Health Act allows such refusals to be over- ruled many patients who might want to do this will probably see it as a pointless exercise. It is not possible for the authors to cover everything in a short article but it is not clear in this study whether such options would have been agreed (for example to be hospitalised but not medicated). Although we might assume that that the majority of patients would prefer not to be detained while outcomes measures are focused on service measures such as days in hospital it is unlikely that such opt-out advance statements would be approved or seen as successful. If the outcome is patient satisfaction with the service received then different kinds of agreements can be reached. This article does not give any indication of how the patients felt about the use of the crisis plans. Did any feel they had been invoked inappropriately? Or too early? Opt-in agreements may reduce the use of Mental Health Act provisions but if this means that patients loose the safeguards of the Act this might not always be appropriate. The new mental health (Care and Treatment) (Scotland) Act 2003 introduces advance statements, which, for the first time have to be taken into account when compulsory treatment is being decided. Although these measures probably do not go as far as some people might wish (Atkinson et al 2003, in press) it will, nevertheless, be instructive to see how far they are taken up and respected. Atkinson JM, Garner HC., Gilmour H (in press – Aug 2004) Models of advance directives: user and professional views Social Psychiatry and Psychiatric Epidemiology Atkinson JM., Garner HC., Patrick H., Stuart S (2003) The development of potential models of advance directives in mental health care Journal of Mental Health 12 575-584 Competing interests: Dr Atkinson has received grant funding from the Nuffield Foundation to research advance directives in mental health |
|||