Abstract
For two decades, treatment of acute mental health episodes in Australia has been increasingly provided by community-based services [1]. In Victoria, Crisis Assessment and Treatment (CAT) teams [2] assess an individual's need for hospitalization and then facilitate hospital admission or treat the person in his or her own environment for up to 8 weeks. Their work is complemented by Community Mental Health Centres (CMHCs) and Mobile Support and Treatment Teams (MSTTs) for non-acute patients. From 1988/1989 to 1994/1995, total numbers of these service types increased from 18 to 65 with the addition of 200 staff from 1993 to 1995. CAT services are now well established in each of the 21 area mental health services [3].
Establishment of CAT teams in Australia was stimulated by demonstration trials of home-based acute care inthe 1970s [4–6]. These trials found that no additional burden accrued for relatives of patients with home-based care compared with those who had hospital treatment. In addition, the Hoult et al. [5], study reported that only 2% of relatives who had experienced community treatment preferred hospital treatment for their relative. A conclusion that most family carers would welcome community-based treatment may seem warranted. However, differences between CAT services in Victoria and service provision in the earlier studies challenge such a conclusion.
First, the high satisfaction ratings by recipients of the then new services may have been partly due to temporary effects of staff enthusiasm and positive expectations (although one later study [7] suggests otherwise). Second, in the studies noted above, treatment by the community teams lasted well beyond the acute episode. Thus, carer satisfaction and burden measures related to the entire period of community management; data about the acute period were not specifically reported. Carers may prefer different services in acute compared with recovery periods. Third, only one study [5] directly asked family members which service they preferred, community or hospital. Fourth, it is not clear to what extent the family member respondents in these studies had experienced both hospital and community care and were thus in a position to make an informed judgement of the relative merits of each. Lastly, in Victoria, CAT teams work with patients for a maximum of 8 weeks before referral to other services: a substantially shorter time frame than the 12 months or more of the demonstration studies.
Typically, more than 50% of psychiatric patients live with a family member [7–9]. Despite the trend to community care, hospitalization is still highly valued by family caregivers [10]. Indeed, observations by the first author, while working on a CAT team, were that many families seemed to prefer hospital care for their acutely ill relative. These observations and the limitations of demonstration studies noted above, led to the development of this study.
Given the rapid increase in home-based treatment in Australia and elsewhere, surprisingly little research has sought family carers' views about current communitybased services such as CATs.
Aims
The first aim of the study was to assess the proportion of family carers who preferred CAT team care to hospitalization when their mentally ill relative experiences a relapse. (In reality, hospitalization without CAT assessment is not possible.)
The second aim of the study was to identify predictors of preference for hospital or CAT treatment. Variables previously found to be associated with burden and adaptive coping include demographic variables, perceptions of the relative's illness, attitudes towards psychiatric hospitals and expectations about future coping.
Method
Participants
The 77 participants in this study were carers of a person with a serious mental illness currently receiving treatment in the public mental health system in the State of Victoria. All had experienced contact with inpatient and CAT services within the previous 5 years.
Development of the Carer Questionnaire
Drawing upon burden and coping literature, a Carer Questionnaire with four sections was developed.
Section a: demographic information. This includes the age of the relative/carer [11], socioeconomic status [12], culturalbackground [13], [14] and the living arrangements of carers and their ill relatives [11].
Section b: the Attitudes to Psychiatric Hospitals Questionnaire [15] comprising 36 items requiring Yes/No responses.
Section c: five scales devised to measure psychological variables: perceived severity of illness [12], [13], [16]; cumulative subjective burden; expectations of coping during a relapse and of outcome for treatment (hospital vs CAT) [17]; and challenging behaviours exhibited by the relative during an acute episode. Items for each scale included both positively and negatively worded statements and responses were marked on seven- or five-point Likert scales.
Section d: preference for hospital versus CAT team care. Three seven-point Likert scale items sought service preference. Comments on this choice were also requested.
Based on feedback and item data from pilot testing (n = 41 carers), the final Carer Questionnaire comprised 86 items. The five psychological scales had adequate internal consistency (α = 0.63–0.88).
Recruitment of participants
All public mental health patients from the Northern and Central Eastern areas of Melbourne who had experienced both CAT team and inpatient care in the previous 5 years were identified from the State mental health data base.
