|Year : 2021 | Volume
| Issue : 1 | Page : 22-29
Characteristics and Clinical Outcomes of Patients Attending a Victorian Metropolitan Crisis Intervention Team
Mukund G Rao1, Partha Das2, Karuppiah Jagadheesan1, Vinay Lakra3
1 North West Area Mental Health Service, Coburg, VIC 3058, Melbourne, Australia
2 Austin Health, Heidelberg, VIC 3084. Honorary Clinical Fellow, University of Melbourne, Melbourne, Australia
3 North West Area Mental Health Service, Coburg, VIC 3058. Associate Professor, University of Melbourne, Melbourne, Australia
|Date of Submission||14-Jul-2020|
|Date of Decision||25-Nov-2020|
|Date of Acceptance||06-Feb-2021|
|Date of Web Publication||29-Apr-2021|
Dr. Mukund G Rao
North West Area Mental Health Service, 35 Johnstone Street, Broadmeadows VIC 3047
Source of Support: None, Conflict of Interest: None
Background: Little is known about the nature of service users who seek crisis community care in recent times in the Australian context. Objectives: The objective of this study was to describe the sociodemographic, clinical, and service provision characteristics and 12-month clinical outcomes of patients in a metropolitan crisis intervention team. Methods: Patients who were registered during the study period (May 1, 2015–October 30, 2015) for crisis intervention from a metropolitan community mental health team were included for this retrospective cohort study. The type of psychosocial stressor triggering the crisis was assessed by the social readjustment scale. Results: A situational crisis or adjustment disorder (26.6%) was the most common primary diagnosis, followed by an affective disorder. Deliberate self-harm behavior was the leading risk behavior (18.1%). Major injury or illness to self (16%) was the main psychosocial stressor associated with crisis presentation. The primary health sector was the main source of referral and discharge destination. Nearly 40% of patients were re-referred within a 12-month period since index contact. The characteristics of re-referred patients were men, living with a housemate or other family, triage category C, diagnosis of a mood disorder, needing medication supervision, and discharged to inpatient treatment during the index episode of care. Conclusions: A continuous and collaborative model of care between the primary health sector and community mental health services might be more beneficial in the early identification and management of the acute crisis in a subgroup of patients. A diverse range of skills are needed for clinicians working in the crisis intervention service in the current times.
Keywords: Clinical profiles, community treatment, crisis intervention, models of care, service improvement
|How to cite this article:|
Rao MG, Das P, Jagadheesan K, Lakra V. Characteristics and Clinical Outcomes of Patients Attending a Victorian Metropolitan Crisis Intervention Team. World Soc Psychiatry 2021;3:22-9
|How to cite this URL:|
Rao MG, Das P, Jagadheesan K, Lakra V. Characteristics and Clinical Outcomes of Patients Attending a Victorian Metropolitan Crisis Intervention Team. World Soc Psychiatry [serial online] 2021 [cited 2021 Jul 25];3:22-9. Available from: https://www.worldsocpsychiatry.org/text.asp?2021/3/1/22/315124
| Introduction|| |
Alongside deinstitutionalization, a policy guideline for delivering urgent community based mental health care, referred to as the crisis assessment and treatment (CAT) service, was laid down in Victoria about a quarter of a century ago. Studies detailing community treatment for mental disorders in Australia date as far back as the early 1980s.. The CAT service has since become the gatekeeper for inpatient treatment and has now been incorporated into a broader category of acute community intervention service. Much of the available research on the CAT team services and its delivery model has been done in Europe and North America.,,,
There have been studies that have investigated this model of care in the Australian context. In a cross-sectional analysis of the 384 patients followed by the Northern Area CAT team during March 1999–February 2000, psychosis (45.1%) was the most common illness, followed by affective disorders (28.6%), anxiety disorders (13.3%), personality disorders (5.2%), no diagnosis (4.7%), and then substance use disorders (3.1%).
