Predictors of Outcome in a Short-Term PsychiatricDay Hospital Program

M. Potvin Kent, K. Busby, M. Johnston, J. Wood, and C. Docherty

Abstract: This study assessed selected chronicity, social sup-port, and personality variables as predictors of outcome in a3-week psychiatric day hospital program. Measured outcomeincluded pre- and post-treatment scores on the BDI, STAI, andSCL-90-R from 224 patients. A single outcome variable basedon the average standardized residual changes scores for thesemeasures was derived to assess whether symptom severity atdischarge was greater or less than predicted. Predictor variableswere analysed using multiple regression. Chronicity variablespredicted outcome, with patients hospitalized more than onceand those with personality disorders more symptomatic thanexpected after treatment. Social support and personality vari-ables failed to predict outcome; however, patients who scoredhigher on the MMPI Si scale were more symptomatic thanexpected at discharge. Although these results possess marginalclinical utility in terms of accounting for symptom changevariation, this study overcame some methodological difficultiesseen in prior day hospital literature. Future research shouldconsider a prospective approach, including random treatmentassignment, comprehensive and diverse outcome measures, andexploration of specific diagnostic groups. © 2000 ElsevierScience Inc.

Introduction

Numerous studies have pointed to the effectivenessof psychiatric day hospital treatment [1–5]. How-ever, there are few consistent findings regardingsignificant predictor variables or who benefits mostfrom this treatment modality. A number of factorsmay account for this current situation, includingprogram variations in terms of length, treatment

philosophy, and diagnostic mix [6] and method-ological issues surrounding adequacy of sampling,isolated predictor variables, and diverse outcomemeasures [6–11].

The research that examines predictor variablesfor short-term (less than 3 months) psychiatric dayhospitals is rare, and research that explores predic-tor variables in day hospital settings that cater ex-clusively to patients suffering from affective andpersonality disorders is particularly rare. Recently,Johnston and Busby [12] attempted to predict suc-cess of 47 patients suffering from affective disordersin a 3-week short-term day hospital setting. Theyexamined marital status, length of illness, Beck De-pression Inventory (BDI) intake scores, MinnesotaMultiphasic Personality Inventory (MMPI) depres-sion sub-scale scores (MMPI-D) at intake, and DSMIII-R Axis IV ratings of psychosocial stressors aspotential predictors. Outcome in the short-termprogram was determined by residual change scoresderived from pre- and post-treatment General Se-verity Index (GSI) scores on the SymptomChecklist-90-Revised (SCL-90-R). Their results indi-cated that length of illness, pre-treatment BDI, andMMPI-D scores were significantly related to posi-tive changes in symptomatology, whereas maritalstatus and Axis IV ratings of psychosocial stressorswere not. Further analyses using multiple regres-sion indicated that the five predictor variables incombination accounted for 46.4% of the variance inoutcome.

The methodological strengths of the above study[12] included the use of a therapeutically relevantoutcome measure and the use of multiple predictorvariables. The results of this study, however, arequite specific since they focus uniquely on thosepatients suffering from an affective disorder to theexclusion of those diagnosed with a personality

Department of Psychiatry, Ottawa Hospital–General Campus,Ottawa, Canada (M.P.K., K.B., M.J.), Department of Psychology,Carleton University, Ottawa, Canada (M.P.K., K.B., J.W.), Schoolof Psychology, University of Ottawa, Ottawa, Canada (K.B.,C.D.), Department of Psychiatry, University of Ottawa, Ottawa,Canada (K.B., M.J.).

Address reprint requests to: Keith Busby, Ph.D., Departmentof Psychiatry, University of Ottawa/Ottawa Hospital–GeneralCampus, 501 Smyth Road, Ottawa, Ontario, Canada K1H 8L6.

General Hospital Psychiatry 22, 184–194, 2000184© 2000 Elsevier Science Inc. All rights reserved.ISSN 0163-8343/00/$–see front matter

655 Avenue of the Americas, New York, NY 10010PII S0163-8343(00)00061-X

disorder. Further research is needed in this area tohelp determine valid predictors of outcome inshort-term psychiatric day hospital settings with anaffective disordered and personality disorderedpopulation.

The MMPI [13] has an extensive history and hasbeen used previously as a predictor of outcome ingeneral psychiatric settings [14–16]. Due to its well-established clinical utility, further knowledge re-garding its predictive power would be valuable.The use of clinically relevant adjunctive measures isparticularly significant in a brief partial hospitaliza-tion program, where time-limited clinical assess-ment can be enhanced. One area that remains un-explored in the partial hospitalization literature iswhether the MMPI might serve as a useful predic-tor of outcome in a day hospital setting. Dunn et al.[17] addressed this question by examining 42 dis-turbed psychiatric patients diagnosed with affec-tive disorders and psychotic disorder who com-pleted a minimum of 3 weeks in a process-orientedpsychiatric day hospital. They concluded that hav-ing four MMPI sub-scales at levels above 80 wasindicative of poor outcome and an increased likeli-hood of future hospitalizations. The MMPI sub-scales that recurred at levels above 80 generallyincluded the D, Pa, Pt, Sc, and Si clinical scales.Elevated scores on the Hy sub-scale were also neg-atively correlated with poor attendance in the dayhospital program. Unfortunately, statistical datawere not provided in this study and thus it isimpossible to determine the magnitude of the find-ings.

