Day hospital treatment for mood disorders

Conducting Outcomes Research in a Clinical Practice Setting: The Effectiveness and Acceptability of Acceptance and Commitment Therapy (ACT) in a Partial Hospital Program

Multiple challenges exist integrating research into clinical practice, particularly in acute care settings where randomized controlled trials may be impractical or unethical. Partial or day hospitals are one such setting. As compared to outpatients and inpatients, relatively little research is conducted or reported in partial hospital program (PHP) patients, leaving providers in this setting without a solid empirical basis from which to draw. We report treatment outcomes and patient satisfaction from the first 750 patients enrolled in a clinical research PHP utilizing the acceptance and commitment therapy (ACT) treatment model. ACT is a well-established, transdiagnostic behavior therapy. However, to date no study has examined the use of ACT in acute day hospitals. We hypothesized that applying ACT with this patient group would result in significantly improved depression, anxiety, functioning, and quality of life from intake to discharge. We additionally expected that patients would report high satisfaction with ACT treatment groups. Patients (n = 750 full sample, n = 518 completed treatment) completed daily measures of symptoms, functioning, and ACT processes at intake and discharge, and postgroup satisfaction surveys. Results showed significant improvements in symptoms and impairment. ACT process variables also increased over the course of treatment. Importantly, patient satisfaction was high for all groups. Thus, ACT provides an appropriate, flexible, effective, and satisfactory model for this patient group. A comparison of our findings using ACT to the limited research using other models in PHP settings is discussed, as well as challenges in the overall process of integrating research into routine clinical care.

Predictors of Outcome of Acute Partial Hospitalization: An Exploratory Study

To identify predictors of outcome of acute partial hospital (PH) treatment, patients admitted during a 15-month period were studied. Outcomes were change in the Behavior and Symptom Identification Scale and readmission within 30 days. Predictors were clinical and demographic variables obtained on all patients. Most patients (92%) improved during acute PH treatment, only 5% were readmitted, and average changes were moderate to large. However, many patients still had significant symptoms and behavioral problems at discharge, 56.5% missed at least 1 day, and 16.5% dropped out. Less acute improvement was associated with greater long-term impairment, worse treatment attendance, more previous treatment episodes, and fewer medication changes. Readmission was associated with less acute improvement and its predictors, and with nonattendance. In summary, acute outcome in PH was predicted by functioning more generally. Factors that affect patients' acute PH responses may also affect functioning in other areas. These findings suggest possible modifications of PH practices and programs.

Treatment Within an Adult Mental Health Day Program: Examining Psychosocial Outcomes

Day hospital programs provide stabilization, medication optimization, and therapeutic intervention for individuals experiencing acute psychiatric illnesses. The current study investigated treatment impact within an adult day hospital setting in a large Canadian general acute care hospital. A total of 196 patients were sampled in a naturalistic design. Participants filled out measures at admission and discharge, including the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, the World Health Organization Disability Assessment Schedule 2.0, the Behavior and Symptom Identification Scale-24, the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form, and the Emotion Regulation Questionnaire (ERQ). Paired sample t-tests revealed significant improvements from admission to discharge on all but one measure, the ERQ Suppression scale. Overall, patients improved during treatment in terms of psychopathology and disability, and perceived quality of life. When the emotion regulation strategy of reappraisal was increasingly used over the duration of the treatment, improvements were observed in symptomatology, quality of life, and enhanced functionality. This article highlights the impact of therapeutic interventions received within a Canadian day hospital program.

A Mixed Program of Psychoeducational and Psychological Rehabilitation for Patients With Bipolar Disorder in a Day Hospital Setting

The present study describes a new mixed program of psychoeducational and psychological interventions for bipolar patients, applicable during everyday practice. Thirty-two bipolar patients recruited at a psychiatric day-hospital service have been admitted to a program consisting of 30 meetings and 2 follow-ups at 6 and 12 months. The psychoeducational support determined a general improvement of all included patients. At baseline, patients with residual depression had higher Hamilton Depression Rating Scale (HDRS) scores than euthymic patients (mean score ± SD: 21.25 ± 3.92 vs. 7.00 ± 2.95, respectively). After psychoeducation sessions, the HDRS scores of euthymic patients remained stable (mean ± SD: 7.00 ± 3.74), whereas the HDRS scores of depressed patients demonstrated a statistically significant improvement (mean ± SD: 14.00 ± 6.72, t = 2.721, p = 0.03). Results of the Connor-Davidson Resilience scale and specifically constructed questionnaire Questionario per la Valutazione della Conoscenza e dell'Apprendimento per il Disturbo Bipolare showed a statistically significant improvement in resilience and insight in all recruited patients. Psychoeducational intervention as adjunctive treatment to pharmacotherapy seems to be very effective in bipolar patients, not only for those in the euthymic phase, but this model could also be extended to patients with an ongoing mild or moderate depressive episode.