Hugo et al. in 2002 studied the effect of community based mobile emergency service (n = 304) against hospital-based emergency services (n = 201) on rates of hospital admission. This study revealed no group differences in age, gender, case management, and provisional primary diagnoses but revealed that the community-based services group had more additional diagnoses. It also found that hospital-based assessments were associated with higher admission rates (43%) than community-based assessments (13%).
Adesanya in 2005 studied the impact of CAT team intervention on hospital admission rates in a regional Victorian mental health service using a pre- and post study design. This study compared profiles of patients admitted before (n = 69) and after (n = 53) the introduction of CAT service. This study found that being single was the only significant variable associated with admission in the post CAT period. Both groups did not differ in other sociodemographic characteristics. There were no significant differences in reasons for, and duration of admission, number of and reasons for readmissions, length of stay, and diagnostic categories. In both groups, adjustment disorder was the most common diagnosis, whereas personality disorder was the least common diagnosis in both study periods.
A study by Happell et al. in 2009 into clinical outcomes when crisis-based care was initiated by a nurse versus standard care revealed no difference in outcomes between these two types of care plans. This study included 103 patients in which a majority were women, voluntary patients, and born in Australia. The top three diagnoses were depressive disorder, schizophrenia, and schizoaffective disorder.
Monshat et al. studied the effect of psychological interventions by CAT clinicians and found that 74% of clinicians' contact time involved the provision of psychological interventions. The nature of psychological support ranged from focusing on the therapeutic alliance, psychoeducation (“meta-strategies”), supportive therapy, cognitive behavioral therapy, other forms of psychotherapy, critical (regarding risk management and planning for ongoing care), and practical support to deal with psychosocial issues. This study did not detail how often different strategies were provided to patients.
Perhaps the first study to detail the referral sources, discharge destinations, and clinical interventions provided by a crisis team was done in New South Wales. This study included 677 patients during a 10-week period. In this study, self-referral was the major referral source (25%), followed by community mental health service (17%), emergency departments and psychiatric emergency care center (16%), family and friends (13%), and inpatient psychiatric units (13%), and discharge to a community mental health service was the most common discharge pathway (42%). Only 9% needed inpatient treatment. Clinical interventions were of four types, namely postdischarge follow-up (31%), triage support (30%), support with case management (23%), and acute assessment and treatment (16%).
A recent systematic review (n = 37 studies) exploring the effectiveness of the crisis resolution model of care concluded that evidence is not of high quality and that longitudinal outcomes are poorly investigated. A Cochrane review concluded that crisis intervention could possibly reduce readmissions for patients with severe mental illnesses based on a single randomized controlled trial despite limitations of the data (relative risk: 0.75; confidence interval: 0.5–1.13).
Thus, there are limitations in the current evidence base due to studies being either cross sectional in nature,,, or comparing community versus hospital crisis intervention.
In this context, we carried out this study with two objectives: (i) to describe the sociodemographic, clinical characteristics, and service provision of patients who attended a crisis intervention service during the study period (index contact) and (ii) to understand their clinical outcomes at 12 months after the index contact by examining the rate and characteristics of patients who re-entered the community mental health service for acute care. The first objective was to illustrate the nature of patients needing acute crisis care in the current (contemporary) period, whereas the second objective was to study the long-term effectiveness of acute crisis intervention which was not studied before.
| Methods|| |
For this study, we used a retrospective cohort design given that such a study design is a standard approach in exploring long-term outcomes. There was no comparison group as it would have been difficult to equate crisis intervention with another service delivery, e.g., standard community mental care in terms of crisis management. Participants for this study were patients who were registered with the crisis intervention service between May 1, 2015 and October 30, 2015 at Hume Community Team (HCT) of North West Area Mental Health Service (NWAMHS).
