Context and Policy Issues
Mental health conditions, such as anxiety disorders, personality disorders, mood disorders and substance abuse disorders, are common health concerns. For example, the lifetime prevalence of anxiety disorders has been estimated at up to 31% according to a global survey1 and the prevalence of post-traumatic stress disorder (PTSD) in United States military personnel has been reported at 14 to 16%.2 These disorders are often associated with functional impairment and reduced quality of life.1
Anxiety disorders, personality disorders, mood disorders and substance abuse disorders are managed with either pharmacological therapy, psychotherapy or a combination of the two. Canadian PTSD guidelines1 consider psychological treatment to be first-line in treatment of PTSD, which may include cognitive behavioural therapy (CBT), cognitive therapy, stress management, psychodynamic therapy, among other modalities. The Canadian Network for Mood and Anxiety Treatments3 from 2016 consider CBT, interpersonal therapy and behavioural activation as first-line psychological treatment options for major depressive disorder.
Psychological therapy for various mental health disorders can be delivered in varying durations, intensities and frequencies (e.g., weekly versus daily) and in varied settings (e.g., inpatient versus internet delivery by therapist).1,3 Intensive day therapy involves patients receiving daily treatment (e.g., full or half day sessions) for several weeks at a time. These sessions are provided on an outpatient basis such that patients can be in their usual surroundings when they go home and apply their learning to normal life. Outpatient treatment involves patients receiving one outpatient appointment per week (e.g. for one hour). Patients can also receive group therapy once or twice a week (e.g. for one to two hours) on an outpatient basis. Finally, patients may also receive psychological therapy in residential care (residential treatment) or as an inpatient, where the patient is admitted to a treatment center or clinic to receive intensive treatment.4
In some conditions, such as PTSD in Veterans, residential treatment has been commonly used. For example, a 2016 study reported that of 12,270 American veterans treated for dual PTSD and substance abuse between 1993 and 2011, 54% received residential rehabilitation treatment.4 However, there is growing interest in using intensive day treatment programs for PTSD instead of residential or inpatient treatments.5 As such, there is a question as to the effectiveness of intensive day treatment compared to residential treatment and other modalities.
A 2012 CADTH Rapid Response report (summary with critical appraisal) examined the clinical evidence surrounding day programs for PTSD.6 This report found that day programs may be effective for PTSD, but that the studies identified were small and of low quality.
Further, there was a lack of evidence comparing day treatment to other types of treatment (e.g., residential treatment).
A 2015 Joanna Briggs evidence summary examined day hospital treatment versus inpatient treatment for psychiatric disorders.5 The report concluded that day hospital treatment may provide a reduction in inpatient care and improve outcomes in patients suitable for day treatment programs. The report identified a 2011 Cochrane review7 of day hospital treatment for acute psychiatric conditions (i.e., schizophrenia, mood disorders, other disorders), which concluded that day hospital treatment was as effective as inpatient care for patients with acute psychiatric conditions.
The aim of this review is to provide an up-to-date assessment of the clinical effectiveness, cost-effectiveness and evidence-based guidance on intensive day treatment for various mental health disorders.
Research Questions
- 1.
What is the clinical effectiveness of intensive day treatment programs in adults with various mental health disorders?
- 2.
What is the cost-effectiveness of intensive day treatment programs in adults with various mental health disorders?
- 3.
What are the evidence-based guidelines associated with the use of intensive day treatment programs in adults with various mental health disorders?
Key Findings
The available evidence suggests that intensive day treatment (such as day hospital treatment) is effective in treating various mental health disorders; however, there is limited data comparing the effectiveness of intensive day treatment to other psychological treatment modalities. The limited data available suggests there may be no difference between intensive day treatment and other treatment approaches such as inpatient treatment or standard weekly outpatient treatment. No cost-effectiveness studies or guidelines were identified.
