Let’s talk about outpatient treatment for adolescents as a standard for follow-up care after discharge from psychiatric hospitalization.

Why Do Teens Need to “Step Down” Through Levels of Care?

We’ll preface this article by saying that outpatient treatment is one of the core foundational elements of psychiatric treatment worldwide. In most cases, it’s both the entry point to and exit from treatment for mental health, behavioral, or alcohol/substance use disorders. Although, in truth, that’s a somewhat misleading way to think about treatment. As humans, we like narratives, and we’re comfortable when a story – in this case the story of a teenagers’ treatment journey – has a clearly identifiable beginning, middle, and end.

However, the course of treatment for and the experience of a mental health or addiction disorder is rarely linear. And while a teen with a mental health or addiction disorder may stop attending formal therapy, most people who’ve been through treatment understand this one important fact:

Recovery is a lifelong journey.

The goal is total independence, of course. Outpatient treatment is an important part of reaching that goal. When we say it’s often both the entry and exit point to/from treatment, what we mean is that a teen may experience mental health issues, consult an outpatient therapist, uncover significant issues, participate in more immersive levels of care, learn how to manage symptoms, then go back to outpatient treatment when they’re ready.

That process is called stepping up and stepping down through the various levels of care, which include:

• Outpatient Treatment
• Intensive Outpatient Treatment (IOP)
• Partial Hospitalization Treatment (PHP)
• Residential Treatment (RTC)
• Psychiatric Hospitalization

We list those in order of treatment immersion and intensity. Outpatient programs are the least immersive and intensive, while psychiatric hospitalization is the most immersive and intensive. That may imply that during psychiatric hospitalization, adolescents – or anyone, for that matter – receive the most therapy, support, and psychiatric treatment.

However, that’s not the case. During psychiatric hospitalization, it’s the monitoring and supervision that’s the most intense – not the psychiatric treatment.

Why?

The Role of Psychiatric Hospitalization for Adolescents

Here’s the answer:

Psychiatric hospitalization is for teens in crisis who are at imminent risk of harming themselves or others. The twin goals of psychiatric hospitalization are safety and stabilization. When the medical team in a psychiatric hospital determines a teen is safe – meaning they’re not going to harm themselves or someone else – and stable– meaning they can carry out basic life functions such as eating, attending to personal hygiene, and things like dressing – they will discharge them from psychiatric hospitalization.

In most cases, upon discharge, teens receive a referral to a less immersive level of care, such as a residential program (RTC), a partial hospitalization program (PHP), an intensive outpatient program (IOP), or outpatient treatment.

The idea is that once a teen is safe and stable, that’s when the bulk of the therapeutic work begins. During a crisis, most teens are unable to do the work required for treatment and recovery. Emotions are too high, behavior can be erratic, and they’re unable to get a handle on either. That’s why it’s called a crisis. That’s why they enter a psychiatric hospital. They’re there for a short period of time – three days on the short side, ten days on the long side – then, when they’re ready, they step down.

But not all teens step down through the levels of care. In fact, they might not participate in any follow-up treatment at all: not outpatient treatment, intensive outpatient, virtual outpatient, or any psychiatric treatment for teens whatsoever.

This article will discuss information from several peer-reviewed journal articles. These papers examine:

• Rate of follow-up care teens receive upon discharge from psychiatric hospitalization
• Specific types of outpatient treatment teens receive
• Common disorders treated during follow-up
• The consequences of not following up psychiatric hospitalization with outpatient treatment

Let’s take a look at these studies.

How Many Teens Step Down to Outpatient Treatment?

For the data on follow-up rates, types of follow-up, and the disorders most commonly treated during follow-up, we’ll use data from three studies:

• “Access to Outpatient Pediatric Mental Health Care After Emergency Department Discharge,” published in 2021 in the journal Pediatric Emergency Care
• “Post-Discharge Services and Psychiatric Rehospitalization Among Children and Youth,” published in 2011 in the journal Administration and Policy in Mental Health and Mental Health Services Research
• “Association of Timely Outpatient Mental Health Services for Youths After Psychiatric Hospitalization With Risk of Death by Suicide,” published in 2020 in the Journal of the American Medical Association: Pediatrics (JAMA Pediatrics)

For those interested in taking a deep dive into the research, we recommend reading these articles and following the sources they cite. There’s plenty of information there, available to all. For the rest, we’ll discuss the data on rates of follow up care now.

