Moving assertive community treatment into standard practice

Barriers and Facilitators to Staff Recruitment and Retention for ACT Teams: Perspectives of Staff and Participants

The behavioral health workforce has been experiencing deepening problems with recruitment and retention, particularly in publicly funded settings serving individuals with serious mental illnesses. This quality improvement project gathered Assertive Community Treatment (ACT) participant (service user) and provider perspectives on workforce challenges. The authors conducted 8 interviews with ACT participants and 9 focus groups with ACT current staff, team leaders, and former staff. Interviewees discussed barriers to recruitment and retention, including inadequate compensation, work becoming more task-oriented during periods of short staffing, a lack of understanding of what ACT work entails, and elements of the team-based model of care; and facilitators of recruitment and retention, including other aspects of the team-based model of care, connections with colleagues and ACT participants, and flexibility. ACT participants had variable experiences regarding availability of their teams. Recommendations from focus groups and interviews include increasing flexibility, improving awareness of ACT work, optimizing team functioning, addressing staff wellness, and attending to risk. Findings include key insights that may help address the critical workforce shortages in public behavioral health settings.

Long-term efficacy of a continuity-of-care treatment model for patients with severe mental illness who transition from in-patient to out-patient services

BACKGROUND

Despite its significance, ensuring continuity of care demands substantial resources, which might not be readily accessible in many public healthcare systems. Studies indicate that continuity of care remains uncertain in numerous healthcare systems.

AIMS

This study aimed to assess the effectiveness of a continuity-of-care model for patients with severe mental illness (SMI), providing seamless treatment from discharge from a closed ward to subsequent psychiatric, psychological and rehabilitation services.

METHOD

Data from patients discharged before (1 January to 31 December 2018) and after (1 June 2021 to 31 May 2022) full implementation of the model were analysed and compared in terms of average duration of hospital stay, emergency department visits within 90 days of discharge, readmission rate within a year post-discharge and initiation of rehabilitation process.

RESULTS

In the post-implementation period (n = 482), the average admission time significantly decreased from 30.51 ± 29.72 to 26.77 ± 27.89 days, compared with the pre-implementation period (n = 403) (P = 0.029). Emergency department visits within 90 days following discharge decreased from 38.70 to 26.35% of discharged patients (P < 0.001). The rate of readmission decreased from 50.9 to 44.0% (P = 0.041) for one readmission and from 28.3 to 22.0% (P = 0.032) for two readmissions in the year following discharge. Additionally, the proportion of patients entering formal rehabilitation increased from 7.94 to 12.03% (P = 0.044).

CONCLUSIONS

This study highlights the effectiveness of a continuity-of-care model spearheaded by senior psychiatrists and involving paramedical personnel. These findings underscore the significant potential of the model to substantially enhance mental health services and outcomes. Moreover, they emphasise its relevance for patients, clinicians and policy makers.

Improving patient-centered care for HIV and mental illness: exploring hospital and community integration through education

Current models of care delivery are failing patients with complexity, like those living with HIV, mental illness and other psychosocial challenges. These patients often require resource-intensive personalized care across hospital and community settings, but available supports can be fragmented and challenging to access and navigate. To improve this, the authors created a program to enhance integrated, trauma-informed care through an innovative educational role for a HIV community caseworker embedded in an academic HIV Psychiatry clinic, called the Mental Health Clinical Fellowship. Through qualitative interviews with 21 participants (patients, physicians, clinicians and Mental Health Clinical Fellows) from October 2020-March 2023, the authors explore how implementation of this program affects patient experiences and satisfaction with care. Patients described their care experiences as less stigmatizing, more accessible, holistic and coordinated. They often attributed this to the integration between fellow and psychiatrist, and specifically the accessible stance of community organizations embedded within a hospital, which helped build trust. Interchangeable and integrated support by caseworker and psychiatrist improved patient engagement in psychiatric management and patient satisfaction with their care. Cross-context and cross-disciplinary care provision that includes providers from community and hospital working directly together to deliver care can improve care for patients with significant complexity.

Perceptions of ACT Team Members on the Implementation of Physical Health Services: A Qualitative Study

BACKGROUND

Adults with severe mental illnesses have mortality rates 2.5 to 3 times higher than the general population, largely due to medical illnesses. Those with the most profound mental illnesses are served by assertive community treatment (ACT) teams that provide intensive mental health care; however, there are no clearly established models to integrate physical health treatment into ACT and this is a critical gap in the literature.

AIMS

To describe perceptions of ACT team members regarding services provided for their clients to treat physical health, how those services can be improved, and what implementation strategies would likely be needed to promote uptake and sustainability of those services on ACT teams.

METHOD

Qualitative interviews were conducted via Zoom using a semistructured interview guide with 19 employees from three ACT teams in a southeastern state. Interview transcripts were analyzed, using manifest content analysis, a form of qualitative analysis, to identify key themes in the interview transcripts.

RESULTS

ACT team members described limited physical health services for their clients. They reported (1) system-level barriers to improving physical health care, such as inadequate tools and training; and (2) patient-level barriers, such as limited awareness of physical care needs. ACT team members reported the need for additional medical staff and strengthened relationships with primary care providers. They also recommended changes in policy, education, and quality monitoring to implement new physical health care services.

CONCLUSIONS

Findings suggest intervention components and implementation strategies for improving physical health care of ACT consumers.

Service users' perceptions of relevant and helpful components of an integrated care concept (ACCESS) for psychosis

Introduction

Psychotic disorders have a significant impact on patients' lives and their families, and long-term treatment with individually tailored multimodal combinations of therapies is often required. Integrated care (IC) concepts such as the "Hamburg Model (ACCESS)" with a focus on psychotic disorders, includes different (therapeutic) components with pharmaco- and psychotherapy, family involvement, home treatment and the option of using a 24/7 crisis hotline. All components are offered by a therapeutically-oriented assertive community treatment (TACT) team in a need-adapted manner. So far, however, little is known about which specific components are regarded as especially relevant and helpful by the users of IC.

Methods

Patients currently participating in IC completed a questionnaire as part of the continuous quality assurance study (ACCESS II) in which they were asked to rate the different components of treatment according to their relevance and helpfulness, considering the individual's unique experiences with IC and needs in mental health care. Furthermore, they were asked to make suggestions regarding additional helpful components of treatment.

Results

Fifty patients participated in this survey (23% of the patients currently participating in the IC concept). For participants, the most helpful and important factors were having the same therapist in the long-term and the 24/7 crisis telephone. Additional components suggested by patients included more addiction-specific therapies and increased focus on vocational rehabilitation and integration.

Conclusion

From the perspective of the users of IC, long-term care from a trusted therapist with whom there is a therapeutic relationship and the possibility to reach someone they already know from the TACT team 24/7 serves as the best basis for effective care, fostering trust, understanding, and open communication. In contrast, home treatment remains a relevant aspect of evidence-based care for people with severe mental illness, but perhaps surprisingly, is not viewed as the most important issue.

