In the most comprehensive study of its kind, researchers have found that the inpatient length of stay for youth with mental illness fell more than sixty percent between 1990 and 2000, despite concurrent increases in illness severity and self-harm, and declining transfers to intermediate and inpatient care within the same population.
Lead author, Brady Case, MD, with the Bradley Hasbro Children's Research Center, the Brown Medical School Division of Child and Psychiatry Fellowship Program, and the New York University School of Medicine, analyzed data from one thousand community hospitals nationwide and found that in the course of a decade, the average length of inpatient hospitalization for youth undergoing mental health treatment declined from 12.2 days to 4.5 days.
"These trends prompt serious questions about diagnostic practices and quality of care for children and adolescents with mental disorders," says Case.
The study appears in the January 2007 issue of the Archives of General Psychiatry.
The authors found that children and adolescents treated for mental illness were discharged from community hospitals far more quickly in 2000 than ten years earlier. However, in the same year, more youth were diagnosed with psychotic, depressive, and bipolar disorders, and more were found to have intentionally harmed themselves. The total number and population rate of discharges did not change, but the total number of inpatient days and the average cost per visit each fell by approximately one half. They also report that transfers to short-term, nursing, and other inpatient facilities declined.
"During a decade which saw the emergence of managed mental health care and increased use of psychotropic medications by young people, our findings raise concerns about diagnostic practices and quality of inpatient care for mentally ill youth," says Case.
While these findings reflect changes in diagnostic patterns for children and adolescents, the authors do not know if this trend is because youth treated in hospitals are increasingly ill, or because the understanding of pediatric mental illness has evolved, or because mental health providers must indicate more severe diagnoses to obtain payment.
"Most troubling is the possibility that, driven by financial and other pressures, mental health providers are discharging severely ill youth too early in treatment. However, it may be that mental health providers are using hospital resources more efficiently and that children are increasingly being treated safely in day programs, clinics, and private offices," says Case.
Inpatient stays at Bradley Hospital, the nation's first psychiatric hospital for children and adolescents, seem to concur with this study.
"While the average length of stay at Bradley Hospital is a bit longer than what's found in the study, we've seen the trend toward shorter lengths of stay occur over the last decade. It's been necessary to develop rapid and systematic assessments of our child and adolescent patients and to develop comprehensive treatment plans faster than ever before because of the pressure from health insurance companies to discharge patients quickly. In spite of this pressure, we have to consistently try to do what is best for the child and adolescent and their families," says Jeffrey Hunt, MD, director of Bradley's Adolescent Program.
Over the years, Hunt's team has created new programs to augment existing inpatient treatment in order to manage adolescents with serious mood disorders and impulse control problems (such as is seen with early onset bipolar disorder). In addition, he says that the expansion of day hospital programs and therapeutic school programs have been critical to the safe outcomes for patients.
"We are able to maintain more prolonged contact with patients and their families by utilizing these newer services. However, even with the existence of these programs it is unlikely that we can shrink the length of an inpatient stay more than it already is," says Hunt.
Inpatient mental health professionals now routinely evaluate, treat, and discharge depressed children and adolescents in four days, well before the onset of response to antidepressants or the emergence of side effects. To do so safely requires access to extensive clinical resources, including specialized inpatient mental health services and intensive outpatient follow-up, the authors report.
"It remains unclear whether the changes we found represent a more efficient use of hospital resources, a withdrawal of necessary services, or some combination of both. Further research can clarify the extent to which community hospitals are meeting the mounting clinical demands of increasingly rapid diagnosis and treatment of mentally ill youth," says Case.
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