Johnston and Busby [12] also attempted to pre-dict the outcome of 47 patients suffering from af-fective disorders after 3 weeks of day hospitaliza-tion by examining the intake scores of the D sub-scale of the MMPI. Their results indicated that Dscores were positively related to outcome as mea-sured by residual change scores derived from pre-and post-GSI scores of the SCL-90-R. When thisvariable was combined with duration of currentillness and pre-treatment BDI scores, 47% of thevariance in the outcome measure was explained.Unfortunately, information regarding the uniquecontribution of the D sub-scale of the MMPI wasnot provided. In summary, there is initial evidencethat the MMPI shows promise as a valid predictorin day hospital settings, but further research isneeded to replicate and extend the exploration of itspredictive utility in partial hospitalization treat-ment.

In order to contribute to the relatively small lit-

erature that has examined short-term day hospitals,this study aimed to assess selected patient demo-graphic, diagnostic, and personality variables pre-dictive of outcome in a 3-week day hospital pro-gram. In addition, this study aimed to improveupon some of the methodological problems thathave been frequently cited in the long-term dayhospital literature that has focused previously onmore mixed diagnostic populations. For this rea-son, the therapeutically relevant outcome measureof symptom change was used in this study andmultiple predictor variables were employed so thatthe combined effects of these variables and the in-teractions among them could be assessed.

Hypotheses

The following variables were chosen and assessedas potential predictors of outcome: age, number ofprior psychiatric hospitalizations, duration of psy-chiatric difficulties, presence of a personality disor-der, living arrangement, marital status, employ-ment status, and Psychopathic Deviate (Pd),Paranoia (Pa), Social Introversion (Si), Family Prob-lems (FAM), Social Discomfort (SOD), and Nega-tive Treatment Indicator (TRT) intake scores on theMMPI/MMPI-2. Hypotheses relating to these vari-ables were elaborated by organizing these variablesinto three categories: (1) chronicity, (2) social sup-port, and (3) personality variables.

Chronicity

It was hypothesized that: 1) younger patientswould have greater symptom reduction than olderpatients as measured by the BDI [18], the STAI [19],and SCL-90-R [20]; 2) those with no prior history ofhospitalization would have greater symptom re-duction than those with a history of prior hospital-ization; 3) those with a shorter duration of psychi-atric difficulties would have greater symptomreduction than those patients with a longer history;and 4) the absence of a co-morbid personality dis-order would be predictive of greater symptom re-duction as measured by the selected outcome mea-sures.

Social Support

The variables of living arrangement, marital status,the FAM content scale of the MMPI-2, and employ-ment status were analyzed within the framework ofa social support model. Intuitively, it made sense to

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argue that increased social support while in a short-term day hospital treatment program would resultin better outcome. It was thus hypothesized thatthose patients who lived with others, who weremarried/living common-law, who were employedprior to admission, and who had lower scores onthe FAM subscale of the MMPI-2 (indicating a lessquarrelsome and more affectionate and loving fa-milial atmosphere than those with higher FAMscores [21]) would have greater symptom reductionas measured by the BDI, STAI, and SCL-90-R.

Personality Variables

It was hypothesized that 1) elevated scores on thePd scale would be predictive of poorer outcomesince individuals with high Pd elevations are gen-erally uninterested in seeking treatment and oftenseek treatment in response to the demands of others[21,22]; 2) elevated scores on the Pa scale wouldpredict poorer outcome (less symptomatic change)since these individuals generally have difficulty es-tablishing a therapeutic rapport [21,22]; and 3) ele-vated scores on the Si scale would be related topoorer outcome since these individuals would havedifficulty in the group setting.

In terms of the MMPI-2 content scales, it washypothesized that: 1) elevated scores on the SODscale (indicating a preference for being alone and adislike for group situations; [21]) would be associ-ated with decreased symptom reduction aftershort-term day hospital treatment as measured bythe BDI, STAI, and SCL-90-R; 2) elevated scores onthe TRT scale would predict poorer outcome sincethese individuals do not believe that anyone canhelp them and often appear inflexible with regardto initiating life changes [21].

Method

Subjects

Between October of 1993 and June of 1997, theAcute Day Hospital (ADH) at the Ottawa Hospital–General Campus admitted 341 patients. To be ac-cepted into this program, prospective patients werescreened by a multidisciplinary team according tospecific inclusion and exclusion criteria. Criteriawere based on the Day Treatment AppropriatenessScale designed by Lefkovitz [23]. Inclusion criteriaincluded: 1) a level of impairment severe enough towarrant hospitalization; 2) evidence of recent stres-sors that led to the impairment; or 3) underlying

character pathology and/or lack of an adequatesupport system that necessitated intensive inter-vention; 4) an adequate pre-morbid level of func-tioning such that substantial improvement could beexpected in a three-week intensive program; and 5)the patient was motivated to attend the programand was a voluntary patient. Patients signed in-formed consent to treatment and the collection ofinformation for research purposes.

Exclusion criteria included: 1) the presence of anorganic brain syndrome or a developmental hand-icap that would impede the patient’s ability to ben-efit from the program; 2) the presence of disruptiveor aggressive behavior; 3) active drug or alcoholabuse; and/or 4) active suicidal behavior. Patientssuffering from a mental illness that required hospi-talization and patients who could be better man-aged in a less intensive setting were also excluded.

