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

Lead Research Organisation: King's College London
Department Name: Health Service and Population Research

Abstract

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.

Technical Summary

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.

Publications

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Borschmann R (2013) Joint crisis plans for people with borderline personality disorder: feasibility and outcomes in a randomised controlled trial. in The British journal of psychiatry : the journal of mental science

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Clement S (2013) Mass media interventions for reducing mental health-related stigma. in The Cochrane database of systematic reviews

 
Description NIHR Training Fellowship
Amount £107,000 (GBP)
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 09/2016 
End 08/2019
 
Description South London and Maudsley Foundation Trustees
Amount £13,000 (GBP)
Organisation South London and Maudsley (SLAM) NHS Foundation Trust 
Sector Public
Country United Kingdom
Start  
 
Description CRIMSON partners 
Organisation University of Birmingham
Department School of Psychology Birmingham
Country United Kingdom 
Sector Academic/University 
PI Contribution Coordination of research programme
Collaborator Contribution Individual research site coordination
Impact Current publications are listed in the publication section. Further papers are currently in submission.
Start Year 2007
 
Description CRIMSON partners 
Organisation University of Manchester
Department Faculty of Medical and Human Sciences
Country United Kingdom 
Sector Academic/University 
PI Contribution Coordination of research programme
Collaborator Contribution Individual research site coordination
Impact Current publications are listed in the publication section. Further papers are currently in submission.
Start Year 2007
 
Title Joint Crisis Plan 
Description The Joint Crisis Plan (JCP) is a tool to help mental health service users plan for a potential future mental illness relapse. CRIMSON was a late stage trial where we did not find the anticipated reduction in our primary outcome (compulsory psychiatric admissions) but did highlight a positive benefit on patient reported outcome of the therapeutic relationship. 
Type Therapeutic Intervention - Psychological/Behavioural
Current Stage Of Development Late clinical evaluation
Year Development Stage Completed 2012
Development Status On hold
Clinical Trial? Yes
Impact We have preliminary expressions of interest from clinicians in the NHS. 
URL http://www.isrctn.com/ISRCTN11501328
 
Description Acute Mental Health Ward seminars 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach Regional
Primary Audience Health professionals
Results and Impact Presenting to health care professionals regarding strategies for dealing with mental health crises and relapse with a particular focus on improving the experiences of service users, staff and carers.

Originally invited to present in Nottingham and was subsequently invited to present in London.
Year(s) Of Engagement Activity 2009
 
Description Carer's group Birmingham 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact Presenting the intervention - Joint Crisis Plan - to a group of mental health carers in Birmingham. Leading discussion on a range of issues associated with relapse and using the process of the Joint Crisis Plan as a guide for how to plan for and address mental health relapse.

Carers group was very interested in the intervention and subsequently contacted the research team for copies of Joint Crisis Plan.
Year(s) Of Engagement Activity 2011
 
Description Centre for Social Justice 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach National
Primary Audience Health professionals
Results and Impact Roundtable discussion hosted by the Centre for Social Justice. Participants from the Department of Health, Members of the Ministerial Advisory Group on Equalities in Mental Health and Clinicians. Invited presentation on 'Can coercion be reduced? - what is the national and international evidence?'

Influencing stakeholders
Year(s) Of Engagement Activity 2012
 
Description ENMESH 2011 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Paper Presentation
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Conference presentation with approximately 200 people in the audience. Discussion afterwards regarding the impact of our intervention in the context of Community Treatment Orders for mental health service users

Discussion
Year(s) Of Engagement Activity 2011
 
Description Lima Shared Decision Making Conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Paper Presentation
Geographic Reach International
Primary Audience Health professionals
Results and Impact 10 attendees at a symposium on the CRIMSON trial as it applied to shared decision making

made several important contacts for potential future collaboration
Year(s) Of Engagement Activity 2013
 
Description Online film regarding intervention 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Type Of Presentation Paper Presentation
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact A short film made by service users about the pros and cons of making a Joint Crisis Plan - aimed at helping future service users to decide whether they would like to make a Joint Crisis Plan and to help professionals understand some of the issues involved in making a Joint Crisis Plan

The film has been completed and will shortly be available online.
Year(s) Of Engagement Activity 2009,2010,2011,2012
 
Description The Japanese Association for Emergency Psychiatry. 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach International
Primary Audience Health professionals
Results and Impact Invited presentation to Tokyo health professionals

Contacts made
Year(s) Of Engagement Activity 2013
 
Description Westminster Briefing 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Presenting to parliamentarians regarding the Implication of the Mental Health Act amendments and in particularly presenting the Joint Crisis Plan intervention as an example of an effective community mental health intervention

There was a great deal of interest from those present
Year(s) Of Engagement Activity 2009