Sage Journals: Discover world-class research

Abstract

Objectives: This study aims to assess the effectiveness of day programs against other treatment modalities in adolescents with mental illnesses (including substance abuse). It also aims to identify patient and program factors associated with favourable outcomes for adolescents with mental illness treated in therapeutic day programs.

Method: An extensive database search of published literature was conducted, supplemented by hand-searching of references of retrieved articles, and a search by author. There was no restriction by study design. Relevant studies were identified and appraised using standardised criteria.

Results: Of the 231 studies identified in the search, 26 were relevant to this review. The majority of studies identified day programs as effective. There was a lack of adequate comparisons between day programs and other organisational arrangements.

Conclusions: The quality of the studies identified was low. Twenty-two of the 26 studies did not have an adequate control group. Higher-quality research is required in the evaluation of the effectiveness of day programs, and the identification of other factors promoting successful outcome in the treatment of adolescent mental illness.

Keywords

adolescence day treatment mental health services treatment outcome

Therapeutic day programs can be considered synonymous with partial hospitalisation. The latter has been defined as ‘an ambulatory treatment program that includes the major diagnostic, medical, psychiatric, psychosocial, and prevocational treatment modalities designed for patients with serious mental disorders who require coordinated, intensive, comprehensive, and multidisciplinary treatment not provided in an outpatient setting’ [1].

Day programs have been identified as an area of need for the treatment of adolescents with mental illness in both Australia and New Zealand [2],[3]. The World Health Organization definition of adolescence (10–19 years) was used in this review [4].

Psychiatric and emotional problems have been consistently identified as one of the major health problems in adolescence both in Australasia and elsewhere [4],[5]. Studies examining the prevalence of psychiatric disorder in adolescents have concluded that between 20%% and 45%% of this age group have a diagnosable disorder [6–12]. Adolescents with mental illness have increased morbidity and mortality in the future [13],[14].

Therapeutic day programs represent an alternative to residential programs in the treatment of adolescents with mental illness [1]. This systematic review had two objectives. The first was to assess the effectiveness of day programs against other treatment modalities (including inpatient and outpatient treatment) in adolescents with mental illness (including substance abuse). The second was to identify patient and program factors associated with favourable outcome for adolescents with mental illness treated in therapeutic day programs.

Method

Literature search

A comprehensive search of medical, psychiatric, sociological and Australasian databases was conducted using validated strategies. Complete details are given elsewhere [15].

References of the retrieved studies were hand-searched and a search was conducted by author's name for any author identified more than once from the above search strategies. Studies written in English or any European language from 1980 onwards were accepted for the review.

Exclusion criteria

Studies were excluded from the present review if: (i) any participant was under 8 years or over 25 years of age; (ii) all participants were under 12 years or over 20 years of age; (iii) participants were described as having mild disease, of low IQ, or autistic; (iv) there was more than one statistically significant difference at baseline between comparison groups; and (v) results already reviewed were presented in a second publication.

Appraisal methodology

Articles were formally appraised using standardised methods [16]. The evidence was graded using the five levels of the US Preventive Services Task Force protocol [17].

Results

There were 231 studies identified from the search. A single reviewer (RW) identified and appraised the 26 studies included in the review.

Effectiveness of day programs in the treatment of adolescents with mental illness

Eight studies evaluated the effectiveness of therapeutic day programs in the treatment of adolescents with mental illness.

One randomised, controlled trial (grade I evidence) was identified [18] comparing multi-systemic therapy with ‘usual care’ in 155 juvenile offenders aged between 10 and 19 years in the United States. There was a statistically significant decrease in emotional distress experienced by the multi-systemic therapy group (p < 0.006), but no improvement in re-arrest rates or in peer relations. This study was limited by the lack of baseline data comparing the two groups and the generalisability was uncertain since 80%% of the participants were African-American.

