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Crisis Assessment and Treatment Service
Dr. Shashjit L Varma, Crisis Assessment & Treatment Team, Grampians Psychiatric Services,
Ballarat Health Services, Ballarat 3350, Victoria, Australia.
The management of urgent psychiatric cases is seen to be crucial to the future organization of hospital and community services. Anecdotal evidence suggests that Crisis Assessment & Treatment (CAT) service is very useful in the community mental health service. Having completed 3 years of CAT, this report aims to share our experiences on patients referred to CAT services, during that period, at the Grampians Psychiatric Services. Patients, who are in psychaitric crisis are referred to CAT. A detailed history and examination includes: socio-demographic variables, referring agencies, reason for referral, diagnosis, the CAT intervention done and the outcome. Following the CAT teams intervention, the patients are then linked back to the appropriate agencies.
Of the patients referred to the CAT team till now, 4/5th were managed in the community. The admission rate was quite less (1/5 th referrals). Our experiences suggests that the CAT is a very effective service available with the community psychiatric services. In addition to the patients being managed closer to their home, a reduction in hospital admissions could also be achieved, which in turn helps in cost savings.
There is now a considerable body of research evidence indicating that community based programs which include crisis intervention, have clinical outcomes that are no worse than, and by some criteria superior to, hospital care programs (Braun et al, 1981; Dean & Gadd, 1990). Most serious psychiatric conditions are chronic relapsing conditions. Admission to a psychiatric facility for the acute relapses does little to influence the long term outcome of the illness and with the move away from the institutional care, it offers very short respite to the relatives (Dean & Gadd, 1990). The studies indicate that hospitalization may not be necessary in many cases and reasonably good results may be achieved by active follow up in the community.
Grampians Psychiatric Services (GPS) is one of 8 regions providing psychiatric care for patients with serious mental illness in Victoria. It covers 45,000 sq. km., with a population of 182,000 and has a population density of 4.1 per sq. km. CAT service is one aspect of GPS.
The target group for CAT services is:
* People, aged sixteen to sixty-four years, in the acute phase of a mental illness, or at risk of an acute episode, who require intensive treatment and support from adult public psychiatric services, with priority to those for whom public psychiatric inpatient admission is being considered.
* People, aged sixteen to sixty-four years, in psychiatric crisis whose community living arrangements are breaking down as a result of their mental illness, who require intensive out-of-hours intervention to prevent psychiatric inpatient admission.
* Adolescents under eighteen years and older people over sixty-five years who are in the acute phase of a mental illness and are referred through specialist mental health services for urgent out-of-hours community based assessment in order to determine whether intensive, time-limited intervention can prevent acute inpatient admission.
Back in 1990, Reynolds et al, reported that their Crisis team had halved the admission rate of the hospital. Another study from Australia was done by Hoult et al, 1983, reported that community treatment, did not increase the burden upon the community, was considered to be significantly more satisfactory and helpful by patients and their relatives and the cost was less than standard care.
Anecdotal evidence indicates that CAT is doing a great role in the community mental health service but till now we could trace only a few published scientific study in Australia to demonstrate it. Inspite of CAT remaining in news, the general claim and enthusiasm about CAT is based on little or no empirical data, as shown by paucity of studies. There is much lore about the services but no data (Geller et al , 1995). Geller et al, 1995, surveyed national data in USA on the use and evaluation of mobile crisis services in 39 states. The study reported that although the use of mobile crisis services was associated with favourable outcomes for the patients and families and with lower hospitalization rates, very few centres collect evaluative data on the effectiveness of those services. The survey concluded that the claim of efficacy are based on little or no empirical evidence. A few studies (Trimboli, 1987; Fisher et al, 1990) however, found no significant reduction in admission rates.
