Partial Hospitalization Research Articles

Changes in suicide capability during short-term partial hospital treatment

Suicide capability (fearlessness about death [FAD], preparation, and perceived capability [PC]) is presumed to be static, or to increase with exposure to provocative events. However, tests of this assumption have primarily used non-clinical samples. We examined short-term changes in capability among patients in a partial hospital program. We enrolled 296 adult patients (186 [62.7%] female; Mage=36.13, SDage=14.75) who completed diagnostic interviews and questionnaires assessing demographics, capability, and suicide ideation (SI) at intake. Capability was re-assessed twice during treatment and again at discharge, and SI was re-assessed at discharge. We used latent growth modeling (LGM) to quantify changes in capability. FAD, preparation, and PC decreased from intake to discharge (ps<0.001, ds=0.24–0.63) and unconditional LGM models suggested that all facets changed significantly throughout treatment. FAD was positively associated with preparation (r = 0.57) and PC (r = 0.25) at intake (ps<0.001), but changes in FAD did not predict changes in other facets. Greater SI at intake was concurrently associated with higher capability (βs=0.26–1.83, ps<0.01) and predicted steeper declines in preparation (β=-0.23) and PC (β=-0.04), ps=0.04. Finally, higher intake preparation predicted more severe SI at discharge (β=0.16, p<.001). There was no control group and there was unequal spacing between in-treatment assessments among participants. Results for SI may have been impacted by floor effects. Results suggest that aspects of capability can change over a short time. Conceptually related facets of capability did not change together; thus, future investigations of the short-term dynamics of capability should not treat it as a unitary construct.

Latent classes of symptom trajectories during partial hospitalization for major depressive disorder and generalized anxiety disorder

BackgroundA variety of treatments have been empirically validated in the treatment of major depressive disorder and generalized anxiety disorder. Researchers commonly evaluate symptom change during treatment using single model curves, however, modeling multiple curves simultaneously allows for the identification of subgroups of patients that progress through treatment on distinct paths. MethodsLatent growth mixture modeling was used to identify and characterize distinct classes of symptom trajectories among two samples of patients with either MDD or GAD receiving treatment in a daily partial hospital program. ResultsFour depression symptom trajectories were identified in the MDD sample, and three anxiety symptom trajectories were identified in the GAD sample. Both samples shared symptom trajectory classes of responders, rapid responders, and minimal responders, while the MDD sample demonstrated an additional class of early rapid responders. In both samples, low symptom severity at baseline was associated with membership in the responder class, though few other patterns emerged in baseline characteristics predicting trajectory class membership. At treatment discharge, those in the minimal responder class reported poorer outcomes on every clinical measure. Patients within each class reported similar scores at discharge as compared to each other class, indicating that class membership affects clinical measures beyond symptom severity. LimitationsPatient demographic characteristics were relatively homogeneous. Group-based trajectory modeling inherently involves some degree of uncertainty regarding the number and shape of trajectories. ConclusionsIdentifying symptom trajectories can provide information regarding how patients are likely to progress through treatment, and thus inform clinicians when a patient deviates from expected progress.

Prevalence and Correlates of Hair Pulling Disorder and Skin Picking Disorder in an Acute Psychiatric Sample.

Hair pulling disorder (HPD; trichotillomania) and skin picking disorder (SPD; excoriation disorder) are understudied psychiatric disorders. The aim of this study was to examine the prevalence and correlates of HPD and SPD in an acute psychiatric sample. Semistructured interviews and self-report measures were administered to patients in a psychiatric partial hospital (N = 599). The past-month prevalence of HPD and SPD was 2.3% and 9%, respectively. HPD and SPD had highly similar clinical characteristics and a strong co-occurrence. Patients with HPD/SPD were significantly younger than other patients and more likely to be female. Logistic regression controlling for age and sex showed that diagnosis of HPD/SPD was not significantly associated with suicidal ideation, suicidal behaviors, nonsuicidal self-injury, or emotional disorder diagnoses (e.g., borderline personality disorder, major depressive disorder). HPD/SPD status was significantly associated with an increased risk of generalized anxiety disorder. However, patients with HPD/SPD did not differ from other patients on self-report measures of generalized anxiety, depression, and distress intolerance. HPD and SPD are common and frequently co-occurring disorders in psychiatric settings.

