Assertive Community Treatment Research Articles

Adding Suicide Prevention to the Triple Advantages of Injectable Long-Acting Second-Generation Antipsychotics

With the advent of new treatment perspectives for schizophrenic patients, long-acting injectable antipsychotics promise to provide relapse prevention, neuroprotection, and lower mortality rates (1). In preliminary studies, scholars have also indicated that such treatments could play a central role in suicide prevention in patients (2, 3) for whom suicide is the most likely cause of premature death, in addition to repercussions for caregivers and clinicians. Both Kraepelin (4) and Bleuler (5) highlighted the issue of suicide risk among patients suffering from schizophrenia. Modern studies provided an intricate list of risk factors for suicide, pointing to numerous issues in the management and treatment of schizophrenic patients. Individuals at higher risk are generally unmarried young white males who achieved proper functioning before the onset of the disorder (6). Such patients may easily be overwhelmed by hopelessness and depression, as well as becoming demoralized and being aware that their previous lifestyle cannot be maintained. Such patients feel socially isolated, fear further mental deterioration, have higher rates of substance abuse, and may lose faith in the treatments. Suicide attempts and hospitalizations are frequent, and each time they may realize that both medical and family support is limited; moreover, ad hoc interventions are not available or are difficult to implement. There are also further risk factors for suicide in schizophrenia, such as post-psychotic depression, agitation or motor restlessness, poor adherence to treatment, and command hallucinations (although not well ascertained in terms of statistical significance). However, risk factors often yield too many false positives, pointing to the need for suicide assessments based on factors such as an understanding of mental pain and demoralization, as well as therapeutic relationships, foreseeable life events that may impact the patient, social support, and the available resources. Furthermore, suicide risk is indirectly related to relapse, illness progression, the number of hospitalizations, and plans for rehabilitation after discharge (7). Each admission to a psychiatric ward may represent a further loss of hope and faith in the treatments. The risk of suicide seems to peak not only shortly after discharge, as reported routinely in the literature, but also shortly after admission (7). This fact points to the implementation of human–environmental factors for providing ward safety and close supervision in both inpatient and community settings, especially in the cases of reduced adherence to treatment. Among the various risk factors, preventative actions should be directed over those factors that are modifiable and can be targeted by proper treatment actions (8). Furthermore, suicide risk seems to be higher when patients develop demoralization syndrome, in which repeated exacerbations of psychotic symptoms, functional deterioration compared with premorbid abilities, and a non-delusional awareness of the effects of an illness can lead to feelings of hopelessness, depression, and, ultimately, suicide. Suicidal behavior is also a major issue among patients with first-episode psychosis (9, 10). It is noteworthy that integrated compared with typical treatment proved to be effective in reducing both suicide and other causes of death; the Opus Study (9) demonstrated the effectiveness of this strategy. Such an intervention involved a) assertive community treatment (ACT); b) antipsychotic medication; c) psychoeducational family treatment; and d) social skills training. It resulted in lower mortality for any cause and lower suicide rates. Mortality in Schizophrenia and Pharmacological Treatment A recent study by Bitter et al. (11) highlighted the reduction in life expectancy among patients with schizophrenia. Of note is the fact that, compared with the controls, 20-year-old males with schizophrenia had their life expectancy reduced by 11.5 years and females by 13.7 years; the analogous numbers for 45-year-old schizophrenics were 8.1 and 9.6 years, respectively. Taipale et al. (12) explored mortality in a large sample of approximately 30,000 patients and found that second-generation long-acting antipsychotic therapies [SG LATs; ranking: paliperidone palmitate > oral aripiprazole > long-acting injection (LAI) risperidone > LAI haloperidol > LAI perphenazine > oral perphenazine > LAI olanzapine > LAI zuclopenthixol] were associated with the lowest cumulative mortality rate. In 7.5 years, a follow-up SG LAT observation revealed the lowest cumulative mortality rate as compared with first-generation (FG) and SG oral and with no antipsychotic use. The use of LATs reduces the risk of death by 33% when compared to the corresponding oral equivalent. Such results are in line with further investigations by the same group of researchers (13), who reported their observations over 8 years. They observed that the risk of treatment failure or relapse after discontinuing antipsychotics does not decrease over time and that patients maintaining long-term antipsychotic treatment had increased survival rates.

