In their comprehensive review, Johnson et al¹ emphasize that acute psychiatric care consumes a substantial part of the resources available for mental health services, but that evidence on which models are associated with the most positive patient experiences and outcomes remains surprisingly limited.

It is well documented that continuity of care and therapeutic relationships are regarded as important factors by patients in mental health services^{2, 3}. There is also evidence that these factors are important in acute psychiatric care. Continuity of care has been shown to be positively associated with outcomes in acute psychiatric services⁴. Regarding therapeutic relationships, the majority of service users identify emotional support as a core component of crisis resolution team care, and emphasize the need to be given enough time and opportunity to tell their story and talk about their feelings and difficulties⁵.

Building and maintaining a therapeutic relationship is difficult in inpatient acute psychiatric care, but has been shown to be possible and to contribute to lower use of coercion, higher patient satisfaction and better adherence to medication⁶. There is a need to adapt professional training in building and maintaining therapeutic relationships to the typical acute care setting, with limited time available and other restrictions. Research methods assessing ther­­apeutic relationships also need to be adapted to acute psychiatric care, where the patients have personal contact with their responsible clinician as well as with other staff members.

Organization of acute care tends to focus on ready access to the services during a mental health crisis. Less attention is often given to building a therapeutic relationship during the acute care and to securing continuity of care in the transfer of contact to further services. In psychiatric inpatient units, this may result in short inpatient stays, with emphasis on medication and little time available to develop a therapeutic alliance and interacting with the patient as a person, as well as lack of securing adequate personal contact in the process of transfer to the following services. Too short length of stay or a discharge without appropriate follow-up may lead to repetitive short-term stays in acute psychiatric wards. Both length of stays and securing follow-up by health services in the community after discharge have been shown to be positively associated with reduction in readmissions⁷.

Patients with serious psychiatric disorders may be more likely to keep a stability in their condition when they are allowed a long-term contact with clinicians with whom they have developed a trusting rela­­tionship, and they may need time to develop a similar relationship to a general practitioner or someone else in primary care. An additional problem is that many general practitioners are over-burdened and have limited capacity to follow up patients with mental illnesses.

It should also be considered that mental health crises often reflect problems that have developed over time and become gradually more serious. Early interventions may address problems when they are less serious and require less efforts for improvement, and low-threshold services may be provided as part of mental health care or primary care. Brief patient-controlled admission (PCA) to a mental health ward in a community center represents such a low-threshold model, which has been innovated in Norway, and is found useful by patients. PCA stays are typically a maximum of 5 days⁸.

The crisis resolution teams in Norway have emphasized early intervention and low-threshold services in addition to community-based crisis interventions for patients who would otherwise be admitted to an inpatient unit. Compared to those in the UK, the Norwegian teams provide crisis care to a broader patient group, with more psychological interventions and less psychotropic medication management⁹. This practice also includes longer visits or sessions with more time for psychological help and for developing a therapeutic relationship.

Like several other team-based health services, crisis resolution team care is a complex model in which several persons provide a wide range of interventions. Variations among team practices suggest that it is hard to practice all elements or components well, and that sometimes different components can compete, e.g., ensuring rapid response to new referrals vs. providing intensive care with frequent visits to current service users. Local adaptations are often necessary, and this may add to challenges in comparing complex interventions across sites and countries.

Johnson et al’s overview describes a wide range of acute psychiatric care models used in various stages and contexts. For most of these models, there is a lack of research-based evidence, and achieving evidence for all these models may not be possible. However, a possible path may be to use research models currently under development for complex interventions to study individual elements of acute psychiatric care. If such research could identify which elements are critical for what types of clinical effect, these elements could be applied and studied within various models and contexts.

One dilemma of the increasing special­ization and differentiation in mental health services, including acute psychiatric care, is the increasing discontinuity of care for service users who need services through several phases of illness. Models with more generic or integrated teams may secure more continuity in the personal relationships between the service user and the service provider. Efficiency requirements focus on management of disorders, but often leave little room for the interaction of providers with persons with these disorders.

We need to know more about which out­comes are most important for service users and what elements of acute psychiatric care contribute to the various outcomes. As a part of this, it is important to better understand how continuity of care and therapeutic relationships contribute to positive patient experiences and outcomes in acute psychiatric care, and how these two critical elements may be provided.

