The ability of Psychosocial Care Centers specialized in Alcohol and Drugs to handle crises

Objective: to assess the ability of 24-hour Psychosocial Care Centers specialized in Alcohol and Other Drugs to handle the users’ crises in comprehensive care. Method: a quantitative, evaluative, and longitudinal study was conducted from February to November 2019. The initial sample consisted of 121 users, who were part of the comprehensibly care in crises by two 24-hour Psychosocial Care Centers specialized in Alcohol and other Drugs in downtown São Paulo. These users were re-evaluated 14 days after admission. The ability to handle the crisis was assessed using a validated indicator. The data were analyzed using descriptive statistics and regression of mixed-effects models. Results: 67 users (54.9%) finished the follow-up period. During crises, nine users (13.4%; p=0.470) were referred to other services from the health network: seven due to clinical complications, one due to a suicide attempt, and another for psychiatric hospitalization. The ability to handle the crisis in the services was 86.6%, which was evaluated as positive. Conclusion: both of the services analyzed were able to handle crises in their territory, avoiding hospitalizations and enjoying network support when necessary, thus achieving the de-institutionalization objectives.


Introduction
A mental health crisis can be defined as a critical moment characterized by disrupting a person's organization in its psychological, social, biological, spiritual, or cultural dimensions (1) . A crisis can be triggered by various situations beyond a person's limits. It usually involves a context signaled by changes, losses, and threats. Also, it is often marked by intense anxiety, uncertainty, unpredictability, and possible violence, due to the suffering expressed far beyond the psychiatric symptomatology (2) .
In Alcohol and Other Drugs (AOD) clinical management, crises can be relieved or worsened due to the effect of the substance(s) of choice or to their absence.
Generally, characteristics such as craving, intoxication, overdose, and withdrawal symptoms are observed, in addition to the difficulty establishing interpersonal relationships, issues commonly related to the reduction of length of stay in the care spaces (3) .
Although not always qualified as urgent, crisis moments require immediate admission (1,4) . For more than a decade, the World Health Organization (WHO) has recommended that these services be preferentially carried out in the community context and by teams or specialized mental health services; however, these resources are still not sufficiently available or structured at the global level (3)(4)(5) .
A systematic literature review corroborated by recent national and international studies found that the lack of specialized and trained services for this management, the reproduction instances of coercive, authoritarian, and biomedical asylum practices, the failures in the articulation of the network, and the influences of the family and the community due to the need for hospitalization are some impasses for crisis care not to be successful in extrahospital assistance (2,4,(6)(7) .
In the context of psychoactive substance use, it is common for users' access to community mental health services to be relatively lower when compared to other mental disorders, due to the specific characteristics of their needs (3) . In addition, a longitudinal analysis carried out in the United States identified that the proportion of alternative community services for managing crisis situations in this population group was reduced by almost 10% in the country in seven years (8) .
Even in scenarios such as Italy, the Netherlands, and Brazil, which implemented similar deinstitutionalization models with a focus on community care, the assistance provided for crises is still one of the most critical points in mental health care, which evidences the need to evaluate this practice (2,4) . varying from six to 12 days depending on the service territory characteristics. They allow the inpatients to stay up to 14 days, with possible time extensions, considering the needs inherent to each case (9) .
Studies that characterized comprehensive care at CAPS AD III in different Brazilian regions identified that the bed occupancy rate varies from 86% to 100% and that, after discharge, from 22.6% to 36.3% of the users return in new crises, emphasizing recurrence and complexity in the management of these cases, especially in contexts of social vulnerability (2,10) .
The Ministry of Health (Ministério da Saúde, MS) considers that "successful admissions at crisis moments are essential to comply with the CAPS objectives, namely: treat severe and persistent mental disorders and avoid hospitalization" (11) . In this sense, the CAPS' ability to handle crises is considered one of the main indicators to guarantee the space of these services in the Psychosocial Care Network (Rede de Atenção Psicossocial, RAPS), especially in this historical political moment marked by setbacks and devaluation of Brazilian psychosocial care (12) .
Indicators are important information tools in mental health; however, it is unusual to find standardized programs in the scientific literature because they are generally associated with specific public systems for different realities, which weakens the evaluation process, especially in low-income countries (13) .
Internationally, the assessments of care services for drug users are based on programs and policies specific to each country (3) . Some common indicators ensure crisis care exclusively in the community environment and no relapses (new crises) (4,14) . Similarly, in Brazil, 24

Research design
The current study has an evaluative and longitudinal design and a quantitative approach. It sought to evaluate the "CAPS AD III's ability to handle crises" as a result indicator and to verify the changes and effects obtained from comprehensive care at the following moments: T 0full admission; and T 1 -after 14 days (time established by ministerial ordinance for permanence in full admission).
Evaluation indicators aim at supporting objective changes in the system, analyzing the presence or absence of the effect after the observation.

