Improved Rehabilitation Outcomes for Persons With and Without Problematic Substance Use After 2 Years With Assertive Community Treatment-A Prospective Study of Patients With Severe Mental Illness in 12 Norwegian ACT Teams

Background: Persons with severe mental illness often face difficulties in accessing and receiving adequate services enabling them to live independently. Many have co-occurring substance use problems that increase the risk of adverse outcomes. Community-based service models have been implemented around the world, including assertive community treatment (ACT), but the knowledge of rehabilitation outcomes in different subgroups is limited. We aimed to explore rehabilitation outcomes among patients suffering severe mental illness with and without substance use problems who had received ACT services for at least 2 years. Additionally, we compared differences in changes between the two groups. Methods: A total of 142 patients who received services for 2 years from the first 12 Norwegian ACT teams were included. Eighty-four (59%) had problematic substance use, while 58 (41%) did not. Data regarding housing, activity, symptoms, functioning, and subjective quality of life were collected upon enrollment into ACT and at 2 years of follow-up. Clinician-rated scales and self-report questionnaires were used. Changes within the two groups and differences in change between the groups were assessed using generalized linear mixed models. Results: Both groups were more likely to have good housing, higher level of functioning, and less anxiety and depressive symptoms after 2 years. The odds of good housing among participants with problematic substance use increased only after adjusting for age and gender. Participants with problematic substance use had less severe symptoms, particularly negative and manic symptoms, while participants without problematic substance use reported improved satisfaction with life in general. Neither group experienced a change in having a meaningful daily activity, positive symptoms, practical and social functioning, or subjective quality of life. The reduction of manic symptoms in the substance use group was the only difference between the groups. Conclusion: After 2 years, patients with and without problematic substance use experienced improvements in several important domains. Furthermore, the improvements were similar in both groups for most outcomes. This may suggest that ACT has a place in the continued effort toward integrated and comprehensive community services empowering patients with severe mental illness to achieve and sustain an independent life, including marginalized groups with severe substance use.

Model fidelity and team members' experiences of assertive community treatment in Norway: a sequential mixed-methods study

Background

Assertive community treatment (ACT) is an evidence-based treatment for people with severe mental illness, and this model is used widely throughout the world. Given the various adaptations in different contexts, we were interested in studying the implementation and adaptation of the ACT model in Norway. The first 12 Norwegian ACT teams were established between 2009 and 2011, and this study investigated the teams' model fidelity and the team members' experiences of working with ACT.

Methods

To investigate implementation of the ACT model, fidelity assessments were performed 12 and 30 months after the teams started their work using the Tool for Measurement of Assertive Community Treatment (TMACT). Means and standard deviations were used to describe the ACT teams' fidelity scores. Cohen's effect size d was used to assess the changes in TMACT scores from the first to second assessment. Qualitative focus group interviews were conducted in the 12 teams after 30 months to investigate the team members' experiences of working with the ACT model.

Results

The fidelity assessments of the Norwegian teams showed high implementation of the structural and organizational parts of the ACT model. The newer parts of the model, the recovery and evidence-based practices, were less implemented. Four of the six subscales in TMACT improved from the first to the second assessment. The team members experienced the ACT model to be a good service model for the target population: people with severe mental illness, significant functional impairment, and continuous high service needs. Team members perceived some parts of the model difficult to implement and that it was challenging to find effective ways to collaborate with existing health and social services.

Conclusion

The first 12 Norwegian ACT teams implemented the ACT model to a moderate degree. The ACT model could be implemented in Norway without extensive adaptations. Although the team members were satisfied with the ACT model, especially the results for their service users, inclusion of the ACT team to the existing service system was perceived as challenging.

How clinicians make decisions about CTOs in ACT: a qualitative study

BACKGROUND

The first 12 Norwegian assertive community treatment (ACT) teams were piloted from 2009 to 2011. Of the 338 patients included during the teams' first year of operation, 38% were subject to community treatment orders (CTOs). In Norway as in many other Western countries, the use of CTOs is relatively high despite lack of robust evidence for their effectiveness. The purpose of the present study was to explore how responsible clinicians reason and make decisions about the continued use of CTOs, recall to hospital and the discontinuation of CTOs within an ACT setting.