The clinical impact of a crisis resolution home treatment team

OBJECTIVES

To evaluate the impact of treatment provided by a Crisis Resolution Home Treatment Team (CRHTT) in terms of preventing hospital admission, impact on service user's symptoms and overall functioning, as well as service user's satisfaction with the service. Secondary objectives were to evaluate the patient characteristics of those attending the CRHTT.

METHODS

All the service users treated by the CRHTT between 2016 and 2020 were included. Service users completed the Brief Psychiatric Rating Scale (BPRS), the Health of the Nation Outcome Scale (HoNOS), and the Client Satisfaction Questionnaire-version 8 (CSQ-8) before and after treatment by the CRHTT. Admission rates were compared between areas served by the CRHTT and control, before and after the introduction of the CRHTT, using two-way ANOVA.

RESULTS

Between 2016 and 2020, 1041 service users were treated by the service. Inpatient admissions in the areas served by the CRHTT fell by 38.5% after its introduction. There was a statistically significant interaction between CRHTT availability and time on admission rate, F (1,28) = 8.4, p = .007. BPRS scores were reduced significantly (p < .001), from a mean score of 32.01 before treatment to 24.64 after treatment. Mean HoNOS scores were 13.6 before and 9.1 after treatment (p < .001). Of the 1041 service users receiving the CSQ-8, only 180 returned it (17.3%). Service users' median responses were "very positive" to all eight items on the CSQ-8.

CONCLUSIONS

Although our study design has limitations this paper provides some support that CRHTT might be effective for the prevention of inpatient admission. The study also supports that CRHTT might be an effective option for the treatment of acute mental illness and crisis, although further research is needed in this area.

[LeiP#netz - Leipziger Psychiatrie Netzwerk - A Pilot Project to Implement the Functional Basic Model by Steinhart and Wienberg in a Defined Psychiatric Care Region]

BACKGROUND

The functional basic model (Steinhart, Wienberg) offers the theoretic ground for a pilot project which emphasis on outpatient treatment in psychiatric care.

METHODS

The following subgoals were pursued a) networking with providers/institutions/actors located in the study region; (b) evaluation of the offered services for the purpose of mapping psychosocial care. Consequently, a project-based survey instrument was developed and applied for the survey of all care providers.

RESULT

Merging and networking of all actors was started successfully. All services needed for psychiatric care of severe mentally ill people are provided in the study region. While counselling and prevention tend to be well-maintained structures, there is a lack of access to low-threshold care such as crisis management, retreats alternatives to hospitals and assertive multi-professional complex treatment.

"It's Complicated": Using Education to Bridge Essential Care Between Hospital and Community for Complex Patients with HIV

OBJECTIVE

For the most complex patients, like those with HIV and mental illness, integrated care occurs across diverse community and hospital contexts. There is a need for cross-discipline and cross-context educational opportunities for diverse providers to learn integrated care skillsets in real practice settings. The authors developed a Continuing Professional Development (CPD) experience for frontline case workers to be embedded in a hospital-based HIV psychiatry clinic that aims to enhance collaborative skills across hospital and community settings, called the Mental Health Clinical Fellowship.

METHODS

Through qualitative pre- and post-interviews with 16 participants from October 2020 to October 2021, the authors explored patient, physician, clinician, resident learner, and the Mental Health Clinical Fellow's learning experiences and the impact on patient care.

RESULTS

Preliminary findings elucidate some common challenges providers experience in providing care to this complex population, including facing uncertainty of diagnosis and management, and not having enough time or resources to navigate this uncertainty. The opportunity to work and learn across disciplines through the fellowship reduced challenges, and also facilitated adaptive expertise development.

CONCLUSIONS

Cross-context and cross-discipline education opportunities facilitate perspective-sharing and enhanced ability to develop adaptive expertise in caring for complex populations. There is also promise for improving care and decreasing fragmentation because of the educational experience.

Advancing research on teams and team effectiveness in implementation science: An application of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework

Background

Effective teams are essential to high-quality healthcare. However, teams, team-level constructs, and team effectiveness strategies are poorly delineated in implementation science theories, models, and frameworks (TMFs), hindering our understanding of how teams may influence implementation. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework is a flexible and accommodating framework that can facilitate the application of team effectiveness approaches in implementation science.

Main Text

We define teams and provide an overview of key constructs in team effectiveness research. We describe ways to conceptualize different types of teams and team constructs relevant to implementation within the EPIS framework. Three case examples illustrate the application of EPIS to implementation studies involving teams. Within each study, we describe the structure of the team and how team constructs influenced implementation processes and outcomes.

Conclusions

Integrating teams and team constructs into the EPIS framework demonstrates how TMFs can be applied to advance our understanding of teams and implementation. Implementation strategies that target team effectiveness may improve implementation outcomes in team-based settings. Incorporation of teams into implementation TMFs is necessary to facilitate application of team effectiveness research in implementation science.

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.

What Explains Changes in Availability of Specialty Mental Health Services in Organized Settings?

Policy Points Community mental health facilities often do not offer the full range of evidence-based clinical and support services for individuals with serious mental illness. Facilities were no more likely to offer six of seven services studied in 2019 compared with 2010 in both Medicaid expansion and nonexpansion states. For-profit facilities generally experienced the largest declines in service availability, while public facilities experienced the smallest declines with small increases in availability of select services. New payment models that incentivize the offer of specialty support services may be needed to encourage adoption of clinical and support services by specialty mental health organizations.

CONTEXT

Community mental health facilities often do not offer the full range of evidence-based clinical and support services for individuals with serious mental illness. This creates equity issues, particularly when low-income and minority communities have access to fewer facilities. Medicaid expansion might encourage facilities to offer these services. However, this decision may also be affected by facility ownership type or mediated by service cost structure, particularly in the absence of innovative payment mechanisms. In this study, we determine whether and how Medicaid expansion and facility ownership are associated with changes in specialty mental health service availability in organized settings over time.

METHODS

We estimated two-way fixed effects models using six cross-sections of the National Mental Health Services Survey and compared changes in facility-reported offering of seven services from 2010 to 2019 (54,885 facility years): psychotropic medication, case management, family psychoeducation, psychiatric emergency walk-in services, supported employment, assertive community treatment, illness management, and recovery services. We tested whether Medicaid expansion and facility ownership (private for-profit, private not-for-profit, public) were associated with differential changes in service availability from 2010 to 2019.

FINDINGS

Overall, facilities were no more likely to offer nearly all services in 2019 than 2010. We found smaller declines for psychotropic medication and psychiatric emergency walk-in services among facilities in Medicaid expansion states compared to declines in non-Medicaid expansion states (6.3 (95% CI 95% CI = 1.8-10.7) and 5.5 (95% CI = 0.2-10.8) percentage points respectively). For-profit facilities experienced the largest declines in availability from 2010 to 2019, while public facilities experienced the smallest declines and some increases in availability of select services.

