Partial Hospital Setting Research Articles

Implementing Measurement-Based Care in a Youth Partial Hospital Setting: Leveraging Feedback for Sustainability.

This paper describes the successful implementation of Measurement-Based Care (MBC) within a Partial Hospitalization Program (PHP) for children and adolescents. Measurement-based care (MBC), the practice of using patient-reported measures routinely to inform decision-making, is associated with improved clinical outcomes for behavioral health patients (Jong et al., Clinical Psychology Review 85, 2021; Fortney & Sladek, 2015). MBC holds great promise in partial hospital programs (PHP) to improve outcomes, yet implementation strategies are as complex as the setting itself. This paper provides a case study example of MBC implementation in a PHP for youth. Over the course of 18months, an interdisciplinary staff of approximately 20 behavioral health professionals provided partial hospitalization level of care to 633 (39% in-person, 61% telehealth) youth from ages 5 to 18years old. MBC in this setting incorporated daily patient self-report and weekly caregiver-reported measurements. This descriptive reconstruction, which includes examples of the data that were used during the implementation project, illustrates specific barriers and facilitators in a successful implementation in the local PHP setting. Implementation strategies to address workflow integration, leadership and supervision, and coaching are described, including evolution of these strategies over the course of implementation. Practical considerations for implementing MBC in youth PHP settings are discussed. Finally, the authors explore the potential relationships between the data-driven MBC model of decision making and the development of resilient organizations.

Sexual misconduct among elementary and middle school‐aged children in partial hospitalization setting

Often discussions of sexual misconduct of minors center on adult‐on‐child incidents; however, the frequency of student‐on‐student sexual misconduct has been on the rise. Sexual misconduct is defined as any conduct which is sexual in nature and is unwelcome and engaged in without consent. Sexual misconduct can include a range of behaviors including sexual harassment and unwanted touching. Recent data indicates that one‐half to three‐quarters of child sexual abuse and assault victimization experiences are committed by other children.

6.89 Identification of Potential Risk Factors for Suicidality Among Black and White Youth Aged 10 to 17 in a Partial Hospitalization Setting

6.89 Identification of Potential Risk Factors for Suicidality Among Black and White Youth Aged 10 to 17 in a Partial Hospitalization Setting

Changes in Perspective-Taking During Cognitive Behavioral Therapy in a Partial Hospital Setting

Changes in Perspective-Taking During Cognitive Behavioral Therapy in a Partial Hospital Setting

Youth Top Problems in an Acute Psychiatric Sample: Describing Consumer-Nominated Treatment Needs in an Adolescent Partial Hospital Setting.

Given the wide range of diagnostic presentations treated in partial hospital programs, finding efficient ways to identify and measure progress on the chief concerns of consumers in these settings is important. The current study uses a self-administered version of the Top Problems Assessment to describe treatment targets identified by youth and their caregivers presenting for care at an adolescent partial hospital setting. Caregiver-youth agreement on these chief concerns upon admission and predictors of agreement were explored. About one-third (34.65%) of caregiver-youth pairs did not match on any target problems. Although anxiety and depression were the most commonly cited top problems in this sample, caregivers and youth exhibited disagreement on these domains. Treatment teams in acute care settings such as a partial hospital program can benefit from careful assessment surrounding the initial goals of treatment as youth and their caregivers may not agree on the referral problems upon entering a program.

Skin Picking Scale-Revised: Diagnostic accuracy and optimal cut-off scores in university and psychiatric settings

The Skin Picking Scale-Revised (SPS-R) is an eight-item self-report measure of skin picking disorder (SPD) severity. The aim of this study was to examine the diagnostic accuracy of the SPS-R and develop cut-off scores in university and psychiatric settings. We administered the SPS-R to (1) university students with SPD (n = 73) and without SPD (n = 148) and (2) patients in a psychiatric partial hospital with SPD (n = 50) and without SPD (n = 403). Scores on the SPS-R accurately predicted SPD diagnostic status in both samples (area under the curve >0.95). A total score of 9 demonstrated an optimal balance between sensitivity, specificity, and predictive values in both samples. The results suggests that SPS-R has acceptable diagnostic accuracy and can be used as a screening tool to help identify individuals with SPD for research purposes in university and partial hospital settings.

Telehealth Treatment of Patients With Borderline Personality Disorder in a Partial Hospital Setting During the COVID-19 Pandemic: Comparative Safety, Patient Satisfaction, and Effectiveness of In-Person Treatment.

