Predicting Patients
Feasibility of Day Treatment for Unselected Referred for Inpatient Psychiatric Treatment: Results of a Randomized Trial Herman Kluiter, Robert Marjolijn Ruphan,
Objective: had
Because
major
previous
disadvantages
studies
domly
assigned
Control was
attempted
week
that
number tory
as soon
40%
ofthe
depressive
symptoms, of these
contraindications used
in this
(AmJ
and
spent
for patients
needed
in the
and
treatment
all
1 03
away
under
other
study
facilitated
Psychiatry
1992;
but first
week, by
May
1 7, 1 992.
1, 1991;
From
revision
of Groningen. Address reprint Social Psychiatry, University
RB Groningen,
treatment
controlled
Liesbeth
treatment
American
Dec.
18,
1991;
Psychiatry,
accepted
University
requests to Dr. Kluiter, Department of Groningen, P.O. Box 30.001,
Am]
149:9,
Psychiatric
September
was
Results:
completely illness,
this
unselected
found.
This
on
in the
hospital
least
the
subject restrictive
Day
is feasible 57 were
experimental
compared
versus group
suggests were
for
condition.
average
was
satisfac-
another
40%.
were
unwarranted.
the
The
admissions,
ofpatients,
that
environment
to the
ofprevious registrars
for ran-
day treatment ofnights per
treatment
infeasible number
psychiatrists
were studies
to the
treatment a random-
conducted
no
selection The
variables absolute
criteria approach
possible.
149:1199-1205)
of Social
Lindeboom
was
In
of 9700
the Netherlands.
The authors thank complex data. Copyright © 1992
Psychiatry
received
the Department
to inpatient
authors
assigned
care.
qualified
very psychiatric treatment modality should face two basic questions: For which categories of patients is it feasible? and How does it affect their psychosocial functioning? Neither question has yet been answered conclusively for day treatment as an alternative to inpatient treatment. In nine controlled inquiries (1-12) over more than 25 years, day treatment has been studied for a total of 545 patients referred for hospitalization. Nearly onehalf participated in the two oldest studies (1-4), which are not well documented. With one exception (1, 2), the patient groups have been selected too stringently to penmit unmitigated conclusions. Authors of reviews who have claimed that the second question has been fully (13-15) or partially (16, 17) decided in favor of such day treatment have neglected the limited generalizations that can be drawn from the subjects studied. Zwerling, Wilder, and Levin (1, 2) conducted the
Received
the
the
physical
E
Jan.
were
from
Conclusions:
day
as an alternative
In the experimental condition, permitted. The average number
standard
experimentalpatients
against
in nearly
condition
differences.
Ph.D.
and predict the extent to which day treatment inpatient treatment. Method: Of 1 60 patients,
patients
away
predictive
treatment shortcomings,
standard clinical care. as the patient’s condition
experimental
ofsurveillance
applied
control
received
of nights for
level
to the
patients
ofday
or methodological
ized controlled trial to estimate unselected patients referred for
J. Nienhuis,
Giel, M.D., Fokko and Durk Wiersma,
for
management
Association.
1992
of the
only controlled study in which the two questions have been addressed conjointly for an unselected group refenred for full-time hospitalization, but this study had shortcomings. The randomization ratios fluctuated during enrollment (1), which is undesirable from a methodological point of view (18). Outcome measurement was limited to unstandardized ratings of the patient’s psychiatric status and family adjustment by the patient and/or a relative, and these ratings were not assessed at baseline (2). Several essential sociodemognaphic data were not reported, so evaluation of the equivalence of the control and experimental groups was impossible (1, 2). Nevertheless, this study was important because it did not exclude any patients considered for admission, approaching each patient with the intention to use alternative treatment. This enabled a cornpanison of patients for whom day treatment turned out to be feasible with those who could not be treated adcording to that alternative. Five additional randomized studies on day treatment as an alternative to hospitalization have been published (3-9). Three others applied a weaker design (10-12), comparing patients directly referred to day treatment with globally equivalent groups of inpatients. Such nonrandom allocation can easily produce unbalanced groups (18), as occurred in one study (10): 37% of the
1199
DAY TREATMENT
TABLE
1. Controlled
Studies
on Day Treatment
as an Alternative
to Inpatient
Patie
Patients Considered Study
for
Random
assignment
subjects
Actually
Selected
for
Study
Total Assigned N
%
378
378
100
-
142
-
Day
to
Treatment
Assigned
to Full
Hospitalization
Remarks
of
to groups
Zwerling Kris
Selection
nts
Treatment
and Wilder
(1)
(3)
Herz
et al. (5)
Washburn
Dick
et al. (6)
et al. (8)
189
189
