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Brief versus standard hospitalization: The differential costs
Abstract
The authors compared the use of inpatient and day care services, number of readmissions, use of special services, use of drugs, costs to family and community, and differential dollar costs of three treatment approaches--brief hospitalization followed by day care, brief hospitalization followed by outpatient care, and standard hospitalization. They found that, among patients who had families willing to care for them, brief hospitalization followed by either day or outpatient care was less expensive in terms of hospital costs and costs to the family than standard hospitalization.
... Roth und Veltin (1974) (Roth & Veltin, 1974, S. 55 (Rüesch et al., 2013). Brenner, Rössler und Fromm (2003) Hertz, Endicott et al. (1975Endicott et al. ( , 1976Endicott et al. ( , 19771971) Cohen, Nee, Fleiss, & Herz, 1979;Endicott, Herz, & Gibbon, 1978). ...
... Tageskliniken reduzierten jedoch weder die Wiederaufnahmerate, noch die Belastung von Bezugspersonen; sie verbesserten auch nicht das soziale Funktionsniveau der Patienten (Marshall et al., 2003). Marshall et al. (2011) International gab es für die Wirksamkeit tagesklinischer Behandlung damit bis Ende der 1990-er Jahre viele Belege, die in den oben genannten Metaanalysen zusammengefasst wurden Endicott et al., 1978;Herz, Endicott, & Gibbon, 1979;Herz et al., 1975Herz et al., , 1977Herz et al., 1971;Longabaugh et al., 1983;McCrady, 1986;Moscowitz, 1980;Schene, van Wijngaarden, Poelijoe, & Gersons, 1993;Sledge et al., 1996a;Sledge, Tebes, Wolff, & Helminiak, 1996b). ...
... Toutefois, si la supériorité de la stratégie alternative diminue avec le temps, elle reste, soit moins coûteuse sur une période observée de deux ans [18], [29], [28], soit pas plus coûteuse, sur une période observée de 4 ans. ...
... -Parmi les autres études anglo-saxonnes, certaines décrivent l'efficacité identique de la stratégie alternative [18], [29], [27], [33], comparée à l'hospitalisation traditionnelle, d'autres, aussi nombreuses, [36], [41], [43], [22], [17], [28], [20], démontrent son efficacité supérieure. ...
Biblio n° 1256 Mars 1999 Les noms d'auteurs apparaissent par ordre alphabétique Toute reproduction de textes, graphiques ou tableaux est autorisée sous réserve de l'indication de la source et de l'auteur. En cas de reproduction du texte intégral ou de plus de 10 pages, le Directeur du CREDES devra être informé préalablement.
... Canadian studies by Fenton(3) and Coates(4) have contributed to this literature. Brief hospitalization and day treatment have also been shown to produce comparable outcomes at less cost when compared to "standard" hospitalization programs (5). A very important issue which is deserving of careful study remains that of how to ensure that dollars follow patients from institutions into community programs. ...
... Partial hospitalization, which is defined as day treatment that provides comprehensive, multidisciplinary services for clients with severe mental disorders (Casarino, Wilner, & Maxey, 1982), arose as an alternative to inpatient treatment. As an alternative to hospitalization, partial hospitalization has been demonstrated to be as effective or better than inpatient treatment in terms of improving symptoms and preventing relapse (Dick, Cameron, Cohen, Barlow, & Ince, 1985;Greene & De La Cruz, 1981;Herz, 1982;Herz, Endicott, Spitzer, & Mesnikoff, 1971;Washburn, Vanicelli, Longabaugh, & Scheff, 1976) and in containing costs (Endicott, Herz, & Gibbon, 1978;Washburn et al., 1976). However, partial hospitalization is now often used to provide rehabilitative day treatment or day care (i.e., social and recreational activities) services rather than hospital diversion (Rosie, 1987). ...