A survey of national trends in psychiatric patients found incompetent to stand trial: reasons for the reinstitutionalization of people with serious mental illness in the United States.

Recent information indicates that the number of forensic patients in state hospitals has been increasing, largely driven by an increase in patients referred to state hospitals as incompetent to stand trial (IST). This survey was intended to broaden the understanding of IST population trends on a national level. The authors developed a 30-question survey to gather specific information on IST commitments in each state and the District of Columbia. The survey was administered to all 50 states and the District of Columbia via email. Specific individuals identified as primary administrators responsible for the care and evaluation of IST admissions in each state were contacted. A total of 50 out of the 51 jurisdictions contacted completed the survey. Fully 82% of states indicated that referrals for competency evaluation were increasing. Additionally, 78% of respondents thought referrals for competency restoration were increasing. When asked to rank factors that led to an increase, the highest ranked response was inadequate general mental health services in the community. Inadequate crisis services were the second ranked reason. Inadequate number of inpatient psychiatric beds in the community was the third highest, with inadequate assertive community treatment services ranking fourth. Understanding the national trend and causes behind the recent surge in referrals for IST admissions will benefit states searching for ways to remedy this crisis. Our survey indicates most states are facing this issue, and that it is largely related to insufficient services in the community.

Effectiveness of a housing support team intervention with a recovery-oriented approach on hospital and emergency department use by homeless people with severe mental illness: a randomised controlled trial.

Many people who are homeless with severe mental illnesses are high users of healthcare services and social services, without reducing widen health inequalities in this vulnerable population. This study aimed to determine whether independent housing with mental health support teams with a recovery-oriented approach (Housing First (HF) program) for people who are homeless with severe mental disorders improves hospital and emergency department use. We did a randomised controlled trial in four French cities: Lille, Marseille, Paris and Toulouse. Participants were eligible if they were 18 years or older, being absolutely homeless or precariously housed, with a diagnosis of schizophrenia (SCZ) or bipolar disorder (BD) and were required to have a high level of needs (moderate-to-severe disability and past hospitalisations over the last 5 years or comorbid alcohol or substance use disorder). Participants were randomly assigned (1:1) to immediate access to independent housing and support from the Assertive Community Treatment team (social worker, nurse, doctor, psychiatrist and peer worker) (HF group) or treatment as usual (TAU group) namely pre-existing dedicated homeless-targeted programs and services. Participants and interviewers were unmasked to assignment. The primary outcomes were the number of emergency department (ED) visits, hospitalisation admissions and inpatient days at 24 months. Secondary outcomes were recovery (Recovery Assessment Scale), quality of life (SQOL and SF36), mental health symptoms, addiction issues, stably housed days and cost savings from a societal perspective. Intention-to-treat analysis was performed. Eligible patients were randomly assigned to the HF group (n = 353) or TAU group (n = 350). No differences were found in the number of hospital admissions (relative risk (95% CI), 0.96 (0.76-1.21)) or ED visits (0.89 (0.66-1.21)). Significantly less inpatient days were found for HF v. TAU (0.62 (0.48-0.80)). The HF group exhibited higher housing stability (difference in slope, 116 (103-128)) and higher scores for sub-dimensions of S-QOL scale (psychological well-being and autonomy). No differences were found for physical composite score SF36, mental health symptoms and rates of alcohol or substance dependence. Mean difference in costs was €-217 per patient over 24 months in favour of the HF group. HF was associated with cost savings in healthcare costs (RR 0.62(0.48-0.78)) and residential costs (0.07 (0.05-0.11)). An immediate access to independent housing and support from a mental health team resulted in decreased inpatient days, higher housing stability and cost savings in homeless persons with SCZ or BP disorders.

Development and psychometric properties of a new brief scale for subjective personal agency (SPA-5) in people with schizophrenia.