CAT team of Grampians Psychiatric Services, at Ballarat Base Hospital, Ballarat, was formed in October, 1994 with the aim to manage the patients with serious mental illness of Ballarat, Grampians and Wimmera, in the community. The team comprises of a Consultant psychiatrist, a psychiatric registrar, community/registered psychiatric nurses, psychologist and social worker. Target group for CAT services is: 1] people aged 16-64 years in acute phase of mental illness or crisis; 2] people in psychiatric crisis whose community living arrangements are breaking down; and 3] people under 18 years or over 64 years in acute phase of mental illness for urgent out-of hours assessment in order to determine whether an intensive intervention can prevent a hospital admission
The patients in crisis are referred primariliy by general practitioners, A&Es, police, families, private psychiatrist, continuing care service, relationship Australia and even self. The patients are evaluated for the basic socio-demographic variables, referring agencies, reason for referral, diagnosis, the CAT intervention done and the outcome.
The initial assessment is done by two of the team members and the final psychiatric diagnosis is made in consultation with the consultant psychiatrist according to the DSM-IV diagnostic criteria. The plan of management is discussed by the whole team and executed accordingly. Potential admission patients deserved extra attention and effort to keep them in the community.
'Potential admission' patients are defined as patients fulfilling one of the following criteria:
1) severely psychotic - deteriorating mental state,
2) danger to self,
3) danger to others and
4) non-compliance to treatment.
When the team felt that it was not possible to keep those patients in the community they were then admitted for a short duration for inpatient management often with a recommendation for an early discharge. Following the CAT teams' intervention, the clients were then linked back to the appropriate agencies.
CAT services have been the subject of considerable public interest, resulting particularly from the work between police and mental health services in response to high risk situations. Other agencies which get involved with CAT are emergency departments, ambulance services, drug and alcohol services, intellectual disability services and protective services. Another point of interest was the radical new idea of restricting admission to psychiatric services and instead managing the clients in the community. This very idea received a lot of resistance.
Many of our patients, like those of earlier studies (Reynolds et al, 1990, Hoults et al, 1983) live in predominantly middle class areas and suffered from one of the functional psychosis. Reynolds et al, 1990 opined that Crisis teams would be less effective for those living in more deprived socioeconomic areas and for other diagnostic groups. We found it to be the same in our situation. Patients with certain diagnostic categories (especially persons with personality disorder/drug and alcohol problems) were less available on follow up, thus hampering our effectiveness.
Referrals from all catchment areas highlights the awareness about CAT services among health professionals and general population. The ability of the CAT team to respond to crisis call from remote areas (50-70 km) is challenging and rewarding as well. Out of region patients (5%) represent a group which receives immense benefit from a services like this. Once the crisis is taken care of, they can then receive follow up from their respective areas. An important itinerant group of people are often a managment problem as they do not comply to the management plan; are the people on the move and tap several agencies on their way. They get their crisis resolved and then move along without adequate follow-up and compliance to land up in yet another crisis.
One of the policies of CAT is to restrict the number of days of hospitalization of a patient by intensive follow-up and management in the community. This procedure provides treatment close to home and is appreciated by patients and relatives. At times it may be troublesome to the families but mostly, it is accepted as a better alternative to psychiatric hospital admission. Intensive follow-up may sometimes mean visiting a patient 2-3-4 times a day giving medications, counseling and support to both patients and their families. The cost effectiveness of CAT can only be achieved if involvement is less, otherwise admission may be a better option, and we have achieved that level of function.
Another method adopted by us to decrease hospitalization is Early Discharge Management (EDM). EDM means, discharging the patients from hospitals as soon as they are settled on medication and follow-up at home. This is done in consultation with the treating team. A management plan is set up and CAT takes over the patients from the hospital, as soon as the discharge plan is finalized. When the patient is settled he/she is then handed over to the continuing care team for long term follow-up. Thus CAT facilitates the integration of patients from hospital to home/community.
Most of the patients referred to CAT are from A & E and they are generally of attempted suicide or parasuicides. This is one of the very difficult, important and crucial roles a CAT team has to perform: assessing a crisis situation in an emergency unit of a hospital. Patients have just gone through a terrible crisis in their lives which motivated them to cry for help (by attempting suicide). The important part is the assessment and prediction of the risk of further suicidal actions. It is on this clinical judgment that CAT decides whether to follow-up the patients in the community or to admit them in a psychiatric unit. Taking on a patients who has just attempted suicide and who is not willing to live, leaves us with a very narrow space to work. As a quarter of CAT's referrals come from A & E, our service has posted a community psychiatric nurse (CPN) at the A & E for immediate assessments of the psychiatric emergencies. The CPN is currently on an experimental basis of three months and may be there for long time if the experiment bears fruit.