Confirmatory factor analysis of Acute Suicidal Affective Disturbance in a sample of treatment-seeking eating disorder patients

Introduction: We examined the factor structure of Acute Suicidal Affective Disturbance (ASAD) in individuals with eating disorders. ASAD is a proposed diagnosis with four symptoms: rapidly increasing suicidal intent, social or self-alienation, hopelessness regarding the previous symptoms, and overarousal. Methods: Patients with eating disorders (N = 378) completed self-report symptom questionnaires at admission to a partial hospitalization program for eating disorders. Using proxy measures, we conducted a confirmatory factor analysis (CFA) of the one-factor model of ASAD. Results: Initial model fit was poor. We iteratively revised the model to include theoretically-justified correlated residuals (i.e., those between items intended to measure the same ASAD symptom). After these modifications, model fit remained mediocre. We next conducted a multiple-group CFA to compare ASAD between individuals with the restricting subtype of anorexia nervosa (the “ANR” model, n = 145) and individuals with binge/purge disorders (i.e., bulimia nervosa and the binge-purge subtype of anorexia nervosa; the “BP” model, n = 234). The final model had mediocre fit with partial invariance between subgroups; the ASAD factor mean was higher in the BP model. We additionally tested a bifactor model, with similar findings. Limitations: Our use of proxy measures of ASAD items may have resulted in imprecise measurement of ASAD symptoms, pointing to the importance of future research using validated measures of ASAD. Conclusions: We found moderate support for ASAD in an eating disorder sample, with invariance between eating disorder phenotypes. Our findings suggest that the ASAD diagnosis may not fully generalize to eating disorder samples.

The impact of between-session habituation, within-session habituation, and weight gain on response to food exposure for adolescents with eating disorders.

Exposure therapy is a promising treatment for eating disorders (EDs). However, questions remain about the effectiveness of exposure to feared foods during the weight restoration phase of treatment, and the importance of between-session and within-session habituation. We recruited 54 adolescents from a partial hospitalization program (PHP) for EDs which included daily food exposure. Throughout treatment, participants provided subjective units of distress (SUDS) ratings before and after eating a feared food, and completed measures of ED symptomatology. Multilevel models found that pre-exposure SUDS decreased over time, providing some evidence that between-session habituation occurred. In contrast, the difference between pre-exposure and post-exposure SUDS did not decrease over time, indicating that within-session habituation did not occur. Weight gain predicted greater between-session habituation to feared foods, but did not predict within-session habituation. Between-session habituation, but not within-session habituation, predicted favorable treatment outcomes, including weight gain and improvements on the Children's Eating Attitudes Test and Fear of Food Measure. Partial hospitalization programs that include daily exposure to feared foods may be effective at decreasing anxiety about foods for adolescents with EDs who are experiencing weight restoration. Further research is warranted to replicate our findings challenging the importance of within-session habituation, and to better understand between-session habituation and inhibitory learning as mechanisms of change when conducting food exposure for EDs. This study provides some evidence that PHPs that include food exposure may be useful for adolescents with EDs who are experiencing weight restoration. Between-session habituation, but not within-session habituation, predicted favorable treatment outcomes. Further research is needed to determine whether clinicians can disregard within-session habituation when conducting food exposure for EDs, and understand the importance of between-session habituation as a potential mechanism of food exposure.

Child Oriented FamilyTherapy as a Key Component in Young Children's Psychiatric Treatment

The Child Oriented FamilyTherapy (COF) is a new therapeutic method aiming towards infants in the playing age group and their families. COF is - originally invented in Scandinavia - spreading over Germany since the beginning of the 21st century. The prevalence for psychiatric disorders in toddlers, preschoolers and young infants in Germany lies between 14 and 22 %. Treatment in an outpatients' clinic with partial hospitalization is indicated whenever the psychosocial resources are too low or the symptoms are too severe to be treated in an ambulant environment. The outpatients' department for pediatric psychiatry in Gelsenkirchen is the first institution in its field to use COF as one module to treat their young patients and their families. Due to the setting adjustments of the original method are necessary, for example a conceptualization of disease, the use of COF as a diagnostic method and the embedding of COF in an underlying treatment plan.

