Home treatment in child and adolescent psychiatry: An analysis of effectiveness and integrated care

Research area: Psychological & psychiatric interventions

Duration: April 2020 – November 2020
Language: German

Publication: HTA Project report No. 129: http://eprints.aihta.at/1275/

 

Background:

Mental illnesses are among the most common diseases in children and adolescents worldwide. The prevalence rates range between nine and 22 percent [1-2]. Austria is in the upper range with a prevalence rate of about 20 percent compared internationally. Almost one-third of all ten to 18-year-old Austrians are affected by mental illness [3-4]. However, a large proportion of the affected children and adolescents are not in psychological or psychotherapeutic treatment [5].

Structural deficits of treatment services are present on both sides, intramurally (fully and partially inpatient) as well as on an extramural care level (established specialists and outpatient clinics). However, only 50 percent of the needed treatment units are available in the intramural sector throughout Austria, whereby capacities are distributed very heterogeneously across the nine Austrian federal states. In comparison, extramural care has been expanded by about 25 percent [3-4, 6-7]. Due to the lack of inpatient treatment units, sick children and adolescents are also admitted to the adult psychiatry. However, adult psychiatry neither shows the needed resources nor specially trained staff for the care of mentally ill minors [3-4].

The traditional care model for children and adolescents with a severe psychiatric illness is specialised psychiatric inpatient treatment. Such inpatient treatment concepts focus primarily on symptom relief while carrying the risk of isolating the child from the family, community relationships and/or the educational system. Accordingly, and against the background of lacking inpatient treatment units for mentally ill children and adolescents, alternative approaches such as intensive, integrated and psychiatric home programs should be considered [8]. One concept is home treatment for mentally ill children and adolescents. It guarantees the same intensity of treatment as in an inpatient context without interrupting the continuity of personal relationships (family, social or school) [10].

In general, two forms of home treatment can be distinguished: a temporary treatment as acute crisis intervention or a medium-term treatment (approximately 3-6 months), which includes the complete range of multidisciplinary treatment - comparable to the inpatient setting. The goals of this treatment method as an alternative to inpatient care are, for example, the avoidance of chronification (through earlier treatment) and the resulting medical or social follow-up costs, as well as a reduction in drop-out rates. At the same time, the consequences of overload in the inpatient setting can be avoided. Besides, particularly the involvement of caregivers (e.g. parents) in the home treatment is important, to achieve a more sustainable effect of the intervention [9-10].

Project objectives and research questions:

The objectives of the present project are, on the one hand, a systematic overview of the effectiveness and safety of home treatment models in child and adolescent psychiatry and, on the other hand, the analysis of home treatment models for a possible integration of the clinically effective and safe models into the Austrian health care system.

Detailed planning or implementation of a home treatment model in Austria or one of the nine Austrian federal states is not part of this project.

The following research questions (RQ) arise from the project objectives:

• RQ1: How effective and safe are home treatment models in child and adolescent psychiatry and for which indications?
• RQ2: How are the clinically effective and safe models designed (personnel and organisational structure, treatment concepts, etc.)?
• RQ3: How are the clinically effective and safe home treatment models integrated into existing care structures and what preconditions/criteria for successful integration of coordinated care can be derived from them?
• RQ4: How and under which conditions could an integration of a home treatment model into the current child and adolescent psychiatric landscape in Austria look like?

Methods:

The following methods are used to answer the four research questions:

• RQ1-3: Systematic review of the clinical effectiveness and safety of home treatment models, as well as the characteristics and criteria of integration of clinically effective and safe home treatment models in child and adolescent psychiatry.

• RQ4: General overview of the current child and adolescent psychiatric care landscape in Austria (with 1-2 federal states as case studies); comparison to international models; expert surveys; analysis of home treatment models for possible integration into the Austrian health care system.

In the first step, a systematic literature search will be conducted to answer RQ1 to RQ3. The literature will be selected taking into account the predefined inclusion and exclusion criteria. All process steps (literature selection, data extraction, quality assessment if necessary) will be performed by one scientist and controlled by a second scientist. After the literature acquisition, the collected outcomes will be extracted or summarised.

