Addressing acute psychiatric distress in the Rhode Island Hospital Partial Hospitalization Program: Preliminary outcome results

Addressing acute psychiatric distress in the Rhode Island Hospital Partial Hospitalization Program: Preliminary outcome results

Villalba, Rendueles II

“Partial hospitalization” is a nonresidential, less costly alternative to full (inpatient) psychiatric treatment. Partial Hospitalization Programs (PHPs) emerged in the United States approximately 40 years ago. Only recently, though, have PHPs achieved popularity – as third party payers have capitalized on the cost savings over inpatient treatment. The Partial Hospitalization industry now must define its niche, evinced from documented clinical outcome as well as cost containment. Toward this goal, Horvitz-Lennon et al.1 reviewed the clinical studies from 1957 to 1997 that compared PHP and inpatient psychiatric treatment. Though prior reviewers claimed that valid conclusions are not presently possible, Horvitz-Lennon et al. cautiously asserted that there is “…no evidence that partial hospitalization is less effective than full hospitalization in the provision of tertiary-level care to mentally ill adults of moderate diagnostic severity….” However, a number of problems confound this claim.

First, thirteen of the eighteen reviewed studies (70% of the overall meta-analysis patient sample) were published more than a decade ago. Consequently, these programs bear little resemblance to the current PHPs and inpatient programs that have been forged by the constraints of managed care. For example, the average duration of PHP treatment (for the set of 12 studies that reported treatment duration) was 2.2 months; the shortest was 0.8 months – compared to a 2000 AABH survey of 145 PHPs, which reported a treatment duration mean of 15 days.2 (The average length of treatment at the Rhode Island Hospital Partial Hospitalization Program is 5 days.) Second, illness severity varies markedly across programs. This, as well as program design heterogeneity, limits the utility of meta-analytic generalization.

In spite of a paucity of published evidence, PHP treatment offers theoretical advantages to its inpatient counterpart. For the medically stable patient, inpatient psychiatric treatment is only absolutely required to manage dangerous behavior or life-threatening debilitation. Many severely ill patients are able to “contract for their safety” and remain in the community while receiving intensive care. This minimizes disruption to their daily routines, maintains uninterrupted support of family and friends, and facilitates learning of coping skills (by encouraging immediate application of newly acquired psychotherapy gains). For some patients, inpatient treatment may become a “retreat” from community stressors and unintentionally support pathological identification with the sick role. This in turn can foster dependence on the hospital milieu. PHPs , on the other hand, are far more open systems, which by their very design impose greater functional demands on attendees. Perhaps for this reason, many patients find it less stigmatizing than inpatient treatment. PHP attendees are expected to assume a greater degree of responsibility for their treatment than their fully hospitalized counterparts.

Acknowledging the need to document the clinical outcome of short-term PHP treatment for acute psychiatric illness, the Rhode Island Hospital Partial Hospitalixation Program (RIHPHP) has been conducting a prospective naturalistic study of its program for the past 4 years. Preliminary results of this work are reported here.

METHODS

All patients admitted to the RIHPHP from 1998 to 2002 were asked to complete self-rated questionnaire inventories of anxiety, depression, and hopelessness at intake and discharge. Anxiety and depression symptoms were chosen for study as they comprise the majority of psychiatric disease burden.3 Hopelessness is a sensitive indicator of suicidal risk-even more predictive than the larger phenomenon of depression.4 Clinical outcome was determined by comparing pre and post-treatment questionnaire scores. Though clinicians used intake questionnaire results to guide individual treatments, they were blind to discharge data and program-level outcome trends.

Study Site and Clinicians

The Rhode Island Hospital Partial Hospitalization Program is located in the Ambulatory Patient Center of the Rhode Island Hospital campus. The program is affiliated with the Brown Medical School and is an active member of the Association for Ambulatory Behavioral Health, (a national peer association for PHPs).

The patient flow is approximately 600 admissions per year. The PHP is open 5 days a week, 6 hours per day. The average length of treatment is 5 days. Currently six clinicians provide care for an average daily census of 12 patients. The clinical team includes two board-certified psychiatrists, three licensed clinical social workers, and one registered nurse.

Treatment consists of psychiatric evaluations, pharmacotherapy, and a daily program of insight-oriented individual psychotherapy, existential group psychotherapy, interpersonal group psychotherapy, and group psycho-education. Patients participate in planning their treatment by collaboratively identifying target problems, as well as treatment-relevant strengths and weaknesses. Individuals who display a capacity for introspection receive insight-oriented (“here-and-now” focused) individual psychotherapy. Patients who are unable to generate or tolerate insight receive supportive individual psychotherapy directed toward problem solving and case management. Family therapy is provided whenever family members are available.

Patients Admission Criteria

Patients must present with acute psychiatric illness that results in significant functional impairment in multiple areas of daily life. Patients must be expected to benefit from short-term psychotherapy or a pharmacological intervention. While patients may experience suicidal or homicidal ideation, they must not pose an imminent risk of acting on these dangerous thoughts. Finally, patients must be able and willing to seek emergency assistance if they have a crisis during non-program hours.

Measures Beck Anxiety Inventory (BAI)

The Beck Anxiety Inventory is a 21 item self-report measure of anxiety severity. Interpretation of scores is as follows: 0-7 minimal, 8-15 mild, 16-25 moderate, and 26-63 severe.5

Beck Depression Inventory (BDI-I)

The Beck Depression Inventory (version I) is a 21 item self-report measure of depression severity. Interpretation of scores is as follows: 0-9 minimal, 10-16 mild, 17-29 moderate, and 30-63 severe. Sub-scale scores may be calculated for a cognitive-affective (questions 1-13) and a somatic-performance factor (questions 14-21).6

Beck Hopelessness Scale (BHS)

The Beck Hopelessness Scale consists of 20 true/false statements that are scored 1 or 0. Total BHS scores range from minimal 0-3, mild 4-8, moderate 9-14 to severe 15-20. Patients who score 9 or greater are 11 times more likely to attempt suicide than those who score less than 9.7 Greene8 studied hopelessness in a general population and found a mean score of 4.5 to be normal. Sub-populations of patients of interest for this study, therefore, are BHS score >4 (displaying pathological hopelessness) and >8 (representing patients at increased risk for suicide).

