The results of this longitudinal survey of a CRHT team in Norway have provided insights into the demographic backgrounds of the patients, how they were referred to the team, and what problems were identified at admission. Although our findings confirmed the general characteristics of patients served by CRHT teams reported for 8 teams in Norway, there are key findings in this study which provide more detailed picture regarding the characteristics of patients at intake. The discussion addresses the key issues from the findings regarding (a) the patient characteristics, (b) a lack of representation by older adults for the service, (c) the referral patterns, and (d) the nature of mental health problems. The findings of this study needs to be interpreted and understood from the Norwegian context of its healthcare system, which operates within the national health insurance framework. This means that cost considerations from the individual perspective in seeking medical and health services are not relevant in Norway while they are critical in privatized systems such as in the US. As the Norwegian context is comparable to the UK, Australian, and Canadian settings, it is possible to make comparisons of our data with those from these countries. The findings also have to be understood in the context in which the CRHT was functioning: (a) the CRHT team had been established about six months prior to the start of data collection, suggesting that the team was still in the learning mode, (b) its operating hours were limited to the day and evening hours on weekdays and day hours on weekends, which means that it was not able to meet the requirement for 24/7 availability for services, (c) there was no staff turnover during the data collection, and (d) it did not have the official gate-keeping authority for psychiatric hospitalization for the DPS, although it performed evaluations of referrals that resulted in hospitalization.
Our findings on personal demographic characteristics are similar to the findings for eight CRHT teams in Norway by Hasselberg, Gråwe, Johnson, & Rudd. We found that the patients of the CRHT team were likely to be those on public financial support mostly due to disability and illness, as was found in the study by Hasselberg et al. reporting only one-quarter of the patients to be in paid employment. These suggest that most of the users of CRHT teams are likely to be those who have long-term mental health problems by which they probably become designated for disability pay. Nearly four fifth of the patients also had long-standing mental health problems or recurrence of existing mental health problems at the time of admission and had been receiving healthcare for them. However, the patients in general did not have severe mental health problems at admission to the CRHT team, although they could have been in crises. These findings suggest that mental health crises may have specific meanings, not necessarily related to a high level of vulnerability to hospitalization, especially to patients who were self referrals to the CRHT team. It is also possible that those referrals to the team by GPs and community mental health professionals may be the results of differentiation by them regarding mental health crises in terms of those requiring hospitalization and those requiring the service of a CRHT team. This seems to suggest that there are two levels of acute mental health crises, one requiring hospitalization and the other resolvable through community-based care. Since the CRHT team did not have an official authority for the gatekeeping role for acute hospitalization in the DPS, it is not possible to determine whether or not this was the process in place. The findings suggest that individuals with long-term mental health problems may often be in need of crisis care for which CRHT teams can play a critical role with their resolution. Whether or not the CRHT played any role in preventing hospitalization is not known in our data. In view of the mandate for the establishment of community mental health services, especially for the functional teams such as CRHT, to prevent hospitalization of people with long-standing mental health problems, these findings require further investigation, especially to examine the conjecture that the availability of CRHT teams may avert hospitalization of patients with long-term mental health problems, by making it possible for them to receive emergency crisis care within the 24 h window in the community, as suggested by Johnson and colleagues[13, 19].
Where are older adults with mental health problems?
We found in this study that this patient-group was represented by more females and those between the ages of 26 and 65 years. Older adults in the ages over 65 were under-represented in the team (6%) compared to the general population in Norway (16%), indicating that older adults were not likely to be referred to CRHT services. Although there are health service units in the community dedicated to the health care of older adults in Norway such as geriatric community health services, day-care for the elderly, and psycho-geriatric units in hospitals, older adults with mental health problems receive services in the same manner as adults in general especially in relation to mental health crises.
Although it is not possible to determine the exact "local" reasons for this low representation of older adults in the study group, the reasons for this finding may be considered as multiple and interconnected. For example, older adults may experience mental health crises differently, they may be able to deal with crises with strategies learnt throughout their lives, they may not be as aware of the availability of the program as well as younger adults, or they may be more reluctant to seek services for mental health problems. The absence of older adults in community mental health care in Norway is also found in the evaluation of the national action plan. Our findings are also in line with the results of the study by Hasselberg et al. of 8 crisis resolution teams in Norway, as they found that most patients were between 20–50 years of age. Bogner et al. also reported that older adults aged 60 years and older of their sample of over 1,000 community-dwelling adults in Baltimore were less likely to consult with mental health specialists and more likely to receive mental health care from primary care physicians. Karlin and Norris also found a lower rate of the use of public mental health services by older adults compared to the younger groups.