Case managers of the identified patients were located and asked to provide carer contact details. Carers were sent a letter, inviting them to complete and return (via stamped, addressed envelope) the Carer Questionnaire.
Results
Response rate and description of participants
Of the 550 registered patients, case managers provided contact details for 223 (40.5%) carers. Reasons for failure to provide carer contacts were recorded by case managers in relation to 166 of their patients. They included the absence of an identifiable family carer (n = 73, 44.0%), language other than English (n = 22, 13.3%), carer refusal, inability to participate due to mental illness or age (n = 21, 12.7%), incomplete case record details or carer uncontactable (n = 18, 10.8%) and no relevant carer for some patients living in supported accommodation or a group home (n = 10, 6.0%). The remaining 13.2% is accounted for by patients refusing to allow their carer to participate (n = 8, 4.8%), strained carer–patient relationships (n = 7, 4.2%) or the patient being paranoid, guarded or uncooperative (n = 7, 4.2%).
Of 223 questionnaires sent to carers, 96 (43.1%) were returned with a total of 77 (34.5%) available for full analysis (19 questionnaires were excluded from analysis because of missing data or because respondents did not meet the criteria of experience of both services).
Most respondents to the questionnaire were aged over 60 (79.8% n = 67), the majority being women (61.9%, n = 52). Most lived with their ill relative (73.8%, n = 62) or saw their relative at least once or twice a week (22.6%, n = 19), indicating frequent contact between carers and their relatives regardless of living arrangements.
Many of the patients had received treatment for a mental illness for over 10 years (41%, n = 41), with more than one-third having over seven admissions to psychiatric hospitals (33.8%, n = 28), reflecting a relatively chronic course of illness in the sample.
Carers reported similar contact rates with both CAT and hospital staff; 44% and 52%, respectively, reported more than 12 contacts over the previous 3 years.
Carer preference
Overall, slightly more of the 77 carers preferred hospital to CAT team treatment (54.5%, n = 42 vs 45.5%, n = 35, respectively), although this difference was not significant (χ2 = 0.636, df = 1, p < 0.05). Carers who preferred hospital treatment tended to be more polarized in their views, with 26.3% (n = 20) and 14.5% (n = 11) expressing a strong preference for hospital and CAT treatment, espectively.
Correlation of demographic and psychological variables with preference
Demographic variables included age, sex and nationality of the carer, income level, relationship to the ill relative and whether the carer was currently living with their relative. Questionnaire responses to all demographic variables were dichotomised for analysis. Scores for the preference variable ranged from 1 (very strong preference for hospital) to 7 (very strong preference for CAT).
All Pearson correlations between demographic variables and preference were low to moderate, ranging from 0.02 to 0.37. Living situation was the only demographic variable significantly correlated with preference (r = −0.20, p = 0.03), indicating a tendency for carers who lived with their ill relative to be more likely to prefer hospital treatment.
All psychological variables were significantly correlated with carer preferences (Table 1). It is noted from these results that (i) carers who had high expectations of the efficacy of either hospital or CAT team services preferred that service (r = −0.36 and 0.65 respectively), and (ii) the more severe and burdensome the carer perceived the mental illness to be, the more they preferred a hospital-based service (r = −0.32 and −0.54 respectively).
Prediction of carer preference: demographic versus psychological variables
A standard regression analysis was conducted to examine the predictive validity of six demographic variables (age, sex, income and nationality of carer, relationship between the carer and relative and living arrangements between relative and carer). Together, they accounted for 11.7% of the variance in preference, F = 1.307, df = 6,59, p < 0.05 (Table 2).
Correlation of psychological variables with carer preference and with each other
Summary of standard regression analysis for demographic variables predicting caregiver preference
A standard regression analysis was also used to examine the role of psychological variables in the prediction of preference (attitudes to psychiatric hospitals, severity of illness, level of burden, coping during a relapse, expected outcome of CAT and hospital care and behaviour checklist). The results are summarized in Table 3.
Summary of standard regression analysis for psychological variables predicting caregiver preference
Together, these seven variables accounted for 56.8% of the variance associated with preference for hospital or community treatment (F = 12.03, df = 7,64, p < 0.05). A much larger proportion of the variance in carer preference was accounted for by the psychological variables than by the demographic variables.
