A comparison of clinical outcomes, service
satisfaction and well-being in people using acute
day units and crisis resolution teams: cohort study
in England
Danielle Lamb, Thomas Steare, Louise Marston, Alastair Canaw ay, Sonia Johnson, James B. Kirkbride,
Brynmor Lloyd-Evans, Nicola Morant, Vanessa Pinfold, Deb Smith, Scott Weich and David P. Osborn
Background
For people in mental health crisis, acute day units (ADUs) provide
daily structured sessions and peer support in non-residential
settings, often as an addition or alternative to crisis resolution
teams (CRTs). There is little recent evidence about outcomes for
those using ADUs, particularly compared with those receiving
CRT care alone.
Aims
We aimed to investigate readmission rates, satisfaction and well-
being outcomes for people using ADUs and CRTs.
Method
We conducted a cohort study comparing readmission to acute
mental healthcare during a 6-month period for ADU and CRT
participants. Secondary outcomes included satisfaction (Client
Satisfaction Questionnaire), well-being (Short Warwick–
Edinburgh Mental Well-being Scale) and depression (Center for
Epidemiologic Studies Depression Scale).
Results
We recruited 744 participants (ADU: n = 431, 58%; CRT: n = 312,
42%) across four National Health Service trusts/health regions.
There was no statistically significant overall difference in read-
missions: 21% of ADU participants and 23% of CRT participants
were readmitted over 6 months (adjusted hazard ratio 0.78, 95%
CI 0.54–1.14). However, readmission results varied substantially
by setting. At follow-up, ADU participants had significantly higher
Client Satisfaction Questionnaire scores (2.5, 95% CI 1.4–3.5, P <
0.001) and well-being scores (1.3, 95% CI 0.4–2.1, P = 0.004), and
lower depression scores (−1.7, 95% CI −2.7 to −0.8, P < 0.001),
than CRT participants.
Conclusions
Patients who accessed ADUs demonstrated better outcomes for
satisfaction, well-being and depression, and no significant dif-
ferences in risk of readmission, compared with those who only
used CRTs. Given the positive outcomes for patients, and the fact
that ADUs are inconsistently provided in the National Health
Service, their value and place in the acute care pathway needs
further consideration and research.
Keywords
Community mental health teams; epidemiology; out-patient
treatment; psychiatric nursing.
Copyright and usage
© The Author(s), 2021. Published by Cambridge University Press
on behalf of the Royal College of Psychiatrists. This is an Open
Access article, distributed under the terms of the Creative
Commons Attribution-NonCommercial-NoDerivatives licence
(http://creativecommons.org/licenses/by-nc-nd/4.0/), which
permits non-commercial re-use, distribution, and reproduction
in any medium, provided the original work is unaltered and is
properly cited. The written permission of Cambridge University
Press must be obtained for commercial re-use or in order to
create a derivative work.
Within the National Health Service (NHS), support for people in
mental health crisis is typically provided by multidisciplinary
crisis resolution teams (CRTs), which aim to avoid in-patient
admission by providing care at home via frequent visits. However,
there is evidence that implementation of national guidelines for
CRTs is highly variable, meaning that some people may not
receive the intensity of support they need,
1
with lack of therapeutic
content and social contact frequently raised as issues.
2
In addition,
CRT care is often dependent on support from carers, which is prob-
lematic where there are no carers, and can lead to excessive burden
even where there are carers.
3
Acute day units
Acute day units (ADUs), previously known as ‘day hospitals’,
4
provide an additional clinical resource for those in mental
health crisis. In England, there is no NHS-specified model, but
ADUs typically offer on-site individual and group sessions
during the day, with patients returning home overnight and at
weekends. ADU care is provided by a multidisciplinary team,
usually including nurses, therapists, psychiatrists and other
mental health professionals.
