The Different Components of Effective Treatment

1. The immediate reduction of the crisis that precipitated an admission to inpatient treatment. At this level of effectiveness, the reduction of symptoms that lead to the admission is the critical measure.

2. The extent to which the changes that occurred in the inpatient stay are maintained after discharge from the hospital. At this level of effectiveness there are three important measures:
    • How symptom changes are sustained
    • An individual's return to functioning (work or school)
    • The length of time an individual stays out of the hospital

3. The extent to which a thorough and effective plan for follow-up care can be developed. At this level of effectiveness there are two important issues:
    • Is the discharge plan tailored to meet the individual's needs?
    • Has the individual complied with the discharge plan?

4. The extent to which the treatments are effective for all of the patients who receive them. If treatment only works for a few of the patients who receive it, then the treatment strategies need to be changed. The critical measure here is the similarity of other aspects of effectiveness (symptom change; return to functional activities; and post-discharge treatment compliance) across different types of patients.

5. Consumer satisfaction is the final important component of the effectiveness of treatment. If people who receive the treatment are happy with it, then they are more likely to continue to do the things that they are asked to do in order to maintain their treatment gains. Many providers who study outcomes examine only satisfaction. Although satisfaction is very important, a satisfied consumer who experiences no changes in their symptoms or functional status is not a treatment success. The crucial measure of satisfaction is the report of the consumer, during and after they have received their treatment.

How do we Measure Effectiveness?

The ideal way to study effectiveness is to examine every patient with an extensive assessment. This is not always possible, because of the large number of patients who are seen at Four Winds (over 2500 per year). What we have done is to intensively study a randomly selected group of patients who are treated at Four Winds. These patients are extensively assessed at admission, discharge, and 30 days and 120 days post discharge. With a specialized staff collecting the information, these patients provide detailed information about their inpatient stay and how they are doing afterwards. This information includes ratings by the therapist, the patient, and the research staff of symptoms, satisfaction, and adjustment. In addition, all patients at Four Winds are rated by their therapist at admission and discharge regarding their symptoms and adjustment and each patient completes a satisfaction rating when they leave. We can compare the results for the entire inpatient service to the results for the selected group.

At this time, we have ratings for over 5,000 persons who have been treated at Four Winds and we have used this information to look at the five areas of outcome as described above. Our commitment to outcomes evaluation has led to the development of this voluminous database.

How Effective is Treatment at Four Winds Hospital?

Symptom Reduction

We examined the changes in symptoms during an inpatient stay for 120 adults and 120 adolescents in the comprehensive outcome study, and all of the adults and adolescents who were treated as inpatients at Four Winds during that same year. Global clinical ratings of symptoms at admission and discharge were obtained from the clinical staff and by the research staff. Research staff and therapists also rated overall function with the Global Assessment of Functioning (GAF).

As you can see in Figures 1 - 3, the therapist and research staff found that the patients who were treated as inpatients improved in both clinical symptoms and overall functional status during their stay. These improvements were also found for patients who had severe symptoms in the areas of depression and psychosis as well.

Figure 1

Figure 2

Figure 3

Maintenance of Treatment Gains

For those patients who we followed up after discharge, a detailed assessment was conducted. This assessment included examinations of the same symptoms that were assessed at admission and discharge as well as ratings of their global functional status. In addition, we found out how many of the patients who were followed up had returned to work or school and how many had been readmitted to the hospital. As you can see in the Figures 4 and 5, from the perspective of both clinical symptoms and overall functional status, the treatment gains experienced during the inpatient stay persisted and improved over a 4-month follow-up period. Only 8% of the adolescents and 7% of the adults were readmitted to psychiatric inpatient care during the 4-month follow-up period. These data suggest that the treatment offered at Four Winds provides lasting benefits.

How Wide-Ranging are the Treatment Gains?

Since we looked at both adolescent and adult inpatients at Four Winds, we were able to compare the size of the treatment gains during inpatient stays across these two groups. As you can see from Figure 5 the adolescent and adult patients experienced and maintained similar treatment gains.

How Well Matched are Follow-Up Plans and the Patients?

Since patients as a rule did very well after discharge, the question is whether this is due to their discharge plan. If they did very well and followed their discharge plan, this would mean that there was a strong relationship between the discharge plan and their good outcome. Discharge plans for both adolescents and adults generally included both psychotherapy and medication. Figure 6 shows how many of the adolescent and adult patients were still taking medication and seeing their therapists 120 days post discharge. As you can see, most patients were still doing what the discharge plan advised four months after they left the hospital. This means that the excellent outcomes seen in most of our patients are associated with the discharge plans that they receive. While high levels of compliance with psychotherapy may not be surprising, their medication compliance of very high is higher than that typically reported in studies of treatment compliance in adolescent and adult inpatient settings.

Figure 4

Figure 5

Figure 6

How Satisfied are the People who Stayed at Four Winds?

We asked all patients at Four Winds about whether they would recommend the hospital to someone else and whether they would be willing to return if their problems re-emerged. As you can see from Figure 7, the great majority gave Four Winds a strong recommendation. We also asked them to rate their satisfaction on a global scale of 1 (Very Unsatisfied) to 4 (Very Satisfied). Figure 7 shows that the overall level of satisfaction was very high.

Over 75% of each group was Satisfied and close to 40% of both groups reported that they were Very Satisfied with the treatment and environment at Four Winds Hospital.

We specifically asked these former patients if they were satisfied enough with our treatment to consider returning if their problems re-occurred. We also asked them if they were satisfied enough with our services to recommend us to a friend or relative who was in need of psychiatric care.

Figure 7

As you can see from the Figure 8, our patients were very likely to recommend our services to others, and indicated a willingness to take advantage of them again if necessary. This is very encouraging, because we are quite aware of the stress often associated with admissions to inpatient psychiatric care.

Figure 8