Home treatment for acute mental healthcare: randomised controlled trial

Coercive Measures in Psychiatry Can Hardly Be Justified in Principle Any Longer-Ethico-Legal Requirements Versus Empirical Research Data and Conceptual Issues

AIM

To review the scientific and empirical evidence that is usually accepted for the ethical and legal justification of coercion in psychiatry.

METHOD

Five key criteria are examined as follows: (1) the demonstrable existence of a mental disorder; (2) the effectiveness of psychiatric measures; (3) the use of coercion as last resort and as least possible restriction; (4) the benefit of the person affected by the coercive measure and (5) the restoration of the affected person's autonomy.

RESULTS

(1) The existence of a demarcation between a mentally ill and a mentally healthy state cannot be confirmed; (2) Pharmacological and psychotherapeutic interventions in psychiatry are not even moderately effective; (3) Coercive measures are usually not used as last resort and as least restrictive measure; (4) Most people affected by psychiatric coercion do not benefit from the measures; (5) It is at least unclear whether autonomy is affected by a mental illness and whether it can be restored through a coercive psychiatric measure.

DISCUSSION

None of the central ethical and legal criteria for the use of coercion in psychiatry are clearly and unambiguously fulfilled according to current research.

IMPLICATIONS

Psychiatric coercion can hardly be justified any longer.

Can a crisis resolution team replace an inpatient ward? Results from a French quasi-experimental study

BACKGROUND

Though promising, the implementation of crisis resolution teams has been unequal across Europe. In France, their deployment is currently receiving interest but there is to date no national policy and the research is scarce.

METHODS

In the present study a psychiatric service converted one of its two inpatient wards into a crisis resolution team (EPSIAD) enabling a quasi-experimental naturalistic design. Variables on admissions, length of hospital stay and patient satisfaction were collected and analysed in the year preceding and the year following the conversion.

RESULTS

In the year following the EPSIAD implementation, there were more admissions of female patients (41.0% vs 49.5%, p = 0.0262), a five-day decrease in the length of hospital stay (p < 0.0001) and increased patient satisfaction, with a particular increase in clarity of information, quality of the relationship with the care staff and service and feeling involved in medical decisions (p < 0.0001).

CONCLUSIONS

The results of the present study indicate that the combination of a hospital ward with a crisis resolution team has the potential to increase global quality of care by providing a complementary mental health service. Crisis resolution teams may provide a viable alternative to hospitalisation that increases patient satisfaction and allows new patients to receive intensive care, with women especially benefiting from care at home. There is a need to cater for patients refusing psychiatric care altogether and hospital inpatient wards might specialise in involuntarily-admitted patient care.

Economic evaluation of intensive home treatment in comparison to care as usual alongside a randomised controlled trial

BACKGROUND

There is a dearth of research on the cost-effectiveness of intensive home treatment (IHT), an alternative to psychiatric hospitalisation for patients experiencing psychiatric crises. We therefore present a health economic evaluation alongside a pre-randomised controlled trial of IHT compared to care as usual (CAU).

METHOD

Patients were pre-randomised to IHT or CAU using a double-consent open-label Zelen design. For the cost-utility analysis, the EuroQol 5-dimensional instrument was used. The cost-effectiveness was assessed using the Brief Psychiatric Rating Scale (BPRS).

RESULTS

Data of 198 patients showed that each additional QALY gained from offering IHT instead of CAU was on average associated with an extra cost of €48,003. There is a 38% likelihood that IHT will lead to more QALYs at lower costs compared to CAU. An improvement of one additional point on the BPRS by offering IHT instead of CAU was associated with an extra cost of €19,203. There is a 38% likelihood that IHT will lead to higher BPRS score improvements at lower costs. Based on the NICE willingness-to-pay threshold of £30,000 (€35,000) per QALY, IHT could potentially be considered cost-effective with a likelihood of 55-60% when viewed from a societal perspective, and > 75% from a health care perspective.

CONCLUSIONS

IHT appears slightly more attractive in terms of cost-utility and cost-effectiveness than CAU, although differences in both costs and effects are small especially when viewed from the societal costs perspective. From the health care sector costs perspective, IHT has a higher probability of being cost-effective compared to CAU.

TRIALS REGISTRATION

Netherlands Trial Register: NTR6151.

[Developing An Initial Best Practice Model For Inpatient Equivalent Psychiatric Home Treatment From The Perspective Of Service Users: Consensus Process With Participatory Features]

AIM

Inpatient-Equivalent Home Treatment (IEHT) for mental health is new in Germany and therefore requires quality development. A best practice model (BPM) for IEHT is being developed from a service user perspective.

METHODS

1. Collection and organization of evidence (literature review; n=55 interviews with service users), 2. qualitative analysis and formulation of criteria; 3. consensus and grouping of criteria (Delphi process).

RESULTS

58 Best practice criteria were developed in 8 groups: 1. Information, access and crisis management; 2. Treatment framework, end of treatment and continuity; 3. Scheduling, organization of contacts and flexibility; 4. Practical support and activation; 5. Treatment and therapy services; 6. Treatment team and staff; 7. Relatives, caregivers and community; and 8. Privacy and behavior in the home environment.

CONCLUSION

The BPM provides initial guidance for a user-centered assessment of the implementation of IEHT.

Exploring correlates of high psychiatric inpatient utilization in Switzerland: a descriptive and machine learning analysis

BACKGROUND

This study investigated socio-demographic, psychiatric, and psychological characteristics of patients with high versus low utilization of psychiatric inpatient services. Our objective was to better understand the utilization pattern and to contribute to improving psychiatric care.

METHODS

One-hundred and twenty inpatients of the University Psychiatric Clinics (UPK) Basel, Switzerland, participated in this cross-sectional study. All patients were interviewed using different clinical scales. As target variables we investigated the number of days of psychiatric inpatient treatment within a 30-month period.

RESULTS

Despite including multiple relevant patient variables and using elaborate statistical models (classic univariate und multiple regression, LASSO regression, and non-linear random forest models), the selected variables explained only a small percentage of variance in the number of days of psychiatric inpatient treatment with cross-validated R 2 values ranging from 0.16 to 0.22. The number of unmet needs of patients turned out to be a meaningful and hence potentially clinically relevant correlate of the number of days of psychiatric inpatient treatment in each of the applied statistical models.

CONCLUSIONS

High utilization behavior remains a complex phenomenon, which can only partly be explained by psychiatric, psychological, or social/demographic characteristics. Self-reported unmet patient needs seems to be a promising variable which may be targeted by further research in order to potentially reduce unnecessary hospitalizations or develop better tailored psychiatric treatments.

Psychosocial Care Delivery in Intensive Home Treatment During a Mental Health Crisis: A Qualitative Thematic Analysis

Community-based intensive home treatment (IHT) is delivered as an alternative to psychiatric hospital admission as part of crisis resolution services. People receiving IHT present with complex mental health issues and are acutely distressed. Home treatment options are often preferred and there is evidence of service fidelity, although less is known about psychosocial care in this setting. Underpinned by a critical realist epistemology, this study aimed to explore psychosocial care in the context of home treatment from the perspectives of staff, service users and family carers. Data were collected using individual interviews and focus groups in two NHS organisations in England. An inductive qualitative thematic analysis resulted in five themes focused on (1) the staffing model and effective care provision, (2) the organisation of work and effective care provision, (3) skills and training and service user need, (4) opportunities for involvement and personal choice, and (5) effective communication. Findings suggest that co-production may improve congruence between IHT service design, what service users and carers want and staff ideals about optimal care. Service designs that optimise continuity of care and effective communication were advocated. Staff training in therapeutic interventions was limited by not being tailored to the home treatment context. Evidence gaps remain regarding the most effective psychosocial care and related training and supervision required. There is also a lack of clarity about how carers and family members ought to be supported given their often-crucial role in supporting the person between staff visits.

Utilization of Psychiatric Hospital Services Following Intensive Home Treatment: A Nonrandomized Clinical Trial

Importance

Home treatment (HT) has been associated with fewer inpatient treatment (IT) readmission days but lacks evidence on reducing combined psychiatric hospital service use (IT, HT, day clinic).

Objective

To assess the association of intensive home treatment (IHT) compared with IT regarding readmission rate, social outcomes, and clinical outcomes.