Inclusion criteria for the systematic literature selection

Population	Children, adolescents and young adults with a mental health diagnosis (F diagnosis according to ICD-10) and an indication for acute inpatient treatment.
Intervention	Home treatment as a short-term treatment in acute crises or medium-term (3-6 months) outreach treatment to shorten or avoid inpatient stays.
Control	Full inpatient stays in a child and adolescent psychiatry Partial inpatient stays in a child and adolescent psychiatry: e.g. day-care clinic Outpatient treatment: established child and adolescent psychiatrists or outpatient clinics Other outreach treatments: e.g. Multi-systemic Therapy (MST), Assertive Community Treatment (ACT), Case Management (CM)
Outcomes	RQ1: Clinical effectiveness outcomes Safety outcomes RQ2: Characteristics of a home treatment model (e.g. range of therapies, interdisciplinary professional groups, financing) RQ3: Characteristics of integration into the care landscape (e.g. coordination, responsibilities)
Study design	Randomised controlled trials (RCTs) Non-randomised controlled trials (NRCTs) Observational studies Systematic reviews Evaluation reports
Publication period	2000 - 05/2020

Exclusion criteria for the systematic literature selection

Population	Children, adolescents and young adults with a mental health diagnosis (F diagnosis according to ICD-10) and a self-harming, suicidal and/or life-threatening physical condition.
Intervention	Long-term (e.g. over several years) or preventive home treatment models
Control	-
Outcomes	-
Study design	Case reports Dissertations
Publication period	-

For answering RQ4, an extended manual literature search of documents on the Austrian child and adolescent psychiatric care landscape will be carried out. To contextualise the possible integration of home treatment models into the Austrian care landscape, 3-5 Austrian child and adolescent psychiatric experts (from different disciplines) and one affected adolescent will be consulted.

Timetable/ Milestones:

Period	Performances
April-May 2020	Scoping: preparation of the project protocol, systematic literature search & selection, extended manual search
June – July 2020	Data extraction & data synthesis
July – Aug 2020	Expert consultation
Aug– Sep 2020	Reporting
Beginning Oct – Middle Oct 2020	Internal review
Middle Oct – Ende of Oct 2020	External review
Beginning Nov – Middle Nov 2020	Layout & finalisation

References:

 [1]    Boege I, Schepker R und Jörg M.F. Vom Hometreatment zur stationsäquivalenten Behandlung (StäB): Ein systematischer Review aufsuchender Behandlung in Deutschland. Zeitschrift für Kinder- und Jugendpsychiatrie (2020), 1-12.

[2]     Wagner G, Zeiler M, Waldherr K, et al. Mental health problems in Austrian adolescents: a nationwide, two-stage epidemiological study applying DSM-5 criteria. Eur Child Adolesc Psychiatry (2017), 26: 1483-1499.

[3]     Thun-Hohenstein L, Fliedl R, Sevecke K, et al. Zukunft der Kinder- und Jugendpsychiatrie in Österreich. Neuropsychiatr (2017), 31:144-149.

[4]     Sonderbericht der Volksanwaltschaft (2017). Kinder und ihre Rechte in öffentlichen Einrichtungen. Zugegriffen am 27.04.2020: https://www.parlament.gv.at/PAKT/VHG/XXVI/III/III_00055/imfname_675750.pdf

[5]     Fuchs M, Karwautz A. Epidemiologie psychischer Störungen bei Kindern und Jugendlichen: Eine narrative Übersichtsarbeit unter Berücksichtigung österreichischer Daten. Neuropsychiatr (2017), 31:96-102.

[6]     Hartl C und Karwautz A. Zehn Jahre Kinder- und Jugendpsychiatrie in Österreich: ein neues ärztliches Sonderfach in den Strukturen des Gesundheitswesens. Neuropsychiatr (2017), 31:103-111.

[7]     Competence Center Integrierte Versorgung (2016). Nahtstellenmanagement in der Versorgung von Kindern und Jugendlichen mit psychischen Auffälligkeiten: Identifizierung konkreter Problembereiche an den Schnittstellen zur Kinder- und Jugendpsychiatrie mit Fokus auf Netzwerke. Zugegriffen am 27.04.2020: https://www.sozialversicherung.at/cdscontent/load?contentid=10008.637782&version=1487064484

[8]     Schmidt M.H, Lay B, Göpel C, et al. Home treatment for children and adolescents with psychiatric disorders. Eur Child Adolesc Psychiatry (2006),15:265–276.

[9]     Boege I, Schepker R, Herpertz-Dahlmann B et al. Hometreatment: Eine effektive Alternative zu konventionellen Behandlungsformen? Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie (2015), 43(6): 411-423.

[10]   Information from the contracting autority.