Of the 341 patients accepted into the program,224 (65.7%) patients had mostly complete data setsand were included in the main analyses. The 117patients for whom intake data, discharge data,and/or diagnostic data were missing were ex-cluded from the main analyses. However, the de-mographic and diagnostic characteristics of thisgroup were examined to ensure their comparabilitywith patients who had complete data.

Treatment Program

This partial hospitalization program is a short-termtreatment program designed for acute psychiatricpatients who would otherwise require inpatientcare. Its aim is to restore individuals to their pre-morbid level of functioning. To accomplish thisend, the program aims to stabilize presentingsymptoms, to mobilize supports, and to adequatelyresolve stressors that initially led to the develop-ment of symptoms. A maximum of eight patientsparticipate in the program at a given time, althoughthe program can accommodate a ninth person inemergencies. Admission to the ADH is open in thatpatients are replaced immediately when they ter-minate the program, generally upon completion of15 working days. The program runs from 9:30 AMto 2:30 PM Monday to Friday and participants at-tend all sessions. Individual sessions are scheduledoutside of these hours.

Treatment at the ADH is in group format. Thecontent of the groups is psychoeducational andpsychotherapeutic. Emphasis is on goal setting, dis-charge planning, and return to pre-morbid levels offunctioning. Patients participate in a variety of 50-

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min groups, including community group, goal set-ting group, stress management group, coping skillsgroup, weekend planning group, family supportgroup, symptom/medication management group,variety group, and occupational therapy workshop.Each group is led by two ADH team members.

Predictor Measures

Predictor variables examined in this study includedage, number of prior psychiatric hospitalizations,duration of psychiatric difficulties (months), thepresence of a personality disorder, living arrange-ment, marital status, employment status, and thePd, Pa, Si, FAM, SOD, and TRT pre-treatmentscores on the MMPI/MMPI-2.

The variables of age, living arrangement, maritalstatus, and employment status were determinedfrom the psychological assessment administered atadmission to the day hospital program.

The MMPI [13], a multidimensional 550-itemquestionnaire designed to provide an assessment ofpersonality traits, was also used as an outcomepredictor in this study. It was completed by 125subjects in this study. The MMPI has been shown tobe psychometrically sound. It possesses short-termtemporal stability [24,25], internal consistency (al-though the standard scales were not developed tobe unidimensional measures), reliability [25], andconvergent and divergent validity. The MMPI hasachieved success in differentiating among patientgroups, including between neurotic and psychoticpatients, between psychiatric patients and controlgroups and between those suffering from anxietyand depression [24].

Ninety-six subjects in this study completed theMMPI-2 [26], an updated revision of the MMPIrather than the original MMPI, since this revisionbecame available part way through the data collec-tion process. The new version has 567 items andincludes the modernization of some items, a re-standardization of norms, a more representativenormative sample and different T-score transfor-mation procedures. More precisely, uniformT-scores (rather than linear T-scores as in theMMPI) were developed for the MMPI-2 so that allthe clinical scales would be distributed similarly. Inaddition, a redefined clinical elevation of a T-scoreof 65 or greater was established (the clinical eleva-tion of the MMPI is a T-score of 70 or greater). Thedevelopment of the MMPI-2 also involved the der-ivation of homogeneous content scales.

Although MMPI and MMPI-2 raw scores gener-

ally are equivalent, typically, the MMPI-2 rawscores are elevated slightly. As a result the T-scoresfor the MMPI-2 tend to be lower than on the MMPI[24,27]. For this reason, those who completed theMMPI and those that completed the MMPI-2 wereexamined separately in the current study.

The MMPI-2 has been shown to be psychometri-cally robust. It possesses convergent and discrimi-nant validity [24,28], short-term temporal stability[24], and internal consistency [29], although stan-dard scales were not designed to be unidimen-sional.

The specific MMPI/MMPI-2 clinical scales exam-ined as potential predictors of outcome in thisstudy included the Pd, Pa, and Si scales. The spe-cific MMPI-2 content scales assessed as predictorsincluded the SOD (comfort in social situations), theFAM (family discord), and the TRT (willingness toreceive treatment and benefit from it; [21]).

Outcome Measures

The BDI [18] is a 21-item questionnaire that wasdesigned to assess the severity of depression inpsychiatric patients. Psychometrically, the BDI hasbeen shown to be quite robust as an outcome mea-sure, showing good convergent and discriminantvalidity [30–32], high internal consistency with psy-chiatric and non-psychiatric samples [30], and goodtest-retest reliability [30]. As an outcome measure,Taylor and Klein [33] concluded that the BDI was amoderately good predictor of recovery and its usein outcome studies.

The STAI-Form Y [19] is composed of two 20-item scales that measure state and trait aspects ofanxiety. The STAI has been shown to be psycho-metrically strong, with good construct validity[19,34] and demonstrating internal consistency andreliability [19]. Stability, measured by test-retest co-efficients, is strong for the ‘trait’ STAI (STAI-T) andweak for the ‘state’ STAI (STAI-S) as one wouldpresume [19]. Good convergent and discriminantvalidity has also been demonstrated with other psy-chometric instruments [19].

The SCL-90-R [20] is a 90-item self-report ques-tionnaire that assesses psychopathology in terms ofnine symptom sub-scales and three global indicesof distress. Since multiple studies [35,36] haveshown that the nine scales are not independent ofone another, that a sizable proportion of items loadon more than one factor, and that it is unlikely thatthe SCL-90-R reliably differentiates subjects suffer-ing from different psychiatric disorders, Strauman

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and Wetzler [37] have recommended that this in-strument should only be used as a general index ofoverall severity of psychopathology. For this rea-son, the current study focused only on the GSI,which is an index combining information regardingthe number of positive symptoms and distress se-verity.