Design, Setting, and Participants

This quasi-experimental, nonrandomized trial was conducted from 2020 to 2022 in 10 psychiatric hospitals in Germany. Propensity score (PS) matching was used to compare both treatment models at the 12-month follow-up using standardized instruments and routine hospital data. All patients were screened until the target sample size was reached, based on these criteria: stable residence with privacy for sessions, no child welfare risk, primary diagnosis within International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes F0X to F6X, residence in the catchment area, no commitment order, no acute suicidality or severe aggression requiring hospitalization, capacity to consent, not participating in other interventional studies, sufficient German language skills, no substantial cognitive deficits or intellectual impairment, and no more than 7 days in IHT or IT before recruitment. Statistical analysis was performed from February to November 2023.

Intervention

IHT provided daily acute psychiatric treatment at home, while IT was psychiatric inpatient treatment as usual. The mean treatment duration of the index treatment was 37.2 days for IHT and 28.2 days for IT.

Main Outcomes and Measures

The inpatient readmission rate was the primary outcome. Secondary outcomes were combined readmission rate, total inpatient days, job integration, quality of life, psychosocial functioning, symptom severity, and recovery.

Results

Of 1396 individuals, 200 patients receiving IHT and 200 patients receiving IT were included (264 female [65%]; mean [SD] age, 45.45 [15.83] years [range, 18-88 years]). Baseline sociodemographic and psychometric characteristics did not differ significantly between the groups. At 12-month follow-up, patients in the IHT group had lower inpatient readmission rate (IHT vs IT: 31.12% vs 49.74% IT; mean difference, 18% [95% CI, 9%-28%; P < .001), combined readmission rate (mean difference, 13% [95% CI, 4%-24%; P < .001), and fewer inpatient days (mean difference, 6.82 days; P < .001) than the IT group.

Conclusions and Relevance

This nonrandomized clinical trial found that patients receiving IHT had a lower likelihood of utilizing hospital-based psychiatric services and spent fewer inpatient days, suggesting that IHT is a viable alternative to IT.

Trial Registration

ClinicalTrials.gov Identifier: NCT04745507.

Who Benefits from Acute Psychiatric Home Treatment? A Systematic Review

Home treatment (HT) treats patients in an acute crisis through an interdisciplinary team with daily appointments for a short treatment period. The effectiveness of HT has already been confirmed. However, only few studies addressed specific patient characteristics associated outcome of treatment. This study aimed to identify patient characteristics associated with successful outcomes of HT. A systematic literature search was conducted according to the PRISMA guidelines. A total of 13 studies were included in the systematic review. Being employed, having a regular income, having an anxiety disorder and family involvement were associated with a successful treatment outcome in HT. High symptom severity and former hospital admissions were associated with unsuccessful treatment outcome in HT in the selected studies. HT seems to be especially beneficial for patients with paid employment or regular income, patients with anxiety disorders, and patients with familial or other social support.

Is it possible to predict hospitalisation during intensive home treatment? A retrospective cohort study

OBJECTIVE

Intensive Home Treatment (IHT) is an alternative to acute inward treatment. The objective of this study was to assess which variables predict that a patient admitted to IHT required transfer to hospital for inward management.

METHODS

We included the first 1000 episodes admitted to IHT and looked for crude associations between potential predictive factors and transfer to hospital. Then, we built a predictive model for this outcome.

RESULTS

The patients with a higher risk of transfer to hospital were those who had previous hospitalisations (OR = 2.6; 95% CI = 1.4-4.7), more admissions in the previous 5 years (median= 0, IQR = 0-1 vs. median = 0, IQR = 0-1.5; p = 0.0011) and a higher clinical severity at IHT admission (mean difference = 0.36; p50 = 0, IQR = 0-1.5 vs. p50 = 0, IQR = 0-1; p = 0.0011). The predictive model included age, previous admissions, clinical severity at IHT admission, and substance use at the beginning of the episode but had a low performance (R2 = 0.115; AUC = 0.752, 95% CI: 0.690-0.814).

CONCLUSION

Our results are consistent with those from previous studies in countries with different mental health systems. Far from cautioning us against using IHT in patients with severe symptoms or previous hospitalisations, these results should encourage us to find ways to offer them greater support at home.

A Change of Paradigm in the Management of Acute Psychiatric Episodes? A Retrospective Cohort Study on Trajectories of Use of Clinical Resources After the Implementation of Intensive Home-Treatment

Intensive home treatment (IHT) has shown to be a feasible alternative to hospitalization for the management of acute psychiatric episodes, but there are no real-world studies assessing if patients with a first IHT use it again for the management of their recurrences. The objectives of this retrospective cohort study were to map the use ofacute treatment resources after the implementation of IHT in our territory through the establishment of trajectories of management, and to disentangle if there are profiles of patients who fit better each trajectory. We included the first 1000 episodes admitted to IHT, of which we selected those that corresponded to the first IHT of a patient (index admission). Trajectories after the index admission were: (T-A) absence of use of acute resources, (T-B) only IHT, and (T-C) at least one hospitalization. Follow-up ranged from 6 months to 6 years. We calculated the frequency of each trajectory and performed univariate analyses searching for associations between trajectory and clinical factors. Among those patients with psychiatric history (N = 659), 66.2% followedT-A, 11.2% T-B, and 22.6% T-C. The probability of following T-C was higher for patients with a psychotic disorder (pBonf = 0.018) and with previous hospitalizations (pBonf < 0.0001). Among those patients without psychiatric history (N = 168), 82.7% followed T-A, 6.6% T-B, and 10.7% T-C. The probability of following T-B was higher for those with a higher severity at the index admission (pBonf = 0.028). This study shows that some -or even all- recurrences of some subjects were successfully managed with IHT, providing real-world evidence for its use in acute psychiatric conditions.

Implementation of a crisis resolution team service improvement programme: a qualitative study of the critical ingredients for success

BACKGROUND

Crisis Resolution Teams (CRTs) offer home-based care for people in mental health crisis, as an alternative to hospital admission. The success of CRTs in England has been variable. In response to this, the CRT Optimization and RElapse prevention (CORE) study developed and trialled a 12-month Service Improvement Programme (SIP) based on a fidelity model. This paper describes a qualitative evaluation of the perspectives of CRT staff, managers, and programme facilitators. We identify barriers and facilitators to implementation, and mechanisms by which service improvements took place.

METHODS

Managers and staff from six purposively sampled CRTs were interviewed, as well as six facilitators who were employed to support the implementation of service improvement plans. Semi-structured focus groups and individual interviews were conducted and analysed using thematic analysis.

FINDINGS

A majority of participants viewed all components of the SIP as helpful in improving practice, although online resources were under-used. Perceived barriers to implementation centred principally around lack of staff time and ownership. Support from both senior staff and facilitators was essential in enabling teams to undertake the work associated with the SIP. All participating stakeholder groups reported that using the fidelity model to benchmark their CRT work to best practice and feel part of a 'bigger whole' was valuable.

CONCLUSION

CRT staff, managers and programme facilitators thought that a structured service improvement programme helped to increase fidelity to a best practice model. Flexibility (from all stakeholders) was key to enable service improvement actions to be manageable within time- and resource-poor teams.

Local government spending and mental health: Untangling the impacts using a dynamic modelling approach

This study investigated the impact of local government spending on mental health in England between 2013 and 2019. Guided by the "Health in All Policies" vision, which encourages the integration of health in all decision-making areas, we explored how healthcare and multiple nonmedical budgeting decisions related to population mental health. We used random curve general cross-lagged modelling to dynamically partition effects into the short-run (from t to t + 1) and long-run (from t to t + 2) impacts, account for unobserved area-level heterogeneity and reverse causality from health outcomes to financial investments, and comprehensive modelling of budget items as an interconnected system. Our findings revealed that spending in adult social care, healthcare, and law & order predicted long-term mental health gains (0.004-0.081 SDs increase for each additional 10% in expenditure). However, these sectors exhibited negative short-term impulses (0.012-0.077 SDs decrease for each additional 10% in expenditure), markedly offsetting the long-term gains. In turn, infrastructural and environmental spending related to short-run mental health gains (0.005-0.031 SDs increase for each additional 10% in expenditure), while the long-run effects were predominantly negative (0.005-0.028 SDs decrease for each additional 10% in expenditure). The frequent occurrence of short-run and long-run negative links suggested that government resources may not be effectively reaching the areas that are most in need. In the short-term, negative effects could also imply temporary disruptions to service delivery largely uncompensated by later mental health improvements. Nonetheless, some non-health spending policies, such as law & order and infrastructure, can be related to long-lasting positive mental health impacts.

[Inpatient Equivalent Home Treatment (IEHT) compared to inpatient psychiatric treatment: 12-month follow-up results of a retrospectively matched cohort study using propensity score]

AIM OF THE STUDY

Comparison of psychiatric services use in the 12-month follow-up period between Inpatient Equivalent Home Treatment (IEHT) and inpatient psychiatric treatment.