NWAMHS caters to people in North West region of Melbourne. This service has community programs in two locations (Broadmeadows and Coburg). The original Crisis Assessment and Treating Team (CATT) was established in 1988 was based at Broadmeadows but following a community service remodeling in 2015, the CATT functions were integrated into these community programs. In general, remodeling saw the integration of different teams (i.e., crisis assessment and treatment team, primary mental health team, mobile support team, and general community mental health team) into a single organizational structure in order to reduce silos and improved operations. Our study was focused on the crisis intervention program locally referred to as the “brief intervention” team of the HCT.
The HCT brief intervention program consists of a multidisciplinary team (MDT) of psychiatric nurses, social workers, occupational therapists, and psychologists that provide brief intervention using the recovery framework. The team is supported by a 0.7 full-time equivalent (FTE) registrar and 0.5 consultant psychiatrist. The team has a rotating roster of 3.16–4.58 FTE MDT staff. The team works from 0830 until 2230 h 7 days a week. Two clinicians from a multidisciplinary background work in each shift (from 0830 until 1700 h, and 1400 till 2230 h). The psychiatry registrar and consultant are available during business hours, with phone support after hours from rotating on-call registrars, junior doctors, and consultants.
Referrals are triaged at the centralized triage offices located at the Royal Melbourne Hospital 24 h a day. The referrals coming from the Hume catchment area of NWAMHS are sent to this team. The patient is assessed by a clinician within the time frames specified by the triage scale.
The following data sources were used to gather patient information: (i) electronic medical records and (ii) the state-wide client management interface system. The data were extracted on a data sheet specifically designed for this study. In addition, after obtaining permission, we used the revised Social Readjustment Scale, a modified version of the Holmes–Rahe stress scale to characterize the nature of the stressor in the time leading up to referral. We have also included admission and discharge scores of the 12-item Health of the Nation Outcome Scale (HoNOS).
Data were de-identified and secured in order to maintain confidentiality. Patients' consent was therefore not required. Ethical approval was obtained from the Melbourne Health Ethics Committee (Approval number: QA2017001).
For this study, descriptive statistics were used to describe the sociodemographic and clinical characteristics. Normality test by Shapiro-Wilk test showed that the data was not normally distributed and hence we used non-parametric inferential statistical tests for group comparisons. While Chi-Square test was used for categorical variables, Mann-Whitney U test was used for continuous variables. To analyse the changes in HoNOS scores between admission to and discharge from crisis intervention service (paired data), Wilcoxon Signed Rank test was used. We chose alpha level of < 0.05 as the indicator of statistical significance. All the data analyses were carried out by the statistical software SPSS Version 26.0 (Released 2019, Armonk, NY: IBM Corp).
| Results|| |
During the 6-month period, 94 patients were referred to the brief intervention team. The mean age of the patients was 40.04 (standard deviation [SD] ± 9.7) years. A majority were informal, Caucasian men, living with a partner, unemployed, or on unemployment benefits [Table 1].
The leading source of referrals was from the primary health sector (25.5%, n = 24), followed by family/self-referred (22.3%, n = 21), hospital based (including inpatient unit) (21.3%, n = 20), emergency services (emergency department, police, ambulance services, and police) (19.1%, n = 18), and community-based mental health services (11.7%, n = 11). A majority (53.2%, n = 50) were category D (to be seen within 72 h), followed by category E (nonurgent or care plan reviews) (37.2%, n = 35), and category C (to be seen within 8 h) (9.6%, n = 9).
Of all patients who received a phone and face to face contact, 70.4% received a medical review. The mean interval to the first contact with patients was 16.06 (±14.7) h, the length of episode of care was 13.1 (SD ± 10.5) days, and the number of medical reviews was 1.8 (SD ± 5.3). The mean discharge HoNOS scores were less (8.7 ± 4.3) compared to HoNOS at entry (10.8 ± 5.5) (Z = −2.92; P = 0.03).