5
As a result, patients are provided
with structured days, more staff contact time and continuity
than is available via CRTs, with opportunities for peer support
from other clients, and a wider range of psychological, social
and medical interventions. ADUs are often used concurrently
with other services (e.g. CRTs, in-patient wards, crisis houses),
with these services all referring to each other. Evidence of the
effectiveness of ADUs is limited, with the most recent meta-ana-
lysis conducted in 2011.
4
This review synthesised evidence from
studies that compared ADUs with hospital admission and con-
cluded that they provide a viable alternative to hospital admission
for some, with similar effectiveness on readmission rates after
discharge, employment, quality of life and treatment satisfaction,
but quality of evidence overall was reported as low.
4
Furthermore, to date there has been no comparison of outcomes
and experiences of people using ADUs compared with those
using CRTs, arguably a more directly comparable type of service.
The current study
We need evidence regarding any additional benefit ADUs may offer
to patients, not only in terms of clinical outcomes, but also on
patient-reported outcomes such as patient experience, well-being
BJPsych Open (2021)
7, e68, 1–8. doi: 10.1192/bjo.2021.30
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and quality of life. The aims of this study were to describe and
compare the clinical and sociodemographic characteristics of
people using ADUs and CRTs; and to compare outcomes in
terms of readmission, well-being, depression and patient satisfac-
tion for those who received ADU care with those who received
only CRT care.
We hypothesised that people receiving ADU care would have
fewer admissions, greater satisfaction and well-being, and less
depression at 6 months, compared with those receiving CRT care
alone.
Method
The authors assert that all procedures contributing to this work
comply with the ethical standards of the relevant national and insti-
tutional committees on human experimentation and with the
Helsinki Declaration of 1975, as revised in 2008. All procedures
were approved by the London Bloomsbury Research Ethics
Committee (reference number 16/LO/2160).
Design and setting
We established a quasi-experimental cohort study of people using
ADU and CRT services and compared readmission to the acute
care pathway during a 6-month period from baseline, as well as
measures of depression, well-being and satisfaction with services.
We recruited four NHS trusts with ADUs and CRTs in England.
A brief characterisation of each NHS trust and ADU is available
in Table 1. More detailed information about each of the NHS
trusts is available in a set of case studies.
6
Participant recruitment
took place between March 2017 and April 2019, with follow-up
completed in September 2019.
We invited people consecutively admitted to each service to par-
ticipate in baseline interviews. Recruitment and data collection
could occur at any point during the initial admission, and up to
14 days after discharge from the service. Telephone or online
follow-up was carried out 8–12 weeks after baseline, with electronic
health record (EHR) outcome data collected at 6 months after
baseline.
Participants
Inclusion and exclusion criteria
Inclusion criteria were as follows: aged ≥18 years, used an ADU/
CRT service for at least 1 week, read and understand English (or
translator available), capacity to provide informed consent and
did not pose too high a risk to others or themselves to participate
(as judged by their current clinical team).
ADU participants could use CRTs concurrently or during the
follow-up period; however, CRT participants were excluded if
they used an ADU at any point during study period. This was to
determine the benefits of ADUs as an addition to the acute care
pathway, over and above CRTs.
Measures
Exposure
Our main exposure was being under the care of an ADU (solely or in
combination with CRT use) for at least 1 week before baseline, com-
pared with CRT care only.
Outcomes
Our primary outcome was time to readmission for acute treatment,
after discharge from CRT or ADU, during the 6-month study period
(starting from the date of recruitment to the study). This was col-
lected via service use data from EHRs. We defined readmission
for acute treatment as any subsequent use of acute mental health
services (CRT, crisis house, ADU or in-patient ward) after discharge
from the service used at baseline during the subsequent 6-month
study period.
Our secondary outcomes were self-reported satisfaction with
mental health services (Client Satisfaction Questionnaire; CSQ),
7
well-being (Short Warwick–Edinburgh Mental Well-being Scale;
SWEMWBS)
8
and depression (Center for Epidemiologic Studies
Depression Scale; CES-D),
9
collected via online questionnaire at
baseline and 8–12 weeks later.