In order to assess change in symptomatology, thestandardized residual change scores of the BDI,GSI, STAI-S, and STAI-T were computed, as recom-mended by Hauser-Cram and Krauss [41]. Thestandardized residual change score is the differencebetween the subject’s actual z score and predicted zscore. It is computed by regressing the discharge zscores on the admission z scores for a given test. Itsadvantage over the simple change score is that ittakes subjects’ initial status and overall level ofchange into account. Positive standardized residualchange scores indicated that subjects were moresymptomatic at discharge than predicted, whereasnegative standardized residual change scores indi-cated that subjects were less symptomatic at dis-charge than predicted. Since the BDI, GSI, STAI-S,and STAI-T standardized residual change scoreswere so highly related (correlations ranged from .60to .81), they present a similar picture of change andthus, were combined into a single scale. When thesefour measures where taken together as a scale, in-ternal consistency was high as indicated by thereliability coefficient (Cronbach’s alpha 5 .90). Forthese reasons, an average standardized residualchange score was computed by adding each sub-ject’s standardized residual change scores and di-viding by the number of scores. It was possible tocalculate such an average since standardized resid-ual change scores which assured equal variancesacross the measures, were used. The average stan-dardized residual change score became the crite-rion variable for further analyses.

Procedure

At admission, each subject completed the MMPI orMMPI-2, BDI, SCL-90-R, and STAI. At discharge,the BDI, SCL-90-R, and STAI were re-administered.A psychiatrist also completed a discharge summarywhich included a five axes DSM-III-R [38] orDSM-IV [39] discharge diagnosis.

Data Analyses

Descriptive statistics (frequencies, means) were em-ployed to generate a sample profile based upon

demographic and clinical information. Simple cor-relations were used to explore the relationshipsamong the various predictor variables and the out-come measure and multiple regression was con-ducted to assess the combined effects of each groupof predictor variables on the outcome measure.Data analyses were conducted with SPSS 7.5 forWindows [40].

Results

Three-hundred and forty-one patients attended theADH between October 1993 and June 1997. A totalof 224 subjects had mostly complete data sets, while117 patients had grossly incomplete data sets pri-marily due to a lack of discharge data. Those sub-jects with missing data were very similar to thosesubjects with complete data sets. ANOVA and x2

square analyses revealed that sex, education, em-ployment, language, marital status, number of hos-pitalizations, DSM Axes I and II diagnoses, andduration of psychiatric difficulties were not signif-icantly different between those subjects with com-plete and incomplete data sets. Small but statisti-cally significant differences were found betweenthese two groups in age and length of stay, withthose in the missing data set being significantlyyounger (M535.09, SD58.78) than subjectswith complete data sets (M538.51, SD59.95;F (1,335)59.61, P5.002). In terms of length ofstay, those subjects in the missing data group hadsignificantly shorter lengths of stay (M512.08,SD54.33) than those with complete data sets(M513.63, SD52.45; F (1,311)516.16, P5.001).In addition, a sizable portion of subjects (n521,22.6%) with missing data attended the program for8 days or less.

Sample Demography and Diagnostic Profile

The demographic and diagnostic data for the mainsample are presented in Tables 1–3. Subjects’ lengthof stay in the ADH program ranged from 4 to 18days. On average, patients (N5220) remained for13.6 days (SD52.45) and 65% of the sample re-mained in the program between 14 and 16 days. Allthose who left the program earlier appear to haveleft with the staff’s consent as collaborated by med-ical chart progress notes.

Outcome

In terms of the change in symptomatology thatoccurred during the 3-week treatment period, the

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BDI, GSI, STAI-S, and STAI-T scores all signifi-cantly (P,.001) decreased at discharge relative toadmission as assessed by ANOVA with repeatedmeasures. Estimates of effect size (eta2) for eachoutcome variable were also computed (see Table 4).

These changes indicated that subjects were lesssymptomatic at discharge than at admission andthat the BDI and GSI accounted for a greater pro-portion of change relative to total variability thanthe STAI.

Chronicity Variables

In order to determine whether chronicity of a psy-chiatric disorder predicted outcome on the averagestandardized residual change score, a multiple re-gression analysis was conducted. Results revealedthat a linear combination of age, number of hospi-talizations, duration of psychiatric difficulties andpresence of a personality disorder shared a small,but significant proportion of the variability in theaverage standardized residual change score (R25.054, R2

adj5.036; F(4,203)52.91, P5.02). An ex-amination of the regression weights for each vari-able revealed that, despite significant zero-ordercorrelations between the number of hospitaliza-

Table 4. Change in symptomatology

MeasureAdmissionMean (SD)

DischargeMean (SD) F* df eta2

BDI 28.52 (10.76) 17.96 (11.38) 223.99 1,197 .532GSI

Raw score 1.76 (0.69) 1.19 (0.70) 200.16 1,222 .472T-score 74.26 (7.59) 66.96 (9.75) 173.69 1,222 .439