Another study compared costs of day treatment and inpatient treatment [19]. There were 205 participants in the inpatient program and 72 in the day program. Participants were not restricted by diagnostic grouping. There was no difference in the total cost between the two programs. Day program participants were significantly younger than the participants in the inpatient arm of the study (p < 0.01), which might have resulted in less-intensive treatment being appropriate and therefore costs in the day program being lower. However, the cost of inpatient treatment was underestimated when the stay was longer than 30 days.

The remaining studies used the before-and- after design (grade II-3 evidence [17]) [20–24]. These studies consistently showed improvements in behavioural outcomes (see Table 1). However, the before-and- after design is inadequate for assessing the effectiveness of day programs. As behaviour change is expected to occur during adolescence, these studies should be considered uncontrolled.

Table 1.

Results of uncontrolled studies evaluating the effectiveness of day programs in the treatment of adolescents with mental illness

Factors affecting the outcome in adolescents with mental illness

Five studies (including one case–control study) assessed factors affecting treatment outcome in adolescents with mental illness.

The case–control study (grade II-2 evidence) compared factors associated with a successful outcome (defined by patients' showing pro-social behaviour) with unsuccessful outcome (defined by patients' running away from the program, placement in more restrictive hospital settings or removal from the program) [25]. There were 36 patients with a successful outcome and 34 patients with an unsuccessful outcome. Participants were aged between 8 and 18 years. The program was described as psychoeducational and included day and residential components. Absenteeism from the program was associated with unsuccessful outcome and day programs showed a higher rate of successful outcomes compared with residential programs. However, it was unclear whether more severe disease was associated with treatment in a residential setting. Therefore, the day versus residential program comparison should be interpreted with caution. Selection of participants was made on the basis of completeness of records which potentially introduces a selection bias. The measures of successful outcome were relatively arbitrary producing a potential misclassification bias.

Three studies which investigated the role of family involvement in treatment of mental illness found favourable results but were of low quality. There was one before-and-after design [24], (grade II-3 evidence) and two descriptive studies [26],[27] (grade III evidence). In one study, there was a low follow-up rate (26%%) in a group with low parental involvement [24]. In another study, different outcomes were studied for different comparison groups [27]. The results of these studies are documented in Table 2.

Table 2.

Results of uncontrolled studies evaluating the influence of family involvement on adolescent mental illness outcome

A descriptive study [28] (grade III evidence) assessed a range of factors as predictors of successful outcome (based on level of functioning [28],[29]). There were 50 participants aged between 13 and 18 years. Outcome was assessed after 2 year follow up. Psychotic illness (p = 0.01), increased diagnostic severity according to the Gossett Timberlawn Adolescent Psychopathology Scale [30] at discharge (p < 0.05) and incomplete program completion (p = 0.02) were associated with poor outcome. A good relationship with peers (p = 0.01) and adults (p = 0.05) was associated with successful outcome. This study was limited by the lack of a control group and the follow-up rate was only 65%%.

Effectiveness of day programs in the treatment of adolescents with drug and alcohol problems

Five studies evaluated the effectiveness of day programs in the treatment of adolescents with drug and alcohol problems. One of these was a retrospective cohort study (grade II-2 evidence), three were before-and-after studies (grade II-3 evidence) and one was cross-sectional (grade III evidence) in design.

The age range was stated as adolescent in the cohort study [31]. The participants were followed for 2 years. Those in the treatment group had a significantly lower school grade point average at baseline but a significantly higher grade point average during treatment (p < 0.01) and at treatment completion (p < 0.05) compared with those not in the treatment group. However, the results of this study should be interpreted with caution since the sample size, age range and follow-up rate were not stated.

Three of the four other studies [32–35] demonstrated a significant reduction in self reported drug use and two of the studies [32],[35] showed a higher rate of high school graduation after participating in a day program. The results of these studies are summarised in Table 3.

Table 3.

Results of uncontrolled studies evaluating the effectiveness of day programs in the treatment of adolescents with drug and alcohol problems

These latter four studies are difficult to interpret given their uncontrolled design. While there was some consistency in the results, it is possible that the positive results occurred due to factors other than the treatment programs. The follow-up rate was low in all three before-and-after studies (less than 70%%) which potentially biases the results towards favouring day programs. All the programs were conducted in the USA and have uncertain generalisability to other countries.

