Introduction

Psychiatric hospitalization is one of the primary therapeutic modalities used to help people with an outbreak of severe mental illness (^{Loch, 2014}). It is noteworthy that psychiatric hospitalization is comprehensively considered beneficial has patients express feeling better than before (^{Tomás et al., 2021}). However, this results in the sense of disruption that hospitalization brings to the hospitalized person’s life (^{Niimura et al., 2016}), as it implies a physical distancing from the person’s familiar and usual spaces for a particular time. Literature has described returning home and resuming daily life after inpatient psychiatric discharge as difficult and complex (^{Tomás et al., 2021}; ^{Mutschler et al., 2019}). The person has to deal with the symbolic weight of psychiatric hospitalization that projects their inability to remain in the community, weakening their sense of autonomy and perceived self-efficacy, but also deal with stigma and discrimination, still present in our society, resulting from the disclosure of psychiatric hospitalization and consequent diagnosed mental illness (^{Tomás et al., 2021}; ^{Mutschler et al., 2019}). Furthermore, several studies point out the possibility that the event of psychiatric hospitalization may be traumatic for the person, impairing their adherence to the therapeutic plan and, in particular, to the use of psychiatric services when they are in the prodromal phase of a new exacerbation episode of their disease (^{Wu, Cheng, Leung, Chow & Lee, 2020}). Moreover, there are adverse outcomes of psychiatric hospitalization that we must consider, such as rehospitalization, suicide, risk of violence, the stigma of their mental illness, and a declining sense of mastery and control over their lives, mainly when there is a history of several admissions or long-stay admissions (^{Loch, 2014}; ^{Birken & Harper, 2017}).

The Crisis Resolution and Home Treatment (CRHT) teams emerge as a way to provide intensive health care to individuals experiencing an acute mental health crisis who receive their treatment at home instead of an inpatient psychiatric unit (^{Lloyd-Evans et al., 2019}; ^{Alba Palé et al., 2019}). This prerogative enlightens the guiding principle for the provision of mental health care that is intended to be mainly community-based and carried out in the least restrictive possible context (^{León-Caballero et al., 2020}; ^{Department of Health, 2001}; ^{European Union Agency for Fundamental Rights, 2012}). On that account, CRHT teams arose as an alternative to psychiatric admission in the mid-1990s with an implementation in several countries such as the United Kingdom, United States, Australia, Norway, Belgium, Germany, Spain, Canada, and the Republic of Ireland (^{Morant et al., 2017}; ^{Wheeler et al., 2015}; ^{Alba Palé et al., 2019}). These countries have published studies on the implementation of CRHT teams reporting a reduction in hospital admissions and treatment costs, as well as higher levels of satisfaction on the part of people who have had access to this type of service compared to those who had usual care (psychiatric hospitalization) (^{Morant et al., 2017}; ^{Wheeler et al., 2015}).

These teams seek out the possibility of offering another therapeutic modality to people in an acute crisis of mental illness, which in many countries, namely Portugal, consists exclusively of psychiatric hospitalization.

In addition to providing home treatment (generally at least daily), CRHT teams provide rapid assessment and the possibility to facilitate early discharge from the hospital by transferring inpatients to intensive home treatment (^{Wheeler et al., 2015}). The recommendations on the functioning and structure of these teams include: (1) a gatekeeping role, with patients admitted to acute beds only if the CRHT team has assessed and agreed that this is necessary; (2) a rapid response with a 24-hour cover, including access to a psychiatrist or a medical prescriber; (3) a minimum of one visit per day; (4) a multidisciplinary response, with high-quality training health workers; (5) a limited number of different visiting professionals per service user; (6) ability to provide medical, psychological and social interventions (^{Wheeler et al., 2015}).

However, there is variability in the organizational characteristics within these teams, and it is not possible to effectively define the characteristics that allow for a consistent definition of the effectiveness of the results obtained (^{Wheeler et al., 2015}).

