CRIMSON Study: RCT of Joint Crisis Plans to Reduce Compulsory Treatment of People with Psychosis

Background: Mental health policy in England emphasises that service users should exercise choice and be treated in the least restrictive way. Despite this, use of compulsory admissions under the Mental Health Act continues to rise. The Joint Crisis Plan (JCP) is so far the only structured intervention shown to reduce compulsory treatment. It aims to empower the holder and to help early detection and treatment of relapse of mental illness. Study design: A multi-site randomised controlled trial of Joint Crisis Plans compared with treatment as usual for people with a history of relapsing psychotic illness. The intervention: The JCP is developed by a mental health service user in collaboration with staff and an independent facilitator. The plan contains information including early warning signs of relapse, details of medication and treatment preferences. Outcomes assessed: (i) Proportion of service users admitted or detained under an order of the Mental Health Act during the follow-up period; (ii) Costs; (iii) Perceived coercion. (iv) Engagement with mental health services; (v) Therapeutic relationship; and (vi) reduced use of the Mental Health Act for the black service users.

Background. The key guiding principles of mental health policy in England are that service users should exercise choice and control over their treatment, and the use of the least restrictive forms of care. Yet despite this, the use of compulsory treatment in England has reached record levels, conflicting with governmental policy and service user preferences. There is particular concern that black service users experience more coercive mental health care than their white counterparts.

Aim: To investigate whether a form of advance directive, the Joint Crisis Plan (JCP) can reduce the use of compulsory treatment under the Mental Health Act for service users with psychotic disorders, compared with treatment as usual.

The main hypotheses tested are: (i) JCPs will significantly reduce the proportion of service users treated under a section of the Mental Health Act at any point during the follow-up period, compared with the control condition. Secondary hypotheses: Compared with the control condition, JCP use will result in significant improvements in: (ii) total costs over the follow-up period and so relative cost-effectiveness, (iii) perceived coercion (iv) service user engagement with mental health services, (v) therapeutic alliance, and (vi) the use of the Mental Health Act for the Black service users during the follow up period.

Intervention: a JCP is developed by a person with severe mental illness in collaboration with mental health staff. The aim is to agree, while the service user is stable, a future plan of care to be implemented in any future crisis, when the service user may be too unwell to express clear views. Held by the service user, it contains his or her treatment preferences for any future emergency, when the service user may be too unwell to express clear views. The JCP format was developed after widespread consultation with national service user groups, interviews with mental health organisations and with individuals using JCPs. Pilot and exploratory trial studies of JCPs have significantly reduced hospital admission, and Mental Health Act use respectively.

Study design: individual-level single-blind RCT of JCPs compared with ?treatment as usual? for people with a history of relapsing psychotic illness in Birmingham, London and Manchester.

Outcomes: in-patient days under compulsion, costs, perceived coercion, service engagement, therapeutic relationship.