The Strengthening the Reporting of Observational
Studies in Epidemiology (STROBE) checklist for observational studies was used as a guide to writing this article (16) .

Setting
This study was conducted in two CAPS AD III from the central region of the municipality of São Paulo -SP, Brazil.
Both services treat similar population groups comprised of people with problematic AOD use and living in extreme social vulnerability. The services have from eight to nine beds for comprehensive care, with an occupancy rate between 80.6% and 100% (data provided by the service). Care is offered by a multi professional team, with 24-hour permanence of the Nursing team.
These services were chosen as the research scenario because they are a reference for a territory of significant complexity regarding social and health needs, which concentrates almost 50% of the street population in São Paulo. In addition to that, it is in this region that one of the largest public scenarios of psychoactive substance use is found, known as "use setting in the Light region" or "crackland" (17) .

Sample
Sample calculation was based on longitudinal studies with the same analysis object (AOD users undergoing treatment) and resorted to measures similar to those of the current study (days of substance use). One of the closest analyses significantly improved the users, with 0.06 points and a standard deviation of 0.165 according to the pre-and post-follow-up difference of means (18) .
Therefore, by considering the same or a larger difference and adopting 95% analysis power, the sample calculation obtained corresponded to 101 participants at the end of the follow-up period.
Considering a 50% probability of sample losses, it was initially foreseen to include 152 subjects; however, the inclusion capability and final initial sample of this study totaled 121 participants. These subjects were included using the convenience approach.

Inclusion, exclusion, and discontinuity criteria
The following were adopted as inclusion criteria: The subjects excluded were those that failed to fully answer the data collection instrument using the "Complete Analysis" perspective (19) . The discontinuity criteria considered in the research corresponded to those individuals that did not answer the interview in the followup period (T 1 ).

Variables and data collection instrument
We used two digital forms for each research moment (T 0 and T 1 ) as data collection instruments, which were accessed via a tablet or cell phone by the data collection team (main researcher, a post-PhD researcher, and female scientific initiation students). The interviews lasted a mean of 30 minutes, and secrecy was ensured for the participants.

Data analysis
The data were analyzed in the R software,  (2,7,10) and the parameters expected by public policies.
We did not find specific studies that used this measure, which was not defined in the validation study (15) .  In times of crisis, they sought care at the CAPS AD III with demands related to a desire to reduce consumption (82.6%; n=100), support for detoxification (71.1%; n=86) and support for living in a situation of extreme social vulnerability, especially on the street (47.1%; n=57).

