Assertive community treatment versus standard treatment for severely mentally ill patients in Denmark: a quasi-experimental trial

[Can intensive home care solve the problem of overcrowded psychiatric beds?]

The growing demand for psychiatric care raises questions about the place and value of alternatives to hospitalization. Community-based intensive care, such as home-based intensive care teams, are models that have been extensively studied and precisely described in international literature. They make it possible to avoid or shorten hospital stays, and have interesting variations for providing access to care in rural areas.

Affordability of Forensic Assertive Community Treatment Programs: A Return-on-Investment Analysis

OBJECTIVE

In this study, the authors assessed return on investment (ROI) associated with a forensic assertive community treatment (FACT) program.

METHODS

A retrospective secondary data analysis of a randomized controlled trial comprising 70 legal-involved patients with severe mental illness was conducted in Rochester, New York. Patients were randomly assigned to receive either FACT or outpatient psychiatric treatment including intensive case management. Unit of service costs associated with psychiatric emergency department visits, psychiatric inpatient days, and days in jail were obtained from records of New York State Medicaid and the Department of Corrections. The total dollar value difference between the two trial arms calculated on a per-patient-per-year (PPPY) basis constituted the return from the FACT intervention. The FACT investment cost was defined by the total additional PPPY cost associated with FACT implementation relative to the control group. ROI was calculated by dividing the return by the investment cost.

RESULTS

The estimated return from FACT was $27,588 PPPY (in 2019 dollars; 95% confidence interval [CI]=$3,262-$51,913), which was driven largely by reductions in psychiatric inpatient days, and the estimated investment cost was $18,440 PPPY (95% CI=$15,215-$21,665), implying an ROI of 1.50 (95% CI=0.35-2.97) for FACT.

CONCLUSIONS

The Rochester FACT program was associated with approximately $1.50 return for every $1 spent on its implementation, even without considering potential returns from other sources, including reductions in acute medical care, crime-related damages, and public safety costs. ROI estimates were highly dependent on context-specific factors, particularly Medicaid reimbursement rates for assertive community treatment and hospital stays.

Multifamily therapy in the community mental health network: A pragmatic randomized and controlled study

Multifamily therapy (MFT) is a psychotherapeutic group intervention for patients with severe mental disorders (SMDs) and their families. The present study is a multicenter, randomized, and controlled trial that analyzes the benefit of MFT during outpatient treatment. The recruited patients were randomly assigned to the experimental group (n = 26), which received 24 MFT sessions in addition to their treatment as usual (TAU), or to the control group (n = 29), which received only TAU (individual and family sessions). Six months after the inclusion in the MFT, the experimental group showed a significant decrease in number of visits to the psychiatric emergency services, number of psychiatric admissions, and the days of admission. The need for hospital care 6 months after recruitment was also lower in the experimental group compared to the control group. These results suggest that the implementation of MFT during outpatient treatment facilitates community management of people diagnosed with mental health problems.

Substance use outcomes among individuals with severe mental illnesses receiving assertive community treatment: A systematic review

Assertive Community Treatment (ACT) is a multidisciplinary treatment approach to support people with severe mental illnesses (SMI) in their recovery. While the majority of ACT recipients report co-morbid substance use issues, limited reviews have evaluated the impact of receiving ACT services on substance use outcomes. The purpose of this systematic review was to evaluate the impact of ACT involvement on substance use outcomes among people with SMI. A systematic literature search was conducted including articles published prior to April 2021. Twenty-nine studies were included in this review. Of them, 15 studies implemented a controlled design (six studies demonstrated high quality) and 14 studies implemented a cohort design. From a synthesis of the reviewed studies, five areas of changes associated with substance use emerged including reduced alcohol and drug use severity, lower prevalence of alcohol and drug use, increased stage of change in substance use treatment, and fewer days of hospitalization and intoxication. Thus, future studies should examine the integration of substance use treatment services as part of ACT interventions for opportunities to enhance recovery outcomes among individuals with SMI.

Patient Outcomes of Flexible Assertive Community Treatment Compared With Assertive Community Treatment

OBJECTIVE

In many European countries, flexible assertive community treatment (FACT) has replaced assertive community treatment (ACT) despite limited evidence for FACT's effectiveness in improving functional and patient-reported outcomes. This study evaluated the effectiveness of FACT relative to ACT in improving functioning, client satisfaction, and the working alliance.

METHODS

The authors used a nonblinded, quasi-experimental controlled study design to compare outcomes of patients treated by ACT teams that were reconfigured to FACT teams with those of patients treated by a remaining ACT team. Patients from nine ACT teams in the Capital Region of Denmark were included. Six of the nine ACT teams were reconfigured to FACT in 2018 and 2019 by integrating them with community mental health teams. The remaining three ACT teams were used as control groups. Assignment to treatment was based solely on administrative considerations.

RESULTS

The study included 131 patients (FACT, N=74; ACT, N=57). Patients treated by FACT teams had poorer personal and social functioning than patients assigned to ACT teams (adjusted difference in means=-2.9, 95% CI=-5.8 to -0.1). No between-group differences were found in client satisfaction or working alliance.

