ArticleLiterature Review

Day hospital versus out-patient care for psychiatric disorders

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Abstract

Psychiatric day hospitals offer care that is less restrictive than in-patient care but more intense than out-patient care. Day hospitals can be used to provide more intense/specialised care to treatment-resistant out-patients (day treatment programmes) or to long-term patients (day care centres). They can also bridge the gap between in-patient and out-patient care (transitional day hospitals). This review compared day hospital care (in day treatment programmes, day care centres and transitional day hospitals) to out-patient care. Overall there was insufficient evidence to determine whether any of the three types of day hospital care had substantial advantages over out-patient care.

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... In addition, the majority of activities would be carried out in a newly-established department of a day hospital, which would be kept spatially separated from the surgical department. The usefulness of such a regime has been noted in almost all research in the field of day care (28)(29)(30)(31)(32)(33). In the renovated process laboratory and anesthesia departments would be excluded, compared to the existing process. ...
... In the renovated process the patient would have the obligation to undergo all laboratory and anesthetic tests at the primary level of health care beforehand. The same is also proposed by other authors (28,29). On the day of the scheduled surgery, the patient would thus come and bring along all the necessary results and a valid referral from a general practitioner. ...
... Consequently, medical staff could also spend less time monitoring the patients. The same conclusions have been made in several other studies (28)(29)(30)(31)(32)(33). This way, patients would not be required to needlessly wait for the morning rounds and their discharge. ...
Article
Introduction: This article relates to the field of studying the impact of business process reengineering on technical efficiency. The reengineering method demonstrates its impact on selected business process, which is knee arthroscopy surgery. The impact of business process reengineering is studied on the example of a typical Slovenian general hospital. Methods: In the first step, we demonstrate the selected business process in the existing situation, while the second step demonstrates a business process, which could be reached in a potential situation. The demonstrated process is a basis for measuring the impact of business process reengineering on technical efficiency of a hospital. Results: The results obtained show that the business process reengineering increases the technical efficiency of the selected general hospital. The volume of labour input in the existing situation was higher by 67,88 %, and the value fixed assets after business process reengineering decreased by 36,25 %, and the value of material costs before business process reengineering increased by 50,9 %. Conclusion: The total volume of labour input in the potential situation thus decreased by 67,88 %, and the total volume of capital input decreased by 36,26 %. This means that business process reengineering does affect the hospital’s technical efficiency, since the latter would increase significantly if all the conditions of reengineering were met.
... A total of 21 reviews were included. 4,5,[18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36] The most relevant reasons to exclude papers were that they did not: focus on severe mental illness, study an organizational change, or have a method section describing their review methods. Of the included reviews, 17 reviews scored 4 to 6 points regarding methodological quality. ...
... 19 One review focused on day care centres, psychiatric day hospitals offering continuing care to patients with severe mental disorders. 29 Day centres were not superior to outpatient care in terms of engagement with care, admission rates, clinical outcomes, patient satisfaction, or costs. A second review unsuccessfully looked for RCTs of nonmedical day centres, offering long-term support for the chronically ill, as an alternative to outpatient departments and day hospitals run by health professionals. ...
Article
To provide a comprehensive overview of the research on organizational changes aimed at improving health care for patients with severe mental illness and to learn lessons for mental health practice from the results. We searched for systematic literature reviews published in English during 2000 to 2007 in PubMed, PsycINFO, CINAHL, EMBASE, and the Cochrane Central Register of Systematic Reviews. Three reviewers independently selected and assessed the studies' quality. Studies involving changes of who delivers health care, how care is organized, or where care is delivered were included. We categorized the studies using an existing taxonomy of 6 broad categories of strategies for organizational change. A total of 21 reviews were included. Among these, 17 had reasonably good methodological quality, Almost all reviews included or intended to include randomized controlled trials (RCTs), 6 reviews did not identify studies that met eligibility criteria. Multidisciplinary teams and integrated care models had been reviewed most frequently (a total of 15 reviews). In most studies, these types of changes showed better outcomes in terms of symptom severity, functioning, employment, and housing, compared with conventional services. Different results were found on cost savings. Other types of organizational changes, such as changing professional roles or introducing quality management or knowledge management, were much less frequently reviewed. Very few reviews looked at effects of organizational changes on professional performance. There is a fairly large body of evidence of the positive impact of multidisciplinary teams and integrated care changes on symptom severity, functioning, employment, and housing of people with severe mental illness, compared with conventional services. Other strategies, such as changes in professional roles, quality or knowledge management, have either not been the subject of systematic reviews or have not been evaluated in RCTs. There is still a lack of insight in the so-called black box of change processes and the impact of change on professional performance.
... Research comparing different mental health settings has to be interpreted also in its respective national context, as the effectiveness of a treatment model in one mental health system may not be replicated in another. This was the case for assertive community treatment (ACT) in the UK [15,16] when compared to the USA and Australia [17,18]. As reviewed by Brenner et al. [19] all settings have their particular advantages and disadvantages, strengths and weaknesses. ...
... After discharge from the index stay, patients were followed up for 1 year. Participants had to fulfill the following criteria: any psychiatric diagnosis according ICD-10 except mental and behavioral disorders due to psychoactive substance use (ICD-10 F10-16, [18][19] and organic, including symptomatic, mental disorders (ICD-10 F0), age between 18 and 65 years. Exclusion criteria were pregnancy and incapacity to consent, e.g., due to an acute and severe psychopathological state. ...
Article
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The present study evaluated a new integrated treatment concept offering inpatient care, acute psychiatric day hospital and outpatient treatment by the same therapeutic team. 178 patients participated in this randomized controlled trial. Data on psychopathology, global and social functioning, patient satisfaction, continuity of care and administrative data was gathered on admission, throughout the course of treatment, upon discharge and at 1-year follow-up. In addition, the physicians in charge rated the therapeutic relationship. The data analysis consists of group-wise comparisons and regression analyses (cross-tabulations and χ(2) test statistics for categorical data and Mann-Whitney U tests for continuous data). Differences between groups over time were analyzed with a series of generalized linear mixed model. The integrated care group showed a significant reduction in psychopathological impairment (20.7 %) and an improvement of psychosocial functioning (36.8 %). The mean number of days before re-admission was higher in the control group when compared to the integrated care group (156.8 vs. 91.5). There was no difference in the number of re-admissions and days spent in psychiatric institutions. This new approach offers a treatment model, which facilitates continuity of care. Beside it improves psychopathological outcome measures and psychosocial functioning in patients with mental illness.
... The review was not concerned with the other modes of 'partial hospitalisation' listed above, i.e. day treatment programmes and day centres, which have been reviewed elsewhere (Marshall 2001). The use of partial hospitalisation as a form of transitional care is also reviewed elsewhere on the Cochrane Library (Johnstone 2001). ...
... 2. The original protocol proposed to look at a number of different ways of using day hospitals, in addition to using them as an alternative to admission. This was too large a project to be contained in a single review, so alternative uses of day hospitals are covered in a separate review (Marshall 2001). ...
Article
Background: Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals. Objectives: To assess the effects of day hospital versus inpatient care for people with acute psychiatric disorders. Search methods: We searched the Cochrane Schizophrenia Group Trials Register (June 2010) which is based on regular searches of MEDLINE, EMBASE, CINAHL and PsycINFO. We approached trialists to identify unpublished studies. Selection criteria: Randomised controlled trials of day hospital versus inpatient care, for people with acute psychiatric disorders. Studies were ineligible if a majority of participants were under 18 or over 65, or had a primary diagnosis of substance abuse or organic brain disorder. Data collection and analysis: Two review authors independently extracted and cross-checked data. We calculated risk ratios (RR) and 95% confidence intervals (CI) for dichotomous data. We calculated weighted or standardised means for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise data. We therefore sought individual patient data so that we could re-analyse outcomes in a common format. Main results: Ten trials (involving 2685 people) met the inclusion criteria. We obtained individual patient data for four trials (involving 646 people). We found no difference in the number lost to follow-up by one year between day hospital care and inpatient care (5 RCTs, n = 1694, RR 0.94 CI 0.82 to 1.08). There is moderate evidence that the duration of index admission is longer for patients in day hospital care than inpatient care (4 RCTs, n = 1582, WMD 27.47 CI 3.96 to 50.98). There is very low evidence that the duration of day patient care (adjusted days/month) is longer for patients in day hospital care than inpatient care (3 RCTs, n = 265, WMD 2.34 days/month CI 1.97 to 2.70). There is no difference between day hospital care and inpatient care for the being readmitted to in/day patient care after discharge (5 RCTs, n = 667, RR 0.91 CI 0.72 to 1.15). It is likely that there is no difference between day hospital care and inpatient care for being unemployed at the end of the study (1 RCT, n = 179, RR 0.88 CI 0.66 to 1.19), for quality of life (1 RCT, n = 1117, MD 0.01 CI -0.13 to 0.15) or for treatment satisfaction (1 RCT, n = 1117, MD 0.06 CI -0.18 to 0.30). Authors' conclusions: Caring for people in acute day hospitals is as effective as inpatient care in treating acutely ill psychiatric patients. However, further data are still needed on the cost effectiveness of day hospitals.
