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[Psychiatric Day Clinics - Evidence for and Importance of Patient-Centered Care]
Abstract
Anliegen: Evaluation und Zusammenfassung der neueren Evidenz sowie Beurteilung des Stellenwerts von Tageskliniken im Versorgungssystem.
Methode: Systematischer Review der Evidenz zur Wirksamkeit und Kosteneffektivität tagesklinischer Behandlung im Vergleich zu stationärer und ambulanter Behandlung.
Ergebnisse: Die Evidenzlage ist nach wie vor unzureichend und widersprüchlich.
Schlussfolgerung: Tageskliniken stellen als Bindeglied zwischen stationärer und ambulanter Behandlung nach wie vor ein wichtiges Element der gemeindepsychiatrischen Versorgung dar, jedoch ist die Evidenz zur Effektivität und Kosteneffektivität im Vergleich zur stationären und ambulanten Behandlung weiterhin unklar.
Grundlagen. Es wurde eine naturalistische Studie durchgeführt, mit dem Ziel, festzustellen, ob Patienten an der psychiatrischen Tagesklinik von der Therapie profitierten und inwiefern bestimmte Merkmale den Behandlungserfolg beeinflussen. Methodik. Es wurden 208 Patienten der Jahre 2015/2016 retrospektiv untersucht. Die Effektivität der Therapie in der Tagesklinik wurde anhand von Veränderungen des GAF(Global Assessment of Functioning)-Scores von 134 Patienten untersucht. Diese Patientengruppe wurde ebenfalls auf Basis klinischer, sozialer Variablen und Art des Behandlungsendes relativ zum Behandlungserfolg evaluiert. Ergebnisse. Die Patienten profitierten höchst signifikant (p < 0,001) von der Therapie an der Psychiatrischen Tagesklinik des Universitätsklinikums Tulln. In Bezug auf den Behandlungserfolg ließ sich kein Unterschied zwischen Männern und Frauen feststellen. Nach Aufteilung per Behandlungsende und psychiatrischer Hauptdiagnose konnten (höchst) signifikante Unterschiede festgehalten werden. Schlussfolgerungen. Die Behandlungseffektivität an einer psychiatrischen Tagesklinik kann ein weiteres Mal bestätigt werden. Für zukünftige Studien wäre eine Kontrollgruppe, im Sinne von Patienten welche nicht therapiert werden, vorteilhaft. Zusätzliche wäre eine zukünftige Studie einschließlich weiterer psychiatrischer und psychologischer Scores notwendig, um weitere Differenzen der Patientengruppe aufzuzeigen.
In diesem Kapitel sollen die Versorgung und die sozialpsychiatrische Versorgungsforschung in ihren Grundlagen und in einigen Ausschnitten dargestellt werden. Zu Beginn wird auf das Thema der Qualität in der sozialpsychiatrischen Versorgung eingegangen. Hier werden zentrale Begriffe, wie z. B. jener der Qualität, erläutert, die eine zentrale Grundlage für die Versorgung und Versorgungsforschung darstellen. Danach wird die sozialpsychiatrische Versorgungsforschung in ihren theoretischen Grundlagen, u. a. in ihren Zielen, Aufgaben und Teildisziplinen skizziert. Darauf aufbauend, wird ein zentraler Teilbereich der Versorgungsforschung, der den sog. Input – d. h. den Bedarf und die Inanspruchnahme sozialpsychiatrischer Leistungen – betrachtet, dargestellt. Danach wird der daran logisch anschließende Bereich des Throughput, der die Modelle, Strukturen und Abläufe sozialpsychiatrischer Angebote betrachtet, detaillierter beschrieben.
Background:
Presently few studies demonstrate improved outcomes in patients with schizophrenia treated in day rehabilitation centres. One reason is the absence of an evidence based protocol for rehabilitation in such centres. Hence further research is required to assess whether such a protocol will improve psychosocial outcomes.
Aims:
We performed a controlled evaluation study of a protocol based rehabilitation day program (RDC) for persons suffering from schizophrenia.
Methods:
Patients from the experimental group (N=50) were treated within the RDC for a 6 month period. The control group were patients on the waiting list for the RDC. Quality of life (MANSA), social functioning (OSA) and self-esteem (Rosenberg) were measured before and after the intervention.