Here’s what researchers in the first study found. Out of 228 adolescents discharged from inpatient psychiatric hospitalization:

• 61% followed up with outpatient care with a psychiatrist or therapist
• 19% followed up with a primary care provider (not a mental health specialist)
• 73% arranged follow-up care within a month
• 58% received follow-up outpatient care more than once a month
• 9% never obtained any follow-up care at all

Those rates of follow-up could be better.

But they’re not bad overall. We do, however, worry about that 9 percent: we’ll address consequences later.

Now let’s look at the second study. Out of 186 adolescents discharged from inpatient psychiatric hospitalization, here’s what researchers found:

• 72% received outpatient care during a 30-month follow-up period. Of those:
  • 66% received specialized outpatient mental health care
  • 34% received support from someone other than a mental health specialist

Those rates of follow-up could also be better.

We’re legitimately concerned about the 34 percent who did not receive follow-up outpatient care from a mental health specialist.

Now let’s look at the third study. Out of 139,694 adolescents discharged from inpatient psychiatric hospitalization, here’s what researchers found:

• 57% received specialized outpatient care within a week of discharge
• Teens more likely to receive outpatient care within a week of discharge included:
  • Those with longer inpatient stays
  • Those who previously received outpatient care
  • Teens in foster care

The teens less likely to receive outpatient care within a week of discharge included:

• • Teens with managed care insurance
  • Non-Hispanic Black teens
  • Teens who were medically ill (unspecified illnesses)

This is the study that raises red flags for us. When a teen exits inpatient hospitalization, they most often need support right away. A week – in our book – is too long to wait, because the consequences of gaps in care or an interruption of care are severe. We’ll talk about that below.

Next, we’ll look at what types of care teens received and the most common disorders treated upon discharge.

What Kind of Outpatient Treatment Did Teens Receive, and for Which Diagnoses?

The first study did not collect data on the types of treatment teens received, the disorders treated, or the outcomes for the patients in the study. The second study did not collect data on the types of mental health disorders treated up discharge, while the third collected data on the disorders treated and some data on the types of treatment. Therefore, the data for this section comes from a mix of available data from the second and third studies.

Here’s what researchers in the second study found:

• 17% of youth received both intensive and non-intensive mental health services
• 11% received only intensive mental health services, including:
  • Partial hospitalization (PHP)
  • Intensive outpatient (IOP)
  • Residential treatment (RTC)
• 36% received non-intensive outpatient mental health services, including:
  • Typical office-based outpatient therapy
  • School counseling
  • Wraparound services
  • Behavior modification
• 8% received support from someone other than a mental health specialist
• 28% received no support at all

That data reveals far too many gaps in treatment. Gaps in treatment can mean an interruption in treatment momentum and progress, which can, in turn, have an impact on overall treatment success: that’s why follow-up outpatient care is critical for teens stepping down from psychiatric hospitalization.

Now let’s look at the second study, which contained data on the mental health disorders treated at follow up, and the types of follow-up visits that occurred.

Disorders Treated

• Depression: 36%
• Bipolar disorder/mood disorder: 33%
• Conduct or oppositional defiance: 6.3%
• Schizophrenia: 5.8%
• Substance use: 3.9%
• ADHD: 3.6%
• Anxiety: 3.5%
• Self-harm: 1%
• Other mental health disorder: 6.9%

Types of Follow-Up Visits

• Psychotherapy: 29%
• Assessment: 19%
• Case management: 17%
• Partial hospitalization: 13%
• Other: 22%

We are now, officially, a broken record on this topic: these numbers can and should be much better. By better we mean a higher percentage of teens should receive some type of care upon discharge from inpatient psychiatric hospitalization.

Why?

Because the consequences of allowing gaps in treatment are significant. Let’s take a look at those consequences now.

What Happens When Teens Do Not Step Down to Outpatient Treatment after Psychiatric Hospitalization?

Reminder: the data on these metrics comes from the second and third study we introduce in the beginning of this article. We’ll start with the second study. The main outcome measure they applied was rehospitalization.