Methods
Literature Search Methods
A limited literature search was conducted on key resources including Ovid Medline, Ovid PsycInfo, PubMed, The Cochrane Library, University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. No methodological filters were applied to limit retrieval by publication type. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published from January 1, 2012 to August 1, 2017.
Rapid Response reports are organized so that the evidence for each research question is presented separately.
Selection Criteria and Methods
One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in .
Exclusion Criteria
Articles were excluded if they did not meet the selection criteria outlined in , they were duplicate publications, or were published prior to 2012.
Critical Appraisal of Individual Studies
The three randomized studies8-10 were critically appraised using Cochrane’s Risk of Bias tool11 for randomized studies and the four non-randomized studies4,12-15 (two of the publications reported results from the same study) were appraised using Down’s and Black checklist.16 Summary scores were not calculated for the included studies; rather, a review of the strengths and limitations of each included study were described narratively.
Summary of Evidence
Quantity of Research Available
A total of 318 citations were identified in the
literature search. Following screening of titles
and abstracts, 275 citations were excluded and 43
potentially relevant reports from the electronic
search were retrieved for full-text review.
Seventeen potentially relevant publications were
retrieved from the grey literature search. Of
these potentially relevant articles, 52
publications were excluded for various reasons.
Eight separate publications met the inclusion
criteria and were included in this report.4,8-10,12-15 These
publications reported the results from seven
individual studies (1 publication12 reported
a sub-group analysis of another included
study13). Appendix 1 describes the PRISMA flowchart of the study selection.
Additional references of potential interest are provided in Appendix 5.
Summary of Study Characteristics
Study characteristics are outlined in Appendix 2.
Study Design
Seven studies (from eight publications), including three randomized controlled trials (RCT),8-10 one retrospective cohort study4 and three uncontrolled before-after studies13-15 were identified regarding the clinical effectiveness of intensive day treatment programs in adults with various mental health disorders.
Country of Origin
Three of the studies were conducted in the USA,4,9,15 two were conducted in Poland,13,14 one in the UK8 and one in Germany.10
Patient Population
One RCT involved patients with PTSD aged 18 to 65,8 one RCT involved patients aged 18 to 55 with opioid dependence9 and one examined patients with major depressive disorder.10
The retrospective cohort study included veterans (mean age 50 years) with PTSD and substance abuse disorders.4 Two uncontrolled before-after studies involved patients aged 18 years or older with neurotic or personality disorders13,14 and one before-after study included patients aged 18 years or older with substance abuse disorders.15
Interventions and Comparators
The RCTs compared intensive cognitive therapy to standard weekly therapy, supportive therapy (weekly therapy focusing on emotions only rather than cognition) and waitlist,8 intensive outpatient treatment to standard outpatient treatment as an adjunct to buprenorphine treatment for opioid dependence,9 and day clinic psychotherapy to inpatient psychotherapy.10
The retrospective cohort study4 compared day hospital treatment to evaluation/brief treatment PTSD units. Two uncontrolled studies evaluated daily treatment involving a combination of individual and group psychotherapy.13,14 One uncontrolled study evaluated daily treatment (combination of group and individual) and less intensive outpatient treatment (where patients could switch back and forth between treatments; see Appendix 2).15 Duration of treatment was not reported in all studies – in studies reporting duration of treatment, it ranged from one week to 14 weeks.8-10,13,14
Outcomes
One RCT8 evaluated clinician and patient-rated severity of PTSD, recovery from PTSD diagnosis, disability, quality of life and depression and anxiety symptoms. Another RCT in opioid dependence assessed drug dependence, addiction severity, risk behaviours, treatment burden, satisfaction and quality of life.9 One RCT evaluated depressive symptoms and depression remission.10
The retrospective cohort study evaluated addiction severity index (drug abuse and alcohol abuse).4 One before-after study evaluated drug use severity score, quality of life, symptoms and function.15 One before-after study assessed the prevalence of suicidal ideation (and the factors associated a reduction in suicidal ideation compared to patients with no reduction).13 Another before-after study evaluated symptom severity and personality functioning scales.14 Further information on specific scales can be found in Appendix 4.
