Evidence-Based Reviews

Psychiatric partial hospitalization programs: What you need to know

Current Psychiatry. 2022 February;21(2):28-32 | doi: 10.12788/cp.0216

References

1. Neffinger GG. Partial hospitalization: an overview. J Community Psychol. 1981;9(3):262-269.

2. Leung MY, Drozd EM, Healy DA, et al. Impacts associated with the Medicare Psychiatric PPS: a study of partial hospitalization programs. February 2009. Accessed January 8, 2022. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/Leung_PHP_PPS_2010.pdf

3. Williams T, Borders TF, Jasinski L. Partial Psychiatric Hospitalization Program Availability in Non-Metropolitan and Non-Metropolitan Hospitals Nationally. Rural and Underserved Health Research Center; 2019.

4. Rosser J, Michael S, eds. Standards and guidelines for partial hospital programs and intensive outpatient programs. Association for Ambulatory Behavioral Healthcare. 2018. Accessed January 8, 2022. https://aabh.org/wp-content/uploads/2021/05/2021-SandG-Final.pdf

5. CMS Manual System PUB. 100-02 Medicare Benefit Policy: Partial Hospitalization Services, Department of Health and Human Services. Centers for Medicare & Medicaid Services; 2004:6-9.

6. Joint Commission. Guide to Joint Commission Behavioral Healthcare Accreditation. Joint Commission; 2007:36.

7. Hoge MA, Farrell SP, Munchel ME, et al. Therapeutic factors in partial hospitalization. Psychiatry. 1988;51(2):199-210.

8. Ricketts T, Kirshbaum MN. Helpfulness of mental health day care: client and staff views. J Adv Nurs. 1994;20(2):297-306.

9. Marshall M, Crowther R, Almaraz-Serrano A, et al. Systematic reviews of the effectiveness of day care for people with severe mental disorders: (1) acute day hospital versus admission; (2) vocational rehabilitation; (3) day hospital versus outpatient care. Health Technol Assess. 2001;5(21):1-75.

10. Horvitz-Lennon M, Normand SL, Gaccione P, et al. Partial versus full hospitalization for adults in psychiatric distress: a systematic review of the published literature (1957-1997). Am J Psychiatry. 2001;158(5):676-685.

11. Sledge WH, Tebes J, Rakfeldt J, et al. Day hospital/crisis respite care versus inpatient care, Part I: Clinical outcomes. Am J Psychiatry. 1996;153(8):1065-1073.

12. Fink EB, Longabaugh R, Stout R. The paradoxical underutilization of partial hospitalization. Am J Psychiatry. 1978;135(6):713-716.

13. Sledge WH, Tebes J, Wolff N, et al. Day hospital/crisis respite care versus inpatient care, Part II: service utilization and costs. Am J Psychiatry. 1996;153(8):1074-1083.

14. Kiser LJ. Treatment-effectiveness research in child and adolescent partial hospitalization. Psychiatr Hosp. 1991;22(2):51-8.

15. Milin R, Coupland K, Walker S, et al. Outcome and follow-up study of an adolescent psychiatric day treatment school program. J Am Acad Child Adolesc Psychiatry. 2000;39(3):320-328.

16. Rosie JS, Azim HF, Piper WE, et al. Effective psychiatric day treatment: historical lessons. Psychiatr Serv. 1995;46(10):1019-1026.

17. Tasca GA, Balfour L, Bissada H, et al. Treatment completion and outcome in a partial hospitalization program: interactions among patient variables. Psychotherapy Res. 1999;9(2):232-247.

18. Howard WT, Evans KK, Quintero-Howard CV, et al. Predictors of success or failure of transition to day hospital treatment for inpatients with anorexia nervosa. Am J Psychiatry. 1999;156(11):1697-1702.

19. Beard C, Hearon BA, Lee J, et al. When partial hospitalization fails: risk factors for inpatient hospitalization. J Nerv Ment Dis. 2016;204(6):431-436.

20. Lieberman PB, Guggenheim FG. Reasons for patient nonattendance during acute partial hospitalization. Psychiatr Serv. 2016;67(6):684-687.

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Advantages and disadvantages

Based on a qualitative literature review, Neffinger¹ outlined potential advantages and disadvantages of PHPs vs inpatient hospitalization (Table¹). While these have not been empirically studied, they may be useful to consider when determining if a PHP would be beneficial for a specific patient.

Which factors are most therapeutic?

