Good mental health care should involve the patient in determining their treatment, and should involve the least restrictive form of care possible. Although the Care Programme Approach (CPA) has resulted in patients in England routinely participating in planning their care, compulsory admissions to psychiatric hospitals have continued to rise over the past decade. Involuntary treatment is generally regarded by patients as a negative experience, and they tend to describe it as unjustified.
In an attempt to reduce the number of compulsory admissions, a group of clinicians and researchers from London, Birmingham and Manchester developed a Joint Crisis Plan (JCP) [In the interests of full disclosure, I have worked and continue to work closely with the Birmingham-based authors]. This plan is developed by the patient and staff together, and contains the patient’s treatment preferences in the case of a psychiatric emergency. The idea behind this is that such planning will improve the early detection and treatment of relapse and avoid the need for compulsory detention.
Although two small studies published in 1999 (Sutherby, 1999) and 2004 (Henderson, 2004) suggested that the JCP approach was efficacious in reducing compulsory admissions, neither was a definitive trial, and neither tested how well JCP could be implemented into general clinical practice.
The authors conducted a single-blind, randomised controlled trial comparing the effectiveness of Joint Crisis Plans (JCPs) with treatment as usual (TAU) for people with severe mental illness. Patients were eligible if they had a relapsing psychotic illness, had been admitted to a psychiatric facility in the previous 2 years, were aged over 16, and were registered on the integrated care system for people with complex mental health needs, the Enhanced Care Programme Approach.
In order to maximise the generalizability of the sample, only current inpatients or those detained under the Mental Health Act were excluded, meaning that translation services were used for those without sufficient English. Patients were followed up 18 months after randomisation.
The primary outcome measure was number of compulsory admissions; secondary outcome measures included number of psychiatric admissions, length of stay, therapeutic relationship, and level of engagement.
569 patients were recruited in roughly equal proportions across the three research sites from more than 5,700 assessed for eligibility (284 received TAU, 285 received JCP).
On an intention-to-treat analysis, there were no significant differences in the primary outcome measure; 56 (20%) of the TAU group and 49 (18%) of the JCP group were admitted compulsorily over the research period, with a mean duration of 20.6 (SD 73.4) days in the TAU group and 22.3 (SD 72.0) days in the JCP group (p-0.63).
There were also no significant differences on any of the secondary outcome measures, with the exception of patient-rated therapeutic relationship, which showed a slight but significant advantage for the JCP group (p=0.049).
An important part of the data collection phase was a qualitative section consisting of focus groups with patients, care coordinators and both together. These groups reported that patients in the JCP group felt more respected and understood by clinicians, and that some clinicians gained a wider understanding of the views of patients.
However, they also demonstrated that poor engagement with the development and implementation of the JCP was commonplace – a surprising finding given that the fidelity rating for the intervention averaged 86% across all sites. Clinicians frequently considered care planning to be a bureaucratic exercise with little clinical benefit.
Strengths and limitations
The study represents a very well powered clinical trial to detect an effect of Joint Crisis Plans on reducing the number of compulsory admissions to psychiatric care. The basis for the study was sound, and fidelity to the intervention was high. Yet it appears that clinician engagement in the intervention was poor. In a third of cases, the full clinical team was not present when the JCP was discussed. In focus groups many patients complained that the content of the JCP was not followed during a subsequent crisis. Clearly, as the authors themselves admit, failure to take account of local staff, organisational context or readiness for the introduction of a complex intervention is likely to have been a crucial limitation.
This trial showed no evidence of effectiveness for the Joint Crisis Plan in reducing compulsory admissions. However, the clear problems with implementing the intervention into routine clinical care demonstrate the difficulties of translating an efficacious treatment into effective practice.
There is a danger that with the publication of this negative study that the earlier positive pilot data will be ignored. There is a strong case for revisiting the JCP approach, but if this is to be successful then there needs to be greater focus on the engagement of clinical teams. In particular, the study needs to have time during the set-up phase to assess attitudes and organisational readiness, and this needs to be constantly monitored throughout the trial. Development of a new fidelity measure will also be required. By improving these aspects of the study, the outcome of a new trial will more accurately indicate the value of the JCP approach.
Thornicroft G, Farrelly S, Szmukler G, Birchwood M, Waheed W, Flach C, Barrett B, Byford S, Henderson C, Sutherby K, Lester H, Rose D, Dunn G, Leese M, Marshall M. Clinical outcomes of Joint Crisis Plans to reduce compulsory treatment for people with psychosis: a randomised controlled trial. Lancet. 2013 Mar 25. pii: S0140-6736(13)60105-1. doi: 10.1016/S0140-6736(13)60105-1. [Epub ahead of print] [PubMed abstract]
Sutherby K, Szmukler GI, Halpern A, Alexander M, Thornicroft G, Johnson C, Wright S. A study of ‘crisis cards’ in a community psychiatric service. Acta Psychiatr Scand. 1999 Jul;100(1):56-61. [PubMed abstract]
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 Jul 17;329(7458):136. Epub 2004 Jul 7.