Day treatment remains a core component in many community mental health programs for persons with severe mental disorders throughout the United States. Many other mental health centers are moving away from day treatment toward psychosocial and vocational rehabilitation programs. Empirical research directly comparing these two systems of organizing outpatient services is needed. In this study the authors compared a rehabilitative day treatment program in one small city with a similar program in a nearby city that changed from day treatment to a supported employment model. Clients who were enrolled in community support services during a baseline year prior to the change and during a follow-up year after the change (71 in the program that changed and 112 in the other) were evaluated during both intervals. In the program that changed, competitive employment improved from 25.4% to 39.4% for all clients, and from 33.3% to 55.6% for those clients who had been regular attenders of day treatment during the baseline. Hours worked and wages earned similarly improved after the program change. For all work variables, clients who had not worked during the baseline year accounted for the improvements in outcome. Meanwhile, employment remained stable in the day treatment program. No negative outcomes were detected. These results indicate that eliminating day treatment and replacing it with a supported employment program can improve integration into competitive jobs in the community.
In the past several years the political ferment focused on the increasing presence of long-term mental hospital patients in the community has stirred thoughtful reactions by many professional as well as political groups. The report in 1977 of the President’s Commission on Mental Health, as well as the official position statement of the American Psychiatric Association in 1978, focused on the systems defects in the country’s attempts to make effective care available to chronic patients throughout the country. Ironically, these very issues had been previously addressed in the Community Mental Health Centers Act of 1963. This act mandated the structures needed for the care of chronic and acute psychiatric patients. Since that time, clusters of inpatient and outpatient units, as well as day, evening and night care programs, have been established in increasing numbers. Some, such as the Day-Night unit at the Allen Memorial Institute in Montreal or the Day Hospital at the Massachusetts Mental Health Center, had been functioning effectively years before the landmark federal legislation had been passed. Grouped under the name of partial hospitalization, these units developed a capacity for treating both acute and chronic patients. By 1968 there was one partial hospital patient for every 40 psychiatric inpatients in the U.S. This trend has continued. By 1976 the ratio had increased to one in 10 and day treatment units had increased to 1,458 in 3,495 mental health facilities of all types.
The health of individuals and the relatively harmonious functioning of our society are interrupted or affected by a number of complex biosocial events. Such events are considered by some to be expressions of moral turpitude and by the more sophisticated to be expressions of disease. These phenomena usually are first described in general and impressionistic terms. Eventually efforts are made to identify their elements and define them in precise and quantitative terms. This has been the case with the heterogeneous group of problems associated with the excessive or seemingly injudicious use of alcoholic beverages. The public inebriate, a human and cosmetic problem of our cities, becomes a community concern when these individuals, usually members of low socioeconomic groups, cluster in unattractive areas of town (Blumberg et al., 1966). The excessive use of alcohol is often observed among persons who engage in physical violence, attempt suicide, or exhibit other socially disruptive behavior (Thum et al., 1973; Beck et al., 1976). The use of alcohol is often blamed for family difficulties and the disruption of marriages (Gil, 1970). Employers have become increasingly aware of the role of alcohol in instances of deficient or unreliable occupational performance (Schlenger, 1975). Inebriates are admitted to hospitals or jails, becoming in this way statistics which signal the presence of an enduring problem (U.S. Federal Bureau of Investigation—Crime in the U.S., 1975).
Major changes have taken place during the last decades in the structure of psychiatric care of many developed countries. Mental hospitals have been closed or drastically reduced in size. In the USA the state hospital population declined from 559 000 in 1955 to 138 000 in 1980 (Brown, 1985) and in the UK from 148 100 in 1954 to 64 800 in 1985 (Audit Commission, 1986). This reduction can partly be explained by shorter admissions, but more important is an ideological shift in the principles of psychiatric care, moving away from the 19th century belief that mentally ill patients required long-term protection in asylums towards the conviction that users of mental health services could function in the community, provided support was available.
Incidence. In many European countries, there seems to be an increase in the incidence of psychotic diseases; this appears to be related to an increase in cyclical and/or structural economic problems resulting from the growing recession in Europe, even though there is no definite evidence of the existence of a causal relationship. This leads to further economic consequences: for example, the number of cases of early retirement due to psychotic diseases is also rising, which produces further costs to society. The increase in incidence of psychotic and/or neurotic disorders, presumably caused in part by the economic development and in turn causing economic problems, provokes an analysis of the management of chronic psychotics in terms of health economics.