METHODS

Semi-structured interviews with eight responsible clinicians combined with patient case files and observations of treatment planning meetings. The data were analysed using a modified grounded theory approach.

RESULTS

The participants emphasized that being part of a multidisciplinary team with shared caseload responsibility that provides intensive services over long periods of time allowed for more nuanced assessments and more flexible treatment solutions on CTOs. The treatment criterion was typically used to justify the need for CTO. There was substantial variation in the responsible clinicians' legal interpretation of dangerousness, and some clinicians applied the dangerousness criterion more than others.

CONCLUSIONS

According to the clinicians, many patients subject to CTOs were referred from hospitals and high security facilities, and decisions regarding the continuation of CTOs typically involved multiple and interacting risk factors. While patients' need for treatment was most often applied to justify the need for CTOs, in some cases the use of CTOs was described as a tool to contain dangerousness and prevent harm.

Responsibilities with conflicting priorities: a qualitative study of ACT providers' experiences with community treatment orders

Background

Patients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment. Few studies have investigated the use of CTOs within an Assertive Community Treatment (ACT) setting, and little is known about how the tension between the patients’ autonomy and the clinicians’ responsibility to act in the patients’ best interest are resolved in practice. The aim of this study was to explore the service providers’ experiences with CTOs within an ACT setting.

Methods

The study was based on reviews of case files of 15 patients, eight individual qualitative in depth interviews and four focus group interviews with service providers involved in ACT and decisions related to CTOs. A modified grounded theory approach was used to analyze the data.

Results

The main theme ‘responsibility with conflicting priorities’ emerged from data analysis (case file reviews, individual interviews and focus group interviews). The balance between coercive approaches and the emphasis on promoting patient autonomy was seen as problematic. The participants saw few alternatives to CTOs as long-term measures to secure ongoing treatment for some of the patients. However, participants perceived the ACT model’s comprehensive scope as an opportunity to build rapport with patients and thereby better meet their needs. The team approach, the ACT providers’ commitment to establish supportive relationships and the frequent meetings with patients in their home environment were highlighted. The ACT approach gave them insight into patients’ everyday lives and, in some cases a greater sense of security when considering whether to take patients off CTOs.

Conclusions

Many of the participants viewed CTOs as helpful in securing long-term treatment for patients. CTO decision-making was described as challenging and complex and presented the providers with many dilemmas. The ACT approach was considered as helpful in that it afforded comprehensive, patient-centered support and opportunities to build rapport.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3097-7) contains supplementary material, which is available to authorized users.

Hospitalisation of severely mentally ill patients with and without problematic substance use before and during Assertive Community Treatment: an observational cohort study

BACKGROUND

Co-occurring substance use increases the risk of hospitalisation in people with severe mental illness, whereas Assertive Community Treatment (ACT) generally reduces hospitalisation in patients with severe mental illness and high inpatient service use. Because the superiority of ACT over standard services amongst patients with problematic substance use is uncertain, the present study examined inpatient service use amongst patients with and without problematic substance use in the 2 years before and the 2 years after they enrolled into ACT teams.

METHODS

This naturalistic observational study included 142 patients of 12 different ACT teams throughout Norway. The teams assessed the patients upon enrolment into ACT using clinician-rated and self-reported questionnaires. We obtained hospitalisation data from the Norwegian Patient Register for the 2 years before and the 2 years after enrolment into ACT. We used linear mixed models to assess changes in hospitalisation and to explore associations between problematic substance use and changes in hospitalisation, controlling for socio-demographic and clinical characteristics.

RESULTS

A total of 84 (59%) participants had problematic substance use upon enrolment into the ACT teams. In the 2 years after ACT enrolment both participants with and without problematic substance use experienced a reduction in total inpatient days. Those with problematic substance use also had fewer involuntary inpatient days. Exploratory analyses suggested that symptom severity and functioning level interacted with problematic substance use to influence change in total inpatient days.

CONCLUSION

These findings may suggest that ACT teams successfully support people with complex mental health problems in the community, including those with problematic substance use, and thereby contribute to a reduction in inpatient service use.

Hospitalization of high and low inpatient service users before and after enrollment into Assertive Community Treatment teams: a naturalistic observational study

Background

Assertive Community Treatment (ACT) is more successful in reducing hospitalization when baseline use is high. However, with a growing recovery-focus, ACT may be useful for people with severe mental illness who are difficult to engage but not high users of inpatient services. This study investigated hospitalization 2 years before and 2 years after ACT enrollment amongst patients both with and without high inpatient services use before enrollment into ACT.