Summary of Critical Appraisal
Detailed findings related to critical appraisal are presented in Appendix 3.
Randomized studies
Two of the RCTs8,10 were considered to have a low risk of bias for randomization, while one study had an unclear risk.9 All RCTs had an unclear risk of bias for allocation concealment as this was not described in the methods of these articles. All RCTs were at high risk of performance bias since none of these trials blinded patients and the outcomes could be affected by lack of blinding. One RCT had low risk of detection bias as outcome assessors were blinded,8 while another RCT was at high risk given lack of blinding of outcome assessors.10 Another RCT had an unclear risk of bias related to blinding of outcome assessment.9 Overall, the amount of missing data in the RCTs was low and was similar across groups. One RCT was at high risk of measurement bias as the trial was conducted over 8 weeks and the authors only reported outcomes at 4 weeks.10 Overall, there is a serious risk of bias from these RCTs due to concerns surrounding blinding of participants, selective reporting of outcomes in one study and lack of blinding of outcome assessors in one study. The included RCTs8-10 had generally small sample sizes (n = 44, n = 121, n = 345); a power calculation was provided in one study.8 In two of the studies multiple secondary outcomes were reported;8,9 it is unclear whether the study was powered for these outcomes and no adjustments were made for multiple outcome testing, increasing the chance of false positive findings. The duration of follow-up ranged from 4 weeks to 40 weeks; thus, these studies provided limited evidence on the long-term efficacy of day hospital treatment. In the study by Dinger et al,10 44 out of 144 patients approached to participate were enrolled. Reasons for non-participation were not provided and minimal patient characteristics were provided thus it is unclear how well these patients reflect the general population. Two studies enrolled consecutive patients8,9 and had low rates of non- participation among patients eligible to take part in the study. Valid and reliable scales were used in the RCTs.8-10
Non-randomized studies
The retrospective cohort study4 involved a large sample size (around 12,000 patients) and the population studied appears to be representative of the general veteran population. The findings and methods of the study were clearly outlined. However, there are some important concerns with this study – the authors did not report on the completeness of the dataset and whether there was any missing data. Further, for the comparison of day hospital treatment to brief PTSD interventions, a bivariate model was used which did not adjust for possible confounders. Finally, a small proportion (8%) of patients actually received treatment in a day hospital compared to 54% in residential programs, thus it is unclear if the number of patients receiving day hospital treatment was large enough to make a meaningful comparison to other modalities.
The before-after study by Rodsinki et al.13 did not involve a comparison group (i.e., patients’ post-treatment condition was compared to their pre-treatment outcomes). The authors did not adjust for the effect of pharmacological treatment and there was wide variability in the length of stay of patients in the program (48 to 199 days). This study involved all patients receiving treatment at this clinic over the study duration, and therefore is likely generalizable to the general population. The before-after study by Cyranka et al.14 similarly did not involve a comparison group. In this study, patients could receive either morning or afternoon treatment. There were differences in the duration and types of treatments patients received in the morning and afternoon; however, all patients were analyzed together. Further, the analysis did not adjust for pharmacological treatment changes which may have occurred over the study period. The sample of patients in Cyranka et al. comprised 72% of patients receiving treatment at the clinic over the study period – 7% of the patients did not complete treatment; however, the characteristics of these patients are not described. In the before-after study by McNeese-Smith, there was no comparison group.15 The patients in this study were a “convenience sample”; thus, it is unclear whether they are representative of the general population. In this study, patients could switch back and forth between intensive (daily) outpatient treatment and less intensive (few days per week) outpatient treatment. However, the authors did not report how much time patients spent in each program. The authors did not adjust for changes in pharmacological therapy in their analysis. The non-randomized studies used valid and reliable scales to measure outcomes.