Personal agency is a variable which potentially facilitates personal recovery in people with serious mental illness. This study aimed to develop a new brief measure for subjective personal agency that can be completed by people with serious mental illness. Two focus group interviews were first conducted with 11 people with schizophrenia to understand the fundamental components of subjective personal agency for people with serious mental illness living in the community. One group comprised six people with schizophrenia living in the community, while the other consisted of five people with schizophrenia working as peer-support workers. We then developed scale items through collaboration with people with schizophrenia and qualitative analysis (stage 1). A cross-sectional survey was then conducted to test the psychometric properties of the new scale among service users with schizophrenia in 18 assertive community treatment teams (stage 2). Factor validity was tested via exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). We evaluated convergent validity with the Boston University Empowerment Scale (BUES), divergent validity with the global assessment of functioning (GAF), internal consistency, and test-retest reliability. Seven items were included in the scale at stage 1. In stage 2, 195 participants completed this scale. EFA revealed a one-factor model with five items. CFA indicated good model fit (χ2 statistics [CMIN] = 8.445, df = 5 (CMIN/df = 1.689), p = 0.133, comparative fit index = 0.974, Tucker-Lewis fit index = 0.949, root mean square error of approximation = 0.077 and standardised root mean squared residual = 0.042). The new scale was significantly correlated with total BUES score (r = 0.526, p < 0.001), but not with GAF score. Cronbach's α for internal consistency was 0.79, and intra-class correlation coefficient for test-retest reliability was 0.70. We developed a new, five-item Subjective Personal Agency scale (SPA-5) that can be completed by people with serious mental illness. Further studies are needed to confirm the results outside Japan.

Reducing Violent Incidents between Police Officers and People with Psychiatric or Substance Use Disorders

This article describes evidence-based strategies designed to reduce the prevalence of police encounters with people in behavioral crisis (PBCs) and to make such encounters less dangerous for all parties when they do occur. Some of these strategies are implemented by law enforcement, including gun violence restraining orders and the training of officers to provide time, distance, and cover during encounters with PBCs. Other strategies involve broader systems of community care, including assertive community treatment for people with serious psychiatric disorders, and critical time interventions for individuals leaving incarceration or inpatient psychiatric care. Broader adoption of such strategies should both reduce the risk of police shootings of PBCs as well as improve the effectiveness and well-being of police officers.

Thirty years onward! Citation analysis of randomized experiments on drug and mental health courts

This study is meant to conduct the first known citation analysis on problem-solving courts (PSCs) using experimental designs. The use of citation analysis is meant to contribute to the experimental literature base by investigating the concept of “research quality.” Using Web of Science, Google Scholar, and ResearchGate, citation counts were performed on drug and mental health courts, excluding self-citations. The total number of citations for the experimental research was gathered, as well as a calculation of the average number of citations per year between 1989 and 2018. Additionally, a temporal analysis was conducted to demonstrate if certain citations were cited frequently initially after publication and then decayed over time. The most cited experiments were on drug courts (n = 12). Specifically, Gottfredson et al.’s (2003) randomized controlled trial on the effectiveness of drug courts amassed 309 citations of Google Scholar and yielded an average of 20.6 citations per year. The same study had 184 citations on ResearchGate, with an average of 12.26 citations per year. For mental health courts (n = 3), the most cited experiment was Cosden et al.’s (2005) evaluation of a mental health court with assertive community treatment, which had 199 citations on Google Scholar and an average of 13.27 citations per year. The study had 133 citations of ResearchGate, which is an average of 8.87 citations per year. The citation analysis presents an assessment of the most influential experiments regarding PSCs. The experimental research studies conducted by Gottfredson et al. (2003) and Cosden et al. (2005) were the most cited literature for drug court and mental health court, respectively, which contributes to the advancement of criminological research pertaining to PSCs.

Outreach to people who survive opioid overdose: Linkage and retention in treatment

Cognitive motivation theories contend that individuals have greater readiness for behavioral change during critical periods or life events, and a non-fatal overdose could represent such an event. The objective of this study was to examine if the use of a specialized mobile response team (assertive outreach) could help identify, engage, and retain people who have survived an overdose into a comprehensive treatment program. We developed an intervention, consisting of mobile outreach followed by medication and behavioral treatment, in Houston Texas between April and December 2018. Our primary outcome variables were the level of willingness to engage in treatment, and percent who retained in treatment after 30 and 90 day endpoints. We screened 103 individuals for eligibility, and 34 (33%) elected to engage in the treatment program, while two-thirds chose not to engage in treatment, primarily due to low readiness levels. The average age was 38.2 ± 12 years, 56% were male, 79% had no health insurance, and the majority (77%) reported being homeless or in temporary housing. There were 30 (88%) participants still active in the treatment program after 30 days, and 19 (56%) after 90 days. Given the high rates of relapse using conventional models, which wait for patients to present to treatment, our preliminary results suggest that assertive outreach could be a promising strategy to motivate people to enter and remain in long-term treatment.

