Joint crisis plans for people with psychosis: economic evaluation of a randomised controlled trial

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(unpublished data available from the authors), as well as the baseline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

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

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