Assertive community treatment in UK practice

Difficult-to-Engage Patients with Severe Mental Illness in Rural Community Settings: Results of the Greek Hybrid Assertive Community Treatment Model of Mental Healthcare

Background: Modified Assertive Community Treatment (ACT) in rural settings may be effective in the care of patients with severe mental illness (SMI) that are difficult to engage in community care. The objective of the present study was to explore the impact of the care by a hybrid ACT team on SMI patients' hospitalizations, length of hospital stay, symptomatology and functioning in a rural community treatment setting in Greece. Methods: The hybrid ACT team is an expansion of the services of the well-established generic Mobile Mental Health Unit in a rural area of Northwest Greece, and delivers home-based care for patients with SMI. This was a 3-year prospective, mirror image, pre-post observational study. Patients' symptomatology, functioning and general outcome were measured with the use of the Brief Psychiatric Rating Scale (BPRS), the Global Assessment of Functioning Scale (GAF), and the Health of the Nation Outcome Scale (HοNOS). Results: The mean age of the 23 enrolled patients was 52.4 years and the mean age of disease onset was 23.5 years, with a mean number of hospitalizations 10.74. Over the 16-month follow-up patients' hospitalizations, both voluntary and involuntary, had been significantly reduced by almost 80%. Length of hospital stay had been significantly reduced by 87%, whereas patients' functioning and symptomatology had been significantly improved, by 17% and 14.5%, respectively. Conclusions: The model of hybrid ACT in rural areas in Greece may be effective in the treatment of difficult-to-engage patients with SMI and may improve patients' outcomes.

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.

Identifying characteristics and practices of multidisciplinary team reviews for patients with severe mental illness: a systematic review

OBJECTIVES

Multidisciplinary teams in mental health receive limited guidance, leading to inconsistent practices. We undertook a systematic review of the characteristics and practices of multidisciplinary team reviews for patients with severe mental illness or in relevant mental health service settings.

METHODS

Sources published since 2000 were located via academic database and web searches. Results were synthesised narratively.

RESULTS

A total of 14 sources were analysed. Important characteristics and practices identified included routine monitoring and evaluation, good communication, equality between team members, and clear documentation practices. Success factors included defined leadership and clear team goals. Four sources described considerations for patients with complex clinical needs, including allocating sufficient time for discussion, maintaining connections with community providers, and ensuring culturally sensitive practices.

CONCLUSIONS

No single best practice model was found, due to variations in team caseload, casemix, and resourcing levels. However, key ingredients for success were proposed. Sources were mostly descriptive; there remains a lack of evidence-based guidance regarding multidisciplinary team review characteristics and practices.

Assessment of Distress and Quality of Life: A Comparison of Self-Assessments by Outpatients with a Schizopsychotic Illness and the Clinical Judgment of Nurses

The aim of this study was to investigate how self-assessments of perceived distress and quality of life in patients with schizopsychotic illness are associated with nurse assessments of symptoms, function and life situation. Data were obtained through interviews that used evidence-based rating and visual analogue self-rating scales. Descriptive statistics, correlation and regression analyses were used to process the data. The results demonstrated that the patient self-ratings did not correlate with the nurse assessments, and the perceived distress was not affected by remission status. The findings indicate that patient self-assessments are not a sufficient basis for decisions regarding appropriate treatment interventions.

Effects of interferential care: a community-based care program for persons with severe problems on several life areas

BACKGROUND AND AIMS

Interferential care differs from the current community-based care programs in that it targets a larger, heterogeneous group and combines brokerage and full service elements in a multi-organizational care team. The team provides all the services itself, but with the aim to prepare clients within a few months for referral to regular (ambulant) healthcare services. The aim of this study was to assess the effectiveness of interferential care.

METHODS

In a multisite, pretest-posttest design, 523 patients of three interferential care teams were followed. Quality of life, problem severity, problems with referral and engagement were assessed at baseline, at referral and again after 6 months. Analyses were performed using linear mixed modeling.

RESULTS

Interferential care showed moderate to strong effects on quality of life and problem severity. These effects persisted (quality of life) or further improved (problem severity) until follow-up 6 months after referral to regular services. There were also small effects on both engagement and problems with referral.

