Johnson et al¹ provide a comprehensive overview of the range of acute services and models of care currently considered and utilized by mental health systems, primarily in high-income countries. Their paper represents an excellent starting point for the evaluation of the range, access and quality of support available to those who experience acute psychosocial distress². The authors make clear that there are multiple possible pathways into care, numerous modalities of assessment that can be applied, and an equally diverse set of potential options for support following assessment.

The breadth and depth of all this is nothing short of remarkable. What is equally remarkable, however, is the lack of a clear evidence-based direction provided by research. This is contrary to the widespread belief that an evidence base exists underpinning the predominantly biomedical approaches found in most high-income countries. As Johnson et al point out, most studies are negative in their findings or do not find benefit for the care model proposed. This results in making approaches to the planning, implementation and evaluation of acute care a wicked problem³. The “scope” and “status” of acute services ­cur­rently generates a very real conundrum for service planners and individual clinicians: what are the best approaches to improving access and quality of care?

Actually, it is unlikely that there will be “best approaches” that are generalizable to individuals in terms of their presentation, time, culture or health care model. What is required is a contextually relevant model of care with adequate evidence. We would suggest that judgements as to whether the acute care approaches available in a society are sufficient and appro­priate mostly belong to the patients that receive them and their support networks⁴. In order to make this evaluation, it seems likely that an understanding of acute psychosocial distress from the patient perspective is a prerequisite and that this should include an understanding of patient rights.

Taken as a whole, the existing evidence suggests that biomedical models for assessment (such as assessment in the emergency department) are largely unhelpful from a patient perspective and may increase the likelihood of inpatient care. This care is often implemented on the basis of a poorly specified “risk” that many wards are not designed to mitigate. Alternatives are therefore needed to develop more effective acute assessment and care.

It is interesting to see that home crisis teams, that are not based in a theoretical model, are more positively received by patients, as are residential community cri­sis homes. These exist throughout New Zealand and anecdotally reflect the positive experiences reported in the literature. Both of these models are less clinical in ori­entation, with a focus on the needs of the person in distress and approaches to meet them, as opposed to a focus on risk. The implication is that the biomedical models outlined as the “tip of the spear” may be insufficient or even outdated, and that co-produced acute care models are needed to adequately supplement them in meeting the needs of patients and their support networks.

We note the differentiation between the overview pertaining to high-income countries and that regarding low- and middle-income countries (LMICs) in Johnson et al’s paper. What is somewhat of concern is the critical lens applied to the issues and approaches that exist in those LMICs. The identified systematic review of mental health interventions for crises in non-specialist settings in LMICs⁵, which found a lack of evidence-based guidelines for crisis care, is consistent with the findings of Johnson et al’s overview generally. As the United Nations (UN) Special Rapporteur pointed out in 2020, “globally, almost all contexts share the need for a paradigm shift in mental health, although what that shift looks like in practice is a matter of much debate… while a dominant global status quo in mental health exists, it is fracturing under the pressure of these divergent and powerful movements and experiences”⁶. Similarly, the World Health Organization (WHO) reports that “sector-wide solutions are required not only in low-income countries, but also in middle- and high-income countries”⁷. The issues identified in LMICs extend, we would suggest, their reach also into high-income countries.

One of the powerful movements to which the UN Special Rapporteur refers is represented by the expectations of countries that have signed and ratified the 2006 UN Convention on the Rights of Persons with Disabilities. This includes particularly the right of persons with experience of disability (including psychosocial disability) to legal capacity, which encompasses both legal standing (the ability to hold rights) and legal agency (the ability to exercise those rights).

A common assumption to counter this approach is the perceived need to substitute the choices of a person with acute psychosocial distress in order to meet his/her needs, for example by using mental health legislation. Arguably these concerns rest on poorly defined concepts, such as “insight”, and there is increasing debate around appropriate capacity assessments⁸, even in acute circumstances⁹. In response, the Convention requires that people are provided with support to make decisions in accord with their own will and preferences even in situations where they may have impaired decision-making skills.

As identified by Johnson et al, the recently published WHO guidance⁷ sets out the core principles of rights-based, recovery-oriented approaches to commu­nity mental health services, including cri­sis services, as being a commitment to respect for legal capacity, non-coercive practices, community inclusion, participation, and the recovery approach. Fundamentally, the needs and rights of the person in distress should be the guide to the model of care delivered.

In sum, Johnson et al provide an excellent overview of the current range of services and quality considerations involved in acute psychiatric care. They point out that the literature is fractured or does not support many of the day-to-day interventions offered. The changing global context, with an ever increasing recognition of the rights of people experiencing acute psychosocial distress, also challenges the status quo.

We would echo the authors’ conclusion that new approaches need to be developed, evaluated and implemented, and we would suggest that rights-based, recovery-oriented approaches should inform any increase in the range, and improved access and quality of, acute psychiatric care. Co-production with people with lived experience and their support networks is likely to best facilitate this change.