There was an absence of studies that compared the effectiveness of day programs and residential programs in the treatment of adolescents with drug and alcohol problems.

Factors affecting the outcome in adolescents with drug and alcohol problems

Ten studies conducted in the USA evaluated factors promoting the successful outcome of adolescents with drug and alcohol problems. All studies were either before-and-after (grade II-3 evidence) or descriptive (grade III evidence) in design.

The three studies examining program characteristics were derived from statistics kept on the National Institute on Drug Abuse database [36–38]. A wide range of factors associated with self reported reduction in drug abuse were identified. These included: (i) ‘drop outs’ attending special schools (p = 0.001); (ii) schools employing experienced counsellors (p = 0.001); (iii) doctors and therapists being perceived by clients as allowing spontaneous action (p = 0.005); (iv) and schools providing special services such as vocational counselling (p = 0.001).

As the results were derived from the same database, it was inappropriate to evaluate for consistency. The three studies lacked an adequate control group.

Three out of four studies that investigated family dynamics in treatment of alcohol and drug problems demonstrated more favourable outcomes with positive family dynamics. In one study [39], an improvement in the drug severity index was associated with the adolescent having a better relationship with the mother (p = 0.002). Adolescents were more likely to drop out of treatment if family therapy had been missed for at least 1 month (p < 0.02) [40]. It is recognised that lack of motivation might act as a confounder in this association. Mothers without substance-abuse problems or who were not receiving treatment and fathers of higher socioeconomic status were both associated with program completion (p < 0.05) in another study [35]. These studies were all limited by their uncontrolled design.

In the other study examining parental factors [41], drug abuse was positively correlated with living with parents (p < 0.001). The participation rate was not stated and it was possible that those not living at home were more difficult to follow up (the study was conducted 3–8 years after participants left the program). Those not followed up might have been more likely to abuse drugs. Alternatively, financial status might be a confounder, with drug abusers more likely to have financial difficulties resulting in incentives to live with parents.

Starting drug abuse at an older age was associated with program completion (p < 0.05) [35] and being ‘high’ at an early age was associated with more relapses (p < 0.05) and lower school grade point averages (p < 0.01) [42]. The latter study was based on self-report data and the participation rate was not stated.

One study examined the role of the substance of abuse in treatment outcome [43]. Marijuana used as the primary drug was associated with poor outcome but, this factor only explained 4%% of the variance in outcome, and the association might have been due to the total amount of marijuana use being proportionately less than for other drugs, resulting in little room for improvement. This study was limited by the use of the before-and-after design and relying on self-report data.

One study examined the role particular psychiatric symptomatology had in predicting outcome [44]. More borderline psychotic symptoms at admission was associated with a greater decrease in drug use as a result of treatment (p = 0.02), and more interpersonal sensitivity symptoms predicted a greater likelihood of patients graduating from high school (p = 0.04). This study relied on self-report data and there was a 30%% drop out rate at follow up.

Conclusions

Adolescent mental illness and substance abuse has been identified as a significant problem and high-priority area in New Zealand health care [3],[4]. The rates of these disorders are high [6–11].

This review has focused on the use of day programs in the treatment of adolescents with mental illness or drug and alcohol problems.

A review such as this is reliant on the quality of the studies identified. The study designs were generally of low quality. The before-and-after study design is not an ideal method of examining the effectiveness of an intervention. As behaviour change was a frequent outcome measure, and behaviour changes with time in the adolescent age group, there are explanations for such behaviour change other than the effectiveness of the treatment program. In the context of this review, this study design should therefore be considered as uncontrolled. Despite this limitation, 15 of 26 studies used this design and a further seven were descriptive in design.

Outcome was assessed using a wide range of measures, with a range of groups and at a range of different times in the treatment process. This allows confidence in studies of suitable quality in a particular type of intervention if the intervention shows consistently positive results. However, it does not allow any form of comparison between the individual studies.