There are no studies of the safety and effectiveness of telehealth psychiatric treatment of partial hospital level of care, in general, and for borderline personality disorder (BPD) in particular. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, the authors compared the effectiveness of their partial hospital treatment program in treating patients with BPD. For both the in-person and telehealth partial hospital level of care, patients with BPD were highly satisfied with treatment and reported a significant reduction in symptoms from admission to discharge. Both groups reported a significant improvement in functioning, coping ability, positive mental health, and general well-being. A large effect size of treatment was found in both treatment groups. No patients attempted suicide. Telehealth partial hospital treatment was as effective as in-person treatment in terms of patient satisfaction, symptom reduction, and improved functioning and well-being for patients with BPD.

Measurement-based Care in the Adolescent Partial Hospital Setting: Implementation, Challenges, & Future Directions

ABSTRACT In this paper, we describe the process of implementing measurement-based care (MBC) in the adolescent partial hospital program setting. First, we outline the rationale for incorporating MBC in this treatment setting. Second, we describe the partial hospital setting in which implementation took place, including the patient population, treatment providers, and structure of programming. Next, we outline the initial implementation of standardized assessments into our programming, including key initial considerations and challenges during implementation. We describe the importance of considering the primary symptom presentations of the patient population when selecting assessment tools, the importance of leveraging existing electronic health record tools to efficiently track and record data collection, and the ability to integrate assessments into clinical workflows. Fourth, we present data describing compliance with implementation, patient outcomes, and providers’ attitudes toward and knowledge of MBC following implementation. We found after the initial implementation period, compliance was high. We also found providers had an overall positive perception of the use of MBC, reporting they perceived it to be helpful to both their clinical practice and patient outcomes. Finally, we discuss future directions for best utilizing standardized assessments in intensive treatment settings.

The Clinical Characteristics of Patients With Borderline Personality Disorder in Different Treatment Settings.

The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project compares patients with borderline personality disorder (BPD) in an outpatient practice (n = 390) and a partial hospital setting (n = 358) on diagnostic comorbidities, symptoms experienced, suicidality, and occupational impairment. The patients in the partial program were diagnosed with significantly more psychiatric disorders and were more frequently diagnosed with dysthymia, generalized anxiety disorder, alcohol and substance use disorders, adjustment disorders, and posttraumatic stress disorder. Those at the partial hospital had significantly higher levels of suicidal ideation than those in the outpatient practice. The samples did not differ on utilization of disability or suicide attempts. Treatment setting may have implications in the recognition of the disorder in clinical practice, the development and support of etiological theories, identification of core deficits, and evaluation of psychosocial morbidity associated with BPD.

Longitudinal Measurement Invariance of the PHQ-9 and GAD-7

Intraindividual change over time is commonly used to estimate treatment effectiveness. However, patients may not respond similarly to a scale after treatment, rendering pre-post change an unreliable metric. The current objective was to investigate longitudinal measurement invariance of the Patient Health Questionnaire-9 and Generalized Anxiety Disorder Scale-7 among 4,323 patients completing a partial hospital program. We used confirmatory factor analysis to determine (1) factor structure at pretreatment and posttreatment and (2) longitudinal invariance, accounting for dependent observations, using both classical and approximate measurement invariance approaches. Results indicated a two-factor solution for both scales. Longitudinal invariance was not established for either scale, thus, using raw score differences from the Patient Health Questionnaire-9 and Generalized Anxiety Disorder Scale-7 for measuring symptom change over time may be problematic. The most longitudinally consistent items captured somatic as opposed to affective/cognitive symptoms. We discuss the potential use of these measures for diagnostic screening and between-group comparisons and suggest alternative ways to monitor client progress over time. Limitations included a majority White sample and uniqueness of a partial hospital setting.

Predictors of Stepping Up to Higher Level of Care Among Eating Disorder Patients in a Partial Hospitalization Program.

Partial hospitalization programming (PHP) is a treatment option available for individuals with eating disorders (ED) who have made insufficient progress in outpatient settings or are behaviorally or medically unstable. Research demonstrates that this level of care yields efficacy for the majority of patients. However, not all patients achieve recovery in PHP and later admit to a higher level of care (HLOC) including residential treatment or inpatient hospitalization. Although PHP is an increasingly common treatment choice for ED, research concerning outcome predictors in outpatient, stepped levels of care remains limited. Thus, the current study sought to identify the predictors of patients first admitted to PHP that later enter residential or inpatient treatment. Participants were 788 patients (after exclusions) enrolled in adolescent or adult partial hospitalization programs in a specialized ED clinic. When compared to patients who maintained treatment in PHP, a significantly greater proportion of patients who discharged to a HLOC had previously received ED residential treatment. Moreover, patients who discharged to a HLOC were diagnosed with a comorbid anxiety disorder and reported greater anxious and depressive symptomatology. A logistic regression model predicting discharge from PHP to a HLOC was significant, and lower body mass index (BMI) was a significant predictor of necessitating a HLOC. Supplemental programming in partial hospitalization settings might benefit individuals with previous ED residential treatment experience, higher levels of anxiety and depression, and lower BMIs. Specialized intervention for these cases is both practically and economically advantageous, as it might reduce the risk of rehospitalization and at-risk patients needing to step up to a HLOC.

