Day hospital versus out-patient care for psychiatric disorders

This review considers the use of day hospitals as an alternative to out-patient care. Three types of day hospital are covered by the review: 'day treatment programmes', 'day care centres' and 'transitional' day hospitals. Day treatment programmes offer more intense treatment for patients who have failed to respond to out-patient care (usually patients with affective or personality disorders). Day care centres offer structured support to patients with long-term severe mental disorders (mainly schizophrenia), who would otherwise be treated in the out-patient clinic. Transitional day hospitals offer time-limited care to patients who have just been discharged from in-patient care.

The review had three objectives. First, to assess the effectiveness of day treatment programmes versus out-patient care for people with treatment-refractory disorders. Second, to assess the effectiveness of day care centres versus out-patient care for people with severe long term disorders. Third, to assess the effectiveness of transitional day hospital care for people who had just been discharged from hospital.

We searched the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 2000), MEDLINE (January 1966 to December 2000), EMBASE (1980 to December 2000), CINAHL (1982 to December 2000), Psyc LIT (1966 to December 2000), and the reference lists of articles. Researchers were approached to identify unpublished studies.

Randomised controlled trials comparing day hospital care (including day treatment programme, day care centre, and transitional day hospital) against out-patient care. Studies were ineligible if a majority of participants were under 18 or over 65, or who had a primary diagnosis of substance abuse or organic brain disorder.

Data were extracted independently by two reviewers and cross-checked. Relative risks and 95% confidence intervals (CI) were calculated for dichotomous data. Weighted or standardised means were calculated for continuous data.

There was evidence from one trial suggesting that day treatment programmes were superior to continuing out-patient care in terms of improving psychiatric symptoms. There was no evidence that day treatment programmes were better or worse than out-patient care on any other clinical or social outcome variable, or on costs. There was no evidence that day care centres were better or worse than out-patient care on any clinical or social outcome variable. There were some inconclusive data on costs suggesting that day care centres might be more expensive than out-patient care. There was evidence from one trial suggesting that transitional day hospital care was superior to out-patient care in keeping patients engaged in treatment, however there was insufficient evidence to judge whether it was better or worse on any other clinical or social outcome variable, or on costs.

There is only limited evidence to justify the provision of day treatment programmes and transitional day hospital care, and no evidence to support the provision of day care centres.