Overall, given the lack of comparison group and other methodological limitations, the evidence from these before-after studies should be considered very low quality.
Summary of Findings
Clinical effectiveness of intensive day treatment programs in adults with various mental health disorders
A detailed summary of findings is presented in Appendix 4.
Recovery from Diagnosis
One RCT evaluated several measures of recovery from PTSD.8 The authors reported that the number needed to treat (NNT) to achieve recovery from PTSD was similar for both intensive day therapy and standard outpatient therapy. In this study, 56.7% of patients receiving intensive therapy achieved remission of PTSD compared to 58.1% for standard cognitive therapy and 30.0% for supportive therapy at 40 weeks (patient rated). The clinician-rated remission rates were similar: 53.3% of patients receiving intensive therapy achieved PTSD remission compared to 74.2% for standard cognitive therapy and 26.7% for supportive therapy (not reported for waitlist). Another RCT investigated remission of depression and found no difference between day hospital and inpatient treatment for rate of remission (17% for inpatients versus 18% for day hospital).10
Severity of Symptoms
Several studies evaluated the effect of day treatment on severity of symptoms. The RCT by Ehlers et al.8 found that intensive therapy and standard therapy reduced PTSD symptom scores similarly, and both treatments were more effective than supportive therapy for PTSD symptoms. Anxiety and depression symptom scores were similar for intensive day treatment and standard cognitive therapy; both were more efficacious than supportive therapy for anxiety and depression symptoms. One RCT found that both intensive outpatient treatment and regular outpatient treatment for opioid dependence significantly improved addiction severity index (ASI) from baseline for drug, alcohol and legal scores (suggesting less addiction and related symptoms), but there was no improvement in social, employment, medical, psychiatric ASI scores in either group.9 Both treatments also improved HIV risk behaviours from baseline. There were no statistically significant differences between intensive therapy and standard outpatient therapy for any outcomes. The RCT by Dinger et al.10 reported that both day hospital and outpatient treatment reduced depression severity (measured with Hamilton Depression Rating Scale [HDRS]) from baseline. There was no difference in change from baseline in HDRS between groups.
The before-after study by Cyranka et al.14 investigated several symptom scales. There were clinically significant decreases in mean subscale scores for the following symptoms: hysteria, depression, hypochondriasis, psychopathic deviate, paranoia, psychasthenia, schizophrenia and social introversion (suggesting improvement of those symptoms). There was a significant increase in hypomania subscale scores and no difference in the masculinity/femininity subscale. This study also evaluated the proportion of patients who achieved subscale results similar to healthy individuals. The proportion of patients who achieved scores similar to healthy patients increased for the following subscales (% increase from baseline): hysteria (14.5%), depression (21.8%), hypochondriasis (26.6%),
psychopathic deviate (7.2%), paranoia (14.5%), psychasthenia (19.3%), schizophrenia (15.7%) and social introversion (17.9%); this suggests improvement on those subscales. The proportion on the hypomania subscale decreased from baseline by 8.6% indicating a worsening of hypomania symptoms.
Rodzinski et al.12,13 evaluated the prevalence of patients with suicidal ideation in their sample before and after intensive day treatment. For women and men, the prevalence of suicidal ideation decreased at the end of therapy compared to baseline. The mean reduction in global neurotic personality disintegration scale was significantly greater in patients whose suicidal ideation improved compared to those whose didn’t; there was a significant difference in both men and women.
The retrospective cohort study by Coker et al.4 (in patients with PTSD and substance abuse disorders) found was no difference in ASI for those treated in day hospitals compared to patients receiving treatment in evaluation/brief PTSD units for both alcohol abuse and drug abuse. Finally, one before-after study in patients with substance abuse disorders15 found the mean drug use composite score was reduced at six months compared to baseline, suggesting less drug use following treatment. The treatment outcomes profile symptom score increased from baseline to six months after treatment completion, indicating an improvement in symptoms in these patients.