71
71
424
90
21
45
45
392
59
15
29
30
350a
91
43
48
26
All referred
patients
Study
group
referred
selected patients
or personality Creed No
et al. (9)
185
102
-
106 86
55
included
Only relapsed psychotic patients included Study group selected from all referred patients Study group selected from referred women only
from with
neuroses
disorders
only
51
51
Study group selected referred patients
SO 43
56 43
75% of subjects were female 70% of subjects were female; 67% had not been hospitalized previously Only men included
from
all
randomization
Michaux Fink
Penk aonly
et al. (10)
et al. (1 1 )
et al. (12) the
patients treatment
lower
bound
of the
number
of patients
48 considered
-
for selection
in the inpatient group, but only 10% in the day group, were from the lowest social class. All of the studies since 1970 (5-12) were primarily outcome studies of rather stringently selected groups of patients. Stringency, in terms of the percent of potentially eligible patients actually included, is shown in table 1 for each of the randomized studies. Corresponding percentages were not available from the reports on the other three inquiries. Their selection criteria did, however, not differ essentially from those in the randomized studies. Thus, the generalizability of effects identified by these studies appears to be seriously limited; statements as to feasibility of day treatment are necessarily restricted to minorities of patients referred for admission. Only two reports (5, 9) provided (scarce) data on the randomly assigned patients who could not be fully maintained in day treatment. The typical day treatment patient studied under controlled conditions appears to be not very ill, to not be very violent, to not be homicidal or noncompliant, to have intact family relations, to not live alone, to be able to rely on someone to provide care, to have no physical illness, to be under 65 years of age, to not be certified, and to be female. (An overview of the distributions of sociodemographic and psychopathological variables in the reviewed studies is available from H.K.) The same impression emerges from uncontrolled studies (19-22) attempting to differentiate patients referred for full hospitalization from those referred to day treatment facilities designed to avoid inpatient care. We conducted a randomized controlled trial in the Netherlands to evaluate the feasibility and effects of day treatment as an alternative to inpatient care. It can be seen as a replication and expansion of the study by Zwerling, Wilder, and Levin (1, 2).
1200
24 could
24 be calculated
from
this
study.
METhOD
Study
Design
From November 1986 to March 1988 a total of 160 patients were randomly assigned to two conditions. All patients were referred for inpatient treatment by psychiatnic outpatient services or their general practitioners, except four who were self-referred. Data from the case register showed that the referral pattern during the period of enrollment did not differ from that in the 2 years before the study. Randomization occurred immediately after acceptance of the patient for admission. Assignment was in blocks of 14 patients, with a fixed ratio of nine expenimental to five control subjects, resulting in 103 expenimental and 57 control patients. Allocation of the majonity of the patients to the experimental condition has distinct advantages when it is unclear whether the expenimenta! treatment can be applied to all patients who are eligible (23, 24). Standardized measures of psychopathology and socia! functioning were assessed at entry and at 1 and 2 years; the patient’s and a relative’s satisfaction with treatment and the burden on the family were also assessed. A regional psychiatric case register recorded all contacts of each patient with mental health care providens and institutions during the 2 years of follow-up. The research team operated independently of the treatment teams. Patients Two forensic
categories patients
of patients were excluded assessed at court request
Am
]
Psychiatry
1 49:9,
from the study: (because they
September
1992
KLUITER,
TABLE
2. Characteristics
of Subjects
in Current
Study of Day Treatment
an d Study by Zwerling
Patients Assigned to Full-Time
Characteristic
N
Female Age (years) 18-24 25-44 45-64 65 Living alone Marital status Single Married Divorced Widowed Education College/university Secondary Elementary None Unemployed Disability pension Involuntary admission Previous admissions None I 2
3 Psychiatric diagnosis Current studyc Substance addiction/abuse Schizophrenia Affective psychosis Depression or anxiety Other DSM-III diagnoses Zwerling and Wilder study’ Schizophrenia Affective psychosis Brain syndromes Involutional psychosis Other psychosis Neurosis or personality disorder apercents
bData
based on on the control
varying group
‘DSM-III diagnoses used. dClassification system not
Was
Psychiatry
149:9,
Attempted (N=103)
ET AL.
