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Meta-Analysis
. 2015 Dec 3;2015(12):CD001087.
doi: 10.1002/14651858.CD001087.pub5.

Crisis intervention for people with severe mental illnesses

Suzanne M Murphy  1 , Claire B Irving, Clive E Adams, Muhammad Waqar
Affiliations
Meta-Analysis

Crisis intervention for people with severe mental illnesses

Suzanne M Murphy et al. Cochrane Database Syst Rev. .

Abstract

Background: A particularly difficult challenge for community treatment of people with serious mental illnesses is the delivery of an acceptable level of care during the acute phases of severe mental illness. Crisis-intervention models of care were developed as a possible solution.

Objectives: To review the effects of crisis-intervention models for anyone with serious mental illness experiencing an acute episode compared to the standard care they would normally receive. If possible, to compare the effects of mobile crisis teams visiting patients' homes with crisis units based in home-like residential houses.

Search methods: We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials. There is no language, time, document type, or publication status limitations for inclusion of records in the register. This search was undertaken in 1998 and then updated 2003, 2006, 2010 and September 29, 2014.

Selection criteria: We included all randomised controlled trials of crisis-intervention models versus standard care for people with severe mental illnesses that met our inclusion criteria.

Data collection and analysis: We independently extracted data from these trials and we estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CI). We assessed risk of bias for included studies and used GRADE to create a 'Summary of findings' table.

Main results: The update search September 2014 found no further new studies for inclusion, the number of studies included in this review remains eight with a total of 1144 participants. Our main outcomes of interest are hospital use, global state, mental state, quality of life, participant satisfaction and family burden. With the exception of mental state, it was not possible to pool data for these outcomes.Crisis intervention may reduce repeat admissions to hospital (excluding index admissions) at six months (1 RCT, n = 369, RR 0.75 CI 0.50 to 1.13, high quality evidence), but does appear to reduce family burden (at six months: 1 RCT, n = 120, RR 0.34 CI 0.20 to 0.59, low quality evidence), improve mental state (Brief Psychiatric Rating Scale (BPRS) three months: 2 RCTs, n = 248, MD -4.03 CI -8.18 to 0.12, low quality evidence), and improve global state (Global Assessment Scale (GAS) 20 months; 1 RCT, n = 142, MD 5.70, -0.26 to 11.66, moderate quality evidence). Participants in the crisis-intervention group were more satisfied with their care 20 months after crisis (Client Satisfaction Questionnaire (CSQ-8): 1 RCT, n = 137, MD 5.40 CI 3.91 to 6.89, moderate quality evidence). However, quality of life scores at six months were similar between treatment groups (Manchester Short Assessment of quality of life (MANSA); 1 RCT, n = 226, MD -1.50 CI -5.15 to 2.15, low quality evidence). Favourable results for crisis intervention were also found for leaving the study early and family satisfaction. No differences in death rates were found. Some studies suggested crisis intervention to be more cost-effective than hospital care but all numerical data were either skewed or unusable. We identified no data on staff satisfaction, carer input, complications with medication or number of relapses.

Authors' conclusions: Care based on crisis-intervention principles, with or without an ongoing homecare package, appears to be a viable and acceptable way of treating people with serious mental illnesses. However only eight small studies with unclear blinding, reporting and attrition bias could be included and evidence for the main outcomes of interest is low to moderate quality. If this approach is to be widely implemented it would seem that more evaluative studies are still needed.

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Conflict of interest statement

There was no potential conflict of interest.

