NIHR DC Discover

NIHR Signal Crisis care for people with mental health issues: some effective interventions but there is a way to go yet

Published on 16 February 2016

doi: 10.3310/signal-000197

Some aspects of crisis care appear effective according to a broad NIHR overview of mental health crisis services. Crisis resolution teams that offer home treatment and support early discharge from hospital, is one successful example – although UK implementation is very variable. Early intervention service models are helpful for people with psychosis, as is collaborative care for those with depression. Crisis houses and acute day hospitals, known as “safe havens”, are popular with service users, and supported employment may help prevent future crises. Finally, liaison psychiatry teams might improve waiting times and reduce re-admission. Many of these interventions are recommended in NICE guidance. Overall, there was sparse evidence on cost-effectiveness.

This was a very broad and complex review, comparing very different kinds of services from police street triage to telephone helplines. The quality of evidence was generally low and high-quality UK evaluations are needed. The authors identified particular gaps in evidence around support before crisis and access to emergency services during crisis. But this review for the first time gives a useful map of current service models and existing evidence along the mental health crisis pathway.

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Why was this study needed?

Spending on mental health is the largest single category of NHS expenditure. In England, in 2014/15, 3617 people per 100,000 of the population in England accessed mental health and learning disability services. The impact in economic and social costs of mental health problems in 2009/10 was £105 billion.

It has been remarked that services for people having a mental health crisis are not always fit for purpose. A CQC survey in 2015 found that only 14% of people who experience a mental health crisis felt that the care they received provided the right response and helped to resolve their situation.

Recognising this, the 2014 Crisis Concordat – an agreement between services involved in the care and support of people in crisis in England – set out how organisations should work together to make sure that people get the help they need. It focused on four main areas of crisis response: support before crisis point; urgent and emergency access to crisis care; quality treatment and care when in crisis; and promoting recovery.

The NIHR funded this review to examine the current state of guidance and evidence across these four stages of care.

What did this study do?

This was a pragmatic review that included evidence-based guidelines, reviews and individual studies. Guidelines, by NICE or NICE accredited bodies, were prioritised. These were usually for specific conditions, such as psychosis or depression. Where these weren’t available, systematic reviews and “reviews of reviews” were consulted. In cases where neither guidelines nor systematic reviews were available, primary studies were reviewed.

Nine NICE guidelines were included, one review of reviews, six systematic reviews and 15 primary studies. All articles focused on developed country healthcare systems, though only three of the 15 primary studies were in the UK. Primary studies were evaluation studies, such as before and after studies, and qualitative research.

Study quality was assessed with a variety of tools according to the study type being appraised. The evidence was generally of low quality. The authors noted a general lack of rigorous randomised trials or appropriate controlled evaluations.

What did it find?

  • Access to support before crisis point: NICE guidelines recommend that people at risk of mental health crisis should receive care and referral quickly. This might include making self-referral easy, telephone support and triage, early detection and training of general health staff. However, there is little reliable evidence as to how this should be done.
  • Urgent and emergency access to crisis care: There was some evidence that liaison psychiatry teams may improve waiting times and reduce readmission (five studies, two of which were in the UK), and that police officers with mental health training were less likely to arrest people with mental health problems but rather take them to a health-care setting (six studies, one in the UK). However, studies in both cases were mostly small and uncontrolled.
  • Quality treatment and care in crisis: Crisis resolution teams were found to be both clinically and cost effective compared to inpatient care (from six randomised controlled trials and two UK economic analyses). However, implementation is variable, with few teams meeting all evidence-based criteria for good practice. Crisis houses and acute day hospitals, which are recommended by NICE, were as effective as inpatient care (one RCT in the USA), but associated with greater service user satisfaction. No cost-effectiveness studies were found. Again, however, the quality of the evidence was low.
  • Promoting recovery/preventing future crises: This was a very broad category of services.  Early intervention service models were found to be effective (and probably cost-effective) for people with psychosis and other serious mental illnesses, as was collaborative care for people with depression, particularly those with chronic physical health problems. Both are recommended by NICE. There was some evidence for supported employment and for peer support. Joint crisis plans are recommended by NICE, but more recent trials have found that implementing crisis plans in routine practice is challenging.