... Supported housing has been developed as a reaction to the deinstitutionalization of patients with chronic psy- chiatric disorders and helps them to live indepen- dently in the community [18,21]. Day and night hospitals are alternatives to inpatient and outpatient treatment [36,41]. ...
Article
Guidelines for the treatment of schizophrenia recommend the combination of pharmacologic and psychosocial interventions. There is a lack of data on the utilization and effects of psychosocial interventions additional to neuroleptic treatment in routine care of schizophrenic patients. In a drug utilization study 495 psychiatrists documented patient and disease characteristics of 1,711 schizophrenic outpatients treated with olanzapine. Data were recorded at five visits during an observation period of 6 months. Psychosocial interventions were reported in 30% of all patients. Compared to patients who were treated with olanzapine alone (nPSI), patients receiving psychosocial interventions (PSI) were more likely to be unmarried and unemployed, and showed significantly higher impairment on relevant psychopathological and psychosocial parameters (e.g. PANSS, GAF, LQLP). After 6 months of treatment with olanzapine patients improved significantly in respect to their schizophrenic symptoms, psychosocial functioning, and quality of life. Patients receiving psychoeducation showed a higher degree of improvement than the other patients. They were more ill at the beginning of the study, but less ill at the end of the study. Patients receiving psychoeducation showed a trend to better medication compliance. The data suggest that psychosocial interventions are a frequently used mode of treatment especially for severe cases of schizophrenia Psychoeducation appears to be especially effective for this patient group with a positive impact not only on psychosocial but also on psychopathological criteria of outcome.
... Therefore, ACT invariably reduces the cost of hospital care, but does not have a clear financial advantage over standard care when other costs are taken into account. According to a review of Marshall et al. [14] , there is no evidence that day-treatment programmes are superior to continuing outpatient care in terms of improving psychiatric symptoms, social outcome, or costs. A French prospective and comparative cohort study over a five-year period demonstrated a significant immediate decrease in both number of admissions and duration of hospital stay after the provision of a mobile crisis intervention team [15] . ...
Article
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Objective: We intended to find out whether an intensification of outpatient care could have an influence on hospitalisations, readmissions, length of stay, coercive measures and involuntary admissions. Method: We investigated the development of some care variables within a district psychiatric hospital responsible for a rural catchment area of 320,000 inhabitants. Associations between inpatient care variables and outpatient activity were assessed by means of multivariate Prais-Winsten regression models for time series. Results: There was a dramatic reduction of mean LOS figures, associated with the activity level of the outpatient clinic. After the conclusion of the deinstitutionalisation process, total number of admissions, cumulative LOS, quotas of involuntary admissions and number of coercive measures did not increase when the number of beds and mean length of stay decreased. Readmissions decreased significantly when outpatient activity increased. Conclusions: Community-oriented ambulatory care on the basis of multi-disciplinary outreach teams seems to be able to reduce high-frequent readmissions and control mean LOS while at the same time a number of coercive measures keep the number of admissions stable. Economic and clinical effects on real inpatient care, however, cannot be definitively evaluated as long as bed provision does not decrease proportionally with the increase of ambulatory activity.
... Social support has been defined in terms of types of support, sources of support, and support function (Brugha, 1995). Family, friends, and statutory as well as voluntary organizations have been identified in a range of studies to provide support to people with mental health problems, and reviews of different bsourcesQ and types of support, such as vocational opportunities, day hospital services, and family interventions, have also been undertaken (Crowther, Marshall, Bond, & Huxley, 2001;Marshall, Crowther, Almaraz-Serrano, & Tyrer, 2001;Pharoah, Rathbone, Mari, & Striener, 2003). Indeed, there is also increasing evidence that family caregivers of people with serious mental heath problems also benefit from improved social support, where the nature of support to families, including the person with the mental health problem, comes from such additional sources as relatives, the clergy, the police, neighbors, and other people recovering from mental health problems (Drake, Wallach, & McGovern, 2005;Pejlert, 2001;Philo, Parr, & Burns, 2002Rammohan, Rao, & Subbakrishna, 2002;Sharkey, 2005;Lee et al., 2006). ...
Article
The Transitional Discharge Model (TDM) has been used to facilitate effective discharge from psychiatric hospital to community. A summary of the research to date on TDM is given. The model is based on the provision of therapeutic relationships to provide a safety net throughout the discharge and community reintegration processes. These relationships include both staff and peer involvement; hospital inpatient staff continue to remain involved with the client until a therapeutic relationship is established with a community care provider, and peer support is offered from a former consumer of mental health services who is currently living in the community. Studies found that the TDM facilitates increased discharge rates, lower readmission rates, and cost savings--making it a collaborative, cost-effective method of providing quality patient care and positive health care outcomes. The TDM Plan of Research is presented and reflects the collaboration between stakeholders and the integration of consumer advocacy, clinical practice, education, policy, and research in various countries.
... Marshall et al. (2002) found that caring for people in acute psychiatric DHs substantially reduced the numbers of people needing inpatient care. However, in the second Cochrane Review there was limited evidence justifying day treatment programmes and post discharge monitoring in acute psychiatric DHs compared to out-patient care (Marshall et al., 2001), and no evidence to support the provision of daycare centres . Similarly, no evidence was found in the Cochrane Review regarding the effectiveness of DCs for people with severe mental illness and Catty et al. (2001) identified the need for randomised controlled trials comparing DH and DC care. ...
Article
Day hospital (DH) care remains a core component of mental health services for older people. However, there has been an ongoing debate about the effectiveness and value for money of DHs in comparison to day centres (DC). The aim was to review the recent research on the effectiveness of day hospitals for older people with mental health problems. A systematic search of relevant research literature over the last decade using the major electronic healthcare databases examining the quality and effectiveness of mental health DHs for older people. In the last decade the evidence for the effectiveness of DHs has continued to increase, but still lags behind research on DHs in general adult psychiatry and geriatric medicine. The review found that DHs appear effective at assessing and meeting needs and that a systematic approach to evaluating quality can be used to improve services. Recent research supports the effectiveness of day hospitals, but further studies are needed in order to provide a more robust evidence base.
... The following study aims to identify prognostic and prescriptive predictors of inpatient and day hospital treatment in patients with MDD. Although several studies point to a comparable effectiveness of both treatment modalities (Dinger et al., 2014;Horvitz-Lennon et al., 2001;Marshall et al., 2001;Zeeck et al., 2015), only few studies focused on prognostic predictors and no study so far addressed the question of prescriptive predictors. In terms of prognostic predictors in inpatient treatment, the absence of ICD-10 F4 co-morbidity (76% had a diagnosis of phobic or anxiety disorders), an episode duration of o24 months, suicidal ideation and fewer previous hospitalizations predicted a better outcome in a naturalistic multi-center study conducted in twelve psychiatric hospitals (Riedel et al., 2011). ...
Article
Background: The study aimed to identify prognostic (associated with general outcome) and prescriptive (associated with differential outcome in two different settings) predictors of improvement in a naturalistic multi-center study on inpatient and day hospital treatment in major depressive disorder (MDD). Methods: 250 inpatients and 250day hospital patients of eight psychosomatic hospitals were assessed at admission, discharge and a 3-months follow-up. Primary outcome was defined as a reduction of depressive symptomatology from admission to discharge and from discharge to follow-up (QIDS-C, total score). Percent improvement scores at discharge and at follow-up were entered as dependent variables into two General Linear Models with a set of predictor variables and the respective interaction terms with treatment setting. The selection of predictor sets was guided by statistical methods of variable preselection (LASSO). Results: Three variables were associated with less improvement from admission to discharge: the number of additional axis-I diagnoses, axis-II co-morbidity (SCID) and lower motivation (expert assessment). Social support (F-SozU) predicted symptom course between discharge and 3-month follow-up. Patients with no absent / sick days prior to admission showed a less favorable symptom course after discharge when treated as inpatients. Conclusions: Patients with co-morbidity show less improvement during the active treatment phase. Motivation can be considered a prerequisite for symptom reduction, whereas social support seems to be an important factor for the maintenance of treatment gains. The lack in prescriptive predictors found may point to the fact that inpatient and day hospital treatment have comparable effects for most subgroups of patients with MDD.
... Ve srovnání s ambulantní léčbou byl v některých studiích prokazován lepší efekt u denních stacionářů ve zlepšení psychické symptomatiky a větší zainteresovanosti pacientů o léčbu, v ostatních ukazatelích klinického stavu, sociálních funkcí a nákladech nebyly shledány signifikantní rozdíly (34,35). ...
... The superiority of day clinic treatment compared to care as usual on symptom severity found in our study has been reported previously (Oka et al., 1999;Cichocki, 2008). However a Cochrane review comparing day clinic care versus outpatient care for people with a diagnosis of a schizophrenia spectrum disorder suggested that there is insufficient evidence of the superiority of day clinic over outpatient care (Marshall et al., 2001;Shek et al., 2009). ...
