Augmenting Evidence-Based Care With a Texting Mobile Interventionist: A Pilot Randomized Controlled Trial

OBJECTIVE

This study aimed to evaluate the feasibility and clinical utility of training intensive psychiatric community care team members to serve as "mobile interventionists" who engage patients in recovery-oriented texting exchanges.

METHODS

A 3-month pilot randomized controlled trial was conducted to compare the mobile interventionist approach as an add-on to assertive community treatment (ACT) versus ACT alone. Participants were 49 individuals with serious mental illness (62% with schizophrenia/schizoaffective disorder, 24% with bipolar disorder, and 14% with depression). Clinical outcomes were evaluated at baseline, posttreatment, and 6-month follow-up, and satisfaction was evaluated posttreatment.

RESULTS

The intervention appeared feasible (95% of participants assigned to the mobile interventionist arm initiated the intervention, texting on 69% of possible days and averaging four messages per day), acceptable (91% reported satisfaction), and safe (no adverse events reported). Exploratory posttreatment clinical effect estimations suggested greater reductions in the severity of paranoid thoughts (Cohen's d=-0.61) and depression (d=-0.59) and improved illness management (d=0.31) and recovery (d=0.23) in the mobile interventionist group.

CONCLUSIONS

Augmentation of care with a texting mobile interventionist proved to be feasible, acceptable, safe, and clinically promising. The findings are encouraging given the relative ease of training practitioners to serve as mobile interventionists, the low burden placed on patients and practitioners, and the simplicity of the technology. The technical resources are widely accessible to patients and practitioners, boding well for potential intervention scalability. When pandemics such as COVID-19 block the possibility of in-person patient-provider contact, evidence-based texting interventions can serve a crucial role in supporting continuity of care.

ACT and Recovery: What We Know About Their Compatibility

While assertive community treatment (ACT) is a widely implemented evidence-based practice, the extent of its recovery orientation has been debated. A literature search identified 16 empirical articles studying recovery and ACT. These 16 studies were classified as involving stakeholder perceptions, interventions, or fidelity measurement. Stakeholders generally viewed ACT as being recovery oriented; research on both interventions and fidelity measurement showed promising approaches. Overall the literature yielded encouraging findings regarding ACT and recovery, though there remains a dearth of research on the topic. We discuss future directions for research and practice to ensure that ACT programs skillfully support recovery.

A Review of Economic Evaluations of Community Mental Health Care

The authors review the methodology and findings of economic evaluations of 42 community mental health care programs reported in the English-language literature between 1979 and 2003. There were three substantial methodological problems in the literature: costs were often not completely specified, the quality of econometric analysis was often low, and most evaluations failed to integrate cost and health outcome information. Well-conducted research shows that care in the community dominates hospital in-patient care, achieving better outcomes at lower or equal cost. It is less clear what types of community programs are most cost-effective. Future research should focus on identifying which types of community care are most cost effective and at what level of intensity they are most effective.

Choice of service provider: how consumer self-determination shaped a psychiatric rehabilitation program

OBJECTIVE

To document the impact of consumer self-selection of service providers on their service receipt and attendance in a psychiatric rehabilitation program.

METHODS

Staff (8 FTE) in a new drop-in resource center tracked their service activities and contacts with consumers using daily service logs. Consumers (N = 46) checked their service needs at enrollment, and recorded their attendance on daily sign-in sheets. Regression analyses were conducted to examine correlations between these service measures and each consumer's count of key providers, with key provider defined as any staff worker with whom the consumer logged the equivalent of more than a full workday of contact (9+ hours) during a 6-month study period.

RESULTS

Service log findings suggest that key service providers were chosen by consumers through informal social interactions with staff. Members who had more key providers were more active in the program and more likely to have checked a need for psychiatric care at enrollment. In spite of member choice of provider, caseloads remained small and staff were able to dedicate their time to services related to their specialty training.

CONCLUSIONS

Facility-based programs can encourage consumer self-selection of service providers without overloading staff or restricting specialty services if they provide ample time for staff and consumers to get to know one another in informal social interactions.

ACT and recovery: integrating evidence-based practice and recovery orientation on assertive community treatment teams

We examine whether Assertive Community Treatment (ACT), a widely implemented and rigorously studied practice, can successfully incorporate a recovery-oriented approach while continuing to retain program fidelity. We briefly review the effectiveness of ACT as an evidence-based practice, with a focus on adaptations to changing populations and contexts. We explore philosophical similarities and differences between ACT and recovery and examine how fidelity standards, a widely used indicator of how ACT teams operate, support or interfere with the adoption of a recovery-oriented practice. Finally, we provide recommendations on how best to incorporate a recovery orientation into existing ACT teams.

Intensive case management: a critical re-appraisal of the scientific evidence for effectiveness

Intensive Case Management (ICM) is widely claimed to be an evidence-based and cost effective program for people with high levels of disability as a result of mental illness. However, the findings of recent randomized controlled trials comparing ICM with 'usual services' suggest that both clinical and cost effectiveness of ICM may be weakening. Possible reasons for this, including fidelity of implementation, researcher allegiance effects and changes in the wider service environment within which ICM is provided, are considered. The implications for service delivery and research are discussed.

Outpatient commitment: the state of empirical research on its outcomes

This article briefly describes the historical conditions in the origin and development of outpatient commitment that framed the discourse on its merits and the empirical studies on its outcomes. It divides those empirical studies into two sets on the basis of the questions addressed and critically reviews them. The review pays particular attention to the latest studies that were able to randomize subjects to experimental and control conditions and that were able to offer enhanced services. Finally, this article presents issues not addressed by the empirical studies on outpatient commitment but that need to be addressed in order to understand the choice of using the law to force persons with mental illness to comply with treatment and receive services in the community.

Meta-analysis: Methods, strengths, weaknesses, and political uses

The general methodology, strengths and weaknesses, and political uses of meta-analysis are examined. As a systematic study of all studies that have been conducted to answer a specific question or hypothesis, meta-analysis is strong in revealing structural flaws and sources of bias in primary research and in posing promising research questions for future study. It cannot exceed, however, the limits of what is reported by primary researchers. Meta-analysis is particularly challenged to quantify the size of a common effect of treatment across reported trials because of (1) the clinical diversity of the trials and (2) the myriad of potential differences among patients with varying characteristics within the trials. Without access to the original data of reported trials, meta-analysis cannot overcome the bias of underpowered trials toward overstatement of the size of main treatment effects, nor the tendency for such trials to falsely conclude there were no statistically significant adverse events. Although severely compromised by ghost-written or honorary-authored reports of primary research, meta-analysis can make use of its methods to focus on the conflicts of interest and likely sources of bias of such research and make known what precautions should be taken by would-be consumers. Examples show how meta-analysis has clarified thinking about the off-label use of selective serotonin reuptake inhibitors for treating child and adolescent depression, use of low-tidal volume respirator assistance for acute lung injury and acute respiratory distress syndrome patients, and the long-term use of COX-2 inhibitors for relieving arthritic pain. Recommendations are made for Congressional action.