Covariates
We collected demographic data and self-rated physical health via
the baseline questionnaire. We collected data from EHRs on admis-
sions and service use; clinical characteristics (ICD-10 diagnosis and
any comorbid diagnoses, physical health diagnoses, substance
misuse, smoking, medication, previous hospital admission);
Health of the Nation Outcome Scales (HoNOS) scores
10
and
content of care (physical assessment carried out, carers involved
in care, psychological input from service used at baseline). Where
patients had multiple diagnoses recorded in their EHR, we recorded
the diagnosis considered to be more severe. We recorded whether
the person had a serious mental illness (SMI), typically defined as
Table 1 NHS trust and team characteristics
NHS
trust Trust characteristics Team Team characteristics
Trust 1 Serving a large and relatively affluent city
in the south of England
ADU A new service at the time of study recruitment, closely linked with the local CRT and located
nearby. Provides primarily psychoeducational and psychological group sessions
CRT 24/7 service offe ring assessment and home treatment, open referral process (e.g. patients can
self-refer)
Trust 2 Serving an inner-city area of a major
metropolitan centre
ADU The service has operated for around 15 years, and is closely linked with the local CRT and
located on the same site. A diverse and strongly arts-based programme of sessions, e.g. art,
dance and drama therapy
CRT 24/7 service, offering assessment and home treatment, open referral process
Trust 3 Serving a medium-sized city in the
Midlands
ADU Operating for around 7 years, with close links to the local CRT and located on the same site.
Provides mostly activity-based sessions, e.g. arts activities, gardening etc.
CRT 24/7 service, offering assessment and home treatment. Referrals are made by health
professionals
Trust 4 Serving a commuter town and rural area
near a large city
ADU The service has operated for around 6 years, with links to the local CRT, but not based nearby.
Provides mostly psychoeducational and psychological sessions
CRT 24/7 service, offering assessment and home treatment, open referral process
NHS, National Health Service; ADU, acute day unit; CRT, crisis resolution team.
Lamb et al
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being diagnosed with schizophrenia, other non-organic psychoses
or bipolar disorder.
11
Procedure
At baseline, ADU/CRT staff screened all people consecutively
admitted to their service from the study start date. All those who
met the inclusion criteria were approached by clinical or research
staff and asked if they were willing to discuss participation further
(except at NHS trusts where individuals had already given
consent to be contacted directly about research projects: in this
instance, researchers contacted people directly, once their eligibility
and any risk-related safety requirements had been established from
clinicians and patient records). Those who agreed to discuss the
study were contacted by a researcher with an information sheet
and an offer to answer any questions. Potential participants were
given at least 24 hours to consider whether they would like to
take part, and then if still interested, they provided written
consent to a researcher, who also collected the baseline data.
Consent and data collection could occur up to 14 days after dis-
charge from initial service use.
Participants were offered £20 (vouchers) reimbursement for
taking part (£10 for the baseline interview and £10 for the follow-
up interview at 8–12 weeks after baseline). Participants were con-
tacted by telephone by a researcher 8–12 weeks after baseline, to
collect follow-up data. At 6 months after baseline, readmission
data were collected from EHRs.
Sample size
A priori, we estimated that a sample size of 400 patients per group
(N = 800) would give 90% power to detect a difference of 12% in the
proportions readmitted in each arm (with an assumption of 50%
readmission in the CRT group), with alpha set to 0.05. It would
also afford 90% power to detect an effect size difference of 0.3 on
the CSQ. This calculation included inflation for clustering by
NHS trust.
Analysis
We calculated descriptive statistics comparing the baseline charac-
teristics of people using ADUs versus those using CRTs for the
sample as a whole, and within NHS trusts. We explored baseline dif-
ferences in demographics, clinical data and content of care, using
parametric and non-parametric tests as appropriate, as well as the
proportion of people using ADUs versus CRTs who were admitted
during the 6-month study period.