Here’s what they found:

• 43% experienced rehospitalization within 30 months of discharge
• 32% experienced rehospitalization within 12 months of discharge
• 8% experienced rehospitalization between 12-24 months after discharge
• 3% experienced a rehospitalization between 24-30 months after discharge

In addition:

• Risk of rehospitalization decreased by 75% for teens who received:
  • Combined intensive/non-intensive mental health treatment
  • Non-intensive outpatient mental health treatment
  • Unspecified outpatient treatment
• Risk of rehospitalization decreased – but not as much – for teens who received:
  • PHP treatment only
  • IOP treatment only

We’ll discuss those results in a moment. We’ll now jump straight to the results for the third study. The primary outcome measure for the teens in this study was suicide risk. Here’s how the researchers phrase this:

Is receipt of mental health follow-up visits within 7 days of hospital discharge associated with risk of suicide among child and adolescent inpatients?

And here’s what they found:

• 57% of teens participated in some form of outpatient mental health treatment within a week of discharge from psychiatric hospitalization
• Outpatient treatment was associated with a decreased relative risk ratio of 0.44 for suicide, which means that teens who did not receive outpatient treatment were 56% more likely to attempt suicide within 6 months of discharge than teens who did receive outpatient treatment.

Now we have enough information to address the topic in the title of this article, “The Importance of Outpatient Treatment After Discharge from Psychiatric Treatment” and answer the question in the first heading, “Why Do Teens Need to ‘Step Down’ Through Levels of Care?”

Continuity of Care Improves Outcomes

That’s the big-picture answer.

An uninterrupted course of treatment for a mental health disorder yields better results than a course of treatment with gaps, inconsistencies, or an absence of follow-up care after inpatient treatment. The first study showed significant deficits in the rate of outpatient follow-up after psychiatric hospitalization. The second study showed failure to participate in follow-up outpatient care was associated with increased risk of rehospitalization. In the third study, failure to participate in follow-up outpatient care was associated with increased risk of a suicide attempt.

We can say with confidence parents of teens hospitalized for mental health crisis want to avoid both those outcomes.

In order to help parents avoid those outcomes, we collated two short lists from a publication called “Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care.” Although it was written for providers and focuses on suicide risk, the steps they recommend apply to any teen stepping down from inpatient hospitalization to a lower level of care.

Here they are.

Parent Tasks: Before Discharge

1. Begin planning for outpatient care immediately, meaning upon admission
2. Engage with the inpatient provider in the post-discharge planning process
3. Engage with school counselors and relevant staff about your plans
4. Create a safety plan, if applicable
5. Connect directly with the outpatient provider and provide all relevant information and records from the inpatient facility

Parent Tasks: After Discharge

1. Engage in outpatient, intensive outpatient, partial hospitalization, or virtual outpatient treatment and support as soon as possible
2. Ensure the outpatient provider has all relevant treatment records from the inpatient treatment facility
3. Participate in outpatient treatment as much as possible.
4. Check in with their teen, their outpatient provider, and the inpatient treatment team to ensure treatment progress matches treatment goals
5. If treatment progress does not match goals, meet with their teen and their outpatient provider to adjust the treatment plan – which may include stepping up to a more intensive level of care.

That last task brings us back to data we said we’d discuss in a moment. In the outcomes from the third study, data showed that teens who participated in IOP or PHP programs only – after discharge – had a slightly higher rate of rehospitalization compared to teens who participated in integrated treatment at less immersive levels. The researchers have an explanation which makes sense to us: those teens were discharged to relatively intensive levels of care – and were probably not ready for them.

That is a logical explanation for why they were re-hospitalized.

That also brings us back to an idea we introduce in the beginning of this article. Treatment for a mental health, behavioral, or addiction disorder does not always follow a linear path, with an easily recognizable, beginning, middle, and end. The narrative is not always tidy. There are starts and stops, successes and setbacks, good days and challenging days.

The importance of treatment – especially outpatient treatment after psychiatric hospitalization – is that teens and families who participate in treatment play a greater role in writing the narrative themselves than teens and families who do not participate in treatment. It takes time, energy, and commitment, but evidence shows that treatment works.

Finding Help: Resources for Outpatient Treatment for Adolescents

If you’re seeking outpatient treatment for adolescents, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.