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The Availability and Effectiveness of Residential Treatment for Persistent Mental Illness
Abstract
We surveyed residential treatment centers (RTCs) providing 24-hour supervision for people with mental illnesses or substance abuse and estimate that there are approximately 4.75 beds per 100,000 people in the United States-a number that is significantly lower than that found in some European countries. We also identified 42 private RTCs specifically designed for the rehabilitation of young adults with persistent mental illnesses, and the characteristics of these programs are summarized in this article. Furthermore, we estimate that the number of beds in the United States available for 24-hour supervised care, whether in public or private hospitals or in residential centers, is approximately 34.8 per 100,000, which is significantly below some estimates of the need for these services. Although the literature on this subject is sparse, we also provide a brief review on the efficacy of residential treatment and describe experience with an initial cohort treated at Clearview Communities, a residential rehabilitation center in Maryland for adults with various mental disorders.
... Research on outcomes of residential treatment is difficult (cf. Arfken, Wilson, & Hegedus, 2002), and relatively scarce compared with research on short-term inpatient treatment such as that provided by psychiatric units of general hospitals (de Girolamo et al., 2014;Mueser & Jeste, 2011), partial hospitalization, assertive community treatment, or community case management (Knable, Cantrell, Vander Meer, & Levine, 2015). Few studies have compared residential with other treatment settings. ...
We present findings from a study of outcomes of residential treatment for people who have mental illness, primarily schizophrenia-spectrum and bipolar disorders. The study assesses a range of individual variables before and after participation in the program, to examine clinical and personal recovery and facilitate program improvement. To our knowledge, it is the longest ongoing outcomes study (15+ years) of its kind. The program, Gould Farm, provides recovery-focused, milieu treatment on a 700-acre working farm. It integrates counseling and medication with a work program that provides opportunities for the development of daily living, social, and work skills as well as mental and physical health. Clients were interviewed in person at intake and at discharge. Also, since study year 10 when the follow-up arm began, former clients were interviewed at 6, 18, and 36 months postdischarge via phone. Interview protocols included standard measures of psychiatric symptoms and functioning, substance use, quality of life, and treatment satisfaction. Follow-up interview protocols also assessed individuals’ living, working, family, and social situations as well as their satisfaction in these areas of recovery. Statistically significant improvements on all measures were found at discharge, and were not moderated by key demographic or clinical factors. Preliminary follow-up data showed maintenance of treatment gains, and high treatment satisfaction. We discuss clinical implications of the findings as well as limitations, directions for future research, and recommendations for sustaining outcomes research in organized care settings.
This study evaluated outcomes for participants of a community-based residential treatment and rehabilitation program. The study used repeated measures to retrospectively evaluate 25 individuals with severe psychiatric disabilities who completed a 1-year follow-up period after discharge from the program. Results indicated that following the program these individuals lived for significantly longer periods in the community in more independent settings and functioned at higher levels than in the 6 years prior to participation in the program. These positive outcomes suggest that residential treatment and rehabilitation may be an important consideration in the care of some individuals with severe psychiatric disabilities.
• This report details the long-term course for systematically rediagnosed (and largely chronically ill) patients with schizophrenia (n =163) and with bipolar (n =19) and unipolar (n = 44) affective disorders from the Chestnut Lodge, Rockville, Md, follow-up study. Their conditions were assessed and they are described rigorously from multiple outcome perspectives. Except in the realm of symptomatic diathesis, striking differences emerged between these major axis I disorders consonant with Kraepelin's original observations. Roughly two thirds of the schizophrenic patients were functioning marginally or worse at follow-up, compared with one third of the unipolar cohort. The reverse held for better outcomes. Outcome varied little as a function of follow-up interval (time) across all diagnostic categories. Representative case examples serve to place the ratings in meaningful clinical contexts.
Background
A growing number of severely ill patients require long-term care in non-hospital residential facilities (RFs). Despite the magnitude of this development, longitudinal studies surveying fairly large resident samples and yielding important information on this population have been very few.
Aims
The aims of the study were (1) to describe the socio-demographic, clinical, and treatment-related characteristics of RF patients during an index period in 2010; (2) to identify predictors and characteristics associated with discharge at the 1-year follow-up; (3) to evaluate clinicians’ predictions about each patient’s likelihood of home discharge (HD).
Methods
A prospective observational cohort study was conducted involving all patients staying in 23 medium-long-term RFs of the St John of God Order with a primary psychiatric diagnosis. A comprehensive set of socio-demographic, clinical, and treatment-related information was gathered and standardized assessments (BPRS, HONOS, PSP, PHI, SLOF, RBANS) were administered to each participant. Logistic regression analyses were run to identify independent discharge predictors.
Results
The study involved 403 patients (66.7 % male), with a mean age of 49 years (SD = 10). The participants’ average illness duration was 23 years; median value for length of stay in the RF was 2.2 years. The most frequent diagnosis was schizophrenia (67.5 %). 104 (25.8 %) were discharged: 13.6 % to home, 8.2 % to other RFs, 2.2 % to supported housing, and 1.5 % to prison. Clinicians’ predictions about HD were generally erroneous.
Conclusions
Very few patients were discharged to independent accommodations after 1 year. The main variables associated with a higher HD likelihood were: illness duration of <15 years and effective social support during the previous year. Lower severity of psychopathology and higher working skill levels were also associated with a significantly greater HD likelihood.
Despite modern treatment approaches and a focus on community care, there remains a group of people who cannot easily be discharged from psychiatric hospital directly into the community. Twenty-four hour residential rehabilitation (a 'ward-in-a-house') is one model of care that has evolved in association with psychiatric hospital closure programmes.
To determine the effects of 24 hour residential rehabilitation compared with standard treatment within a hospital setting.