What does current guidance say on this issue?

The nine NICE guidelines included in this review and their publication dates were: Psychosis and schizophrenia in adults 2014; Psychosis and schizophrenia in children and young people 2013; Service user experience in adult mental health 2011; Self harm 2011; Borderline personality disorder 2009; Psychosis with coexisting substance misuse 2011; Bipolar disorder 2014; Depression in adults 2009; and Depression in adults with a chronic physical health condition 2009.

NICE guideline recommendations were reported as part of the results, as described above.

What are the implications?

The scope of this review was extremely broad and it is clear that much evidence on mental health services for crisis care is both patchy and of low quality. There are however some interventions that appear promising. Crisis resolution teams appear effective, and crisis houses and acute day hospitals are popular with service users. Early intervention service models are effective for people with psychosis, and collaborative care for those with depression. Finally, there is some evidence for supported employment, although this covers a range of initiatives. Most studies did not measure cost-effectiveness compared with usual care.

There is also slightly weaker evidence that liaison psychiatry teams may improve waiting times and reduce readmission, and that training police officers may avoid run-ins with the justice system. Peer support interventions may be effective too.

The low quality of the evidence is at least partly a reflection of the challenges of conducting and evaluating complex interventions in this area. However, recent methodological advances in the evaluation and synthesis of complex interventions should offer future results that will help commissioners. For instance, an ambitious NIHR evaluation is underway of liaison psychiatry services in hospitals. This uses a sophisticated study design, including linked data and careful matching of cohorts of patients using liaison psychiatry services in different hospitals with those not using these services.  There are also a number of ongoing trials, such as the NIHR funded Crisis resolution team Optimisation and RElapse prevention (CORE) study, which will report soon.

This is an area of research that is likely to deliver better and more reliable evidence during the next few years.

Citation and Funding

Paton F, Wright K, Ayre N, et al. Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care. Health Technol Assess. 2016;20(3):1-162.

This project was funded by the National Institute for Health Research Health Technology Assessment (HTA) (project number 14/51/01).

Why was this study needed?

Spending on mental health is the largest single category of NHS expenditure. In England, in 2014/15, 3617 people per 100,000 of the population in England accessed mental health and learning disability services. The impact in economic and social costs of mental health problems in 2009/10 was £105 billion.

It has been remarked that services for people having a mental health crisis are not always fit for purpose. A CQC survey in 2015 found that only 14% of people who experience a mental health crisis felt that the care they received provided the right response and helped to resolve their situation.

Recognising this, the 2014 Crisis Concordat – an agreement between services involved in the care and support of people in crisis in England – set out how organisations should work together to make sure that people get the help they need. It focused on four main areas of crisis response: support before crisis point; urgent and emergency access to crisis care; quality treatment and care when in crisis; and promoting recovery.

The NIHR funded this review to examine the current state of guidance and evidence across these four stages of care.

What did this study do?

This was a pragmatic review that included evidence-based guidelines, reviews and individual studies. Guidelines, by NICE or NICE accredited bodies, were prioritised. These were usually for specific conditions, such as psychosis or depression. Where these weren’t available, systematic reviews and “reviews of reviews” were consulted. In cases where neither guidelines nor systematic reviews were available, primary studies were reviewed.

Nine NICE guidelines were included, one review of reviews, six systematic reviews and 15 primary studies. All articles focused on developed country healthcare systems, though only three of the 15 primary studies were in the UK. Primary studies were evaluation studies, such as before and after studies, and qualitative research.

Study quality was assessed with a variety of tools according to the study type being appraised. The evidence was generally of low quality. The authors noted a general lack of rigorous randomised trials or appropriate controlled evaluations.

What did it find?