... There are three main types of day hospital: 'day treatment programmes', 'day care centres' and 'transitional' day hospitals. (4,6,14,22). ...
Chapter
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The health of the people is a national priority. Health Care System (HCS) infrastructure includes services, facilities, institutions/establishments and organizations. They provide individuals, families and communities with promotive, protective, preventive, diagnostic, curative and rehabilitative measures and services. There are different HCSs all over the world, which are strongly influenced by nation's history, traditions, socio-cultural, economic, political and other factors. But, regardless of all present differences, there are common characteristics, typical for all HCS. In this module three levels of healthcare (primary, secondary, tertiary) are described, as well as their historical development. Concerning sources of funding, there are three main models of National HCS: the Beveridge model, the Bismarck model and the Private Insurance model. HCS are continuously evolving. The quality of HCS is expressed through coverage, access, equity, but also efficiency in use of resources, and financing. HCS facing new challenges, among them are aging of the population, new medical technology, innovations, increasing costs, lack of community involvement and inter-sectoral actions. Downloads of the full chapter are free of charge at: http://www.seejph.com/category/books/
... The psychiatric day hospital is designed to serve children whose psychiatric symptoms have failed to respond to outpatient treatment (''step up''), or children discharged from inpatient care, serving as a bridge between inpatient and outpatient care (''step down'') [27,28]. In the wake of the implementation of health care metrics that aim to prevent hospitalizations, and the renewed emphasis on capitated health care systems, day hospitals will potentially be used more widely across psychiatric systems of care, thus it is critical to examine practice patterns in these intermediate care settings. ...
Article
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The use of seclusion and restraints (SR) in acute hospital settings remains a controversial practice. Despite the focus on SR in the psychiatric services literature, data on SR use in pediatric day hospital settings is lacking. A case-control retrospective analysis for children admitted into a pediatric psychiatry day hospital in a 2-year span examined predictors of SR use. Demographic and clinical descriptors were examined in relation to SR events using univariate and multivariate regression models. Significant univariate risk factors for SR use were psychiatric morbidity, history of physical abuse, post-traumatic stress disorder, having any anxiety disorder, and younger age. Knowledge of risk factors for SR use in pediatric psychiatric day hospitals can avert use of SR and lead to improved safety in a trauma-informed care model.
Article
This study examines sudden gains (SGs), or rapid improvements in symptoms, among adults in treatment for depression in a partial hospitalization program (PHP). This study identifies the proportion of people who experience SGs in a PHP, when SGs occur in treatment, and the association of SGs with outcomes at the end of treatment. The sample included 664 adults consecutively admitted to a PHP program for treatment of depression. Patients were administered the 24-item Behavior and Symptom Identification Scale and the short form of the Quality of Life Enjoyment and Satisfaction Questionnaire. We conducted t tests, multiple regressions, and generalized estimating equations (GEE). Over 40% of the sample experienced SGs, and most of those who experienced SGs did so by the 2nd week of treatment. SGs were associated with significantly greater improvement in depression and quality of life scores at the end of treatment. Results of the GEE indicate that although depression scores significantly decreased for the entire sample, the SG group improved to a greater degree than the group without SGs. The proportion of SGs among people in a PHP is similar to proportions found in traditional outpatient psychotherapy, suggesting that a subset of people receiving psychotherapy may be predisposed to SGs. The timing of SGs in a PHP suggests that SGs are associated with the dose of treatment received. Future research should focus on identifying people predisposed to SGs, as well as the mechanisms by which SGs occur.
Article
Day hospitals are a less restrictive alternative to inpatient admission for people who are acutely and severely mentally ill. This review compares acute day hospital care to inpatient care. It was found that at least one in five patients currently admitted to inpatient care could feasibly be cared for in an acute day hospital. The psychiatric symptoms of inpatients deemed suitable for acute day care appeared to improve more quickly than if the person had been cared for as an inpatient. Day hospital care was also less expensive than inpatient care.
Article
Background: This review considers the use of day hospitals as an alternative to outpatient care. Two types of day hospital are covered by the review: 'day treatment programmes' and 'transitional' day hospitals. Day treatment programmes offer more intense treatment for people who have failed to respond to outpatient care. Transitional day hospitals offer time-limited care to people who have just been discharged from inpatient care. Objectives: To assess effects of day hospital care as an alternative to continuing outpatient care for people with schizophrenia and and other similar severe mental illness. Search strategy: We searched the Cochrane Schizophrenia Group Trials Register (May 2009) and references of all identified studies for further citations. If necessary, we also contacted authors of trials for further information. Selection criteria: Randomised controlled trials comparing day hospital care with outpatient care for those with schizophrenia and other similar severe mental illness. Data collection and analysis: We extracted and cross-checked data independently. We analysed dichotomous data using fixed-effect relative risk (RR) and estimated the 95% confidence interval (CI). If continuous data were included, we analysed this data using the random-effects weighted mean difference (MD) with a 95% confidence interval. Main results: We identified four relevant trials all dating from before 1986 (total n=309 participants); all but one of which (n=37) evaluated day treatment centres. Across time less people allocated to day hospital care tend to be admitted to hospital (beyond one year: n=242, 2 RCTs, RR 0.71 CI 0.56 to 0.89 day treatment centres) but data are heterogeneous (I(2) =74% P=0.05) and should not be taken into account. Data on time spent as an inpatient seem to support this finding but are poorly reported. We found no clear difference between day hospital and outpatient care for the outcome of 'lost to follow up' (at six months: n=147, 3 RCTs, RR 0.97 CI 0.48 to 1.95; at 12 months: n=117, 2 RCTs, RR 0.97 CI 0.48 to 1.95 day treatment centres / transitional day hospital). Scale derived findings on social functioning are equivocal (SAS: n=37, 1 RCT, MD 0.36 CI -0.07 to 0.79 transitional day hospital) but there was some suggestion from small studies that day hospital care may decrease the risk of unemployment (at 12 months: n=80, 1 RCT, RR 0.86 CI 0.69 to 1.06 day treatment centre). Different measures of mental state showed no convincing effect (Symptom Check List: n=30, 1 RCT, MD -90 0.31 CI -0.20 to 0.82 day treatment centre). Poorly reported economic data from decades ago suggested that day hospitals were more costly to establish and run than outpatient care but took no account of other costs such as inpatient stay. Authors' conclusions: Evidence is limited and dated. Day hospital care may help avoid inpatient care but data are lacking on missing on a raft of outcomes that are now considered important, such as quality of life, satisfaction, healthy days, and cost.
Article
This article describes the results of an eight-month follow-up investigation from a randomized controlled trial of day hospital psychotherapy (DHP) compared with outpatient individual psychotherapy (OIP) for patients with personality disorders (N=114). The patients were randomly assigned to either 18 weeks of day hospital treatment followed by long-term conjoint group and individual therapy (DHP), or outpatient individual psychotherapy (OIP). The main outcome measures were attrition rate, suicide attempts, suicidal thoughts, self-injury, psychosocial functioning, symptom distress, and interpersonal and personality problems. The study showed a low dropout rate and a moderate improvement on a broad range of clinical measures for both treatments. However, there was no indication of the superiority of one treatment over the other. Neither was there any indication that day hospital treatment was better for the most poorly functioning patients. Further studies will follow this group of patients for the next few years, the results of which may have implications for resource allocation and the organization of mental health services for patients with personality disorders.
Article
Non-compliance in neuroleptic maintenance treatment is a major concern in schizophrenia. Home-based outpatient care has been shown both to improve medication compliance and reduce relapse frequency. We analysed the need for hospitalisation, levels of functioning and mortality rate during the de-institutionalisation process in 41 schizophrenia patients with repeated hospitalisations and prolonged history of non-compliance. Eighteen of the patients received ambulatory outpatient care (AOC) after discharge. This treatment procedure focuses on enduring neuroleptic maintenance treatment. One of the hospital nurses takes care of home visits every 2-4 weeks. In the 4-year follow-up, half of the patients in the AOC group did not need hospitalisation at all and the number of days of hospitalisation in the whole group diminished by almost four-fifths compared with the previous 4 years. In the non-AOC group, there was a more limited decrease in the number of days of hospitalisation during the corresponding follow-up period. The mortality rates showed a slight tendency towards a better outcome in the AOC group. There was no change in the levels of functioning in the AOC group. This treatment can be carried out with limited resources. It clearly reduces the need for hospitalisation in a subgroup of schizophrenia patients having problems with compliance and recurrent relapse. The effectiveness of AOC on the mortality rates of schizophrenia patients needs further examination.