For an evaluation of a mental health care programme to be comprehensive, it should include an economic component. However, very few cost instruments appear to exist, and only one has been fully described in the literature. This paper seeks to review the studies where costs have been calculated. For this exercise to be facilitated the different elements which make up overall cost are described. A number of areas have experienced economic evaluations, and the more important studies are described. The paper concludes that all too often evaluations either fail to measure costs or do so in an incomplete and inappropriate way.
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.
The number of psychiatric day hospitals is steadily increasing, thus finishing the dualism of in-patient treatment and out-patient treatment. This article informs about the characteristics of patients treated in psychiatric day hospitals, about patients' and their relatives' assessment of treatment, the effectiveness of psychiatric treatment in a day hospital and the cost-effectiveness of day-hospital treatment as compared to in-patient treatment. The study of the most important older publications and the most recently published randomized controlled trials shows the following: first, a great variety of different groups of patients are cared for in this setting, including, among others, mentally ill delinquents, gerontopsychiatric patients, addicted patients and patients with psychosomatic or personality disorders. Within the general psychiatric setting, most day-hospital patients seem to suffer from an at least moderately severe, often chronic disorder. Concerning socio-demographic characteristics of this group, the high unemployment rate is most remarkable. Second, patients' as well as relatives' responses to surveys about satisfaction with treatment are very positive, placing special emphasis on the experienced usefulness of the given structuring of the day, the experienced comradeship, the ongoing contact to the social environment, and the promotion of the patient's autonomy. Patients having already been treated in a day hospital assess this setting even more positive than patients with no such experience. Third, treatment effectiveness is supported by older publications as well as by recent findings of randomized controlled trials: as regards the most important outcome measures (e.g. reduction of symptoms, social functioning, quality of life, burden on relatives), no differences between day-hospital treatment and in-patient treatment could be found. However, day-hospital treatment seems to last significantly longer than in-patient treatment. Fourth, first studies on the cost-effectiveness of day-hospital treatment have found that it might lead to essential cost savings compared to in-patient treatment. However, altogether, with regard to the scientific state of the art, it still has to be stated that the number of empirical studies is yet limited, with randomized controlled trials only being conducted in few centres in the Netherlands, the UK and the USA, i.e. in countries with different approaches to acute day-hospital care. Thus, several suggestions for further research are made, giving top priority to a multi-centre randomized controlled trial using the most common set of outcome measures and carefully describing the applied methods and untoward events. As concerns the practical implications of the available findings, the authors draw the following conclusions should the reported findings be replicated by further studies: first, the capacity of available day-hospital places should be expanded. Second, existing facilities should think about the necessity and the possibility of an internal restructuring of the provided care. Third, as regards the in-service training of young psychiatrists, it might be reasonable to oblige them to practice within this setting for some time, in order to learn its specific characteristics.
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.
Outcome studies of inpatient psychiatric treatment programs in the case of children, adolescents, as well as adults have generally found that extended hospitalization provides little added benefit over shorter inpatient treatment programs averaging no more than one month in length and frequently considerably shorter. As a consequence, brief hospitalizations have become the standard of inpatient care and are increasingly thought of in the larger context of treatment programs that include post-discharge outpatient follow-up and clinical management.
A questionnaire survey (mapping) of day hospitals in the Czech Republic was performed within the framework in an international multi-centric study EDEN (European Day Hospital Evaluation) in collaboration with the Association of Day Hospitals and Crisis Centers. The survey was done since January 2001 to May 2002. From the 35 dispatched questionnaire, 24 were answered. The following observations belong to the most important results: the most frequent functions of day hospitals include: providing psychotherapy, social rehabilitation and supplementing outpatient care. The psychoanalytical, social psychiatric and the case-oriented conduction model, respectively, were most frequent among the therapeutic models. A psychiatrist with psychotherapeutic quantification was leading the day hospital in the cases, a psychologist with psychotherapeutic qualification in seven cases, two day hospitals were headed by a clinical psychologist and a nonerudite clinical psychologist and another professional (social worker) was the head in the five remaining day hospitals. The most frequently used therapeutic method was group psychotherapy, followed by ergo-therapy, community and art therapy, respectively. On the basis of diagnoses in the year 2000, most patients treated in day hospitals were suffering from an anxiotic disorder and disorder in adaptation, followed by disorder in adaptation, patients suffering from mental disorders and behavior disorders induced by the effect of psychoactive compounds, followed by patients suffering from schizophrenia or an schizoaffective compound, followed by patients suffering from schizophrenia or an schizoaffective disorder.