The main presenting diagnoses were situational crisis or adjustment disorder (n = 25, 26.6%), major depressive disorder (n = 15, 16%), bipolar affective disorder (n = 13, 13.9%), substance-induced psychosis (n = 12, 12.8%), psychosis (including schizophrenia and delusional disorder) (n = 11, 11.7%), followed by posttraumatic stress disorder (n = 7, 7.4%), borderline personality disorder (n = 3, 3.2%), mixed anxiety and depressive disorder (n = 4, 4.3%), generalized anxiety disorder (n = 2, 2.1%), grief reaction (n = 1, 1.1%), and acute stress reaction (n = 1, 1.1%). Anxiety disorder (n = 9, 9.6%) and depression (n = 5, 5.3%) were the common comorbid conditions. About 36 patients (38.3%) had a dual diagnosis.
Thirty-four patients (36.2%) had substance use disorder, with common substances being amphetamines (n = 13, 13.8%), cannabis (n = 9, 9.6%), opioids (n = 7, 7.4%), alcohol (n = 3, 3.2%), and benzodiazepines (n = 1, 1.1%). Fifty-two patients (55.3%) had a physical comorbidity with the mean number of physical illnesses was 1.44 (SD ± 0.49). Ten patients (10.6%) had a personality disorder, with borderline personality disorder being the most prominent (n = 7, 18.1%), followed by antisocial personality disorder (n = 2, 2.1%) and another 29 had abnormal personality traits (29.6%), with borderline personality traits being most common (n = 17, 18.1%), followed by antisocial (n = 5, 5.3%) and others (n = 7, 7.5%).
In terms of risk, 17 (18.1%) patients presented with a deliberate self-harm behavior, whereas four presented with a suicidal attempt (4.3%). Suicidal behavior included overdose (n = 2, 2.2%), hanging attempt (n = 1, 1.1%), and jumping from a height (n = 1, 1.1%). Polypharmacy overdose was the predominant self-harm behavior (n = 14), followed by cutting (n = 3). Aggressive behavior (verbal or physical) was noted in 11.7%, and forensic history in 5.3%. Nearly a third (n = 27, 28.7%) presented with a history of poor compliance.
The common psychosocial stressors were major injury or illness to self (16%), separation or reconciliation with partner/mate (10.6%), death of close family member (9.6%), experiencing financial difficulties (9.6%), substance-related issues (9.6%), and being unemployed (5.3%) [Table 2].
|Table 2: Stressor nature - revised version of social readjustment rating scale|
Click here to view
In terms of intervention, 54.1% received a biological intervention, with medication optimization being the most common intervention, whereas psychoeducation (51.1%) was the predominant psychological intervention. Linkage to a public mental health service (18%), private mental health providers (14.9%), general practitioner (13.8%), and care coordination (13.8) were the dominant “other” interventions [Table 3].
Majority of the patients were referred to GP (59.6%) for follow-up [Figure 1]. Thirty-seven patients (39.4%) were re-refereed to a community mental health service within 1 year of discharge.
Compared to patients who did not need re-referral, the re-referred group had a significantly higher proportion of men, living with housemates or other family members, category C index triage referral, mood disorders, needing medication supervision, and discharge destination being hospital/residential care [Table 4]. Twelve patients (12.9%) were admitted to an inpatient unit within 1 year of discharge.
| Discussion|| |
We carried out this retrospective cohort study of patients enrolled into a crisis service of a newly remodeled community mental health clinic. Our study is perhaps the first of its kind in exploring the effectiveness of crisis service in a long-term fashion.
In our study, the crisis service was most commonly used by single, middle-aged men, unemployed, and of Caucasian background. Like a previous study, patients who were voluntary dominated the study sample. The leading referral source was the primary health sector, a finding that is different to a previous study. While suggesting the presence of a strong primary health sector in the study catchment area, this finding could also mean patients were less capable of reaching out to acute mental health services for unexplored reasons. In terms of service delivery, patients were seen within 16 h on average from the time of referral, and the average duration of service involvement was below 2 weeks. Medical input was provided to three-fourths of patients. There was a reduction in HoNOS scores at the time of discharge from the crisis service. There was no previous study to compare these findings.