Research on which factors of PHPs are of therapeutic value is quite limited and primarily consists of surveys of small numbers of participants. Hoge et al⁷ explored the active therapeutic factors responsible for change in the Connecticut Mental Health Center PHP by comparing responses of 20 patients with those of their clinicians. Ninety-five percent of patients rated structure as the top therapeutic factor, followed by interpersonal contact, medication, and altruism. Other factors that were rated as important by 40% or fewer participants were catharsis, learning, mobilization of family support, connection to community, universality, patient autonomy, successful completion, security, feedback on behavior, and practice at home. In a British study⁸ that used a similar method, patients reported that counseling was the most helpful aspect of treatment, followed by medical treatment, while staff picked groups followed by a planned approach.

Evidence supports PHPs’ effectiveness

Some research has suggested that PHPs can be effective, both clinically and in terms of cost. Marshall et al⁹ conducted a systematic review of the effectiveness of an acute day hospital vs inpatient admission vs outpatient care that included 9 trials. They concluded that psychiatric inpatient admissions could be reduced by at least 23% if patients were diverted to an acute day hospital. They also found some evidence that day treatment programs may be superior to outpatient care in improving symptoms in nonpsychotic patients who are refractory to outpatient treatment. In a systematic review of 18 studies, high rates of satisfaction with PHP services suggested PHPs have an advantage over inpatient treatment within 1 year of discharge; patients and families were more satisfied with PHPs.¹⁰ In a study of 197 urban, socioeconomically disadvantaged, severely ill patients, Sledge et al¹¹ compared the clinical outcomes of those who participated in day hospital programs with those of patients who received inpatient care. They found that while overall the 2 approaches produced similar outcomes, there were slightly more positive effects for day hospital programs in measures of symptoms, overall functioning, and social functioning. In terms of cost effectiveness, a 1978 study found that even after correcting for differences in treatment days between inpatient and PHP services, there was a significant financial advantage with PHP (costs were one-third less), primarily because of lower costs per day.¹² In another study, PHP cost savings were 20%, and potential savings were higher for nonpsychotic patients.¹³

Are PHPs appropriate for children and adolescents?

Studies of PHPs for adolescents found that patients made gains in peer relationships, behavioral and academic performance, and control of their emotions.^14,15 A review of PHPs’ effectiveness for children suggested that 66% to 99% of treated patients demonstrated improvement and successful return to community-based schools, and family functioning was a major factor in improvement.¹⁴ In a follow-up study that surveyed patients via telephone >1 year after discharge from a PHP, almost 80% of the children and adolescents were either “doing OK” or were “well-adjusted.”¹⁴ Only 22.5% required inpatient or residential treatment; the majority were doing well in school, with only 7% failing.¹⁴ In addition, 60% of parents reported satisfaction with treatment, and 85% reported functional improvement in their children.¹⁴

Factors that predict PHP success or failure

In an analysis of a day treatment program that provided 4 months of intensive psychodynamic, group-oriented milieu treatment for patients with long-standing personality disorders, Rosie et al¹⁶ found 3 factors that contributed to the success of the PHP:

optimal treatment-patient matching
judicious use of authority in milieu therapy
maintaining close relationships with referral sources.

In a study that compared 58 patients who completed an Ottawa hospital PHP and 44 who did not complete the program, psychological mindedness and chronicity of psychiatric illness were found to predict completion.¹⁷ However, a study of 59 females with anorexia nervosa who were transferred from inpatient care to an eating disorder day hospital program found that a longer duration of illness, amenorrhea, and a lower body mass index were associated with PHP treatment failure and inpatient rehospitalization.¹⁸ One study found that for individuals who were referred to a PHP from inpatient care, suicidal ideation and greater psychotic symptoms were associated with acute inpatient rehospitalization.¹⁹ Other factors associated with PHP nonattendance and treatment failure include limited personal and economic resources, high rates of substance abuse disorders, multiple admissions, and disability.²⁰ In a study of 103 alcohol-dependent patients who completed IOP treatment, 64% were abstinent at 6 months follow-up; relapse was associated with a longer duration of alcohol dependence and a higher number of prior treatments, while favorable outcomes were associated with a lower degree of depression, anxiety, and craving.²¹ Patients with cocaine dependence who completed an IOP showed significant improvements in addiction scores and had more favorable outcomes in employment status and psychological problems if they stayed longer in treatment.²²

Bottom Line

Psychiatric partial hospitalization programs (PHPs) provide a transition from inpatient hospitalization to outpatient treatment for patients who need further stabilization, or serve as an alternative to inpatient treatment for patients who don’t need or want inpatient hospitalization. PHPs can be as effective as inpatient treatment for all but the most seriously ill patients, and are more cost-effective than inpatient treatment.