Alternatives to inpatient mental health care for children and young people

 

Abstract

Background

Current policy in the UK and elsewhere places emphasis on the provision of mental health services in the least restrictive setting, whilst also recognising that some children will require inpatient care. As a result, there are a range of mental health services to manage young people with serious mental health problems who are at risk of being admitted to an inpatient unit in community or outpatient settings.

Objectives

1. To assess the effectiveness, acceptability and cost of mental health services that provide an alternative to inpatient care for children and young people.
2. To identify the range and prevalence of different models of service that seek to avoid inpatient care for children and young people.

Search methods

Our search included the Cochrane Effective Practice and Organisation of Care Group Specialised Register (2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, issue 4), MEDLINE (1966 to 2007), EMBASE (1982 to 2006), the British Nursing Index (1994 to 2006), RCN database (1985 to 1996), CINAHL (1982 to 2006) and PsycInfo (1972 to 2007).

Selection criteria

Randomised controlled trials of mental health services providing specialist care, beyond the scope of generic outpatient provision, as an alternative to inpatient mental health care, for children or adolescents aged from five to 18 years who have a serious mental health condition requiring specialist services beyond the capacity of generic outpatient provision. The control group received mental health services in an inpatient or equivalent setting.

Data collection and analysis

Two authors independently extracted data and assessed study quality. We grouped studies according to the intervention type but did not pool data because of differences in the interventions and measures of outcome. Where data were available we calculated confidence intervals (CIs) for differences between groups at follow up. We also calculated standardised mean differences (SMDs) and 95% CIs for each outcome in terms of mean change from baseline to follow up using the follow-up SDs. We calculated SMDs (taking into account the direction of change and the scoring of each instrument) so that negative SMDs indicate results that favour treatment and positive SMDs favour the control group.

Main results

We included seven randomised controlled trials (recruiting a total of 799 participants) evaluating four distinct models of care: multi-systemic therapy (MST) at home, specialist outpatient service, intensive home treatment and intensive home-based crisis intervention ('Homebuilders' model for crisis intervention). Young people receiving home-based MST experienced some improved functioning in terms of externalising symptoms and they spent fewer days out of school and out-of-home placement. At short term follow up the control group had a greater improvement in terms of adaptability and cohesion; this was not sustained at four months follow up. There were small, significant patient improvements reported in both groups in the trial evaluating the intensive home-based crisis intervention using the 'Homebuilders' model. No differences at follow up were reported in the two trials evaluating intensive home treatment, or in the trials evaluating specialist outpatient services.

Authors' conclusions

The quality of the evidence base currently provides very little guidance for the development of services. If randomised controlled trials are not feasible then consideration should be given to alternative study designs, such as prospective systems of audit conducted across several centres, as this has the potential to improve the current level of evidence. These studies should include baseline measurement at admission along with demographic data, and outcomes measured using a few standardised robust instruments.

 

Plain language summary

Health care services instead of admission to hospital for young people or children with mental health problems

Many countries place emphasis on providing mental health services in the least restrictive setting, recognizing that some children will need to be admitted to hospital.  As a result there are a range of mental health services to manage young people with serious mental health problems in community or outpatient settings who are at risk of being admitted to hospital.

This review found seven studies which evaluated whether these other services helped children and young people with mental health problems.  This review did not find any studies about intensive day treatment (where children attend treatment programmes during the day for a short period of time), intensive case management (health care professionals coordinate services and support for the children), therapeutic foster care (children live with specially trained foster parents) or residential care with inpatient care (children live in a residence, but not a hospital, which provides mental health care services).

The studies evaluated four different types of services.  In Multisystemic therapy (MST) at home, therapists provide therapy to the child and the family together in their home.  Some behaviours in the children, improved with MST.  They also spent fewer days out of school and in hospital. Intensive home treatment provides children with therapy in their home to solve problems with the way they interact with other people in the home and to improve their psychological symptoms.  Children who received this type of service did not improve any more than children who did not.  Intensive home based crisis intervention (Homebuilders model for crisis intervention), focuses on the child and family to learn skills in relationship building, reframing problems, anger management, communication, and cognitive behavioural therapy.  Children with this service had small improvements. Specialist outpatient services are provided by a range of health care professionals in clinics.  Children who received this service did not improve any more than children who did not.

The quality of some of the studies was not high and most did not have enough people to evaluate the true effect of the services.  The evidence we now have provides very little guidance for the development of these types of services.

