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Rapid Responses: Rapid Responses published:
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Authors ignore some important variables
- AK Al-Sheikhli (16 September 2006)
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Care Programme Approach?
- G sathyendra (9 October 2006)
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Hospital admission is not failure!
- Katharine Nolan (10 October 2006)
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Overemphasising non significant results
- Tom R Dening (11 October 2006)
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Eligibility criteria require clarification
- Ruth V Reed, Malid Molloholli (11 October 2006)
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Joint Crisis Plan- A Must
- Mohammed Usman (11 October 2006)
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Authors' reply
- Chris M Flood, Sarah Byford, Claire Henderson, Graham Thornicroft, Morven Leese, George Szmukler, Kim Sutherby. (12 January 2007)
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AK Al-Sheikhli, Loc.Consultant Psychiatrist St.Michael Hospital,Warwick
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EDITOR--This is a very nice study comparing the use of a Joint Crisis plan and Standardised Service Information on two groups of psychiatric patients with Psychotic and non-psychotic bipolar disorder. But some factors are very important and might give different results if controlled--for example, gender, age, alcohol and illicit drugs misuse. Competing interests: None declared |
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G sathyendra, Locum Associate Specialist Oxleas NHS Trust
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Clinicians are expected as part of the (CPA) Care Programme Approach (standard or Enhanced) to discuss with all our patients about crisis plans/risk management in the event of a relapse. Are Joint crisis plans another name for CPA? Or do the authors mean standardised service information is a form of CPA? Apart from the use of Mental Health Act, there is little difference between the groups studied. In the current climate of resource constraints are facilitators affordable? Currently Care co-ordinators engage with the patients to facilitate a cisis plan. Most importantly nearly all service users agree that any measure to reduce compulsary admissions is welcome. Competing interests: None declared |
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Katharine Nolan, FY2 Heartlands hospital Birmingham B9 5SS
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With the advent of “crisis” and “early intervention” teams coupled with the closure of many older inpatient units, psychiatric care is moving rapidly in the direction of community administered health. However, in the rush to achieve this goal it must be remembered that hospital care still has an important role to play. Flood et al. “assume” that patient’s with fewer hospital admissions have a better quality of life but on what basis is this assumption made? Patients who are acutely psychotic are often so far detached from reality that they are unable to function at any level in a socially acceptable way. For these people, I believe hospital provides a refuge that community care never can. It provides a safe environment away from the stresses of everyday life where the patient can receive definitive treatment. It provides relief for family members who would otherwise carry much of the responsibility for the patient’s care in the community. Most importantly, it protects the patient from the destructive nature of their own disease. Destructive that is to their relationships, employment and social interaction, all things that define quality of life, and all things that are much more difficult to rebuild once destroyed. Competing interests: None declared |
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Tom R Dening, Consultant Psychiatrist Fulbourn Hospital, Cambridge, CB1 5EF
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This is a well designed and well conducted study of an interesting idea in mental health. However, the main finding was that there was not a statistically significant difference in total costs between the intervention and control groups. Despite this, the abstract contains the conclusion that there is a high probability that crisis plans are cost effective compared with standard care. This enthusiasm is then compounded by the BMJ, which mentions this on the front cover of the issue, in the Editor's choice and on the This Week in the BMJ page. Phrases used include 'yes, probably' and 'Joint crisis plans seem effective in psychosis'. This seems like poor science to me, possibly reflecting an ideological bias in favour of psychosocial interventions. I cannot conceive that you would allow a drug trial to be reported in this way, nor would you feature a non significant finding from a drug trial on your front cover or editorial pages in this manner. I am concerned that mental health services will shortly be faced with edicts to develop these services when, in reality, the evidence falls some way short of compelling. Competing interests: None declared |
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Ruth V Reed, Senior House Officer in Psychiatry Barnet, Enfield and Haringey Mental Health NHS Trust, Malid Molloholli
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The paper by Flood et al. was interesting and valuable, but upon reading it we were concerned that there may have been an error in the Methods section. In the abstract and the previous research paper (Henderson et al., Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial. BMJ 2004; 329: 136-8), one eligibility criterion is stated as 'a diagnosis of psychotic illness or non-psychotic bipolar disorder'. In the expanded methods section of the paper in this edition, however, the criterion is given as, 'Eligible patients had a clinical diagnosis of psychotic illness'. Bipolar disorder is not mentioned here. It would be necessary to clarify to which group or groups of patients this study refers in order for clinicians to consider implementing the findings. Competing interests: None declared |
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Mohammed Usman, Senior House Officer Leeds Mental Health NHS Trust
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I would assume any crisis plan made should include the service users view and agreement. This is important as any plan made otherwise is liable to be a failure. Even though the 95% confidence interval is wide (-2814 to 5004), one must strive to agree on a joint crisis plan. In this particular article, it is important to know of the basic demographic details of the participants as well as the nature of the illness and risk factors identified. There may be inherent differences in characteristics of the sample population who were not allocated to receiving joint crisis plan. This will have a major impact on the Mental Health Act admissions. Again, admission under the Mental Health act depends on various other factors including availability of other services, service users current state, risks identified and social situation. Hence, even though there is a statistical significance in reducing Mental Health Act admissions this should not be a benchmark. After all, Mental Health Act admissions are sometimes a necessity. Competing interests: None declared |
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Chris M Flood, Lecturer in Mental Health Department of Mental Health, City University, London, E1 2EA, Sarah Byford, Claire Henderson, Graham Thornicroft, Morven Leese, George Szmukler, Kim Sutherby.
