Acute psychiatric care: the need for contextual understanding and tailored solutions

Johnson et al¹ review different aspects of acute psychiatric care, with the aim to identify evidence-based practices in order to increase the range of services and improve access and quality of care. They acknowledge the assortment of services involved as well as the divergent settings across health systems and countries.

Crises are multidimensional phenom­ena and result from complex interactions be­­­­tween mental illness, substance use, emo­tional reserves and social supports. They present complex challenges for assessment of their multiple dimensions and require a multifaceted response.

The quality of evidence for current crisis interventions and models for acute psychiatric care is, at best, moderate. The availa­bility of only few studies, many of which marked by small samples, selective inclusion criteria, narrow focus of assessment of outcomes, and the lack of a comprehensive map of caregiver inputs and medication compliance, argues for the lack of robust evidence base for many interventions^{2, 3}.

Different fidelity scores for implementation of the various intervention models and programs across regions suggest variations in the translation of crisis care packages⁴. The unpredictability of crisis presentations and the need for urgent care complicate the evaluation of interventions. Randomization of participants in crisis raise difficult ethical issues.

Most appraisals have examined issues from health provider perspectives, with lim­ited user involvement in the evaluation of health care delivery. Consumer-led movements rooted in civil rights, social justice and cultural responsiveness appear promising in crisis resolution and even in prevention, and need to be included in future evaluations. The voluntary sector’s involvement in providing peer support, particularly for marginalized communities, while invaluable, needs to be systematically investigated.

The delivery of acute psychiatric care has more recently focused on telepsychiatry and substitutes to in-person interactions. While telephone, videoconferencing facilities and smartphone apps have increased resources, reduced wait times, decreased cost and improved access to care, they have not resolved issues related to digital exclusion, privacy in users’ homes, therapeutic relationships, quality of care and renumeration models. These technologies await evidence for their use in routine clinical practice.

Much of the evidence for acute psychiatric care is from high-income countries. Mental health care in low- and middle-in­come countries, with their financial and human resource constraints, urban-rural divide, and diverse mental illness perspectives (e.g., religious and traditional healer explanatory models, complementary remedies, stigma, taboo) is often marked by inadequate provision of health services, lack of evidence-based intervention guidelines and large treatment gaps. The absence of a rights-based approach, recovery-oriented responses and inclusive community practices in addressing mental health crises, and the high cost, inaccessibility and non-acceptability of specialist mental health services complicate the scenario.

Notwithstanding the success of some programs, the issues related to efficacy, effectiveness and cost-benefit of interventions in acute psychiatric care need to be examined⁵. While randomized controlled trials are the cornerstone of evidence-based medicine, the results of a single trial or a systematic review of a few such investigations, while providing evidence about the efficacy of a treatment (i.e., “The treatment works somewhere”), do not necessarily provide evidence of effectiveness in cli­nical practice (i.e., “The treatment works widely”).

Extrapolating knowledge gained from randomized controlled trials to other pa­tient populations is problematic. The evi­dence for efficacy (“Can it work?”), effectiveness (“Does it work in practice?”) and efficiency (“Is it worth it?”) will need to be addressed before widespread implementation of models and programs⁶. The Hawthorne effect also confounds comparisons between innovative interventions with “standard care control arms”. The motivational response of the subjects may be secondary to the interest, care and attention received through observation and assessment rather than due to the specific intervention.

Changes in clinical practice patterns o­ver time, differences between health sys­tems, and variations in patient demograph­ic and clinical characteristics and in social determinants of health⁷ and mental health⁸, also impact generalizability of clin­ical research. Many crisis presentations are shaped to a great extent by the social, economic and physical environments in which people live. While targeted mental health interventions will help people in crisis, structural, public health and population-wide interventions are needed to level the social gradient in health outcom­es⁸.

Divergent disciplinary perspectives (e.g., crisis intervention theory, psychiatric points of view), different levels of commu­nity supports (e.g., caregiver, peer, professional), task splitting (e.g., triage, assessment and treatment), dissimilar modes of assessments (e.g., face to face, telephone, videoconferencing), varied pathways to care (e.g., health, police), multiagency integration (e.g., police, ambulance, health professionals), distinctive legal status (e.g., voluntary, compulsory, arrest), diverse location of crisis services (e.g., provision at home, within emergency departments, colocation within mental health facilities), wide spectrum of presentations (e.g., situational crisis, personality disorder, substance use/intoxication, psychosis) and the range of harm (e.g., suicidal ideation, deliberate self-harm, suicidal attempt, violence) make comparisons across services and regions difficult. Similarly, diverse ther­apeutic interventions (e.g., psychological, pharmacological, physical restrictive practices) and differences between stepped care models make generalizations problematic.

In addition, variation in population prevalence of crisis presentations, differences in help-seeking behavior, and variation in thresholds for different types of clinical interventions further complicate gen­eralizability. Disparities in budgets, com­munity and hospital infrastructure, and hu­man resources add complexity to comparisons. Despite the success of some mo­dels, and calls for innovative approaches, the dissimilar reality across regions makes the task of identifying universally applicable models challenging.

While the evaluation of interventions is mandatory, their success will not automatically imply their generalizability to other settings. In fact, many complex programs, which often operate in project mode, succeed due to their high levels of financial, ad­ministrative and political support, but are difficult to scale up even across similar settings. Their implementation across different regions, health systems and countries can be extremely challenging.

The heterogeneity of acute psychiatric presentations, variety of interventions and diversity of settings demand the need to understand contexts. The reality of local environments and their distinctive issues demand tailored solutions. Transplanting knowledge structures, formations and prac­tice across different contexts may result in the lack of goodness of fit⁹. Standardized protocols may not recognize locally rel­evant issues, demanding contextual analysis and interpretations grounded in region­al reality. This is particularly true for multi­faceted and multi-disciplinary intervention packages for acute psychiatric and crisis presentations.

Decisions in clinical practice should con­­sider the broader biopsychosocial con­­text, including clinical, psychological, social and economic problems, medical morbidity and risks, and patient and caregiver perspectives. The challenge, while attempting to replicate successful projects, is the need to understand local contexts, incorporate provincial knowledge and attempt to implement regionally tailored solutions.