How effective are different types of day care services for people with severe mental disorders?

Summary

The issue

Day care is considered to be an important component of psychiatric services, but the evidence on different forms of day care is not easy to interpret. This review evaluates five main forms of day care for adults with severe mental disorders: acute psychiatric day hospital care, transitional psychiatric day hospital care, vocational rehabilitation programs (supported employment and pre-vocational training), day care centres and drop-in centres.

Findings

There is evidence to demonstrate the clinical effectiveness of acute day hospital care and the supported employment approach to vocational rehabilitation in those with severe mental disorders. When compared to inpatient care, patients in acute day hospitals spent less time in subsequent inpatient care and achieved more rapid improvement in mental state. There was also some evidence of reduced costs in acute day hospitals compared to inpatient care. Supported employment has been shown to be effective compared to pre-vocational training in American trials, helping patients with severe mental disorders to obtain competitive employment. This evidence was robust across a number of different trials, but no benefits in clinical outcomes were shown.

There is little evidence to support the effectiveness of pre-vocational training, transitional day hospitals or day care centres and no evidence from randomized controlled trials evaluating the effectiveness of drop-in centres.

Policy considerations

While the effectiveness of acute day hospitals is not in doubt, it is not clear that they have any advantages over other more radical alternatives to inpatient admission, such as crisis intervention and home-based care. However, it is conceivable that acute day hospitals might be most beneficial in circumstances where staff resources to deliver such crisis intervention or home based care are limited or where there is a need to deliver complex treatments.

Supported employment approaches appear promising and should be studied further in the European context.

Robust research regarding the cost–effectiveness of transitional day hospitals, day care centres and drop-in centres should be organized before new investment in any of these approaches is made.

Type of evidence

The evidence was drawn from systematic reviews of randomized controlled trials and supplementary individual randomized controlled trials published after the reviews were published.