Prevalence
(%) in Zwerling and Wilder’s Patients for Whom Day Treatment Was Attempted (N=I89)’t’
%
N
%
23
40.4
57
55.3
56.7
8 27 12 10 22
14.0 47.4 21.1 17.5 38.6
13 53 26 11 29
12.6 51.5 25.2 10.7 28.2
-
22 19 12 4
38.6 33.3 21.1 7.0
40 41 14 8
38.8 39.8 13.6 7.8
-
4 10 38 2 48 30 6
7.4 18.5 70.4 3.7 87.3 54.5 10.5
15 17 58 6 86 54 8
15.6 17.7 60.4 6.3 88.7 55.7 7.8
-
24 8 5
18
43.6 14.5 9.1 32.7
38 21 19 25
36.9 20.4 18.4 24.3
I I 17 7 9 13
19.3 29.8 12.3 15.8 22.8
13 36 10 24 20
12.6 35.0 9.7 23.3 19.4
-
-
-
48.2 24.1 13.2 14.4
39.7 10.0 20.6 4.2 2.1 23.3 numbers because of Zwerling and
not all data Wilder were
were available not published.
for all subjects.
specified.
were not admitted for treatment) and patients suffering from any form of dementia. The latter were referred to special institutions. Their exclusion was made explicit, since they might be admitted because of an initially false diagnosis. All other admitted patients from a designated catchrnent area were included, irrespective of age, certification, on any other variable. Zwerling and Wilder’s patient group (1 ) probably matches our cohort best; the scarcity of published data from their study prohibits a definite conclusion. The semiurban catchment area of 95,000 inhabitants is located in the northeastern part of the Netherbands. It is bess prosperous than other areas and has a relatively high rate of unemployment. Essential psychopathological and sociodemognaphic data are presented in table 2. The total group did not differ from all patients admitted to psychiatric hospitals
Am]
NIENHUIS,
and Wilder (1)
Patients for Whom Day Treatment
Hospitalization (N=S7)
GIEL,
September
1992
in the Netherlands in 1 984. The experimental and controb groups were statistically equivalent on DSM-III diagnoses and sociodemographic characteristics. The last column shows corresponding data adapted from the Zwenling and Wilder study for their experimental patients only. Information on their control subjects was not published. Our study includes more patients with three or more previous admissions and fewer admitted for the first time. The DSM-III diagnoses we report are, of course, only roughly comparable to the diagnoses in the Zwerbing and Wilder study. Conditions The trial was atnic hospital.
conducted in a modern In the control condition,
500-bed the
psychipatients
1201
DAY
TREATMENT
TABLE 3. Number of Nights Spent Away From the Hospital by Patients Who Received Full-Time Hospitalization and Patients for Whom Day Treatment Was Attempteda Patients Assigned Full-Time Hospitalization (N=SS)
Mean Number of Nights Away From Hospital per
Patients for Whom Day Treatment Was Attempted (N=97)
to
Week
N
%
N
%
0
20
36.4
19
19.6
>OtoI
II
20.0
9
9.3
>1 to2 >2to3 >3to4 >4toS >Sto6 >6to7
IS 6 3 0 0 0
27.3 10.9 5.5 0.0 0.0 0.0
11 10 10 6 13 19
11.3 10.3 10.3 6.2 13.4 19.6
az504,
p=O.0000
(Mann-Whitney
test
for
independent
The mean for the patients who received full-time 1.02 nights (SD=I.02), and for the experimental nights
samples).
hospitalization patients itwas
was 3.17
(SD=3.S4).