CONCLUSIONS

Patients treated by FACT teams had significantly lower functioning than patients treated by ACT teams, but the clinical relevance or causality of this finding remains unclear. Given the reconfiguration of the FACT teams during follow-up, along with substantial drop-out rates and baseline differences between the two groups, these results must be interpreted with caution. The findings require further examination in a randomized controlled trial that includes fidelity measures of the treatment models.

The Impact of the Community Psychiatric Treatment Program on the User's Quality of Life - experience of the Study Participants

Background

Community psychiatric treatment (CPT) is a novelty in the primary health care system for the people with mental health problems. The service operates according to the Flexible Assertive Community Treatment (FACT) model. FACT is a rehabilitation-oriented clinical case management model based on the ACT model (Assertive Community Treatment).

Objective

This study aimed to assess how involvement in a community psychiatry program affects the quality of life of program participants.

Methods

Between December 2020 and March 2021 we conducted a qualitative study. To obtain information, semi-structured interviews with twelve patients treated in the Community Psychiatric Treatment program were conducted. All restriction regarding COVID pandemic were considered at the research. Content analysis of the text was used for data analysis, which means that we interpreted the analysed text and determine the meaning of individual parts of the text.

Results

Twelve persons participated in the interviews, six of which were women (50%) and six men (50%). All the participants were of Slovenian nationality. They were from 28 to 80 years old, with a mean age of 47 years. We identified twelve categories and four themes: treatment problems, principles of operating of CPT program, satisfaction with inclusion in the CPT and improvement of quality of life through inclusion in the program.

Conclusion

Quality of life is essential for every individual, as well as for people with mental health problems. In our study we have proved that the Community psychiatric programs could significantly impact the quality of life of people with mental health problems.

Impact of integrated behavioral health services on adherence to long-acting injectable antipsychotics

Purpose

Integrated health care occurs when specialty and general care providers work together to address both the physical and mental health needs of their patients. The Substance Abuse and Mental Health Services Administration model of integration is broken into six levels of coordinated, co-located and integrated care. Our institution offers both co-located and integrated care among eight clinic sites. The care team is typically composed of the primary care provider, nurse and medical assistant, but other professionals may be introduced based on the patient’s medical and psychiatric conditions. The purpose of this prospective, quality improvement study was to compare the rates of adherence to long-acting injectable antipsychotics (LAIAs) between both types of integrated primary care settings at our institution. The comparison of the two settings sought to determine which environment provides improved outcomes for patients with serious psychiatric illnesses. Additionally, we aimed to assess the quality of medication-related monitoring and care team composition between care settings, and the ability of pharmacists to deliver interprofessional care team training and education on LAI use in clinical practice.

Design/methodology/approach

Subjects were identified and included in the study if they had received primary care services from our institution within the previous 12 months. Patient demographic and laboratory variables were collected at baseline and when clinically indicated. The rates of adherence between care settings were assessed at intervals that align with the medication’s administration schedule (e.g. every four weeks). Medication-related monitoring parameters were collected at baseline and when clinically indicated. The interprofessional care team completed Likert scale surveys to evaluate the pharmacist’s LAIA education and training.

Findings

There was not a statistically significant difference detected between integrated primary care settings on the rates of adherence to LAIAs. Additionally, there was not a statistically significant difference between rates of adherence to medication-related monitoring parameters or the effect of the patient treatment team composition. There was a statistically significant difference between pre- and post-session survey scores following interprofessional education and training provided by a pharmacist.

Originality/value

Because overall rates of adherence were low, both primary care settings were found to be equivalent. Our study may have been underpowered to detect a difference in the primary endpoint because of the small sample size. However, our study demonstrates that interprofessional education and training may lend itself to changes in practice, which is evident by the clinically significant relative increase in adherence. The Henry J. Austin Health Center network will be implementing a standard operating procedure regarding LAIA management within the primary care setting. Further studies are needed to assess a larger number of patients between both types of primary care settings, as well as the impact of the clinical psychiatric pharmacist as a member of the treatment team.

Predictors of admission to an assertive outreach service for psychosis in Lebanon