Article
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Intensive outpatient mental health programs are proliferating rapidly. However, findings suggest that intensive treatment may be no more effective than standard treatment. This study compared standard to intensive outpatient programs, within both the psychiatric and substance abuse systems of care, on organization, staffing, and treatment orientation; clinical management practices; and services. A total of 723 (95% of those eligible) Department of Veterans Affairs programs were surveyed nationwide. Psychiatric intensive programs have responded appropriately to their more severely ill patients in terms of the amount and orientation of care, and having a rehabilitation focus. However, the relative lack of basic psychiatric services in psychiatric intensive programs, and the overall similarity of substance abuse standard and intensive programs, may explain why intensive programs have not yielded patient outcomes that are superior to those of standard programs. Mental health system planners should consider differentiating intensive programs using broader criteria and methods.
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Community mental health care has shifted focus from resettlement to empowerment, reflecting a wider agenda for social inclusion. This study evaluated mental health day services from the perspectives of thirty-nine clients. Data analysis of the four focus groups explored the implications for occupational therapy. The data collected were subjected to constant comparative analysis and theoretical sampling. Participants described how mental health day services structured their day and enabled access to support networks. However, many perceived aspects of the services as fostering their dependence and threatening sessions they valued. This dependency led to them feeling alienated and wishing to seek greater influence over decisions about their current and future life. The concept of occupational alienation was used to further interpret their situation. Occupational therapy could overcome occupational alienation experienced by mental health day service clients, through the development of services within and beyond day services which promote a sense of belonging and offers meaningful occupation.
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In this paper, Patriek Mistiaen, Else Poot, Sophie Hickox, and Cordula Wagner describe how they conducted a search of the Cochrane Database of Systematic Reviews in order to explore the evidence for nursing interventions. They identify the number of studies, the number of participants, and the conclusions of systematic reviews concerning nursing interventions. They conclude that the Cochrane Database of Systematic Reviews is a valuable source of evidence about nursing interventions, and can be used as a means of developing a research agenda in the case of inconclusive reviews.
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The objective was to explore the relationship between staff related variables and patient outcome in day treatment programmes for patients with personality disorders. The importance of staff size, skill mix and treatment intensity (hours of treatment per week) was examined, in addition to location-specific effects. Multi-centre data routinely collected under non-experimental conditions from nine units, all members of a cooperative network in Norway, were analysed using a multilevel analysis. The data set consisted of treatment unit characteristics for the period 1993-2005, constituting an unbalanced panel of 71 units, together with information from 1574 patients who completed day treatment according to the plan. Patient outcome was measured by change in Global Assessment of Functioning Scale (GAF). Twelve per cent of variation in patient outcome was attributed to the treatment unit level. Staff size and treatment intensity influenced outcome to a minor extent, while an increased proportion of nurses or other college-educated personnel was associated with improved patient outcome. A positive location-specific effect was found in one unit attached to a university. Potential cost savings seem to be apparent with respect to staff size and, to some extent, skill mix.
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This study compared clinical and functional changes, satisfaction with services and costs associated to service use, in participants treated in a day hospital for adults and seniors organized by diagnostic groups, with clients hospitalised. A quasi-experimental design was used. The experimental group was composed of clients (N = 40) treated in a day hospital. The comparison group included clinically and demographically similar clients hospitalised in the same institution (N = 13). Outcomes were symptoms, social participation, self-esteem, service satisfaction, utilization and associated costs. During the index intervention, the level of improvement was significantly greater in the day hospital group regarding symptoms (P = 0.047), self-esteem (P = 0.01) and social participation (accomplishment: P = 0.02; satisfaction: P = 0.008). Following discharge, there was no significant difference in the level of change between the two groups on all variables. Day hospital participants were significantly more satisfied of several dimensions of services (P ≤ 0.01). Comparison of total mean costs of services used 6 months before and after index treatment showed a cost reduction of 38% in the day hospital group and 7% in the hospitalisation group. Day hospitals organized by diagnostic groups lead to positive clinical and economical outcomes over time.
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Introduction The COVID-19 pandemic has forced changes in patient care in Mental Health Day Hospitals (MHDHs). Objectives To study the interventions performed in MHDHs during the pandemic in comparison with those performed in other facilities and to analyze the new hospital admissions en ambos grupos. Method A retrospective multicenter cohort study comparing las intervenciones recibidas por a group of 161 patients ingresados in MHDHs during the lockdown period in Spain with las intervenciones de another group of 109 patients who were treated at other facilities during lockdown. Results MHDHs reduced their face-to-face interventions during lockdown just as much as other facilities but implemented telematic intervention methods to a greater extent. Patients attached to MHDHs during lockdown were admitted significantly less and presented fewer urgent consultations in the following 6 months. Conclusion The use of telepsychiatry made it feasible to adapt MHDHs to periods of lockdown, being useful to improve the continuity of care during the pandemic. Además, se consiguió mantener a reduction in hospital admissions en los pacientes tratados en MHDHs.
Article
Day hospitals provide an organizational framework for complex psychiatric and psychotherapeutic treatments. They have been developed regarding treatment and in number, perhaps surprisingly, to fit existing standards in almost all domains of psychiatry. Similarities exist in the emphasis on acute treatment, in the orientation towards social inclusion, and particularly in the ability to connect with previous treatment settings. Day treatment guidelines exist only in basic form. In general the complex outpatient treatment is led by psychiatrists; the treatment is planned and pre-defined regarding time and goal orientation. It is directed exclusively at patients with severe mental health disorders and practiced by a multi-professional team. A structured treatment milieu is likely to be the main ingredient which includes all somatic-biological and many psychotherapeutic methods. Special options that for the most part have been empirically validated are available for the treatment of post-acute patients, prevention of social exclusion from families and work, detoxification of addicts and psychotherapy of personality disorders. The rapid increase of facilities is expected to persist for some time. Scientific evidence is relatively strong. Given proper indication, financial resources are used with a high degree of efficiency.
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The 'Sunshine Soul Park' is a network of social welfare institutions that provides communitybased rehabilitation services for individuals with mental illness. Assess the effectiveness of the rehabilitation services provided at the 'Sunshine Soul Park' on the psychotic symptoms and social functioning of individuals with schizophrenia and, based on these findings, provide a theoretical model of community-based rehabilitation. Sixty individuals with schizophrenia in the Huangpu District of Shanghai volunteered for the rehabilitation training program provided at six 'Sunshine Soul Park' community centers that involves day treatment, medication monitoring, biweekly rehabilitation training, and other recreational, social, and intellectual activities. A matched control group was recruited from individuals with schizophrenia registered on the Huangpu District registry of the 'Severe Mental Illness Prevention and Rehabilitation System'. All participants continued their medication without change for the full year of follow-up. Both groups were assessed at baseline, and 3, 6, and 12 months after enrollment using the Insight and Treatment Attitude Questionnaire (ITAQ), Social Disability Screening Schedule (SDSS), Generic Quality of Life Inventory-74 (GQOLI-74), and Positive and Negative Syndrome Scale (PANSS). In the intervention group the ITAQ, SDSS, GQOLI-74, and PANSS scores showed statistically significant improvement compared to baseline at each follow-up assessment. Moreover, the trend in improvement in the interventions group is significantly faster than that in the control group. The 'Sunshine Soul Park' rehabilitation training program enhances patients' knowledge about their disorder and improves their social functioning and quality of life. Further studies to assess methods for up-scaling this intervention to other areas of China are warranted.
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Estándares y recomendaciones del Hospital de día.
Chapter
This chapter presents the complexity of definitions for and operations of a day hospital and a daycare centre, their historical development within social psychiatry and the main features of a well-designed framework for running and operating such structures. Those features include a multidisciplinary team and the use of mental institution, case management, psychotherapy interventions, psychosocial rehabilitation and recovery programmes as well as the essential networking of services offered. A detailed presentation of the Franco Basaglia Daycare Centre run by the Rural Development and Mental Health Association in the Northern Suburbs of Athens highlights the need for a change in the biomedical paradigm, as well as the clinical, institutional and theoretical prerequisites for avoiding the phenomena of chronicity and neo-institutionalisation in the community.
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Day clinics have been developing since the 1960s in the world. Their constitution has been influenced by deinstitualization and community care in psychiatry and by therapeutic communities and large groups in psychotherapy. The main functions of day clinics are: an alternative or enlargement of outpatient care; an alternative or continuation of hospitalization; long-term rehabilitation and resocialization of chronic mentally ill people. The basis of a day clinic with psycho. therapeutic care is a psychotherapeutic program led by university educated health professionals with psychotherapeutic specialization. Results of evaluative studies in effectivity show that the treatment results are comparative with in-patient care, day clinics have lower direct costs, but they are feasible only for 23-37% of psychiatric clientele. The first day clinics in the Czech Republic have been founded in the 1960s, but they have been more developed in the 1990s. Up to date there have been 35 facilities counted in the Czech Republic.
