This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
In some areas of England, people experiencing a mental health crisis may now receive short-term care at a psychiatric decision unit as an alternative to an extended wait at an emergency department or being admitted to a psychiatric hospital. The new units assess the severity of the crisis (triage) and may offer therapy; they signpost and refer people to other services.
Researchers explored the role of psychiatric decision units in England. They found that units:
- were scarce
- did not, in general, meaningfully reduce emergency department visits or psychiatric admissions
- generally cost more to run than the savings they generated in the short term (2 years), but analyses did not include non-NHS costs or potential improvements in quality of life
- were valued by service users and clinicians and could improve the quality of care experienced by people in mental health crisis.
The study concluded that, if appropriately organised, units can provide a good alternative to established care pathways for some people. The researchers hope their findings will raise awareness of psychiatric decision units among commissioners.
More information about mental health crises can be found on the NHS website.
The issue: do psychiatric decision units help people in mental health crisis?
People who need urgent professional support because of a mental health condition such as anxiety, depression or psychosis, are said to be in mental health crisis. Increasing numbers attend emergency departments, and the demand on psychiatric inpatient beds is high. People with mental health problems are more likely to have a long wait in the emergency department than those with a physical problem.
In England, new models of care include psychiatric decision units (also known as mental health decision units). They were set up to relieve pressure on emergency departments and psychiatric hospitals, and to improve care for people in mental health crisis. They are intended for people who have complex and frequent crises but who might not benefit from a psychiatric inpatient stay. People are referred to psychiatric decision units by psychiatric liaison teams in emergency departments and other mental health professionals.
Psychiatric decision units provide short stays (1 to 3 days). People experiencing mental health crises are assessed and referred or signposted to other services. Units are usually nurse-led and supported by healthcare assistants with input from psychiatry. They tend to be small (with a capacity of around 6 to 8 people).
Researchers explored the impact and costs of psychiatric decision units.
What’s new?
Few mental health trusts in England (6 out of 53) had psychiatric decision units, the study found.
In 4 of these trusts, the researchers examined electronic patient records covering the 2 years before and after the psychiatric decision unit opened.
This part of the study found that, overall, psychiatric decision units:
- had little impact on psychiatric admissions, mental health presentations at emergency departments or the number of people waiting in an emergency department for 4 hours or more
- were linked with more liaison psychiatry sessions
- reduced psychiatric admissions and improved quality of crisis care when stays were longer, with more staff available
- had more impact on emergency departments when units were larger, and stays shorter.
The researchers then compared mental health service use by 1176 people in the 9 months before and the 9 months after their first visit to a psychiatric decision unit. Use of both inpatient and community mental health care was higher after a first visit to the unit than before, although some mental health trusts saw a reduction in the number of psychiatry liaison sessions. The team noted that a high proportion of first-time users of psychiatric decision units were also new to mental health services, which would explain higher service use after their visit.
Researchers interviewed 39 people using a unit for the first-time (within 1 month of discharge and again 9 months later). They also interviewed 15 members of staff and 19 clinicians who had referred people to units. They found that:
- many service users felt the units were safe, calming and supportive; comments included: ‘the staff were amazing... it felt like a safe place… it didn’t stigmatised’, and ‘it gave you a bit of time… you didn’t feel pressured…’
- others felt they were discharged too quickly (while they still felt suicidal), or said that units were only as helpful as the support they were signposted to; some female service users felt unsafe: ‘you’ve got all these people, you don’t know what they are capable of... you are supposed to feel safe, there’s no privacy at all’
- unit staff said their work was rewarding but emotionally demanding; they felt supported by the team despite a high staff turnover
- clinicians said units were valuable, but that communication between the unit and referring teams could sometimes be clearer.
The research found that psychiatric decision units do not offer cost savings in the short-term (2 years). Costs of a visit varied (from £741 to £4800) as did costs per service user (from £996 to £7442); this was mainly due to different staffing levels, average lengths of stay, and numbers of users per year. The units that had most impact were the most expensive to run.
However, analyses did not consider improvements in quality of life, or costs other than to the NHS. In addition, units could reduce costs over the longer term as people access more appropriate community services and less emergency care, the researchers say. But they suggest that commissioning decisions should not be based solely on financial considerations.
Why is this important?
This study suggests that the units provide good quality care when signposting was good, and people were not discharged too early.
Success and costs varied hugely between sites, because of staff-patient ratios and average lengths of stay. The researchers suggest that units are most effective when integrated with a range of support services in the community.
The study did not capture the experiences of black, Asian and minority ethnic people at psychiatric decision units. Further work is needed to explore the experiences of different ethnic groups.
What’s next?
The study found that in the right circumstances, psychiatric decision units can offer good quality care and reduce psychiatric admissions and mental health attendances at emergency department. The researchers suggest that decision units are most likely to be effective if they:
- are set up either to reduce demand in emergency departments (offering shorter stays and having higher capacity, for instance), or to reduce psychiatric admissions (offering longer stays, more staff and psychosocial interventions such as cognitive behavioural therapy, for instance)
- are integrated into the crisis care pathway alongside a range of community-based support
- signpost to other services that can help people experiencing a mental health crisis
- have sufficient staff to ensure discharge is not hurried.
You may be interested to read
This is a summary of: Gillard S, and others. Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation. Health and Social Care Delivery Research 2023; 11.
Funding: This study was funded by the NIHR Health and Social Care Delivery Research.
Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the original paper.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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