Results:
Statistically significant improvement was shown in social functioning measured by OSA (F(1,96)=33.7; p<0.001), quality of life measured by MANSA (F(1,96)=69.3; p<0.001) and self esteem measured by Rosenberg scale (F(1,96)=84.5; p<0.001) for patients treated in the RDC compared with the control group, conversely, the control group outcomes deteriorated.
Conclusion:
An evidence based protocol for rehabilitation within the RDC lead to improved social outcomes and recovery for persons suffering from schizophrenia.
Background:
Severe borderline personality disorder is associated with a very high psychosocial and economic burden. Current treatment guidelines suggest that several manualized treatments, including day hospital Mentalization-Based Treatment (MBT-DH), are effective in these patients. However, only two randomized controlled trials have compared manualized MBT-DH with treatment as usual. Given the relative paucity of data supporting the efficacy and cost-effectiveness of MBT-DH, the possible influence of researcher allegiance in one of the trials, and potential problems with the generalization of findings to mental health systems in other countries, this multi-site randomized trial aims to investigate the efficacy and cost-effectiveness of manualized MBT-DH compared to manualized specialist treatment as usual in The Netherlands.
Methods/design:
The trial is being conducted at two sites in The Netherlands. Patients with a DSM-IV-TR diagnosis of borderline personality disorder and a score of ≥ 20 on the Borderline Personality Disorder Severity Index were randomly allocated to MBT-DH or treatment as usual. The MBT-DH program consists of a maximum of 18 months' intensive treatment, followed by a maximum of 18 months of maintenance therapy. Specialist treatment as usual is provided by the City Crisis Service in Amsterdam, a service that specializes in treating patients with personality disorders, offering manualized, non-MBT interventions including family interventions, Linehan training, social skills training, and pharmacotherapy, without a maximum time limit. Patients are assessed at baseline and subsequently every 6 months up to 36 months after the start of treatment. The primary outcome measure is the frequency and severity of manifestations of borderline personality disorder as assessed by the Borderline Personality Disorder Severity Index. Secondary outcome measures include parasuicidal behaviour, symptomatic distress, social and interpersonal functioning, personality functioning, attachment, capacity for mentalizing and quality of life. Cost-effectiveness is assessed in terms of the cost per quality-adjusted life year. Outcomes will be analyzed using multilevel analyses based on intention-to-treat principles.
Discussion:
Severe borderline personality disorder is a serious psychological disorder that is associated with high burden. This multi-site randomized trial will provide further data concerning the efficacy and cost-effectiveness of MBT-DH for these patients.
Trial registration:
NTR2175.
Although psychotherapy is considered the treatment of choice for patients with personality disorders (PDs), there is no consensus about the optimal level of care for this group of patients. This study reports the results from the 6-year follow-up of the Ulleval Personality Project (UPP), a randomized clinical trial comparing outpatient individual psychotherapy with a long-term step-down treatment program that included a short-term day hospital treatment followed by combined group and individual psychotherapy.
The UPP included 113 patients with PDs. Outcome was evaluated after 8 months, 18 months, and 3 and 6 years and was based on a wide range of clinical measures, such as psychosocial functioning, interpersonal problems, symptom severity, and axis I and II diagnoses. The results from the 6-year follow-up were evaluated in this study.
At the 6-year follow-up, there were no statistically significant differences in outcome between the treatment groups. Effect sizes ranged from medium to large for all outcome variables in both treatment arms. However, patients in the outpatient group had a marked decline in psychosocial functioning during the period between the 3- and 6-year follow-ups; while psychosocial functioning continued to improve in the step-down group during the same period. This difference between groups was statistically significant.
The findings suggest that both hospital-based long-term step-down treatment and long-term outpatient individual psychotherapy may improve symptoms and psychosocial functioning in poorly functioning PD patients. Social and interpersonal functioning continued to improve in the step-down group during the post-treatment phase, indicating that longer-term changes were stimulated during treatment.Trial registration: NCT00378248.
Day centres for people with psychiatric disabilities need to be evaluated for effectiveness in order to provide the best possible support. This study aimed at investigating the effectiveness of a tailor-made intervention to improve day centre services for people with psychiatric disabilities.