METHODS

In a retrospective 12-month follow-up study, 223 patients from the Inpatient Equivalent Home Treatment (IEHT) intervention group (IG) were compared to a matched inpatient control group (CG) on their utilization of psychiatric services.

RESULTS

The inpatient readmission rate in the IG was significantly 11% lower than in the CG. The number of treatment days in the IG was significantly lower than in the CG. In the IG, psychiatric services at the outpatient clinic were used significantly more often for the first time than in the CG.

CONCLUSION

The present study suggests that IEHT is superior to inpatient treatment in terms of the risk of inpatient readmission and the duration of inpatient treatment days. An outpatient services use effect following IEHT is observed.

Professional relationships during crisis interventions: A scoping review

INTRODUCTION

A crisis can be described as subjective experience that threatens and overwhelms a person's ability to handle a specific situation. In dealing with crises some people are looking for support from professionals. The "professional relationship" between people experiencing a crisis and professionals plays an important role in the successful management of a crisis which has been widely researched in many contexts. However, regarding outpatient services (e. g. crisis resolution home treatment teams), yet empirical evidence remains limited.

OBJECTIVE

We aim to explore descriptions of supportive professional relationships during outpatient crisis interventions in empirical literature. Accordingly, a scoping review was conducted to identify types of evidence, map the key concepts, and point out research gaps.

METHODS

MEDLINE, PsycINFO, CINAHL and Social Science Citation Index were searched for studies reporting empirical data on the professional relationship between people experiencing a crisis (18+) and professionals (e. g. social workers, psychiatrists) during a crisis intervention, defined as a short-term, face-to-face, low threshold, time-limited, outpatient, and voluntary intervention to cope with crises. Studies were excluded if they were published before 2007, in languages other than English and German, and if they couldn't be accessed. Included studies were summarized, compared, and synthesized using qualitative content analyses.

RESULTS

3.741 records were identified, of which 8 met the eligibility criteria. Only one study directly focused on the relationship; the others addressed varied aspects. Two studies explored the perspectives of service users, five focused on those of the professionals and one study examined both. The empirical literature was categorized into three main themes: strategies used to develop a supportive professional relationship, factors influencing the relationship and the nature of these relationships.

DISCUSSION

The results reveal a gap in understanding the nature of supportive professional relationships from the service users' perspective, as well as how professionals construct these relationships.

Prescriptive factors for intensive home treatment in acute psychiatry: a secondary analysis of a randomised controlled trial

BACKGROUND

Intensive home treatment (IHT) aims to prevent psychiatric hospitalisation. Although this intervention is well tested, it is still unknown for whom this intervention works best. Therefore, this study aims to explore prescriptive factors that moderate the effect of IHT compared to care as usual (CAU) on symptom severity.

METHODS

Using data from a randomised controlled trial, 198 participants that experience an exacerbation of acute psychiatric symptoms were included in this secondary analysis. In order to maximise clinical relevance, generally available environmental and clinical baseline factors were included as tentative moderators: age, gender, employment status, domestic situation, psychiatric disorders, psychological symptoms, psychosocial functioning, alcohol and other substance use. The outcome variable symptom severity was measured using the Brief Psychiatric Rating Scale (BPRS) and collected at 26 and 52 weeks post-randomisation. Multiple regression analysis was used to examine which participants' characteristics moderate the effect of IHT on the total BPRS score.

RESULTS

Our results suggest that being employed (B = 0.28, SE = 0.13, 95% CI = 0.03-0.53, p = 0.03) at baseline seems to have a moderation effect, which result in lower symptom severity scores at 26 weeks follow-up for patients who received IHT. This effect was not found at 52 weeks.

CONCLUSIONS

On the basis of the number of factors tested, there is no evidence for robust outcome moderators of the effect of IHT versus CAU. Our conclusion is therefore that IHT can be offered to a diverse target population with comparable clinical results.

TRIAL REGISTRATION

This trial is registered (date of registration: 2016-11-23) at the international clinical trials registry platform (NTR6151).

Study protocol of an observational study in acute psychiatric home treatment: How does home treatment work? Identification of common factors and predictors of treatment success

BACKGROUND

Systematic reviews indicated that home treatment is an effective and cost-saving alternative to conventional acute psychiatric treatment options. Treatment success has often been defined as a reduction of hospital admissions. In the current study, symptoms and well-being are assessed regularly during treatment as an indicator for treatment success. Patients' characteristics such as diagnosis, age, substance use, and motivation for treatment were discussed as predictors for treatment success. A second focal point of the study lies in the examination of the therapeutic relationship in terms of the outcome, which has not yet been systematically investigated in home treatment.

METHODS

This is an observational study with a prospective naturalistic design. Measurements are carried out at baseline, during and at the end of treatment as well as at the 3‑month follow-up. Patients' characteristics as potential predictors for treatment success will be assessed at baseline. In addition, the perceived relationship between the patients and the team will be measured daily and weekly throughout the treatment. Treatment success is by the changes in symptoms and general well-being assessed weekly. We aim to include 82 participants assigned to home treatment. Variance analyses with repeated measurements will be conducted to evaluate treatment success.

CONCLUSION

By examining potential patient- and relationship-related predictors of treatment success, insights into relevant determining variables of treatment success in this setting are expected. The results might help to better identify who benefits the most from home treatment.

The clinical impact of a crisis resolution home treatment team

OBJECTIVES

To evaluate the impact of treatment provided by a Crisis Resolution Home Treatment Team (CRHTT) in terms of preventing hospital admission, impact on service user's symptoms and overall functioning, as well as service user's satisfaction with the service. Secondary objectives were to evaluate the patient characteristics of those attending the CRHTT.

METHODS

All the service users treated by the CRHTT between 2016 and 2020 were included. Service users completed the Brief Psychiatric Rating Scale (BPRS), the Health of the Nation Outcome Scale (HoNOS), and the Client Satisfaction Questionnaire-version 8 (CSQ-8) before and after treatment by the CRHTT. Admission rates were compared between areas served by the CRHTT and control, before and after the introduction of the CRHTT, using two-way ANOVA.

RESULTS

Between 2016 and 2020, 1041 service users were treated by the service. Inpatient admissions in the areas served by the CRHTT fell by 38.5% after its introduction. There was a statistically significant interaction between CRHTT availability and time on admission rate, F (1,28) = 8.4, p = .007. BPRS scores were reduced significantly (p < .001), from a mean score of 32.01 before treatment to 24.64 after treatment. Mean HoNOS scores were 13.6 before and 9.1 after treatment (p < .001). Of the 1041 service users receiving the CSQ-8, only 180 returned it (17.3%). Service users' median responses were "very positive" to all eight items on the CSQ-8.

CONCLUSIONS

Although our study design has limitations this paper provides some support that CRHTT might be effective for the prevention of inpatient admission. The study also supports that CRHTT might be an effective option for the treatment of acute mental illness and crisis, although further research is needed in this area.

[IEHT or inpatient treatment? - First results of the multicenter AKtiV study on inpatient-equivalent home treatment regarding the study population and index treatment]

AIM

The quasi-experimental AKtiV study investigates the effects inpatient-equivalent home treatment (IEHT). This paper describes the study population based on demographic and clinical parameters at baseline and compares the index treatment.

METHODS

Over a period of 12 months 200 IEHT users were included in the intervention group (IG) and 200 inpatients were included in the control group (CG). The comparability of the two groups was ensured by propensity score matching (PSM).

RESULTS

In addition to the PSM variables, IG and CG did not differ significantly from each other variables at study inclusion. The duration of the index treatment was significantly longer in the IG (M=37.2 days) compared to the CG (M=27.9 days; p<0.001).

CONCLUSION

The similarity of the two groups enables comparisons over 12 months, investigating IEHT effects on long-term outcomes.

Premature termination, satisfaction with care, and shared decision-making during home treatment compared to inpatient treatment: A quasi-experimental trial

BACKGROUND

Inpatient equivalent home treatment (IEHT), implemented in Germany since 2018, is a specific form of home treatment. Between 2021 and 2022, IEHT was compared to inpatient psychiatric treatment in a 12-months follow-up quasi-experimental study with two propensity score matched cohorts in 10 psychiatric centers in Germany. This article reports results on the treatment during the acute episode and focuses on involvement in decision-making, patient satisfaction, and drop-out rates.

METHODS

A total of 200 service users receiving IEHT were compared with 200 matched statistical "twins" in standard inpatient treatment. Premature termination of treatment as well as reasons for this was assessed using routine data and a questionnaire. In addition, we measured patient satisfaction with care with a specific scale. For the evaluation of patient involvement in treatment decisions, we used the 9-item Shared Decision Making Questionnaire (SDM-Q-9).