Article
Background: Hospital readmissions caused by relapse in patients with schizophrenia are associated with prognosis. Identifying individuals at high risk of readmission and providing interventions to lower the readmission rate are important. Methods: Patients with schizophrenia who were hospitalized for the first time were recruited from the National Health Insurance Research Database from 2001 to 2010 (n=808, mean age 28.9years) and compared with matched controls. Data on the demographics, cost, and utilization of medical resources of patients who were readmitted were compared with non-readmitted patients. The readmission time curve was analyzed by the Kaplan-Meier method. Result: 570 (70.5%) patients were readmitted within 10years; the median time between admissions was 1.9years, and 25% of subjects were readmitted within 4months of the first hospitalization. There were no significant differences in age, gender, or length of hospitalization between the readmission and non-readmission groups. Taking into account all psychiatric medical services, the readmission group had a significantly higher mean frequency of care and a greater medical cost than the non-readmission group and matched controls. However, there were no significant differences with regard to non-psychiatric medical services. Conclusion: Schizophrenia has a high rate of readmission and high medical cost in naturalistic settings. In addition to the traditional hospital-based treatment model for patients with schizophrenia, the development of an effective intervention program is important, especially in the early years of the disease.
Article
Objectives: The contemporary approach to psychiatric diseases is to refer the patient to community-based care instead of hospital-based care. In addition to medication, it has been found that day-hospital practices have positive results in schizophrenic patients. In this study, our purpose is to report the results of a psychosocial rehabilitation program at Bakırköy Day Hospital for schizophrenic patients receiving medication, and to compare them with the results for schizophrenic patients receiving medication who were not in this program.
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In Germany it is not clear which forms of community mental health care should be encouraged to meet the needs particularly of the severely mentally ill. We performed a literature review of systematic meta-analyses and controlled trials and show that a set of well-evaluated and effective psychiatric care systems is available, of which only a few are being implemented in Germany. It becomes obvious that in Germany organizational requirements for an integration of psychiatric services are not being adequately met, particularly in the case of schizophrenia. Team-based assertive community treatment, crisis intervention teams, community mental health teams, and modern job rehabilitation programs, which have been established primarily in English-speaking countries, could not be effectively adapted for German psychiatric care. At the same time many psychiatric care models have been poorly evaluated. Given the available scientific evidence we comment on future requisites and further developments in German psychiatry to meet the growing need of care for people with severe mental illnesses.
Over the last 35 years we have developed a number of group therapy programs with an orientation toward community therapy. In the last 20 years, even though at certain centers we have maintained a milieu therapy focus, the programs have become less psychodynamic and less democratic – somewhat ‘decaffeinated’, in fact. This, however, does not mean they are less efficient from the point of view of dynamics, because our experience over the years has, in fact, shown the negative effects of the caffeine administered by certain lines of psychoanalytic action and ‘pseudo-democratic’ environments. Many people now consume ‘light’ products and drink decaffeinated coffee on medical advice, and this is what we have decided to do at our centers as we try to illustrate in this article.
Article
There is limited research on outcomes of partial hospitalization programs (PHPs). Questions remain regarding necessary treatment components for favorable outcomes including how to involve parents. There is growing consensus regarding the importance of parent participation in youth mental health treatment. Behavioral parent training (BPT) is an evidenced-based approach based on operant conditioning to target youth behavior through active skills training for parents that has demonstrated benefits across a range of diagnoses. BPT is one of the most extensively studied and effective treatments for reducing oppositional and disruptive behavior in youth. Modifying BPT for use in a youth PHP is appealing given its effectiveness in outpatient settings and its impact across a range of diagnoses. The present study examines the impact of brief BPT within a PHP that serves patients 5–17 years of age. Results demonstrated that patients who received BPT were significantly less likely to visit the emergency department (ED), be admitted to the inpatient psychiatric unit, or be readmitted to the PHP within 1 month of discharge. The results held at six-month post-discharge from the PHP. These results suggest that the addition of BPT to a PHP provides targeted support to optimize parent involvement, which may reduce revisiting the ED and/or acute psychiatric care service utilization following discharge. These results may be particularly useful in revealing crucial treatment components when establishing best practices and/or standards of care for PHPs, though further investigation is required.
Article
Objective: To provide a summary of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guideline for the Management of Schizophrenia. Conclusions: Schizophrenia is a complex and misunderstood illness with a poor public image, but it is more treatable than ever before. A new generation of medication and psychosocial therapies, combined with a first generation of service reform, have created an evidence-based climate of realistic optimism. However, the potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality. The gap between efficacy and effectiveness is wider for schizophrenia than for any other serious medical disorder. These guidelines distil the current evidence and make recommendations based on the best available knowledge. They are based on systematic meta-analyses and comprehensive reviews of the evidence, and their validity is supported by their congruence with several recent rigorous and independent guideline statements from the UK and North America.
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Our objective was to investigate, in a naturalistic, prospective study, the follow-up status of patients with borderline personality disorder (BPD) treated with a combination of day treatment and subsequent outpatient group psychotherapy (G-group, n=12) and compare their status with that of patients with BPD treated in the same day hospital but without subsequent outpatient group therapy (Non-G-group, n=31). At follow-up an average of 34 months after discharge from the day hospital, the G-group patients had a moderate impairment in global health (HSRS), a low level of symptoms (GSI), a low rate of rehospitalization and suicide attempts, and a high rate of remission from substance use disorders. Compared with the Non-G-group, the G-group patients had a significantly higher HSRS and a significantly lower GSI at follow-up. In multivariate analyses controlling for background and treatment variables, number of months in work last year before admission and outpatient group therapy predicted a better HSRS at fol...
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Objective: Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses. Design: Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30
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Schizophrenic patients referred for day treatment at the time of discharge from ten hospitals were randomly assigned to receive day treatment plus drugs or to receive drugs alone. They were tested before assignment and at 6, 12, 18, and 24 months on social functioning, symptoms, and attitudes. Community tenure and costs were also measured. The ten day centers were described on process variables every six months for the four years of the study. Some centers were found to be effective in treating chronic schizophrenic patients and others were not. All centers improved the patients' social functioning. Six of the centers were found to significantly delay relapse, reduce sumptoms, and change some attitudes. Costs for patients in these centers were not significantly different from the group receiving only drugs. More professional staff hours, group therapy, and a high patient turnover treatment philosophy were associated with poor-result centers. More occupational therapy and a sustained nonthreatening environment were more characteristic of successful outcome centers.
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A one-year cohort of patients from a defined catchment area with acute functional disorders were allocated at random to brief care (experimental group) or standard care (control group) in hospital to examine the effect of shortening hospital stay on the clinical and social functioning of patients and the distress abnormal functioning caused to others. A total of 127 patients were interviewed on entry to the study, and 106 were followed up. The brief care group had significantly shorter mean and median lengths of stay than the control group, but there was no difference between the groups in the number of days spent in hospital during subsequent admissions. The groups were well matched for clinical and social variables. Rates of improvement over 13 weeks were essentially the same by all measures of outcome, including the Present State Examination and Patient's Behaviour Assessment Scale, which was developed for the study to measure deterioration in behaviour and social functioning and adverse effects and distress on others. There was no difference between the two groups in burden to the community supporting services, social security requirements, or GP attendances. Improvement rates were nearly identical on all measures within and across diagnostic subgroups. Brief care resulted in a 33% reduction in average length of stay compared with the year before but was associated with a corresponding increase in day hospital use. The short-stay policy continued the year after the study finished.The findings confirm the value of shortening hospital stay and improving day care facilities for most localities.
Article
Objectives: To provide a methodology for the examination of costs and clinical outcomes in two distinct care settings for psychiatric patients inpatient and day hospitals. The major emphasis is on the relationship between costs and outcomes in the two care regimes. Method: The study is a retrospective cost-effectiveness analysis. People living in Sector B catchment area in the Mid-Western Health Board who were admitted to inpatient care, or treated as day hospital patients, between June 1st 1994 -February 28th 1995 are eligible for inclusion in the study. Information on resource use and clinical outcome is available for 92 of these patients. Results: The average weekly cost of care for mentally ill patients in the inpatient setting is over twice the level of the cost of care for people attending the day hospital facility. Pay costs and hotel costs are higher in the inpatient facility. Day hospital care is also more cost-effective than inpatient care, when account is taken of the relationship between cost and clinical outcomes. Conclusion: The study supports the general literature view of the superiority of community care settings for certain categories of mentally ill people. However, the absence of randomisation in the study, incomplete data, and the retrospective nature of the analysis suggests that caution is needed in the interpretation of the results.
Article
In a consecutive sample of 97 day patients from a therapeutic community ward, 52 patients with borderline, schizotypal, or paranoid personality disorders (severe personality disorder-SEVPD) were compared with 23 patients with other personality disorders (OPD) and 22 with no personality disorder (only Axis I disorder) (NOPD). The personality disorder variable had a significant impact on the treatment response measured by the SCL-90 and the Health Sickness Rating Scale even when Axis I disorders, sex, and age were controlled for. The SEVPD group was often discharged in an irregular way and perceived the ward atmosphere as less favorable than the other groups. The NOPD and OPD groups had the same level of nervous symptoms at admittance, whereas at discharge the symptom level was significantly lower in the NOPD group. The results validate the discrimination between Axis I and Axis II disorders.
