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.
- 1Centre for Reviews and Dissemination, University of York (https://www.york.ac.uk/crd/), York, UK.
- 2York Mind, York, UK.
- 3Department of Health Sciences, University of York, York, UK.
- 4Division of Psychiatry, University College London, London, UK.
- 5School of Health Sciences, City University London, London, UK.
- 6Department of Social Policy and Social Work, University of York, York, UK
- DOI: http://dx.doi.org/10.3310/hta20030
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