were treated according to standard hospital care, which included 24-hour hospitalization, medication, regular contacts with a psychiatrist, occupational therapy, and in selected cases, individual, group, behavioral, creative, or psychomotor therapy. In the experimental condition, day treatment was initiated 1 ) at once, 2) after some time had elapsed, or 3) not at all, depending on the patient’s condition and social situation. The patient’s condition and social situation were assessed by a team headed by a psychiatrist or registrar. Close relatives or the patient’s partner were asked to be present. The procedure also served to provide the patient and the relatives with extensive information about the support available. On that occasion it was decided by the available panties whether to initiate day treatment at once on to postpone that decision to a later date. All decisions then and later were the final responsibility of the attending psychiatrist on registrar. (In the Netherlands a registrar is a physician seeking registration as a specialist; in psychiatry a 4-year training is required.) The general clinical criterion for keeping a patient in the hospital overnight was danger to self or to others. The day treatment lasted from 8:30 a.rn. to 4:30 p.m. (weekends excluded). It was provided either in a new day center on the hospital grounds, with a specialized multidisciplinary program, or in a regular clinical unit. During day treatment, nights in the hospital could be prescribed; such a prescription was based on the same criteria and authority as previously stated. While the patient was at home, staff could be contacted by telephone on a 24-hour basis. The hospital staff coblaborated with the regional psychiatric service outside the hospital, which could at all times render assistance at home and was involved in aftercare (25). Measures Feasibility nights per
I
202
was defined week patients
as the average spent away from
number of the hospital
according to plan. The average number of nights was calculated by dividing the sum of the nights away from the hospital by the duration in weeks of the treatment episode. This procedure served to render patients with treatment episodes of different durations comparable. This yields a maximum score of 7 for patients fully in day treatment and a minimum score of 0 for patients fully hospitalized. For the control group, this variable denotes the average number of night leaves given in standard care. This information was missing for eight patients; no differences were found between them and the other patients. Zwerling and Wilder (1, p. 171) constructed an ordinab variable not fully comparable to ours. Their dategory II, which included patients (22%) who were transferned to wards more than once or were transferred once for more than 2 nights, covers a wide range; for instance, 12 of their patients were boarded longer than 14 nights, but how much longer was not reported. For reasons explained further on, the predictor vanable “level of patient’s protection” was determined. It was measured on a 6-point scale: 6=no need of surveillance; S=surveillance at fixed times at the group level; 4=permanent surveillance at the group level, occasional interruptions possible; 3=permanent surveillance at the group level; 2=permanent surveillance at the individual level most of the time and on the group level some of the time; and 1=permanent surveillance at the individual level all of the time. Scores for the morning, afternoon, evening, and night of each day of treatment were provided by the attending nurses. The observation sheets used were tested extensively in a pilot study on 40 patients. Data
Analysis
Distributions of the feasibility variable in the control and experimental conditions were determined. The hypothesis that the experimental patients would rank higher on this variable was evaluated with the MannWhitney test for rank orders (one-tailed, p
Feasibility of Day Treatment for Unselected Referred for Inpatient Psychiatric Treatment: Results of a Randomized Trial Herman Kluiter, Robert Marjolijn Ruphan,
Objective: had
Because
major
previous
disadvantages
studies
domly
assigned
Control was
attempted
week
that
number tory
as soon
40%
ofthe
depressive
symptoms, of these
contraindications used
in this
(AmJ
and
spent
for patients
needed
in the
and
treatment
all
1 03
away
under
other
study
facilitated
Psychiatry
1992;
but first
week, by
May
1 7, 1 992.
1, 1991;
From
revision
of Groningen. Address reprint Social Psychiatry, University
RB Groningen,
treatment
controlled
Liesbeth
treatment
American
Dec.
18,
1991;
Psychiatry,
accepted
University
requests to Dr. Kluiter, Department of Groningen, P.O. Box 30.001,
Am]
149:9,
Psychiatric
September
was
Results:
completely illness,
this
unselected
found.
This
on
in the
hospital
least
the
subject restrictive
Day
is feasible 57 were
experimental
compared
versus group
suggests were
for
condition.
average
was
satisfac-
another
40%.
were
unwarranted.
the
The
admissions,
ofpatients,
that
environment
to the
ofprevious registrars
for ran-
day treatment ofnights per
treatment
infeasible number
psychiatrists
were studies
to the
treatment a random-
conducted
no
selection The
variables absolute
criteria approach
possible.
149:1199-1205)
of Social
Lindeboom
was
In
of 9700
the Netherlands.
The authors thank complex data. Copyright © 1992
Psychiatry
received
the Department
to inpatient
authors
assigned
care.
qualified
very psychiatric treatment modality should face two basic questions: For which categories of patients is it feasible? and How does it affect their psychosocial functioning? Neither question has yet been answered conclusively for day treatment as an alternative to inpatient treatment. In nine controlled inquiries (1-12) over more than 25 years, day treatment has been studied for a total of 545 patients referred for hospitalization. Nearly onehalf participated in the two oldest studies (1-4), which are not well documented. With one exception (1, 2), the patient groups have been selected too stringently to penmit unmitigated conclusions. Authors of reviews who have claimed that the second question has been fully (13-15) or partially (16, 17) decided in favor of such day treatment have neglected the limited generalizations that can be drawn from the subjects studied. Zwerling, Wilder, and Levin (1, 2) conducted the
Received
the
the
physical
E
Jan.
were
from
Conclusions:
day
as an alternative
In the experimental condition, permitted. The average number
standard
experimentalpatients
against
in nearly
condition
differences.