CONCLUSIONS

Specialty mental health services are still not widely offered in community outpatient settings despite significant investments in Medicaid, although Medicaid expansion was associated with slower declines in availability. New payment models that incentivize outpatient facilities to offer clinical and support services may be needed.

The Impact of Policy Changes, Dedicated Funding and Implementation Support on Early Intervention Programs for Psychosis

INTRODUCTION

Early intervention services for psychosis (EIS) are associated with improved clinical and economic outcomes. In Quebec, clinicians led the development of EIS from the late 1980s until 2017 when the provincial government announced EIS-specific funding, implementation support and provincial standards. This provides an interesting context to understand the impacts of policy commitments on EIS. Our primary objective was to describe the implementation of EIS three years after this increased political involvement.

METHODS

This cross-sectional descriptive study was conducted in 2020 through a 161-question online survey, modeled after our team's earlier surveys, on the following themes: program characteristics, accessibility, program operations, clinical services, training/supervision, and quality assurance. Descriptive statistics were performed. When relevant, we compared data on programs founded before and after 2017.

RESULTS

Twenty-eight of 33 existing EIS completed the survey. Between 2016 and 2020, the proportion of Quebec's population having access to EIS rose from 46% to 88%; >1,300 yearly admissions were reported by surveyed EIS, surpassing governments' epidemiological estimates. Most programs set accessibility targets; adopted inclusive intake criteria and an open referral policy; engaged in education of referral sources. A wide range of biopsychosocial interventions and assertive outreach were offered by interdisciplinary teams. Administrative/organisational components were less widely implemented, such as clinical/administrative data collection, respecting recommended patient-to-case manager ratios and quality assurance.

CONCLUSION

Increased governmental implementation support including dedicated funding led to widespread implementation of good-quality, accessible EIS. Though some differences were found between programs founded before and after 2017, there was no overall discernible impact of year of implementation. Persisting challenges to collecting data may impede monitoring, data-informed decision-making, and quality improvement. Maintaining fidelity and meeting provincial standards may prove challenging as programs mature and adapt to their catchment area's specificities and as caseloads increase. Governmental incidence estimates may need recalculation considering recent epidemiological data.

An observational comparison of FACT and ACT in the Netherlands and the US

Assertive Community Treatment (ACT) is a well-defined service delivery model for the care and treatment of the most severely mentally ill in the community with American origins. The Dutch have adapted the model in order to accommodate a broader range of needs and allow more flexible implementation. Functional Assertive Community Treatment (FACT) provides the intensity of care needed to help participants sustain life in the community as well as continuity of care over time for many vulnerable client populations.

Investigating the effects of post-discharge care services for patients with severe psychiatric illnesses on their caregivers' burnout in Sanandaj

Family-based caregivers of psychiatric patients are the backbone of the healthcare system and are, in fact, generally considered as patients themselves. Their commitment and obligation to take care of the in-need and disabled patients in the family can lead to their psychological destruction. This paper attempts to investigate the effects of post-discharge care for patients with severe psychiatric illnesses on the burnout of their caregivers in the Qods Hospital of Sanandaj. This before-after study was performed on 72 subjects divided into two groups of 36, all of whom were chosen from the caregivers of the case and control subjects from family members of the psychiatric patients discharged from Qods psychiatric hospital in 2016. The study was effectively conducted with a control group design. The case group included patients who received home-care services after being discharged, and the caregiver group received nothing but regular care. First, using the hospital files, personal characteristics and diagnosis of the patient were recorded, thus the caregivers' characteristics and their burnout and psychological exhaustion severity were collected by caregiver burden inventory. The data were presented using descriptive-analytic indexes. The results represented that most of the caregivers (95.8%) suffered from moderate to severe burdens at the time of discharge. In using the Kolmogorov-Smirnov test, pre-test scores in two groups supported the normal hypotheses of the data (P = 0.55). Also, the level of significance in the covariance test showed the efficacy of intervention after the test (P = 0.000). In this study, most of the patients' caregivers with severe mental illnesses suffered from moderate to a severe burden, which, of course, seems to be more than other similar studies. Differences in social, cultural, and special regional conditions, as well as the type of applied questionnaire, were of significance. However, despite the mentioned difference, as it is true for other similar studies in Iran and other countries, home-care services have a significant effect on reducing the caregivers' burden after one year. Researches could, besides reducing the burnout of caregivers, provide a model which could help patients in the deprived areas without removing cultural and family roots and without diminishing the role of the family.

Access to mental health support services in Accountable Care Organizations: A national survey

Patients with serious mental illness often lack access to mental health support services. Whether new payment models facilitate access to these services is unknown. We conducted a national survey of accountable care organizations(ACOs) and find that fewer than 50% of ACOs surveyed reported that they have the ability to offer or refer patients to supported employment, family psychoeducation, assertive community treatment and illness, management and recovery services. These findings suggest that even among organizations that are early adopters of payment and delivery reforms -- those most likely to lead innovations in population health -- access to these services is limited.

Integration of Mental Health and Supportive Care in Individuals with Schizophrenia and Cancer: Assertive Community Treatment Model

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Τhe Contribution of Mobile Mental Health Units to Community Psychiatric Care in Greece

The implementation of Mobile Mental Health Units (MMHUs) was a decisive step in the psychiatric reform and the development of community psychiatric care in Greece [...]

Rates and Correlates of Suicidality in VA Intensive Case Management Programs

There has been extensive concern about suicide among veterans, but no study has examined rates and correlates of suicidality in the highly vulnerable group of veterans receiving Veterans Health Administration (VHA) intensive case management services. Veterans participating in a national program evaluation were surveyed at the time of program entry and 6 months later. Sociodemographic and clinical characteristics were documented along with elements of program service delivery. Chi square tests were used to compare rates of suicidality (defined as either having made or threatened an attempt) at baseline and at the 6-month follow-up. Analysis of variance was also used to compare suicidal and non-suicidal veterans at follow-up. Logistic regression analysis was then used to identify independent correlates of suicidality 6 months after program entry. Among the 9921 veterans who later completed follow-up assessments 989 (10.0%) had reported suicidal behavior at program entry as compared to only 250 (2.51%) at 6 months (p < 0.0001). Multivariable logistic regression analysis showed suicidality at 6 months to be associated with suicidality at admission, increased subjective distress on the Brief Symptom Inventory (especially on depression items), violent behavior and decreased quality of life since admission, along with a greater likelihood of receiving crisis intervention, but not other services. Among veterans receiving intensive case management services from VHA, suicidal behavior declined by 75% from admission to 6 months (10-2.5%) and was associated with suicidality prior to program entry, worsening subjective symptoms and greater receipt of crisis intervention services.