To ascertain which of these variables made unique, individual contributions to preference, the squared semipartial correlation was determined.
This expresses the unique contribution of the independent variable to the total variance of the dependent variable [18]. In this case, expected outcome of CAT care was the only significant unique contributor to R2 (sr2 = 0.153, p < 0.01). There was a trend for the individual contributions of expected outcome of hospital care and attitudes toward psychiatric hospitals to approach significance (sr2 = 0.02, p = 0.071 and sr2 = 0.021, p = 0.06, respectively).
In summary, while 56.8% of the variance in preference was accounted for by a combination of the seven psychological variables examined in this study, only expected outcome of treatment by CAT teams made a significant unique contribution (15.3%).
Discussion
The first aim of this study was to assess the preferences of family carers of patients for hospital versus communitybased services during an acute episode. Unlike earlier studies, we found that approximately half of our sample preferred hospital-based services. The second aim was to identify those psychological and demographic factors that were associated with preference for either service. Preference for hospital-based care was consistently associated with the carer's perceptions of the severity of the illness and the patient's behavioural reactions, and their sense of burden and coping during acute episodes. However, only carer expectations about the outcome of CAT team care made a statistically significant unique contribution to overall preference.
Factors associated with carer preference
Psychological variables were better predictors of carer preference than were demographic variables. This suggests that carers' appraisal of treatment type is more influenced by subjective elements of caregiving than by objective indices such as income, age and socioeconomic status. For example, carers who preferred community treatment had positive expectations about outcome of community care and negative expectations about outcome of hospital care. They felt less burdened by their relative's illness, had higher expectations of their ability to cope during a relapse, and perceived their relative's illness and relapse behaviours as less severe (The one demographic variable which was associated with preference – living with the ill relative – supports the notion of severity of burden being a contributing factor.) These results are in accord with Solomon and Draine's [17] finding that social and psychological variables were more predictive of adaptive coping of carers than were demographic factors.
The results suggest that home-based care for acute psychiatric episodes is not as widely embraced by carers in Victoria as previously thought. Further, they indicate that preferences are based on aspects of carers' previous experiences of acute episodes (severity of symptoms, ability to cope, expectations etc.). It seems that the experiences of carers cannot be lumped together into a unitary group; preferences depend on the nature of their relative's illness and on the carers' own psychological reactions.
Differences between the present and earlier studies
There were several differences between the present and earlier studies. First, our population had experienced both services. As earlier studies did not require carer experience of both services (and did not report the extent of it), carers' high satisfaction for community treatment may not have been based on an informed comparison of the two.
Second, our sample comprised families whose relative had experienced more than one episode of acute care. Repeated experience of acute episodes, with their accompanying stress, may cause a greater proportion of carers to prefer respite from their relative in the form of hospitalization. From a service planning perspective, the views of families of repeat service users are particularly important.
Further, we sought preferences for services at the point of relapse, whereas Hoult et al. [5], asked about carer preferences across a 1-year treatment period. It may be that carers prefer hospital treatment for the most acute periods and home-based treatment in periods of greater stability. This issue warrants further investigation.
Our study suggests a different relationship between community treatment and burden than that reported by Hoult et al. [5] or Test and Stein [6]. Contrary to those studies, our carers who lived with their ill relative or who felt more burdened and less able to cope, were more likely to prefer hospitalization. Community treatment may risk increasing the burden of carers who live with their mentally ill relative. This conclusion is supported by the work of Jones [19] who found that level of burden was higher for carers who lived with their ill relative, and by research which suggests that for some carers, hospital provides respite from the demands of caregiving [20].
Finally, the longer time frame of the demonstration studies (12 months) allowed a broader treatment focus for community-based care, including the training of patients in living and social skills and more direct family support and intervention. It is possible that the briefer time frame of the CAT teams in Victoria (8 weeks) precludes delivery of the range of services or depth of relationship with the team to which relatives in the demonstration studies so positively responded.