For our primary outcome, we compared time to readmission in
ADU and CRT participants. We analysed this using Cox’s regres-
sion to produce a hazard ratio. Cohort entry was the date of recruit-
ment and cohort exit date was the date of readmission to acute care
or the 6-month study end-point. We adjusted for variables chosen a
priori, which previous research suggested may be relevant (trust,
age, gender, SMI diagnosis, employment, baseline HoNOS score,
baseline SWEMWBS score and whether the person had previously
been an in-patient). Covariates were added using a stepwise proced-
ure, starting with a bivariate model with NHS trust as a fixed effect,
then adding the variables of age, gender and employment, followed
by diagnosis, HoNOS score, SWEMWBS score and finally, whether
the person had previously been an in-patient. Because of expected
heterogeneity between different NHS trusts, we tested for an inter-
action between type of team (ADU/CRT) and NHS trust as a sensi-
tivity analysis.
For the secondary outcomes, we analysed mean satisfaction,
well-being and depression scores at weeks 8–12, using linear regres-
sion. Stata version 16 for Windows was used for all analyses.
12
Results
Figure 1 be low shows the flow of participants into the study, a nd
thosefollowedupat8–12 we eks. Only one p articipant declined
consent for access to their EHR at the 6-month follow-up,
giving a completion rate of >99% for the primary outcome of
readmission.
Baseline sociodemographic and clinical characteristics
We recruited 743 participants, of whom 431 (57.9%) had received
ADU care and 312 (42.1%) had only received CRT care. Because
of the small number of Black and minority ethnic participants, we
have used undesirably broad ethnic categories. The ADU and
CRT groups were generally similar in terms of sociodemographic
characteristics (full details available in Table 2). Those sociodemo-
graphic characteristics with statistically significant differences
between the groups are outlined below.
ADU participants were older than CRT participants, and
less likely to be employed. Clinically, higher proportions of
ADU participants were diagnosed with psychosis and personality
disorders, and a higher proportion of CRT participants were diag-
nosed with anxiety disorders. A higher proportion of ADU parti-
cipants had previously been admitted to a p sychiatric in-patient
ward.
In terms of content of care when using the ADU or CRT, a much
larger proportion of ADU participants received a physical health
assessment, had carers involved in their care and received psycho-
logical input, compared with CRT participants.
At baseline, CES-D scores were lower in ADU participants than
in CRT participants, whereas SWEMWBS well-being scores were
higher in ADU participants than CRT participants. The mean base-
line total HoNOS score was higher for ADU participants than for
CRT participants, indicating more severe difficulties for ADU
participants.
There were slight differences in the length of index admission
and time at which participants were recruited. ADU participants
had a mean index admission lasting for 60 days (s.d. 38) before
they were discharged, whereas CRT participants had a mean
index admission of 43 days (s.d. 39) before discharge. The
mean difference in length of index admission between ADU
and CRT participants was −17 days, which was statistically sig-
nificant (P < 0.0001, 95% CI − 22.0 to −11.1). ADU participants
were recruited at a mean of 24 days (s.d. 23) into their index
admission (i.e. 24 days after being admitted to the service they
were recruited from), and CRT participants were recruited a
mean of 31 days (s.d. 24) into their index admission. The
mean difference between ADU and CRT participants in time
from index admission to recruited was 7 days, which was statis-
tically significant (P = 0.0001, 95% CI 3.2–9.8).
Follow-up data were collected for >99% of participants for the
primary outcome, and 76% of participants for the secondary out-
comes. The only significant difference between those who did and
did not complete the secondary outcome questionnaires was that
completers were older (mean age 41.6, s.d. 13.7) than those lost to
follow-up (median age 37.8, s.d. 13.0) (P = 0.001, 95% CI −6.2 to
−1.5).
Primary outcome: readmission to acute care over
6-month follow-up period
For the primary outcome at the 6-month time point, 21.4% of ADU
participants were readmitted, compared with 23.4% of CRT partici-
pants, with no statistically significant difference evident. The results
from the Cox regression comparing time to admission in ADU
Outcomes for acute mental healthcare services
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versus CRT participants are shown in Table 2. Model 1 shows a
bivariate analysis, including only team and NHS trust. Model 2
was adjusted for age, gender and employment, whereas model 3
included the remaining covariates (SMI diagnosis, whether partici-
pants had previously been an in-patient, baseline HoNOS score,
baseline SWEMWBS score).