Impact of COVID-19-Related Social Distancing on Delivery of Intensive Case Management

ABSTRACT

Social distancing due to COVID-19 may adversely impact treatment of adults with serious mental illness, especially those receiving intensive forms of community-based care, in part through weakening of the therapeutic alliance. Veterans and staff at a Veterans Affair (VA) medical center were surveyed 3 months after social distancing disrupted usual service delivery in intensive community-based treatment programs. Veterans (n = 105) and staff (n = 112) gave similar multi-item ratings of service delivery after social distancing, which involved far less face-to-face contact and more telephone contact than usual and rated their therapeutic alliances and clinical status similarly as "not as good" on average than before social distancing. Self-reported decline in therapeutic alliance was associated with parallel decline in clinical status indicators. Both veterans and staff indicated clear preference for return to face-to-face service delivery after the pandemic with some telehealth included.

Nursing Science, Mental Illness, and the Family: A Conceptual Framework to Break the Cycle of Suffering

Mental illness is an epidemic in the United States, and there is a gap in care due to minimal integrated programs and transitional community resources. This paper reports the development of a conceptual framework to identify challenges facing families living with mental illness and the integral role nursing plays to positively impact health. An inductive, bottom-up approach was used to develop the Nursing Science, Mental Illness and Family model. Concepts clustered around family health, cycle of suffering, improving outcomes, healthcare policy, and nursing science. Successful, goal-directed interprofessional collaborations are essential for individual-, family-, and system-level interventions to be effective.

Psychiatric Multimorbidity in a Specialized Program for Severely Mentally Ill Veterans

It has been suggested that psychiatric multimorbidity may better characterize severely impaired psychiatric patients than individual severe mental illness (SMI) diagnoses, and that these patients may be better served by centers offering integrated co-located, psychiatric and social services than in conventional clinics providing one-to-one care. We tested the hypothesis that multimorbidity is a critical characteristic of Veterans treated at a co-located multi-service Veteran's Health Administration (VHA) program originally established to treat Veterans living with SMI. Administrative data from the VA Connecticut Health Care System from fiscal year 2012 were used to compare veterans using diverse mental health and social services at the Errera Community Care Center (ECCC), an integrated "one-stop shop" for SMI veterans, and those seen exclusively at standard outpatient mental health clinics. Bivariate and multiple logistic regression analyses were used to compare groups on demographic characteristics, psychiatric and medical diagnoses, service utilization, and psychotropic medication fills. Results: Of the 11,092 veterans included in the study, 2281 (20.6%) had been treated at the ECCC and 8811 (79.4%) had not. Multivariable analysis highlighted the association of treatment in the ECCC and younger age, lower income, homelessness, and especially multimorbidity including both multiple substance use and multiple psychiatric diagnoses. Programs originally designed to address the diverse needs of patients living with SMI and homelessness may be usefully characterized as treating patients with psychiatric multimorbidity, a term of greater clinical relevance. Effectiveness research is needed to evaluate the one-stop shop approach to their treatment.

The Use of Clozapine in the Serious Mental Illness Patients Enrolled in an Assertive Community Treatment Program

Introduction Health care cost is projected to reach 20% of the nation's gross national product (GNP) by 2016. 6.2% of this is from mental health. The National Institute of Mental Health (NIMH) estimates the prevalence of serious mental illness (SMI) at 13.1 million or 5.2% of American adults age 18 or over. Hence, mental health care cost for this patient population is significant. Patients with SMI involved in an Assertive Community Treatment (ACT) program are individuals who experience the most intractable symptoms and the greatest level of dysfunction from their mental illness. These individuals typically are institutionalized in a long-term facility such as the state hospital. Clozapine has shown superior efficacy over first- and most second-generation antipsychotics in both treating treatment-resistant and non-treatment-resistant schizophrenia which has been supported by several large trials. There is also evidence of its efficacy in suicidality, aggression and substance misuse. In fact, clozapine has been approved by the FDA for use in refractory schizophrenia and suicidality in schizoaffective disorder. Due to the risk of agranulocytosis, clozapine is underutilized. The purpose of this study is to conduct a retrospective cohort study through chart review to analyze whether the addition of clozapine to ACT treatment of SMI patients in a community hospital from 2008 to 2018 led to decreased frequency of hospitalizations and increased clinical stability. Materials and methods A retrospective study using electronic medical record (EMR) of patients ages 20 and above who were enrolled in the ACT program at a community hospital from December 1, 2008 to December 31, 2018. Variables were collected from the EMR and de-identified during data collation. Analysis was performed using SPSS software package. Results A total of 179 patients enrolled in the ACT program and their data was extracted from the EMR. Twenty-five (62.5%) of these patient enrollments were on clozapine. They were made up of 53.6% male, 81.9% White/Asian, 18.1% Black; 44.1% ages between 36 to 50 years old, 30.2% were aged 18 to 35 years old, and 25.7% greater than 50 years old. There was no difference in age, sex, race, ethnicity, and insurance type in ACT program between those using clozapine and those not on clozapine. There was a higher proportion of psychiatric hospitalizations among clozapine users compared with the non-clozapine user group (62.5% vs 41.5%, p = 0.019). However, the two groups did not differ from one another in terms of psychiatric emergency visits (p = 0.128) or frequency of ACT visits (p = 0.002). Conclusion Effective treatment that will reduce hospitalizations and the burden of chronic disability in patients with SMI would greatly reduce mental health care cost. Clozapine remains the gold standard in the treatment of refractory schizophrenia. But due to the risk of agranulocytosis, clozapine is underutilized. It was hoped that this study will support the use of clozapine in SMI patients. Disappointingly, the use of clozapine did not prevent relapses and hospitalizations in this patient population and patients on clozapine seemed to have increased hospitalizations, compared to those who were not on clozapine. Perhaps, a different outcome would have occurred if the focus was limited to the patients themselves who were on Clozapine and ascertain what the rate of hospitalization was before the start of clozapine vs after the use of clozapine.

The Use of Long-Acting Injectable Antipsychotics (LAI) in the Serious Mental Illness (SMI) Patients Enrolled in an Assertive Community Treatment (ACT) Program

Introduction

Patients with serious mental illness (SMI) experience highly intractable symptoms and great levels of dysfunction from their mental illness. Relapse prevention is critical as psychopathology, social and occupational functioning worsen with repeated psychotic episodes. Poor medication adherence is a strong predictor of relapse. Use of long-acting injectable antipsychotics (LAI) is among the most effective treatment specially in the context of non-adherence and yet remains underutilized. This single center retrospective study conducted using the electronic medical record (EMR) of patients enrolled in an Assertive Community Treatment (ACT) program at a community hospital was analyzed as to whether use of LAI among these patients reduce the frequency of emergency room visits and hospitalizations.

Materials and methods

Single center retrospective study using EMR of patients ages 20 and above who were enrolled at the ACT program at a community hospital from December 1, 2008 to December 31, 2018. Variables were collected from the EMR and de-identified into an Excel spreadsheet for data collation. Analysis was performed using SPSS software package.