Fourteen days after comprehensive admission (T1),
there was a significant reduction in the consumption of alcohol, marijuana and crack (<0.001) and an increase in days using tobacco and on withdrawal. As presented in Table 2, consumption was evaluated based on the last 30 days. in comprehensive admission at the CAPS AD III, as well as that they reported that this resource contributed positively to face the crisis moment. In addition to that, 79% (n=53) asserted that their requirements/needs were met.
As for the referrals described in Figure 1, of the 67 users who were admitted in a crisis in the ten months of the research and who finished the follow-up period, nine  The characteristics of the users referred to other health services are presented in Table 3. territory. This result is corroborated by international studies, which evidenced that most of the crisis demands in mental health are solved by community services or specialized teams in the community (4,20) . As an example, a study in Switzerland identified 12.7% of referrals for hospitalization (20) . We did not find studies that evaluated the CAPS AD III's ability to handle crises.
The profile of the participants included in the current study is similar to that of other studies on comprehensive care in CAPS AD III: men, homeless, with low schooling and problematic use of alcohol, tobacco, and crack (2,7,10) .
This profile differs from other contexts since, in many countries from North America, the United Kingdom, and Europe, special attention is given to crisis management actions for opioid users and their consequences (3,21) .
Situations that resulted in referral by the CAPS AD III were largely associated with physical health problems.
This result is expected for this type of care, as these services lack the structural and human resources to deal with emergencies of this nature. In addition to that, among the three referrals associated with deterioration in substance use or mental health problems, only one required psychiatric hospitalization.
Intoxication due to the use of AOD is one of the demands that most justifies clinical or psychiatric referral of users assisted in crisis in the community services, accounted for between 28.4% and 40% of the cases (14,20) .
In addition to that, referrals often occur directly to hospitals without the patients receiving any other type of care (21) .
An analysis that reflects on the professionals' conceptions identified that they sometimes do not recognize their responsibility for managing and welcoming a person in crisis at the CAPS III, believing that the role of this service as a central RAPS device is that only "stable" users be assisted. In contrast, people in times of psychological disorganization should be referred to health services such as general hospitals (22) .
On the other hand, consistent with the current study, in the territory and avoid long-term hospitalizations (2) .
The international scientific production highlights the need for a cultural change about what is meant by a crisis in mental health and how it should be addressed, as this is not just a crisis inherent to the person, but also to the context (4,23) . A number of research studies point out that the physical proximity of the services, the determinants of regular access to community care, and the preparation of the teams in this approach are essential to achieve positive results in crisis management in the community (21)(22) . This conceptual opposition weakens the dissemination and expansion of deinstitutionalization, which further reinforces the importance of evaluating the model of territorial care with a psychosocial approach (22) . A study that sought to identify actions of attention to the crisis and the meanings that involve them stated that, for structuring intervention policies during crises in mental health, three axes must be considered: territory, care and accountability (24) . In the context of CAPS AD, we include Harm Reduction (HR) as a fourth axis. This approach takes place in the territory through co-responsibility between professional and user, respects the rights and encourages the autonomy of the person who is in care, even if in times of crisis, not reducing the complexity of the situations that permeate the crisis to the withdrawal need and/or requirement (25) .
In the CAPS, there is space for immediate care for serious situations, although mainly for the needs that develop over the 14 days in comprehensive admission, as the crisis is not one-off since it also manifests itself in the detoxification process, generating intense and lasting anxiety, associated with abstinence or craving for substance use, as well as in discharge planning when the user's return to the life context is conditioned by vulnerabilities, which deserves special attention from health teams (22,24) .
Users admitted at the CAPS AD III are exposed to stressful and conflicting factors. In their daily lives, they experience situations of humiliation, exclusion, precariousness, unmet basic needs, the impossibility of exercising citizenship, housing problems and fragile and/or non-existent family and social ties, in addition to countless risk situations that can trigger a mental health crisis, even when there is a need for protection, a possible alternative with comprehensive admission (10) .
Considering this complexity, a strategy adopted in Trieste (Italy) is to develop a program that seeks to monitor users who present signs or have already experienced crisis situations and were admitted by community services. The team discusses and updates a document daily, according to the perception of crisis risk.

Detailed information is evaluated (different manifestations,
substance use, major events, etc.) along with possible preventive or care continuity interventions. The main objective of this program is to offer daily and singular care, closer and more flexible, so that users are fully assisted in their territory and, if they happen to present crises, these are overcome with less distress intensity (4) .
Comprehensive admission is a fundamental tool to allow users to experience and go through the crisis moment with safety and freedom, without further harm.
The gateway for this care is considered a strategic path in the network to accommodate the demand since, with 24-hour assistance, users can benefit from all the resources offered by the services (1) . In addition to that, the presence of Nursing teams, including weekends, and the support of peers in the community services, can contribute to the good result of management in crises, with a significant improvement in the biopsychosocial aspects (8) .
The break to take care of the crisis can be considered a clinical act. A strategy that opens up conditions for the exchange, speaking and listening to the subjects, and consequent resumption of possibilities. It represents an opportunity for users to take care of the distress caused by problematic AOD use and social exclusion (1) . In this sense, dialogue and establishing a relationship of trust offered in this device can ease approaches to users in crisis, allowing professionals and the person in care to access in more depth the relationship between consumption and care planning, in addition to medication support (4) .
From this perspective, many studies point to some benchmarking parameters for attention to crises, of which we highlight the following: be allowed in each situation (1,4) .
The current study contributes to scientific progress by