This review also has biases inherent in its design. Published literature only was searched. As unpublished literature is known to be biased towards studies without significant results [45] some studies of this type may potentially have been omitted. In addition, although internationally recognised and validated search strategies were used, they are not 100%% sensitive and may have missed potentially relevant articles.

The large number of studies which took place in the USA (86%%) and the wide period of time over which they were conducted (1980 onwards) affects the generalisability of the outcomes. It should not be assumed that the results of these studies could be replicated in another location and time period.

There has been strong motivation to evaluate therapeutic day programs in the USA in an effort to control the costs resulting from inpatient stay. However, in Australasia there are few inpatient beds for adolescents with mental illness. There was minimal data comparing outpatient programs with day programs. It would also have been of interest to evaluate the effect day programs had on reducing the length of inpatient stay. These are both areas for future research.

The evaluation of day programs for adolescents with mental illness was limited: six studies identified were before-and-after in design. One randomised, controlled trial was identified but was of minimal relevance since the intervention evaluated was normally performed in the home setting. A cost comparison was also identified that compared day programs with inpatient care. However, the study had considerable limitations, which did not allow any conclusions to be drawn.

Three other studies examined the role of parental involvement in the outcome of treatment of adolescents with mental health problems. These three studies were relatively weak in design (grade II-3 and grade III evidence), but two of them had evidence that parental involvement improved outcome. Impact was assessed at program completion in two studies and outcome was not followed up later.

Five studies conducted in the United States investigated the effectiveness of day programs in the treatment of adolescent substance abuse. No randomised, controlled trials were identified. There was some inconsistency in specific outcomes between the studies but overall results were positive.

The 10 studies that investigated factors influencing the outcome of adolescents in substance-abuse treatment programs were characterised by low-quality, inconsistent results, and most studies assessed a different range of variables. However, it appeared that outcome was more likely to be positive when substance abuse started at an older age.

It is concluded that an assessment of the effectiveness of day programs for adolescents with mental illness cannot be made on present evidence. In addition, while day programs showed some consistency in reducing substance abuse and improving educational outcomes, further, higher quality research was required in this area. There were insufficient studies to compare the effectiveness of day programs with other therapeutic modalities.

The studies evaluating the effectiveness of family therapy in adolescents with serious mental illness were weak and this area requires further research.

There was an absence of comparisons between residential and day programs to assess the relative effectiveness of these two interventions in the treatment of adolescent substance abuse.

The limitations of the studies included in this report have been discussed. However, it needs to be recognised that performing high-quality studies in the evaluation of day programs is difficult. Particular issues involve designing studies with better control groups and having an adequate sample size.

Footnotes

Acknowledgements

Thanks are due to Elspeth MacDonald for her constructive criticism of this review, New Zealand Health Technology Assessment staff and Judy Walker and Gaylia Powell of the Health Funding Authority, Southern Branch, New Zealand. This review was originally performed for the Health Funding Authority (HFA).

References

1. American Psychiatric Association . Guidelines for standards for partial hospitalization. American Psychiatric Association New York County District Branch, New York 1980.

2. Victoria's Mental Health Service . The framework for service delivery – child and adolescent services. Mental Health Branch, Victorian Government Department of Human Services, Melbourne 1998.

3. Ministry of Health . A strategic framework for specialist mental health services for children and young people in New Zealand. Ministry of Health, WellingtonNew Zealand 1998, Draft for consultation.

4. World Health Organization . Final report: regional working group on health needs of adolescents. Regional Office for the Western Pacific of the World Health Organization, Manila 1980.

5. Silva

. Health in adolescence. New Zealand Medical Journal 1988; 101: 689–692.

6. Costello

Angold

Burns

Erkanli

Stangl

Tweed

. The Great Smoky Mountains study of youth. Archives of General Psychiatry 1996; 53: 1137–1143.