Article
THIS PAPER outlines the background to the conceptualization, and the tentative instrumentation of "community adaptation." Data from an initial study using the "Community Adaptation Schedule" is presented. Applications for the evaluation of community mental health programs are discussed.The Need for Program Evaluation The interest being stimulated in the field of community mental health compels attention to the many voices1 raised in warning about the need for research and evaluation. Properly feared is a possible digression that may cause embarrassment decades hence. The undertaking of carefully controlled studies in this field has been hampered by the lack of sound evaluation techniques. Besides the Well—known difficulties of measuring change after an intervention, the absence of an appropriate criterion relevant to the goals of community mental health makes the task that much harder. Approaches embodying crisis consultation, multilevel prevention, short-term treatment, sector analysis, and the
Article
Forty five day-care hospital and 52 full-time patients were evaluated two and 12 months after release (91.5% of the treatment sample). At two months, symptom differences favoring full hospitalization were less pronounced than they had been at the time of patients' release; social adjustment as reported by patients was better in the day than in the full-time sample. After one year, symptomatology in the two groups differed only in that day patients were significantly more intrapunitive than inpatients; the social performance of day subjects was superior to that of their full-time counterparts, according to both patients and their relatives. Further, 78% of day-care heads of households were employed. compared with only 52% of full-time patients in that category (P<.05). Incidence and duration of relapse were not significantly different in the two samples.
Article
• Schizophrenic patients referred for day treatment at the time of discharge from ten hospitals were randomly assigned to receive day treatment plus drugs or to receive drugs alone. They were tested before assignment and at 6, 12, 18, and 24 months on social functioning, symptoms, and attitudes. Community tenure and costs were also measured. The ten day centers were described on process variables every six months for the four years of the study. Some centers were found to be effective in treating chronic schizophrenic patients and others were not. All centers improved the patients' social functioning. Six of the centers were found to significantly delay relapse, reduce symptoms, and change some attitudes. Costs for patients in these centers were not significantly different from the group receiving only drugs. More professional staff hours, group therapy, and a high patient turnover treatment philosophy were associated with poor-result centers. More occupational therapy and a sustained nonthreatening environment were more characteristic of successful outcome centers.
Article
I. Background of Study IN January of 1963 the psychiatric day hospital and the psychiatric inpatient service, both facilities of the San Mateo County Mental Health Services, began a project which gave the day hospital staff the opportunity to screen patients who had been accepted for hospitalization for alternate treatment in the day hospital. These facilities—day hospital as well as psychiatric ward—are located at the San Mateo County General Hospital in San Mateo on different floors. The psychiatric ward is a 30-bed unit for emergency admission and treatment with an "open door" policy and "therapeutic community" orientation dating back to 1956. The day hospital was established in January of 1961 in its present location on the ground floor of the hospital.The project was set up to answer the following questions:1. What percent of patients considered in need of full-time hospitalization on a
Article
THE CONCEPT of sociopsychiatric treatment, the development of effective chemotherapy, and enormous public investment in community mental health facilities have radically affected the structure of psychiatric treatment within the United States. Mental health facilities geared to handle the diversity of patients for whom the traditional and often isolated mental hospital was once the only treatment resource have been and are being constructed. The comprehensive community mental health center, as outlined by the National Institute of Mental Health,1 consists of five essential and interrelated services: inpatient, outpatient, partial hospitalization, emergency, and consultation-education. The specificity of these services, however, has not been clearly delineated.2 For whom is partial hospitalization appropriate? Upon what basis should treatment assignments to the outpatient service be made? The present study is an attempt to compare two community based services and to determine whether each is capable
Article
The effectiveness of a 6-week anxiety management course at a mental health day hospital was researched. The author was motivated to research these sessions due to her own observations of the clients' progress in the groups. There was also an increasing demand for anxiety management groups with many clients being referred by general practitioners. The subjects were 37 clients. The diagnosis of the clients varied but anxiety must have been identified as a problem. Four of the 6-week courses were run over a period of 10 months. The course was evaluated using three questionnaires: the Hospital Anxiety and Depression (HAD) Scale, the Spielberger Questionnaire (state and trait) and the Fear Questionnaire. The clients completed the questionnaires four times: pre-treatment, at the beginning and at the end of the course, and at 2 months post-treatment. A control group was used. The data collected from the questionnaires were analysed using paired t-tests. The results showed that the anxiety management course was effective, with a statistically significant reduction in symptoms by the end of the course. The control group did not show significant change. It was the HAD Scale that showed the statistically significant positive change. The state section of the Spielberger Questionnaire followed the same pattern as the HAD Scale and showed a reduction in symptoms, although it was not statistically significant. The results of the Fear Questionnaire suggested that the clients' phobias were not treated by the anxiety management course. A client satisfaction questionnaire was used and participants made positive comments about the value of the course.
Article
In a previously reported study by the authors (see record 1976-28530-001) of inpatient and day hospitalization, 59 seriously ill female psychiatric patients were randomly assigned to an inpatient or a day hospital setting. The present study compared the 29 seriously ill patients randomly assigned to the day hospital with a control group of 34 "usual" day patients. Ss were assessed on 14 outcome measures, some of which were derived from the Psychiatric Status Schedules and the Psychiatric Evaluation Form. The experimental group showed significantly more improvement from baseline to subsequent time periods in 3 distinct areas: global mental status, subjective distress, and family adjustment. The controls, on the other hand, spent fewer nights in the hospital, used the hospital facilities significantly less during the 1st 3 mo, and incurred a significantly lower cost for the same period. Two measures—number of social work contacts and amount of time spent in the treatment milieu—indicated that experimentals initially required more staff effort than controls, but at later time periods the reverse was true. (29 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
The authors of this volume detail the day-to-day operations of the [time-limited] Edmonton Day Treatment Program [for patients with personality disorders] and include its objectives, structures, and guiding principles, with illustrations of group process and staff roles. The volume provides a comprehensive set of general principles and suggestions for effectively conducting a day treatment program, with presentations of common problems and ways to deal with them. . . . The authors also include the research results of a large-scale clinical trial investigation into the efficacy of this treatment approach. This book will be of interest to practitioners in partial hospitalization, group therapists, and those working with patients suffering from affective and personality disorders, including staff from public and private clinics and hospitals, psychiatrists, psychologists, social workers, occupational therapists, and nurses. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
59 seriously ill, female, 16-72 yr old psychiatric patients were randomly assigned, after 2-6 wks of inpatient evaluation, to an inpatient or day service where they were evaluated, along with a control group of 34 "usual" day hospital patients, for up to 24 mo. Data from the Psychiatric Status Schedule, Psychiatric Evaluation Form, Dynamic Assessment Scale, and other similar measures indicate that for the range of patients studied, day treatment is, on the whole, superior to inpatient treatment in 5 distinct areas: subjective distress, community functioning, family burden, total hospital cost, and days of attachment to the hospital program. The findings of other controlled studies are confirmed and extended to include previously unreported outcome dimensions and a broader socioeconomic population. (25 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Treatment effects of a 12-wk day-treatment program were explored on measures of psychiatric distress (Brief Symptom Inventory) and maladaptive schemas (Schema Questionnaire Short Form; J. Young, 1990). 84 program completers (aged 22–57 yrs) showed significant pre–post change in psychiatric distress and on 3 of 15 schema: vulnerability to harm, social alienation, and defectiveness. Other schema did not change over the 12 wks. 15 waiting-list controls demonstrated no improvement in either distress level or in any of the 15 schema while waiting to be admitted to the program. Only 1 of the 15 schema, abandonment, predicted treatment outcome on changes in psychiatric distress level. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Objective: To compare direct and indirect costs of day and inpatient treatment of acute psychiatric illness. Design: Randomised controlled trial with outcome and costs assessed over 12 months after the date of admission. Setting: Teaching hospital in an inner city area. Subjects: 179 patients with acute psychiatric illness referred for admission who were suitable for random allocation to day hospital or inpatient treatment. 77 (43%) patients had schizophrenia. Interventions: Routine inpatient or day hospital treatment. Main outcome measures: Direct and indirect costs over 12 months; clinical symptoms, social functioning, and burden on relatives over the follow up period. Results: Clinical and social outcomes were similar at 12 months, except that inpatients improved significantly faster than day patients and burden on relatives was significantly less in the day hospital group at one year. Median direct costs to the hospital were £1923 (95% confidence interval £750 to £3174) per patient less for day hospital treatment than inpatient treatment. Indirect costs were greater for day patients; when these were included, overall day hospital treatment was £2165 cheaper than inpatient treatment (95% confidence interval of median difference £737 to £3593). Including costs to informants when appropriate meant that day hospital treatment was £1994 per patient cheaper (95% confidence interval £600 to £3543). Conclusions: Day patient treatment is cheaper for the 30-40% of potential admissions that can be treated in this way. Carers of day hospital patients may bear additional costs. Carers of all patients with acute psychiatric illness are often themselves severely distressed at the time of admission, but day hospital treatment leads to less burden on carers in the long term. Key messages When inpatient treatment is avoidable day hospital treatment is cheaper for acutely ill psychiatric patientsCarers of acutely ill psychiatric patients experience severe distress and warrant help in their own rightInpatient treatment relieves symptoms more rapidly than day hospital treatment but may lead to increased burden on carers one year later
Article
A brief interview schedule for assessing social functioning is described which is particularly suited for assessing non-psychotic patients. Interrater reliability by the intraclass correlation coefficient for each part of the schedule ranged from 0.45 to 0.81 on audiotape ratings and from 0.50 to 0.80 with independent interviews. A version of the schedule for informants gave similar levels of agreement. Ratings from patients and informants taken independently revealed highly significant agreement on all sections of the schedule (p
Article
The efficacy of a problem-solving skills training group was evaluated with a sample of mentally ill chemical abusers. Twenty-nine day treatment patients were recruited into the study, and then randomly assigned to either a problem-solving group (i.e., treatment) or to the standard day treatment program (i.e., control). The treatment group received 12 sessions of structured problem-solving training in addition to the standard treatment. Problem-solving skills and perceiced stress were assessed pre- and post-treatment, and at a one-month follow-up. Results indicated that treated patients' problem-solving skills were not enhanced, nor were stress levels substantially reduced at either post-treatment or follow-up. The implications of these findings, especially with respect to research with the mentally ill chemical abuser population, are discussed.