RESULTS

Patients were comparable in both groups with regard to sociodemographic and clinical characteristics. Mean length-of-stay was 37 days for IEHT and 28 days for inpatient treatment. In both groups, a similar proportion of participants stopped treatment prematurely. At the end of the acute episode, patient involvement in decision-making (SDM-Q-9) as well as treatment satisfaction scores were significantly higher for IEHT patients compared to inpatients.

CONCLUSIONS

Compared to inpatient care, IEHT treatment for acute psychiatric episodes was associated with higher treatment satisfaction and more involvement in clinical decisions.

Technologically assisted intensive home treatment: feasibility study

Introduction

In recent year, many attempts have been made to provide patients with alternatives to psychiatric hospitalization during acute distress. Although several hospitalization alternatives have been offered, most of them still require patients to be distanced from their families, friends, and the social environment.

Methods

In this report we describe the implementation of a novel approach to psychiatric care termed "Technologically assisted Intensive Home Treatment", where patients arriving to emergency settings are directed to home care with technological aids that enable close monitoring and ongoing contact with their therapists.

Results

We describe the rationale and treatment principles of the treatment, and provide an elaborative description of the implementation process during the first year of implementation.

Discussion

Additional attention is given to factors associated with early dropout from the program, in order to inform readers of predictors to optimal care. Limitations and directions for future research and practice are discussed.Clinical Trial Registration: The study was registered in the database of clinical trials (registration number SHEBA-19-6555-MW-CTIL) and in the Ministry of Health (registration number MOH_2022-08-22_011992).

Patient satisfaction in inpatient psychiatric treatment compared with inpatient equivalent home treatment in Germany: an in-depth qualitative study

Background

Inpatient treatment (IT) is the predominant form of psychiatric care in Germany and worldwide, whereby forms of psychiatric treatment have mainly evolved in the direction of home services. Inpatient equivalent home treatment (IEHT) is a new and additional pillar of psychiatric acute care provision legally embedded since 2018 in Germany.

Objective

The aim of this study was to conduct an in-depth exploration as little qualitative research has been performed so far in Germany to examine possible differences in patient satisfaction with IT compared with IEHT.

Methods

In the current qualitative study, N = 9 patients of a German hospital providing IT and IEHT were interviewed with the problem-centered interview. Inclusion criteria were IT or IT with subsequent IEHT. The theoretical sampling method was applied to select test persons in the research process. The experiences of the participants during their psychiatric treatment were analyzed using a qualitative content analysis.

Results

The results of both types of psychiatric treatment refer to different satisfaction factors during the treatment period. The function of fellow patients, the setting of the treatment, the conditions in place, and the relationship to relatives turn out to be pivotal for patient satisfaction. In addition, the quality of the therapy and relationship to caregivers itself can have an impact on patient satisfaction, particularly by shared decision making. During the IEHT, patient satisfaction can be strengthened by the possibility to handle daily tasks, to be close to relatives, while not so close to fellow patients, whereas IT patients are mostly satisfied because of the distance to their everyday life and the closeness to fellow patients. The choice of the form of psychiatric treatment according to the individual needs of the patients seems to be one key driver that can in turn increase patient satisfaction. In addition, a clean and hygienic environment seems to be critical for our respondents as a lack of it is one of the reasons to drop out of treatment.

Conclusions

Despite its limitations, this hypothesis-generating study is one of the first investigating German IEHT in comparison with IT in an in-depth qualitative approach contributing to a patient-oriented and cost-effective psychiatric treatment. Although hospitals are highly complex organizations and therefore not directly comparable, other German and international providers of IEHT may derive several generic success factors from this study for the development and improvement of patient satisfaction.

Service use preceding and following first referral for psychiatric emergency care at a short-stay crisis unit: A cohort study across three cities and one rural area in England

BACKGROUND

Internationally, hospital-based short-stay crisis units have been introduced to provide a safe space for stabilisation and further assessment for those in psychiatric crisis. The units typically aim to reduce inpatient admissions and psychiatric presentations to emergency departments.

AIMS

To assess changes to service use following a service user's first visit to a unit, characterise the population accessing these units and examine equality of access to the units.

METHODS

A prospective cohort study design (ISCTRN registered; 53431343) compared service use for the 9 months preceding and following a first visit to a short-stay crisis unit at three cities and one rural area in England. Included individuals first visited a unit in the 6 months between 01/September/2020 and 28/February/2021.

RESULTS

The prospective cohort included 1189 individuals aged 36 years on average, significantly younger (by 5-13 years) than the population of local service users (<.001). Seventy percent were White British and most were without a psychiatric diagnosis (55%-82% across sites). The emergency department provided the largest single source of referrals to the unit (42%), followed by the Crisis and Home Treatment Team (20%). The use of most mental health services, including all types of admission and community mental health services was increased post discharge. Social-distancing measures due to the COVID-19 pandemic were in place for slightly over 50% of the follow-up period. Comparison to a pre-COVID cohort of 934 individuals suggested that the pandemic had no effect on the majority of service use variables.

CONCLUSIONS

Short-stay crisis units are typically accessed by a young population, including those who previously were unknown to mental health services, who proceed to access a broader range of mental health services following discharge.

How to measure staff continuity in intensive psychiatric home treatment: a routine data and single case analysis

Background

Intensive forms of outreach mental health care (IOC) such as crisis resolution or home treatment teams are increasingly implemented as alternatives to inpatient admission, providing recovery-oriented treatment at home at comparable costs and outcomes. However, one issue with IOC is the lack of continuity regarding staff members who provide home visits, complicating relationship building and meaningful therapeutic exchange. The aim of this study is to validate existing primarily qualitative findings using performance data and to explore a possible correlation between the number of staff involved within IOC treatment and the service users' length of stay (LOS).

Methods

Routine data from an IOC team in a catchment area in Eastern Germany were analyzed. Basic parameters of service delivery were calculated and an in-depth descriptive analysis regarding staff continuity was performed. Further, an exploratory single case analysis was conducted, presenting the exact sequence of all treatment contacts for one case with low and one with high staff continuity.

Results

We analyzed 10.598 face-to-face treatment contacts based on 178 IOC users. The mean LOS was 30.99 days. About 75% of all home visits were conducted by two or more staff members simultaneously. Service users saw an average of 10.24 different staff per treatment episode. On 11% of the care days, only unknown staff, and on 34% of the care days at least one unknown staff member conducted the home visit. 83% of the contacts were performed by the same three staff members and 51% were made by one and the same staff member. A significant positive correlation (p = 0.0007) was found between the number of different practitioners seen by a service user in the first seven days of care and the LOS.

Conclusion

Our results suggest that a high number of different staff in the early period of IOC episodes correlates with an extended LOS. Future research must clarify the exact mechanisms of this correlation. Furthermore, it should be investigated how the multiple professions within IOC teams influence the LOS and the quality of treatment and what quality indicators may be suitable to ensure treatment processes.

Involuntary admissions to the emergency department: a retrospective observational study

AIMS

The main objective of this study was to describe patients who were involuntarily admitted to the emergency department of Lausanne University Hospital on involuntary admission in 2018 in terms of age, gender, emergency department length of stay, the motive for involuntary admission, use of psychoactive substances, diagnosis, and destination at emergency department discharge, with or without discontinuation of involuntary admission.

METHODS

This retrospective, observational, and monocentric study included patients 18 years and older admitted to the emergency department of Lausanne University Hospital on involuntary admission from January 1, 2018, to December 31, 2018. Patients were identified by the Cantonal Medical Office of Vaud. The emergency department length of stay and patient destination on discharge from the emergency department were extracted from the patient flow database, and discharge letters and involuntary admission were extracted from the electronic archiving software. Descriptive statistics were processed by using means and standard deviations for quantitative variables with a normal distribution and median and interquartile range for non-normally distributed data.

RESULTS

During the study period, 83 patients were admitted on involuntary admission to the emergency department. The majority of the patients were male (58%) with a mean age of 55 (±20) years. The median emergency department length of stay of patients with an involuntary admission was between 9 and 16 hours, depending on whether the involuntary admission was confirmed or discontinued after patient assessment in the emergency department. In comparison, the median emergency department length of stay was 6 hours for patients overall. The two principal diagnoses described were psychiatric (schizophrenia) and mental and behavioural disorders due to psychoactive substance use. Half of the patients on involuntary admission consumed psychoactive substances, primarily alcohol, and had a mean ethanolaemia of 53 (±32) mmol/l.