Johnson 等人¹全面概述了目前主要在高收入国家的精神卫生系统考虑和使用的紧急服务和护理模式的范围。他们的论文代表了一个很好的起点，可以评估那些经历急性社会心理困扰的人²可获得的支持范围、获取途径和质量。作者明确指出，有多种可能的护理途径、多种可应用的评估方式，以及评估后支持的同样多样化的潜在选择。

这一切的广度和深度都令人瞩目。然而，同样值得注意的是，研究缺乏明确的循证方向。这与普遍认为存在支持大多数高收入国家的主要生物医学方法的证据基础相反。正如约翰逊等人指出的那样，大多数研究的结果都是负面的，或者没有发现所提出的护理模型有好处。这导致急性护理的规划、实施和评估方法成为一个棘手的问题³。紧急服务的“范围”和“状态”目前给服务规划者和个体临床医生带来了一个非常现实的难题：改善医疗服务的可及性和质量的最佳方法是什么？

实际上，就个人表现、时间、文化或医疗保健模式而言，不太可能存在可推广到个人的“最佳方法”。所需要的是具有足够证据的上下文相关的护理模式。我们建议，判断一个社会中可用的急性护理方法是否充分和适当，主要属于接受这些方法的患者及其支持网络⁴。为了进行这种评估，从患者的角度理解急性社会心理困扰似乎是一个先决条件，这应该包括对患者权利的理解。

总体而言，现有证据表明，用于评估的生物医学模型（例如急诊科的评估）从患者的角度来看基本上没有帮助，并且可能会增加住院治疗的可能性。这种护理通常是根据许多病房不旨在减轻的未明确规定的“风险”来实施的。因此，需要替代方案来开发更有效的急性评估和护理。

有趣的是，不基于理论模型的家庭危机小组更受到患者的积极欢迎，社区危机之家也是如此。这些在整个新西兰都存在，并且有趣地反映了文献中报道的积极经验。这两种模型都不太注重临床，重点关注处于困境中的人的需求和满足他们的方法，而不是关注风险。这意味着，被概述为“矛尖”的生物医学模型可能不够充分，甚至已经过时，需要共同制作的急性护理模型来充分补充它们，以满足患者及其支持网络的需求。

我们注意到 Johnson 等人的论文中关于高收入国家的概述与关于低收入和中等收入国家 (LMIC) 的概述之间的区别。有点令人担忧的是，对这些 LMIC 中存在的问题和方法的批判性视角。已确定的针对中低收入国家非专业环境中危机的心理健康干预措施的系统评价⁵，发现缺乏基于证据的危机护理指南，这与 Johnson 等人的概述的结果大体一致。正如联合国 (UN) 特别报告员在 2020 年指出的那样，“在全球范围内，几乎所有情况下都需要在心理健康方面进行范式转变，尽管这种转变在实践中看起来如何是一个备受争议的问题……而一个占主导地位的全球心理健康的现状是存在的，但在这些不同而强大的运动和经历的压力下，它正在破裂” ⁶。同样，世界卫生组织 (WHO) 报告称，“不仅低收入国家需要全部门的解决方案，中等和高收入国家也需要” ⁷. 我们建议，中低收入国家发现的问题也延伸到高收入国家。

联合国特别报告员提到的强大运动之一是签署和批准 2006 年《联合国残疾人权利公约》的国家的期望。这尤其包括有残疾经历（包括社会心理残疾）的人享有法律行为能力的权利，包括法律地位（持有权利的能力）和法律代理（行使这些权利的能力）。

反对这种方法的一个常见假设是，为了满足他/她的需求，例如通过使用心理健康立法，需要替代患有急性社会心理困扰的人的选择。可以说，这些担忧依赖于定义不明确的概念，例如“洞察力”，并且围绕适当的能力评估⁸的争论越来越多，即使在紧急情况下⁹也是如此。作为回应，公约要求为人们提供支持，使他们即使在决策能力可能受损的情况下也能按照自己的意愿和偏好做出决定。

正如 Johnson 等人所指出的，最近发布的 WHO 指南⁷列出了社区精神卫生服务（包括危机服务）基于权利、以康复为导向的核心原则，作为对尊重法律能力、非强制性的承诺实践、社区包容、参与和恢复方法。从根本上说，处于困境中的人的需求和权利应该是提供护理模式的指南。

总之，Johnson 等人对急性精神科护理中涉及的当前服务范围和质量考虑提供了极好的概述。他们指出，文献不完整或不支持所提供的许多日常干预措施。不断变化的全球环境，以及对遭受严重社会心理困扰的人们的权利的日益认可，也对现状提出了挑战。

我们会赞同作者的结论，即需要开发、评估和实施新的方法，我们建议基于权利、以康复为导向的方法应该为急性精神科护理范围的增加、获取和质量的提高提供信息. 与有生活经验的人和他们的支持网络共同制作可能最好地促进这种变化。