在他们的综合评价中，Johnson 等人¹强调急性精神科护理消耗了可用于精神卫生服务的很大一部分资源，但关于哪些模型与最积极的患者体验和结果相关的证据仍然令人惊讶地有限。

有充分的证据表明，护理和治疗关系的连续性被患者视为心理健康服务中的重要因素^{2, 3}。还有证据表明，这些因素在急性精神病治疗中很重要。护理的连续性已被证明与急性精神科服务的结果呈正相关⁴。关于治疗关系，大多数服务使用者将情感支持视为危机解决团队护理的核心组成部分，并强调需要给予足够的时间和机会讲述他们的故事，谈论他们的感受和困难⁵。

在住院急性精神科护理中建立和维持治疗关系是困难的，但已被证明是可能的，并有助于减少强制使用、提高患者满意度和更好地坚持服药⁶。有必要使建立和维持治疗关系的专业培训适应典型的急症护理环境，但可用时间有限且受到其他限制。评估治疗关系的研究方法也需要适应急性精神病护理，在这种护理中，患者与其负责的临床医生以及其他工作人员进行个人接触。

急症护理的组织往往侧重于在精神健康危机期间随时获得服务。在紧急护理期间建立治疗关系以及在将接触转移到进一步服务时确保护理的连续性通常较少关注。在精神科住院病房中，这可能导致住院时间短，重点是药物治疗，很少有时间发展治疗联盟并与患者作为一个人进行互动，以及在转移到医院的过程中缺乏确保足够的个人接触以下服务。住院时间过短或出院后没有适当的随访可能会导致在急性精神病病房反复短期住院。⁷ .

如果允许患有严重精神疾病的患者与已建立信任关系的临床医生长期接触，他们可能更有可能保持病情稳定，并且他们可能需要时间与全科医生建立类似的关系或其他初级保健人员。另一个问题是，许多全科医生负担过重，对精神疾病患者进行随访的能力有限。

还应该考虑的是，心理健康危机往往反映了随着时间的推移而发展起来并逐渐变得更加严重的问题。早期干预可能会在问题不太严重且需要较少努力进行改进时解决问题，并且可以作为精神卫生保健或初级保健的一部分提供低门槛服务。在社区中心的心理健康病房进行短暂的患者自控入院 (PCA) 代表了这种低门槛模型，该模型已在挪威进行了创新，并被患者发现有用。PCA 逗留时间通常最多为 5 天⁸。

除了以社区为基础的危机干预措施之外，挪威的危机解决小组还强调了早期干预和低门槛服务，这些患者本来会被送入住院病房。与英国相比，挪威团队为更广泛的患者群体提供危机护理，更多的心理干预和更少的精神药物管理⁹。这种做法还包括更长的访问或会话，有更多的时间进行心理帮助和发展治疗关系。

与其他几个基于团队的卫生服务一样，危机解决团队护理是一个复杂的模型，其中几个人提供广泛的干预措施。团队实践之间的差异表明，很难很好地实践所有元素或组件，并且有时不同的组件可以竞争，例如，确保对新转诊的快速响应与通过频繁访问当前服务用户来提供重症监护。当地的适应通常是必要的，这可能会增加比较不同地点和国家的复杂干预措施的挑战。

Johnson 等人的概述描述了在不同阶段和环境中使用的各种急性精神病护理模型。对于这些模型中的大多数，缺乏基于研究的证据，并且可能无法为所有这些模型获得证据。然而，一种可能的途径可能是使用目前正在开发的复杂干预研究模型来研究急性精神科护理的各个要素。如果此类研究能够确定哪些要素对哪些类型的临床效果至关重要，则可以在各种模型和环境中应用和研究这些要素。

精神卫生服务（包括急性精神病护理）日益专业化和差异化的一个困境是，对于在疾病的多个阶段需要服务的服务使用者的护理越来越不连续。具有更通用或集成团队的模型可以确保服务用户和服务提供者之间的个人关系更具连续性。效率要求侧重于疾病的管理，但通常很少为提供者与这些疾病患者的互动留下空间。

我们需要更多地了解哪些结果对服务使用者最重要，以及急性精神科护理的哪些要素对各种结果有贡献。作为其中的一部分，重要的是要更好地了解护理和治疗关系的连续性如何有助于患者在急性精神病护理中的积极体验和结果，以及如何提供这两个关键要素。