Methods

This naturalistic observational study included 142 patients from 12 different ACT teams throughout Norway. Of these, 74 (52 %) were high users of inpatient services before ACT. The teams assessed the patients upon enrollment using clinician-rated and self-reported questionnaires. Hospitalization data from 2 years before and 2 years after enrollment into ACT were obtained from the Norwegian Patient Registry. Linear mixed models were used to assess changes in hospitalization and to explore associations between these changes and patient characteristics.

Results

When the participants enrolled into the ACT teams, high users of inpatient care were younger, more often living alone and more often subject to involuntary outpatient treatment than low users. The participants spent significantly fewer days in hospital during the 2 years of ACT follow-up compared to the 2 years before enrollment. The reduction was more evident amongst high users, whereas low users had an initial increase in inpatient days in the first year of ACT and a subsequent decrease in the second year. More severe negative symptoms and previous high use of inpatient care were associated with a reduction in both total and involuntary inpatient days. Additionally, a reduction in involuntary inpatient days was associated with being subject to involuntary outpatient treatment upon enrollment into ACT.

Conclusion

The findings in this study may suggest that ACT contributes to more appropriate use of inpatient care, possibly by reducing the presumably avoidable hospitalization of high users and increasing the presumably needed inpatient care of low users.

Associations Between Quality of Life and Functioning in an Assertive Community Treatment Population

OBJECTIVE

Level of functioning is positively associated with subjective quality of life for people with severe mental illness, but a detailed relationship between functioning and satisfaction with various life domains is largely unknown, and this gap prompted this study.

METHODS

Demographic and clinical data were obtained from 149 patients engaged with 12 assertive community treatment teams in Norway. Multivariate regression analyses were used to explore associations between subjective quality of life and patient characteristics.

RESULTS

Analyses confirmed positive associations between quality of life and age, functioning, and weekly contact with family and friends and a negative association with anxiety and depressive symptoms. Positive associations between several areas of practical and social functioning and satisfaction with related life domains also were found.

CONCLUSIONS

Although a causal direction of the associations between functioning and life satisfaction has not been determined in this study, the positive findings might indicate that programs aiming to improve functioning could affect patients' quality of life.

Increased influence and collaboration: a qualitative study of patients' experiences of community treatment orders within an assertive community treatment setting

Background

Since 2009, 14 assertive community treatment (ACT) teams have started up in Norway. Over 30 % of the patients treated by the ACT teams were subject to community treatment orders (CTOs) at intake. CTOs are legal mechanisms to secure treatment adherence for patients with severe mental illness. Little is known about patients’ views and experiences of CTOs within an ACT context.

Methods

The study was based on qualitative in depth interviews with 15 patients that were followed up by ACT teams and that were currently subjected to CTOs. The data were analyzed by using a modified grounded theory approach.

Results

While some participants experienced the CTO as a security net and as an important factor for staying well, others described the CTO as a social control mechanism and as a violation of their autonomy. Although experiencing difficulties and tensions, many participants described the ACT team as a different mental health arena from what they had known before, with another frame of interaction. Despite being legally compelled to receive treatment, many participants talked about how the ACT teams focused on addressing unmet needs, the management of future crises, and finding solutions to daily life problems. Assistance with housing and finances, reduced social isolation, and being able to seek help voluntarily were positive outcomes emphasized by many patients.

Discussion

The participants had different views of being on a CTO within an ACT setting. While some remained clearly negative to the CTO, others described a gradual transition toward regarding the CTO as an acceptablesolution as they gained experience of ACT. Many of the participants valued the supportive relationship withthe ACT team, and communication with the care providers and the care providers’ attitudes could make a significant difference. The study shows that the perception of coercion is context dependent, and that the relationship between care providers and patients is of importance to how patients interpret the providers’ behavior and the restrictive interventions.

Conclusions

Although some patients focused on loss of autonomy and being compelled to take medications, other patients emphasised the supportive relationships they had with the ACT teams and that they had received help with housing, finances, and other daily life problems. Thus, being on mandated community treatment could be acceptable in the opinion of several of the patients, provided that they received other services that they found beneficial.