Effectiveness of a psychosomatic day hospital treatment for the elderly: A naturalistic longitudinal study with waiting time before treatment as control condition

https://doi.org/10.1016/j.jpsychores.2013.11.012Get rights and content

Abstract

Objective

In 2006 the psychosomatic day hospital for the treatment of acute mental illness of elderly people opened as the first clinic of its kind in Germany. The aim of this study was to determine treatment effectiveness and identify possible effects on health care utilization.

Methods

Designed as a naturalistic study with waiting time before admission as a control condition, the primary outcome was the level of depressive symptoms as measured by the hospital anxiety and depression scale. Secondary outcomes were depressive and somatoform symptoms and syndromes as measured with the patient health questionnaire, patient perception of interpersonal problems and health care use before and after treatment.

Results

After treatment significant improvement (p < 0.01) with moderate effect sizes (ES) was found in all variables from admission to discharge (ES from 0.3 to 0.8) and also to follow-up (ES from 0.2 to 0.6). Improvement remained stable at follow-up. Furthermore, after psychosomatic treatment a reduction in medical service usage was visible. Number of consultations (pre: 13, post: 9), number and length of hospital stays (pre: 1, 7 weeks, post: 0, 3 weeks) were both significantly (p < 0.001) reduced six months after treatment as compared to the period six months prior to treatment.

Conclusion

Results indicate that the psychosomatic day hospital treatment of the elderly is successful. Reduced usage of health care and the lower costs for day hospital treatment compared to inpatient treatment point to a positive cost–effect-ratio. Expanding this psychosomatic intervention would be useful in reducing the current gap in mental health care for the elderly.

Introduction

In geronto-psychiatric research only a small number of studies concentrate on the effectiveness of day hospital treatment [1], [2], [3]. These studies suggest day hospital treatment to be a valuable and cost effective alternative to inpatient care of patients with mental illness. Some studies of depressed elderly patients receiving day hospital treatment show a significant reduction of depressive symptoms, increased cognitive performance, and positive effects on social life, physical performance, and quality of life [4], [5], [6], [7], [8], [9]. Clinical experience suggests some additional advantages of day hospital treatment compared to inpatient treatment: Patients are not torn away from their home and social ties, therefore resistance against psychotherapeutic treatment might be smaller. However, evidence from empirical studies is missing.

Psychosomatic medicine as an own specialty besides general psychiatry is a particularity of the German health care system. Besides medical treatment and social counseling, psychosomatic inpatient and day hospital treatment focus strongly on psychotherapeutic treatment methods. As a consequence, patients with severe cognitive disturbances are not treated in psychosomatic day hospitals. Compared to psychiatric day clinics less patients with dementia, psychotic illness, and addiction disorders receive treatment. Psychosomatic day hospitals focus mainly on affective disorders, anxiety disorders, somatoform and stress-related disorders [9], [10]. Compared with research on psychiatric day hospital treatment, there is very little research focusing on psychosomatic day hospital treatment. The rare studies on psychosomatic day hospitals are either uncontrolled longitudinal trials or focus on the differences between inpatient and outpatient psychosomatic treatment [9], [10], [11], [12]. Only one study focusing on women suffering from bulimia used a randomized-controlled design [13].

So far, no studies are published on psychosomatic day hospital treatment for elderly patients despite their specific treatment needs. Elderly patients have to cope with the effect of aging and are affected by a wide range of losses: the loss of a beloved person, the loss of work or hobbies they cannot carry on, or the loss of bodily integrity. Chronic illness and frailty may be experienced as a narcissistic trauma resulting in low self-esteem and in feelings of despair [14]. Psychotherapeutic interventions can help to cope with negative affects and should facilitate a mourning process, which may improve adaptation to a life with a physical handicap [15]. To better adjust to these difficulties and to better cope with such loss is a central focus of psychosomatic treatment for the elderly [16]. Group treatment as performed in day hospital treatment provides an excellent opportunity for mutual support of patients [17].

This study aims to evaluate the effects of a psychosomatic treatment for the elderly in a day hospital setting. Compared with a waiting time without specific treatment, we expect treatment in the day hospital to significantly improve the psychological condition (anxiety and depression), physical discomfort, and interpersonal behavior of the patients. Concurrently, we expect medical service usage to decrease.

