Effectiveness of Crisis Resolution Home Treatment for the Management of Acute Psychiatric Crises in Southern Switzerland: A Natural Experiment Based on Geography

Abstract

Background Crisis Resolution Home Treatment (CRHT) is an alternative to inpatient treatment for acute psychiatric crises management. However, evidence on CRHT effectiveness is still limited. In the Canton of Ticino (Southern Switzerland), in 2016 the regional public psychiatric hospital replaced one acute ward with a CRHT. The current study was designed within this evaluation setting to assess the effectiveness of CRHT compared to standard inpatient treatment. Methods CRHT was offered to patients aged 18 to 65 with an acute psychiatric crisis that would have required hospitalization. Exclusion criteria were acute drug/alcohol intoxications, extreme agitation/aggressive behaviour, risk of suicide/self-harm, compulsory hospitalization, being an inmate and, due to practical reasons, living in the southern area of Ticino. We used a natural experiment based on geography, where intervention and control groups were formed according to the place of residence. Primary endpoints were reduction of psychiatric symptoms at discharge, treatment duration in days, and rate and length of readmissions during a two-year follow-up period after discharge. Safety during the treatment period was measured with the number of serious adverse events (suicide/suicide attempts, major self-harm episodes, acute alcohol/drug intoxications, aggressions to caregivers or family members). We used linear, log-linear, logistic and difference-in-differences regression models with propensity scores for the main analysis. Results We enrolled 321 patients; 67 were excluded because the treatment period was too short and 17 because they were transferred before the end of the treatment. 237 patients were available for data analysis, 93 in the intervention group and 144 in the control group. No serious adverse event was observed during the treatment period in both groups. Reduction of psychiatric symptoms at discharge (p-value=0.359), readmission rates (p-value=0.563) and length of readmissions (p-value=0.770) during the two-year follow-up period did not differ significantly between the two groups. Treatment duration was significantly higher in the treatment group (+29.6% on average, p-value=0.002) Conclusions The effectiveness of CRHT for the management of acute psychiatric crises was comparable to standard hospitalization. Further research is needed to identify relevant implementation elements, processes, and procedures, and the system level integration and scalability of CRHT in mental health services. Trial registration ISRCTN38472626 (17/11/2020, retrospectively registered)