Results

A total of 179 patients enrolled in the ACT program and their hospitalizations were extracted from the EMR. Seventy-six (42.5%) of these hospitalizations had patients on LAI. The hospitalizations were made up of 53.6% male, 81.9% White/Asian, 18.1% Black; 44.1% ages between 36 and 50 years old, 30.2% ages between 18 and 35 years old, and 25.7% greater than 50 years old. There was no difference in age, sex, race, ethnicity, insurance type and time spent in ACT program between those using LAI and those not on LAI. There was a higher proportion of psychiatric hospitalizations among LAI users compared with the non-LAI user group (57.9% vs 37.4%, p = 0.007). However, the two groups did not differ from one another in terms of psychiatric emergency visits (p = 0.266) or frequency of ACT visits (p = 0.062).

Conclusion

To date, all of the new-generation antipsychotic LAI have demonstrated a statistically and clinically significant decrease of relapse rates over placebo. Despite this, LAIs are not widely prescribed for a variety of reasons, including the reservations of patients, clinicians and payers. It would seem, though, that our patient population at the ACT program do not seem to benefit from use of LAI in relapse prevention. These results are counterintuitive in that one would expect that patients with serious mental illness would benefit from use of LAI. Perhaps, individuals with SMI are a different subset of population and they do not respond as well to LAI.

Computational Mechanism for the Effect of Psychosis Community Treatment: A Conceptual Review From Neurobiology to Social Interaction

The computational underpinnings of positive psychotic symptoms have recently received significant attention. Candidate mechanisms include some combination of maladaptive priors and reduced updating of these priors during perception. A potential benefit of models with such mechanisms is their ability to link multiple levels of explanation, from the neurobiological to the social, allowing us to provide an information processing-based account of how specific alterations in self-self and self-environment interactions result in the experience of positive symptoms. This is key to improving how we understand the experience of psychosis. Moreover, it points us toward more comprehensive avenues for therapeutic research by providing a putative mechanism that could allow for the generation of new treatments from first principles. In order to demonstrate this, our conceptual paper will discuss the application of the insights from previous computational models to an important and complex set of evidence-based clinical interventions with strong social elements, such as coordinated specialty care clinics (CSC) in early psychosis and assertive community treatment (ACT). These interventions may include but also go beyond psychopharmacology, providing, we argue, structure and predictability for patients experiencing psychosis. We develop the argument that this structure and predictability directly counteract the relatively low precision afforded to sensory information in psychosis, while also providing the patient more access to external cognitive resources in the form of providers and the structure of the programs themselves. We discuss how computational models explain the resulting reduction in symptoms, as well as the predictions these models make about potential responses of patients to modifications or to different variations of these interventions. We also link, via the framework of computational models, the patient's experiences and response to interventions to putative neurobiology.

Empowering Features and Outcomes of Homeless Interventions: A Systematic Review and Narrative Synthesis

The purpose of this systematic review and narrative synthesis was to identify homeless interventions with empowering features and evaluate their effectiveness for developing the psychological empowerment of services users. To identify and evaluate intervention studies, we combined the theoretical frameworks of empowering settings and psychological empowerment (PE). Our conceptualization of PE included outcomes aligned with the intrapersonal, interactional, and behavioral components. Relational outcomes were also included and conceptualized as antecedents for PE development. After systematic searching and screening, 37 studies were included for review. Interventions with empowering features included supported housing, case management, skills and knowledge acquisition, and mutual support. Interventions that were competency-building effectively improved outcomes aligned with the intrapersonal PE component. Interventions that were collaborative and competency-building effectively improved outcomes aligned with the behavioral PE component. Weak evidence suggested that interventions with empowering features may effectively improve outcomes aligned with the interactional PE component. Interventions that promoted and developed support effectively improved relational antecedents. Findings align the empirical evidence for homeless interventions with theoretical conceptions of empowering features and processes. Findings may be applied to the design and implementation of homeless interventions to incorporate empowering features and to facilitate the development of homeless services users' PE. Highlights Empowerment theory was applied to review homeless interventions literature. Empowering homeless interventions included supported housing and mutual support, for example. Empowering interventions contributed to indicators of emotional and behavioral empowerment. Fewer empowering interventions contributed to indicators of cognitive empowerment. Service user involvement may facilitate improvements in indicators of psychological empowerment.

Social determinants of mental health care systems: intensive community based Care in the Veterans Health Administration

BACKGROUND

Since deinstitutionalization in the 1950s-1970s, public mental health care has changed its focus from asylums to general hospitals, outpatient clinics and specialized community-based programs addressing both clinical and social determinants of mental health. Analysis of the place of community-based programs within a comprehensive health system such as the Veterans Health Administration (VHA) may illuminate the role of social forces in shaping contemporary public mental health systems.

METHODS

National VHA administrative data were used to compare veterans who exclusively received outpatient clinic care to those receiving four types of specialized community-based services, addressing: 1) functional disabilities from severe mental illness (SMI), 2) justice system involvement, 3) homelessness, and 4) vocational rehabilitation. Bivariate comparisons and multinomial logistic regression analyses compared groups on demographics, diagnoses, service use, and psychiatric prescription fills.

RESULTS

An hierarchical classification of 1,386,487 Veterans who received specialty mental health services from VHA in Fiscal Year 2012, showed 1,134,977 (81.8%) were seen exclusively in outpatient clinics; 27,931 (2.0%) received intensive SMI-related services; 42,985 (3.1%) criminal justice services; 160,273 (11.6%) specialized homelessness services; and 20,921 (1.5%) vocational services. Compared to those seen only in clinics, veterans in the four community treatment groups were more likely to be black, diagnosed with HIV and hepatitis, had more numerous substance use diagnoses and made far more extensive use of mental health outpatient and inpatient care.

CONCLUSIONS

Almost one-fifth of VHA mental health patients receive community-based services prominently addressing major social determinants of health and multimorbid substance use disorders.

Où en sommes-nous? An Overview of Successes and Challenges after 30 Years of Early Intervention Services for Psychosis in Quebec: Où en sommes-nous? Un aperçu des réussites et des problèmes après 30 ans de services d'intervention précoce pour la psychose au Québec

INTRODUCTION

Over the last 30 years, early intervention services (EIS) for first-episode psychosis (FEP) were gradually implemented in the province of Quebec. Such implementation occurred without provincial standards/guidelines and policy commitment to EIS until 2017. Although the literature highlights essential elements for EIS, studies conducted elsewhere reveal that important EIS components are often missing. No thorough review of Quebec EIS practices has ever been conducted, a gap we sought to address.

METHODS

Adopting a cross-sectional descriptive study design, an online survey was distributed to 18 EIS that existed in Quebec in 2016 to collect data on clinical, administrative, training, and research variables. Survey responses were compared with existing EIS service delivery recommendations.

RESULTS

Half of Quebec's population had access to EIS, with some regions having no programs. Most programs adhered to essential components of EIS. However, divergence from expert recommendations occurred with respect to variables such as open referral processes and patient-clinician ratio. Nonurban EIS encountered additional challenges related to their geography and lower population densities, which impacted their team size/composition and intensity of follow-up.