THE EFFECT OF ASSERTIVE COMMUNITY TREATMENT TOWARDS ANXIETY AND DEPRESSION ON BREAST CANCER CLIENT

Background: Breast cancer increases the occurrence of psychosocial problems, namely anxiety and depression. Anxiety and depression have shown an effect on the quality of life. Assertive Community Treatment is a psychosocial service that involves the family's role in overcoming breast cancer client anxiety and depression.Objective: This study aimed to determine the effect of Assertive Community Treatment towards anxiety and depression of breast cancer clients.Method: The research design used was quasi-experiment with a pre-posttest control group design. This research subject determines by using purposive sampling. The study population was breast cancer clients who seek treatment at Public Health Center of Medokan Ayu in Surabaya. The sample is breast cancer clients who have inclusion criteria a) age 30-60 years old, b) live with her partner, c) has chronic pain ± 1-5 years. The instrument is PDQBC (Psychosocial Distress Questionnaire Breast Cancer subscales anxiety and depression. Data analysis used paired T-Test and Independent T-Test.Result: Paired T test results showed anxiety values in the treatment group p = 0.000, depression value p = 0.001. The results of the independent T test statistic obtained p value = 0.000 showed a significant difference between anxiety and depression of breast cancer clients in the control group and the treatment group.Conclusion: Assertive Community Treatment provides a good impact in order to reduce the level of anxiety and depression in clients with breast cancer. Assertive Community Treatment (ACT) is recommended to be given by teams. Key words: Assertive Community Treatment, Anxiety, Depression, Breast Cancer Clients, Palliative.

Assertive Community Programs for Patients with Severe Mental Disorders: Are Benefits Sustained After Discharge?

The benefits of assertive community treatment (ACT) on patients with severe mental disorders are well established over short or medium term. However, studies that investigate long term outcomes are remarkably scarce. Thus, this study aimed to evaluate patient's long term clinical and psychosocial evolution after discharge from ACT. An assessment was conducted on 29 patients characterized by inpatient facilities heavy use and refusal of care, who were included in an ACT program 8.7 (SD = 0.7) years ago and discharged 6.3 (SD = 1.8) years ago. Results of the follow up showed decreased rates of hospitalizations and symptomatology, as well as sustained improvement in adherence to care, in quality of life and in social functioning. This data suggests that ACT programs can help refractory to care patients to gain clinical and psychosocial improvement and lay foundation for better long-term adherence to care. Results also suggest that ACT didn't imply a lifetime treatment.

精神障害者家族会家族のACT（包括型地域生活支援プログラム）への期待と活動

精神障害者家族会家族のACT（包括型地域生活支援プログラム）への期待と活動

P.398 Effectiveness of an assertive outreach program for the treatment of schizophrenia in Belgium

We measured the longitudinal double spin asymmetries ALL for single hadron muoproduction off protons and deuterons at photon virtuality Q2<1(GeV/c)2 for transverse hadron momenta pT in the range 1GeV/c to 4GeV/c. They were determined using COMPASS data taken with a polarised muon beam of 160GeV/c or 200GeV/c impinging on polarised 6LiD or NH3 targets. The experimental asymmetries are compared to next-to-leading order pQCD calculations, and are sensitive to the gluon polarisation ΔG inside the nucleon in the range of the nucleon momentum fraction carried by gluons 0.05<xg<0.2.