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We would like to respond to comments made on our recent paper, Joint crisis plans for people with psychosis: economic evaluation of a randomised controlled trial1. Firstly a point of clarification; the diagnostic inclusion criterion for participants in this study, as reported both in the main clinical paper2, and the economic evaluation, was any psychotic disorder (as given in the APA DSMIV, or ICD10) or non-psychotic bipolar disorder. We excluded drug induced psychotic disorders. Our inclusion criteria used the OPCRIT classification for identifying psychosis 3. One correspondent suggested that different variables between treatment arms may have been responsible for our results. The two arms of the trial were well balanced with respect to diagnostic categories (unpublished data available from the authors), as well as the baseline clinical and demographic variables shown in Table 1 of the first paper on this trial (Henderson et al, 2004). Of note, history of violence, which is associated with substance misuse, was also well balanced between the arms at baseline. Thus, while an explanation of the results in terms of imbalance in alcohol or illicit drug misuse cannot be ruled out, there is no reason to think that this would have occurred given the balance in other variables. On the issue of Joint Crisis Plans (JCPs) being similar to the Care Programme Approach (CPA), it is very important to make a distinction between the process of making a JCP and the CPA. The JCP is a fundamentally different way of working as it is a collaborative process that is user-centred where the user has the final choice of what is included in the plan. CPA is a policy-led and obligatory approach (about to be revised by the Department of Health) but it is sometimes a rather administrative staff-led process rather than being user-led. The emphasis in a CPA meeting compared to the JCP planning overall is different. It is not standard practice for CPA's to incorporate the JCP style approach to joint decision making. Our control group (Standardised Service Information) was not a form of CPA as one reader enquired, but rather the additional provision of information leaflets to service users in the control group. All participants in both arms were subject to the CPA, and as part of the randomisation process, participants were stratified with regard to their CPA level (standard vs. enhanced). With regard to the comment from one reader that stated we may be 'overemphasising non-significant results’, we would disagree. The methodology used to explore cost-effectiveness and the associated uncertainty is now widely recognized as an appropriate decision-making tool in economic evaluation. Claxton et al 4 clearly highlight the perversity (and indeed the cost to society) of selecting technologies with the lowest chance of being cost-effective, simply because the differences in cost-effectiveness are not statistically significant. We are grateful to all the contributors for their comments and questions. Chris Flood, Sarah Byford, Claire Henderson, Graham Thornicroft, Morven Leese, George Szmukler, Kim Sutherby. Reference List (1) Flood C, Byford S, Henderson C, Leese M, Thornicroft G, Sutherby K et al. Joint crisis plans for people with psychosis: economic evaluation of a randomised controlled trial. BMJ 2006; 333:729. (2) Henderson C, Flood C, Leese M, Thornicroft G, Sutherby K, Szmukler G. Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial. BMJ 2004; 329(7458):136. (3) McGuffin P, Farmer A, Harvey I. A polydiagnostic application of operational criteria in studies of psychotic illness. Development and reliability of the OPCRIT system. Arch Gen Psychiatry 1991; 48(8):764-770. (4) Claxton K, Sculpher M, Drummond M. A rational framework for decision making by the National Institute For Clinical Excellence (NICE). Lancet 2002; 360(9334):711-715. Competing interests: None declared |
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