THE EFFECTIVENESS OF JOINT CRISIS PLANS IN REDUCING HOSPITAL ADMISSIONS FOR ETHNIC MINORITY SERVICE USERS WITH SEVERE MENTAL ILLNESS ? FINDINGS OF THE CRIMSON TRIAL

Introduction: This thesis contains three studies which are embedded within the larger CRIMSON trial; an individual level, randomised control trial comparing joint crisis plans with treatment as usual for people with severe mental illness. This thesis presents sub-analysis from CRIMSON, testing hypotheses about ethnic minorities only within the context of the wider trial. Recruitment and utilisation of the intervention by ethnic minorities is also investigated.Methods: The joint crisis plan intervention documented the service users? treatment preferences for the event of a future crisis. The plan was formulated collaboratively by the service user and their clinical team and was negotiated by an independent facilitator. The settings for the trial were community mental health teams across three sites in England. The hypotheses tested were that compared to receiving treatment as usual, the intervention group would experience fewer compulsory hospital admissions, fewer psychiatric hospital admissions and an improved working alliance with their care coordinator. Following a systematic review, strategies were implemented to overcome barriers to recruiting ethnic minorities into the CRIMSON trial. Diary entries were maintained in the Manchester/Lancashire site detailing attempts to overcome barriers encountered with the recruitment of ethnic minorities. Content analysis was carried out on the completed joint crisis plans to assess culturally relevant statements made regarding service users? mental health and future treatment.Results: In the sub-analysis 182 participants were randomised (94 experimental, 88 control group). No evidence of treatment effect was seen for compulsory hospital admissions (OR 0.87, 95%CI 0.43-1.77, p=0.71) any psychiatric admissions (OR 1.18, 95%CI 0.62-2.24, p=0.62) or service user rated working alliance (B=2.69, 95%CI -2.95-8.32, p=0.35). Additional sub-analysis found differential effects of the intervention on specific ethnic groups, with a reduction in overall admissions observed for black participants and an increase in admissions for south Asian and white British service user on any admission. Strategies for reducing barriers to participation into the research from ethnic minorities were implemented and 50% of south Asian and black service users who were eligible for CRIMSON were recruited. 28% of south Asian and black participants made culturally relevant statements within their joint crisis plans. This figure was significantly higher for south Asian (44%) compared to black (20%) participants (p=0.03). Conclusions: This thesis suggests that joint crisis plans may have a differential effect on people from different ethnic groups, for reasons that at present we do not understand. This is interesting because it emphasises the importance of analyses that look at ethnic minorities and the way that they may help elucidate the effects of complex interventions. It also suggests that different ethnic minorities may react in different ways. This thesis certainly supports the value of efforts to recruit ethnic minorities. It is recommended that future work around joint crisis plans should take a qualitative approach to aid the understanding of what lies behind these apparent differential effects.