Brief history, current status, and future place of assertive community treatment

Cycles of reform in the history of psychosis treatment in the United States

The history of psychosis treatment follows a series of four cycles of reform which provide a framework for understanding mental health services in the United States. The first three cycles of reform promoted the view that early treatment of mental disorders would reduce chronic impairment and disability. The Moral Treatment era (early 1800's to 1890) featured freestanding asylums, the Mental Hygiene movement (1890 to World War II) introduced psychiatric hospitals and clinics, and the Community Mental Health Reform period (World War II to late 1970's) produced community mental health centers. None of these approaches succeeded in achieving the disability-prevention goals of early treatment of psychosis. The fourth cycle, the Community Support Reform era (late 1970's to the present) shifted the focus to caring for those already disabled by a mental disorder within their communities and using natural support systems. This shift embraced a broader social welfare framework and included additional services and supports, such as housing, case management, and education. Psychosis became more central during the current Community Support Reform era partly because individuals with psychosis continued to have disabling life experiences despite efforts at reform. Some degree of recovery from psychosis is possible, and individuals with serious impairment may move towards social integration and community participation. Early intervention for young people with psychosis focuses on reducing the negative sequelae of psychosis and promotes recovery-oriented changes in service delivery. The role of social control, the involvement of service users and their families, and the balance between psychosocial and biomedical treatments play an important role in this history. This paper describes the reform cycles, their political and policy contexts, and what influenced its successes and shortcomings.

Use of generic social services and social integration of patients with a severe mental illness in Belgium: Individual and services network determinants

BACKGROUND

Patients with severe mental illnesses (SMI) have low levels of social integration, which could be improved if they used social services. To our knowledge, however, the extent to which they use generic social services remains unknown.

AIMS

We assessed the extent to which patients with SMI use generic social services and the factors that may drive that usage.

METHOD

In 2014, we carried out a multi-setting clustered survey of patients with severe mental disorders (n = 1,019, participation rate = 71%) and of services (n = 517, participation rate = 53%) in 19 networks of services, covering most of Belgium. On the one hand, we asked patients, amongst other, about their health condition, their social integration in the community, and their use of social services of different types. On the other hand, we asked each service to report on its relationships with other services in the services networks.

RESULTS

On average, patients' use of generic social services within the previous 6 months was low (6%-16%), with the exception of administrative services. There were few differences in usage according to the severity of patients' symptoms, but some differences according to gender and age were observed. Social integration was improved when generic social services were more central in the networks.

CONCLUSIONS

We suggest that generic social services should be more central in mental health services networks.

Exploring the ideal practice for occupational therapists on assertive community treatment teams

Introduction

Canadian occupational therapists are employed as case managers on assertive community treatment (ACT) teams to support community living for individuals with severe and persistent mental illnesses. In this position, occupational therapists act primarily as generalists, typically attending appointments with clients, supervising medication adherence, supporting basic living needs, and managing client crises. Occupational therapists may also provide psychotherapy and coping skill groups, as well as profession-specific practices, such as skills training. Exploring how ACT occupational therapists describe their perceived ideal practice may support transformation in long-standing, occupational therapy practices on ACT teams.

Method

This qualitative, interpretive description study involved 11 Canadian ACT team occupational therapists in one individual, semi-structured in-depth interview using an interview guide containing open-ended questions. Interview transcripts were analyzed to identify themes pertaining to therapists’ descriptions of their perceived ideal occupational therapy practice on ACT teams.

Results

Three themes emerged: (a) Engaging in practice “with intention”; (b) Finding the space for occupational therapy practice; and (c) Supporting clients in their recovery to find their best occupational self.

Conclusions

The findings highlight practice possibilities for occupational therapist working on ACT teams and provide a foundation for advocating for better use of specific occupational therapy practices within community mental health settings.

Innovation and Its Discontents: Pathways and Barriers in the Diffusion of Assertive Community Treatment

Policy Points Widespread diffusion of policy innovation is the exception rather than the rule, depending as it does on the convergence of a variety of intellectual, political, economic, and organizational forces. The history of Assertive Community Treatment (ACT) provides a compelling case study of this process while also showing how conditions may shift over time, altering the scenarios for continued program expansion. Diffusion of a program like ACT challenges government to play a nuanced role in which public endorsement and resources are used to strengthen a worthwhile service, but without suppressing flexibility and ongoing experimentation as core program values. Acceptance as a proven form of "evidence-based practice" is a critical element in the validation of ACT and other community mental health interventions that combine clinical and social features in novel ways. However, the use of conventional evidence-based research as a singular gold standard of program value narrows the range of stakeholder input, as well as the evaluation methodologies and forms of data deemed worthy of attention.

CONTEXT

Originating at the county level in Wisconsin in the early 1970s, Assertive Community Treatment is one of the most influential mental health programs ever developed. The subject of hundreds of research studies and recipient of enthusiastic backing from private advocacy organizations and government agencies, the program has spread widely across the United States and internationally as a package of resources and management techniques for supporting individuals with severe and chronic mental illness in the community. Today, however, ACT is associated with a rising tide of criticism challenging the program's practices and philosophy while alternative service models are advancing.