CONCLUSIONS

Only a third of patients admitted on involuntary admission saw this measure confirmed after their assessment in the emergency department. Involuntary admissions with admission to the emergency department is used to force patients to be examined by an emergency physician or even a psychiatrist. On-call and primary care physicians seemed to lack the time or resources to set up alternatives to emergency department admissions on involuntary admission, especially in situations in which the involuntary admission was discontinued after an emergency department assessment. This demonstrates the inappropriate use of this measure because a patient cannot be involuntarily hospitalised in an emergency department.

Intensive community and home-based treatments for eating disorders: a scoping review study protocol

INTRODUCTION

Institutionally based intensive treatment modalities (inpatient, day patient and residential treatments) for eating disorders (EDs) are associated with high treatment costs and significant challenges for patients and carers, including access difficulties and disruption to daily routines. Intensive community and home-based treatments have been suggested as alternatives to institutionally based intensive treatments for other severe mental illnesses, with promising clinical, social and health economic outcomes. The possible advantages of these treatments have been proposed for EDs, but this emerging area of research has not yet been systematically investigated. This scoping review aims to map the available literature on intensive community and home treatments for EDs, focusing on their conceptualisation, implementation and clinical outcomes.

METHODS

This proposed scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol extension for Scoping Reviews checklist and the Joanna Briggs Institute Reviewer's Manual. This review will include any peer-reviewed study concerning intensive community and home-based treatments for any EDs, with no restrictions on geographical context or study design. Grey literature will also be considered. The literature search will be conducted in four databases: PubMed, PsycInfo, MEDLINE and Web of Science. Two researchers will independently screen the titles, abstracts and text of the returned articles for eligibility. Data charting and analysis will consist of a narrative description of the included studies, quantitative and qualitative findings relative to the aims of this scoping review. Gaps in the literature will be highlighted to inform future research, clinical practice, and policy.

ETHICS AND DISSEMINATION

Ethical approval is not required as all data are available from public sources. The results of this scoping review will be disseminated through peer-reviewed publication, conference presentation, and social media.

Feeling coerced during voluntary and involuntary psychiatric hospitalisation: A review and meta-aggregation of qualitative studies

Objective

This review aimed to provide an aggregative synthesis of the qualitative evidence on patients' experienced coercion during voluntary and involuntary psychiatric hospitalisation.

Design

A qualitative review.

Data sources

The search was conducted, in five bibliographic databases: Embase.com, Ovid MEDLINE(R) ALL, APA PsycINFO Ovid, Web of Science Core Collection and the Cochrane Database of Systematic Reviews.

Review methods

Following the Joanna Briggs Institute approach, a systematized procedure was applied throughout the review process, from data search to synthesis of results. The reporting of this review was guided by the standards of the PRISMA 2020 statement. The quality of the included studies was critically appraised by two independent reviewers using the JBI Critical Appraisal Checklist. Included findings were synthesized using meta-aggregation. Confidence in the review findings was assessed following the Confidence in the Output of Qualitative research synthesis (ConQual) approach.

Results

A total of 423 studies were identified through the literature search and 26 were included in the meta-aggregation. Totally, 151 findings were extracted and aggregated into 27 categories and 7 synthesized findings. The synthesized findings focused on: the patients' experience of the hospitalisation and the associated feeling of coercion; the factors affecting this feeling, such as the involvement in the decision-making process, the relationships with the staff and the perception of the hospital treatment as effective and safe; the coping strategies adopted to deal with it and the patients' suggestions for alternatives. All synthesized findings reached an overall confidence score of "moderate". The seven findings were downgraded one level due to dependability limitations of the included studies.

Conclusion

Based on these findings, seven recommendations for clinical practice where developed, such as fostering care ethics, promoting patients' voice and shared decision-making, and enhancing patients' perceived closeness, respect and fairness. Five recommendations for future research were also prompted, for instance improving the methodological quality and cultural variation of future qualitative studies, and exploring the psychosocial impact of experienced coercion on patients. For these recommendations to be effectively implemented, a profound change in the structure and culture of the mental health system should be promoted. The involvement of patients in the design, development and scientific evaluation of this change is strongly recommended.

Effectiveness of a Community-Based Crisis Resolution Team for Patients with Severe Mental Illness in Greece: A Prospective Observational Study

This prospective observational study evaluated the effectiveness of a crisis resolution team (CRT) for outpatient treatment of psychiatric patients experiencing an acute episode of severe mental disorder. The effectiveness of the CRT (n = 65) was assessed against the care-as-usual [CAU group (n = 65)]. Patients' clinical state, overall functioning, quality of life and satisfaction were respectively evaluated at baseline, post intervention and three-month post-intervention.CRT patients compared to the CAU group, had significantly improved outcomes concerning clinical state and patient satisfaction at post intervention phase. Statistically significant improvement was also recorded for the dimensions of environment, physical and psychological health related to quality of life. No significant differences were observed between the two groups regarding overall functioning.On the basis of these results, reforming of existing crisis-management services, in Greece, using the CRT model may improve substantially the services offered to psychiatric patients.

Patients' experiences and satisfaction with home treatment for acute mental illness: a mixed-methods retrospective study

BACKGROUND

Home treatment (HT) has been proposed as a patient-centred alternative to acute mental inpatient care although evidence of patient-reported outcomes has remained limited.

AIMS

The aim of this study was to examine patient experiences and satisfaction with HT.

METHODS

This retrospective mixed-methods study included telephone interviews of 159 patients receiving HT between 2016 and 2019. Associations between patients' characteristics and global satisfaction (ZUF-8 scale) were assessed. Differences between HT patients and inpatients were tested on a propensity score -matched inpatient sample. Qualitative analyses were conducted using thematic analysis.

RESULTS

Global satisfaction with HT was slightly higher than in the inpatient sample (p = 0.019). There was no relationship between satisfaction and patients' characteristics, such as gender, age, main psychiatric diagnosis, and treatment duration, but satisfaction was higher for patients who perceived HT as their only treatment option. Participants particularly appreciated the person-centred care and practical support whereas staff continuity and medical treatment were main sources of dissatisfaction.

CONCLUSION

The results indicate that HT seems to be a more patient-centred alternative to inpatient treatment and might close a gap in the psychiatric care of patients who preferred not to use inpatient services but needed higher treatment intensity than outpatient treatment.

Taking an Evidence-Based Approach to Involuntary Psychiatric Hospitalization

The field of psychiatry has placed a growing emphasis on research-based diagnostic and treatment practices related to mental illness. Involuntary hospitalization is a controversial and potentially lifesaving intervention in psychiatric care; yet, to what degree is this practice evidence based? This Open Forum examines the ethical and logistical limitations to traditional research, such as randomized controlled trials and observational studies, surrounding involuntary psychiatric hospitalization. Given recent efforts across the United States to expand the use of involuntary hospitalization, the authors call for systematic data collection to monitor, study, and guide the use of this intervention.

Effectiveness of crisis resolution home treatment for the management of acute psychiatric crises in Southern Switzerland: a natural experiment based on geography

BACKGROUND

Crisis Resolution Home Treatment (CRHT) is an alternative to inpatient treatment for acute psychiatric crises management. However, evidence on CRHT effectiveness is still limited. In the Canton of Ticino (Southern Switzerland), in 2016 the regional public psychiatric hospital replaced one acute ward with a CRHT. The current study was designed within this evaluation setting to assess the effectiveness of CRHT compared to standard inpatient treatment.

METHODS

CRHT was offered to patients aged 18 to 65 with an acute psychiatric crisis that would have required hospitalization. We used a natural experiment based on geography, where intervention and control groups were formed according to the place of residence. Primary endpoints were reduction of psychiatric symptoms at discharge measured using the Health of the Nation Outcome Scales, treatment duration in days, and rate and length of readmissions during a two-year follow-up period after discharge. Safety during the treatment period was measured with the number of serious adverse events (suicide/suicide attempts, major self-harm episodes, acute alcohol/drug intoxications, aggressions to caregivers or family members). We used linear, log-linear and logistic regression models with propensity scores for the main analysis.

RESULTS

We enrolled 321 patients; 67 were excluded because the treatment period was too short and 17 because they were transferred before the end of the treatment. Two hundred thirty-seven patients were available for data analysis, 93 in the intervention group and 144 in the control group. No serious adverse event was observed during the treatment period in both groups. Reduction of psychiatric symptoms at discharge (p-value = 0.359), readmission rates (p-value = 0.563) and length of readmissions (p-value = 0.770) during the two-year follow-up period did not differ significantly between the two groups. Treatment duration was significantly higher in the treatment group (+ 29.6% on average, p-value = 0.002).