Using machine-learning to predict sudden gains in treatment for major depressive disorder

ObjectiveSudden gains during psychotherapy have been found to consistently predict treatment outcome but evidence on predictors of sudden gains has been equivocal. To address this gap, the present study utilized three machine learning algorithms to predict sudden gains during treatment for major depressive disorder. MethodWe examined predictors of sudden gains in two large samples of individuals receiving treatment in a partial hospital setting (n = 726 and n = 788; total N = 1514). Predictors included age, gender, marital status, education, employment status, previous hospitalization, comorbid diagnoses, and pretreatment measures of depressive and generalized anxiety symptoms. We used three machine learning models: a Random Forest model, a Random Forest model with an adaptive boosting meta-algorithm, and a Support Vector Machine model. ResultsIn both samples, sudden gains were identified and found to significantly predict outcome. However, none of the machine learning algorithms was able to identify robust predictors of sudden gains. Thus, even though some models achieved fair prediction of sudden gains in the training subset, prediction in the test subset was poor. ConclusionsDespite the use of a large sample and three machine-learning models, we were unable to identify robust demographic and pretreatment clinical predictors of sudden gains. Implications for clinical decision making and future studies are discussed.

Applying adherent DBT Principles to treatment in a partial hospital setting: An analysis over 5-years of outcomes from intake to discharge.

A small number of studies to date have examined Partial Hospital (PH) that utilize a Dialectical Behavior Therapy (DBT) model. Preliminary findings suggest DBT PH programs can be effective in various symptom reduction. This study examined clinically relevant outcomes and included a heterogeneous clinical sample over a five-year period. Specifically, the present study assessed pre-post data to examine changes in symptoms of depression, anxiety, hopelessness, and overall degree of suffering from intake to discharge in a DBT PH. Findings showed symptom reduction from intake to discharge for depression, anxiety, hopelessness, and suffering for all 5 years. This DBT PH program was successful at reducing various symptoms in a sample of psychiatric patients. Clinicians might consider the advantages of placing patients in PH programs versus an inpatient stay or consider utilizing DBT-informed PH programs after an inpatient hospitalization as a form of step-down care.

Resource Document Calls for Improved Residency Training on SUDs

Resource Document Calls for Improved Residency Training on SUDs

Using ACT with children and adolescents: Considerations and cautions

Recently a colleague was telling me about a group game they had played with children in a partial hospital setting. It involved a values auction where group members could buy different values written on the board with monopoly money. At the end of the auction the children discussed the values they had purchased and the reasons why. I was surprised that the 9‐ to 12‐year‐olds were as invested in the game as they were. My colleague noted that the skill of the week was “living your best life” and that groups that week had focused on values and value clarification.

Treatment Outcomes in a Partial Hospital Program for Patients with Social Anxiety Disorder: The Effects of Comorbid Major Depression

Although previous studies have examined the impact of comorbid major depressive disorder (MDD) on social anxiety disorder (SAD), the results have been somewhat mixed. Furthermore, most studies have been conducted in inpatient or outpatient settings. Given the large body of literature that suggests that this particular comorbidity can have negative effects on treatment efficacy and outcomes, it is important to continue to explore its impact. The present study aims to clarify contradictions in the literature and expands on previous studies by examining patients in a partial hospitalization setting. Patients at Rhode Island Hospital with a diagnosis of SAD were compared to those with comorbid SAD and MDD on pre-treatment and post-treatment measures of anxiety and depression. The results indicated that while the comorbid group showed significantly less improvement post-treatment on anxiety symptoms and constructs related to remission from depression, they did not show significantly less improvement on depression symptoms. The implications of these results for clinical practice are discussed. KEYWORDS: Social Anxiety Disorder; Major Depressive Disorder; Comorbid Anxiety Disorders; Comorbid Mood Disorders; Treatment Outcomes; Partial Hospitalization Program

Managing Patients With Severe and Enduring Anorexia Nervosa: When Is Enough, Enough?