Predicting substance use disorder treatment follow-ups and relapse across the continuum of care at a single behavioral health center

IntroductionSubstance use disorder is often a chronic condition, and its treatment requires patient access to a continuum of care, including inpatient, residential, partial hospitalization, intensive outpatient, and outpatient programs. Ideally, patients complete treatment at the most suitable level for their immediate individual needs, then transition to the next appropriate level. In practice, however, attrition rates are high, as many patients discharge before successfully completing a treatment program or struggle to transition to follow-up care after program discharge. Previous studies analyzed up to two programs at a time in single-center datasets, meaning no studies have assessed patient attrition and follow-up behavior across all five levels of substance use treatment programs in parallel. MethodsTo address this major gap, this retrospective study collected patient demographics, enrollment, discharge, and outcomes data across five substance use treatment levels at a large Midwestern psychiatric hospital from 2017 to 2019. Data analyses used descriptive statistics and regression analyses. ResultsAnalyses found several differences in treatment engagement based on patient-level variables. Inpatients were more likely to identify as Black or female compared to lower-acuity programs. Patients were less likely to step down in care if they were younger, Black, had Medicare coverage were discharging from inpatient treatment, or had specific behavioral health diagnoses. Patients were more likely to relapse if they were male or did not engage in follow-up SUD treatment. ConclusionsFuture studies should assess mechanisms by which these variables influence treatment access, develop programmatic interventions that encourage appropriate transitions between programs, and determine best practices for increasing access to treatment.

A benchmarking approach for characterizing providers’ patterns of treating patients with substance use disorder

It is difficult to identify fraud, waste, and abuse (FWA) in substance use disorder (SUD) treatment. Insurers use outlier detection models to detect SUD-related FWA but these models require credible benchmarks based on cross-payer claims data. To our knowledge, these benchmarks have not been established for SUD-related services frequently cited in fraud cases — drug screening, psychotherapy, and partial hospitalization. We used de-identified and aggregated data from FAIR Health’s national database of commercial claims, including ACA marketplace plans, from 2014 to 2018 to establish regional benchmarks. We provide additional benchmarks for providers in specialties that most frequently submit claims for patients with SUD. These benchmarks can either be used to determine if a provider’s frequency of claims per-patient-per-month is unusual, potentially signaling FWA, or within a common range for the region or specialty. Our findings can be used to improve detection of FWA – a critical step towards improving the quality of treatment.

HISTOPATHOLOGIC FEATURES OF KIDNEY TUMORS AND COMPARISON OF PATIENTS TREATED WITH RADICAL AND PARTIAL NEPHRECTOMY AT OSIJEK UNIVERSITY HOSPITAL CENTER FROM 2017 UNTIL THE END OF 2021.

The objective of this study was to present results of kidney tumor treatment at Osijek University Hospital Center over a 5-year period and to compare the outcomes between patients treated with radical nephrectomy (RN) and partial nephrectomy (PN). From November 2016 until the end of 2021, there were 280 consecutive PNs and RNs included in this cross-sectional study. Exclusion criteria were nephrectomies due to non-oncologic reasons and transitional cell carcinoma. There were 229 RNs and 51 PNs, median age of all patients was 62.5 (range 34-84) years. In the RN group, there were 197 renal cell carcinomas (RCC), predominantly clear-cell subtype, while among others there were 8 multilocular cystic renal neoplasms of low malignant potential (MCRNLMP) and 6 oncocytomas and angiomyolipomas each. There were 44 RCCs, 4 oncocytomas, 1 MCRNLMP and 2 cysts removed with PN; median R.E.N.A.L. score was 5. RN group had greater tumor diameters and higher tumor grade, higher postoperative creatinine levels and complications of higher grade. There was no difference in median hospital stay (6 days) and follow-up (20 months). With regard to oncologic safety, preservation of kidney function and lower overall morbidity, PN should be preferred to RN whenever oncologically safe and technically feasible.

