Crisis-planning interventions for people with psychotic illness or bipolar disorder: systematic review and meta-analyses

Abstract

Background Mental health services lack a strong evidence base on the most effective interventions to reduce compulsory admissions. However, some research suggests a positive impact of crisis-planning interventions in which patients are involved in planning for their future care during a mental health crisis. Aims This review aimed to synthesise randomised controlled trial (RCT) evidence on the effectiveness of crisis-planning interventions (for example advance statements and joint crisis plans) in reducing rates of compulsory hospital admissions for people with psychotic illness or bipolar disorder, compared with usual care (PROSPERO registration number: CRD42018084808). Method Six online databases were searched in October 2018. The primary outcome was compulsory psychiatric admissions and secondary outcomes included other psychiatric admissions, therapeutic alliance, perceived coercion and cost-effectiveness. Bias was assessed using the Cochrane collaboration tool. Results The search identified 1428 studies and 5 RCTs were eligible. One study had high risk of bias because of incomplete primary outcome data. Random-effects meta-analysis showed a 25% reduction in compulsory admissions for those receiving crisis-planning interventions compared with usual care (risk ratio 0.75, 95% CI 0.61–0.93, P = 0.008; from five studies). There was no statistical evidence that the intervention reduced the risk of voluntary or combined voluntary and compulsory psychiatric admissions. Few studies assessed other secondary outcomes. Conclusions Our meta-analysis suggests that crisis-planning interventions substantially reduce the risk of compulsory admissions among individuals with psychotic illness or bipolar disorder. Despite common components, interventions varied in their content and intensity across the trials. The optimal models and implementation of these interventions require further investigation. Declaration of interest E.M., S.L., S.J. and B.L.-E. received funding from the National Institute for Health Research during the conduct of the study.

The PACT advance decision-making template: preparing for Mental Health Act reforms with co-production, focus groups and consultation

“…The PACT is a model with explicit space and guidance for personalised input into medico-legal assessment, while also allowing ‘authentication’ of the document itself, through elements such as documented assessment of capacity when drafting and specification of review period. They are also designed to challenge the model of ADM as primarily a tool to avoid compulsory treatment ( de Jong et al, 2016 ; Molyneaux et al, 2019 ), by identifying and faciliating diverse outcomes; building, for example, on law reform supporting ‘self-binding’ in jurisdictions such as the Netherlands and Washington State ( Berghmans & van der Zanden, 2012 ; Varekamp, 2004 ).…”

“…Advance decision making (ADM) for mental health crises is widely approved, but under-used and under-resourced, particularly when compared to ADM in physical healthcare settings. Existing research on ADM in severe mental illness (SMI) has confirmed interest amongst key stakeholders ( Hindley et al, 2019 ; Swanson, Swartz, Ferron, Elbogen, & van Dorn, 2006b ), together with some effectiveness in reducing coercion and increasing therapeutic alliance ( de Jong et al, 2016 ; Molyneaux et al, 2019 ; Thornicroft et al, 2013 ). However, difficulties in achieving uptake, engagement with legal provision and successful implementation are consistent ( Hindley et al, 2019 ; Morriss, Mudigonda, Bartlett, Chopra, & Jones, 2017 ; Swanson et al, 2006b ) and there is limited exploration of the diversity of potential outcomes beyond a reduction in compulsory admission.…”

Efficacy of interventions to reduce coercive treatment in mental health services: umbrella review of randomised evidence

“…1). [40][41][42][43][44][45][46][47][48][49] From these ten systematic reviews we retained and included in statistical re-analysis the three non-overlapping systematic reviews with the largest number of component studies ( Fig. 1 and supplementary material).…”

Advance decision-making in mental health – Suggestions for legal reform in England and Wales

“…De Jong et al (2016) includes two additional larger studies, which individually report no overall reduction in compulsory treatment, and conclude, somewhat confusingly, that there is a clinically significant reduction in compulsory admissions. A systematic review and meta-analysis commissioned by the IRMHA reported that crisis planning interventions, such as advance directives, reduced compulsory admissions but not voluntary or overall admissions (Molyneaux et al, 2018).…”