CAT generally remains in news due to the huge number of agencies coming in contact with it such as, GPs, social services, relationships agencies, various protection services and police to name a few. The most common request is to admit 'a particular person' in the psychiatric facility. The problem may vary from a criminal behaviour, aggressiveness, destructibility, suicidal behaviour, domestic dispute, relationship problems, drugs and alcohol problems. Mostly there may not be a serious mental problem/illness and the referrals may then be directed to appropriate agencies.
The most common diagnosis we see is adjustment disorders. The different agencies involved in referrals at our centre may be the reason of us receiving adjustment problems more. An area of challenge is personality disorder patients. They are generally viewed negatively by mental health professionals, but we have tried to take on personality disorder patients as a challenge. Fifty percent of our patients with personality disorder were given some form of help, which prevented their admission in crisis situations. Since the formation of CAT, admission rates for personality disorders have decreased considerably.
Thus we see CAT services are fraught with challenges and a 24 hour crisis team needs an enthusiastic and highly motivated team. Over the years, CAT has established itself as a useful tool of the community mental services. In addition of the patients being managed close to their home, a massive reduction in hospital admissions could also be achieved, which in turn helps in cost savings, a priority of many modern organizations.
Caution & Recommendations
1. What is important is that once the crisis is over, the patients should be handed over to relevant agencies for a long term management and follow up. CAT should be checking on the long term outcome of these patients.
2. In our enthusiasm we should remain very much aware of the problems faced by the family and carers. In our enthusiasm for managing one patient in the community we should not be creating two new ones (from the family).
3. As also mentioned earlier (Reynolds et al 1990), it is possible that enthusiasm and commitment of the members of the CAT, who had chosen this type of work, had a positive influence on the patients and relatives perceptions of the outcome. It is possible that the results would not be as positive if, the staff had been less committed to the provision of a 24 hour crisis service. Diluting the CAT team by merging it with community teams may not produce the same results and may even have detrimental effect on client outcome.
4. Intensive follow up, long term management, rehabilitation and especially involvement of multiple agencies may become costlier than hospitalization itself. Then one of the main purpose of community mental health services may be defeated.
5. Hoult et al, 1983 stressed that if community treatment is opted for purely because it is the 'cheaper' mode of treatment and attention is not paid to the quality of community treatment, then the consequences will be negative rather than positive.
6. To achieve full effectiveness, CAT services should be taken as, a compliment to the standard management of psychiatric patients and not as, an alternative to the regular management.
7. With deinstitutionalisation Gps are seeing psychiatric patients as never before. Thus, GPs should be given adequate training and "Continuing Medical Education" in mental health care, so that they are confident enough to manage these cases.
- Braun P, Kochansky G, Shapiro R et al. Overview: deinstitutionalisation of psychiatric patients, a critical review of outcome studies. American Journal of Psychiatry 1981;138; 736-749.
- Dean C & Gadd EM. Home treatment for acute psychiatric illness. British Medical Journal 1990; 301; 1021-1023.
- Fisher WH, Geller JL, Wirth-Cauchon J. Empirically assessing the impact of mobile crisis capacity on state hospital admissions. Community Mental Health Journal. 1990; 26; 245- 253.
- Geller JL, Fisher WH, McDermermeit M. A national survey of mobile crisis services and their evaluation. Psychiatric Services 1995; 46;9; 893-897.
- Hoult J, Reynolds I, Charbonneau-Powis M, Weeks P and Briggs. Psychiatric hospital versus community treatment: the results of a randomized trial. Australian and New Zealand Journal of Psychiatry 1983; 17; 160-167.
- Reynolds I, Jones JE, Berry DW and Hoult JE. A crisis team for the mentally ill: the effect on patients, relatives and admissions. The Medical Journal of Australia. 1990; 152; 646-652.
- Trimboli C. The implementation of Richmond report in Western Sydney: an evaluation. Sydney: Western Metropolitan Health Region, NSW Department of Health, 1987.