Approximately 20% of patients with anorexia nervosa develop severe and enduring anorexia nervosa (SE-AN), manifest by decades-long illnesses. At certain points, demoralized and/or based on judicious appraisals of the seeming futility of further professional treatment to radically alter their course, some SE-AN patients decide that "enough is enough" and opt out of intensive treatment. This article considers courses and treatment options available at these stages for patients, families, and clinicians. The author uses clinical illustrations, Socratic questioning, and available literature to explore questions of treatment strategies with patients struggling with SE-AN. SE-AN patients have frequently received care in varieties of medical, psychiatric, and specialized eating disorders inpatient, residential, partial hospital, and outpatient treatment settings. Patients may reject further high-intensity treatment for judicious or capricious reasons, but may still accept lower intensity treatments. Some may reject any and all offers of treatment. Clinicians' treatment recommendations, not always coinciding with patients' wishes, are influenced by numbers of clinical, social, and professional pressures, including those from families, treatment settings, regulatory bodies, and payors. When managing patients with decades-long disease and multiple comorbidities, clinicians must be realistic about the low odds of effecting cure and adjust treatment expectations accordingly. For patients with SE-AN, a variety of low-intensity treatment approaches, at times extending to palliative and hospice care, may be useful. Clinicians should always strive to provide humane comfort and support, as closely aligned to patients' judicious wishes as realistically possible.

Evidence-Based Practice in a Pediatric Partial Hospitalization Setting

ABSTRACTAlthough evidence-based treatments exist for a variety of youth mental health conditions, few of them have been developed and tested at higher levels of care, where characteristics of both the patient and the setting may make them challenging to implement. This contributes to a well-documented divide between clinical research and practice settings, and it limits our understanding of how youth with higher levels of clinical complexity might meaningfully access scientifically supported care. In this paper, we describe efforts to use evidence-based practice in a real-world partial hospitalization (PHP) setting for youth ages 6–12 years. We describe both system and clinician-level constraints as well as efforts to overcome them in providing care for youth with the full spectrum of severe psychopathology. Focusing on two specific domains, group cognitive behavior therapy (CBT) and parent training, we describe efforts to work flexibly guided by the principles set forth in well-established protocols. Challenges and future directions for bringing evidence-based care to hospital-based settings are discussed.

Levels of perceived control and treatment response in a brief partial hospital setting

BackgroundPerceived internal and external control have long been theorized to relate to development and maintenance of anxiety (Barlow, 2002) and depression (Seligman, 1975). Experimental research studies investigating perceived control have largely focused on anxiety within cross-sectional samples and have shown that low levels of perceived internal and external control are associated with higher levels of anxiety (Gallagher et al., 2014) and depression (Brown & Siegel, 1988; Wardle et al., 2004). The majority of previous research has looked at the combined effects of perceived internal and external control and has not investigated these constructs as potential treatment targets in intensive, short-term clinical settings. MethodsThe current study examined the associations of perceived internal and external control as they relate to anxiety and depression symptom change in a partial hospital sample. ResultsBoth perceived internal and external control increased significantly over brief, intensive treatment. Further, greater gains in internal perceived control were related to greater reductions in anxiety and depression symptoms. DiscussionOur study was limited in that it did not include a control group or follow-up data. This study provides evidence that perceived internal control is related to change in symptoms in a diagnostically diverse and severe population, after very brief intensive treatment. Future studies should investigate if perceived internal control is a mechanism of change in treatment and explore how to maximize the development of perceived internal control in treatment, to maximize reduction in symptoms.

Family Stress Moderates Emotional and Behavioral Symptoms in a Child Partial Hospital Setting

Partial hospitalization programs are an increasingly utilized, multidisciplinary treatment for children with social, emotional, and behavioral needs. Although previous work suggests these programs improve children’s mental health functioning, outcomes research has been limited. This study examines moderators of emotional and behavioral outcomes in children with serious mental illness, with particular focus on demographic (age, race, insurance type, and gender) and family (stressors and supports) factors. The study includes 287 children ages 7–13. Children completed standardized questionnaires at admission and discharge including the Behavior Assessment System for Children-2 the Child Depression Inventory 2, and the Screen for Child Anxiety Related Disorders while caregivers completed the Strengths and Difficulties Questionnaire. Results indicate improvements in children’s anxiety, depressive symptoms, psychological adjustment, and emotional symptoms. Furthermore, children with private insurance reported significant decreases in depressive (p < 0.001) and emotional symptoms (p< 0.001) compared to children with state funded insurance. Females reported sharper decreases in depressive symptoms (p< 0.001) compared to males (p= 0.019). Finally, children in families with no stressors in the past month demonstrated sharper declines in depressive symptoms (p< 0.001) compared to children in families with one or more stressors in the past month (p= 0.001). Family support did not moderate these outcomes. This study suggests partial hospitalization programs may be effective in improving emotional and behavioral problems. This study suggests family stressors are important to consider and emphasize in treatment.