Community supported discharge service for teenagers leaving psychiatric hospital

Ten percent of adolescents have a mental illness in the UK (Green et al, 2005), but 70% are not receiving effective treatment (Public Health England, 2015). Even after treatment, teenagers leaving hospital have an especially high rate of self-harm and relapse (Gunnell et al, 2008).

Unfortunately, mental health care is expensive, and the NHS is not equipped to support all adolescents in need. NICE recommends community-based support for adolescents leaving psychiatric care (NICE, 2016). This could be beneficial, as it would provide another source of local support and is likely to be a less expensive treatment option. However, there has been little research on this.

Ougrin and colleagues are changing that. Existing research shows that community-based care could be effective for adults leaving psychiatric care, so they decided to test a similar model with adolescents. They investigated whether a Supported Discharge Service (SDS; involving assisting with school integration, creating individual crisis plans, and social and physical support) was more effective than usual care.

Extended inpatient care can disrupt relationships that are essential for positive development, including those with family, school, peers, the community, and workplaces.

Methods

106 participants aged 12-18 were randomly assigned to either usual care (following guidelines outlined by Corrigan and Mitchell, 2002) or the Supported Discharge Service (SDS).

Researchers measured the time that participants spent in hospital, as well as changes in their psychological health and general functioning. Six months later, they assessed participants’ self-harm, satisfaction with the service, and school attendance.

Researchers also assessed the cost-effectiveness of the SDS compared with usual care using general functioning scores and quality-adjusted life years (QALYs); a commonly-used method.

The Supported Discharge Service investigated in this trial involved assisting with school integration, creating individual crisis plans, and social and physical support.

Results

The results for all measured outcomes were as follows:

The number of days spent in hospital in the Supported Discharge Service (SDS) group (34 days) compared to the usual care group (50 days) was not significantly lower after adjusting for pre-randomisation differences in hospital bed use
There was no significant improvement in clinical symptoms or general functioning in the SDS condition
Patient satisfaction scores were similar across the two groups
Significantly more participants in the SDS condition were reintegrated into school at the 6-month follow up. They also took significantly fewer days off
The SDS group reported significantly fewer episodes of self-harm at the 6-month follow up
Cost-effectiveness analyses showed that the SDS had a 58% chance of being cost-effective when compared with usual care and assessed against improvements in general functioning.

However, when assessing participants with psychosis, participants who were from minority ethnic groups or participants who were low-functioning, there was no significant differences between the two treatment groups in any measured variables.

Adolescents who received the Supported Discharge Service were more likely to be integrated into school and had lower levels of self-harm at follow-up.

Conclusions

The authors concluded:

Our findings suggest that intensive community treatment models might be used with and as an alternative to usual inpatient care. Supported discharge services could be cautiously considered for implementation by other treatment centres.

The Supported Discharge Service (SDS) did not significantly improve the number of days participants spent in hospital, their clinical symptoms or their general functioning compared to usual care.
However, adolescents who received the Supported Discharge Service were more likely to be integrated into school and had lower levels of self-harm at follow-up.
The SDS was also more cost-effective.

Strengths and limitations

These results provide vital and unique evidence that community treatments can be effective for adolescents. The use of real treatment teams may have caused some variation between the care that patients received, but does allow us to easily extrapolate the results to the real world.

However, these real treatment teams introduce a certain amount of bias. The teams knew which condition each participant was assigned to, and may have been more enthusiastic about the novel Supported Discharge Service (SDS). The effectiveness of the SDS may have been exaggerated due to this.

Also, participants were not categorised by diagnosis, and so we cannot be sure how effective this intervention is across diagnoses. It is mentioned that the SDS was ineffective with psychosis patients, but we cannot identify why from these results. It is possible that SDS is less effective in dealing with more complex mental illnesses.

Also, as highlighted earlier, adolescents leaving psychiatric hospital have a high rate of relapse (Patton, 2018). This might not have been captured by the (relatively short) 6-week follow-up. It is therefore still unclear whether the SDS improves the rate of relapse in the long-term.

Lastly, the measures used in this study all relied on self-reporting, which may have given an unreliable picture of the participants’ wellbeing. Reliance on participants’ own reports of their recovery may have inflated the effectiveness of the SDS.

Longer-term follow-up is needed to assess whether benefits of early interventions are sustained for disorders that might relapse and recur over the course of decades.

Implications for practice

The key question raised by the findings of this study is obvious: is the Supported Discharge Service (SDS) worth implementing if the clinical outcomes are no better than usual care?

Based on these findings, the answer is surely yes.

Crucially, the clinical outcomes from the SDS were the same as usual care; it still delivered a high standard of care. Outside of clinical outcomes, the SDS offered other benefits.

The SDS group had lower levels of self-harm and higher school attendance. Ensuring that a teenager leaving hospital reintegrates effectively back into their community could protect them from the notoriously high levels of relapse that this population can experience.

Also importantly, the SDS was cost-effective. In the face of a struggling NHS and cuts to funding, cost-effective interventions that deliver a high standard of care are something to be excited about.

Of course, there needs to be further investigation, but it seems clear from this study that the potential for community treatments is strong.

These findings suggest that intensive community treatment models might be used with and as an alternative to usual inpatient care.

King’s MSc in Mental Health Studies

This blog has been written by a student on the Mental Health Studies MSc at King’s College London. A full list of blogs by King’s MSc students from can be found here, and you can follow the Mental Health Studies MSc team on Twitter.

We regularly publish blogs written by individual students or groups of students studying at universities that subscribe to the National Elf Service. Contact us if you’d like to find out more about how this could work for your university.

Links

Primary paper

Ougrin D, Corrigall R, Poole J, Zundel T, Sarhane M, Slater V, Stahl D, Reavey P, Byford S, Heslin M, Ivens J, Crommelin M, Abdulla Z, Hayes D, Middleton K, Nnadi B, Taylor E. (2018) Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychiatric emergencies: a randomised controlled trial. Lancet Psychiatry. 2018 Jun;5(6):477-485. doi: 10.1016/S2215-0366(18)30129-9. Epub 2018 May 3.

Other references

Frith, E. (2017) Inpatient Provision for Children and Young People with Mental Health Problems (PDF).

Green, H., Mcginnity, A., Meltzer, H., Ford, T., & Goodman, R. (2005) Mental Health of Children and Young People in Great Britain: 2004 (PDF). Office for National Statistics.

Gunnel et al (2008). Hospital admissions for self harm after discharge from psychiatric inpatient care: cohort study. BMJ, vol.337.

NICE (2016) Transition between inpatient mental health settings and community or care home settings.

Patton, G.C. (2018), Early Supported Discharge: Getting Adolescents Back on Track. The Lancet Psychiatry, vol. 5, issue 6, p.452-453.

Public Health England. (2015). Early adolescence: Applying All Our Health.

The Mental Elf