RESULTS Demographics

Demographic data for a sample of 1862 patients treated in the PHP from 1998 to 2002 are reported in Table #1. Referrals to the RIHPHP are as follows: 41% are stepped down from the RIH inpatient Psychiatry unit, 18% are direct admissions from the Emergency Service, 3% originate from the Psychiatric Consult-Liaison Service, and the remaining 38% comprise referrals from outpatient clinicians (both internal and external to the RIH network). Diagnostic distributions are included in the tabulated “Results.”

In a sample of 600 consecutive RIHPHP admissions, 93% of the patients were taking psychotropic medication at the time of their admission. Of those receiving medication, 76% were using more than one agent, averaging 3.4 + or -1.6 medications. Thirty one percent of patients were taking antipsychotic medication.

Clinical Outcomes

The Rhode Island Hospital Partial Hospitalization Program patients showed significant improvement in all study measures over the 5-day average length of treatment. (Tables 2-5) Patients displayed a high degree of disease burden – averaging 1.7 diagnoses per patient and scoring in the moderate to severe range of the BAI, BDI and BHS. All diagnostic groups (except the obsessive compulsive disorder (OCD) sample) achieved statistically significant and clinically robust improvement on all three of these measures. For the total patient sample studied, anxiety and depression decreased by 41% and 30% respectively. The cognitive-affective and somatic-performance dimensions of depression decreased 34% and 27% respectively. While improvement in these measures were seen in patients with personality disorders, the size of their improvement was smaller than the improvement seen in patients with only Axis I diagnoses.

Eighty percent of patients presented with pathological hopelessness (BHS>4); 63% exceeded the threshold (BHS>8) predictive of an 11 fold increased risk (over the general population), for attempting suicide. Statistically significant and clinically robust improvement in hopelessness was observed in virtually all patient-groups. Patients presenting with dysthymic disorder displayed the highest degree of hopelessness. Despite showing substantial improvement, patients presenting with dysthymia or personality disorders continue to display high levels of hopelessness at discharge. In fact, 34% of all patients admitted to the PHP scored >8 at the time of their discharge. The average intake BHS score for the total patient sample (N=768) was 10.5. This is alarmingly higher than the average intake score, 6.4 (N=276), derived from the pooled data of three earlier inpatient studies.9,10,11 In fact, the current study’s average discharge score of 7.0 (N=768) is higher than the intake scores of these prior inpatient studies. These data suggest that the management of psychiatric (suicidal) crisis has evolved dramatically in recent decades. Under the influence of managed care, psychiatric care providers are “tolerating” a markedly greater degree of pathology and risk in the community.

CONCLUSION

This prospective naturalistic study found that the Rhode Island Hospital Partial Hospitalization Program, a short-term acute care PHP, achieved substantial clinical improvement across numerous clinical domains for many different diagnostic groups. Despite these gains howevet, aggressive managed care constraints on length-of-stay assure that a substantial percentage of patients leave the PHP only partially recovered.

REFERENCES

1. Horvitz-Lennon M, Normant ST, Gaccione P, Frank RG. Partial versus full hospitalization for adults in psychiatric distress: A systematic review of the published literature (1957-1997). Am J Psychiatry 2001;158:676-85.

2. Association of Ambulatory Behavioral Health (2001) unpublished survey data.

3. Kesslcr RC, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatry 1994;51:8-19.

4. Kovaks, Beck, Weissman. Hopelessness: An Indicator of Suicidal Risk, Suicide 1975;5(2): 98-103.

5. Beck AT, Steer RA. Beck Anxiety Inventory Manual. San Antonio: The Psychological Corporation, Harcourt Brace & Company, 1993.

6. Beck AT, Steer RA. Beck Depression Inventory Manual, San Antonio: The Psychological Corporation, Harcourt Brace & Company, 1993.

7. Beck A, Weissman A, Lester D, Trexler L. Beck Hopelessness Scale (BHS), in Handbook of Psychiatric Measures. Washington, DC: American Psychiatrie Association, 2000: 268-70.

8. Greene SM. Levels of measured hopelessness in the general population. Br J Clin Psychol 1981;20:11-4.

9. Durham. TW. Norms, reliability, and item analysis of the Hopelessness scale in general psychiatric, forensic psychiatric, and college populations. J Clin Psychol 1982;38:597-600.

10. Steer RA, Kumar G. Hopelessness in adolescent psychiatric inpatients, Psychol Reports 1993;72: 559-64.

11. Breier S, Bramlett RK. Time perspective of substance abuse patients: Comparison of the scales in Stanford Time Perspective Inventory, Beck Depression Inventory and Beck Hopelessness Scale, Psychol Reports 1995;77: 899-905.

Rendueles Villalba II, MD, is the Director of the Rhode Island Hospital Partial Hospitalization Program and Clinical Assistant Professor, Department of Psychiatry and Human Behavior, Brown Medical School.

CORRESPONCENCE:

Rendueles Villalba II, MD

Rhode Island Hospital

Jane Brown Building, Suite 504

593 Eddy Street

Providence, RI 02903

Phone: (401) 444-5228

Fax: (401) 444-6180

e-mail: Rvillalba@lifespan.org

Copyright Rhode Island Medical Society Oct 2003

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