20. Safety of patients under the care of crisis resolution home treatment services in England

Here is the reference for a recent paper in Lancet Psychiatry that -in my opinion- raises unwarranted concerns about the safety of intensive home treatment.

Hunt I, Rahman S, While D, et al. Safety of patients under the care of crisis resolution ome treatment services in England : a retrospective analysis of suicide trends from 2003 to 2011. Lancet Psychiatry 2014;1, issue 2: 135-141

This study is one of a series conducted by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness ( NCISH). ( The 2001 NCISH study ” Safety First ” is posted on this website # 12 under research )

The stimulus for the study is  data from the  2013 Annual NCISH report which indicated that the number of suicides in people under the care of crisis resolution home treatment ( CRHT) teams has been increasing and suggested that more suicides are now happening in patients under the care of these services than in those admitted to inpatient care.

All people who died by suicide between 2003 ( when CHRT was implemented inEngland ) and 2011 , and had been in contact with mental health services in the  12 months before death were identified.

The rate of suicide under CRHT was calculated using the number of referrals for care ( termed episodes ) as the denominator . The rate of suicide among inpatients was calculated by using the number of admissions as the denominator

Over the period of the study , a significant  increase was recorded in the number of suicides in CRHT patients from a mean of 80 in 2003/2004 to 163 in 2010/2011 -giving an overall mean of 140 deaths .  By contrast, the mean number of inpatient suicides fell by more than a half from 163 in 2003/2004 to 76 in 2011- an overall mean of 117

The overall suicide rate during the study period  for CRHT patients was 14.6 per 10,000 episodes , whereas for inpatients it was 8.8 per 10,000 admissions.

Over the course of the study the suicide rate per year fell for both CRHT and inpatient care  : from 15.3 to 12.4 per 10,000 episodes and  from 9.9 to 6.3 per 10,000 admissions

Overall, the average number of suicides per year under CRHT was 140- 20% higher than the number dying while admitted to hospital over the course of the study and increasing to twice as many in the last five years of the study

What is the significance of these findings? Should it raise doubts about the comparative safety of intensive home treatment ?

In my opinion, without information on the relative increase in the number of CRHT patients over the study period , and without information regarding lengths of admissions and episodes, it is impossible to draw any confident conclusions

The use of two different denominators ; episodes of CRHT treatment versus admissions , while not quite like comparing apples and oranges appears to be like comparing apples of different sizes regarding length of exposure to risk.

To illustrate, consider the methodology of road traffic safety research in comparing traffic deaths , say, in rural versus urban areas. The rate of traffic deaths is calculated by the number of deaths divided by some measure of exposure to risk-usually number of deaths per 100 million vehicle miles. The further you drive the greater the risk of dying in a traffic accident; the longer you are a potentially suicidal patient in the care of a treatment service, the greater the risk is that you will die while under the care of that service ( offset of course by the benefits of treatment )

Duration of intensive home treatment is usually longer than  inpatient care -which -according to Dr Hunt ( personal communication ) has been getting shorter in England

A principle of CRHT is that staff stay involved ” until the problem is resolved”; frequency of visits is gradually reduced,  cost of care becomes gradually less so the pressure to discharge patients  quickly can be less than hospital care where you are either occupying a costly bed or not . But-paradoxically, this longer duration of care in home treatment comes with a greater exposure to the risk that a patient will die by suicide while ” on the books” of the service . A likely common scenario would be a patient is admitted to an inpatient bed for  up to a week, is considered appropriate for early discharge to CRHT where a duration of treatment up to six weeks would be common. After admission to hospital the risk of suicide is greatly increased for many weeks thereafter. A graph -figure 20 on p 48 of the Safety First” report in post # 12 under research on this website illustrates this. It shows the number of suicides that occurred each week after discharge from hospital: 164 first week; 100 at week 4; 70 at week 6, finally reaching a plateau of 50 at week 10

As Isaac Sakinofsky -a Canadian expert on suicide stated in an article in the Canadian Journal of Psychiatry 2014, 59, ( 3) : 131-140, ” the fall in UK inpatient suicide , likely an artifact of bed downsizing, is tempered by a corresponding rise in suicides in patients cared for by CRHT’s; that is, the risk has been transferred to the community ”

A similar comment is made in an article by N.Kapur et al ( of NCISH) in Psychological Medicine ( 2013) , 43: 61-71: ” the rate of suicide among psychiatric patients has fallen considerably…..a transfer of risk to the period after discharge or other clinical settings such as CRHT cannot be ruled out ”

Even though the above methodological limitations are listed in the Lancet article, the authors then over reach themselves by raising premature unwarranted concerns about CRHT safety and make policy recommendations not supported by this study.

Such comments include: ” individuals cared for under these services ( CRHT) seemed at higher risk than those who were admitted and ” ….suggesting that inpatient care might reduce suicide risk more effectively than CRHT”

Not one of the numerous studies of intensive home treatment comparing it to hospital treatment has shown an increased risk of suicide

Of course researchers must present their findings freely without regard for how mental health policies are affected . However, this is not the case here. The  findings of this research raise very important issues that need to be investigated further, however, no clear conclusions about the safety of intensive home treatment can be drawn at this time. My concern is that  the additional unwarranted comments of the authors could be used by skittish administrators and health care planners as a rationale to nix much needed innovations in mental health care delivery in countries like Canada who are far behind in adopting intensive home treatment except for pockets of innovation such as Kitchener Ontario and Vancouver British Columbia





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