Supplemental Material for How Does Emotion Regulation Change During Psychotherapy? A Daily Diary Study of Adults in a Transdiagnostic Partial Hospitalization Program

Supplemental Material for How Does Emotion Regulation Change During Psychotherapy? A Daily Diary Study of Adults in a Transdiagnostic Partial Hospitalization Program

Downstream effects of high patient volume pressure on PHPs: A child psychiatry trainee's perspective

Rhode Island boasts some of the most robust access to specialized child and adolescent mental health care across the country, with one of the highlights being the unique access to various levels of care. Child and adolescent psychiatry applicants from across the country are attracted to the breadth of program variety. In particular, Rhode Island uniquely possesses a significant number of specialized partial hospitalization programs (PHP) for children and teens, some of which are nationally recognized and appeal to patients and families throughout the United States.

Prevention of 90-day inpatient detoxification readmission for opioid use disorder by a community-based life-changing individualized medically assisted evidence-based treatment (C.L.I.M.B.) program: A quasi-experimental study.

Evidence for community-based strategies to reduce inpatient detoxification readmission for opioid use disorder (OUD) is scant. A pilot program was designed to provide individualized structured treatment plans, including addressing prolonged withdrawal symptoms, family/systems assessment, and contingency management, to reduce readmission after the index inpatient detoxification. A non-randomized quasi-experimental design was used to compare the pilot facilities (treatment) and comparison facilities before and after the program started, i.e., a simple difference-in-differences (DID) strategy. Adults 18 years and older who met the Diagnostic and Statistical Manual of Mental Disorders version 5 criteria for OUD and had an inpatient detoxification admission at any OUD treatment facility in two study periods between 7/2016 and 3/2020 were included. Readmission for inpatient detoxification in 90-days after the index stay was the primary outcome, and partial hospitalization, intensive outpatient care, outpatient services, and medications for OUD were the secondary outcomes. Six statistical estimation methods were used to triangulate evidence and adjust for potential confounding factors between treatment and comparison groups. A total of 2,320 unique patients in the pilot and comparison facilities with 2,443 index inpatient detoxification admissions in the pre- and post-periods were included. Compared with patients in comparison facilities, patients in the C.L.I.M.B. facilities had higher readmission in the pre-period (unadjusted readmission 17.0% vs. 10.6%), but similar rates in the post-period (12.3% vs. 10.6%) after the implementation of the pilot program. For 90-day readmission, all DID estimates were not statistically significant (adjusted estimates ranged from 6 to 9 percentage points difference favoring the C.L.I.M.B. program). There was no significant improvement in the secondary outcomes of utilizations in lower level of care and medications for OUD in C.L.I.M.B. facilities. We found a reduction in readmission in the pilot facilities between the two periods, but the results were not statistically significant compared with the comparison facilities and the utilization of lower level of care services remained low. Even though providers in the pilot OUD treatment facilities actively worked with health plans to standardize care for patients with OUD, more strategies are needed to improve treatment engagement and retention after an inpatient detoxification.

Telehealth treatment of patients with major depressive disorder during the COVID-19 pandemic: Comparative safety, patient satisfaction, and effectiveness to prepandemic in-person treatment

BackgroundThe COVID-19 pandemic impelled a transition from in-person to telehealth psychiatric treatment. There are no studies of partial hospital telehealth treatment for major depressive disorder (MDD). In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the effectiveness of partial hospital care of patients with MDD treated virtually versus in-person. MethodsOutcome was compared in 294 patients who were treated virtually from May 2020 to December 2021 to 542 patients who were treated in the in-person partial program in the 2 years prior to the pandemic. Patients completed self-administered measures of patient satisfaction, symptoms, coping ability, functioning, and general well-being. ResultsIn both the in-person and telehealth groups, patients with MDD were highly satisfied with treatment and reported a significant reduction in symptoms from admission to discharge. Both groups also reported a significant improvement in positive mental health, general well-being, coping ability, and functioning. A large effect size of treatment was found in both treatment groups. Contrary to our hypothesis, the small differences in outcome favored the telehealth-treated patients. The length of stay and the likelihood of staying in treatment until completion were significantly greater in the virtually treated patients. LimitationsThe treatment groups were ascertained sequentially, and telehealth treatment was initiated after the COVID-19 pandemic began. Outcome assessment was limited to a self-administered questionnaire. ConclusionsIn an intensive acute care setting, delivering treatment to patients with MDD using a virtual, telehealth platform was as effective as treating patients in-person.

