The number of deaths by suicide among mental health patients treated at home by crisis resolution home treatment teams (CRHT), has more than doubled in England in recent years, rising from an average of 80 in 2003-2004 to 163 in 2010-2011, according to new research published in The Lancet Psychiatry. In contrast, suicides on psychiatric wards fell by more than half, from 163 in 2003-2004 to 76 in 2010-2011.
The research also reveals that despite an 18% fall in the suicide rate among people receiving community care by CRHT teams between 2003 and 2011, the overall suicide rate among patients cared for at home remains higher than the overall psychiatric inpatient suicide rate (14.6 per 10,000 episodes under home care vs 8.8 per 10,000 hospital admissions).
"Our findings suggest that crisis resolution home treatment settings are associated with a high suicide risk," explains study leader Dr Isabelle Hunt from The University of Manchester, UK. "CRHT has been used increasingly during the period we have studied and the number of patients dying by suicide is growing. The rate is consistently higher compared with psychiatric inpatients, suggesting that inpatient care might reduce suicide risk more effectively than crisis resolution home treatment."
Using data from the National Confidential Inquiry into Suicide and Homicide by people with Mental Illness and the Mental Health Minimum Dataset, researchers from the University of Manchester investigated rates and number of suicides among adult mental health patients treated by the NHS in England between 2003 and 2011.
The researchers found that over the 9 year study period, the average number of people dying by suicide each year while under the care of home treatment teams was 140, compared with 117 among inpatients: 20% lower over the whole study period.
The findings also showed that 44% of people who died by suicide under the care of CRHT services lived alone. A third of all suicides under CRHT teams happened within 3 months of discharge from psychiatric inpatient care.
According to Professor Nav Kapur, senior author of the study, "The safety of individuals cared for by crisis resolution home treatment teams should be a priority for mental health services. For certain groups of high-risk patients including those who live alone or who have recently been discharged from hospital, home treatment might not be the most appropriate care setting. The success in reducing suicide among in-patients now needs to be repeated in patients receiving treatment for mental illness at home."
Professor Louis Appleby, Director of the National Confidential Inquiry, commented "CRHT has been an important alternative to hospital admission for patients who are acutely ill, but we need to ensure that it is used safely, especially at a time when bed closures are putting pressure on mental health services."
Writing in a linked Comment, Professor Thomas Becker and Dr Nicolas Rόsch from Ulm University in Germany say, "Due to the massive expansion of CRHT services, patients most in crisis and in need of help are more likely to be under the care of CRHT nowadays. However, moving the balance of care too far away from in-patient care may complicate the clinical task of coping with suicidal symptoms because those may sometimes be better dealt with in in-patient care settings. Balanced care models require both a sufficient provision of high-quality in-patient care and crisis resolution and home treatment teams with high clinical aptitude."
- Isabelle M Hunt, Mohammad Shaiyan Rahman, David While, Kirsten Windfuhr, Jenny Shaw, Louis Appleby, Nav Kapur. Safety of patients under the care of crisis resolution home treatment services in England: a retrospective analysis of suicide trends from 2003 to 2011. Lancet Psychiatry, June 2014 DOI: 10.1016/S2215-0366(14)70250-0
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