Hence, it is crucial to analyze and highlight CRHT teams’ effectiveness in reducing days of treatment, relapse, and rehospitalization of adults (18-65 years) compared to treatment as usual defined as inpatient treatment.

This study provides an opportunity to define the efficacy and safety of CRHT teams compared to inpatient treatment and put forward the development of this kind of service to manage mental health crises.

Methods

To accomplish these aims, we will develop a systematic review of the current literature by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2019 Statement.

To ensure that this systematic review has no duplication until now, on March 12th, 2022, we conducted a preliminary search of JBI EBP Resources on Ovid, PROSPERO, Cochrane Database of Systematic Reviews, MEDLINE Complete, and Database of Abstracts of Reviews of Effects (For more details see https://data.mendeley.com/datasets/kj9x4hzbz8/1). No current or active systematic reviews were found. However, we need to document review papers that partially address the same issue but do not present the same focus we propose.

^{Wheeler et al.’s review (2015}) “excluded studies comparing CRT services to treatment as usual where the latter involved only inpatient care or outpatient appointments with a psychiatrist” (p. 3) and therefore does not integrate publications from countries where the mental health system is particularly hospital-based. Furthermore, the search for papers is until November 2013 (the included studies date between 1993 and 2011), and it does not include studies from Latin countries like Spain or Italy. Regarding ^{Toot, Devine, & Orrell’s (2011}) paper, the participants of this review are older people with mental health problems. Finally, ^{Towicz, Yang, Moylan, Tindall, & Berk’s publication (2021}) presents a narrative review about home care treatment’s design, implementation, and outcomes, stating that there is limited evidence regarding clinical measures and consumer satisfaction, and effects on caregivers and staff. Regrettably, we could not retrieve the full text even though we requested a copy directly from the authors.

Results

Through data synthesis, we will organize results according to: (1) primary outcomes, such as, days of treatment, relapse (as defined by each study), and rehospitalization; and (2) secondary outcomes, comprising service user satisfaction, dropout rate, and the proportion of patients with adverse events (suicide, self-harm, or aggression/violence). The principal summary measure will be the correlation coefficient due to correlational findings, that will only take place if data are homogeneous, otherwise the synthesis will only be narrative. However, a descriptive summary of means, standard deviations, correlation coefficients, p-values, and effect sizes will also be synthesized, where available in studies. A summary of each study will be written in a Word document in a tabular form accompanied by a narrative synthesis.

We expect to publish this review in 2024 in a peer-review journal.

Conclusions

This paper consists of a systematic review protocol produced according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2019 Statement. The aims of analyzing and highlighting the effectiveness of CRHT teams intervention compared to treatment as usual represents an opportunity to define the efficacy and safety of CRHT teams compared to inpatient treatment and put forward the development of this kind of service for the management of mental health crises.

Regarding the development of the theme and its secondary investigation, we intend to align its results with the impetus for implementing a psychiatric home hospitalization unit in countries like Portugal, where we practice our profession as specialist nurses in mental health and psychiatry nursing. Home hospitalization is already a reality in our country, but building a path for this to be a reality for other areas of care, such as mental health, may mean the need to build more evidence. The decisions taken to carry out this research project provide robustness to the proposals that may emerge from this work, contributing to a change in mentality and reducing professionals’ resistance, accustomed to traditional treatment. Therefore, research emerges pragmatically as part of the driving force behind health services management that can influence decision-making and consequent investments.

We wish to strengthen the arguments necessary for the change process, associating it with feelings of greater security and optimism. New models of care, like CRHT, advocate transferring health professionals’ settings to a more naturalist environment, as is the case of home hospitalization. We believe that nurses should constitute themselves as key elements in the search for new possibilities for care responses, contribute to their decentralization and actively contribute to the construction and dissemination of services in the places where they are needed, that is, within communities and in closeness to people.

With this tone, we seek to become agents of change dedicated to the innovation and optimization of health services through the proposal to implement psychiatric home hospitalization units.