Ph.D.
and predict the extent to which day treatment inpatient treatment. Method: Of 1 60 patients,
patients
away
predictive
treatment shortcomings,
standard clinical care. as the patient’s condition
experimental
ofsurveillance
applied
control
received
of nights for
level
to the
patients
ofday
or methodological
ized controlled trial to estimate unselected patients referred for
J. Nienhuis,
Giel, M.D., Fokko and Durk Wiersma,
for
management
Association.
1992
of the
only controlled study in which the two questions have been addressed conjointly for an unselected group refenred for full-time hospitalization, but this study had shortcomings. The randomization ratios fluctuated during enrollment (1), which is undesirable from a methodological point of view (18). Outcome measurement was limited to unstandardized ratings of the patient’s psychiatric status and family adjustment by the patient and/or a relative, and these ratings were not assessed at baseline (2). Several essential sociodemognaphic data were not reported, so evaluation of the equivalence of the control and experimental groups was impossible (1, 2). Nevertheless, this study was important because it did not exclude any patients considered for admission, approaching each patient with the intention to use alternative treatment. This enabled a cornpanison of patients for whom day treatment turned out to be feasible with those who could not be treated adcording to that alternative. Five additional randomized studies on day treatment as an alternative to hospitalization have been published (3-9). Three others applied a weaker design (10-12), comparing patients directly referred to day treatment with globally equivalent groups of inpatients. Such nonrandom allocation can easily produce unbalanced groups (18), as occurred in one study (10): 37% of the
1199
DAY TREATMENT
TABLE
1. Controlled
Studies
on Day Treatment
as an Alternative
to Inpatient
Patie
Patients Considered Study
for
Random
assignment
subjects
Actually
Selected
for
Study
Total Assigned N
%
378
378
100
-
142
-
Day
to
Treatment
Assigned
to Full
Hospitalization
Remarks
of
to groups
Zwerling Kris
Selection
nts
Treatment
and Wilder
(1)
(3)
Herz
et al. (5)
Washburn
Dick
et al. (6)
et al. (8)
189
189
71
71
424
90
21
45
45
392
59
15
29
30
350a
91
43
48
26
All referred
patients
Study
group
referred
selected patients
or personality Creed No
et al. (9)
185
102
-
106 86
55
included
Only relapsed psychotic patients included Study group selected from all referred patients Study group selected from referred women only
from with
neuroses
disorders
only
51
51
Study group selected referred patients
SO 43
56 43
75% of subjects were female 70% of subjects were female; 67% had not been hospitalized previously Only men included
from
all
randomization
Michaux Fink
Penk aonly
et al. (10)
et al. (1 1 )
et al. (12) the
patients treatment
lower
bound
of the
number
of patients
48 considered
-
for selection
in the inpatient group, but only 10% in the day group, were from the lowest social class. All of the studies since 1970 (5-12) were primarily outcome studies of rather stringently selected groups of patients. Stringency, in terms of the percent of potentially eligible patients actually included, is shown in table 1 for each of the randomized studies. Corresponding percentages were not available from the reports on the other three inquiries. Their selection criteria did, however, not differ essentially from those in the randomized studies. Thus, the generalizability of effects identified by these studies appears to be seriously limited; statements as to feasibility of day treatment are necessarily restricted to minorities of patients referred for admission. Only two reports (5, 9) provided (scarce) data on the randomly assigned patients who could not be fully maintained in day treatment. The typical day treatment patient studied under controlled conditions appears to be not very ill, to not be very violent, to not be homicidal or noncompliant, to have intact family relations, to not live alone, to be able to rely on someone to provide care, to have no physical illness, to be under 65 years of age, to not be certified, and to be female. (An overview of the distributions of sociodemographic and psychopathological variables in the reviewed studies is available from H.K.) The same impression emerges from uncontrolled studies (19-22) attempting to differentiate patients referred for full hospitalization from those referred to day treatment facilities designed to avoid inpatient care. We conducted a randomized controlled trial in the Netherlands to evaluate the feasibility and effects of day treatment as an alternative to inpatient care. It can be seen as a replication and expansion of the study by Zwerling, Wilder, and Levin (1, 2).
