Item 4

National Audit Office (2007) Helping people through mental health crisis: The role of Crisis Resolution and Home Treatment Services

CRHT teams provide acute home treatment for people whose mental health crisis is so severe that they would otherwise have been admitted to an inpatient ward. Users of CRHT are typically suffering from severe mental illness such as psychosis, severe depression or bipolar affective disorder (manic depression). (p.5)

1.2 Most people with mental health problems receive treatment in the community, for example from their GP or a Community Mental Health Team. But acute services are also a crucial part of mental health services. Severe psychiatric illnesses are often episodic in nature, with sufferers experiencing both stable phases and periods where their symptoms become more intense. During such periods, they require acute mental health services to provide intensive monitoring and support and help them return to stability. 

1.3 At one time, such services were available only in hospitals, with people in crisis having to be admitted as inpatients to receive the treatment they needed. More recently, and in common with practice in a number of other countries,13 the Department of Health has aimed to ensure that prompt and effective help in times of crisis is provided in an appropriate and safe place as close to home as possible. This aim reflects the development of new clinical techniques and drugs facilitating treatment outside hospital, as well as a growing recognition since the middle of the twentieth century that institutionalisation is the least beneficial option for many users of mental health services.14 Long inpatient stays can mean service users become disconnected from their home and working lives, leading to increased social exclusion, stress and risk of relapse after discharge. (p. 12-13)

3.22 Both ward and CRHT managers reported instances of patients being admitted even when the managers considered the service user an appropriate candidate for CRHT - ward managers reported this in 16 per cent of the 500 admissions examined. CRHT managers reported that for 20 per cent of the service users referred to them who had subsequently been admitted, the admission would have been better avoided.

3.23 The reasons given why service users had been admitted in these cases varied widely, but included insistence by the Consultant Psychiatrist, accommodation problems or homelessness, patient preference and carers' anxiety about being able to cope. These indicate areas in which strengthening CRHT services and links to other services would provide scope to further reduce admissions in appropriate cases.' (p.24)

3.26 The broad range of choice for a person in crisis remains quite limited: they can either engage in short-term intensive home-based treatment, or be admitted to hospital. Indeed, very few alternatives to hospital are available to CRHT teams beyond their own staff providing therapy to service users in service users' homes. Several CRHT managers suggested that access to alternativesto hospital admission could increase their capacity for delivering CRHT: four of the 25 identified a need for short term respite or crisis accommodation, and three identified a need for acute day hospitals. (p.25)

Chisholm & Ford (2004) Transforming Mental Health Care 

Eligibility criteria - who is the service for?

Although the criteria should reflect the local situation, the starting point should be the criteria set

by the MH-PIG. These are based on evidence of effectiveness and cost-effectiveness.

The MH-PIG states that AO should be targeted at adults between the ages of 18 and approximately

65 who have one or more of the following:

• a severe and persistent mental disorder (e.g. schizophrenia, major affective disorders) associated with a high level of disability;

• a history of high inpatient or intensive home-based care (e.g. more than two admissions or more than six months' inpatient care in the past two years);

• difficulty in maintaining lasting and consenting contact with services;

• multiple and complex problems including one or more of the following:

• history of violence or persistent offending;

• significant risk of personal self-harm or neglect;

• poor response to previous treatment;

• dual diagnosis of substance misuse and serious mental illness;

• detention under the Mental Health Act (1983) on at least one occasion in the past two years;

• unstable accommodation or homelessness.

Most of the teams that we visited had attempted to adhere to these criteria, although in some cases they had modified them. From a sample of ten AOTs, most specified severe mental illness and difficulty with engagement as inclusion criteria, whereas only half specified high use of inpatient beds (see Figure 1). There was some evidence that eligibility criteria are adjusted according to the level of local need. For example, in an area of relatively low need there might be a lower threshold for acceptance into the service than in an area of high need. This runs the risk of providing people with an intensive service from which they do not derive great benefit.

Common exclusion criteria are:

• sole diagnosis of substance misuse;

• sole diagnosis of personality disorder.

Other teams do not exclude specific groups but deal with referrals on a case-by-case basis. Hemming et al. (2002) state that services should not be offered or declined on the basis of diagnostic category alone. For example, an individual with a personality disorder, with chaotic engagement and use of services, together with many complex social care problems, may well respond to the intensive support that AO can provide. The Norwich Intensive Support Team reports some success with people with borderline personality disorder, who make up around ten per cent of the caseload. (p.5-6)

Eligibility criteria - who is the service for?

The MH-PIG states that CR/home treatment should be targeted at adults aged 16-65 years old with severe mental illness (e.g. schizophrenia, manic depressive disorders) who are undergoing an acute crisis of such severity that, without the involvement of a CR/home treatment team, hospitalisation would be necessary. In every locality there should be the flexibility to decide to treat those who fall outside this age group, where appropriate.