Eating disorder behaviors as a form of non-suicidal self-injury

Nonsuicidal Self-Injury (NSSI), the purposeful harming of one's body tissue without suicidal intent. NSSI frequently co-occurs with other self-destructive forms of psychopathology, such as eating disorders (ED); however, it remains unclear if ED behaviors are used as a form of NSSI. This exploratory study examined the occurrence of Self-Injurious Disordered Eating Symptoms (SIDES), as well as differences in clinical correlates and treatment outcomes between NSSI patients with and without SIDES. Participants included 1,327 patients admitted for partial hospitalization or intensive outpatient treatment for NSSI (87.4% female; 75.3% Non-Hispanic White). Data were collected at admission and discharge as part of routine clinical outcome assessment. Results indicate that 29.5% of the sample engaged in SIDES, while most were not diagnosed with an ED. Patients that engaged in SIDES reported greater clinical severity at baseline, including greater general psychopathology, lower quality of life, and worse functional impairment, as well as more clinically severe NSSI (e.g., greater number of methods, higher urge to self-injure, greater intrapersonal functions). No differences in treatment outcomes were found. These findings suggest that some NSSI patients perceive ED behaviors as a form of NSSI and that SIDES may be a marker for a more severe clinical presentation.

An Analysis of the Relationship Between Self-Compassion, Psychological Inflexibility, Psychological Health, and PTSD Severity in a Partial Hospitalization Program

PTSD symptoms and psychological inflexibility have been linked to a lack of self-compassion and poor psychological health. Prior work has explored these relationships in a trauma-exposed undergraduate population and found that, while self-compassion was correlated with PTSD symptom severity at the bivariate level, this relationship was no longer significant when accounting for psychological inflexibility. Additionally, self-compassion and psychological inflexibility predicted psychological health. The present study sought to test these findings in PTSD patients enrolled in an exposure-based partial hospitalization program. Acceptance and Commitment Therapy (ACT)-consistent measures (i.e., Valued Living Questionnaire, Behavioral Activation for Depression Scale [Short Form], Quality of Life Enjoyment and Satisfaction Questionnaire [Short Form]) were used to assess psychological health. The PTSD checklist for DSM-5 and the Acceptance and Action Questionnaire (II) were used to measure PTSD symptoms and Psychological Inflexibility, respectively. Our results were largely consistent with previous investigations. We found a negative relationship between psychological inflexibility and psychological health, as well as a positive relationship between psychological inflexibility and PTSD symptom severity. Future research should measure these constructs across different time points to explore the benefit of viewing self-compassion and other related constructs (e.g., courage and love) as values in an ACT model for PTSD treatment.

Adolescent eating disorder treatment outcomes of an in-person partial hospital program versus a virtual intensive outpatient program.

