[Direct costs of acute day hospital care: results from a randomized controlled trial]

Acceptance and commitment therapy in a psychiatric day hospital-A longitudinal naturalistic effectiveness trial

Objectives

Despite the transdiagnostic approach and the good cross-professional applicability, only few studies have examined the effects of Acceptance and Commitment Therapy (ACT) in a naturalistic clinic setting. This study aims to help closing this gap by investigating the effects of ACT in a psychiatric day hospital during COVID pandemic. It was investigated whether psychopathological symptomology decreased, and quality of life and general functioning improved with the treatment. Additionally, longitudinal effects were tested.

Methods

Participants in this follow-up-design were 92 patients (64.1% female) of a psychiatric day hospital. Survey data of clinical symptoms, quality of life and global functioning were assessed at three time points (with admission, discharge, and 3 months after treatment). Differences between time points were tested using two-sided paired samples t-tests. Additionally, the reliability of change index (RCI) was calculated.

Results

From pre-treatment to post-treatment, symptomology decreased significantly (d = 0.82-0.99, p < 0.001), and global functioning as well as quality of life increased significantly (d = 0.42-1.19, p < 0.001). The effects remained relatively stable, with no significant change between post-treatment and follow-up. The difference between pre-treatment and follow-up was significant for clinical symptoms, physical and psychological wellbeing, and global quality of life (d = 0.43-0.76, p < 0.007).

Conclusion

The significant and sustained improvement in all measures indicates that patients are benefiting from the treatment. Since the trial was neither randomized nor controlled, effects have to be interpreted with caution. Possible influences of the pandemic are discussed.

Clinical trial registration

http://www.drks.de/DRKS00029992, identifier DRKS00029992.

[Effectivity of Inpatient and Day-clinic Psychosomatic-Psychotherapeutic Treatment]

AIM

(Partial) inpatient psychotherapy is well implemented in Germany. To better understand efficacy factors and effects, efficacy studies are necessary. This naturalistic study investigates the effectiveness of inpatient and day clinic psychotherapy as well as patient-and disorder-related factors influencing individual symptom improvements.

METHODS

Patients at a psychosomatic-psychotherapeutic university hospital treated from 2015 to 2019 who completed the BSI-18 either at admission and discharge (n=1366) or at admission and three-month catamnesis (n=497) were included in the analysis.

RESULTS

Improvements in global symptom severity showed moderate effect sizes. Descriptively, these were larger for day clinic patients than for those receiving treatment as inpatients-especially in the follow-up comparison (immediately after discharge: dinpatient=0.401, dday clinic=0.482; three months after discharge: dinpatient=0.403, dday clinical=0.807). Day hospitalized patients differed significantly from inpatients-slightly in age, employment status, ability to work and initial symptom burden, moderately in the number of mental comorbidities and strongly in their main diagnoses. Socio-demographic factors showed no positive influence on symptom improvement, initial symptom severity a moderate positive influence and the number of mental comorbidities a complex influence.

DISCUSSION

In general, this study confirms the effectiveness of (partial) inpatient psychosomatic therapy. The relevance of day clinic offers is emphasised in the context of cost efficiency and good integration into everyday life, but under consideration of individual treatment indications.

Psychiatric Acute Day Hospital as an Alternative to Inpatient Treatment

For the first time in the Swiss health care system, this evaluation study examined whether patients with acute psychiatric illness who were admitted for inpatient treatment could be treated in an acute day hospital instead. The acute day hospital is characterized by the possibility of direct admission of patients without preliminary consultation or waiting time and is open every day of the week. In addition, it was examined whether and to what extent there are cost advantages for day hospital treatment. Patients who were admitted to the hospital with a referral to an inpatient admission were treated randomly either fully inpatient or in the acute day hospital. As a pilot study, 44 patients were admitted to the study. Evidence of efficacy could be provided for both treatment settings based on significant reduction in psychopathological symptoms and improvement in functional level in the course of treatment. There were no significant differences between the two settings in terms of external assessment of symptoms, subjective symptom burden, functional level, quality of life, treatment satisfaction, and number of treatment days. Treatment in the day hospital was about 45% cheaper compared to inpatient treatment. The results show that acutely ill psychiatric patients of different symptom severity can be treated just as well in an acute day hospital instead of being admitted to the hospital. In addition, when direct treatment costs are considered, there are clear cost advantages for day hospital treatment.

[Acute day hospital as a cost-effective alternative to inpatient therapy]

BACKGROUND

This is a study of the cost-benefit advantage of the model project acute day hospital (ATK) compared to inpatient care.

METHODS

The study was performed retrospectively and examined the direct costs and the Global Assessment of Functioning (GAF) in a matched sample.

RESULTS

The day clinic treatment compared to inpatient therapy showed at a cost benefit of 2.68: 1 at a slightly delayed increase in GAF-value.

CONCLUSION

The treatment in ATK is more than twice as cheap compared to inpatient treatment, but at a slightly slower improvement in symptoms.

Day hospital versus admission for acute psychiatric disorders

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.

From general day hospital treatment to specialized treatment programmes

Approximately one third of day hospitals in Europe can be designated as predominantly psychotherapeutic. They address mainly patients with personality disorders (PD), but also eating disorders and chronic mood and anxiety disorders without PD. As day treatment programmes tend to become associated with mental health centers, their treatment intensity also tends to become reduced. Available data suggest that approximately 10 hours of treatment a week is sufficient. Is such treatment more effective than specialized outpatient treatment? This research question will probably set the agenda in the years to come. In response to this challenge, day treatment should become more specialized. Data from the Norwegian Network of Psychotherapeutic Day Hospitals (n = 2.205) demonstrate that the majority of day treatment patients suffer from borderline and avoidant PD. Programmes for patients with borderline PD are well developed. The authors call for programme development for patients with avoidant PD.