We searched the Cochrane Schizophrenia Group Trials Register (May 2002 and February 2004).
We included all randomised or quasi-randomised trials that compared 24 hour residential rehabilitation with standard care for people with severe mental illness.
Studies were reliably selected, quality assessed and data extracted. Data were excluded where more than 50% of participants in any group were lost to follow-up. For binary outcomes we calculated the relative risk and its 95% confidence interval.
We identified and included one study with 22 participants with important methodological shortcomings and limitations of reporting. The two-year controlled study evaluated "new long stay patients" in a hostel ward in the UK. One outcome 'unable to manage in the placement' provided usable data (n=22, RR 7.0 CI 0.4 to 121.4). The trial reported that hostel ward residents developed superior domestic skills, used more facilities in the community and were more likely to engage in constructive activities than those in hospital - although usable numerical data were not reported. These potential advantages were not purchased at a price. The limited economic data was not good but the cost of providing 24 hour care did not seem clearly different from the standard care provided by the hospital - and it may have been less.
From the single, small and ill-reported, included study, the hostel ward type of facility appeared cheaper and positively effective. Currently, the value of this way of supporting people - which could be considerable - is unclear. Trials are needed. Any 24 hour care 'ward-in-a-house' is likely to be oversubscribed. We argue that the only equitable way of providing care in this way is to draw lots as to who is allocated a place from the eligible group of people with serious mental illness. With follow-up of all eligible for the placements - those who were lucky enough to be allocated a place as well as people in more standard type of care - real-world evaluation could take place. In the UK further randomised control trials are probably impossible, as many of these types of facilities have closed. The broader lesson of this review is to ensure early and rigorous evaluation of fashionable innovations before they are superseded by new approaches.
Assessing deinstitutionalization as a social policy requires examining a system of programs rather than single, "model" services. The authors report an evaluation of 19 residential treatment programs in Hennepin County, Minnesota, that provide three different levels of care (intensive, transitional, and supportive) for mentally ill clients. Data on client characteristics, program outcomes, and hospitalization costs were collected in two study periods between 1980 and 1985. The results showed that the programs served three distinct client subpopulations that differed in recidivism, vocational status, discharge setting, and costs according to the type of program. Clients in all programs made substantial gains in community integration, and as a group the programs were cost-effective.
A comprehensive cost comparison was made of resource utilization by seriously disabled chronic psychiatric patients randomly assigned to inpatient care and to an experimental residential program that provided an intermediate level of 24-hour care. At the end of the two-year study period, no significant changes in patients' clinical condition were observed, but costs for the experimental group averaged about $14,500 less (in 1981 dollars) than for the controls. The cost model included all treatment costs and nontreatment costs such as medical care, community services, case management, law enforcement and fire safety, maintenance outside the mental health system, and collateral costs. The study findings suggest that a program such as this one may be a viable alternative to back-ward long-term care for seriously disabled chronic patients.
The authors describe two psychosocially oriented community residential facilities for patients with persistent and severe mental disorders and multiple failures at community tenure, and they report a retrospective study designed to evaluate treatment outcomes of program residents.
The study employed a retrospective single-group repeated-measures design to evaluate 104 patients who completed the one-year follow-up. One-year mean number of admissions to and days in a hospital or crisis center during the two years before program entry were compared with mean admissions and days for the follow-up year; employment status, living status, and Global Assessment of Functioning (GAF) Scale scores at program entry and at one-year follow-up were also compared. Thirteen sociodemographic and clinical variables were individually tested for association with outcome.
Hospital and crisis center admissions and days were significantly reduced during the follow-up year. At one-year follow-up, a significantly greater proportion of patients were employed and living independently, and fewer were homeless. GAF scores were significantly higher. No significant correlations between outcome and sociodemographic and clinical variables were found.
Despite design limitations of the study, the findings suggest that psychosocial residential treatment models can offer cost-effective and clinically efficacious care to persistently mentally ill patients.
The NHS is no longer a virtual monopoly provider of mental health residential care. This makes it difficult to assess the volume, range and adequacy of local provision.
Local data collectors used standard instruments to collect detailed information about 368 facilities (with 1951 residents) providing mental health residential care in eight districts. Because local definitions were inconsistent, facilities were reclassified on the basis of facility size and extent of day and night cover. The eight categories of accommodation are compared on levels of staffing, staff qualifications and the characteristics of their residents.
There was a nearly threefold variation between districts in the total number of residential places available per unit of population, and even greater variation in the number of places with 24-hour waking cover. Most residents have long-term, severe mental illness and severe impairment. Long-stay wards accommodate people who pose greater risk of violence than do the two types of non-hospital facility with 24-hour waking cover (P < 0.001). The former also employ a much greater proportion of staff with formal care qualifications and, in particular, nursing qualifications than the latter (49% v. 15%, P < 0.001).
It is suggested that one consequence of the diversification in provision of mental health residential accommodation has been a relative reduction in the proportion of provision available to the most severely disabled. This might apply particularly to those who pose a risk of acting violently.
In Italy, where all mental hospitals have been gradually phased out since 1978, psychiatric patients requiring long-term care are being treated in non-hospital residential facilities (NHRFs). However, detailed data on these facilities are sparse.
The Progetto Residenze (PROGRES) residential care project is a three-phase study, the first phase of which aims to survey the main characteristics of all Italian NHRFs.
Structured interviews were conducted with the manager of each NHRF.
On 31 May 2000 there were 1370 NHRFs with 17 138 beds; an average of 12.5 beds each and a rate of 2.98 beds per 10 000 inhabitants. Residential provision varied ten-fold between regions and discharge rates were very low. Most had 24-hour staffing with 1.42 patients per full-time worker.
There is marked variability in the provision of residential places between different regions; discharge rates are generally low.
Health United States 2012. U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration
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