Background
Schizophrenia is a common and burdensome illness, with implications not only for the health service but for a host of other care agencies – public and private – as well as for patients, families and the wider society.
Method
The paper reviews available UK evidence on the cost of schizophrenia (broadly defined) and on the cost-effectiveness of treatment options and alternative care arrangements. New evidence potentially alters our view of the costs of this illness.
Results
Aggregating the identifiable direct and indirect costs of schizophrenia for England suggests an annual cost of £2.6 billion, but even this sum omits some indirect impacts which cannot currently be costed. Just over half the identified total is accounted for by the direct costs falling to the NHS, local authorities, charities and the criminal justice system. In helping to tackle this cost burden, there is now a body of evidence on cost-effective community care arrangements, antipsychotic drugs and psychological interventions.
Conclusions
Although the costs of schizophrenia are considerable, there are treatments and care arrangements which can reduce this aggregate burden while maintaining or improving effectiveness.
The paper presents a literature review of research findings on acute treatment in psychiatric day hospitals, and outlines the design of an ongoing multi-site study on the effectiveness of acute day hospital treatment. The review is based on relevant older publications and recent randomised controlled trials comparing day hospital treatment with inpatient care. The findings suggest that (a) a wide range of patient groups are cared for in day hospitals, (b) both patients and their relatives assess day hospital treatment favourably, (c) treatment in day hospitals is at least as effective as inpatient care, and (d) day hospital treatment may lead to significant cost savings as compared to in-patient care. There are, however, a number of important questions that cannot be answered on the basis of the existing literature, and further research on the topic is warranted. The EDEN-study (European Day Hospital Evaluation) is a randomised controlled trial comparing day hospital treatment with conventional in-patient care and following the same protocol in five European countries (Czech Republic, Germany, Poland, Slovakia, and United Kingdom). Aims and methods of the study are presented.
Professor R. G. Priest and Dr K. A. Day have prepared a discussion document on the future of mental hospital sites on behalf of the Public Policy Committee ( Psychiatric Bulletin , April 1990, 14, 245–248), and may be complimented for stating their views in such detail.
The major objectives of this work are (1) to determine the Eh-pH conditions under which pyrite is stable, (2) to determine the mechanism of the initial stages of pyrite oxidation and (3) to determine if the semi-conducting properties of pyrite effects its oxidation behavior. It is known that moderate oxidation of pyrite produces a hydrophobic surface product. This hydrophobic product makes it extremely difficult to depress pyrite in coal flotation circuits. The eventual objective of this work is to prevent pyrite oxidation in order to better depress pyrite in coal flotation circuits. In this work clean, unoxidized pyrite surfaces are being produced by fracturing pyrite electrodes in an electrochemical cell. It has been shown that pyrite assumes a unique potential referred to as the ``stable potential`` at the instance it is fractured and that this potential is several hundred millivolts more negative than the steady state mixed potential of pyrite. It has also been shown that by holding the potential of pyrite at its stable potential during fracture, pyrite undergoes neither oxidation nor reduction. It has also been found that fresh pyrite surfaces created by fracture in an electrochemical begin to oxidize at potentials that are about 200 mV more negative than the potentials reported in the literature for pyrite oxidation. This is attributed to the fact that most work on pyrite has employed polished electrodes that have pre-existing oxidation products on the surface. The existence of a pH dependent stable potential for freshly fractured pyrite electrodes was based on studies conducted mainly on pyrite from Peru.
The economic effects of mental disorder on individuals and their families and on society have received little scientific attention. Late life depression imposes substantial disability and it affects all spheres of function. Therefore, the development of rational health policy regarding this disorder requires prospective evaluation of related costs and the determination of the value of proposed interventions. A vigorous review and analysis of the existing literature provides a framework for synthesis of an aggressive research agenda which emphasizes four major areas: (1) Improved diagnostic rigour; (2) Integration of economic and epidemiologic methods; (3) Microscopic studies of individual and family costs; (4) Interventional benefit/cost analysis.