Schizophrenia is a chronic, debilitating mental illness that contributes significantly to the global burden of disease. Assertive outreach treatment for patients with schizophrenia and psychotic disorders has been implemented to improve treatment adherence and outcomes. The suitability of this model of care outside the western context has not been fully established. We describe the characteristics of 45 patients enrolled in the Psychosis Recovery Outreach Program (PROP), a program developed at a leading psychiatric facility in Lebanon. We collected twelve-month data for patients and used logistic regression models to identify predictor variables for enrollment in the service compared to those receiving standard treatment. Patients were mostly males (77.8%), younger than 39 years (80%), of college or higher education (68.2%), and diagnosed with schizophrenia (46.7%) or schizoaffective disorder (48.9%). About one-quarter (22.7%) had a comorbid cannabis use disorder. A majority received more than one oral antipsychotic (75.6%) while half (51.1%) were maintained on a long-acting injectable (LAI) antipsychotic. The following variables were significant predictors of enrollment in PROP: having a comorbid cannabis use disorder (OR 2.83 [1.25 - 6.37]), being prescribed a LAI antipsychotic (OR 9.99 [4.93-20.24]) or more than one oral antipsychotic (OR 4.57 [2.22-9.39]), visiting the emergency department more than once (OR 8.7 [2.64-28.68]), and admission to the psychiatry unit (OR 13.91 [3.17-60.94]). In addition, those following up in PROP were younger and less likely to be in the oldest age group (over 54 years) [OR 0.11 (0.01-0.93)], less likely to be females (OR 0.39 [0.18-0.81]), and less likely to be diagnosed with "other psychotic disorder" as compared to schizophrenia (OR 0.14 [0.03 - 0.62]). Our findings highlight that the assertive outreach model of care is applicable to its target population in the context of psychiatric care in Lebanon, namely young individuals with psychosis, higher comorbidities and a severe course of illness.

A Qualitative Study on the Implementation of Flexible Assertive Community Treatment - an Integrated Community-based Treatment Model for Patients with Severe Mental Illness

Introduction

Flexible Assertive Community Treatment (FACT) is a model of integrated care aiming to increase continuity of care for individuals with severe mental illness. FACT teams have been implemented in many countries by merging Assertive Community Treatment (ACT) and standard care from Community Mental Health teams (CMHTs). However, there has been little research on how practitioners experienced the fusion of these teams.

Aim

This study explores how former ACT and CMHT practitioners perceived the implementation of FACT.

Method

Perceptions of the FACT model, implementation strategies and adaptations of the model were investigated through 17 semi-structured interviews with FACT practitioners.

Results

Perceived positive contributions of FACT included the recognition that FACT addressed a service gap for a group of patients who could benefit from increased support and improved integration of outpatient and hospital care. Perceived disadvantages of FACT included the experience that FACT drew away resources from ACT patients with the highest psychiatric needs. The findings also describe barriers to implementation, such as lack of perceived benefit of FACT, the maintenance of traditional work culture and insufficient organisational capacity. These challenges required the negotiation of local implementation strategies and adaptations.

Conclusion

FACT increases access to intensive care for a broader group of patients with severe mental illness. However, findings from this study also suggest that the increased caseload in FACT compared with ACT and a changed mindset may not reflect the needs of the smaller group of patients who find it difficult to engage with mental health care services.

The effect of flexible assertive community treatment in Denmark: a quasi-experimental controlled study

BACKGROUND

Flexible assertive community treatment (FACT) is a community-based treatment model for patients with severe mental illness that has been widely implemented despite little evidence for its effectiveness. We aimed to evaluate the effect of FACT on mental health care outcomes compared with treatment from standard community mental health teams (CMHTs) or assertive community treatment (ACT) teams in Denmark.

METHODS

We did a quasi-experimental, propensity-score matched, controlled study in five FACT teams, four ACT teams, and five CMHTs in the Capital Region of Denmark. The FACT teams were established on May 1, 2016 (the index date). Patients were identified through the Danish Psychiatric Register and the study population consisted of all patients receiving care from any of these teams on the index date. Assignment to treatment was based on administrative considerations and was not done by the researchers. Patient data were collected from Danish registers. The primary outcome was analysed in the intention-to-treat population and compared mental health care outcomes (psychiatric admissions and bed days, outpatient contacts, self-harm, coercion, and death by any cause) for patients under the care of CMHTs or ACT teams that were reconfigured to FACT teams (CMHT-FACT or ACT-FACT) with patients who remained under the care of CMHTs and ACT teams. Patients who received FACT were matched using propensity scores with control patients from CMHTs and ACT teams to balance differences in baseline characteristics.

FINDINGS

On May 1, 2016, 2034 individuals (887 in the CMHT-FACT group, 887 in the matched CMHT group, 130 in the ACT-FACT group, 130 in the matched ACT group) were enrolled and were followed up from Nov 1, 2016, to Nov 1, 2018. The number of outpatient contacts was higher for patients receiving FACT than for those in the control groups (CMHT-FACT vs CMHT: incidence rate ratio 1·15; 95 % CI 1·10-1·20; ACT-FACT vs ACT: 1·15; 1·03-1·29). Patients receiving FACT had fewer admissions than those in the control groups (CMHT-FACT vs CMHT: 0·84; 0·76-0·92; ACT-FACT vs ACT: 0·71; 0·59-0·85). However, there were no significant differences in total inpatient days, use of coercion, episodes of self-harm, or deaths.

INTERPRETATION

To our knowledge, this is the first study to investigate the effect of FACT compared with treatment from a CMHT or ACT team. Our results suggest that FACT can provide a more intensive approach in terms of increased outpatient contacts than CMHT care or ACT. FACT requires further evaluation through randomised controlled trials that include a cost-effectiveness component before wider implementation.

FUNDING

Mental Health Services in the Capital Region of Denmark.