In the Netherlands, adolescents with severe psychiatric disorders typically used to be admitted to a psychiatric ward for several months [1]. However, long term psychiatric admission may be associated with a variety of negative outcomes, such as feeling displaced from home, family and friends, stagnation in social and emotional development or relapse of crisis because of lack of involvement of patients’ networks in regular treatment and is very expensive [2,3].
Consequently, mental health care policy is now moving from long term admission towards intensive but short admission, followed by forms of intensive home treatment (IHT). Also, a clear need for more cost-effective forms of treatment is emerging. In search for more (cost-)effective treatment modalities, mental health services should be provided in the least restrictive setting, leading to different methods of outpatient treatment such as Crisis Resolution Teams implemented in the United Kingdom [4,5,6]. This was introduced in adult mental health care and research has shown outpatient treatment to reduce the number and duration of admissions, increase satisfaction of patients, decrease family burden and be more cost-effective [4,5,6,7,8].
In children and adolescents both intensive community services and inpatient care have been found to be associated with clinical improvements in most studies [9]. Thereby, intensive community services were associated with shorter hospitalizations, greater patient satisfaction and lower costs [9]. Home-based multisystem therapy (MST) showed to be effective at decreasing externalizing symptoms, improving family functioning and school attendance, together with higher satisfaction scores randomly assigned to inpatient hospitalization [10,11]. Supported discharge services provided by an intensive community treatment team reduced psychiatric inpatient care for adolescents at 6 months follow-up compared to usual admission care, without differences in functional status and symptoms of mental health disorders between groups [12]. However, while developing new treatment models for youth in psychiatric crisis and moving from inpatient to outpatient treatment, inpatient treatment can be warranted in individual cases [6]. As such, short term studies show promising results, whereas results of long-term follow-up and independent replication of the results of intensive community treatment in youth are urgency [9, 13,14].
In January 2015 a new Child and Youth Act was introduced in The Netherlands, that states that local municipalities are responsible for their youth policy, including mental health provisions [15]. Partly due to this change, there was a need to provide intensive nonclinical treatment for adolescents in psychiatric crisis, for example, severe depression, food refusal, disabling obsessive-compulsive disorder, often accompanied with school refusal. We developed an intervention based on Crisis Resolution and Home Treatment principles in which IHT is provided with a maximum of four months [16]. Mental health professionals visit patients at their home and treat their family together with the patient. Before start or during IHT, there is a possibility of short admission (with a maximum of 2 weeks) at a psychiatric high & intensive care (HIC) unit, together with their caregivers. The same mental health professionals of IHT are involved in the treatment of the patient and their caregivers during this short admission at the HIC. Short admission was thought to be feasible, since research showed most health gains to occur during the first weeks [16,17,18]. IHT principles are primarily based on solution-focused therapy [19] and attachment based family therapy (Bosmans, 2016), although individual interventions (e.g., medication, cognitive behaviour therapy) can be provided as well. IHT strongly focuses on improvement of the relationship between patient and caregivers, reintegration into school, work and hobby, reducing self-harming behaviour and increasing the adolescent’s motivation for therapy. This may prevent clinical admission, developing a dependency of hospital environment and being stigmatized as adolescent. Monthly evaluations of the patient and families take place at the hospital by both a child and adolescent psychiatrist and psychologist. According to the diagnosis and needs of the patient, pharmacotherapy and psychological therapies may be added.
Up till now, no studies regarding the clinical outcome of IHT in combination with the possibility of short admission of the adolescent with caregivers at a HIC in a child- and adolescent psychiatric setting have been published.
This study aimed to investigate treatment outcome of IHT, combined with HIC, by measuring the clinical outcome of adolescents with severe psychiatric crisis. As such, adolescents with a broad spectrum of psychiatric diagnoses, i.e. developmental disorders, eating disorders, anxiety and depression disorders, psychosis, comorbid disruptive behaviour disorders, personality disorders and symptoms of severe immediate risk to self and others were included in this study. Clinical functioning was established at start of treatment and after 2- and 4-months follow-up. Our hypothesis is that IHT will improve clinical outcome of the adolescents and families and lower risk for hospitalization.