A literature review of the development of the community psychiatric nursing service in the UK was carried out to locate influences on the emerging role of the CPN, to isolate components of practice, and to identify current issues for service delivery. This assisted in identifying differing models of practice prior to a review of the experience of CPNs with clinical supervision in their practice. Consideration of this will appear in the next issue of NTResearch.
The authors review includes: the historical background, standards, functional issues, efficacy and alternative models of care of partial hospitalization programs in North America. The emphasis is placed on those issues which are of relevance when planning alternative programs to inpatient hospitalization.
At the heart of the family psychoeducational approach is the need expressed by families experiencing significant burdens in caring for their ill relatives for more information and concrete advice about their relatives' illness and treatment. The programs reported in the literature that have been developed to respond to these needs have shown significant positive results. It is hypothesized in this study that the educational aspect of these programs is a significant mode of action or core component of these programs. To test the effectiveness of this core or minimal educational module directed toward families of persons with a chronic mental illness, an all-day educational workshop was conducted with family members (N = 22) who live with a relative with a schizophrenic illness. Results attest to the benefits of an educational model of intervention with families of persons with a chronic mental illness. The study offers some preliminary implications, both theoretical and practical, for the role of social workers in working with caregivers of the chronically mentally ill
Les auteurs discutent de la litterature publiee sur une modification possible a l'hospitalisation traditionnelle en psychiatrie : l'hospitalisation breve. Ils font ensuite part de l'experience de 30 mois realisee a l'unite de traitement transitoire du Pavillon Albert-Prevost. Enfin, les auteurs soulignent que bien que Ia recherche et la pratique courante favorisent une telle approche, cette modalite de traitement est peu employee; diverses raisons pouvant expliquer cet etat de fait sont envisagees.
Administered a questionnaire to 152 families with a schizophrenic spouse and 1,832 urban families in Poland to provide information on the lifestyles of the former. The questionnaire was designed by D. Markowska for the Polish Academy of Science (1980) to determine everyday lifestyles of the Polish population. The World Health Organization's IX Revision Diagnostic Criteria for schizophrenia were adopted and diagnoses were verified by 2 senior psychiatrists. Results indicate that (1) families with schizophrenic spouses are not considerably different from other families; (2) autonomy of the nuclear family from the extended family characterized both populations; (3) recreational functions of families are affected by the presence of schizophrenia; and (4) the amount of information about schizophrenia understood by the schizophrenic's family correlates negatively with adaptation to the disease. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
IntroductionPhenomenology and DiagnosisEpidemiology and CourseFamilial–Genetic Basis of Spectrum ConceptsNeurobiological CorrelatesTreatment OptionsSummaryReferences Extending the Schizophrenia Spectrum Even Further. Authored by Gordon ClaridgeSchizotypy: Theoretical Considerations, Latent Structure, and the Expanded Phenotype. Authored by Mark F. LenzenwegerEmpirical Characterization of the Schizophrenia Spectrum. Authored by Loring J. IngrahamExploring Schizophrenia Across the Continuum. Authored by Elaine F. WalkerSchizophrenia Spectrum Disorders and the Psychotic Continuum. Authored by Victor PeraltaDimensions of Schizotypy in Symptomatic, Neurocognitive and Psychophysiological Indicators. Authored by Keith H. Nuechterlein, Kenneth L. Subotnik and Robert F. AsarnowThe Role of Syndromes and Neurophysiology in Conceptualizing the Schizophrenia Spectrum and Predisposing Influences. Authored by John GruzelierIrremediable Flaws in the Schizophrenia Spectrum Concept. Authored by C. Robert CloningerDo Not Dismiss the Single Major Locus Hypothesis So Quickly. Authored by Philip S. Holzman, Deborah L. Levy and Steven MatthysseSchizophrenia Spectrum: Where to Draw the Boundary? Authored by Gisela Gross and Gerd HuberIs There a Place for the Nature–Nurture Hypothesis in the Aetiology of Schizophrenia Spectrum Disorders? Authored by Allan F. Mirsky and Connie C. DuncanSchizophrenia Spectrum—a “Terra Flexibilis”. Authored by Andreas MarnerosSome Open Research Issues Concerning Schizophrenia Spectrum Disorders. Authored by J. D. GuelfiSchizophrenia Spectrum Disorders Revisited. Authored by Muhammed Afzal Javed