7. Beals

Piasecki

Nelson

. Psychiatric disorder among American Indian adolescents: prevalence in Northern Plains youth. Journal of the American Academy of Child and Adolescent Psychiatry 1997; 36: 1252–1259.

8. Verhulst

Van der Ende

Ferdinand

Kasius

. The prevalence of DSM–III–R diagnoses in a national sample of Dutch adolescents. Archives of General Psychiatry 1997; 54: 329–336.

9. Feehan

McGee

Raja

Williams

. DSM–III–R disorders in New Zealand 18–year–olds. Australian and New Zealand Journal of Psychiatry 1994; 28: 87–99.

10.

10. McGee

Feehan

Williams

Partridge

Silva

Kelly

. DSM–III disorders in a large sample of adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 1990; 29: 611–619.

11.

11. Fergusson

Horwood

Lynskey

. Prevalence and comorbidity of DSM–III–R diagnoses in a birth cohort of 15 year olds. Journal of the American Academy of Child and Adolescent Psychiatry 1993; 32: 1127–1134.

12.

12. Offord

Boyle

Szatmari

. Ontario Child Health Study II. six–month prevalence of disorder and rates of service utilization. Archives of General Psychiatry 1987; 44: 832–836.

13.

13. Feehan

McGee

Williams

. Mental health disorders from age 15 to age 18 years. Journal of the American Academy of Child and Adolescent Psychiatry 1993; 32: 1118–1126.

14.

14. Amaddeo

Bisoffi

Bonizzato

Micci

Tansella

. Mortality among patients with psychiatric illness: a ten–year case register study in an area with a community–based system of care. British Journal of Psychiatry 1995; 166: 783–788.

15.

15. New Zealand Health Technology Assessment . Adolescent therapeutic day programmes and community–based programmes for serious mental illness and serious drug and alcohol problems. New Zealand Health Technology Assessment, Christchurch 1998.

16.

16. Group Health Cooperative of Puget Sound . Provider education and guidelines. Group Health Cooperative of Puget Sound, Seattle, WA 1996.

17.

17. US Preventive Services Task Force . Guide to clinical preventive services: an assessment of the effectiveness of 169 interventions. Williams & Wilkins, Baltimore 1989.

18.

18. Henggeler

Melton

Brondino

Scherer

Hanley

. Multisystemic therapy with violent and chronic juvenile offenders and their families: the role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology 1997; 65: 821–833.

19.

19. Kiser

Ackerman

Pruitt

. A comparison of intensive psychiatric services for children and adolescents: cost of day treatment versus hospitalization. International Journal of Partial Hospitalization 1987; 4: 17–27.

20.

20. Blackman

Pitcher

Rauch

. A preliminary outcome study of a community group treatment programme for emotionally disturbed adolescents. Canadian Journal of Psychiatry 1986; 31: 112–118.

21.

21. Ensink

Robertson

Zissis

Leger

de Jager

. Conduct disorder among children in an informal settlement. South African Medical Journal 1997; 87: 1533–1537.

22.

22. Orchard

Macleod

. Adolescent day program: a two year retrospective review. Canadian Journal of Psychiatry 1990; 35: 554–556.

23.

23. Kettlewell

Jones

. Adolescent partial hospitalization: some preliminary outcome data. Journal of Clinical Child Psychology 1985; 14: 139–144.

24.

24. Waugh

Kjos

. Parental involvement and the effectiveness of an adolescent day treatment program. Journal of Youth and Adolescence 1992; 21: 487–497.

25.

25. Leone

Fitzmartin

Stetson

Foster

. A retrospective follow–up of behaviorally disordered adolescents: identifying predictors of treatment outcome. Behavioral Disorders 1986; 11: 87–97.

26.

26. Jansen

. Benefits of a family–oriented approach in adolescent treatment. Social Casework 1986; 67: 410–417.

27.

27. Ginsberg

. Adolescent day hospital: a cost–effective treatment alternative. International Journal of Partial Hospitalization 1987; 4: 167–173.

28.