The nature of CAT and inpatient acute care
The results of this study need to be interpreted in the context of the nature of the services provided by CAT teams and acute inpatient wards in Victoria. These services do not work in isolation. The CAT teams act as gatekeepers to inpatient care, and for virtually all inpatient admissions, the client and possibly carers have had contact with the CAT team. CAT staff are frequently engaged in early discharge management, which enables more rapid discharge. The admission and early discharge management functions of the CAT teams are services provided in addition to the more familiar role of community treatment without hospitalization. Our questionnaire did not ask carers which CAT services they had experienced, thus we do not know whether their views about future community treatment of their relatives were influenced by the type of CAT services they had experienced. Data from the CAT team in the study area for 4 of the 5 years of the study period (Carter K: personal communication, 2000) shows that 45% of patients assessed by the team were admitted, 30% received community treatment without hospitalization, 11% received early discharge management, and the remainder were referred elsewhere. Acute care systems differ between and sometimes within States. Using the terminology of Hambridge and Rosen [21], CAT teams are ‘crisis teams’, ratherthan ‘extended hours teams’ in which a single team deals with both crisis and continuing care (p.439).
Preferences of carers, patients and professionals
Our study does not address patients' preferences for acute episode care. Preferences of patients for different service options do not always coincide with those of professionals [22], nor with those of their families [23]. This study attempts to more clearly understand the needs and wishes of family caregivers in relation to acute care. However, service planners also need to understand and give proper weight to the needs and wishes of the patients, and to evidence for the efficacy of alternative interventions and service contexts.
Implications
The preference of only half of the carers for the Victorian mental health system's front line service (CAT) suggests that non-hospitalization, even with standard CAT team support, provides an insufficient level of service for many carers. Some may reasonably wish for respite from care or responsibility during acute episodes. A reappraisal of the needs of carers who feel insufficiently supported by standard CAT services may be beneficial.
This study also invites caution in application of findings from model programmes to routine services that have followed. In this case, the service model now in widespread operation in Victoria differs substantially in length of involvement and scope from the original demonstration projects. It deserves evaluation in its own right rather than assuming that most of the benefits of the model programmes will replicate.
Limitations of the study
The fact that we commenced our case identification process with 550 patients and report data fromonly 77 carers may at first glance give the impression of a low response rate with attendant risks of generalizing to all carers. However, the method of sampling in this study was unique in its attempt to identify all known carers of patients from a defined geographical area who had experienced both inpatient and CAT team care, and involved both a case identification process and a survey. In the case identification process, we were able to identify carers of only 223 (40.5%) of the 550 patients who, according to the statewide database, met the criterion of recorded CAT and inpatient registrations in the study period. The exact number of patients identified by the database who were in contact with carers is not clear, because case managers did not record why they did not provide carer details for 161 (49%) of the patients identified. Thus we remain unsure how complete our identification of carers turned out to be.
However, we believe that a strength of our study was the unbiased process of recruitment of families which started with the identification of all patients experiencing both forms of service, followed by an attempt to establish whether they had contact with their families, who were then invited to participate. The alternatives, nomination of patients by case managers or recruitment through family carer support organizations, would be less representative of those experiencing the two forms of service. The actual response rate to the questionnaire of 43% is comparable with other mailed familysurveys [24], [25]
The sampling method was unlikely to identify firstepisode or brief disorders, thus the findings address caregiving for patients with established disorders. In addition, the carers comprised mainly women caring for their adult child. Studies focusing on less typical caregiving relationships may reveal different treatment preferences.
Conclusions
Mental health workers who assess suitability of patients for acute home-based treatment in Australia do so with the understanding that it is the treatment of choice of the mental health system. This study suggests that only about half of all carers who have experienced both hospital and CAT team care in Victoria prefer the latter for acute episodes. The contrast between these results and those of demonstration studies may be attributable to this study's focus on preference rather than satisfaction, its focus on care during acute relapse or, more likely, to the more limited service offered by Victorian CAT teams.
Carer preference for acute service type is more strongly associated with psychological variables (subjective burden, ability to cope, attitude toward hospitalization and expectations about the outcome for their relative), than demographic characteristics such as age or income level. These variables are worthy of further study and may be important for clinicians to assess and discuss with carers when decisions about service type are being negotiated.
Footnotes
Acknowledgements
The authors gratefully acknowledge the assistance of Mental Health Branch, Department of Human Services, Victoria, who provided medical record numbers from the PRISM database. Kevin Carter and staff of the Northern and Central East Area Mental Health Services assisted greatly with data collection. Carol Newnham assisted with the manuscript and Philip Burgess and Tom Trauer provided comments on an earlier version. Thanks also to Ben Ong for statistical advice.