Outcomes of Acute Partial Hospital Treatment: Comparison of Two Programs and a Waiting List Control

OBJECTIVE

To investigate the effectiveness of acute, very brief partial hospital treatment, and the comparative benefits of different types of partial hospitalization programs (PHPs), this exploratory study examined changes in psychiatric symptoms and elements of cognitive functioning during an acute PHP compared with a waiting list control, and also compared such changes in 2 PHPs that treated similar patient groups but used different treatment approaches.

METHODS

Patients were admitted to 2 PHPs, one utilizing cognitive-behavioral therapy and the other interpersonal and existential psychotherapy. Assessments were collected at the start of a waiting list control period, as well as at admission to and discharge from the PHP. In both programs, patients completed self-report assessments of anxiety (Beck Anxiety Inventory), depression (Beck Depression Inventory), hopelessness (Beck Hopelessness Scale), and resilience (Dispositional Resilience Scale) at admission and discharge; a subset of cognitive-behavioral therapy patients completed the same measures while on a waiting list.

RESULTS

During acute partial hospitalization (mean length of stay, 5.3±3.0 d), patients (N=2000) improved significantly (Cohen d=0.39 to 1.1) on all 4 measures of symptom severity and cognitive functioning. Although some changes were observed in the subjects on the 2-week waiting list, they were less than during a 1-week PHP admission. No significant differences in outcomes were found between the 2 PHPs.

CONCLUSIONS

Across 2 different acute PHPs, significant reductions in symptom severity and improvements in elements of cognitive functioning were observed. Findings indicate that acute PHP treatment may produce moderate-sized treatment effects in a 1-week period that seem unrelated to specific psychotherapeutic methods.

Who benefits the most from psychiatric day hospitals? A comparison of three clinical groups

Comparison of the effects of psychiatric day hospital programs between homogenous clinical groups is an important issue that requires more attention. One group of day hospital patients who have not been included in most studies are people with cluster B personality disorders. The purpose of this study was to compare clinical and social participation outcomes in three groups of individuals treated in a psychiatric day hospital: patients with psychotic disorders, patients with mood and anxiety disorders, and patients with cluster B personality disorders. A pre-experimental, pre-test post-test design was used. During the first and last week of treatment, as well as 6 months after discharge, 20 participants in each group completed questionnaires on severity of symptoms, distress, accomplishment, satisfaction with social participation, and self-esteem. During the intervention, there was significant improvement in all groups on all variables, except for self-esteem in people with psychotic disorders, which remained stable. The patients with psychotic disorders showed significantly less improvement than the two other groups in severity of symptoms, distress, and self-esteem. Following discharge, the degree of change was comparable in the three groups on all variables based on between-groups analyses. However, based on within-group analyses, patients in the mood and anxiety disorders group continued to show significant improvement over time after discharge on self-esteem, accomplishment, and satisfaction with social participation, while no significant changes were seen in the other two groups. Although all three clinical groups made significant gains during their participation at the day hospital and maintained these gains after discharge, those with mood and anxiety disorders benefited the most from their day hospital experience.

Cognitive and behavioral changes related to symptom improvement among patients with a mood disorder receiving intensive cognitive-behavioral therapy

OBJECTIVE

To examine the relationship between cognitive and behavioral changes associated with cognitive-behavioral therapy (CBT) and treatment response in an intensive partial hospital (PH) setting.

METHODS

Study participants were 105 patients with mood disorders receiving treatment in a private psychiatric PH setting. The flexible treatment model used evidence-based CBT interventions adapted to the PH context, with emphases on psychoeducation and skills training. Participants completed self-report measures at admission and discharge to assess psychological distress, depression, negative automatic thoughts, and behavioral activation. Mean treatment duration was 9 days.

RESULTS

Decreased negative automatic thoughts and increased behavioral activation predicted reduction of depressive symptoms; however, only decreased negative automatic thoughts was predictive of patients' overall level of psychological distress.

CONCLUSIONS

These results suggest that a CBT intervention adapted for use in a PH setting can be an effective treatment for severe mood disorders. Furthermore, although the design used in this study precludes causal inferences, depressive symptom improvement appears to be associated with decreased negative automatic thoughts and increased behavioral activation. Implications for the delivery of CBT in PH programs and future directions for research are discussed.

