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15-05-2013 | Mental health | Article

Joint crisis plans fall short in reducing compulsory admissions


Free abstract

medwireNews: Joint crisis plans (JCPs) do not appear to significantly reduce compulsory admissions among patients with psychosis, but they may have a positive effect on therapeutic relationships between patients and their clinicians, say researchers.

Graham Thornicroft (Institute of Psychiatry, London, UK) and colleagues report that a "clinician's readiness to engage in the approach could be a crucial component of success."

In their CRIMSION (CRisis plan IMpact: Subjective and Objective coercion and eNgagement) study, the team found that JCPs were not formulated in specific meetings in 48% of cases, but instead during usual clinical review meetings.

"Our qualitative work suggests that many patients could not remember the JCP planning meeting as distinct from a routine CPA [Care Programme Approach] meeting," the researchers report.

"Further, many patients complained that the content was not followed during a subsequent crises."

The study involved 569 patients with psychosis who had had at least one psychiatric admission in the previous 2 years and were on the Enhanced Care Programme Approach register.

The patients were randomly assigned to a JCP (n=285) group, which involved the patients formulating treatment preferences with their clinicians for future psychiatric emergencies, or treatment as normal.

During a median follow up of 18.5 months, there was no significant difference between the two groups in terms of compulsory admissions, at 49 (18%) for those with JCPs and 56 (20%) for the control group.

The mean duration of compulsory admissions also did not differ, at 22.3 days in the JCP group and 20.6 days in the control group.

The findings were similar for any admission, compulsory or voluntary, and when the data were adjusted for site.

The only difference found was a 1.29-point improvement in the patient-rated therapeutic relationship, according to scores on the Working Alliance Inventory.

Qualitative data collected through 12 focus groups - five patient groups, five care coordinator groups, and two combined groups - provided support for an improvement in patients' views of the therapeutic relationships.

Patients felt respected and understood by clinicians, while clinicians gained a wider understanding of their patients' views of care, say Thornicroft et al.

"However, a more common scenario was poor engagement with the process of developing the JCP and implantation of the JCP in practice."

In a related comment, Sonia Johnson (University College London, UK) suggests that "one meeting between patients and professionals is unlikely to be sufficient to counteract a culture of professional dominance in decision making where this prevails."

medwireNews ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2013

By Lucy Piper, Senior medwireNews Reporter

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