IntroductionHistory of TreatmentCourse of SchizophreniaTerminologyRehabilitationStigmaSummaryReferences What Works for the Rehabilitation of Schizophrenia? A Brief Review of the Evidence. Authored by Kim T. MueserThe Stigma of Mental Illness: Some Empirical Findings. Authored by Jo C. PhelanReducing the Stigma Associated with Schizophrenia. Authored by Richard WarnerThe Influence of Stigma on Preventive Efforts in Psychotic Disorders. Authored by Patrick McGorryDisability, Stigma and Discrimination: A View from Outside the USA. Authored by Heinz HäfnerThe Toxic Effects of Stigma. Authored by Harold M. VisotskyThe Conceptualization of Long-term, Disabling Psychiatric Disorders. Authored by Pedro RuizUtility of Multiaxial Assessment in the Rehabilitative Work with Chronically Disturbed Patients. Authored by Marianne C. Kastrup“Clanning” for Recovery. Authored by Ulf MalmStigma and Schizophrenia: The Greek Experience. Authored by Marina EconomouDisability and Stigma Prevention: The Russian Experience. Authored by Vassily S. YastrebovAre Western Models of Psychiatric Rehabilitation Feasible and Appropriate for Developing Countries? Authored by Michael R. PhillipsIs Schizophrenia a Chronic Illness? The Experience of Developing Countries. Authored by R. Srinivasa MurthyPrevention of Disability and Stigma: Experience from a Developing Country. Authored by Muhammad Rashid Chaudhry
IntroductionThe Overall Costs of SchizophreniaPrincipal Cost DriversEconomic EvaluationsCost–Outcome Evidence: PharmacotherapiesCost–Outcome Evidence: Psychological TherapiesCost–Outcome Evidence: Care ArrangementsSummaryReferences Is Schizophrenia Worth the Cost? Authored by Gavin AndrewsMorality and Cost in the Management of Schizophrenia. Authored by Paul BebbingtonCaveat Emptor: Pitfalls in Measuring the Costs of Schizophrenia. Authored by Richard WarnerThe Economic Consequences of Schizophrenia. Authored by Steven S. SharfsteinThe Many and the Few: Evidence-based Mental Health in a Primary-care-led Health Service. Authored by Linda GaskThe Long-term Course of Schizophrenia and its Economic Consequences. Authored by Durk WiersmaHealth Economics in Schizophrenia: Clouding or Clarifying? Authored by Tom BurnsThe Economic Burden of Schizophrenia. Authored by Marc De Hert and Joseph PeuskensLack of Comprehensive Care for Schizophrenic Patients: Is it Due to Prohibitive Costs or Insufficient Advocacy? Authored by Thomas DetreThe Role of Cost-effectiveness Analysis in Improving the Treatment of Schizophrenia. Authored by Herbert Y. MeltzerMedical Cost Outcomes of the Atypical Antipsychotics. Authored by Dennis A. RevickiThe Costs of Schizophrenia-new Treatments and New Economics. Authored by Melvin Sabshin
Prior to the 1970s, individual and group psychotherapies for schizophrenia were generally based on psychodynamic theories, or theories that conceived of schizophrenia as being caused by the behaviour or communication patterns of the sufferer's family. Following the introduction of effective antipsychotic medication in the 1960s, there was a shift of focus away from psychological interventions for schizophrenia. Gradually, there was dissatisfaction with the over-reliance on pharmacological treatments for schizophrenia, as it emerged that a high proportion of individuals with schizophrenia continued to experience positive symptoms of psychosis despite taking antipsychotic medication. Thus, controlled trials of psychological interventions designed to promote acquisition of social skills and reduce relapse by improving family atmosphere emerged in the 1980s. Their positive results were well received and promoted increased interest in psychological therapies in this population. Concurrent with these developments, the usefulness of cognitive therapy for the symptoms of depression encouraged clinicians and researchers to extend its techniques to the treatment of medication-resistant positive symptoms of psychosis.
Recent research suggests that, for some people with severe mental illness, supported employment could improve vocational outcomes for little additional expense. This study describes the costs and client outcomes in one mental health center that converted two rehabilitative day treatment programs to supported employment. Converting from day treatment to supported employment improved vocational outcomes significantly without increasing costs. Although total costs for community treatment were lower in both sites after implementing supported employment, differences appeared to be due to decreasing unit costs over the study period. Results illustrate the importance of testing the effects of cost estimation methods on findings.
