Residential Treatment for Patients in Crisis

To the Editor: Increasing hospital costs and diminishing funds have stimulated the development of treatment alternatives for persons with serious mental illness. Several studies have investigated day treatment programs as alternatives to hospitalization, but few have assessed the effectiveness of residential crisis alternatives (1,2). We report here the results of a prospective study evaluating the change in functioning of program residents from admission to discharge from a residential crisis facility.

The facility where the study took place is staffed by physicians, psychologists, nurses, social workers, and other mental health workers. It combines intensive psychiatric assessment with psychopharmacologic, psychotherapeutic, and milieu treatments. We postulated that a short-term residential crisis intervention, with psychopharmacologic and psychosocial rehabilitation, would facilitate a 20 percent or greater improvement in residents' daily functioning.

Subjects in the study were 29 men and 21 women who voluntarily entered the residential crisis facility over a ten-month period in 1996 and 1997. The men had a mean±SD age of 37.1±9 years and the women a mean age of 41.4±11 years. Twenty-four subjects had a DSM-IV diagnosis of major depressive disorder, 19 of schizophrenia, and seven of bipolar disorder. The average length of stay was 12.4±7.5 days.

All subjects signed a written informed consent form. Staff took an extensive psychosocial history, and a physician administered a DSM-IV structured diagnostic interview. At admission and discharge a single rater with extensive training administered the Scale of Functioning (SOF), a well-validated 15-item scale assessing social functioning in such areas as orientation, appointment compliance, socialization, financial management, and independence of living arrangements (3). Scores on the scale range from 15 to 60, with higher scores indicating higher functioning. In addition, clinical staff independently completed the Global Assessment of Functioning (GAF) Scale when subjects were admitted to and discharged from the crisis facility. Scores on the GAF range from 0 to 100, with higher scores indicating higher functioning.

Subjects' mean±SD SOF scores were 29.7±5.2 at admission and 36±7.2 at discharge, a statistically significant difference (F=102.43, df= 1,49, p<.001). Mean±SD scores on the GAF also increased significantly, from 36.4±6.4 at admission to 46.6± 8.3 at discharge (F=166.18, df=1,49, p<.001). Although both males and females showed improvement between admission and discharge as measured by both the SOF and the GAF, for females the improvement was statistically significant. SOF scores increased from 30.2±5.4 to 38.6±6.8 (F=8.19, df=1,48, p<.01), GAF scores from 35.5±5.9 to 48±9.1 (F= 4.59, df=1, p<.04).

On the SOF, diagnosis influenced the degree of improvement between admission and discharge. For patients with major depression, SOF scores increased from 32.6±4.5 to 40.2±5.6 (F=94.52, df=1,23, p<.001); for bipolar disorder, from 29.4±4.1 to 37±3.5 (F=27.45, df=1,6, p<.002); and for schizophrenia, from 26±4.1 to 30.4±6.4 (F=15.45, df=1,18, p<.001).

Short-term residential crisis treatment programs may be a cost-effective alternative to inpatient hospitalization. They offer clients crisis psychiatric treatment, a supportive network of clinicians to facilitate life skills training, housing support, and placement into transitional living programs. This pilot study suggests that residential crisis treatment significantly improved patients' psychosocial functioning as measured by the SOF and GAF scales. The SOF reflected a 21 percent improvement in functioning and the GAF a 28 percent improvement.

We have presented a descriptive report of an uncontrolled study, and our results should be interpreted cautiously. Further comparative research investigating the utility of residential crisis treatment is needed, with specific emphasis on its impact on symptomatology, functioning, quality of life, and social adjustment.

Dr. Dolnak and Dr. Rapaport are affiliated with the department of psychiatry at the University of California, San Diego. Dr. Hawthorne is with the Community Research Foundation in San Diego.