Home-based treatment and psychiatric admission rates: experience of an adult community mental health service in Ireland

A scoping review of studies into crisis resolution teams in community mental health services

BACKGROUND AND PURPOSE OF ARTICLE

Crisis Resolution Teams (CRT) for rapid assessment and short-term treatment of mental health problems have increasingly been implemented internationally over the last decades. Among the Nordic countries, the CRT model has been particularly influential in Norway, where 'Ambulante akutteam (AAT)' is a widespread psychiatric emergency service for adult patients. However, the clinical practice of these teams varies significantly. To aid further development of the service and guide future research efforts, we carried out a scoping review to provide an up-to-date overview of research available in primary studies focusing on phenomena related to CRTs in English and Scandinavian literature.

METHODS

A systematic literature search was conducted in the bibliometric databases MEDLINE, Embase, PsychINFO, Scopus, and SveMed+. Included studies were thematically analyzed using a qualitative method.

RESULTS

The search identified 1516 unique references, of which 129 were included in the overview. Thematic analysis showed that the studies could be assigned to: (1) Characteristics of CRTs (k = 45), which described key principles or specific interventions; (2) Implementation of CRTs (k = 54), which were descriptive about implementation in different teams, or normative about what clinical practice should include; and (3) Effect of CRTs (k = 38).

CONCLUSIONS

The international research literature on CRTs or equivalent teams is extensive. Many sub-themes have been studied with various research methodologies. Recent studies provide a better evidence base for how to organize services and to select therapeutic interventions, but there is still a need for more controlled studies in the field.

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.

Hospitalization and Some Sociodemographic Characteristics of Patients Registered with a Community Mental Health Center

One of the most important indicators evaluating the effectiveness of community mental health centers is the decrease in hospitalization rates of registered patients. The aim of our study was to compare the annual hospitalization rates of patients receiving community mental health services before enrollment with the annual hospitalization rates after enrollment. The study included 400 patients with a registration period of at least 1 year as of the end of 2018. Wilcoxon signed rank test was used to test the significance of the difference between pre-registration and post-registration patients' annual hospitalizations. The annual hospitalization rates (0.32 ± 0.35) and the annual hospitalization rates (0.15 ± 0.35) before and after registration were found to be statistically significant (p < 0.001). Annual hospitalization rates decreased by 54.58%. Our Community Mental Health Center, which provides community-based mental health services, has led to a significant decrease in annual hospitalization rates thanks to the services provided.

Forging successful partnerships in psychosis research: lessons from the Cavan–Monaghan First Episode Psychosis Study

Embedding psychosis research within community mental services is highly desirable from several perspectives but can be difficult to establish and sustain, especially when the clinical service has a rural location at a distance from academic settings with established research expertise. In this article, we share the experience of a successful partnership in psychosis research between a rural Irish mental health service and the academic department of a Dublin medical school that has lasted over 30 years. We describe the origins and evolution of this relationship, the benefits that accrued and the challenges encountered, from the overlapping perspectives of the academic department, the mental health service and psychiatric training. We discuss the potential learning that arose from the initiative, particularly for national programme planning for early intervention in psychosis, and we explore the opportunities for enhanced training, career development and professional reward that can emerge from this type of partnership.

Home treatment services for acute mental disorders: an all-Ireland survey

OBJECTIVES

To determine the distribution, functioning and perceived impact of home-based treatment (HBT) teams for acute mental disorders on the island of Ireland.

METHODS

A 28-item questionnaire exploring the structure, staffing and operation of HBT teams was emailed to all clinical directors of mental health services in Ireland (n=26) and Northern Ireland (NI) (n=5). Quantitative data was analysed using the Survey Monkey package, while free-text responses to open questions were analysed for thematic content.

RESULTS

In total, 11 of 16 (68%) mental health services in Ireland and four of five (80%) in NI confirmed the presence of HBT teams. For 80% of respondents the primary function of HBT was as an alternative to inpatient admission. All NI respondents reported provision of a 24/7 HBT service. A 7 day a week service was reported by 82% of Republic of Ireland respondents. In total, 70% of respondents reported a gate-keeping role for their teams. Staffing levels and multidisciplinary representation varied widely. Most respondents perceived HBT as improving patient/carer experience and cost-effectiveness.