STAI-S 57.61 (12.39) 48.83 (13.87) 76.04 1,218 .259STAI-T 59.52 (9.66) 52.51 (11.12) 86.81 1,209 .293

* P,.001

Table 1. Categorical demographic variables formain sample

Variable Frequency Valid %

SexMale 61 27.2Female 163 72.8

LanguageEnglish 181 81.2French 42 18.8

Marital statusSingle 69 30.8Married/common-law 102 45.5Separated 28 12.5Divorced 21 9.4Widowed 4 1.8

EducationSome elementary school 4 1.8Some high school/CEGEP 80 36.0Some college/university 124 55.9Post-graduate training 14 6.3

Current living arrangementAlone 47 21.7With spouse/partner 40 17.4With spouse and children 59 27.2With children 13 6.0With parents/family 37 17.1With roommate 18 8.3With other 3 1.4

EmploymentEmployed 108 48.2Unemployed 106 47.3Student 7 3.1Retired 3 1.3

Duration of psychiatric difficultiesLess than 12 months 77 34.412–36 months 63 28.1More than 36 months 84 37.5

Table 2. Continuous demographic variables formain sample

Variable N M SD

Age 224 38.51 9.95Number of previous hospitalizations 209 1.23 1.89Length of stay 220 13.63 2.45

Table 3. DSM diagnosis for main sample

Diagnosis Frequency Valid %

Axis IMood disorder 147 65.6Anxiety disorder 21 9.4Adjustment disorder 26 11.6Substance-related disorder 11 4.9Psychotic disorder 5 2.2Eating disorder 3 1.3Other disorders 2 0.9Absence of Axis I disorder 9 4.0Total 224 100.0

Axis II-Personality disordersPresence 57 25.7Absence 165 74.3Total 222 100.0

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tions (r5.161, P5.02) and the presence of a per-sonality disorder (r5.148, P5.032) with the crite-rion variable, neither of these variables uniquelycontributed to the criterion variable at P,.05. It isimportant to note, however, that the regressionweights for the number of hospitalizations (B5.131, P5.061) and the presence of a personalitydisorder (B5.135, P5.053) almost reached signif-icance. The average standardized residual changescores were greater (indicating more symptoms atdischarge than predicted) with greater previoushospitalizations and the presence of a personalitydisorder (see Table 5).

Social Support Variables

None of the social support variables (marital status,employment status, living arrangement, and FAMsubscale), either in combination (R25.033, R2

adj52.01; F (4,90)5.77, ns) or individually, werefound to be significantly related to outcome, andtherefore, predictive of symptom change.

Personality Variables

Combined, the selected clinical MMPI scales didnot share a significant proportion of the variabilityof the average standardized residual change score(R25.053, R2

adj5.03; F (3,121)52.26, ns). Despitethis overall non-significant effect, when individualregression weights for the Pd, Pa, and Si sub-scalesof the MMPI were examined, the Si sub-scale (B5.193, P5.05) was significant. Si correlated with theaverage standardized residual change score (r5.213, P5.018). This correlation indicated that as Siscores increased (indicating more introversion), theoutcome measure also increased suggesting thatsubjects were more symptomatic at discharge thanpredicted.

Selected variables of the MMPI-2 were also ex-amined as potential predictors since 96 subjectscompleted this instrument. Combined, the Pd, Pa,Si, SOD, and TRT scales of the MMPI-2 did notshare a significant proportion of the variability ofthe average standardized residual change score(R25.063, R2

adj5.011; F(5,90)51.21, ns).

Discussion

Significant change between admission and dis-charge was demonstrated, as measured by the BDI,GSI, STAI-S, and STAI-T. This result replicatesthose of Piper et al. [2] and Azim et al. [7] who, incontrolled studies, described symptom improve-ment in long-term programs with affective disor-dered and personality disordered patients, andwith mixed diagnostic populations respectively. Itis also consistent with results from an earlier inves-tigation within the same day hospital program asthe present study, using inpatient controls [3].Symptom improvement has also been shown in a6-week day hospital program for patients sufferingprimarily from affective and adjustment disorders[1]. The present study suggests that subjects didimprove in the ADH, but since no control groupwas used it cannot be concluded that this improve-ment was due solely to treatment program effects.

As evident by the effect sizes (eta2 values) ob-tained, the BDI and GSI measures showed greatersensitivity to change than the STAI for our partic-ular program and patient sample. These results arecongruent with the fact that the proportion of oursample with affective disorders was relatively high(65.7%) and the notion that the GSI reflects a gen-eral level of psychological distress that is commonacross all diagnostic categories. These findings haveimportant implications for future studies undertak-ing similar program evaluation, whereby choice ofoutcome measures that employ a symptomatologycomponent need to be sensitive to diagnostic mix.

The general question that this study originallyposed was whether multiple variables, taken indi-vidually or in combination, sampled from chronic-ity, social support and personality factors couldpredict symptom reduction after short-term dayhospitalization. With regard to chronicity, a combi-nation of the selected variables were predictive ofsymptom reduction. Most significantly, in accor-dance with previous reports [42,43], having a co-morbid personality disorder was independently in-dicative of less symptom reduction than predictedat discharge. In addition, the current study revealed

Table 5. Average residual change score accordingto number of hospitalizations andpersonality disorder diagnosis

Predictor variable M SD

No. of hosp.Never 2.17 .76Once 2.04 .90More than once .19 .88

Personality disorderPresence .20 .91Absence 2.07 .89

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that, independently, prior psychiatric hospitaliza-tion was associated with less symptom reductionthan predicted post-treatment. This finding is incontrast to that of Piper et al. [6] in their 18-weekday hospital program, which found that previoushospitalization was significantly related to positiveinterpersonal functioning at discharge, but was notrelated to the outcome variables of general symp-tomatology and target objectives, social maladjust-ment and dissatisfaction, or pathological depen-dency. Such differences may not be remarkableconsidering that the Piper et al. [6] study was con-ducted in a setting with a different program length(18 weeks), program orientation (psychodynamic)and population (higher percentage with personalitydisorders) than the current study. It is feasible thatthe same variables might not predict outcome whenthere are such great program and population dif-ferences.