In general older adults are vulnerable to mental health problems because of (a) the decline in physical and psychological robustness in older age, (b) the shrinking social support system, and (c) changes in personal situations such as retirement, the loss of a spouse or relocation. Studies from different countries for example,[23–25] have shown the prevalence rates of depression among older adults to be between 10 to 20%. Depression represents the major portion of mental health problems in older adults, and depression in older adults is associated with frailty, increased dependence in ADL, and physical comorbidity. Furthermore, Burroughs et al. suggested that both primary care practitioners and patients view depression in older adults as justifiable and that older adult patients specifically consider depression with passivity, limited expectations of treatment, and not necessarily legitimate reason for seeking medical help. As there is a paucity of studies looking into the reasons for the lack of representation by older adults for this type of service, it is critical to gain an understanding regarding this issue in order to have insights about the nature of mental health problems experienced by this age group and the reasons for low utilization of community mental health services by older adults.
Referral to the team by self or family members in large numbers suggests that patients or their families were able to apply certain criteria to make decisions about their situations of mental health crises. It is likely that since most patients had long-term mental health problems they or their families were able to make decisions regarding when to seek crisis care. The finding is important also in another sense in that some of CRHT services only allow referrals by professionals, in which cases patients would have to go through an additional step in health services in order to be referred to CRHT teams.
Our findings also suggest an important role played by primary care physicians in referring patients to CRHT teams. It is possible that many people consider their primary care physicians as initial contacts for most of medical care within the healthcare system. This also has implications regarding the low representation of older adults for this type of services discussed earlier, as primary care physicians may play a gate-keeping role for mental health care for older adults especially if they were guided by the attitude regarding depression in older adults as 'justifiable' and not requiring psychiatric treatment.
In addition, the finding that about half of the patients were referred to the CRHT team by healthcare professionals and services including mental healthcare and emergency services suggests that these referring professionals and services made judgments regarding the appropriateness of the services by the CRHT team for these patients. However, it is not clear from the data whether the establishment of the CRHT was filling a need that existed in the community for mental health crises care or it was an additional service that became available re-distributing the services for mental health in the community. Since the data for this paper were only from the patients who were admitted to the CRHT team, it is not possible to compare the referral sources of those admitted to the team and those who were referred to the team but not admitted to the team.
The nature of mental health problems
The findings that most of the patients had received mental health care previously and had existing mental health problems suggest that mental health crises are intrinsically related to existing mental health problems. However, the long-term mental health problems these patients had may not be severe psychiatric disorders such as schizophrenia and schizoaffective disorders. In line with the findings by Hasselberg et al., the level of mental health problems the patients experienced at admission was not severe clinically with about one third of the patients having no clinically significant problems and one fifth with only stress responses, along with additional one fifth with depression and only 15% with self-harm and psychotic problems. The study of a crisis resolution and home treatment team in Edinburgh by Barker et al. found 17% of their sample with the diagnosis of schizophrenia/schizoaffective disorders and 25% with depression on ICD-10, while somewhat differently Johnson et al. in a quasi-experimental study of CRT found 25% of the sample to have the diagnoses of schizophrenia/schizoaffective disorders, 55% with psychotic symptoms, 14% with elevated mood, and 59% with depressive symptoms. The proportions of persons with depression appear to be in the range of 25 to 59% in these studies in line with our finding, suggesting the magnitude of depression in relation to mental health crises. The significant differences are in the prevalence of psychosis reported in different studies. Such disparities in the diagnostic make-up of patients seeking crisis care may be due to the instruments used for the assessment, i.e., HoNOS versus ICD-10, to the different service configurations in the community for mental health care, or because of the different sampling bases for the studies. The low number of patients with psychosis in this study may be due to the possibility that patients with long-term psychosis may be aligned with community psychosis/rehabilitation teams and receive crisis care as well as the routine care from this type of teams available at the DPS level in Norway.
