Determinants of Completion and Use of Psychiatric Advance Statements in Mental Health Care in the Netherlands.

OBJECTIVE: Crisis plans are a type of psychiatric advance statement (PAS) that describe how to recognize early signs of a psychiatric crisis and how to handle crisis situations. Although PASs may help reduce the occurrence of crises, their implementation in clinical practice is problematic. This study examined patient and clinician characteristics associated with successful completion of a crisis plan and determined how often a plan was consulted in a crisis situation. METHODS: Participants were 139 crisis-prone outpatients and their clinicians recruited in the context of a randomized controlled trial in the Netherlands studying the effects of crisis plans. Multivariate logistic regression analyses examined associations between patient and clinician characteristics and completion of a crisis plan. Descriptive and univariate statistics were used to determine subsequent use of crisis plans. RESULTS: Of the 139 patients, 64% completed a crisis plan. Higher completion rates were associated with a better clinician-rated working alliance, a lower education level of the patient, and fewer years of professional experience of the clinician. Of the 89 patients who completed a crisis plan, 38 later experienced a crisis, and plans were consulted for a third of these patients (34%). For those whose crisis involved involuntary admission, a smaller proportion had their plans consulted, compared with those whose crisis involved an outpatient emergency visit or voluntary admission. CONCLUSIONS: PAS completion was associated not only with patient and clinician characteristics but also with a positive working alliance. PAS use did not occur in all cases, especially not when patients were involuntarily admitted.

Working Alliance in Patients with Severe Mental Illness Who Need a Crisis Intervention Plan.

Working alliance has been characterized as an important predictor of positive treatment outcomes. We examined whether illness insight, psychosocial functioning, social support and locus of control were associated with working alliance as perceived by both patient and clinician. We assessed 195 outpatients with psychotic or bipolar disorders. Our findings indicated that patients rated the alliance more positively when they experienced a greater need for treatment, fewer behavioral and social problems, and more psychiatric symptoms. Clinicians rated the alliance more positively in patients who reported fewer social problems and better illness insight. Patients' demographic characteristics, including being female and married, were also positively related to the clinician-rated alliance. Our results suggest that patients and clinicians have divergent perceptions of the alliance. Clinicians may need help developing awareness of the goals and tasks of patients with certain characteristics, i.e., singles, men, those with poor illness insight and those who report poor social functioning.

Effect of crisis plans on admissions and emergency visits: a randomized controlled trial.

OBJECTIVE: To establish whether patients with a crisis plan had fewer voluntary or involuntary admissions, or fewer outpatient emergency visits, than patients without such a plan. DESIGN: Multicenter randomized controlled trial with two intervention conditions and one control condition. PARTICIPANTS: Adult outpatients diagnosed with psychotic or bipolar disorder who had experienced at least one psychiatric crisis in the previous two years. INTERVENTION: Two types of advance statement were used: (1) a crisis plan formulated by the patient with the help of a patient advocate (Patient Advocate Crisis Plan: PACP); and (2) a crisis plan developed together with the clinician (Clinician-facilitated Crisis Plan: CCP). OUTCOME: The percentages of patients admitted voluntarily or involuntarily (on an emergency basis or by court order), and the percentage who made outpatient emergency visits over an 18-month follow-up period. RESULTS: A total of 212 patients were included: 69 in the PACP condition, 70 in the CCP condition, and 73 in the control condition. No effects of the two interventions were found on the numbers of voluntary admissions, involuntary admissions and emergency visits. Regarding involuntary admissions, there was no significant effect on emergency admissions, which were 17% (12/69) in the PACP condition, 10% (7/70) in the CCP condition, and 19% (14/73) in the control condition. There was a significant effect on planned court-ordered admissions, with 16% (11/69) in the PACP condition, 10% (7/70) in the CCP condition, and 26% (19/73) in the control condition. Finally, the interventions had no effect on outpatient emergency visits, with 32% (22/69) in the PACP group, 31% (22/70) in the CCP group, and 34% (25/73) in the control group. CONCLUSIONS: Crisis plans may be an effective intervention for reducing court-ordered admissions in patients with psychotic and bipolar disorders. TRIAL REGISTRATION: Current Controlled Trails NTR1166.