Speed of Recovery
One RCT evaluated speed of recovery in patients with PTSD.8 The authors found that the baseline-adjusted mean PTSD symptom scores were lower for intensive outpatient therapy compared to all other treatments (standard outpatient treatment, supportive therapy) at three weeks, which led the authors to conclude that seven-day intensive therapy achieved faster symptoms reduction compared to standard therapy.
Quality of Life
One RCT8 reported improved quality of life scores (measured via the Quality of Life Enjoyment and Satisfaction Questionnaire) from baseline for all treatments (intensive day therapy, standard outpatient treatment, supportive therapy). The RCT by Mitchell et al.9 in opioid dependent patients found that intensive outpatient therapy improved several quality of life domains but there was no difference compared to regular outpatient therapy. One before-after study9 evaluated quality of life in patients with substance abuse disorders and found that quality of life scores increased following treatment and were higher six months after completion of intensive day therapy compared to baseline.
Disability and Function
One RCT in patients with PTSD found that disability scores decreased from baseline (suggesting less disability following treatment).8 A before-after study in patients with substance use disorders reported that function scores increased from the beginning of treatment to 6 months after therapy completion, suggesting improved function following intensive day treatment.15
Satisfaction
One RCT evaluated treatment satisfaction and found no significant difference between intensive and standard groups at three or six months; the majority of patients in the entire sample were satisfied at six months (89% and no difference between groups).9
Veterans with PTSD
One study specifically evaluated the effect of day treatment for veterans with PTSD4 (patients in this study also had concomitant substance use disorders). The study found that there was no difference in ASI composite scores between day hospital treatment and evaluation/brief inpatient PTSD units, suggesting no difference in addiction severity between treatments. A small proportion (8%) of patients in the study received day hospital treatment and the authors did not measure any outcomes other than ASI. Day hospital treatment was only compared to brief/evaluation PTSD units. Thus, this study provides limited evidence surrounding day hospital treatment of veterans with PTSD.
Cost-effectiveness of intensive day treatment programs in adults with various mental health disorders
The review did not identify any studies which address this question.
Evidence-based guidelines associated with the use of intensive day treatment programs in adults with various mental health disorders
The review did not identify any publications which address this question.
Limitations
There are several limitations in the body of evidence retrieved in this report. Most of the studies identified were small and short-term, and had methodological flaws; thus, the overall quality of evidence is low. Three of the studies had no control group, while the comparator differed across the other eligible studies. This makes it difficult to assess the comparative efficacy of day treatment. There was heterogeneity in the types of patients included in the eligible studies, which also limits the ability to make firm conclusions about the effectiveness of day hospital treatment. The three eligible RCTs all examined different patient populations (PTSD, depression, opioid dependence). Further, there was heterogeneity in how outcomes were reported across studies. For example, quality of life and substance use was measured using various scales and subscales which makes it difficult to compare results across studies. Because many of the studies had short-term follow-up (e.g., the longest follow-up in any study was 40 weeks), there is a lack of evidence on long-term efficacy of day hospital treatment. Finally, none of the included studies were conducted in Canada (or North America), and it is uncertain whether the findings from this report are applicable to the Canadian context. This review did not identify any economic evaluations or evidence-based guidelines.
Conclusions and Implications for Decision or Policy Making
The studies included in this report suggest that intensive day treatment is effective in treating various mental health disorders, such as PTSD, substance use disorders and personality disorders. However, there are few studies on the effectiveness of intensive day treatment compared to other psychological treatment modalities and the available studies have methodological limitations. The limited available evidence suggests that there may be no difference in effectiveness between intensive day treatment and other treatment approaches (such as standard once weekly cognitive therapy or inpatient treatment); however, there were important concerns with these studies including methodological flaws, small sample sizes, heterogeneity of outcomes and populations across studies, and short duration of follow-up.