METHODS

To trace the history of the Assertive Community Treatment movement, a diffusion-of-innovation framework was applied based on relevant concepts from public policy analysis, organizational behavior, implementation science, and other fields. In-depth review of the literature on ACT design, management, and performance also provided insight into the program's creation and subsequent evolution across different settings.

FINDINGS

A number of factors have functioned to fuel and to constrain ACT diffusion. The former category includes policy learning through research; the role of policy entrepreneurs; ACT's acceptance as a normative standard; and a thriving international epistemic community. The latter category includes cost concerns, fidelity demands, shifting norms, research contradictions and gaps, and a multifactorial context affecting program adoption. Currently, the program stands at a crossroads, strained by the principle of adherence to a long-standing operational framework, on the one hand, and calls to adjust to an environment of changing demands and opportunities, on the other.

CONCLUSIONS

For nearly 50 years, Assertive Community Treatment has been a mainstay of community mental health programming in the United States and other parts of the world. This presence will continue, but not in any static sense. A growing number of hybrid and competing versions of the program are likely to develop to serve specialized clientele groups and to respond to consumer demands and the recovery paradigm in behavioral health care.

The Gloucester assertive community treatment team: A description and comparison with other services

Assertive Community Treatment (ACT) has developed globally as a model of community care for the severely mentally ill. However, in the United Kingdom there is mixed evidence regarding improvements in outcome and concerns about ACT teams having poor fidelity to the original ACT model.

Objective: This study presents the fidelity characteristics of an established ACT team serving Gloucester City. It describes service user demographic and illness data and compares these findings to other important studies in the United Kingdom.

Method: The Dartmouth Assertive Community Treatment Scale was applied to rate the Gloucester ACT team's fidelity characteristics. The Gloucester Caseload Project Demographic Pro-Forma was collected from all of the team's 79 service users.

Results: The population of severely mentally ill ACT service users in Gloucester City were an older and more “disabled” group compared to the classic ACT studies. Furthermore, although findings indicate a high level of fidelity to the original ACT model, the team it is still associated with high levels of inpatient treatment.

Conclusion: High fidelity ACT services appear to be associated with high admission rates. Therefore teams should not be viewed as alternatives to hospital admission but have goals of improving engagement and social functioning. Furthermore, findings have allowed the team to benchmark its service and target areas for further service development. More consistent reporting of fidelity data on ACT research would facilitate comparison across different services.

Increasing quality of life and reducing HIV burden: the PATH+ intervention

The heightened risk of persons with serious mental illness (SMI) to contract and transmit human immunodeficiency virus (HIV) is a public health problem. Our objective was test the effectiveness of a community-based advanced practice nurse intervention to promote adherence to HIV and psychiatric treatment regimens call Preventing AIDS Through Health for Positives (PATH+). We enrolled 238 HIV-positive subjects with SMI who were in treatment at community HIV provider agencies from 2004 to 2009. Participants in the intervention group were assigned an advanced practice nurse who provided community-based care management at a minimum of one visit/week and coordinated their medical and mental healthcare for 12 months. A parallel process latent growth curve model using three data points for biomarkers (baseline, 12 and 24 months) and five data points for health related quality of life (baseline, 3, 6, 12, and 24 months) showed moderate to excellent fit for modeling changes in CD4, viral load, and mental and physical SF-12 subscales. Results suggest that positive effects for PATH+ persisted at 24 months; 12 months after the intervention ended. This project demonstrates the effectiveness of a nurse-led, community-based, individually tailored adherence intervention. We demonstrated improved outcomes in individuals with HIV/SMI and regarding health-related quality of life and reductions in disease burden.

Utilization of evidenced based dialectical behavioral therapy in assertive community treatment: examining feasibility and challenges

Assertive Community Treatment (ACT) programs have been treating individuals with chronic and severe mental illness since the 1970s. While ACT programs were developed to address the treatment needs of severely mentally ill persons traditionally suffering from chronic mental illnesses, ACT programs are seeing a growing number of persons with co-morbid personality disorders. The efficacy of traditional ACT programs in treating individuals with co-occurring personality disorders is uncertain, in particular individuals with co-morbid Borderline Personality Disorder (BPD). Dialectical Behavior Therapy (DBT) has been proposed as an effective approach to treating clients with BPD in this setting. The purpose of this paper is to examine the value of DBT for individuals with BPD in ACT programs. The writers discuss the prevalence of Borderline Personality Disorders in ACT populations, briefly review the literature on DBT in ACT, address the feasibility of implementing DBT in an ACT model, examine potential barriers to this implementation, and highlight potential areas for future research.