Figures

1
1
Study flow diagram 2014 search
2
2
Study flow diagram (2010 UPDATE).
3
3
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 1 Hospital use: 1. Unable to keep to initial trial protocol as regards admission.
1.2
1.2. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 2 Hospital use: 2. Repeat admissions including index admission.
1.4
1.4. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 4 Hospital use: 4. Repeat admissions excluding index admission.
1.5
1.5. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 5 Hospital use: 5. Repeat admissions excluding index admission ‐ compulsory detentions only.
1.6
1.6. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 6 Hospital use: 6. Treatment failure.
1.7
1.7. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 7 Hospital use: 7. Days in acute care.
1.9
1.9. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 9 Leaving the study early (unwilling or unable to provide infomation): 1. Patients.
1.10
1.10. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 10 Leaving the study early (unwilling or unable to provide information) 2. Relatives.
1.11
1.11. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 11 Death: 1. Any cause.
1.12
1.12. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 12 Death: 2. By cause.
1.13
1.13. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 13 Harm to self or others.
1.14
1.14. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 14 Global state: 1. GAS (endpoint score, range 1‐100, low=poor) (loss in some cases is greater than 30%).
1.15
1.15. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 15 Global state: 2. SAS (endpoint score, high=poor) (loss in some cases in greater than 30%).
1.16
1.16. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 16 Global state: 3. GAS scale change data by 3 months (+ve change=good, data likely to be skewed).
1.17
1.17. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 17 Global state: 4. SAS change data by 3 months (‐ve change=good, data likely to be skewed).
1.18
1.18. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 18 Mental state ‐ general: 1. Unwell by 12 months.
1.19
1.19. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 19 Mental state ‐ general: 2. BPRS (endpoint score, range 24‐168, high=poor) (loss in standard group >30% for 6 months or more).
1.20
1.20. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 20 Mental state ‐ general: 3. PEF (endpoint score, range 0‐5, high=poor) (loss is greater than 30%).
1.22
1.22. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 22 Mental state ‐ general: 5. BPRS scale change data by 3 months (‐ve change=good, data likely to be skewed).
1.23
1.23. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 23 Mental state ‐ general: 6. PSE scale change data by 3 months (‐ve change=good, data likely to be skewed)..
1.24
1.24. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 24 Mental state: general PANSS (endpoint score, range 30‐210, high=poor).
1.25
1.25. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 25 Mental state ‐ specific: 1. Unsociable (reported by relatives).
1.26
1.26. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 26 Mental state ‐ specific: 2. Aggression (reported by relatives).
1.27
1.27. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 27 Mental state ‐ specific: 3. Various problems at 4 months (reported by relatives).
1.28
1.28. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 28 Burden ‐ family: 1. Disruption to daily routine.
1.29
1.29. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 29 Burden ‐ family: 2. Disruption to social life.
1.30
1.30. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 30 Burden ‐ family: 3. Financial strain.
1.31
1.31. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 31 Burden ‐ family: 4. Physical illness due to patient's illness.
1.32
1.32. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 32 Burden ‐ family: 5. Overall burden is great.
1.33
1.33. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 33 Burden ‐ community: 1. Not employed by 20 months.
1.34
1.34. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 34 Burden ‐ community: 1a. In paid work by 6 months.
1.35
1.35. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 35 Burden ‐ community: 2. Various outcomes by 12 months.
1.36
1.36. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 36 Burden ‐ community: 3. Arrested.
1.37
1.37. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 37 Burden ‐ community: 4. Homelessness.
1.38
1.38. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 38 Satisfaction ‐ patient: 1. Various outcomes by 12 months.
1.39
1.39. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 39 Satisfaction ‐ patient: 2. Patient satisitfied with care: Satisfaction Scale (endpoint score, range 0 ‐32, low=poor).
1.40
1.40. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 40 Satisfaction: Patient: 3. VSSS Scale (low=poor).
1.41
1.41. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 41 Satisfaction ‐ relatives: 1. Feels patient is not improved.
1.42
1.42. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 42 Satisfaction ‐ relatives: 4. Various outcomes by 12 months.
1.43
1.43. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 43 Satisfaction ‐ relatives: 3. Would have preferred patient to have received other treatment.
1.44
1.44. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 44 Satisfaction ‐ relatives: 2. Dissatisfied with treatment received.
1.46
1.46. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 46 Quality of Life MANSA patient endpoint score, range 0 ‐ 88, low=poor.
1.47
1.47. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 47 Quality of Life MANSA‐short form patient endpoint score, low=poor.
1.48
1.48. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 48 Quality of life: EQ‐5D range 0 to 1, low=poor.
1.49
1.49. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 49 Social contacts.
1.50
1.50. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 50 Social functioning: LSP‐staff endpoint score, range 0‐156, low=poor.
1.51
1.51. Analysis
Comparison 1 CRISIS INTERVENTION vs STANDARD CARE, Outcome 51 Clinical and social problems HoNOS ‐ staff endpoint score, range 0‐48, high=poor.
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