In the current study, duration of psychiatric dif-ficulties was not found to be predictive of symptomchange at discharge. This finding was particularlyunexpected given that, within the same setting,Johnston and Busby [12] concluded that there was arelationship between SCL-90-R symptom changescores at discharge and length of illness. This dis-parity could perhaps be accounted for by the factthat they solely examined outcomes of patients suf-fering from affective disorders while in the currentstudy, a more heterogeneous population (see Table3) was examined. It could be argued that variablesmay differ in their predictive utility depending ondiagnostic mix.

The selected social support variables were notpredictive of symptom reduction, independently orin combination, in the current study. Marital statushas been previously examined and results havebeen equivocal [12,17,44,45]. The variables of em-ployment status, living arrangement, and the FAM(MMPI-2) have not been examined as potential pre-dictors of outcome in any studies with affectivedisordered and personality disordered patients inpartial hospitalization programs. This makes rele-vant comparisons difficult to make. Employmentstatus and living arrangement have been examinedin the long-term literature with mixed diagnosticpopulations, but no clear trends have developed.More research is needed to determine the relevanceof these variables as predictors of outcome in short-term day hospital settings.

With respect to personality variables, only the Siscale from the MMPI was predictive of symptomchange. Higher Si scores, indicating higher levels of

social introversion, were associated with greaterdistress than predicted at discharge. This findingsuggests that those patients who experience dis-comfort in group settings, and thus may not partic-ipate as actively in the group therapy process, maynot benefit as greatly from day hospitalization.

It is important to note that, in contrast to theMMPI results, the Si scale of the MMPI-2 was notpredictive of symptom reduction. This discrepancyis particularly noteworthy given that the Si scale inthe MMPI and MMPI-2 are virtually identical (onlyone item was deleted and six others were revisedgrammatically or modernized in the MMPI-2; [26]).In view of the number of statistical analyses thatwere conducted in the current study, this findingmight be the result of a Type I error. Alternatively,assuming this difference does not reflect a statisticalerror, this discrepancy could be the result of a sig-nificant shift in the psychopathological profile ofthe patients in the ADH. Because those who com-pleted the MMPI and those who completed theMMPI-2 roughly represented ordered temporalgroups, with those completing the MMPI enteringthe program before those completing the MMPI-2,comparisons between these two groups were made.As previously noted, these results revealed thatthose who completed the MMPI were more symp-tomatic at discharge than predicted and had signif-icantly higher rates of previous psychiatric hospi-talization than those who completed the MMPI-2.These findings suggest that those patients whowere referred to the program in the latter part of itsexistence exhibited less pathology than those whowere initially referred. This shift may have resultedbecause referring clinicians became more familiarwith the program and thus, referred their psychiat-ric patients more quickly (i.e., upon presentation ofinitial psychiatric distress). Another possible expla-nation may relate to a subtle shift within the pro-gram (i.e., program evolution in the assessmentprocedure might have occurred). Perhaps closer toprogram inception, acceptance was more variable,such that a greater range of pathology was admis-sable. As the program continued, acceptance crite-ria were presumably tightened.

It is worth noting that, with the exception of theSi scale in the MMPI, none of the other selectedMMPI or MMPI-2 scales examined were signifi-cantly correlated with the symptom change out-come measure. Such negative results have beenseen in other psychiatric settings [15,46–48]. Al-though none of the previous studies has reviewedthe predictive utility of the Pd, Pa, SOD, and TRT in

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a day hospital setting, the previous literature andthe results of the current study lead one to questionwhether the Pa, Pd, SOD, and TRT scales are valu-able predictors of outcome. It is particularly note-worthy that the TRT, which purports to measurenegative treatment attitudes toward mental healthpractitioners and treatment, is not correlated withsymptom reduction since one would intuitively ex-pect such a correlation. Again, selection bias infavour of choosing patients who would likely ben-efit and comply with ADH treatment, makes itunlikely that patients on the extreme end of the TRTscale would be accepted in the first place. Althoughfurther research that examines the use of MMPI/MMPI-2 sub-scales as predictors of outcome in dayhospital settings is needed in order to help deter-mine whether these personality variables areworthwhile predictors in this milieu, it might bemore fruitful to explore other personality variablessuch as psychological mindedness (the ability toidentify intrapsychic elements), quality of objectrelations (an individual’s lifelong pattern of estab-lishing various types of relationships) or copingstrategies. This avenue might be more valuablesince these personality variables have been shownto be useful predictors by Piper et al. [6,44] inlong-term day hospital settings with patients suf-fering from affective disorders and personality dis-orders.

Strengths and Limitations

The present study attempted to overcome some ofthe methodological flaws seen in the long-term dayhospital literature with mixed diagnostic popula-tions such as the use of therapeutically-relevantoutcome measures and the reliance on simple re-gression techniques. As such, symptom change wasused as the outcome measure rather than the mea-sure of program completion as has commonly beenused in the long-term day hospital literature. Inaddition, multiple predictor variables were em-ployed so that the combined effects of these vari-ables could be assessed. Other strengths of thisstudy included the large number of subjects whoparticipated and the extensive amount of demo-graphic and diagnostic information available onthis sample that could be used in future research aspotential predictors of outcome.