28. Huestis

Ryland

. Outcome after partial–hospital treatment of severely disturbed adolescents. International Journal of Partial Hospitalization 1990; 6: 139–153.

29.

29. Garber

. Follow–up of hospitalized adolescents. Bruner–Mazel, New York 1972.

30.

30. Gossett

Lewis

Barnhard

. To find a way: the outcome of hospital treatment of disturbed adolescents. Brunner/Mazel, New York 1983.

31.

31. Kirk

Chapman

Sadler

. Documenting the effectiveness of adolescent substance abuse treatment using public school archival records. High School Journal 1990; 74: 16–21.

32.

32. Friedman

Utada

Glickman

. Outcome for court–referred drug–abusing male adolescents of an alternative activity treatment program in a vocational high school setting. Journal of Nervous and Mental Disease 1986; 174: 680–688.

33.

33. Hubbard

Cavanaugh

Craddock

Rachal

. Characteristics, behaviours, and outcomes for youth in the TOPS. Treatment services for adolescent substance abusers, Friedman

Beschner

. US Department of Health and Human Services, Rockville, MD 1985; 49–65.

34.

34. Friedman

Schwartz

Utada

. Outcome of a unique youth drug abuse program: a follow–up study of clients of Straight, Inc. Journal of Substance Abuse Treatment 1989; 6: 259–268.

35.

35. Feigelman

. Day–care treatment for multiple drug abusing adolescents: social factors linked with completing treatment. Journal of Psychoactive Drugs 1987; 19: 335–344.

36.

36. Friedman

Glickman

. Program characteristics for successful treatment of adolescent drug abuse. Journal of Nervous and Mental Disease 1986; 174: 669–679.

37.

37. Friedman

Glickman

Kovach

. The relationship of drug program environmental variables to treatment outcome. American Journal of Drug and Alcohol Abuse 1986; 12: 53–69.

38.

38. Friedman

Glickman

. Residential program characteristics for completion of treatment by adolescent drug abusers. Journal of Nervous and Mental Disease 1987; 175: 419–424.

39.

39. Friedman

Terras

Kreisher

. Family and client characteristics as predictors of outpatient treatment outcome for adolescent drug abusers. Journal of Substance Abuse 1995; 7: 345–356.

40.

40. Weidman

. Family therapy and reductions in treatment dropout in a residential therapeutic community for chemically dependent adolescents. Journal of Substance Abuse Treatment 1987; 4: 21–28.

41.

41. Feigelman

Hyman

Amann

Feigelman

. Correlates of persisting drug use among former youth multiple drug abuse patients. Journal of Psychoactive Drugs 1990; 22: 63–75.

42.

42. Marshall

Marshall

Heer

. Characteristics of abstinent substance abusers who first sought treatment in adolescence. Journal of Drug Education 1994; 24: 151–162.

43.

43. Friedman

Glickman

Morrissey

. Prediction to successful treatment outcome by client characteristics and retention in treatment in adolescent drug treatment programs: a large–scale cross validation study. Journal of Drug Education 1986; 16: 149–165.

44.

44. Friedman

Glickman

. Effects of psychiatric symptomatology on treatment outcome for adolescent male abusers. Journal of Nervous and Mental Disease 1987; 175: 425–430.

45.

45. Easterbrook

Berlin

Gopalan

Matthews

. Publication bias in clinical research. Lancet 1991; 337: 867–872.

46.

46. Miller

. Louisville behaviour checklist. Western Psychological Services, Los Angeles 1988, Revised edn..

Therapeutic Day Programs in the Treatment of Adolescents with Mental Illness

Abstract

Keywords

Method

Literature search

Exclusion criteria

Appraisal methodology

Results

Effectiveness of day programs in the treatment of adolescents with mental illness

Factors affecting the outcome in adolescents with mental illness

Effectiveness of day programs in the treatment of adolescents with drug and alcohol problems

Factors affecting the outcome in adolescents with drug and alcohol problems

Conclusions

Footnotes

Acknowledgements

References