Intended for healthcare professionals


Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial

BMJ 2004; 329 doi: (Published 15 July 2004) Cite this as: BMJ 2004;329:136
  1. Claire Henderson (hendersc{at}, MRC special training fellow in health services research1,
  2. Chris Flood, research assistant1,
  3. Morven Leese, statistician1,
  4. Graham Thornicroft, professor of community psychiatry1,
  5. Kim Sutherby, consultant psychiatrist2,
  6. George Szmukler, dean3
  1. 1 Health Services Research Department, Institute of Psychiatry, King's College London, London SE5 8AF
  2. 2 South London and Maudsley NHS Trust, Croydon CR0 1XT
  3. 3 Institute of Psychiatry, King's College London, London
  1. Correspondence to: C Henderson
  • Accepted 6 May 2004


Objective To investigate whether a form of advance agreement for people with severe mental illness can reduce the use of inpatient services and compulsory admission or treatment.

Design Single blind randomised controlled trial, with randomisation of individual patients. The investigator was blind to allocation.

Setting Eight community mental health teams in southern England.

Participants 160 people with an operational diagnosis of psychotic illness or non-psychotic bipolar disorder who had experienced a hospital admission within the previous two years.

Intervention The joint crisis plan was formulated by the patient, care coordinator, psychiatrist, and project worker and contained contact information, details of mental and physical illnesses, treatments, indicators for relapse, and advance statements of preferences for care in the event of future relapse.

Main outcome measures Admission to hospital, bed days, and use of the Mental Health Act over 15 month follow up.

Results Use of the Mental Health Act was significantly reduced for the intervention group, 13% (10/80) of whom experienced compulsory admission or treatment compared with 27% (21/80) of the control group (risk ratio 0.48, 95% confidence interval 0.24 to 0.95, P = 0.028). As a consequence, the mean number of days of detention (days spent as an inpatient while under a section of the Mental Health Act) for the whole intervention group was 14 compared with 31 for the control group (difference 16, 0 to 36, P = 0.04). For those admitted under a section of the Mental Health Act, the number of days of detention was similar in the two groups (means 114 and 117, difference 3, −61 to 67, P = 0.98). The intervention group had fewer admissions (risk ratio 0.69, 0.45 to 1.04, P = 0.07). There was no evidence for differences in bed days (total number of days spent as an inpatient) (means 32 and 36, difference 4, −18 to 26, P = 0.15 for the whole sample; means 107 and 83, difference −24, −72 to 24, P = 0.39 for those admitted).

Conclusions Use of joint crisis plans reduced compulsory admissions and treatment in patients with severe mental illness. The reduction in overall admission was less. This is the first structured clinical intervention that seems to reduce compulsory admission and treatment in mental health services.


  • Embedded Image The training pack for the development of a joint crisis plan can be found on

    We thank all participants, their informal carers, and care staff for their help in conducting the study.

  • Contributors CH, CF, ML, GT, GS, and KS designed and performed the study. CH and ML did the statistical analysis. GT is the guarantor.

  • Funding CH was supported by a Medical Research Council training fellowship in health services research, and CF was supported by a South London and Maudsley Trust health services research committee grant.

  • Competing interests None declared.

  • Ethical approval Ethics Committees of the South London and Maudsley NHS Trust, Lewisham University Hospital, South West London and Saint George's NHS Trust, and Thames Gateway NHS Trust.

  • Accepted 6 May 2004
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