  • Access to support before crisis point: NICE guidelines recommend that people at risk of mental health crisis should receive care and referral quickly. This might include making self-referral easy, telephone support and triage, early detection and training of general health staff. However, there is little reliable evidence as to how this should be done.
  • Urgent and emergency access to crisis care: There was some evidence that liaison psychiatry teams may improve waiting times and reduce readmission (five studies, two of which were in the UK), and that police officers with mental health training were less likely to arrest people with mental health problems but rather take them to a health-care setting (six studies, one in the UK). However, studies in both cases were mostly small and uncontrolled.
  • Quality treatment and care in crisis: Crisis resolution teams were found to be both clinically and cost effective compared to inpatient care (from six randomised controlled trials and two UK economic analyses). However, implementation is variable, with few teams meeting all evidence-based criteria for good practice. Crisis houses and acute day hospitals, which are recommended by NICE, were as effective as inpatient care (one RCT in the USA), but associated with greater service user satisfaction. No cost-effectiveness studies were found. Again, however, the quality of the evidence was low.
  • Promoting recovery/preventing future crises: This was a very broad category of services.  Early intervention service models were found to be effective (and probably cost-effective) for people with psychosis and other serious mental illnesses, as was collaborative care for people with depression, particularly those with chronic physical health problems. Both are recommended by NICE. There was some evidence for supported employment and for peer support. Joint crisis plans are recommended by NICE, but more recent trials have found that implementing crisis plans in routine practice is challenging.

What does current guidance say on this issue?

The nine NICE guidelines included in this review and their publication dates were: Psychosis and schizophrenia in adults 2014; Psychosis and schizophrenia in children and young people 2013; Service user experience in adult mental health 2011; Self harm 2011; Borderline personality disorder 2009; Psychosis with coexisting substance misuse 2011; Bipolar disorder 2014; Depression in adults 2009; and Depression in adults with a chronic physical health condition 2009.

NICE guideline recommendations were reported as part of the results, as described above.

What are the implications?

The scope of this review was extremely broad and it is clear that much evidence on mental health services for crisis care is both patchy and of low quality. There are however some interventions that appear promising. Crisis resolution teams appear effective, and crisis houses and acute day hospitals are popular with service users. Early intervention service models are effective for people with psychosis, and collaborative care for those with depression. Finally, there is some evidence for supported employment, although this covers a range of initiatives. Most studies did not measure cost-effectiveness compared with usual care.

There is also slightly weaker evidence that liaison psychiatry teams may improve waiting times and reduce readmission, and that training police officers may avoid run-ins with the justice system. Peer support interventions may be effective too.

The low quality of the evidence is at least partly a reflection of the challenges of conducting and evaluating complex interventions in this area. However, recent methodological advances in the evaluation and synthesis of complex interventions should offer future results that will help commissioners. For instance, an ambitious NIHR evaluation is underway of liaison psychiatry services in hospitals. This uses a sophisticated study design, including linked data and careful matching of cohorts of patients using liaison psychiatry services in different hospitals with those not using these services.  There are also a number of ongoing trials, such as the NIHR funded Crisis resolution team Optimisation and RElapse prevention (CORE) study, which will report soon.

This is an area of research that is likely to deliver better and more reliable evidence during the next few years.

Citation and Funding

Paton F, Wright K, Ayre N, et al. Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care. Health Technol Assess. 2016;20(3):1-162.

This project was funded by the National Institute for Health Research Health Technology Assessment (HTA) (project number 14/51/01).

Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care

Published on 16 January 2016

Paton, F.,Wright, K.,Ayre, N.,Dare, C.,Johnson, S.,Lloyd-Evans, B.,Simpson, A.,Webber, M.,Meader, N.