CONCLUSIONS

Most Quebec EIS offer adequate services but lack resources and organizational support to adhere to some core components. Recently, the provincial government has created EIS guidelines, invested in the development of new programs and offered implementation support from the National Centre of Excellence in Mental Health. These changes, along with continued mentoring and networking of clinicians and researchers, can help all Quebec EIS to attain and maintain recommended quality standards.

The Care of Patients With Complex Mood Disorders

This article focuses on some common dilemmas facing clinicians, patients, and families in managing the treatment of complicated mood disorders. Specifically, this article reviews the interaction of depressive states, including unipolar, bipolar, and mixed, with other adversities, including comorbid physical and psychological disorders, personality vulnerabilities, misuse of drugs and alcohol, and social and family problems. These issues are not always clearly differentiated from the depressive illness. Each of these adversities can worsen an existing mood disorder and influence the patient's resolve to persist with a treatment plan. Although this article is not focused strictly on treatment-resistant depression, these coexisting issues make depressive states harder to manage therapeutically. For brevity, the aim of this article has been limited to discussion of some complex situations that psychiatrists in general practice may encounter.

Implementation of a Global Treatment Budget in Psychiatric Departments in Germany-Results and Critical Factors for Success From the Staff Perspective

BACKGROUND

Despite evidence from other countries for its effectiveness, flexible and integrative psychiatric treatment (FIT) is not part of the German standard healthcare system. Since 2013, German legislative reform has enabled a test implementation of FIT based on a global treatment budget. Because the budget is not restricted to any particular activity, this legislation opens the possibility of enhancing linkages between inpatient-, outpatient- and day-patient treatment structures. As staff involvement is a relevant component in successful implementation, we aimed in this study to judge the degree of FIT implementation based on staff members' experiences and evaluations of FIT.

METHOD

Within an exploratory study design, we administered a standardized written survey to rate experiences and evaluations of physicians, psychologists, and nurses in the first 13 FIT projects between October 2016 and February 2017. The sample consisted of 352 nurses, 127 physicians, 84 psychologists, and 132 special therapists. We identified critical factors for successful implementation from the staff perspective by logistic regression analysis.

RESULTS

Staff evaluations of the degree of FIT implementation were generally favorable, although some staff reported no experiences with one or several FIT-specific components. We found considerable differences in the assessments between the occupational groups. The only common factor for successful FIT implementation shared by physicians, psychologists, and nurses was the opportunity to join training programs on the objectives of FIT. Other critical factors for successful implementation were work conditions, the number of nurses/special therapists per physician/psychologist, and project duration. These factors together explained 49% of the variance of physician/psychologist evaluations and 34% for nurse evaluations. Individual staff members' characteristics were less important than structural- or FIT characteristics as explanatory factors for the degree of FIT implementation.

IMPLICATIONS

Results point to the importance of new forms of multi-professional cooperation, training programs, improvement of work conditions, and guidance of the implementation process by systematic Change Management for future implementations of FIT. Our exploratory findings require further validation to guide practical improvements in FIT implementation. Longitudinal observations and a multilevel analysis should yield a better understanding of the relevant variables from different organization levels and their possible interactions.

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.

Stigma and discrimination in individuals with severe and persistent mental illness in an assertive community treatment team: Perceptions of families and healthcare professionals

AIM

To explore family member and staff perceptions of clients' experiences of stigma and discrimination, in those living with severe and persistent mental illness in an Assertive Community Treatment Team.

METHOD

This qualitative study used the Discrimination and Stigma Scale to conduct structured face-to-face and telephone interviews of family members and healthcare professionals, working with the Assertive Outreach Team (AOT) (an Assertive Community Treatment Team) of a northern inner suburban catchment of Sydney, New South Wales, Australia.

RESULTS

Forty-one people participated in the study (23 AOT clinical staff members and 18 family members). Family and clinical staff commonly reported stigma and discrimination amongst their relatives and clients, respectively. Four overarching themes emerged from the data: (1) appearance and behaviour, (2) avoidance and being shunned, (3) key areas of life affected by discrimination and (4) impacts of discrimination and skills to cope with discrimination.

CONCLUSION

Reports of stigma and discrimination were common, yet varied between groups with clinical staff commonly witnessing experiences and impacts of discrimination in everyday life, with families' reports being substantially less. Due to the strong advocacy and support provided by the AOT model, clinical staff often buffered experiences of stigma and discrimination. Further research is needed to explore effective interventions to reduce experiences of discrimination in this population group.

[Specific components for integrative and flexible care models according to § 64b SGB V]

BACKGROUND

There is a need for a theoretical model for evaluating integrative and flexible care models according to § 64b of the Social Security Statutes Book V (SGB V).

MATERIAL AND METHODS

An iterative process of data collection and analysis has been executed according to grounded theory methodology.

RESULTS

A total of 11 specific components have been identified and shown to be robust and practicable and compatible with the data from the literature.

CONCLUSION

These components can be used for implementation, quality management and evaluation of projects for treatment models according to § 64b SGB V.

[Implementation of New Flexible and Integrative Psychiatric Care Models (According to §64b SGB V) in Rural Northern Germany in Comparison to Federal Territory]

AIM

New treatment models (according to §64b German Social Code) have been introduced in Germany to improve flexible and integrated forms of psychiatric care. The aim of this study was to analyse the specific conditions under which many of these models have been implemented in the federal state of Schleswig-Holstein (SH) in comparison to other federal regions.

METHODS

A standardized survey reached 383 patients in seven psychiatric departments, among them three departments in SH. In addition, routine data and data evaluating the grade of implementation in these departments were analysed.

RESULTS

Departments in SH showed more developed implementation processes, compared with departments in other regions. Implemented changes were perceived and evaluated as being better by patients in SH.

CONCLUSIONS

Implementation processes of flexible and integrated forms of care according to §64b were particularly successful in SH. Extensive political support is discussed as a major reason, among others, for this development.

Let’s Get Real about Person- and Family-Centred Geriatric Home Care: A Realist Synthesis

Cette étude a examiné les mécanismes complexes intervenant lors de la prestation de soins axés sur la personne et la famille (SAPF) par des équipes de soins gériatriques à domicile. Une approche par synthèse réaliste a été utilisée pour élaborer un cadre d’évaluation qui a inclus 159 références provenant de la littérature scientifique, des consultations d’experts canadiens en SAPF, des recherches ciblées dans les bases PubMed/MEDLINE® et CINAHL, et des recensions de la littérature grise canadienne. Les références ont été sélectionnées par deux personnes, selon une approche consensuelle avec évaluation de la qualité. Les données ont été extraites et synthétisées en tenant compte du contexte, des mécanismes et des configurations des résultats dans un cadre théorique de SAPF d’équipe pour les soins gériatriques à domicile. Le cadre présente les contributions spécifiques prédominantes des infirmières, des ergothérapeutes et des physiothérapeutes, leurs apports collectifs impliquant des communications pour des équipes virtuelles, ainsi que le soutien du système nécessité pour la prestation de SAPF d’équipe complets. Les résultats de cette étude pourraient contribuer à l’amélioration de l’éducation sur les SAPF et des lignes directrices sur les pratiques exemplaires, en vue d’assurer une prestation plus intégrée des SAPF dans les soins gériatriques offerts à domicile ou dans d’autres milieux comportant des équipes de soins.