CONCLUSIONS

CRHT was comparable to standard hospitalization in terms of psychiatric symptoms reduction, readmission rates and length of readmissions, but it was also characterized by a longer first treatment period. However, observational evidence following the study indicated that CRHT duration constantly lowered over time since its introduction in 2016 and became comparable to hospitalization, showing therefore to be an effective alternative also in terms of treatment length.

TRIAL REGISTRATION

ISRCTN38472626 (17/11/2020, retrospectively registered).

Knowledge and attitude towards home treatment among referring healthcare professionals and self-referring patients to a psychiatric hospital: Better information is needed

BACKGROUND

Home treatment (HT) is a patient-centred and cost-effective alternative to acute psychiatric inpatient care. However, the progress of its implementation and utilisation in routine care is slow.

AIMS

The aim of this study was to examine the knowledge and attitude towards HT among healthcare professionals.

METHOD

This observational study included telephone-based semi-structured interviews of 140 referring healthcare professionals including 35 self-referring patients to a large psychiatric hospital in Switzerland during 6 months in 2020. We assessed their knowledge, attitude and experience with HT along with sociodemographic characteristics, professional background and the intention for the referral. We completed the interviews with routine medical data of the referred patients such as diagnoses or symptom severity.

RESULTS

Regarding referrals for inpatient treatment (involuntary and voluntary), half of the referring healthcare professionals and 80% of the self-referring patients had no prior experience or knowledge of HT. Knowledge of HT differed in the order of the participants' working places. We found that most participants were uncertain about the inclusion/exclusion criteria for HT. Despite the low levels of knowledge, attitudes towards HT were overall positive.

CONCLUSIONS

Our results indicate that a proportion of the patients referred for inpatient treatment might have been eligible for HT too. The referring healthcare professionals' and patients' unfamiliarity and uncertainty with HT seems to be an important reason that home-based treatment approaches are still underused, although they are viewed very positively. Besides providing more information to potential referring health professionals, psychiatric hospitals should always carry out a standardized evaluation if HT is an option in patients who are referred for inpatient treatment.

At home or in hospital: Home treatment and mental health stigma

BACKGROUND

Stigmatized attitudes towards people with mental illness may influence treatment choice for oneself and others.

AIM

To gauge the attitudes of the UK general public towards treatment at home for mental illness and to assess the extent to which non-acceptability was related to stigmatized attitudes.

METHODS

Two hundred and two (101 female) people living in the UK completed an online (vignette) questionnaire in which we asked demographic details and personal experience of mental illness. To measure stigma, we used an adapted version of the Attitudes to Mental Illness Questionnaire (AMIQ) with vignettes asking about treatment at home and using scales for social distance and poor expectations; participants also filled in the Mental Health Knowledge Schedule (MAKS).

RESULTS

Participants did not evidence overall agreement with treatment at home for mental illness (i.e. >0; range = -16-to-+16, Mean (M) = 0.86, 95% confidence interval (CI) = -0.08, 1.80, p = .073), although they showed significant agreement with treatment at home should they experience mental illness themselves (range = -8-to-+8, M = 1.36, CI = 0.82, 1.89, p < .001). Acceptability for treatment at home differed according to specific mental illness considered (range = -4-to-+4); depression (M = 0.47, CI = 0.13, 0.81, p = .006) and alcohol abuse (M = 1.46, CI = 1.14,1.77, p < .001) were considered suitable for being treated at home but schizophrenia was not (M = -0.78, CI = -1.13,-0.43, p < .001). Multivariate analyses revealed that older age and attitudes indicating comfort with less social distance from people with mental illness were independently associated with treatment at home agreeability.

CONCLUSIONS

Public acceptability of home treatment for mental illness remains ambivalent in the UK, most obviously when considering treatment approaches for individuals other than themselves and for people with schizophrenia. Disagreement with home treatment is particularly evident in younger people and those who prefer less social contact with people with mental illness.

Acute psychiatric care: approaches to increasing the range of services and improving access and quality of care

Acute services for mental health crises are very important to service users and their supporters, and consume a substantial share of mental health resources in many countries. However, acute care is often unpopular and sometimes coercive, and the evidence on which models are best for patient experience and outcomes remains surprisingly limited, in part reflecting challenges in conducting studies with people in crisis. Evidence on best ap-proaches to initial assessment and immediate management is particularly lacking, but some innovative models involving extended assessment, brief interventions, and diversifying settings and strategies for providing support are potentially helpful. Acute wards continue to be central in the intensive treatment phase following a crisis, but new approaches need to be developed, evaluated and implemented to reducing coercion, addressing trauma, diversifying treatments and the inpatient workforce, and making decision-making and care collaborative. Intensive home treatment services, acute day units, and community crisis services have supporting evidence in diverting some service users from hospital admission: a greater understanding of how best to implement them in a wide range of contexts and what works best for which service users would be valuable. Approaches to crisis management in the voluntary sector are more flexible and informal: such services have potential to complement and provide valuable learning for statutory sector services, especially for groups who tend to be underserved or disengaged. Such approaches often involve staff with personal experience of mental health crises, who have important potential roles in improving quality of acute care across sectors. Large gaps exist in many low- and middle-income countries, fuelled by poor access to quality mental health care. Responses need to build on a foundation of existing community responses and contextually relevant evidence. The necessity of moving outside formal systems in low-resource settings may lead to wider learning from locally embedded strategies.

Accessibility and interventions of crisis resolution teams: a multicenter study of team practices and team differences in Norway

BACKGROUND

Components of crisis resolution teams' (CRTs) practices have been defined in recommendations and a fidelity scale, and surveys have reported how team leaders describe CRT practices. However, studies on CRTs have not measured and reported details of the crisis intervention provided to individual service users. The present study aimed to measure how various components of CRT practice were provided to individual service users and differences in practice between CRTs.

METHODS

The study was exploratory and part of a prospective multicenter pre-post project on outcome of CRT treatment in Norway. Accessibility and intervention components of 25 CRTs were measured for 959 service users at the first contact after referral and in 3,244 sessions with service users. The data on CRT practice components were analyzed with descriptive statistics and factor analyses, and differences between teams were analyzed using ANOVA and calculating the proportion (intraclass correlation coefficient) of total variance that was due to differences between teams.

RESULTS

One-third of the service users had their first session with the CRT the day of referral and another third the following day. Treatment intensity was mean 1.8 sessions the first week, gradually decreasing over subsequent weeks. Three of ten sessions were conducted in the service user's home and six of ten in the team's location. Eight of ten sessions took place during office hours and two of ten in the evening. The CRT provided assessment and psychological interventions to all service users. Family involvement, practical support, and medication were provided to two of ten service users. Between CRTs, significant differences were identified for a substantial proportion of practice components and especially for several aspects of accessibility. Cluster analysis identified two clusters of CRTs with significant differences in accessibility but no significant differences in the use of intervention components.

CONCLUSIONS

Measurements of accessibility and interventions provided to individual service users gave a detailed description of CRT practices and differences between teams. Such measurements may be helpful as feedback on clinical practice, for studying and comparing crisis resolution team practices, and in future studies on the association between different outcomes and potential critical elements of crisis interventions.

[Inpatient equivalent home-treatment: an overview]

Inpatient equivalent home-treatment (IEHT) was implemented in Germany in 2018. Persons with a mental disorder can be admitted to acute multiprofessional IEHT to avoid or shorten inpatient hospital treatment. Exclusion criteria are amongst others lack of consent of cohabitants or endangerment of self and others. Advantages of IEHT include normalization and reduction of stigma. Nevertheless, administrative requirements are high. While there is international evidence for home treatment and crisis resolution teams, there is still a lack of evidence for the concept of IEHT, although specific studies are currently being carried out (e.g. AktiV study financed by the Innovation Fund). Overall, IEHT is important for mental health services and should be further developed.

Is Home Treatment for Everyone? Characteristics of Patients Receiving Intensive Mental Health Care at Home

We aimed at determining differential characteristics of patients treated by a home treatment (HT) team compared to patients treated on hospital wards. Of 412 consecutively admitted patients, 194 (47.1%) were at least partially treated at home, whereas 218 (52.9%) received inpatient treatment only during an episode of acute illness. A multivariate logistic regression model identified current employment to increase the odds of HT (p < 0.001). A primary diagnosis of anxiety or stress-related disorder (p < 0.001), other rare primary diagnoses such as personality disorders (p < 0.001), and more pronounced clinician-rated social problems (p = 0.041) decreased the odds of HT. Overall, it remained difficult to clearly specify suitability for HT based on available sociodemographic and clinical characteristics. This might indicate that responsible clinicians consider HT to be a viable alternative to hospital care and hence initiate HT for a relatively broad spectrum of patients.