Despite these strengths, it is important to notethat in the current study no control group wasutilized as program effectiveness has been previ-ously established [3]. Building on known effective-

ness, therefore, the purpose of the present studywas simply to measure predictors of outcome.While the findings may have limited clinical utility,the current study nonetheless contributes to theliterature by providing an improved methodologyand impetus for further developments in this area.

One final limitation of this study is its reliance onarchival data. This necessarily increases the likeli-hood of omissions, incompleteness, inaccuracies,and the a priori selection of information to collect.Also, data were originally collected for clinical pur-poses and thus did not always possess the detail orspecificity required for research purposes. As a re-sult, some subjective interpretations were appliedto information in the data-collection process.

Conclusion

The present study represented an attempt to clarifywhether selected patient variables, in combinationor individually, might predict symptom change in ashort-term day hospital setting. Although it wasdemonstrated that chronicity variables were predic-tive of symptom change, this result possesses lim-ited utility since only 5% of the variability in symp-tom change at discharge could be accounted for. Assuch, chronicity may not be as utilitarian as otherfactors in patient selection criteria for short-termday hospital programs. Arguably, predictor vari-ables might be more easily identified if specificdiagnostic groups are examined [12,49].

Predictor variables might also be more easilyidentified in this setting if a variety of outcomemeasures are used. Although symptom change is amore valuable outcome measure than programcompletion, and has been more commonly used inthe day hospital literature, symptom change onlytaps one aspect of patient functioning. Quality oflife measures and individualized assessment of pa-tients’ therapeutic goal achievement (from patientand therapist perspectives) might also be a valuableaddition to such an outcome evaluation.

The continued exploration of significant predic-tor variables in the short-term day hospital settingremains a valuable pursuit. The ability to identifythose patients who do and do not do well in theseprograms has implications for program change andfor the development of new programs.

References

1. Howes JL, Haworth H, Reynolds P, Kavanaugh M:Outcome evaluation of a short-term mental health

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day treatment program. Can J Psychiatry 42:502–508,1997

2. Piper WE, Rosie JS, Azim HFA, Joyce AS: A random-ized trial of psychiatric day treatment for patientswith affective and personality disorders. Hosp Com-munity Psychiatry 44:757–764, 1993

3. Russell V, Mai F, Busby K, et al: Acute day hospital-ization as an alternative to inpatient treatment. CanJ Psychiatry 41:629–637, 1996

4. Schene AH, van Wijngaarden B, Poelijoe NW, Ger-sons BPR: The Utrecht comparative study on psychi-atric day treatment and inpatient treatment. ActaPsychiatr Scand 87:427–436, 1993

5. Washburn S, Vannicelli M, Longabaugh R, Scheff B-J:A controlled comparison of psychiatric day treatmentand inpatient hospitalization. J Consult Clin Psychol44:665–675, 1976

6. Piper WE, Joyce AS, Azim HFA, Rosie JS: Patientcharacteristics and success in day treatment. J NervMent Dis 182:381–386, 1994

7. Azim HFA, Weiden TD, Ratcliffe WD, et al: Currentutilization of day hospitalization. Can Psychiatr As-soc J 23:557–566, 1978

8. Beigel A, Feder SL: Patterns of utilization in partialhospitalization. Am J Psychiatry 126:1267–1274, 1970

9. Case N: The dual-diagnosis patient in a psychiatricday treatment program. J Sub Abuse Treat 8:69–73,1991

10. Ferber JS, Oswald M, Rubin M, Ungemack J, SchaneM: The day hospital as entry point to a network onlong-term services: a program evaluation. HospCommunity Psychiatry 36:1297–1301, 1985

11. Vidalis AA, Baker GHB: Factors influencing effective-ness of day hospital treatment. Int J Soc Psychiatry32:1–6, 1986

12. Johnston M, Busby K: The Acute Day Hospital: Pre-dictors of outcome. Paper presented at the annualmeeting of the Canadian Psychiatric Association, Cal-gary, Alberta, September, 1997.

13. Hathaway SR, McKinley JC: Manual for the Minne-sota Multiphasic Personality Inventory. New York,The Psychological Corporation, 1967

14. Leonard CV: The MMPI as a suicide predictor. JConsult Clin Psychol 45:367–377, 1977

15. Aaronson AL, Dent OB, Kline CD: Cross-validationof MMPI and MMPI-2 predictor scales. J Clin Psychol52:311–315, 1996

16. Young RC, Gould E, Glick ID, Hargreaves W: Per-sonality inventory correlates of outcome in a fol-low-up study of psychiatric hospitalization. PsycholRep 46:903–906, 1994

17. Dunn RJ, Staley D, Sexton DL: Psychiatric dayhospitalization: Multiple perspectives on outcome.Int J Part Hosp 1:287–299, 1982

18. Beck AT, Rush AJ, Shaw BF, Emery G: CognitiveTherapy of Depression. New York, Guilford Press,1979

19. Spielberger CD: Manual for the State-Trait AnxietyInventory. Palo Alto, CA, Consulting PsychologistsPress, 1983

20. Derogatis LR: Description and bibliography for theSCL-90-R and other instruments of the psychopathol-

ogy rating scale series. Unpublished manuscript,Johns Hopkins University, School of Medicine, 1983