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Benefit--cost analysis as a form of "social profitability analysis" can be a powerful tool in the overall evaluation of alcoholism treatment efforts. Alcoholism treatment potentially leads to a multiplicity of benefits in addition to sobriety. Benefit--cost analysis provides a methodology for converting many of these diverse benefits into a common metric (dollars), thereby allowing the comparison of aggregate benefits and treatment costs. The analysis thus leads to the expression of treatment outcome in terms of the return on investment. A benefit--cost analysis conducted on 3034 clients from the Oklahoma data base indicated a return to society of 1 invested in alcoholism treatment. Such data may represent a critical portion of the information required for responsible resource allocation decisions.
This study compares the cost of treating 23 children admitted to a residential treatment unit in a psychiatric hospital and 23 children admitted to the same unit after it was converted to a day treatment program, through a retrospective chart review. The two groups were similar in age, gender, diagnosis, severity of pathology, family functioning and support, the number of subjects who dropped-out, and treatment outcome. The average length of stay on the unit dropped from 19.6 to 6.1 months, and the average cost of treatment per child decreased from 9,213 (Canadian dollars, adjusted for inflation). The sharp decrease in treatment time with day treatment may be the result of close links with community schools and maintaining the child in the family and community. The cost savings can be attributed to the shorter hospital stays and the lower operating costs of day treatment. Implications of these findings will be discussed with respect to health care policy including the need to raise awareness of day treatment as a cost-effective alternative to residential hospital treatment.
As a treatment modality for serious mental disorders, partial hospitalization has been proven to have therapeutic and economic advantages. However, it has relatively low utilization and poor third-party reimbursement compared to the more traditional outpatient and inpatient treatments. The authors provide a review and update of the definitions, historical development, models, staffing, and referral patterns of partial hospitalization. They comment on the role of the psychiatrist as a member of the multidisciplinary team in this treatment setting.
Notes that, at present, families find themselves playing an integral role in the caretaking of mentally ill individuals, and are in need of supportive family counseling. Psychologists are in an ideal position to consult to families and staff; however, curricular revisions are needed to educate and train psychologists for this task. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Many studies have shown that there are cost-effective alternatives to 24-hour hospital care. The new era of medical economics emphasizes prospective payment and alternative delivery systems. This provides new opportunities for psychiatric patients to receive appropriate care outside the traditional inpatient context.
This study illustrates the necessity for and compatibility of both acute and specialised care roles within psychiatric teaching hospitals. Clinical investigators and sub-specialists need a source of patients. The hospital must provide effective acute care in order to be credible as a treatment facility in the local community and hence, to attract appropriate and representative referrals for research and teaching purposes. At the same time, specialised research units cannot be expected to respond to all demands for acute service. A model of organisation consisting of acute care and specialist units, such as the one described in this paper, can fulfil both the needs for service and for research and teaching. While it is not possible to conclude that the PCS specifically assisted or adversely affected the development of the research and clinical sub-specialisation of other wards that occurred during the period of this study, it is important to note that the in-patient caseload of the hospital, as measured by annual admissions, was maintained over the period reviewed while at the same time there was a net reduction of 16 beds in the hospital.
In recent years, several controlled studies have evaluated the value of different lengths of psychiatric hospitalization and of alternatives to hospitalization. The author reviews such studies, noting that most findings suggest that longer stay does not decrease subsequent hospitalization, and does not clearly improve social adjustment or diminish psychopathology. Longterm hospitalization may increase the patient's commitment to continued psychiatric care, but short stay with optimal aftercare planning may be just as beneficial. Long-term hospitalization is necessary clinically for some patients, but the evidence is consistent and convincing in indicating that hospitalization should be kept as short as feasible.
A comparison has been made of costs within in-patient units in a large Scottish psychiatric hospital. Cost differences were found between short-stay, rehabilitation and long-stay psychosis units and beds for the elderly with mental disorder. These differences reflected staffing levels, particularly of nurses. The costs were greater than average for psychiatric hospitals and approximated to geriatric units - a finding in keeping with the high occupancy of beds by the elderly. Existing long-stay elderly patients require to be considered separately in distinguishing elderly in-patient costs without psychogeriatric care offered by society.
