ObjectiveTo establish whether patients with a crisis plan had fewer voluntary or involuntary admissions, or fewer outpatient emergency visits, than patients without such a plan.DesignMulticenter randomized controlled trial with two intervention conditions and one control condition.ParticipantsAdult outpatients diagnosed with psychotic or bipolar disorder who had experienced at least one psychiatric crisis in the previous two years.InterventionTwo types of advance statement were used: (1) a crisis plan formulated by the patient with the help of a patient advocate (Patient Advocate Crisis Plan: PACP); and (2) a crisis plan developed together with the clinician (Clinician-facilitated Crisis Plan: CCP).OutcomeThe percentages of patients admitted voluntarily or involuntarily (on an emergency basis or by court order), and the percentage who made outpatient emergency visits over an 18-month follow-up period.ResultsA total of 212 patients were included: 69 in the PACP condition, 70 in the CCP condition, and 73 in the control condition. No effects of the two interventions were found on the numbers of voluntary admissions, involuntary admissions and emergency visits. Regarding involuntary admissions, there was no significant effect on emergency admissions, which were 17% (12/69) in the PACP condition, 10% (7/70) in the CCP condition, and 19% (14/73) in the control condition. There was a significant effect on planned court-ordered admissions, with 16% (11/69) in the PACP condition, 10% (7/70) in the CCP condition, and 26% (19/73) in the control condition. Finally, the interventions had no effect on outpatient emergency visits, with 32% (22/69) in the PACP group, 31% (22/70) in the CCP group, and 34% (25/73) in the control group.ConclusionsCrisis plans may be an effective intervention for reducing court-ordered admissions in patients with psychotic and bipolar disorders.Trial registrationCurrent Controlled Trails NTR1166.

Our evidence supports the importance of model fidelity for improving patient outcomes.

BackgroundDue to fragmented mental, somatic, and social healthcare services, it can be hard to engage into care older patients with severe mental illness (SMI). In adult mental health care, assertive community treatment (ACT) is an organizational model of care for treating patients with SMI who are difficult to engage. So far all outcome studies of assertive community treatment have been conducted in adults.MethodsIn a randomized controlled trial design we compared the effectiveness of ACT for elderly patients with that of treatment as usual (TAU). Sixty-two outpatients (60 years and older) with SMI who were difficult to engage in psychiatric treatment were randomly assigned to the intervention or control group (32 to ACT for elderly patients and 30 to TAU). Primary outcomes included number of patients who had a first treatment contact within 3 months, the number of dropouts (i.e. those discharged from care due to refusing care or those who unintentionally lost contact with the service over a period of at least 3 months); and patients’ psychosocial functioning (HoNOS65+ scores) during 18 months follow-up. Secondary outcomes included the number of unmet needs and mental health care use. Analyses were based on intention-to-treat.ResultsOf the 62 patients who were randomized, 26 were lost to follow-up (10 patients in ACT for elderly patients and 16 in TAU). Relative to patients with TAU, more patients allocated to ACT had a first contact within three months (96.9 versus 66.7%; X2 (df = 1) = 9.68, p = 0.002). ACT for elderly patients also had fewer dropouts from treatment (18.8% of assertive community treatment for elderly patients versus 50% of TAU patients; X2 (df = 1) = 6.75, p = 0.009). There were no differences in the other primary and secondary outcome variables.ConclusionsThese findings suggest that ACT for elderly patients with SMI engaged patients in treatment more successfully.Trial registrationNTR1620

BackgroundIllness Management and Recovery (IMR) is intended to provide a structured psychosocial programme that helps to manage the disabling effects of severe mental illnesses such as schizophrenia and bipolar disorders. It is curriculum based and aims to improve different aspects of illness management and recovery through interventions such as goal-setting, psycho-education, coping and social skills training. Its overall aim is to improve illness outcomes and support subjective and objective recovery. To date there have been four RCTs on IMR; as these yielded mixed results, further research is needed. Our hypotheses aim to test the interrelatedness assumed in Mueser’s Conceptual Framework for IMR for the many aspects of illness management, illness management outcomes and recovery.Methods/designThis randomised multi-centre, single-blinded clinical trial is intended to compare IMR with treatment as usual for 200 outpatient clients with a severe and persistent mental illness (SMI). We will investigate whether IMR leads to better illness management, fewer symptoms and fewer relapses, and also to better subjective and objective recovery. The primary outcome measure is the score on the client version of the Illness Management and Recovery Scale. Secondary outcome measures are the clinician version of the Illness Management and Recovery scale, measures of illness management, coping, symptoms, the number of relapses, and measures of recovery. Measurement will take place before randomisation, and 12 and 18 months after randomisation.DiscussionOverall, our study has the following strengths: 1.) our use of an RCT design in a country where the earlier RCTs on IMR were not conducted; 2.) the fact that participants will consist not only of people with a diagnosis of schizophrenia, but also of those with various types of SMI; 3.) our inclusion of 200 participants; and 4.) the fact that we will explore the working mechanisms described in Mueser’s Conceptual Framework for IMR. Finally, 5.) because the RCT will be conducted in everyday clinical practice, we believe that the generalisability of our results will be good.Trial registrationThe Netherlands National Trial Register (identifier: NTR 5033). Date registered: 13 January 2015.