The effects of crisis plans for patients with psychotic and bipolar disorders: a randomised controlled trial.
BACKGROUND
Crises and (involuntary) admissions have a strong impact on patients and their caregivers. In some countries, including the Netherlands, the number of crises and (involuntary) admissions have increased in the last years. There is also a lack of effective interventions to prevent their occurrence. Previous research has shown that a form of psychiatric advance statement - joint crisis plan - may prevent involuntary admissions, but another study showed no significant results for another form. The question remains which form of psychiatric advance statement may help to prevent crisis situations. This study examines the effects of two other psychiatric advance statements. The first is created by the patient with help from a patient's advocate (Patient Advocate Crisis Plan: PACP) and the second with the help of a clinician only (Clinician facilitated Crisis Plan: CCP). We investigate whether patients with a PACP or CCP show fewer emergency visits and (involuntary) admissions as compared to patients without a psychiatric advance statement. Furthermore, this study seeks to identify possible mechanisms responsible for the effects of a PACP or a CCP.


METHODS
This study is a randomised controlled trial with two intervention groups and one control condition. Both interventions consist of a crisis plan, facilitated through the patient's advocate or the clinician respectively.Outpatients with psychotic or bipolar disorders, who experienced at least one psychiatric crisis during the previous two years, are randomly allocated to one of the three groups. Primary outcomes are the number of emergency (after hour) visits, (involuntary) admissions and the length of stay in hospital. Secondary outcomes include psychosocial functioning and treatment satisfaction. The possible mediator variables of the effects of the crisis plans are investigated by assessing the patient's involvement in the creation of the crisis plan, working alliance, insight into illness, recovery style, social support, locus of control, service engagement and coping with crises situations. The interviews take place before randomisation, nine month later and finally eighteen months after randomisation.


CONCLUSIONS
This study examines the effects of two types of crisis plans. In addition, the results offer an understanding of the way these advance statements work and whether it is more effective to include a patients' advocate in the process of creating a psychiatric advance statement. These statements may be an intervention to prevent crises and the use of compulsion in mental health care. The strength and limitations of this study are discussed.


BACKGROUND
Current Controlled Trails NTR1166.
Ruchlewska
A
A
Erasmus MC, University Medical Center, Department of Psychiatry, Rotterdam, The Netherlands. j.ruchlewska@erasmusmc.nl
Mulder
C L
CL
Smulders
R
R
Roosenschoon
B J
BJ
Koopmans
G
G
Wierdsma
A
A
D000223:Adaptation, Psychological; D000293:Adolescent; D000328:Adult; D016223:Advance Directives / Q000706:statistics & numerical data*; D000368:Aged; D001714:Bipolar Disorder / Q000175:diagnosis / Q000628:therapy*; D003134:Commitment of Persons with Psychiatric Disorders; D003156:Community Mental Health Services / Q000379:methods / Q000458:organization & administration; D003419:Crisis Intervention / Q000379:methods / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010344:Patient Advocacy; D010347:Patient Care Planning; D010348:Patient Care Team / Q000458:organization & administration; D017060:Patient Satisfaction; D011618:Psychotic Disorders / Q000175:diagnosis / Q000628:therapy*