Section snippets

Design of the study

This is a naturalistic study using waiting time before admission as a control condition. Between September 2008 and April 2010, all consecutive patients referred for day hospital for elderly patients to the Psychosomatic department of the Nuremberg General Hospital (NGH) were approached. The patients were included in the study if an indication for psychosomatic day hospital treatment was made in a pre-treatment assessment by a psychosomatic specialist. The patients were primarily referred by

Study sample

124 patients fulfilled the inclusion criteria (i.e. met indication for treatment in our day hospital), the admission of 8 patients was canceled, therefore 116 patients started therapy. Exclusion criteria and reasons for canceled admission are presented in a CONSORT flow chart (Fig. 1). Nine patients dropped out early from treatment (drop-out rate = 8%). At follow-up, completed questionnaire results were available for 95 out of 107 patients, all of whom were discharged on schedule (return rate = 

Discussion

This study is a naturalistic study with a 5-week waiting time before the 5-week intervention as control condition. A randomized controlled trial (RCT) was difficult due to the organization of inpatient and day hospital psychosomatic treatment in Germany. Before treatment can begin, outpatient, day hospital, or inpatient treatment must be indicated and then approved by the health insurance provider. Thus, comparison with an untreated control group or with an attention control group was not

Conclusion

The present study shows that older patients can profit from psychosomatic treatment in a day hospital setting. The results support the recommendation of expanding this specific treatment option. Compared to inpatient treatment, day hospital setting holds a number of advantages for the psychosomatic treatment of elderly patients such as a lower barrier to treatment, possibility of remaining in a familiar environment and maintaining social contacts, less potential for regression, and direct

Conflict of interest statement

No author has to declare any conflict of interest regarding the submitted manuscript and the reported study.

Acknowledgments

We gratefully thank Prof. Cornel Sieber, chair of the Department of Geriatrics at Erlangen University and – at the time of the study – chair of the Department of Internal Medicine II at NGH for his support in establishing the psychosomatic day hospital for the elderly at the NGH and his remarks on a previous draft of this manuscript, and Amanda Sandell and Lisa Albrecht for the stylistic improvements.

References (37)

  • H Wormstall et al.

    Treatment courses and therapeutic effectiveness of a psychogeriatric day hospital

    Fortschr Neurol Psychiatr

    (2001)
  • A Zeeck et al.

    Partial hospitalisation: indication and characteristical aspects of the setting, shown by the example of the day clinic in Freiburg/Germany

    Psychother Psychosom Med Psychol

    (2002)
  • A Zeeck et al.

    Inpatient psychotherapy or partial hospitalisation?

    Psychotherapeut

    (2003)
  • A Zeeck et al.

    Inpatient or day clinic treatment? Results of a multi-site study

    Psychosoc Med

    (2009)
  • A Canuto et al.

    Longitudinal assessment of psychotherapeutic day hospital treatment for elderly patients with depression

    Int J Geriatr Psychiatry

    (2008)
  • A Zeeck et al.

    Inpatient versus day treatment for bulimia nervosa: results of a one-year follow-up

    Psychother Psychosom

    (2009)
  • I Wheelock

    Psychodynamic psychotherapy with the older adult: challenges facing the patient and the therapist

    Am J Psychother

    (1997)
  • CE Scheidt et al.

    Psychodynamic aspects of coping with illness in stroke—experiences with a psychotherapy group

    Psychother Med Psychol

    (1992)
  • Cited by (11)

    • The multi-disciplinary arena of psychosomatic medicine – Time for a transitional network approach

      2020, European Journal of Psychiatry
      Citation Excerpt :

      This suggests that patients with milder somatic conditions may be equivalently treated for affective complaints in the day clinic setting compared to what they would receive as inpatients. Comparable results were found for depressed elderly patients, denoting a reduction in their overall health care utilization because the costs for day hospital treatment are lower than for inpatient care.61 This indicates that integrated day care treatment might also have a positive influence on somatic symptom burden or somatic treatment adherence and efficacy.

    • Psychosomatic medicine in old age

      2017, Zeitschrift fur Gerontologie und Geriatrie
    View all citing articles on Scopus
    View full text