CONCLUSION

Interferential care offers significant improvements in quality of life and problem severity in persons who have severe problems on several life areas and who are currently not reached by healthcare services. It is a promising community-based care program for healthcare systems in which regular care already contains many elements of home-based practice.

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

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

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

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

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

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

Nidotherapy for people with schizophrenia

BACKGROUND

Nidotherapy is a therapeutic method that principally aims to modify the environment of people with schizophrenia and other serious mental illnesses, whilst working in conjunction with, or alongside other treatments. Rather than focusing on direct treatments or interventions, the aim is to help the individual identify the need for, and work to effect environmental change with the aim of minimising the impact of any form of mental disorder on the individual and society.

OBJECTIVES

To review the effects of nidotherapy added to standard care, compared with standard care or no treatment for people with schizophrenia or related disorders.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (December 2011) and supplemented this by contacting relevant study authors, handsearching nidotherapy articles and manually searching reference lists.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that compared nidotherapy with standard care or no treatment.

DATA COLLECTION AND ANALYSIS

We independently selected and quality assessed potential trials. We reliably extracted data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data. Scale data were only extracted from valid scales. For non-skewed continuous endpoint data, we estimated mean difference (MD) between groups. Skewed data have been presented in the Data and analyses as 'other data', with acknowledged means and standard deviations. We assessed risk of bias for the included study and used GRADE to create a 'Summary of findings' table.

MAIN RESULTS

We included only one study that compared nidotherapy-enhanced standard care with standard care alone (total 52 participants); this study was classified by its authors as a 'pilot study'. The duration of the included study was 18 months in total. The single study examined the short-term (up to six months) and medium-term (between six and 12 months) effects of nidotherapy-enhanced standard care versus standard care.Nidotherapy-enhanced standard care was favoured over standard care for social functioning in both the short term (n = 50, 1 RCT, MD -2.10, 95% CI -4.66 to 0.46) and medium term (n = 37, 1 RCT, MD -1.70, 95% CI -4.60 to 1.20, Very low quality); however, these results did not reach statistical significance. Results concerning engagement with non-inpatient services favoured the intervention group in both the short term (n = 50, 1 RCT, MD 2.00, 95% CI 0.13 to 3.87) and medium term (n = 37, 1 RCT, MD 1.70, 95% CI -0.09 to 3.49), with statistical significance evident in the short term, but not in the medium term. Results of people leaving the study early favoured the intervention in the short term (n = 52, 1 RCT, RR 0.86, 95% CI 0.06 to 12.98), with slight favour of the control group at medium term (n = 50, 1 RCT, RR 0.99, 95% CI 0.39 to 2.54); again, these results did not reach statistical significance. Results for the adverse effects/events of death (measured by 12 months) favoured the intervention (n = 52, 1 RCT, RR 0.29, 95% CI 0.01 to 6.74, Very low quality) but with no statistical significance. Skewed results were available for mental state, service use, and economic outcomes, and present a mixed picture of the benefits of nidotherapy.

AUTHORS' CONCLUSIONS

Further research is needed into the possible benefits or harms of this newly-formulated therapy. Until such research is available, patients, clinicians, managers and policymakers should consider it an experimental approach.

Treatment outcome in patients receiving assertive community treatment

In an observational study of severely mentally ill patients treated in assertive community treatment (ACT) teams, we investigated how treatment outcome was associated with demographic factors, clinical factors, and motivation for treatment. To determine psychosocial outcome, patients were routinely assessed using the Health of the Nation Outcome Scales (HoNOS). Trends over time were analyzed using a mixed model with repeated measures. The HoNOS total score was modeled as a function of treatment duration and patient-dependent covariates. Data comprised 637 assessments of 139 patients; mean duration of follow-up was 27.4 months (SD = 5.4). Substance abuse, higher age, problems with motivation, and lower educational level were associated with higher HoNOS total scores (i.e., worse outcome). To improve treatment outcome, we recommend better implementation of ACT, and also the implementation of additional programs targeting subgroups which seem to benefit less from ACT.