The intervention was devised to bridge identified gaps in the services and lasted for 14 months. Eight centres were allotted to the intervention (55 attendees) or comparison condition (51 attendees). Fidelity to the intervention and major events in the day centres were assessed. The outcomes were degree of meaningfulness found in the day centre occupations, satisfaction with the rehabilitation received, satisfaction with everyday occupations and quality of life.
The fidelity to the intervention was good, but more positive events, such as new occupational opportunities, had taken place in the comparison units. No differences were identified between the intervention and the comparison group regarding changes from baseline to the 14-month follow-up in perceived meaningfulness among day centre occupations, satisfaction with everyday occupations or quality of life.
The intervention seemed ineffective, but the positive events in the comparison group resembled the measures included in the tailor-made interventions. This first intervention study in the day centre context has hopefully helped to generate hypotheses and methods for future research.
Objective
In 2006 the psychosomatic day hospital for the treatment of acute mental illness of elderly people opened as the first clinic of its kind in Germany. The aim of this study was to determine treatment effectiveness and identify possible effects on health care utilization.
Methods
Designed as a naturalistic study with waiting time before admission as a control condition, primary outcome was level of depressive symptoms as measured by the Hospital Anxiety and Depression Scale. Secondary outcomes were depressive and somatoform symptoms and syndromes as measured with the Patient Health Questionnaire, patient perception of interpersonal problems and health care use before and after treatment.
Results
After treatment significant improvement (p < 0.01) with moderate effect sizes (ES) was found in all variables from admission to discharge (ES from 0.3 to 0.8) and also to follow-up (ES from 0.2 to 0.6). Improvement remained stable at follow-up. Furthermore, after psychosomatic treatment a reduction in medical service usage was visible. Number of consultations (pre: 13, post: 9), number and length of hospital stays (pre: 1,7 weeks, post: 0,3 weeks) were both significantly (p < 0.001) reduced six months after treatment as compared to the period six months prior to treatment.
Conclusion
Results indicate the psychosomatic day hospital treatment of the elderly is successful. Reduced usage of health care and the lower costs for day hospital treatment compared to inpatient treatment point to a positive cost-effect-ratio. Expanding this psychosomatic intervention would be useful in reducing the current gap in mental health care for the elderly.
Day-hospital-based treatment programmes have been recommended for poorly functioning patients with personality disorders (PD). However, more research is needed to confirm the cost-effectiveness of such extensive programmes over other, presumably simpler, treatment formats.
This study compared health service costs and psychosocial functioning for PD patients randomly allocated to either a day-hospital-based treatment programme combining individual and group psychotherapy in a step-down format, or outpatient individual psychotherapy at a specialist practice. It included 107 PD patients, 46% of whom had borderline PD, and 40% of whom had avoidant PD. Costs included the two treatment conditions and additional primary and secondary in- and outpatient services. Psychosocial functioning was assessed using measures of global (observer-rated GAF) and occupational (self-report) functioning. Repeated assessments over three years were analysed using mixed models.
The costs of step-down treatment were higher than those of outpatient treatment, but these high costs were compensated by considerably lower costs of other health services. However, costs and clinical gains depended on the type of PD. For borderline PD patients, cost-effectiveness did not differ by treatment condition. Health service costs declined during the trial, and functioning improved to mild impairment levels (GAF > 60). For avoidant PD patients, considerable adjuvant health services expanded the outpatient format. Clinical improvements were nevertheless superior to the step-down condition.
Our results indicate that decisions on treatment format should differentiate between PD types. For borderline PD patients, the costs and gains of step-down and outpatient treatment conditions did not differ. For avoidant PD patients, the outpatient format was a better alternative, leaning, however, on costly additional health services in the early phase of treatment.Trial registration: Clinical Trials NCT00378248.
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.
For patients with cluster B personality disorders there is no consensus regarding the optimal treatment setting. The aim of this study was to compare the effectiveness of different psychotherapeutic settings for patients with cluster B personality disorders, i.e. outpatient, day hospital, and inpatient treatment.
The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 207 patients with a DSM-IV-TR axis II cluster B diagnosis. Patients were assigned to 3 different settings of psychotherapeutic treatment and effectiveness was assessed at 18 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45), and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences.