We included a cross-trust interaction between team (ADU or
CRT) and NHS trust in model 4, which showed there were
significant differences across NHS trusts in terms of the primary
outcome of readmission (likelihood ratio test P < 0.001). Model 4
showed that within trust 1, the risk of readmission was statistically
significantly lower for ADU participants than CRT participants. In
trusts 2 and 4, there was no statistically significantly difference in
risk of readmission. In trust 3, the risk of admission was statistically
significantly higher for ADU participants than CRT participants.
Full results are given in Table 3.
Total patients
screened = 5176
ADU patients excluded
= 217/1153 (18.8%)
CRT patients excluded
= 2123/4023 (52.8%)
Total patients
excluded = 2340/5176
(45.2%)
Excluded
ADU CRT
Attended <1 week
74 (34.1%) 960 (45.2%)
Cannot understand English
10 (4.6%) 49 (2.3%)
Too high risk
82 (37.8%) 704 (33.2%)
Lacks capacity
9 (4.1%) 29 (1.4%)
Under 18 years of age
0 24 (1.1%)
Previously screened
0 1 (<0.1%)
Previously declined
2 (0.9%) 14 (0.7%)
CRT who attended ADU post-
baseline
0 168 (7.9%)
Cannot identify from allocation
lists
0 2 (0.1%)
Taken part previously
23 (10.6%) 28 (1.3%)
Never attended/did not
engage
17 (7.8%) 14 (0.7%)
In-patient
0 56 (2.6%)
Other
0 74 (3.5%)
Total
217 2123
Eligible but not recruited ADU CRT
Declined 168 (33.2%) 317 (20.0%)
Discharged before contact 337 (66.7%) 1267 (80.0%)
Completed baseline too late 0 4 (<0.1%)
Total 505 1587
Total eligible ADU patients recruited = 431/936 (46.0%)
Total eligible CRT patients recruited = 312/1900 (16.4%)
Total eligible patients recruited = 743/2836 (26.2%)
Total ADU case-load during recruitment period = 1153 (22.3%)
Total CRT case-load during recruitment period = 4023 (77.7%)
ADU participants followed up at 8–12 weeks = 325/431 (75.4%)
CRT participants followed up at 8–12 weeks = 241/312 (77.2%)
Total participants followed up at 8–12 weeks = 566/743 (76.1%)
ADU patients eligible
but not recruited
= 505/936 (54.0%)
CRT patients eligible
but not recruited
= 1587/1900 (83.5%)
Total patients
eligible but not recruited
= 2092/2836 (73.8%)
Fig. 1 Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) diagram of the flow of participants into the study. ADU,
acute day unit; CRT, crisis resolution team.
Lamb et al
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Secondary outcomes: satisfaction, well-being and
depression at 8–12 weeks
We found statistically significantly higher patient satisfaction (CSQ)
scores and well-being scores (SWEMWBS), and lower levels of
depression (CES-D) in ADU participants than CRT participants
at the 8–12 week follow-up period. The full results the linear regres-
sions examining these differences in fully adjusted models are
shown in Table 4.
Discussion
Summary of results
In a fully adjusted model, there was no significant difference
between ADU and CRT participants in terms of readmission over
6 months. However, once an interaction effect was included in the
analysis, significant differences between ADU and CRT participants
became apparent, with ADU participants in different NHS Trusts
being variously at increased, decreased or no different risk of
readmission, compared with CRT participants. At 8–12 weeks,
after accounting for baseline differences in participant characteris-
tics, ADU participants had significantly higher satisfaction scores,
with better well-being and lower depression scores than CRT parti-
cipants. These results indicate that, despite serving a more unwell
client group (as suggested by the lower proportion of ADU partici-
pants in employment, and higher proportions with SMI diagnoses
and previous hospital admission), overall, ADUs produce compar-
able outcomes in terms of readmission, and better satisfaction,
depression outcomes and well-being than CRTs.