21. Butcher JN: MMPI-2 in Psychological Treatment.New York, Oxford University Press, 1990

22. Butcher JN, Williams CL: Essentials of MMPI-2 andMMPI-A Interpretation. Minneapolis, MN, Univer-sity of Minnesota Press, 1992

23. Lefkovitz PM: The assessment of suitability for par-tial hospitalization: The Day Therapy Appropriate-ness Scale. Int J Part Hosp 1:45–57, 1982

24. Graham JR: MMPI-2: Assessing Personality and Psy-chopathology (2nd ed.). Oxford, Oxford UniversityPress, 1993

25. Parker KCH, Hanson RK, Hunsley J: MMPI, Ror-schach, and WAIS: a meta-analytic comparison ofreliability, stability, and validity. Psychol Bull 103:367–373, 1988

26. Hathaway SR, McKinley JC: Manual for the Minne-sota Multiphasic Personality Inventory-2. New York,University of Minnesota Press, 1989

27. Harrell TH, Honaker M, Parnell T: Equivalence of theMMPI-2 with the MMPI in psychiatric patients. Psy-chol Assess 4:460–465, 1992

28. Ben-Porath YS, McCully E, Moshe A: Incrementalvalidity of the MMPI-2 content scales in the assess-ment of personality and psychopathology by self-report. J Person Assess 61:557–575, 1993

29. Butcher JN, Dahlstrom WG, Graham JR, Tellegen A,Kaemmer B: Manual for the restandardized Minne-sota Multiphasic Personality Inventory: MMPI-2. Anadministrative and interpretative guide. Minneapo-lis, MN, University of Minnesota Press, 1989

30. Beck AT, Steer RA, Garbin MG: Psychometric prop-erties of the Beck Depression Inventory: Twenty-fiveyears of evaluation. Clin Psychol Rev 8:77–100, 1988

31. Clark DC, Cavanaugh SV, Gibbons RD: The coresymptoms of depression in medical and psychiatricpatients. J Nerv Ment Dis 171:705–713, 1983

32. Prudhomme L, Baron P. Utility of the Beck Depres-sion Inventory in clinical research: some additionaldata. Rev Eur Psychol Appl 43:311–314, 1993

33. Taylor EB, Klein DN: Assessing recovery indepression: validity of symptom inventories. CognTher Res 13:1–8, 1989

34. Okun A, Stein REK, Bauman LJ, Johnson Silver E:Content validity of the Psychiatric Symptom Index,CES-Depression Scale, and State-trait Anxiety Inven-tory from the perspective of the DSM-IV. Psychol Rep79:1059–1069, 1996

35. Cyr JJ, McKenna-Foley JM, Peacock E: Factor struc-ture of the SCL-90-R: is there one? J Person Assess49:571–578, 1985

36. Hafkenscheid A: Psychometric evaluation of theSymptom Checklist (SCL-90) in psychiatric inpa-tients. Person Ind Diff 14:751–756, 1993

37. Strauman TJ, Wetzler S: The factor structure of theSCL-90-R and the MCMI scale scores: within measureand interbattery analyses. Multivar Behav Res 27:1–20, 1992

38. American Psychiatric Association. Diagnostic andStatistical Manual of Mental Disorders (3rd ed., re-vised). Washington, DC, Author, 1987

39. American Psychiatric Association. Diagnostic and

Psychiatric Day Hospital Predictors of Outcome

193

Statistical Manual of Mental Disorders (4th ed.).Washington, DC, Author, 1994

40. SPSS 7.5 for Windows-Graduate Pack. Chicago, IL,SPSS Inc., 1997

41. Hauser-Cram P, Krauss MW: Measuring change inchildren and families. J Early Intervent 15:288–297,1991

42. Karterud S, Vaglum S, Friis S, et al: Day hospitaltherapeutic community treatment for patients withpersonality disorders: an empirical evaluation of thecontainment function. J Nerv Ment Dis 180:238–243,1992

43. Vaglum P, Friis S, Irion T, et al: Treatment response ofsevere and non-severe personality disorders in a ther-apeutic community day unit. J Person Dis 4:161–172,1990

44. Piper WE, Joyce AS, Rosie JS, Azim HFA: Psycholog-ical mindedness, work and outcome in day treat-ment. Int J Group Psychother 44:291–311, 1994

45. Carney MWP, Ferguson RS, Sheffield BF: Psychiatricday hospital and community. Lancet 6:1218–1220,1970

46. Chisolm SM, Crowther JH, Ben-Porath YS: SelectedMMPI-2 scales ability to predict premature termina-tion and outcome from psychotherapy. J Person As-sess 69:127–144, 1997

47. Hilsenroth MJ, Handler L, Toman KM, Padawer JR:Rorschach and MMPI-2 indices of early psychother-apy termination. J Consult Clin Psychol 63:956–965,1995

48. Munley PH, Busby R: MMPI-2 Negative TreatmentIndicators Scale and irregular discharge. Psychol Rep74:903–906, 1994

49. Dazord A, Gerin P, Seulin C, Duclos A, Amar A:Day-treatment evaluation. Therapeutic outcome aftera treatment in a psychiatric day-treatment center:another look at the outcome equivalence paradox.Psychother Res 7:57–70, 1997

Kent et al.

194