CONCLUSIONS

Our findings suggest that the implementation of the HBT model in Ireland has not fulfilled the aspirations set out in mental health policy in both Irish jurisdictions. Many areas have no HBT services while wide variations in staffing levels and functioning persist. However, mental health services with established HBT teams appear convinced of their positive impact. An All-Ireland forum on HBT may help to define the model in an Irish context and standardise its future resourcing, operation and evaluation.

Home-based crisis team in North Cork service description and patient-related outcomes

OBJECTIVE

Home-based crisis team (HBCT) in North Cork was established in 2013 to provide short term, intensive home treatment to people who are experiencing acute mental health problems, with the aim of averting hospital admission wherever possible or supporting patients discharged from hospital.

METHODS

A retrospective descriptive study design was adopted to describe the activities of the North Cork HBCT over a 1 year period. Data were analysed using R version 3.4.0 for Windows.

RESULTS

A total of 388 patients were referred to the HBCT in 2015, of which 328 required assessments. General practitioners (GPs) made 56% of all referrals. The most common referral reason was low mood (40%). Stepped-up care to the psychiatric inpatient unit was required for 12.4% of patients, 62% were discharged to the outpatient clinic for routine follow-up.

CONCLUSION

Many common psychiatric presentations can be managed at home with the support of the HBCT although hospital admission is required for significant numbers.

Longer Duration of Untreated Psychosis Hinders Improvement in Treatment of Chronic Schizophrenia: Community Based Early Intervention is an Evidence Based Option

To determine the effects of community-based mental health services on the quality of life and disease symptoms of chronic schizophrenia patients and to determine the effects of duration of untreated psychosis on outcome. The first year records of schizophrenia patients who had been followed up at Zeytinburnu CMHC for at least 12 months, have been used to asses outcome using initial and 12th month quality of life (QoL), positive and negative symptom scale (PANSS) scores. Highly significant improvements were shown in the QoL and PANSS scores. There were significant differences between the two study groups (duration of untreated psychosis >2 years, versus duration of untreated psychosis <2 years) in terms of improvements in QoL and PANSS scores. Formation of early intervention teams that seek to provide preventive activities (i.e. for schizophrenia) in countries that have changed to community based mental health systems is a sound mental health implementation.

Profile and activities of a rural home-based psychiatric treatment service in Ireland

OBJECTIVES

This study described the profile, activities and patient-related outcomes of a long-established home-based treatment (HBT) service in Ireland.

METHODS

A retrospective descriptive study design was adopted to review and describe the activities of the Cavan HBT team over a 5-year period. Data including demographics, referral details, duration of admissions and outcome/disposal were retrospectively collected from the home treatment team mental health register of admissions between 2006 and 2010. Data were analysed using SPSS version 15 for windows.

RESULTS

A total of 783 patients were referred to the team over the study period, of which 722 were admitted for home treatment. Most referrals (51%) were from General Practitioners and the commonest reason for referral/admission for home treatment was low mood (26%). While 10% required stepped-up care to the psychiatric inpatient unit, 77% were successfully discharged to the out-patient clinic for routine follow-up care.

CONCLUSIONS

Common psychiatric illnesses can be safely and effectively managed with HBT within the context of a spectrum of therapeutic options in a community psychiatric service.

Neighbourhood-level socio-environmental factors and incidence of first episode psychosis by place at onset in rural Ireland: the Cavan-Monaghan First Episode Psychosis Study [CAMFEPS]

BACKGROUND

Little is known about associations between the social environment and risk for psychosis within rural settings. This study sought to investigate whether such associations exist within a rural context using a prospective dataset of unusual epidemiological completeness.

METHOD

Using the Cavan-Monaghan First Episode Psychosis Study database of people aged 16 years and older, both ecological analyses and multilevel modelling were applied to investigate associations between incidence of psychosis by place at onset and socio-environmental risk factors of material deprivation, social fragmentation and urban-rural classification across electoral divisions.

RESULTS

The primary finding was an association between more deprived social contexts and higher rates of psychotic disorder, after adjustment for age and sex [all psychoses: incidence rate ratio (IRR)=1.12, 95% CI (1.03-1.23)].

CONCLUSIONS

These findings support an association between adverse socio-environmental factors and increase in risk for psychosis by place at onset within a predominantly rural environment. This study suggests that social environmental characteristics may have an impact on risk across the urban-rural gradient.