Patients in all 3 settings improved significantly in terms of psychiatric symptoms, social and interpersonal functioning, and quality of life 18 months after baseline. The inpatient group showed the largest improvements. The comparison of outpatient and inpatient treatment regarding psychiatric symptoms showed a marginally significant result (p = 0.057) in favour of inpatient treatment.
Patients with cluster B personality disorders improved in all investigated treatment settings, with a trend towards larger improvements of psychiatric symptoms in the inpatient setting compared to the outpatient setting. Specialised inpatient treatment should be considered as a valuable treatment option for cluster B personality disorders, both in research and in clinical practice.
Anliegen: In den letzten Jahren befinden sich Tageskliniken in einem Prozess der konzeptionellen Neubestimmung, der bislang noch nicht systematisch erfasst wurde. Methode: Mit einem strukturierten Instrument wurden Ende des Jahres 2001 aktuelle Struktur- und Leistungsmerkmale allgemeinpsychiatrischer Tageskliniken in der Bundesrepublik Deutschland erhoben. Ergebnisse: Generell hat die tagesklinisch vorgehaltene allgemeinpsychiatrische Behandlungskapazität noch nicht den nach wissenschaftlichen Erkenntnissen möglichen Umfang erreicht, was insbesondere für ländliche Regionen einzelner Bundesländer zutrifft. 56 % der befragten Tageskliniken verstehen sich mittlerweile insbesondere als Alternative zur vollstationären Behandlung sowie als schwerpunktmäßig psychotherapeutisches Behandlungsangebot. Ein Vergleich zwischen den meist in den letzten Jahren etablierten Einrichtungen in den „neuen” Bundesländern mit der Situation in den „alten” Ländern verdeutlicht die stringentere Orientierung auf das akutpsychiatrische Aufgabenfeld in den erst kürzlich begründeten Tageskliniken. Dies schlägt sich insbesondere im aktuellen Spektrum der klinischen Hauptdiagnosen, der durchschnittlichen Gesamtbehandlungsdauer, den einrichtungsbezogenen Kontraindikationen sowie in der Ausrichtung angebotener diagnostischer Maßnahmen nieder. Bei weitgehend einheitlichen administrativen Gegebenheiten, findet sich in den deutschen psychiatrischen Tageskliniken eine erhebliche Variation der einrichtungsbezogenen Stellenanzahl in den Kernberufsgruppen. Schlussfolgerungen: Ausbildungsrichtlinien, spezifische Weiterbildungsangebote und insbesondere die personelle Ausstattung müssen dem gewandelten Aufgabenspektrum von Tageskliniken Rechnung tragen. Die einzelne Einrichtung sollte ihre zentrale(n) Programmfunktion(en) klar definieren und Auswirkungen auf ihre Stellung im regionalen Versorgungssystem transparent kommunizieren.
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.
Psychiatrische Tageskliniken können auf eine langjährige Geschichte zurückblicken. Psychotherapeutische Tageskliniken für
bestimmte Störungsgruppen oder mit Schwerpunkt auf bestimmten Psychotherapieverfahren sind hingegen noch eine Seltenheit.
Im April 1998 wurde im Universitätsklinikum Hamburg-Eppendorf, Klinik für Psychiatrie und Psychotherapie, eine verhaltenstherapeutische
Tagesklinik als Teil eines komplexen stationär – teilstationär – ambulanten verhaltenstherapeutischen Versorgungsangebots
eröffnet. Die rasche, hohe Akzeptanz durch Patienten und Zuweiser legen einen ausgesprochenen Bedarf für ein solches Therapieangebot
nahe. Wir wollen darstellen, wie eine verhaltenstherapeutische Tagesklinik arbeitet und was sie von den traditionellen psychiatrischen
Tageskliniken unterscheidet.
Psychiatric day care has a long tradition. However, psychotherapeutic day care institutions specialising in particular disorders
or certain therapeutic approaches are still the exception. A day care unit for behaviour therapy was established at the Clinic
for Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf in 1998 as part of a complex inpatient, day care,
and outpatient behaviour therapy unit. The immediate and high acceptance by patients and their doctors indicates a strong
need of such a treatment setting. We present how this day care unit works and how it differs from the traditional psychiatric
day care.