Distribution and Correlates of Assertive Community Treatment (ACT) and ACT-Like Programs: Results From the 2015 N-MHSS

OBJECTIVE

The study examined the availability and characteristics of assertive community treatment (ACT) programs across mental health treatment facilities in the United States.

METHODS

Prevalence and correlates of facilities that reported offering ACT, broadly defined as intensive community services for serious mental illness provided by multidisciplinary teams in the clients' natural settings and including both ACT and "ACT-like" programs, were examined by using data from the National Mental Health Services Survey. Availability of services essential to the ACT model in these facilities was also examined.

RESULTS

Of the 12,826 surveyed facilities, 13.4% reported offering ACT, with significant variability among states. Of the facilities with ACT, 19.2% reported offering all core ACT services. Few facilities offered peer support, employment, and housing services. Compared with programs at facilities that did not offer all core ACT services, facilities with ACT programs that offered these services had higher odds of being publicly owned (odds ratio [OR]=2.12, 95% confidence interval [CI]=1.64-2.74) and of receiving federal (OR=3.60, CI=2.17-5.98) or grant funding (OR=1.87, CI=1.45-2.41). Facilities with ACT that offered all core services also had higher odds of offering other services important to individuals with serious mental disorders.

CONCLUSIONS

Substantial differences existed in availability of ACT and ACT-like programs among states, with evidence of a large unmet need overall, even when a very broad and inclusive definition of ACT was used. Few ACT programs offered all core services. Legislative, administrative, and funding differences may explain some of the variability.

Do Home-Based Psychiatric Services for Patients in Medico-Social Institutions Reduce Hospitalizations? Pre-Post Evaluation of a French Psychiatric Mobile Team

World Health Organization recommends the implementation of alternatives to full-time hospitalizations. Psychiatric home-care has known a worldwide development in the last 20 years. The psychiatric mobile team for social and medico-social institutions in Saint-Etienne, France, (Equipe mobile d'intervention en établissements Sociaux et Médico-sociaux, ESMS) aims to support professionals from medico-social housing institutions (MSHI) in order to maintain people in housing. The objective of the study was to evaluate the efficiency of home-based interventions to reduce hospitalizations and improve collaboration between psychiatric hospital facilities and MSHI. We used a pre-post study design. A same cohort of patients living in a MSHI one year before intervention and one year after implementation of the ESMS was studied. Hospitalizations were compared between the two periods. A survey was conducted for qualitative evaluation among professionals in MHSI. Sixty-three patients were included. Most patients suffered from psychotic disorders (71%). We found a significant decrease in the mean number of admissions per year from 2,06 to 1,48 (Wilcoxon signed rank test; df64; p = 0,01). Mobile-team interventions included answering phone calls, home visits, coordination meetings, or clinical interviews with patients in inpatient and outpatient services, with an average of 9,3 interventions per patient (SD = 11,4). ESMS was evaluated as "essential" for 73% of 11 professionals from MSHI who answered the questionnaire in May 2017. Assertive Community Treatment and Crisis Resolution Teams are the most studied home-care models in psychiatry. Our results tend to show the efficiency of mobile-team interventions in MSHI, to enhance partnerships.

Meeting the Mental Health Needs of the Homebound: A Psychiatric Consult Service Within a Home-Based Primary Care Program

The growing population of homebound adults increasingly receives home-based primary care (HBPC) services. These patients are predominantly frail older adults who are homebound because of multiple medical comorbidities, yet they often also have psychiatric diagnoses requiring mental health care. Unfortunately, in-home psychiatric services are rarely available to homebound patients. To address unmet psychiatric need among the homebound patients enrolled in our large academic HBPC program, we piloted a psychiatric in-home consultation service. During our 16-month pilot, 10% of all enrolled HBPC patients were referred for and received psychiatric consultation. Depression and anxiety were among the most common reasons for referral. To better meet patients' medical and psychiatric needs, HBPC programs need to consider strategies to incorporate psychiatric services into their routine care plans.

Families in Assertive Community Treatment (ACT) Teams in Norway: A Cross-Sectional Study on Relatives' Experiences of Involvement and Alienation

International research shows that relatives of people with mental illness are rarely involved by mental health services. Assertive Community Treatment (ACT) has been recently implemented in Norway. The experience of relatives of ACT users is largely unknown. The aim of this study was to explore relatives' experience with ACT-teams in Norway. Data were collected using the family involvement and alienation questionnaire, consisting of experiences of approach, and alienation from the provision of professional care. 38 Relatives participated in this study. A majority experienced a positive approach (openness, confirmation, and cooperation) from the ACT teams, which also was considered better compared to previous services. They considered openness and cooperation as essential aspects from the professionals. Almost half did not feel alienated (powerlessness and social isolation). Higher level of being approached positively was significantly associated with lower level of feeling alienated. The knowledge of what constituted relatives' positive experiences with the ACT teams should be transferred into practice regarding how to form a positive alliance with relatives.

Training in Good Psychiatric Management for Borderline Personality Disorder in Residency: An Aide to Learning Supportive Psychotherapy for Challenging-to-Treat Patients

Given many competing demands, psychotherapy training to competency is difficult during psychiatric residency. Good Psychiatric Management for borderline personality disorder (GPM) offers an evidence-based, simplified, psychodynamically informed framework for the outpatient management of patients with borderline personality disorder, one of the most challenging disorders psychiatric residents must learn to treat. In this article, we provide an overview of GPM, and show that training in GPM meets a requirement for training in supportive psychotherapy; builds on psychodynamic psychotherapy training; and applies to other severe personality disorders, especially narcissistic personality disorder. We describe the interpersonal hypersensitivity model used in GPM as a straightforward way for clinicians to collaborate with patients in organizing approaches to psychoeducation, treatment goals, case management, use of multiple treatment modalities, and safety. A modification of the interpersonal hypersensitivity model that includes intra-personal hypersensitivity can be used to address narcissistic problems often present in borderline personality disorder. We argue that these features make GPM ideally suited for psychiatry residents in treating their most challenging patients, provide clinical examples to illustrate these points, and report the key lessons learned by a psychiatry resident after a year of GPM supervision.