1200
24 could
24 be calculated
from
this
study.
METhOD
Study
Design
From November 1986 to March 1988 a total of 160 patients were randomly assigned to two conditions. All patients were referred for inpatient treatment by psychiatnic outpatient services or their general practitioners, except four who were self-referred. Data from the case register showed that the referral pattern during the period of enrollment did not differ from that in the 2 years before the study. Randomization occurred immediately after acceptance of the patient for admission. Assignment was in blocks of 14 patients, with a fixed ratio of nine expenimental to five control subjects, resulting in 103 expenimental and 57 control patients. Allocation of the majonity of the patients to the experimental condition has distinct advantages when it is unclear whether the expenimenta! treatment can be applied to all patients who are eligible (23, 24). Standardized measures of psychopathology and socia! functioning were assessed at entry and at 1 and 2 years; the patient’s and a relative’s satisfaction with treatment and the burden on the family were also assessed. A regional psychiatric case register recorded all contacts of each patient with mental health care providens and institutions during the 2 years of follow-up. The research team operated independently of the treatment teams. Patients Two forensic
categories patients
of patients were excluded assessed at court request
Am
]
Psychiatry
1 49:9,
from the study: (because they
September
1992
KLUITER,
TABLE
2. Characteristics
of Subjects
in Current
Study of Day Treatment
an d Study by Zwerling
Patients Assigned to Full-Time
Characteristic
N
Female Age (years) 18-24 25-44 45-64 65 Living alone Marital status Single Married Divorced Widowed Education College/university Secondary Elementary None Unemployed Disability pension Involuntary admission Previous admissions None I 2
3 Psychiatric diagnosis Current studyc Substance addiction/abuse Schizophrenia Affective psychosis Depression or anxiety Other DSM-III diagnoses Zwerling and Wilder study’ Schizophrenia Affective psychosis Brain syndromes Involutional psychosis Other psychosis Neurosis or personality disorder apercents
bData
based on on the control
varying group
‘DSM-III diagnoses used. dClassification system not
Was
Psychiatry
149:9,
Attempted (N=103)
ET AL.
Prevalence
(%) in Zwerling and Wilder’s Patients for Whom Day Treatment Was Attempted (N=I89)’t’
%
N
%
23
40.4
57
55.3
56.7
8 27 12 10 22
14.0 47.4 21.1 17.5 38.6
13 53 26 11 29
12.6 51.5 25.2 10.7 28.2
-
22 19 12 4
38.6 33.3 21.1 7.0
40 41 14 8
38.8 39.8 13.6 7.8
-
4 10 38 2 48 30 6
7.4 18.5 70.4 3.7 87.3 54.5 10.5
15 17 58 6 86 54 8
15.6 17.7 60.4 6.3 88.7 55.7 7.8
-
24 8 5
18
43.6 14.5 9.1 32.7
38 21 19 25
36.9 20.4 18.4 24.3
I I 17 7 9 13
19.3 29.8 12.3 15.8 22.8
13 36 10 24 20
12.6 35.0 9.7 23.3 19.4
-
-
-
48.2 24.1 13.2 14.4
39.7 10.0 20.6 4.2 2.1 23.3 numbers because of Zwerling and
not all data Wilder were
were available not published.
for all subjects.
specified.
were not admitted for treatment) and patients suffering from any form of dementia. The latter were referred to special institutions. Their exclusion was made explicit, since they might be admitted because of an initially false diagnosis. All other admitted patients from a designated catchrnent area were included, irrespective of age, certification, on any other variable. Zwerling and Wilder’s patient group (1 ) probably matches our cohort best; the scarcity of published data from their study prohibits a definite conclusion. The semiurban catchment area of 95,000 inhabitants is located in the northeastern part of the Netherbands. It is bess prosperous than other areas and has a relatively high rate of unemployment. Essential psychopathological and sociodemognaphic data are presented in table 2. The total group did not differ from all patients admitted to psychiatric hospitals
Am]
NIENHUIS,
and Wilder (1)
Patients for Whom Day Treatment
Hospitalization (N=S7)
GIEL,
September
1992
in the Netherlands in 1 984. The experimental and controb groups were statistically equivalent on DSM-III diagnoses and sociodemographic characteristics. The last column shows corresponding data adapted from the Zwenling and Wilder study for their experimental patients only. Information on their control subjects was not published. Our study includes more patients with three or more previous admissions and fewer admitted for the first time. The DSM-III diagnoses we report are, of course, only roughly comparable to the diagnoses in the Zwerbing and Wilder study. Conditions The trial was atnic hospital.