We noted adjustment disorder/situational crisis was the most common diagnosis, a finding which agrees with a previous study but disagrees with studies in which affective and psychotic disorders dominated the diagnostic category., It is noteworthy that these two studies, were from the same mental health service which thus could be reflective of the patient population relevant to this particular mental health service.
Another point of difference was the increased rate of patients with personality traits in our study compared to older studies., Furthermore, in contrast to a study done nearly two decades ago, we found more than a 10-fold increase in substance use disorder diagnosis (i.e., 3% vs. 36%). The increasing prevalence of substance use in the Australian population has been reported. Together, our findings highlight the changing landscape of primary diagnosis in patients needing crisis service.
In terms of primary behaviors of concern for referral, we found deliberate self-harm and aggression as the common reasons. Polypharmacy overdose was the most common self-harm method. These presentations can be understood in the background of primary diagnosis among patients in this study. Psychological therapies such as psychoeducation and supportive therapy and optimizing medication doses were the common therapeutic strategies that we found in our study. Often, patients were discharged to their general practitioners (i.e., primary health-care providers). The rate of inpatient admission was only 9%, a finding that differs from a previous study.
Analysis of stressors identified injury or illness to self, relationship difficulties, matters related to work and finance, and substance abuse as the common psychosocial factors. We could not find another study to compare our data; however, our findings hint at the need for strategies at the population level to address these common stressors.
An important finding of our study was the nature of re-referred patients. We found that just below 40% of patients needed re-referral to the community mental health services and only about 13% of patients needed inpatient treatment during the first 12 months of discharge from the index crisis service episode of care. Subanalysis identified the following characteristics in the re-referred subgroup: they were mostly men, living with a housemate or other family, having index referral being category C, a diagnosis of a mood disorder, a need for medication supervision in the index episode of care, and those who needed hospital admission. While we have no previous study to compare our findings, it appears that the re-referred patients represented a seriously unwell group. Further research is needed to understand the characteristics of this subgroup and explore what strategies could have reduced or prevented the need for re-referrals.
Our findings have two broad implications for service delivery. The first implication is regarding the existing model of community care. At present, community mental health teams in Victoria provide episodic care, i.e., patients are discharged to their primary care provider once their mental state improves. In the background of the primary health sector being the key referral and discharge sources, and the finding that a high proportion of re-referred patients had a serious mental illness, a continuous shared care model for patients with serious mental illnesses is necessary to identify and treat relapses early. The need for a review of community mental health care has recently been emphasized by the Victorian Royal Commission into the mental health.
The second implication is about resources and clinician skill sets needed to provide a consumer focused and sustainable acute crisis intervention model of care. The nature of primary diagnoses and the extent of substance use and personality pathology found in our study underscores the role of psychosocial triggers in acute deterioration in mental state. This would mean that clinicians in crisis intervention services need to have a wide range of skill sets appropriate to support patients to navigate the contextual factors associated with their presentation to crisis services. Such a need was reflected in our study in that clinicians were predominantly providing psychoeducation and supportive therapy. Other therapies of relevance are motivational interviewing, trauma-informed therapy, counseling specific to substance use, etc.
Retrospective studies have limitations and this includes the retrospective cohort design. The strengths of our study are detailed descriptions of clinical characteristics, service provision, psychosocial stressors through a standardized instrument, and long-term outcomes. A prospective cohort study with a comparison group and larger sample size will help to confirm our findings.
| Conclusions|| |
Crisis intervention service is an essential component of any community mental health service and it can reduce inpatient service use. There is a need for ongoing partnership and support for primary health-care providers as this sector being the major source of referrals as well as discharge pathway. A collaborative, continuous model of care and ensuring clinicians are well versed and trained in a broad range of psychological therapies and social interventions will help in early identification and timely management given the changing demographic of patients needing acute crisis care.
Financial support and sponsorship
Funding was granted as part of the North Western Mental Health Seed Grant Program of Melbourne Health (approval number: QA2017001).
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]