Short-term cognitive behavioral partial hospital treatment: a pilot study

OBJECTIVE

Brief, cost-contained, and effective psychiatric treatments benefit patients and public health. This naturalistic pilot study examined the effectiveness of a 2-week, cognitive-behavioral therapy (CBT) oriented partial hospital program.

METHODS

Study participants were 57 patients with mood, anxiety, and/or personality disorders receiving treatment in a private psychiatric partial hospital (PH) setting. A flexible treatment model was used that adapts evidence-based CBT treatment interventions to the PH context with emphases on psychoeducation and skills training. Participants completed self-report measures at admission and after 1 and 2 weeks, to assess stabilization and functional improvements, with added attention to the acquisition of cognitive and behavioral skills. The data were analyzed using repeated measures analyses of variance and correlation.

RESULTS

Participants reported a decrease in symptoms and negative thought patterns, improved satisfaction with life, and acquisition and use of cognitive and behavioral skills. Skill acquisition was correlated with symptom reduction, reduced negative thought patterns, and improved satisfaction with life.

CONCLUSIONS

Results of this pilot study suggest that a 2-week PH program can be effective for a heterogeneous patient population with mood, anxiety, and/or personality disorders. These findings are promising given the prevalence of treatments of such brief duration in private sector PH programs subject to the managed care marketplace. Future studies are planned to test this flexible PH treatment model, with particular attention to the effectiveness of the CBT approach for the treatment of different disorders and to whether effectiveness is sustained at follow-up. Further study should also examine whether skill acquisition is a mechanism of change for symptom reduction and functional improvements.

Evaluation of a psychiatric day hospital program for elderly patients with mood disorders

BACKGROUND

Very little is known about the utility of psychiatric day hospitals for elderly adults with mood disorders. The objectives of this study were to evaluate a long-standing day-hospital program and to explore whether demographic and non-demographic patient characteristics were associated with treatment outcomes.

METHOD

We used t-tests to compare retrospective admission and discharge data for 708 patients over a 16-year period, and multiple regression to examine predictors of improvement.

RESULTS

Depressed patients showed statistically and clinically significant improvements on the Geriatric Depression Scale and the Hamilton Depression Rating Scale. The number and severity of depressive symptoms at admission were strongly related to treatment outcomes. After controlling for initial levels of depression, demographic characteristics did not predict improvement, and axis I and II diagnoses modestly and inconsistently predicted improvement.

CONCLUSIONS

A biopsychosocially-focused day-hospital treatment program was associated with improvements in depression in a large sample of elderly adults with mood disorders. Except for depression severity at admission, patient characteristics had very little impact on treatment outcomes, suggesting that day hospital programs are beneficial for a wide range of depressed elderly adults.

A psychiatric mother-baby day hospital for pregnant and postpartum women

Major depression and other psychiatric disorders are common during pregnancy and the postpartum period, yet these disorders remain largely under-diagnosed and under-treated. Developing programs that are uniquely tailored to meet the needs of perinatal psychiatric patients can improve both the quality and acceptability of care. In this report, we describe the development and implementation of a novel mother-baby day hospital service designed to meet the mental health needs of this special population, and present preliminary data regarding treatment acceptability and effectiveness. Our experience using this model of care for the past five years has suggested that specialized units such as this one represent an acceptable, effective, fiscally viable approach to the care of pregnant and postpartum psychiatric patients. Further research is needed to more thoroughly assess the effectiveness of this type of specialized perinatal service.

Fixed values and a flexible partial hospital program model

Since the 1990s, societal and economic factors have constrained mental health care service delivery in the United States. Partial hospital (PH) programs have been presented with the challenge of using limited resources to treat complex patients in very short time frames; yet predominant psychosocial models and evidence-based treatment approaches have not adjusted sufficiently to the combined demands of patient care and the new health care environment. An updated PH model can advance existing psychosocial theory and practice. The basic assumption of the model is that both clinical and organizational aspects of a PH program must be inherently adaptable to maintain consistent effectiveness. The set of fixed values described here are instrumental in establishing priorities, guiding decision making, and creating a proactive, flexible organization. These values are drawn from the history of psychosocial and milieu treatments from the 1930s to the present and from assumptions and practices of cognitive-behavioral therapy, and are augmented by insights from psychodynamic psychiatry, business management, and leadership. The PH treatment approach aims to translate evidence-based cognitive-behavioral treatments into pragmatic interventions with emphases on psychoeducation and skills training. The context is brief treatment (i.e., one to two weeks) for mood, anxiety, and personality disordered patients in a private sector, managed care environment. Elements of this model may be generalized to inpatient, residential, and intensive outpatient programs, as well as to those that are starting up or being reorganized.