Article
The authors report the results of their controlled study to compare the efficacy of day versus inpatient hospitalization for those patients for whom both treatments are equally feasible clinically. Newly admitted inpatients from the catchment area were randomly assigned to either day or inpatient care. Outcome evaluations, including measures of psychopathology and role function, were conducted at various follow-up intervals. The authors found clear evidence of the superiority of day treatment on virtually eveny measure used to evaluate outcome.
Article
Background: Unemployment rates are high amongst people with severe mental illness, yet surveys show that most want to work. Vocational rehabilitation services exist to help mentally ill people find work. Traditionally, these services have offered a period of preparation (Pre-vocational Training), before trying to place clients in competitive (i.e. open) employment. More recently, some services have begun placing clients in competitive employment immediately whilst providing on-the-job support (Supported Employment). It is unclear which approach is most effective. Objectives: To assess the effects of Pre-vocational Training and Supported Employment (for people with severe mental illness) against each other and against standard care (in hospital or community). In addition, to assess the effects of: (a) special varieties of Pre-vocational Training (Clubhouse model) and Supported Employment (Individual Placement and Support model); and (b) techniques for enhancing either approach, for example payment or psychological intervention. Search strategy: Searches were undertaken of CINAHL (1982-1998), The Cochrane Library (Issue 2, 1999), EMBASE (1980-1998), MEDLINE (1966-1998) and PsycLIT (1887-1998). Reference lists of eligible studies and reviews were inspected and researchers in the field were approached to identify unpublished studies. Selection criteria: Randomised controlled trials of approaches to vocational rehabilitation for people with severe mental illness. Data collection and analysis: Included trials were reliably selected by a team of two raters. Data were extracted separately by two reviewers and cross-checked. Authors of trials were contacted for additional information. Relative risks (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data were calculated. A random effects model was used for heterogeneous dichotomous data. Continuous data were presented in tables (there were insufficient continuous data for formal meta-analysis). A sensitivity analysis was performed, excluding poorer quality trials. Main results: Eighteen randomised controlled trials of reasonable quality were identified. The main finding was that on the primary outcome (number in competitive employment) Supported Employment was significantly more effective than Pre-vocational Training; for example, at 18 months 34% of people in Supported Employment were employed versus 12% in Pre-vocational Training (RR random effects (unemployment) 0.76 95% CI 0.64 to 0.89, NNT 4.5). Clients in Supported Employment also earned more and worked more hours per month than those in Pre-vocational Training. There was no evidence that Pre-vocational Training was more effective in helping clients to obtain competitive employment than standard community care. Reviewer's conclusions: Supported employment is more effective than Pre-vocational Training in helping severely mentally ill people to obtain competitive employment. There is no clear evidence that Pre-vocational Training is effective.
Article
106 patients with anxiety, phobic, and depressive neuroses referred to the outpatient clinics of 6 psychiatrists were randomly assigned to outpatient care or two forms of psychiatric day care. Ratings of symptoms and social adjustment were recorded before treatment and after 4 and 8 months in 89 patients. There were no important differences in the outcome of day care and outpatient treatment although patients were more satisfied with the outpatient service. Because outpatient care is more economical of time and personnel it should be preferred to psychiatric day care for many neurotic disorders.
Two private day hospitals and an insurance company offering group health coverage to federal employees undertook a pilot study to determine if providing insurance coverage for day hospitalization on the same basis as for inpatient treatment was a feasible means of controlling the cost of psychiatric care. The study included 31 patients who otherwise would have been hospitalized; most had histories of severe psychiatric disorders and extensive treatment. Using the measure that the day hospital patients would have been in inpatient treatment for the same number of days, the authors estimate that the use of day treatment saved the insurer more than $255,000. They recommend that day hospitalization be reimbursed on the same basis as inpatient care if a day hospital can meet stringent criteria ensuring that it provides active, appropriate treatment, and they present a list of such criteria.
Article
The effect of a treatment program (E) providing inpatient care, a day hospital, community housing, and sheltered work are compared with a program (C) emphasizing rapid discharge. A group of 94 male general psychiatric patients were randomized to the two units. Outcome data collected at 18 months from admission revealed small but significant differences between the total samples in employment, maintenance of treatment contact, use of medication, and social adjustment. More C than E patients were in the hospital after the 14th month. Program effects varied considerably with patient type. Patients with less social disability had somewhat better employment outcomes with the E program, but no differences in use of services. Patients with a better prognosis by measure of psychopathology (Minnesota Multiphasic Personality Inventory cluster and diagnosis of schizophrenia) spent less inpatient time in the E program, but were not helped to better employment outcomes. Patients with greater social handicap were not differentially affected. More E patients than C with a poorer prognosis stayed in outpatient treatment and used antipsychotic medications. Patients in the E group with better previous employment and more social isolation used the E day hospital and community housing more heavily than other E subgroups.
Article
A total of 175 newly admitted inpatients who lived with families were randomly assigned to three treatment groups: standard inpatient care (discharge at the therapist's discretion), brief hospitalization (one week or less) with transitional day care available, and brief hospitalization without day care. Outpatient aftercare was offered to all patients. The three groups showed no significant differences as to amount of improvement in levels of psychopathology at 3 and 12 weeks, but the briefly hospitalized patients were able to resume their vocational roles sooner. There were no significant differences among the groups in readmission rates.
Article
The authors compared treatment results for 141 schizophrenic patients randomly assigned to short-term or long-term hospitalization. Test results indicated that the long-term group was functioning significantly better one year after admission according to global measures only. The authors caution that the differences between the two groups, although statistically reliable, were modest and may have been confounded by the amount of psychotherapy the patients received after hospitalization. Although there appears to be a general advantage to the long-term approach, further work will be needed to identify patient subgroups for whom this more expensive treatment is cost effective.
Article
A controlled, prospective study examined the relative effectiveness of short-term versus long-term psychiatric hospitalization. The results of a two-year follow-up of a sample of 141 schizophrenic patients are reported here. The differences favoring long-term subjects that were apparent at one year postadmission had decreased by two years postadmission. However, there appears to be an interaction between prehospital functioning and length of hospital stay, with subjects who had good prehospital functioning doing better at two years when assigned to long-term hospitalization. Subjects with poor prehospital functioning did about equally well, regardless of length of stay, and may even have showed some tendency to do better with a shorter hospital stay. This reversal of effect was more prominent for women, although this sex difference was not statistically significant.
Article
Partial hospitalization continues to be underutilized even though its clinical effectiveness for a variety of psychiatric patients has been demonstrated. The authors investigated the potential economic advantage of partial hospitalization by comparing matched groups of day hospital patients and inpatients who had comparable symptoms and prognoses on admission. They present one-year follow-up data documenting the comparability of the study groups on clinical outcome measures and the cost advantages favorable the partial hospitalization group. They discuss possible causes of the paradoxical underutilization of the clinically effective and lower-cost partial hospitalization, which include institutional factors, patients' clinical characteristics, family resistance, and clinician bias.
Article
A research study was designed to test the hypothesis that acutely schizophrenic patients treated for a few minutes a day in a specially designed, city-county hospital outpatient clinic could remit as frequently, rapidly, and economically as a similar group managed on the ward of the same hospital. The results of the study permitted acceptance of the hypothesis. To wit, 90% of the clinic patients remitted in a median time of 12.5 days, as opposed to 70% of the ward patients remitting in a median time of 19.5 days and for approximately six times the cost.