The guidance further states that the service is not usually appropriate for individuals with:

• mild anxiety disorders;

• primary diagnosis of alcohol or other substance misuse;

• brain damage or other organic disorders, including dementia;

• learning disabilities;

• exclusive diagnosis of personality disorder;

• recent history of self-harm but not suffering from a psychotic illness or severe depressive illness;

• crisis related solely to relationship issues.

In practice, rather than focusing on people with severe mental illness, teams are concentrating on whether the alternative would be hospital admission. This means that thresholds for accepting people may be affected by the availability of other alternatives to hospital admission, including services more appropriate than hospital, to which people with less severe problems can be diverted. (p.22)

McGlynn (2006) CRHT: A Practical Guide

Clearly defined target population

The main focus for CRHT teams is on people with schizophrenia, those with bipolar affective disorders and severe depression, and people with borderline personality disorders. One area of controversy isthe relationship that CRHT teams have with A&E departments. An unpublished survey at the Norfolk and Norwich hospital in 2005 revealed that about 90% of patients whom mental health services were asked to see in the A&E department did not require the CRHT team service. Ideally A&E departments should have their own mental health liaison service to deal with requests for mental health assessments and only pass on to the CRHT team cases at risk of admission to the psychiatric unit. CRHT teams can have a helpful role in supporting non-target groups in crisis for a few days until they can be passed on to other community-based services. Unfortunately, in too many areas, CRHT teams are used to undertake all A&E mental health work, to the detriment of their capacity to deliver home treatment. (p.15-16)

Mental Health Foundation (2012) Take Control: Self-management in care and treatment planning

Who a crisis resolution service is for

The main target group will often be adults between 16-65 years of age, whose mental illness is of such severity that they are at risk of requiring psychiatric hospitalisation. The focus will generally be on individuals with either a psychotic or depressive illness who are currently experiencing an acute episode. Suicidal acts or threats, or acts or threats of violence towards others may be common scenarios when clients are first seen. Given these broad client referral types, the service must also be flexible, both in terms of age and psychiatric diagnosis. For example, a referred client who is over 65 years old can be accepted if he or she still receives adult services. Also, someone diagnosed with personality disorder or a dual diagnosis of mental illness and alcohol or substance misuse who is in crisis may also be accepted. Referrals will often need to be determined on an individual basis.

Who a crisis resolution service is not for

Anxiety disorders: The service is not for people with mild anxiety disorders. For example, people with agoraphobia, who would probably benefit more from behavioural therapy.

Alcohol or substance abuse: Crisis services are also not for people with a primary diagnosis of alcohol or substance abuse. People who have mental illness as a primary diagnosis, may often have problems with alcohol or substance abuse as a result of their mental illness, but if this is not the case, appropriate specialist services should be sought.

Organic disorders: The service is also not for people with brain damage or other organic disorders, such as dementia.

Learning disabilities: Crisis resolution services cannot be expected to treat individuals with a primary diagnosis of learning disability. Referrals may however, be accepted where there is also a strong mental illness component present combined with a mild learning disability and no other local services are available.

Overdose cases with no mental illness: It is not appropriate to refer cases of individuals who have recently overdosed but who are not suffering from a mental or severe depressive illness.

Relationship issues and situations of domestic violence: Again, if mental illness is not a feature in such situations, this would be an inappropriate referral.

Deciding eligibility criteria

It is important to determine whom the service is for before the team takes action. The service manager should develop a clear written policy to be circulated to potential referrers. These would include local GPs, A&E (accident and emergency) departments as well as CMHTs (community mental health teams). Where possible, some face-to-face management discussions about referrals should occur before the team becomes operational. Such a policy should state both acceptance and exclusion criteria. However, it may only be the actual trial and error of operational practice that refines these criteria. (p.13-14)

Department of Health (2001) Mental Health Policy Implementation Guide

3.1 Who is the Service for?

Commonly adults (16 to 65 years old) with severe mental illness (e.g. schizophrenia, manic

depressive disorders, severe depressive disorder) with an acute psychiatric crisis of such

severity that, without the involvement of a crisis resolution/home treatment team,

hospitalisation would be necessary. (NB) In every locality there should be flexibility to

decide to treat those who fall outside this age group where appropriate.

This service is not usually appropriate for individuals with:

• Mild anxiety disorders

• Primary diagnosis of alcohol or other substance misuse

• Brain damage or other organic disorders including dementia

• Learning disabilities

• Exclusive diagnosis of personality disorder

• Recent history of self harm but not suffering from a psychotic illness or severe

depressive illness

• Crisis related solely to relationship issues (p.11)