Though virtual outpatient psychotherapy for eating disorders is likely effective, less is known about virtual higher levels of care. The current study examined the clinical outcomes of a family-based virtual intensive outpatient program (vIOP) for youth with eating disorders which was developed in response to the COVID-19 pandemic, compared to the same institution's in-person partial hospital program (PHP). Treatment outcomes were assessed via chart review in 102 patients between the ages of 9-23 (M=15.2, SD=2.5) who were predominantly cisgender female (84.3%) and primarily diagnosed with anorexia nervosa (64.7%) or atypical anorexia (23.5%). Participants were either treated in the in-person PHP before the pandemic (n=49) or the vIOP during the pandemic (n=53). Percent expected body weight (%EBW) was examined at baseline, end of treatment, 3-months post-treatment, and 6-months post-treatment, as well as the frequency of medical, psychiatric, and residential admissions before, during, and after vIOP or PHP participation. Linear mixed models demonstrated no effect of treatment modality (in-person versus virtual) on %EBW over time. The duration of the vIOP was, on average, 12 calendar days longer, though the amount billed for the vIOP was lower. Survival analyses and Cox regression models did not suggest differences in the frequency of hospital and residential treatment admissions during treatment (vIOP: 9.4%, PHP: 10.0%) or post-treatment (vIOP: 15.0%, PHP: 10.2%). Findings support virtual family-based programs as suitable alternatives to in-person treatment and underscore the potential cost-effectiveness of a family-based IOP versus PHP. This study demonstrates that a virtual, family-based, intensive outpatient program for youth with eating disorders had similar treatment outcomes to an in-person partial hospitalization program. Specifically, the virtual and in-person programs had similar weight restoration outcomes and rates of medical, psychiatric, or residential treatment admissions during or after treatment initiation. Findings support the use of virtual treatment, even for youth requiring a high level of intervention.

Avoidant restrictive food intake disorder and suicidal ideation

Most DSM-5 eating disorder diagnoses are associated with elevated suicide risk; however, little is known about the relationship between Avoidant/Restrictive Food Intake Disorder (ARFID) and suicidal ideation. The aim of the current study was to examine suicidal ideation within an adult ARFID sample. Patients with eating disorders (N = 936), some of whom met criteria for a current DSM-5 diagnosis of ARFID (n = 79), completed the Beck Depression Inventory II Item 9, regarding suicidal ideation. The study was conducted within an eating disorder treatment facility that offers inpatient, residential, partial hospitalization program, and intensive outpatient levels of care. Findings suggest no significant pairwise differences in suicidal ideation prevalence between participants with ARFID and those with any other ED diagnosis. Thorough screening for suicidal thoughts and risk among those with ARFID is warranted at all levels of care. We suggest that future research expand upon this work in a larger adult ARFID sample.

Comparison of patient-reported distress during harm avoidance and incompleteness exposure tasks for youth with OCD

Exposure and response prevention is the front-line treatment for OCD, but many patients do not achieve symptom remission. Most theories of exposure mechanism suggest that eliciting and/or tolerating distress is necessary for exposure effectiveness. Moreover, research suggests that the type of distress may relate to treatment response, such that patients with “incompleteness” OCD symptom presentations exhibit poorer response than patients with “harm avoidance” symptom presentations. However, no studies have examined differences in distress during harm avoidance versus incompleteness exposure tasks. The current study examined differences in patient-reported distress during harm avoidance and incompleteness exposure tasks for 280 youth with severe OCD in a partial hospitalization program. Participants reported less distress and more often exhibited “flat,” unchanging distress trajectories during exposure tasks targeting incompleteness compared to harm avoidance. Findings provide preliminary evidence of differences in emotional processes during harm avoidance versus incompleteness exposure tasks for youth with OCD.

50.2 When Family-Based Treatment (FBT) at the Dinner Table Isn't Enough: FBT in Intermediate Levels of Care

Eating disorders are severe mental illnesses that have only increased in prevalence and severity during the COVID-19 pandemic. While family-based treatment (FBT) remains the gold standard of treatment for adolescents with eating disorders, the strictly outpatient FBT modality has had to be extrapolated to higher levels of care to effectively treat these young people with severe illnesses in partial hospitalization programs (PHPs) and residential programs (RESs).

3.128 Impact of Sleep on Anxiety and Depression Symptoms Before and During COVID-19

Previous research has shown that sleep difficulties are associated with symptoms of depression and anxiety in youth. During the peaks of COVID-19, many children were homebound and faced interruptions to their academic and social development as well as their sleep schedules. Thus, there was likely an exacerbation of sleep problems for youth during COVID-19. Using data collected from youth in a partial hospitalization program (PHP), we investigated if enrollment in the program before vs during COVID-19 moderated the associations of sleep difficulties with symptoms of depression and anxiety.