Health Technol Assess Volume 20 , 2016

BACKGROUND: Crisis Concordat was established to improve outcomes for people experiencing a mental health crisis. The Crisis Concordat sets out four stages of the crisis care pathway: (1) access to support before crisis point; (2) urgent and emergency access to crisis care; (3) quality treatment and care in crisis; and (4) promoting recovery. OBJECTIVES: To evaluate the clinical effectiveness and cost-effectiveness of the models of care for improving outcomes at each stage of the care pathway. DATA SOURCES: Electronic databases were searched for guidelines, reviews and, where necessary, primary studies. The searches were performed on 25 and 26 June 2014 for NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database, and the Health Technology Assessment (HTA) and PROSPERO databases, and on 11 November 2014 for MEDLINE, PsycINFO and the Criminal Justice Abstracts databases. Relevant reports and reference lists of retrieved articles were scanned to identify additional studies. STUDY SELECTION: When guidelines covered a topic comprehensively, further literature was not assessed; however, where there were gaps, systematic reviews and then primary studies were assessed in order of priority. STUDY APPRAISAL AND SYNTHESIS METHODS: Systematic reviews were critically appraised using the Risk Of Bias In Systematic reviews assessment tool, trials were assessed using the Cochrane risk-of-bias tool, studies without a control group were assessed using the National Institute for Health and Care Excellence (NICE) prognostic studies tool and qualitative studies were assessed using the Critical Appraisal Skills Programme quality assessment tool. A narrative synthesis was conducted for each stage of the care pathway structured according to the type of care model assessed. The type and range of evidence identified precluded the use of meta-analysis. RESULTS AND LIMITATIONS: One review of reviews, six systematic reviews, nine guidelines and 15 primary studies were included. There was very limited evidence for access to support before crisis point. There was evidence of benefits for liaison psychiatry teams in improving service-related outcomes in emergency departments, but this was often limited by potential confounding in most studies. There was limited evidence regarding models to improve urgent and emergency access to crisis care to guide police officers in their Mental Health Act responsibilities. There was positive evidence on clinical effectiveness and cost-effectiveness of crisis resolution teams but variability in implementation. Current work from the Crisis resolution team Optimisation and RElapse prevention study aims to improve fidelity in delivering these models. Crisis houses and acute day hospital care are also currently recommended by NICE. There was a large evidence base on promoting recovery with a range of interventions recommended by NICE likely to be important in helping people stay well. CONCLUSIONS AND IMPLICATIONS: Most evidence was rated as low or very low quality, but this partly reflects the difficulty of conducting research into complex interventions for people in a mental health crisis and does not imply that all research was poorly conducted. However, there are currently important gaps in research for a number of stages of the crisis care pathway. Particular gaps in research on access to support before crisis point and urgent and emergency access to crisis care were found. In addition, more high-quality research is needed on the clinical effectiveness and cost-effectiveness of mental health crisis care, including effective components of inpatient care, post-discharge transitional care and Community Mental Health Teams/intensive case management teams. STUDY REGISTRATION: This study is registered as PROSPERO CRD42014013279. FUNDING: The National Institute for Health Research HTA programme.

The review looked at a range of interventions. Below are some brief definitions.

  • Crisis resolution and home treatment teams are any type of crisis-orientated treatment of an acute psychiatric episode by staff with a specific remit to deal with such situations.
  • Crisis houses are a residential alternative to acute admission during crisis.
  • Acute day hospital care is diagnostic and treatment services for acutely ill individuals who would otherwise be treated in traditional psychiatric inpatient units.
  • Early intervention services are specialist services set up to provide treatment and support for young people who are experiencing symptoms of psychosis for the first time, and during the first three years following a first episode of psychosis.
  • Psychiatric liaison teams work in general hospitals and provide psychiatric assessment and treatment to those patients who may be experiencing distress whilst in hospital. They provide an interface between mental and physical health.

The Crisis Concordat proposed four key stages of the mental health crisis care pathway:

1. Access to support before crisis point: the provision of readily accessible support 24 hours a day and 7 days a week. This is for people who are close to crisis and need quick access to support that may help prevent escalation of their problems.

2. Urgent and emergency access to crisis care: when people need emergency help related to their mental health needs when in crisis. The emphasis is on treatment being accessed urgently and with respect, in a similar manner to a physical health emergency.

3. Quality of treatment and care when in crisis: the provision of support and treatment for people in mental health crisis. Effective treatment is provided by competent practitioners, who focus on the service user’s recovery, and is provided in a setting that best suits their needs.

4. Promoting recovery/preventing future crises: the provision of services that will support the process of recovery for people with mental health problems and help them stay well.

Expert commentary

It is good to see the steady accumulation of evidence to support crisis intervention and home treatment teams that are fast becoming a core service within the NHS. Of all the changes made to services in the era of deinstitutionalisation, it is this that has the greatest potential to reduce reliance on hospitals.

Professor Tom Craig, Professor of Social Psychiatry, King’s College London