The findings of this report align with findings of previous evidence syntheses on this topic,5,6 which found that intensive day treatment appears to be effective in managing mental health disorders but that comparative efficacy evidence was limited. While there is growing interest in using intensive day treatment for mental health disorders, it is currently unclear whether it offers an advantage over other treatment approaches in terms of efficacy. Given the lack of health economic data, the cost-effectiveness of intensive day treatment is also uncertain at this time.
References
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Gates MA, Holowka DW, Vasterling JJ, Keane TM, Marx BP, Rosen RC. Posttraumatic stress disorder in veterans and military personnel: epidemiology, screening, and case recognition.
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Chu WH. Psychiatric disorder management: day hospital care vs inpatients care. Adelaide, Australia: The Joanna Briggs Institute; 2015 Oct 9. (JBI evidence summary: evidenced- informed practice at the point of care).
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Dinger U, Klipsch O, Kohling J, Ehrenthal JC, Nikendei C, Herzog W, et al. Day-clinic and inpatient psychotherapy for depression (DIP-D): a randomized controlled pilot study in routine clinical care.
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Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions [Internet]. Version 5.1.0. London (England): The Cochrane Collaboration; 2011 Mar. [cited 2017 Sep 7]. Available from:
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McNeese-Smith DK, Faivre CL, Grauvogl C, Warda NU, Kurzbard MA. Substance abuse treatment processes and outcomes in day/outpatient health maintenance organization setting.
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PubMed: 25202809]
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Appendix 1. Selection of Included Studies
Appendix 2. Characteristics of Included Publications
Characteristics of Included Randomized Controlled Trials
Characteristics of Included Non-Randomized Studies
Appendix 3. Critical Appraisal of Included Publications
Critical Appraisal for Randomized Studies Using Cochrane Risk of Bias Tool
Critical Appraisal for Non-Randomized Studies Using Downs and Black Checklist
Appendix 4. Main Study Findings and Author’s Conclusions
Summary of Findings of Randomized Controlled Trials
Summary of Findings for Non-Randomized Studies
Appendix 5. Additional References of Potential Interest
Intervention similar to intensive day treatment
Beidel DC, Frueh BC, Neer SM, Lejuez CW. The efficacy of Trauma Management Therapy: a controlled pilot investigation of a three-week intensive outpatient program for combat- related PTSD.
J Anxiety Disord. 2017 Aug;50:23–32. [
PubMed: 28545005]
Lenz AS, Lancaster C. A mixed-methods evaluation of intensive trauma-focused programming. J Couns Dev. 2017;95(1):24–34.
Meyers L, Voller EK, McCallum EB, Thuras P, Shallcross S, Velasquez T, et al. Treating veterans with PTSD and borderline personality symptoms in a 12-week intensive outpatient setting: findings from a pilot program.
J Trauma Stress. 2017 Apr;30(2):178–181. [
PubMed: 28329406]
Murray H, El-Leithy S, Billings J. Intensive cognitive therapy for post-traumatic stress disorder in routine clinical practice: a matched comparison audit.
Br J Clin Psychol. 2017 Jul 25; [
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Unclear if intervention met criteria for intensive day treatment.
Reif S, Acevedo A, Garnick DW, Fullerton CA. Reducing behavioral health inpatient readmissions for people with substance use disorders: do follow-up services matter?
Psychiatr Serv. 2017 Aug 1;68(8):810–818. [
PMC free article: PMC5895963] [
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Sobanski JA, Klasa K, Cyranka K, Mielimaka M, Dembinska E, Muldner-Nieckowski L, et al. Effectiveness of intensive psychotherapy in a day hospital evaluated with neurotic personality inventory KON-2006.
Psychiatr Pol. 2015;49(5):1025–1041. [
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About the Series
Rapid Response Report: Summary with Critical Appraisal
Suggested citation:
Intensive day treatment programs for mental health treatment: a review of clinical effectiveness, cost effectiveness, and guidelines Ottawa: CADTH; 2017 Sep. (CADTH rapid response report: summary with critical appraisal).
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