 

摘要

背景

兒童與年輕住院患者其心理健康照護的替代療法

在英國和其他地方目前的政策重點是提供心理健康服務在最少限制的環境，同時也承認有些兒童需要住院照護。因此，有一範圍的心理健康服務用來管理有嚴重心理健康問題的年輕人，其有入住社區住院中心或門診機構的風險。

目標

1.評估心理健康照護的效果，可近性及成本，其提供兒童和年輕人住院照護之替代療法之。2.確認不同服務模式的範圍及盛行率，其試圖避免兒童和年輕人住院照護。

搜尋策略

我們的檢索包括Cochrane Effective Practice and Organisation of Care Group Specialised Register (2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, issue 4), MEDLINE (1966 to 2007), EMBASE (1982 to 2006), the British Nursing Index (1994 to 2006), RCN database (1985 to 1996), CINAHL (1982 to 2006) and PsycInfo (1972 to 2007)。

選擇標準

提供專科照護的心理健康照護隨機對照試驗，排除一般門診病人規定的範圍，作為住院患者心理健康照護的替代療法，針對年齡5 – 18歲的兒童或年輕人其有嚴重心理健康狀康需要專科照護排除一般門診病人規定的資格。對照組接受住院或相同機構的心理健康照護。

資料收集與分析

兩位作者分別摘錄資料並評估研究的品質。我們依據介入措施的型態分類研究但不加總資料，因為介入措施及結果測量不同。對可獲得的資料計算在追蹤期間群組間差異的信賴區間(confidence intervals (CIs))。我們也針對每項結果依據基本資料至追蹤期間的平均值變化計算標準化的平均差(standardised mean differences (SMDs))及95% CIs。我們計算標準化平均差(SMDs)(考量變化的方向及每種測量工具的分數)以便負的SMDs意指結果偏向治療組而正的SMDs意指結果偏向對照組。

主要結論

我們蒐集7篇隨機對照試驗(納入總共799名參與者)其評估4種不同的照護模式：居家的多系統療法(multisystemic therapy (MST))，專科的門診照護，集中式的居家治療，與集中式以家庭為基礎的危機介入措施(家庭建造者(‘Homebuilders’)模式的危機介入措施)。接受以家庭為基礎之多系統療法的年輕人其具體的症狀有些微的改善作用，且他們花較少的天數可以到學校外面及家裡以外的地方。在短期的追蹤期間對照組其適應力及凝聚力有較大的進步；這項結果並未持續至第四個月的追蹤。在評估使用‘Homebuilders’模式之集中式以家庭為基礎的介入措施試驗中，兩組皆有少數，明顯進步的病患。評估集中式居家治療的兩篇試驗，或專科門診服務的試驗中在追蹤期間沒有發現差異。

作者結論

目前以實證為基礎的品質很少提供作為服務發展的指引。如果隨機對照試驗不可行，則應考量其它的研究設計，如建立跨數間醫學中心的前瞻性審查系統，因為其具有潛力可以改善目前證據的水準。這些研究應包括住院時基本資料的測量及人口學資料，並使用數個標準化健全的工具測量結果。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

許多國家重視提供心理健康服務在最少限制的環境，並承認有些兒童需要住院照護。因此，有一範圍的心理健康服務用來管理有嚴重心理健康問題的年輕人，其有入住社區住院中心或門診機構的風險。這篇回顧找到7篇研究，其評估是否這些其他的服務有助於心理健康問題的兒童和年輕人。這篇回顧沒有找到任何有關集中式日間治療(兒童參與日間短期的治療計畫)的研究，集中式病例管理(健康照護專家整合服務並提供支持予兒童)，治療性的收養照護(兒童與特別受訓練的收養父母居照)或社會服務的住院照護(兒童居住於一間住宅，但不是醫院，它可以提供心理健康照護服務)。研究評估4種不同的服務模式。在居家的多系統療法(MST)中，治療師一起提供治療予兒童及其家人，在他們的家中。兒童的某些行為可以藉由MST改善。他們也花較少的時間可以到學校外面及醫院。集中式居家治療在兒童的家中提供治療予兒童，以解決他們和家中其他人互動的問題並改善他們的精神症狀。接受這種服務模式的兒童相較於未接受的兒童並未有任何較多的改善。集中式以家庭為基礎的危機介入措施(家庭建造者模式的危機介入措施)，重視兒童及家庭學習關係建立的技巧，重建問題，情緒管理，溝通，及認知的行為治療。接受這種服務的兒童有些微的進步。專科門診服務是診所提供一範圍的健康照護專家。接受這種服務模式的兒童相較於未接受的兒童並未有任何較多的改善。有些研究的品質不佳且大多數沒有足夠的人數以評估服務的真實效果。我們現在能提供發展這些類型服務的指引的證據很少。