Comparison with previous research
In terms of the primary outcome, readmission to acute services, we
are not aware of previous research directly comparing ADU and
CRT services. The most recent meta-analysis of research on
Table 2 Sociodemographic characteristics, clinical characteristics and baseline measures
ADU CRT Significance
Sociodemographic characteristics
Age, years, mean (s.d.) 41.8 (14.0) 39.2 (13.0) Mean difference − 2.6, 95% CI −4.6 to −0.5, P = 0.0 1
Gender
Male 220 (51.0) 140 (44.9) P = 0.1
Female 211 (49.0) 172 (55.1)
Ethnicity
White (UK and non-UK) 362 (84.6) 251 (82.3) P = 0.2
Black (UK, African, Caribbean, other) 23 (5.4) 17 (5.6)
Asian (UK, South Asian, Chinese, other) 28 (6.5) 17 (5.6)
Mixed 15 (3.5) 20 (6.6)
Employed (yes) 126 (29.2) 133 (42.6) P < 0.001
Marital status
Single 268 (62.2) 189 (60.6) P = 0.4
Cohabiting 41 (9.5) 37 (11.9)
Married 88 (20.4) 69 (22.1)
Divorced 31 (7.2) 15 (4.8)
Widowed 3 (0.7) 2 (0.6)
Clinical characteristics
ICD-10 primary diagnosis
Psychosis 80 (19.1) 40 (14.0) P =0.01
Mood disorders 210 (50.0) 143 (50.2)
Anxiety 55 (13.1) 55 (19.3)
Personality disorders 63 (15.0) 30 (10.5)
Other 12 (2.9) 17 (6.0)
SMI (yes) 139 (33.1) 80 (28.1) P = 0.2
Physical health
Excellent 21 (4.9) 17 (5.5) P = 0.2
Very good 84 (19.5) 49 (15.7)
Good 147 (34.1) 101 (32.4)
Fair 124 (28.8) 85 (27.2)
Poor 55 (12.8) 60 (19.2)
Comorbidity
Mental health 100 (23.6) 74 (23.9) P = 0.1
Physical health 101 (23.8) 57 (18.4)
Both 58 (13.7) 38 (12.3)
Substance misuse (yes) 103 (24.3) 85 (27.6) P = 0.5
Smoker (yes) 172 (41.1) 114 (38.4) P = 0.4
Previous hospital admission (yes) 248 (57.5) 116 (37.2) P < 0.001
No. of previous admissions, mean (s.d.) 1.44 (2.5) 1.09 (3.0) Mean difference − 0.3, 95% CI −0.8 to 0.1
Content of care
Physical assessment 340 (80.4) 106 (34.2) P < 0.001
Carers involved 183 (43.1) 102 (32.9) P =0.01
Psychological input 248 (58.8) 174 (41.2) P < 0.001
Baseline measures
CES-D, mean (s.d.) 16.4 (5.3) 17.5 (5.4) Mean difference 1.1, 95% CI 0.4–2.0, P = 0.009
SWEMWBS, mean (s.d.) 20.5 (5.0) 19.3 (5.0) Mean difference − 1.2, 95% CI −2.1 to −0.4, P = 0.0 04
HoNOS, mean (s.d.) 14.1 (6.1) 12.43 (6.2) Mean difference −1.7, 95% CI −2.6 to −0.7, P < 0.001
ADU and CRT data are n (%) unless otherwise specified. P-values relate to t-tests for continuous variables and χ
2
-tests for categorical variables.
ADU, acute day unit; CRT, crisis resolution team; SMI severe mental illness; CES-D, Center for Epidemiologic Studies Depression Scale; SWEMWBS, Short Warwick–Edinburgh Mental Well-
being Scale; HoNOS, Health of the Nation Outcome Scales.
Outcomes for acute mental healthcare services
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