Psychiatric Day Hospital and Its Impact on Patients Clinical Stability: The Reality of Faro (Portugal) Unit

Psychiatric Day Hospitals are alternatives to classic hospitalization, staying in an intermediate position between full-time hospitalization and outpatient treatment. The main purpose of this work was to investigate the impact of the therapeutic program developed in a Psychiatric Day Hospital (of Faro-Portugal) on the clinical stability of the patients. It is a descriptive-correlational retrospective study, implemented through the consultation of the SCLINIC computer platform regarding the years 2015, 2016 and 2017. The records of 127 users were analysed. There was a predominance of mood disorders (n = 55; 43.3%), followed by schizophrenia, schizotypal and delusional disorders (n = 43, 33.9%). The majority of patients had a structured occupational plan after discharge (n = 106, 83.46%). In the year following the frequency of Day Hospital, compared to the year prior to admission, there was a reduction in the number of full-time hospitalizations, outpatient visitations/consultations, prescribed drugs and emergency episodes, with statistically significant differ-ences. The positive impact of the frequency of Day Hospital had on patients’ clinical stability was the improvement in all studied variables. The Psychiatric Day Hospital of Faro-Portugal contributes to decreasing the number of full time hospitalizations, outpatient visitations/consultations and emergency episodes, maintaining patients’ clinical stability and reducing the public financial costs related to their therapeutic intervention.


Introduction
The concept of Psychiatric Day Hospital isn't new-the first experience of this Open Journal of Psychiatry kind arose in 1933, at the Psychiatric Hospital of Moscow [1]. It was exclusively designed for psychotic patients and their main purpose was the promotion of rehabilitation aiming the patients' entry into the labour market, to strengthen the productive performance during Stalin administration. The term "Day Hospital" only first appeared in 1946, through the initiative of Donald Cameron [1] [2]. This unit was inaugurated at the Memorial Institute of Psychiatry of the Allan MacGill University of Montreal. Initially it offered psychiatric treatments based on insulin shocks, group and individual psychotherapy and electroconvulsive therapy, but later became progressively more flexible to meet the individual needs of each patient [1] [3] [4] [5]. Psychiatric Day Hospitals reached an extraordinary evolution, spreading through Europe, United States and Canada. In less developed countries, they emerged as part of initiatives from professionals trained in these nations [1] [3] [4]. Several factors led to this phenomenon, which induced the replacement of asylum psychiatry model by the community care and socially inclusive pattern [1]: • The increase of psychiatric illnesses in the Post World War II, associated with problems related to labour market adaptation; • The entry of women into the labour force; • The progressive transition from extended families to nuclear families making it difficult to support members who became ill; • The recognition of psychotherapy as a form of extra-hospital treatment; • The need of ensure the clinical stability of patients with fewer resources, aiming at reducing the overall cost of the disease.
At Portugal, in the late 1950s and early 1960s it became evident that the model of asylum psychiatry was manifestly insufficient. Several factors contributed to this change of mentalities [6]: • The increasing industrialization and the creation of a stronger and more demanding working class; • The increase in the prevalence of mental illness due to the Portuguese overseas war (Guinea-Bissau, Angola, Mozambique, India). This led to the beginning of community psychiatry at Miguel Bombarda Lisbon psychiatric hospital, model which later spread to the rest of the country [6].
It was within this context that appears, in 1957, the first Day Hospital in Portugal, by the psychiatrist Barahona Fernandes, at Júlio de Matos Lisbon psychiatric hospital [7] [8]. Currently Psychiatric Day Hospital remains an alternative to classic hospitalization, staying in an intermediate position between full-time hospitalization and outpatient treatment [9]. It is defined by the Portuguese Central Administration of Health Systems (ACSS) as: "an organizational structure of a health institution with its own physical space, where qualified technical and human resources are provided, with scheduled care, for a period normally not exceeding 12 hours, not requiring overnight stay" [9]. It functions at the lev- standards and, if this is not possible, to find the most appropriate activity in order to avoid relapses. It is equally important for the patient to learn how to express emotions through verbal language, and improve therapy adherence [10].
Concerning personality disorders, Day Hospitals helps these patients, which are difficult to treat in outpatient setting, associated with a high consumption of resources in the emergency department and in outpatient clinics. Usually they are people with a low level of success in their attempts for family/social integration, particularly those with: traits of narcissistic, histrionic, borderline personality, which predispose to repeated situations of family/social conflict; phobic/avoidant personality; severe obsessive-compulsive symptomatology. Day Hospitals can act mainly in patients recovering from a hypo/manic phase or from a depressive condition, providing support to family/professional reintegration. Day Hospitals allow the treatment of more complicated eating behaviour disorders cases with supervision of the diet, without the necessity of full-time hospitalization [10]. In

Methods
The main objective of this work was the study of the impact of the therapeutic

Results
It has been studied a sample integrating the totality of the patients (n = 127) attended in the Day Hospital during the 3 years. The safety of personnel and clinical data are guaranteed under the auspices of the Ethics Committee of the DPSM-CHUA, which previously authorized this statistical study. The patients were predominantly female (65%), aged between 40 -50 years old. Its distribution by municipalities is shown in Table 1.

Discussion
Patients treated at the Hospital Day live mainly in the nearest towns of this unit, with residual presence in the more peripheral cities like Vila Real de Santo    [15]. Psychiatric Day hospitals can be a valid alternative to classic hospitalization and home care, with advantages, not only economic but also, related to the improving user's quality of life. In this study should be considered some limitations, since it analyses data only from 3 years of operation of the Day Hos-Open Journal of Psychiatry pital of DPSM-CHUA-Faro-Portugal. Throughout its implementation, it was not possible to increase this range since the data prior to 2015 are not computerized and the information is widely dispersed, carrying on several gaps. In the future, with complete databases, this issue can be corrected and the inclusion of other variables, such as the degree of satisfaction with the treatment, the quality of life and the degree of psychopathology, will allow broader and more robust evaluation. This study is not representative of the general population.

Concluding Remarks
The main objective of this research study was to investigate the impact on clini-