Hospital-in-the-Home as a Model for Mental Health Care Delivery: A Narrative Review

Objective: Hospital-in-the-home (HITH) is a service model widely adopted in medical specialties to help alleviate pressure on the availability of inpatient beds and allow patients to receive acute care in familiar surroundings. To date, such models are not widely utilized in mental health care. The authors review existing HITH-type mental health services, focusing on the domains of design, implementation, and outcomes.Methods: An electronic database search was conducted of MEDLINE, PsycINFO, CINAHL, Embase, Scopus, Web of Science, and Google Scholar. Fifty-six studies were eligible for inclusion in this review. Because of heterogeneous methods and outcome reporting in the available research, a narrative approach was used to highlight key themes in the literature.Results: Mental health HITH services exist under a wide range of names with differing theoretical origins and governance structures. Common characteristics and functions are summarized. The authors found moderate evidence for a reduced number and length of hospital admissions as a result of mental health HITH programs. HITH is likely to be cost-effective because of these effects. Limited evidence exists for clinical measures, consumer satisfaction, and effects on caregivers and staff.Conclusions: Mental health HITH services are an effective alternative to inpatient admission for certain consumers. The authors propose a definition of HITH as any service intended to provide inpatient-comparable mental health care in the home instead of the hospital. Standardized studies are needed for systematic analysis of key HITH outcomes.

Home Treatment for Acute Mental Health Care: Protocol for the Financial Outputs, Risks, Efficacy, Satisfaction Index and Gatekeeping of Home Treatment (FORESIGHT) Study

Background

Crisis Resolution and Home Treatment (CRHT) teams represent a community-based mental health service offering a valid alternative to hospitalization. CRHT teams have been widely implemented in various mental health systems worldwide, and their goal is to provide care for people with severe acute mental disorders who would be considered for admission to acute psychiatric wards. The evaluation of several home-treatment experiences shows promising results; however, it remains unclear which specific elements and characteristics of CRHT are more effective and acceptable.

Objective

This study aims to assess the acceptability, effectiveness, and cost-effectiveness of a new CRHT intervention in Ticino, Southern Switzerland.

Methods

This study includes an interventional, nonrandomized, quasi-experimental study combined with a qualitative study and an economic evaluation to be conducted over a 48-month period. The quasi-experimental evaluation involves two groups: patients in the northern area of the region who were offered the CRHT service (ie, intervention group) and patients in the southern area of the region who received care as usual (ie, control group). Individual interviews will be conducted with patients receiving the home treatment intervention and their family members. CRHT members will also be asked to participate in a focus group. The economic evaluation will include a cost-effectiveness analysis.

Results

The project is funded by the Swiss National Science Foundation as part of the National Research Program NRP74 for a period of 48 months starting from January 2017. As of October 2021, data for the nonrandomized, quasi-experimental study and the qualitative study have been collected, and the results are expected to be published by the end of the year. Data are currently being collected for the economic evaluation.

Conclusions

Compared to other Swiss CRHT experiences, the CRHT intervention in Ticino represents a unique case, as the introduction of the service is backed by the closing of one of its acute wards. The proposed study will address several areas where there are evidence gaps or contradictory findings relating to the home treatment of acute mental crisis. Findings from this study will allow local services to improve their effectiveness in a challenging domain of public health and contribute to improving access to more effective care for people with severe mental disorders.

Trial Registration

ISRCTN registry ISRCTN38472626; https://www.isrctn.com/ISRCTN38472626

International Registered Report Identifier (IRRID)

DERR1-10.2196/28191

[Comparison of Inpatient Equivalent Home Treatment (IEHT) with Standard Inpatient treatment: A Matched Cohort Study]

OBJECTIVE

Effectiveness of Inpatient Equivalent Home Treatment (IEHT) was examined in comparison to standard psychiatric inpatient treatment. IEHT is similar to the internationally known Home Treatment or Crisis Resolution Teams. It provides acute psychiatric treatment at the user's home, similar to inpatient hospital treatment in terms of content, flexibility, and complexity.

METHODS

This retrospective matched control study used routine data of 86 patients (IEHT, n = 43, standard inpatient treatment n = 43). Readmission rates and cumulative hospital days were compared within a 12-month-follow-up time period.

RESULTS

The readmission rate was lower and cumulative treatment days were longer after IETH. However, both group differences were not statistically significant.

CONCLUSION

The present study indicates that IEHT is not inferior to standard inpatient treatment in terms of the risk of readmission.

Home Treatment for Acute Mental Healthcare: Who Benefits Most?

Home treatment (HT) has been proposed as an alternative to inpatient treatment for individuals in acute mental crises. However, there is limited evidence concerning the effectiveness of HT to date. The aim of this study was to investigate which patients benefit most from HT. The concept and utilization of two HT services in Switzerland were retrospectively compared based on routine medical data of all patients who were treated in one of the two HT services between July 2016 and December 2017. We examined which patient characteristics were related to successful replacement of hospital care by HT based on a calculated success score using binary regression analyses. The whole sample included 408 individuals with an average age of 43 years and of whom 68% were female. As a result of conceptual similarities, in both HT settings, the typical patient was middle-aged, female and having an affective disorder as the main diagnosis. Half of the treatment cases met the criteria of successful replacement of hospital care (> 50% of the total treatment episodes in HT, treatment duration < 40 days and treatment terminated by mutual agreement). The results of the regression analyses indicated that patients with a lower symptom severity at admission (lower HoNOS score) and those who were employed had more likely a successful replacement of hospital care.The findings suggest that patients with acute mental disorders who have a certain level of functioning and social support might benefit most from HT in the sense of successful replacement of hospital care.

[Evidence on the effects of crisis resolution teams, home treatment and assertive outreach for people with mental disorders in Germany, Austria and Switzerland - a systematic review]

BACKGROUND

Based on international randomized controlled trials (RCT) the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) recommends acute treatment in the domestic environment (AHU) and intensive outreach treatment (IAB) with the highest level of evidence; however, due to large differences in national healthcare systems the transference of results from international studies to the healthcare systems in Germany, Austria and Switzerland could be limited.

OBJECTIVE

Evaluation of studies on outreach psychiatric treatment forms in Germany, Austria and Switzerland and discussion of the results in the light of international evidence.

MATERIAL AND METHODS

A systematic literature search for clinical trials on outreach community treatment from Germany, Austria and Switzerland was conducted in the PubMed database.

RESULTS

A total of 19 publications were identified which could be assigned to 5 publications on 4 studies with 2857 patients on AHU and 14 publications on 10 studies with 3207 patients on IAB. The studies on AHU showed this treatment form to be superior regarding the duration of inpatient stay and healthcare costs. The studies on IAB showed more positive outcomes in comparison to controls regarding symptoms, severity of illness, substance abuse, functioning level, remission, satisfaction with treatment, quality of life, healthcare costs, work and housing situations.

CONCLUSION

The studies from Germany, Austria, and Switzerland suggest that outreach community treatment is superior regarding several outcome parameters. Thus, there are no indications suggesting that international evidence could not be valid for these countries. Additionally, with one RCT for AHU and one for IAB the requirements for an evidence level of 1b for outreach community treatment in the healthcare systems in question are fulfilled.

Fidelity to an evidence-based model for crisis resolution teams: a cross-sectional multicentre study in Norway

BACKGROUND

Crisis resolution teams (CRTs) are specialized multidisciplinary teams intended to provide assessment and short-term outpatient or home treatment as an alternative to hospital admission for people experiencing a mental health crisis. In Norway, CRTs have been established within mental health services throughout the country, but their fidelity to an evidence-based model for CRTs has been unknown.

METHODS

We assessed fidelity to the evidence-based CRT model for 28 CRTs, using the CORE Crisis Resolution Team Fidelity Scale Version 2, a tool developed and first applied in the UK to measure adherence to a model of optimal CRT practice. The assessments were completed by evaluation teams based on written information, interviews, and review of patient records during a one-day visit with each CRT.

RESULTS

The fidelity scale was applicable for assessing fidelity of Norwegian CRTs to the CRT model. On a scale 1 to 5, the mean fidelity score was low (2.75) and with a moderate variation of fidelity across the teams. The CRTs had highest scores on the content and delivery of care subscale, and lowest on the location and timing of care subscale. Scores were high on items measuring comprehensive assessment, psychological interventions, visit length, service users' choice of location, and of type of support. However, scores were low on opening hours, gatekeeping acute psychiatric beds, facilitating early hospital discharge, intensity of contact, providing medication, and providing practical support.