Preliminary outcome study on assertive community treatment in Japan

AIMS

The beneficial effects of assertive community treatment (ACT), which has been widely acclaimed as being successful in several foreign countries, must also be objectively evaluated with respect to the transition from inpatient to community-based mental health treatment in Japan. This was the first study that examined effects of the ACT program in Japan using pre/post design data of the pilot trial of the ACT program in Japan project.

METHODS

The study included 41 subjects hospitalized at Kohnodai Hospital, National Center of Neurology and Psychiatry between May 2003 and April 2004 for severe mental illness and who met inclusion criteria for entry regarding age, diagnosis, residence, utilization of mental health services, social adjustment, and ability to function in daily activities. All subjects provided informed consent for study participation and were followed for 1 year after hospital discharge.

RESULTS

Comparison of the number of days and frequency of inpatient psychiatric hospitalization and frequency of emergency psychiatric visits between the 1-year period before hospitalization and 1-year period after hospital discharge showed a significant decrease in number of days and frequency of hospitalization. Comparison at 1 year after discharge with baseline showed no change in satisfaction with overall quality of life or Brief Psychiatric Rating Scale scores, but the Global Assessment of Functioning score significantly increased, and the antipsychotic dose (chlorpromazine equivalent) significantly decreased.

CONCLUSION

Despite some limitations in methodology and conclusions, this study suggests that ACT enables persons with severe mental illness to live for longer periods in the community, without worsening of symptoms, decreased social function, or deterioration in quality of life.

The efficacy of assertive community treatment to treat substance use

BACKGROUND

Assertive Community Treatment (ACT) has been studied extensively in people with severe mental illness, but there have only been a few clinical trials in which substance use was one of the measured outcomes.

OBJECTIVE

The goal of this article was to describe the efficacy of ACT in treating co-occurring substance use disorders and suggest approaches to make it more efficacious.

DESIGN

A literature review was conducted and randomized clinical trials describing ACT's impact on substance use were reviewed.

RESULTS

Four randomized clinical trials of ACT that measured substance abuse adequately were identified, all of which showed small to no effect on substance abuse compared with control conditions. Methodological issues might account for the small effects. ACT might further reduce substance use by being paired with evidenced-based substance abuse treatment, helping clients become housed or helping them manage their money better.

CONCLUSION

Integrated ACT, in which the ACT team provides substance abuse counseling, has the potential to reduce substance use by several mechanisms, but this has been difficult to demonstrate in clinical trials when participants in control groups receive similar interventions.

Substance Use Among Persons with Serious Mental Illness in Eastern Ontario

One hundred and eighty persons with serious mental illness (SMI) in eastern Ontario, receiving services from assertive community treatment teams in Brockville and Kingston were interviewed about substance use. Data were compared to survey findings for the Ontario population. Tobacco use was higher among both men and women in the SMI sample, but use of alcohol and drugs in the past 12 months was lower than population data. The frequency of alcohol use was significantly greater than drug use among the SMI sample.

Co-occurring mental and substance use disorders: promising approaches and research issues

This paper surveys the mental health and drug user treatment literature, identifying promising approaches and research issues in the treatment of co-occurring mental illness and substance use disorders. The prevalence and classification of co-occurring disorders are briefly reviewed, and selected treatment models currently in use are described. Three models are cited as representing particularly promising approaches--comprehensive integrated treatment, assertive community treatment, and the modified therapeutic community--and best practices are summarized. This paper proposes a research agenda focused on relevant emerging treatment issues.

Pentavalent treatment: preliminary effects on state hospital utilization

The purpose of this exploratory study was to determine if a low-cost alternative to assertive community treatment (ACT) programs could achieve results comparable to those previously reported by high-fidelity ACT programs with regard to state hospital utilization by patients with long-term, treatment-refractory serious mental illness and high rates of hospital recidivism. A sample of 30 patients was exposed to a low- cost alternative to ACT for a 12-month period. A quasi-experimental research design was used to compare state hospital utilization by the treatment group and a matched comparison group. The treatment group exhibited significantly less state hospital utilization than the comparison group and had an 88% reduction in state hospital utilization in comparison to its 10-year baseline. Low cost alternatives to ACT programs may be as effective as high-fidelity programs in reducing state hospital utilization and may be more easily adaptable to the current structure, operation, and financial constraints of community mental health centers.

Intensive case management in Australia: a randomized controlled trial

This study compared intensive case management (ICM) with standard clinical case management in a well-resourced community mental health service in Australia. A total of 73 severely disabled clients of an existing clinical service were randomly allocated to either ICM (caseload 10 clients per clinician) or standard case management (caseload up to 30 clients per clinician) and followed up for 12 months. A greater proportion of clients receiving ICM showed improved social functioning, these clients had fewer psychiatric hospital admissions involving police, and were more likely to engage and remain in treatment compared to those who received standard case management. Clients receiving ICM did not show a reduction in hospitalization duration or total number of episodes. It is suggested that future studies of ICM should focus on which aspects of treatment produce positive outcomes, how they can be applied to routine clinical settings, and over what period of time outcomes are sustained.