Article
Employed a pre–posttreatment control group design to compare the treatment effects of partial hospitalization to those of full-time hospitalization. Ratings of home and community adjustment were obtained from community informants (relatives or close friends) for 2 groups of Ss: (a) 24 day-hospital clients (partial hospitalization condition) matched on age (average age 32 yrs), education, and intelligence with (b) 24 inpatient clients (full-time hospitalization condition), and from an unmatched sample of 79 consecutive inpatient admissions. Treatment outcome was measured by clients' pre- and postscores on the Personal Adjustment and Role Skills scale. Results show that all groups evidenced improvement 2 mo after treatment started, particularly on measures of symptom reduction. Although patterns of improvement were comparable for both settings in univariate data analyses, multiple discriminant function analysis indicated that the day hospital sample evidenced greater gains in attentiveness and in employment. Gains favoring the day hospital sample were more striking for the unmatched 3-group comparison than for the matched 2-group comparison. Findings indicate that partial hospitalization is an attractive alternative to inpatient psychiatric hospitalization. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
A study was undertaken to evaluate the efficacy of the Day Treatment Center as an alternative to rehospitalization for chronic psychiatric patients. The project utilized a subject as his own control design comparing equal time intervals before and during Day Treatment Center involvement. The study demonstrates the efficacy of the Day Treatment Center as a therapeutic modality that not only helps prevent hospitalization, but also assists in decreasing the average length of stay when admission is unavoidable.
Article
This article presents the long-term follow-up effects of brief vs standard hospitalization on families. One hundred seventy-five newly admitted inpatients who lived with their families were randomly assigned to standard inpatient care, brief hospitalization followed by the availability of transitional day care, and brief hospitalization. All patients were offered follow-up outpatient treatment. Initial length of stay was 11 days for both brief hospitalization groups and 60 days for the standard group. The long-term results generally indicate little differential effect between treatments. When differences occurred, they generally favored the brief groups. For example, at one year the standard group families were judged to have a higher overall level of burden than the brief-day families. The findings suggest that patients are more likely to be rehospitalized because of their psychopathology than because of family burden.
Article
This study compares day hospitalization with traditional outpatient treatment effecting rehospitalization, symptomatology, mood, community, and vocational adjustment for 30 recently discharged schizophrenic patients. Results indicate day hospital patients were significantly more involved in work and training activities, but had no significant difference in the other areas of measurement.
Article
Tested hypotheses, empirically generated from rating scales, which predicted that patients treated in partial, day hospital settings improve more in intellectual efficiency and social interaction than patients treated in full-time, inpatient settings. Thirty matched pairs of day hospital and inpatient volunteers were administered a group psychological test battery at the beginning of treatment and then 5 weeks later. The day hospital sample differed significantly on 7 of 24 pre- and posttest measures, the inpatient sample on 2. Gains occurred primarily in increased intellectual efficiency and social interaction. Multiple discriminant function analyses yielded no significant pretest differences, but posttest differences approached significance (p less than .06); day hospital patients registered increased Extraversion (Eysenck Personality Inventory).
Article
The present study examined characteristics of comparable samples of patients admitted to nonaffiliated day and full-time psychiatric hospitals. Moreover, the influence of the day hospital program on symptomatology and social functioning was assessed. In general, the results indicated that day patients were of higher socioeconomic status and had fewer previous hospitalizations in comparison to 24-hour patients. While fewer day patients were diagnosed as psychotic, they did obtain higher scores of social inadequacy, depression and social introversion. Participation in the day hospital program was generally found to be related to decreased psychopathology, increased self-esteem and social role activities, and symptom relief. However, patients suffering from functional psychoses were found to demonstrate improvement below the average of the patient sample. These results were discussed in relation to previous research.
Article
A controlled, prospective, two-year follow-up study examined the relative effectiveness of short-term vs long-term psychiatric hospitalization. Results of the inpatient phase for a sample of 74 nonschizophrenic patients are reported here. About four weeks after admission the patients hospitalized for a short stay were discharged, and at that time were functioning better than the patients in the long-stay group. When the patients hospitalized for a long stay were discharged, three to fur months after admission, they were then functioning as well as, but not noticeably better than, the patients in the short-stay group had been at their earlier time of discharge. Patients with affective disorders were more impaired at admission and improved more than patients with other diagnoses, regardless of length of stay.
Article
• A controlled, prospective study examined the relative effectiveness of short-term versus long-term psychiatric hospitalization. Results of a two-year follow-up of a sample of 74 nonschizophrenic subjects are reported here. Two years affer admission there were no statistically reliable differences in functioning between short-term and long-term subjects with diagnoses of either affective disorders, or neurosis and personality disorders (including hysterical personality disorder). The findings reported do not support extended hospitalization for patients with these diagnoses. Caution regarding these findings is suggested by an anecdotal impression that short-term hospitalization may not have allowed for proper diagnosis and treatment for some persons in the affective disorder group.
Article
The author present two-year follow-up data of a controlled study of 175 newly admitted inpatients who lived with families, comparing the relative efficacy of brief hospitalization (with and without transitional day care) and standard hospitalization (with all patients offered outpatient aftercare). The long-term results confirm the preliminary finding that brief hospitalization is preferable to longer term hospitalization for most patients. Briefly hospitalized patients spent significantly less time as inpatients and showed less psychopathology and impairment in role functioning. In contrast to preliminary findings, the long-term results indicate that use of day care reduced the number of inpatient days.
Article
The Global Assessment Scale (GAS) is a rating scale for evaluating the overall functioning of a subject during a specified time period on a continuum from psychological or psychiatric sickness to health. In five studies encompassing the range of population to which measures of overall severity of illness are likely to be applied, the GAS was found to have good reliability. GAS ratings were found to have a greater sensitivity to change over time than did other ratings of overall severity or specific symptom dimensions. Former inpatients in the community with a GAS rating below 40 had a higher probability of readmission to the hospital than did patients with higher GAS scores. The relative simplicity, reliability, and validity of the GAS suggests that it would be useful in a wide variety of clinical and research settings.
Article
A total of 175 newly admitted inpatients who lived with families were randomly assigned to three treatment groups: standard inpatient care (discharge at the therapist's discretion), brief hospitalization (one week or less) with transitional day care available, and brief hospitalization without day care. Outpatient aftercare was offered to all patients. There was no major differential family burden as a function of length of hospitalization. Generally, brief hospitalization had several positive effects on family functioning, primarily earlier resumtption of occupational roles and less financial burden, with few significant deleterious effects.
The authors, after giving an outline of the history of what is known as day-clinics, comment on the importance of such institutions as a link between psychiatric inpatient and outpatient treatment. The results obtained in the treatment in day-clinics of 120 mental patients are compared with those obtained for 120 inpatients. Also discussed are a number of conclusions drawn from results to date. The authors finally consider the future development of this particular field of therapy.
Article
Previous attempts at program evaluation of partial hospitalization programs have consisted largely of descriptive and anecdotal reports of programs and patient characteristics. There have been no comparative or experimental studies of the effectiveness of differing day treatment programs. In the current study, Goal Attainment Scaling, a goal-oriented program evaluation system, was used with 56 randomly selected partial hospitalization patients who attended two day hospitals: one program was based on behavioral-educational methods, and the other was an eclectic program based on the concepts of a therapeutic community. Patients attending the behavioral-educational program showed greater attainment of their therapeutic goals than did the patients involved in the eclectic program. The greater effectiveness of the behavioral-educational day program increased from the 3-month follow-up to the 2-year follow-up.
Article
The authors compared treatment results for 141 schizophrenic patients randomly assigned to short-term or long-term hospitalization. The patients received intensive treatment and were on partially fixed drug dosage schedules. Test results indicated that the short-term group was functioning better at four weeks. However, at discharge (21 to 28 days for short-term patients; 90 to 120 days for long-term) the long-term group showed significantly better functioning. There were no significant differences between the groups on symptomatology at discharge. The authors discuss the implications of these findings for decisions regarding length and type of hospitalization for schizophrenic patients.
Article
The authors studied the effect of long-term versus short-term hospitalization on a group of 74 patients with the diagnoses of affective disorder, neurosis and personality disorder, and hysterical personality one year after their admission to the hospital. Although they had found in an earlier study that short-term patients seemed to integrate more rapidly in the hospital, the results reported in this study showed no statistically reliable differences between the long-term and short-term groups. In contrast to the author's results for schizophrenic patients, their findings for nonschizophrenic patients do not support extended hospitalization.
Observations of 392 women admitted to a psychiatric hospital indicated that 24 were well suited to treatment in a day center and that 208 could feasibly be treated there. However, only 59, or 28 per cent of those for whom day care was feasible, were able to take advantage of that alternative. The others were excluded by financial limitations, refusal to accept the day center option, administrative delays, and inaccurate classification of treatment setting. The authors believe that underuse of the day center was due as much to doctors' inexperience, personal biases, and unfamiliarity with the facilities as it was to psychopathology and financial realities. They found that many clinicians were not aware of the factors that affect their decisions about the use of a partial hospitalization setting.