CONCLUSIONS

The CORE CRT Fidelity Scale was applicable and relevant to assessment of Norwegian CRTs and may be used to guide further development in clinical practice and research. Lower fidelity and differences in fidelity patterns compared to the UK teams may indicate that Norwegian teams are more focused on early interventions to a broader patient group and less on avoiding acute inpatient admissions for patients with severe mental illness.

Implementation, efficacy, costs and processes of inpatient equivalent home-treatment in German mental health care (AKtiV): protocol of a mixed-method, participatory, quasi-experimental trial

BACKGROUND

Over the last decades, many high-income countries have successfully implemented assertive outreach mental health services for acute care. Despite evidence that these services entail several benefits for service users, Germany has lagged behind and has been slow in implementing outreach services. In 2018, a new law enabled national mental health care providers to implement team-based crisis intervention services on a regular basis, allowing for different forms of Inpatient Equivalent Home Treatment (IEHT). IEHT is similar to the internationally known Home Treatment or Crisis Resolution Teams. It provides acute psychiatric treatment at the user's home, similar to inpatient hospital treatment in terms of content, flexibility, and complexity.

METHODS/DESIGN

The presented naturalistic, quasi-experimental cohort study will evaluate IEHT in ten hospitals running IEHT services in different German regions. Within a multi-method research approach, it will evaluate stakeholders' experiences of care, service use, efficacy, costs, treatment processes and implementation processes of IEHT from different perspectives. Quantitative surveys will be used to recruit 360 service users. Subsequently, 180 service users receiving IEHT will be compared with 180 matched statistical 'twins' receiving standard inpatient treatment. Assessments will take place at baseline as well as after 6 and 12 months. The primary outcome is the hospital re-admission rate within 12 months. Secondary outcomes include the combined readmission rate, total number of inpatient hospital days, treatment discontinuation rate, quality of life, psycho-social functioning, job integration, recovery, satisfaction with care, shared decision-making, and treatment costs. Additionally, the study will assess the burden of care and satisfaction with care among relatives or informal caregivers. A collaborative research team made up of researchers with and without lived experience of mental distress will conduct qualitative investigations with service users, caregivers and IEHT staff teams to explore critical ingredients and interactions between implementation processes, treatment processes, and outcomes from a stakeholder perspective.

DISCUSSION

By integrating outcome, process and implementation research as well as different stakeholder perspectives and experiences in one study, this trial captures the various facets of IEHT as a special form of home treatment. Therefore, it allows for an adequate, comprehensive evaluation on different levels of this complex intervention.

TRIAL REGISTRATION

Trial registrations: 1) German Clinical Trials Register (DRKS), DRKS000224769. Registered December 3rd 2020, https://www.drks.de/drks_web/setLocale_EN.do ; 2) ClinicalTrials.gov, Identifier: NCT0474550 . Registered February 9th 2021.

The effects of intensive home treatment on self-efficacy in patients recovering from a psychiatric crisis

Background

This study evaluated whether providing intensive home treatment (IHT) to patients experiencing a psychiatric crisis has more effect on self-efficacy when compared to care as usual (CAU). Self-efficacy is a psychological concept closely related to one of the aims of IHT. Additionally, differential effects on self-efficacy among patients with different mental disorders and associations between self-efficacy and symptomatic recovery or quality of life were examined.

Methods

Data stem from a Zelen double consent randomised controlled trial (RCT), which assesses the effects of IHT compared to CAU on patients who experienced a psychiatric crisis. Data were collected at baseline, 6 and 26 weeks follow-up. Self-efficacy was measured using the Mental Health Confidence Scale. The 5-dimensional EuroQol instrument and the Brief Psychiatric Rating Scale (BPRS) were used to measure quality of life and symptomatic recovery, respectively. We used linear mixed modelling to estimate the associations with self-efficacy.

Results

Data of 142 participants were used. Overall, no difference between IHT and CAU was found with respect to self-efficacy (B = − 0.08, SE = 0.15, p = 0.57), and self-efficacy did not change over the period of 26 weeks (B = − 0.01, SE = 0.12, t (103.95) = − 0.06, p = 0.95). However, differential effects on self-efficacy over time were found for patients with different mental disorders (F(8, 219.33) = 3.75, p < 0.001). Additionally, self-efficacy was strongly associated with symptomatic recovery (total BPRS B = − 0.10, SE = 0.02, p < 0.00) and quality of life (B = 0.14, SE = 0.01, p < 0.001).

Conclusions

Although self-efficacy was associated with symptomatic recovery and quality of life, IHT does not have a supplementary effect on self-efficacy when compared to CAU. This result raises the question whether, and how, crisis care could be adapted to enhance self-efficacy, keeping in mind the development of self-efficacy in depressive, bipolar, personality, and schizophrenia spectrum and other psychotic disorders. The findings should be considered with some caution. This study lacked sufficient power to test small changes in self-efficacy and some mental disorders had a small sample size.

Trial registration This trial is registered at Trialregister.nl, number NL6020.

Police Encounters, Agitation, Diagnosis, and Employment Predict Psychiatric Hospitalisation of Intensive Home Treatment Patients During a Psychiatric Crisis

Objective: This study aims to determine factors associated with psychiatric hospitalisation of patients treated for an acute psychiatric crisis who had access to intensive home treatment (IHT). Methods: This study was performed using data from a randomised controlled trial. Interviews, digital health records and eight internationally validated questionnaires were used to collect data from patients on the verge of an acute psychiatric crisis enrolled from two mental health organisations. Thirty-eight factors were assigned to seven risk domains. The seven domains are "sociodemographic", "social engagement", "diagnosis and psychopathology", "aggression", "substance use", "mental health services" and "quality of life". Multiple logistic regression analysis (MLRA) was conducted to assess how much pseudo variance in hospitalisation these seven domains explained. Forward MLRA was used to identify individual risk factors associated with hospitalisation. Risks were expressed in terms of relative risk (RR) and absolute risk difference (ARD). Results: Data from 183 participants were used. The mean age of the participants was 40.03 (SD 12.71), 57.4% was female, 78.9% was born in the Netherlands and 51.4% was employed. The range of explained variance for the domains related to "psychopathology and care" was between 0.34 and 0.08. The "aggression" domain explained the highest proportion (R ² = 0.34) of the variance in hospitalisation. "Quality of life" had the lowest explained proportion of variance (R ² = 0.05). The forward MLRA identified four predictive factors for hospitalisation: previous contact with the police or judiciary (OR = 7.55, 95% CI = 1.10-51.63; ARD = 0.24; RR = 1.47), agitation (OR = 2.80, 95% CI = 1.02-7.72; ARD = 0.22; RR = 1.36), schizophrenia spectrum and other psychotic disorders (OR = 22.22, 95% CI = 1.74-284.54; ARD = 0.31; RR = 1.50) and employment status (OR = 0.10, 95% CI = 0.01-0.63; ARD = -0.28; RR = 0.66). Conclusion: IHT teams should be aware of patients who have histories of encounters with the police/judiciary or were agitated at outset of treatment. As those patients benefit less from IHT due to the higher risk of hospitalisation. Moreover, type of diagnoses and employment status play an important role in predicting hospitalisation.

From research to practice: Implementing an experimental home treatment model into routine mental health care

Background

In line with previous findings, in a recent randomized controlled trial (RCT), we found that home treatment (HT) for acute mental health care can reduce (substitute) hospital use among severely ill patients in crises. This study examined whether the findings of the RCT generalize to HT services provided under routine care conditions.

Methods

We compared patients who received HT during the RCT study phase with patients who received the same HT service after it had become part of routine mental health services in the same catchment area. Sociodemographic and clinical characteristics as well as service use (HT and hospital bed days) were compared between the RCT and the subsequent routine care study period.

Results

Compared to patients who received HT during the RCT, routine care HT patients were more often living with others, less often admitted compulsorily, more often diagnosed with anxiety and stress-related disorders (ICD-10 F4) and less often diagnosed with schizophrenia spectrum disorders (F2). When compared to patients who were exclusively treated on hospital wards, involvement of the HT team in patients’ care was associated with a clear-cut reduction of hospital bed days both during the RCT and under routine care conditions. However, unlike during the RCT study period, involvement of HT was associated with longer overall treatment episodes (inpatient + HT days) under routine care conditions.

Conclusions

HT seems to reduce the use of hospital bed days even under routine care conditions but is at risk of producing longer overall acute treatment episodes.