The Effectiveness of Day Programs

The first reports of effective day hospitals (Bierer, 1948; Cameron, 1947; Dzhagarov, 1937) stressed the innovative strategy of using these programs in place of inpatient treatment. This strategy had several obvious benefits in addition to the fact that it is much less expensive to provide day treatment than inpatient hospitalization. Day programs allowed patients to stay in the community, which reduced stigma and helped maintain normal contacts and supports. Day programs also eliminated the need for what was often a difficult transition back to the community after a long inpatient stay.

The first evaluations of day programs in the United States focused on the question of how this treatment strategy compared with inpatient hospitalization. This research was

TABLE 6.1

A Schematic Presentation of the Theoretical Spectrum of Partial Hospitalization Programs Subdivided into Three Parallel Continua Representing (A) General Taxonomy, (B) Primary Function, and (C) Differential Characteristicsa

A.

General Taxonomy

Day Hospital

Day Treatment

Day Care

B.

Primary

Alternative to inpatient

Supplement to traditional

Functional maintenanace

Function

transitional setting

outpatient treatment, vocational rehabilitation

C.

Differential Characteristics

Treatment Goal

Stabilize acute episode

Catalyze rapid improvement Minimize Subsequent treatment

Prevent further deterioration and rehospitalization

Treatment

Psychopharmacology/

Intensive psychotherapy

Activity therapy, and

Modality

supportive therapy

and structure

advocacy

Symptom

Intensity

Acute

Pre/post acute

Chronic

Age

Mixed

Younger

Older

Staffing Pattern

Medical mental health

Nonmedical mental

Predominantly

professionals

health professionals

paraprofessionals

Patient/

Staff Ratio

4

6

15+

Maximum

Census

12

20 to 40

50+

Treatment

Duration

2 to 4 weeks

3 to 4 months

Indefinite

Organizational

Closely allied to

Separate from but

No necessary relationship to

Relationships

emergency and/or inpatient unit

available to inpatient or emergency unit

inpatient or emergency unit

aReprinted with permission from Neffinger, G. G. (1981). Partial hospitalization: An overview. Journal of Community Psychology, 9, 263.

nearly unanimous in finding that day hospitalization was both clinically superior and more economical than inpatient hospitalization. In a 1971 study, Herz, Endicott, Spitzer, and Mesnikoff randomly assigned patients to either inpatient treatment or day hospitalization and found that day treatment was superior on each of their outcome measures.

A similar study by Washburn, Vannicelli, Longabaugh, and Scheff (1976) found that initially, day hospitalization was superior to inpatient hospitalization in reducing subjective distress, improving community functioning, and reducing family burden, total hospital cost, and length of stay in the program. At a 24-month reassessment, they found that there was no longer a difference between the day hospital and inpatient hospital groups. It is interesting to speculate why the differences between the day program and inpatient groups fade after 2 years. The most likely explanation is that for many of these individuals the disease process may have reasserted itself, blurring the advantages gained by attending day programming. An alternative explanation is that day programming improves outcomes faster than the usual natural course of the illness (as discussed in Chapter 3). Perhaps by 2 year's time, the functioning of those who were served in inpatient settings "naturally" reached the level of those served in day programming. As the advantages of day hospi-talization became clear, the focus of research moved toward determining which elements of the day hospital were most effective. Neffinger's work cited earlier is one example of this effort. Probably the most important study in this area to date was done by researchers working for the Veterans Administration (VA). Taking advantage of the large number of day hospitals operated by the VA, Linn, Caffey, Klett, Hogarty, and Lamb (1979) randomly assigned patients from 10 different hospitals to receive either day treatment plus psychotropic drugs or psychotropic drugs alone. The positive results of day programming were not immediately apparent. At the initial 6-month follow-up, the researchers found no difference between the two groups. But, at the 18-month follow-up, they found that the combination of medication plus day treatment was superior to medication alone. Individuals who had received day treatment plus medication had fewer episodes of hospitalization, spent less time in the hospital, and had better social functioning. Day treatment plus medication was found to be clearly superior on almost every outcome measure. Interestingly, they also found that the overall treatment cost of day treatment plus medication was not higher than the treatment cost of medication alone. This might be considered a surprising result, since the recipients of day treatment with better outcomes were receiving more services than those receiving medication alone. The lower cost of their treatment was due to the fact that they used fewer inpatient services, spending fewer days hospitalized. These hospital services have a very high cost.

Analyzing the results further, the researchers found some sharp differences between programs on the outcome variables under study. They found that six of the day hospitals produced positive outcomes, while the other four day hospitals produced outcomes no better than medication alone. They proceeded to study which program factors were associated with both positive and negative outcomes. One important finding was that the six centers producing positive outcomes had costs that were not much greater than the cost of drugs alone, whereas the costs of the four centers with poor outcomes were significantly higher. After reviewing their findings the authors concluded that:

High patient turnover and brief but more intensive treatment, particularly in terms of psychotherapeutic counseling by professionals, may lead to relapse for some schizophrenic patients. (Linn et al., 1979, p. 1061)

In short, group psychotherapy, which costs more because it requires more professionally trained and higher paid staff, also produced poorer outcomes. This evidence supports a more practical, supportive, skills training approach (in contrast to more traditional therapy), which is one of the hallmarks of PsyR.

Beigel and Feder (1970) had similar results, finding that persons with more persistent conditions do poorly in programs designed to provide treatment more appropriate for individuals experiencing acute symptoms. This indicates that certain types of programs are effective for persons in different phases of their illness and ineffective or even harmful for others. These findings also imply that depending on the stage of their illness, they have different treatment needs and goals, the attainment of which may best be achieved in specifically designed programs.

The more recent research has focused on achieving specific outcomes and has examined clubhouse programs. For example, a comparison of outcomes achieved by assertive community treatment programs (see Chapter 7) and clubhouse programs conducted by Stein, Barry, Van Dien, Hollingsworth, and Sweeney (1999) found strong similarities on measures of vocational activity, social relationships, social networks, and community integration. Similarly, Macias (2001) reported on a long-term experimental comparison of the employment results of a program of assertive community treatment (PACT) team (see Chapter 7) and an ICCD-certified clubhouse in Worcester, Massachusetts. Not surprisingly, the PACT team, considering its assertive outreach component, was clearly superior in retaining consumers in the program in contrast to the completely voluntary nature of the clubhouse. PACT was also superior with regard to the proportion of people who achieved employment, although this difference diminished with time. Clubhouse members actually worked more total days for higher hourly pay and earned more money over the length of the study. Interestingly, clubhouse member jobs were more likely to be "white collar and professional rather than manual labor" (Macias, 2001, p. 2). While the relatively lower employment rates among clubhouse members support criticisms of PsyR day programming as increasing dependency and lowering expectation regarding employment (e.g., Bond, Dietzen, McGrew, & Miller, 1995), the clubhouse results point to better, longer lasting, and more career-oriented employment (Macias, 2001).

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  • brandon
    What the difference between psychosocial rehabilitation and day treatment?
    1 year ago

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