However, since more than two thirds of the patients in our study were judged to be in need of emergency assistance at admission and more than half of the patients were referred by healthcare professionals including 21% by mental health professionals and services, it seems that there apparently were needs for services by the CRHT team for these patients. It is possible that these professionals held a view of mental health crises which can be addressed successfully by CRHT services, although it is possible that the thresholds for referrals for crisis care by mental health professionals and by primary care physicians may be different in general, and that patients with more serious mental health crises may have been referred to inpatient psychiatric emergency units bypassing CRHT teams completely. There were no data available in this study regarding the exact nature of crises that brought the patients to this service. However, the pattern of the clinical problem types extracted for this group of patients indicate that mental health crises may not be clinically definable, and may culminate from complex problems.
In addition to the clinical problems such as stress responses, depression, and self-harm, problems with social relations and daily activities were prevalent in the patients, suggesting that mental health crises are not simply associated with clinical symptoms but also with problems of daily life. Of the 18 CRHT teams in Wales surveyed by Jones and Jordan only six teams accepted patients with problems with social relations or daily activities, suggesting that by themselves these may not be considered as mental health crises by some CRHT teams. Jones and Jordan also reported that most of the teams accepted patients with psychosis, affective disorders, substance misuse disorders, personality disorders, and anxiety disorders. Although the clinical problem types constructed in our data are somewhat different from these types, our results correspond with the acceptance of various mental health problems represented by such disorders for the team's services. While the exact nature of mental health crises is unknown, CRHT teams in general respond to crises stemming from many different types of mental health problems.
Given the characteristics of the patients who received services from the CRHT team, there is a need for further research to gain understandings about the nature of mental health crises that bring patients to the attention of CRHT services and their relationships with psychiatric diagnoses. One limitation in the study regarding mental health problems is the lack of risk measures. Since mental health crises have implications for risks to self and others, it is critical to have a sensitive instrument to measure the risk. With a sensitive risk measurement it may be possible to capture the nature of mental health crises that are appropriate for CRHT teams, even if the overall level of clinical problems is not intense. There also is a need for further research regarding the use of assessment tools such as HoNOS in relation to mental health crises and psychiatric diagnoses.
It is neither clear nor possible in this study to judge how many of these patients would have been hospitalized without the services by the CRHT team or whether they would have received similar services from other sectors of mental health care in the community. Especially since the CRHT team did not have an official gate-keeping role for hospitalization within the DPS, the impact of CRHT on hospitalization rate is difficult to assess. A further step in our project could be to obtain psychiatric hospitalization data including diagnoses retrospectively in the DPS for the study period in order to compare patient characteristics of the study group to the inpatient group. This could provide a deeper understanding regarding the role CRHT teams play in managing mental health crisis in the community. There is a need to study the reasons for referral from the perspectives of self/family and healthcare professionals in order to gain a greater understanding of the meanings of mental health crises and the role of CRHT services.
The major clinical implication of the results of this study is in relation to the role of professional services by CRHT teams. The clinical characteristics of patients seeking services by CRHT teams may influence the types of services provided to them. Since the severity level of mental health problems is not intense in this population, the modes of crises care may need to be reframed by how mental health crises are viewed by patients, healthcare professionals, and professionals within CRHT teams.
There are several shortcomings related to this study. The data on HoNOS and GAF for the level of mental health problems at admission and at discharge were based on the team members´ subjective assessments. The team members were trained on the use of these instruments several times during the course of the study and there was no staff turnover in the team during the data collection, suggesting a high level of standardization in data collection with these instruments in the study. However, there are possibilities for registration or recall bias, for which reliability or validity testing was not done in this study.
This being a study of one CRHT team makes generalization of the findings difficult, although the results provide a basis for gaining insights regarding the workings of CRHT teams. Furthermore, the setting of this study is Norway, which has a specific healthcare system including mental health care. Therefore, the referral patterns found in the study may be very specific to Norway.
The assessment instruments used in the data (i.e., HoNOS and GAF) are general and do not provide information regarding the nature of mental health crises. There is a need for a better assessment tool regarding mental health crises.