Intensive home treatment better than hospitalization for patients with psychiatric crisis: Lancet

Netherlands: Intensive home treatment is a safe and effective partial replacement for the traditional psychiatric crisis, suggests an article published in The Lancet Psychiatry. The treatment led to a reduction in admission days, causing patients to stay longer in their social environment, with similar clinical effects, patient satisfaction, and adverse events.

Despite the fact that de-institutionalization has been underway for decades, hospitalization followed by low-intensity outpatient care remains the standard therapy for patients experiencing an acute psychiatric crisis. As an alternative to inpatient care, intensive home treatment for patients in a severe psychiatric crisis has been devised. As a result, Jurgen Cornelis and colleagues conducted this study to assess the possibility of intensive home treatment to reduce bed days and its clinical effectiveness in comparison to standard care.

Patients between the ages of 18 and 65 were recruited from the psychiatric emergency service and psychiatric emergency wards of Amsterdam's two largest mental health institutions. Patients with at least one DSM-IV-TR or DSM-5 condition who are in a mental crisis and for whom psychiatrists have indicated or completed a clinical admission may be included. Upon first contact with the patient, trained psychiatric emergency service and hospital experts performed the automated web-based pre-randomization procedure. A seeded pseudo-random number generator assigned patients (2:1) to intense home care or standard care. After randomization, informed permission was obtained as soon as the patient was mentally capable, which was within 14 days.

Professionals and patients were not blinded to treatment because of the nature of the study. Intensive home therapy was designed in consultation with patients and family, as well as a diverse professional team, and was adapted to the nature of the crisis and the aims of patients and relatives. The primary outcome of the main analyses was the total number of admission days 12 months following randomization. Linear mixed modeling studies with constrained maximum likelihood estimation were used to assess the effect of treatment conditions on outcome measures.

The key findings of this study were as follows:

1. 246 people were enrolled in the trial between November 15, 2016, and October 15, 2018.

2. There were 111 males (45%) and 135 women (55%) in all, with a mean age of 41.01 years.

3. 85 participants (35%) and 114 (46%) of the participants were foreign-born.

4. Data about ethnicity wasn't available. After a year, the average number of days spent receiving intensive home treatment was 42,47 (SD 53,92), compared to 67,02 (SD 79,03) for treatment as usual.

5. This is a reduction of 24.55 days (SD 10,73), or 36.6%. 26 adverse events were recorded, and 23 (89%) of them involved suicide attempts.

6. There were no appreciable differences in the proportion of patients in each group who experienced a reported adverse event. Five patients took their own lives.

7. There were no treatment-related fatalities.

In conclusion, overall, researchers discovered that intense home care significantly lowers the need for acute psychiatric inpatient beds without sacrificing patient safety. In stark contrast to the high hopes for the beneficial benefits of intense home therapy, the improvement in quality of life, or treatment satisfaction, there was no difference when compared to standard care.

Reference: 

Cornelis, J., Barakat, A., Blankers, M., Peen, J., Lommerse, N., Eikelenboom, M., Zoeteman, J., Van, H., Beekman, A. T. F., & Dekker, J. (2022). The effectiveness of intensive home treatment as a substitute for hospital admission in acute psychiatric crisis resolution in the Netherlands: a two-centre Zelen double-consent randomised controlled trial. In The Lancet Psychiatry. https://doi.org/10.1016/s2215-0366(22)00187-0