Evaluating the Quality of Rural Intensive Case Management Services using Administrative Data: an Exploratory Study

Assertive Community Treatment (ACT) for people with severe mental illness is an effective approach that is increasingly implemented in rural areas. Low-cost methods of evaluating fidelity to program models are needed to assure services are delivered as intended. In 2007, the Veterans Health Administration implemented an ACT-like Mental Health Intensive Case Management (ACT/ICM) program for SMI veterans in rural areas. This study demonstrates the use of administrative data, reflecting patient characteristics and intensity of service delivery, to characterize services delivered by these programs, to compare them to general mental health programs at the same VA medical centers, and to each other. A total of 298,509 veterans received mental health services at VA medical centers that also operated a rural ACT/ICM program in FY 2012. Altogether 854 (0.29%) received ACT/ICM services for 1 year or more (long term participants) and 259 (.09%) received them for less than 1 year (new entrants). Logistic regression showed ACT/ICM patients were distinguished by diagnoses of schizophrenia, bipolar disorder, and major depression; larger numbers of psychiatric or substance abuse visits; and use of 3 or more classes of psychotropic medication. The model had a high c statistic of 0.91. Propensity scores allowed clear identification of programs most and least conforming to the profile of a "typical" rural ACT/ICM program. Low cost administrative data can be used to identify programs successfully conforming to an empirically derived rural model of ACT/ICM. Further validation of this approach is needed.

Delirium tremens and alcohol withdrawal nationally in the Veterans Health Administration

BACKGROUND AND OBJECTIVES

Alcohol withdrawal-especially delirium tremens (DT)-is a potentially life-threatening condition. While short-term treatment regimens and factors that predispose to more severe symptomatology have been extensively studied, little attention has been paid to the clinical epidemiology and long-term care of the chronic medical, addictive, psychiatric, and psychosocial problems faced by these patients.

METHODS

National Veterans Health Administration data from fiscal year 2012 were examined to identify veterans diagnosed with DT; with withdrawal but not DT (WNDT); and with Alcohol Use Disorder (AUD) but neither DT nor WNDT. They were compared on sociodemographic characteristics, psychiatric and medical co-morbidities, and health service and psychotropic medication use, first with bivariate analyses and then multiple logistic regression.

RESULTS

Among the 345,297 veterans diagnosed with AUD, 2,341 (0.7%) were diagnosed with DT and 6,738 (2.0%) with WNDT. Veterans diagnosed with either WNDT or DT were more likely to have been homeless, had more comorbid medical and psychiatric disorders, were more likely to be diagnosed with drug use disorders, utilized more health services, received more psychotropic medications, and were more likely to receive naltrexone. They were more likely to receive specialized legal, housing, vocational, and psychosocial rehabilitation services, as well as intensive case management.

CONCLUSIONS

Adults with WNDT and DT suffer from multiple chronic conditions and long-term service models are needed to coordinate the work of multiple specialists and to assure continuity of care.

SCIENTIFIC SIGNIFICANCE

This national study identifies sociodemographic characteristics, comorbidities, and service utilization patterns associated with WNDT and DT.(Am J Addict 2017;26:722-730).

Addressing Structural Barriers to HIV Care among Triply Diagnosed Adults: Project Bridge Oakland

People who are "triply diagnosed" with HIV, mental health issues, and substance-related disorders face tremendous barriers connecting to and remaining in HIV care. Authors of this article implemented Project Bridge Oakland (PBO), an intervention based on harm reduction and trauma-informed care, to help maintain continuity of care for triply diagnosed adults through cycles of criminal justice involvement. From August 2011 to December 2014, a clinical social worker and an HIV physician provided intensive case management for 19 clients living in Oakland, California. By working with clients across a multitude of community, clinic, and correctional spaces while maintaining a low threshold for services, the social worker was able to engage a severely marginalized population in HIV care. This article details the PBO strategies for assisting with a wide range of services needed for community stabilization, navigating criminal justice involvement, and establishing a therapeutic relationship through mundane practices such as eating and waiting for appointments. This article illustrates how programs aimed at stabilizing triply diagnosed clients in the community and connecting them to HIV care require coordination among providers, outreach to engage clients, ample time to work with them, and flexibility to account for the complexities of their day-to-day lives and experiences.

Symptoms, functioning and quality of life after treatment in a residential sub-acute mental health service in Australia

The aim of this study was to assess clients' and service providers' perspectives on changes in mental health after an admission to a residential recovery-focused, sub-acute service, in Australia. Clients were either step-up clients, entering the service directly from the community, or step-down clients who were transitioning from an inpatient unit to home. During the 30-month period of data collection (August 2011 to January 2014) all clients (N = 102) were invited to participate in the longitudinal study and 41 clients consented to be involved (38% response rate). At admission and exit, participants completed the Behaviour and Symptom Identification Scale (Basis-32) and service providers completed the Life Skills Profile-16 and Health of the Nations Outcome Scales. Follow-up data 3 months after exit were available for 12 clients, including the Basis-32 and a self-report measure of quality of life (Assessment of Quality of Life 8-dimension). Both client groups reported positive improvements between admission and exit in the areas of relation to self and others, psychosis, daily living and presence of depression or anxiety symptoms. Service providers reported gains for clients in the areas of self-care, level of symptoms and presence of social problems. At 3 months, clients generally reported positive quality of life, although there was no significant change in symptoms and functioning. This study demonstrates that after an admission to a sub-acute service, step-up clients experience an improvement in their symptoms and functioning, have avoided a hospital admission and are well enough to return home. Step-down clients also experience further improvements in their symptoms and functioning, indicating that the service has assisted them in their transition to independent living after a hospital admission. Sub-acute residential units provide a continuation of care for inpatients preparing to return home, and people with a mental health problem living in the community who experience an escalation in symptoms and prefer an alternative to hospital.

Lessons From Medicaid's Divergent Paths On Mental Health And Addiction Services

Over the past fifty years Medicaid has taken divergent paths in financing mental health and addiction treatment. In mental health, Medicaid became the dominant source of funding and had a profound impact on the organization and delivery of services. But it played a much more modest role in addiction treatment. This is poised to change, as the Affordable Care Act is expected to dramatically expand Medicaid's role in financing addiction services. In this article we consider the different paths these two treatment systems have taken since 1965 and identify strategic lessons that the addiction treatment system might take from mental health's experience under Medicaid. These lessons include leveraging optional coverage categories to tailor Medicaid to the unique needs of the addiction treatment system, providing incentives to addiction treatment programs to create and deliver high-quality alternatives to inpatient treatment, and using targeted Medicaid licensure standards to increase the quality of addiction services.

"Sometimes What They Think is Helpful is Not Really Helpful": Understanding Engagement in the Program of Assertive Community Treatment (PACT)

This exploratory study recruited a purposive sample of twelve clinical staff from a Program of Assertive Community Treatment (PACT) team in central Virginia to understand the perceptions and experiences related to assertive engagement. The researchers coded the transcribed data initially as twenty-three sub-themes and further refined the data into four overarching themes: characteristics of assertive engagement, PACT engagement strategies and engagement strategies for difficult to engage clients. Further analysis emphasized that PACT team members emphasized the importance of the therapeutic relationship for engagement, which proves challenging for hard-to-engage clients.