Die Akut- und Postakutbehandlung der Alkoholabhängigkeit beinhaltet eine individuelle Kombination ambulanter, teilstationärer
oder stationärer Therapiemaßnahmen. Sie reicht vom ärztlichen Ratschlag, „motivationaler Intervention“ über die „qualifizierte
Entzugsbehandlung“ bis hin zur psychotherapeutischen und pharmakologischen Rückfallprophylaxe im Sinn einer Rehabilitationsbehandlung.
Unter Nutzung dieser Interventionen lassen sich Abstinenzquoten von über 60% über 1Jahr erzielen. Für den behandelnden Arzt
sind neben der ausreichenden diagnostischen Sicherheit motivierende Gesprächstechniken und Kenntnisse über wirksame therapeutische
Möglichkeiten der ambulanten und stationären Entzugsbehandlung, der medikamentösen Rückfallprophylaxe und der Vermittlung
in rehabilitative Maßnahmen notwendig.
The acute and post acute treatment of alcohol dependence consists of an individual combination of outpatient, day care or
inpatient therapy approaches, including medical advice, motivational intervention, qualified detoxification, and psychotherapeutic
and pharmacological relapse prevention treatment. Using these therapy approaches abstinence rates of 60–70% over 1 year can
be achieved. In addition to a sufficient diagnostic assessment the practitioner applies motivational interview techniques
as well as knowledge on effective therapeutic measures of outpatient and inpatient detoxification, pharmacological relapse
prevention and the referral to a rehabilitation facility.
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.
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.
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.
Acute psychiatric day care has been proposed as an alternative to conventional inpatient care, yet the evidence of its effectiveness is inconsistent and based only on single-site studies in 3 countries. The aim of this multicenter randomized controlled trial was to establish the effectiveness of acute day hospital care in a large sample across a range of mental health care systems.
The trial was conducted from December 2000 to September 2003 in 5 European countries, with a sample of 1117 voluntarily admitted patients. Immediately before or very shortly after admission to the participating psychiatric facilities, patients were randomly allocated to treatment in a day hospital or an inpatient ward. Psychopathology, treatment satisfaction, subjective quality of life, and social disabilities were assessed at admission, at discharge, and 3 and 12 months after discharge. An intention-to-treat analysis was conducted using fixed-effects linear models with structured error covariance matrices and covariates.
Day hospital care was as effective as conventional inpatient care with respect to psychopathologic symptoms, treatment satisfaction, and quality of life. It was more effective on social functioning at discharge and at the 3- and 12-month follow-up assessments.
This study, which has more than doubled the existing evidence base, has shown that day hospital care is as effective on clinical outcomes as conventional inpatient care and more effective on social outcomes.
ClinicalTrials.gov identifier NCT00153959.
Although previous studies suggested that psychiatric day hospital care is a valuable alternative to inpatient treatment, its effectiveness for elderly patients is disputed. Small number of cases, poor definition of the psychotherapeutic setting, and absence of systematic assessment at different time points may explain the observed discrepancies. We performed an assessment of a psychiatric day hospital treatment combining individual and group psychotherapy in a series of 122 elderly depressed outpatients.
The Geriatric Depression Scale, Short Form Survey, as well as a Therapeutic Community Assessment Scale and Group Evaluation Scale were repeated at admission, 3, 6, 12 months and discharge. The day hospital program was based on psychotherapeutic treatment combining individual and group settings. All patients presented with major depression or a depressive episode of bipolar disease. Variables included severity of depressive symptoms, quality of life, adhesion to therapeutic community treatment and progress in groups of psychotherapy, art-therapy, and psychomotricity.
There was a significant reduction of depressive symptoms, and improvement in mental quality of life across all time points studied. Adhesion to therapeutic community increased from admission to discharge. This was also the case for the progress in group therapy for all three groups used, yet the evolution of this parameter at intermediate time points was highly variable. Neither demographic characteristics, nor pharmacological treatment or presence of stressful life events predicted the clinical improvement.
Psychotherapeutic care program in day hospitals may improve clinical status and quality of life in elderly depressed patients.
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