Compared psychiatric patients referred for treatment before and after the 1978 Italian Psychiatric Act that limited readmissions and prohibited first admissions to the traditional long-term mental hospital. Three areas were studied that differed in sociodemographic characteristics and outpatient services. The trend of admissions tended to fall after the new Act. Local differences are discussed. (17 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
During the early 1960s partial hospitalization emerged as an important component of community-based psychiatric treatment. Initially partial hospitals offered all types of treatment to all types of patients. To help mental health professionals make informed decisions when matching specific treatments to specific patient characteristics, the authors define three kinds of partial hospitals--intensive care, chronic care, and rehabilitation partial hospitals--and propose selection criteria for referral to each model. Factors to be considered in making differential therapeutic decisions between a specific type of partial hospital program and alternative methods of treatment, such as inpatient treatment, are discussed.
The study used a societal costs model to estimate costs of assertive community treatment for persons with severe mental illness.
Resource use and cost data were collected for mental health, health, social, and law enforcement, and other maintenance services and family services for 94 clients enrolled in a mobile community treatment program in Madison, Wisconsin. Data sources included self-reports of clients and family members, private and public agency records, and insurance claims files. To make more precise estimates, outcome definitions were broadened, data sources were cross-validated, and prices of services were calculated independently of agencies' charges for such services.
Average societal costs for participants in the study were estimated at 29,965 in 1994 dollars). Use of a less sophisticated model with less careful costing methods would have resulted in an estimated average cost at least 30 percent lower. Maintenance costs (cash payments from government programs, subsidies, and in-kind services) were the largest cost component, followed by mental health treatment, family burden, indirect treatment, and law enforcement. Most of the financing for these services came from the public sector (85 percent).
Accurate, reliable, and consistent measurement of societal costs will aid in the complex task of rationing fixed health and mental health care budgets.
Three sorts of economic studies have addressed the treatment of schizophrenia. Studies of the total costs of the illness to whole communities have examined the economic effects of changes in both the illness and its treatment; naturalistic studies of cohorts of patients have addressed relationships between costs, needs and clinical outcomes; and randomized controlled trials of various kinds of community care and traditional care have produced data on the relative cost effectiveness of the new treatments. The Madison model of training in community living is generally cheaper for society than traditional care, consistently produces better satisfaction and, in some studies, has produced better clinical outcomes as well. Other models of care have produced similar outcomes at lower cost. A study that includes home-based rehabilitation for patients with established schizophrenic illness has produced better outcomes at similar costs. In general terms, cost savings are achieved by shortening the length of stay in hospital. Day care--often preceded by a short admission--has been shown to be cost-effective as an alternative to traditional hospitalization. The results of randomized control trials cannot be generalized to all those needing acute admission to hospital, since all studies have excluded many patients from the trials. There is some evidence that higher community costs are associated with better outcomes.
The purpose of this paper is to present initial findings from a retrospective chart review of geriatric day treatment patients in order to focus attention on this potentially important area, add to the limited database in this area, and generate hypotheses for future investigations.
Data were abstracted from the charts of 100 geriatric day treatment patients over a period of approximately 5 years (1985-1989). Descriptive, univariate, and multiple regression techniques were used to describe the patients and identify variables associated with their outcomes.
The typical patient in this program was a widowed white woman in her 70s who suffered from a depressive disorder. During the initial treatment period (usually approximately 3 months), 57% of the patients experienced some clinical improvement. Variables associated with a favorable outcome included diagnosis of a mood disorder rather than a psychotic disorder, better initial functional status, greater initial social support, fewer stressful events during treatment, and longer duration of treatment.
Geriatric day treatment can be effective and merits further study as a mode of treatment for psychiatrically ill elderly patients.
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.
A total of 175 newly admitted inpatients who lived with their families were randomly assigned to three treatment groups: standard inpatient care and brief hospitalization with and without transitional day care. Case reports of 6 of the 9 patients considered "study failures" illustrate that effective postdischarge adaptation is limited by the patients' degree of impairment as well as the family and community capacity to accept them. Although rapid return to the community is beneficial to many patients, rigid adherence to this policy is neither wise nor clinically effective.
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.
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.