conducted in a modern In the control condition,
500-bed the
psychipatients
1201
DAY
TREATMENT
TABLE 3. Number of Nights Spent Away From the Hospital by Patients Who Received Full-Time Hospitalization and Patients for Whom Day Treatment Was Attempteda Patients Assigned Full-Time Hospitalization (N=SS)
Mean Number of Nights Away From Hospital per
Patients for Whom Day Treatment Was Attempted (N=97)
to
Week
N
%
N
%
0
20
36.4
19
19.6
>OtoI
II
20.0
9
9.3
>1 to2 >2to3 >3to4 >4toS >Sto6 >6to7
IS 6 3 0 0 0
27.3 10.9 5.5 0.0 0.0 0.0
11 10 10 6 13 19
11.3 10.3 10.3 6.2 13.4 19.6
az504,
p=O.0000
(Mann-Whitney
test
for
independent
The mean for the patients who received full-time 1.02 nights (SD=I.02), and for the experimental nights
samples).
hospitalization patients itwas
was 3.17
(SD=3.S4).
were treated according to standard hospital care, which included 24-hour hospitalization, medication, regular contacts with a psychiatrist, occupational therapy, and in selected cases, individual, group, behavioral, creative, or psychomotor therapy. In the experimental condition, day treatment was initiated 1 ) at once, 2) after some time had elapsed, or 3) not at all, depending on the patient’s condition and social situation. The patient’s condition and social situation were assessed by a team headed by a psychiatrist or registrar. Close relatives or the patient’s partner were asked to be present. The procedure also served to provide the patient and the relatives with extensive information about the support available. On that occasion it was decided by the available panties whether to initiate day treatment at once on to postpone that decision to a later date. All decisions then and later were the final responsibility of the attending psychiatrist on registrar. (In the Netherlands a registrar is a physician seeking registration as a specialist; in psychiatry a 4-year training is required.) The general clinical criterion for keeping a patient in the hospital overnight was danger to self or to others. The day treatment lasted from 8:30 a.rn. to 4:30 p.m. (weekends excluded). It was provided either in a new day center on the hospital grounds, with a specialized multidisciplinary program, or in a regular clinical unit. During day treatment, nights in the hospital could be prescribed; such a prescription was based on the same criteria and authority as previously stated. While the patient was at home, staff could be contacted by telephone on a 24-hour basis. The hospital staff coblaborated with the regional psychiatric service outside the hospital, which could at all times render assistance at home and was involved in aftercare (25). Measures Feasibility nights per
I
202
was defined week patients
as the average spent away from
number of the hospital
according to plan. The average number of nights was calculated by dividing the sum of the nights away from the hospital by the duration in weeks of the treatment episode. This procedure served to render patients with treatment episodes of different durations comparable. This yields a maximum score of 7 for patients fully in day treatment and a minimum score of 0 for patients fully hospitalized. For the control group, this variable denotes the average number of night leaves given in standard care. This information was missing for eight patients; no differences were found between them and the other patients. Zwerling and Wilder (1, p. 171) constructed an ordinab variable not fully comparable to ours. Their dategory II, which included patients (22%) who were transferned to wards more than once or were transferred once for more than 2 nights, covers a wide range; for instance, 12 of their patients were boarded longer than 14 nights, but how much longer was not reported. For reasons explained further on, the predictor vanable “level of patient’s protection” was determined. It was measured on a 6-point scale: 6=no need of surveillance; S=surveillance at fixed times at the group level; 4=permanent surveillance at the group level, occasional interruptions possible; 3=permanent surveillance at the group level; 2=permanent surveillance at the individual level most of the time and on the group level some of the time; and 1=permanent surveillance at the individual level all of the time. Scores for the morning, afternoon, evening, and night of each day of treatment were provided by the attending nurses. The observation sheets used were tested extensively in a pilot study on 40 patients. Data
Analysis
Distributions of the feasibility variable in the control and experimental conditions were determined. The hypothesis that the experimental patients would rank higher on this variable was evaluated with the MannWhitney test for rank orders (one-tailed, p