The Role of Illness Identity in Assertive Community Treatment

Assertive community treatment (ACT) provides comprehensive clinical services, including vocational rehabilitation, to individuals with psychiatric disorders for which traditional community mental health services are insufficient. ACT is an evidence-based intervention yielding many positive outcomes, yet service recipients continue to struggle with workforce involvement. The purpose of this study is to determine whether internalized stigma, psychiatric hospitalization, and psychiatric symptoms are associated with work-related self-efficacy among ACT service recipients. A total of 72 individuals with severe mental illness were recruited from ACT programs in three counties in a Mid-Atlantic state. Multiple linear regression was conducted to examine the relationship between work-related self-efficacy and the independent variables of internalized stigma, psychiatric hospitalization, and psychiatric symptoms. Higher internalized stigma scores were negatively associated with work-related self-efficacy (β = −.31, t = −2.32, p &lt; .05), while psychiatric hospitalization in the past year was positively associated with work-related self-efficacy (β = .22−.27, t = −2.13, p &lt; .05). Findings from this study suggests internalized stigma to be an important recovery variable requiring the attention of ACT team members when preparing individuals for work, while countering the assumption that recent hospitalization is a barrier to work-related self-efficacy.

Innovation and Its Discontents: Pathways and Barriers in the Diffusion of Assertive Community Treatment.

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. 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. 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. 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.

Programme d’activité physique et troubles graves de santé mentale : étude de cas d’une équipe communautaire de traitement intensif (ÉCTI)

Context: As a therapeutic intervention, physical activity has the potential to improve the quality of life of individuals with severe mental illnesses.Objectives: The goal of this case study was to conduct an in-depth examination of an individualized physical activity program for patients suffering from severe mental illnesses that was implemented by an Assertive Community Treatment (ACT) team in Ottawa, Canada.Method: Using a mixed-methods design, physical health parameters were measured over a nine-month period and semi-structured interviews were conducted with fourteen patients and five staff members.Results: The findings showed a significant reduction in weight following the evaluation period, as well as positive effects in terms of patients' self-esteem, autonomy, and socialization. The quality of the therapeutic relationship, the elimination of barriers, and the continued involvement of staff members were some of the key characteristics that led to the program's success.Discussion/conclusion: These promising results are an indication of the feasibility of this type of intervention among patients with severe mental illnesses as a therapeutic approach to improve their quality of life and support their recovery and social integration.

Reduction of Involuntary Admissions in Patients With Severe Psychotic Disorders Treated in the ACCESS Integrated Care Model Including Therapeutic Assertive Community Treatment.

Objective: The ACCESS treatment model offers assertive community treatment (ACT) embedded in an integrated care program to patients with severe psychotic disorders. Compared to standard care, it proved to be more effective in terms of service disengagement and other outcomes in patients with psychotic disorders over 12, 24, and 48 months. Many patients with severe mental disorders experience involuntary admissions which can be potentially traumatic. In this study, we assessed the effect of ACT on reducing involuntary admissions over an observation period of 4 years.Method: One hundred seventy-one patients treated in ACCESS were included in this study. The primary outcome was rate of involuntary admissions during 48 months. Secondary outcomes were differences between those with and without involuntary admissions in the 2 years prior to ACCESS regarding change of psychopathology, severity of illness, psychosocial functioning, quality of life, satisfaction with care, medication non-adherence, and service-disengagement.Results: Of 171 patients, 58 patients (33.9%) were involuntarily admitted to hospital in the past 2 years before entry. During the 4 years of treatment, 16 patients (9.4%) were involuntarily admitted to hospital which was a significantly lower rate compared to the 2 years before inclusion in ACCESS (p < .001). Comparing the two groups, larger improvements in severity of illness (p = .004) and functional status (p = .043) were detected in the group with no history of involuntary admissions. At 4-year follow-up, of the remaining patients, 69.2% (n = 81) were full adherent (p < .001), compared to 18.9% (n = 31) at baseline with no differences between the two groups over the study period (p = .25). Over 4 years, only 13 patients (13.2%) were service-disengaged due to non-practical reasons.Conclusions: In this long-term study, we were able to demonstrate a reduction in involuntary admissions in four treatment years compared to the 2 years prior to admission to the ACCESS model in patients with severe and mostly multiphase schizophrenia spectrum disorders and affective disorders with psychotic features. This may help prevent patients from suffering from a potentially traumatic experience during treatment in the psychiatric system.Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT01888627.

Model fidelity and team members\u2019 experiences of assertive community treatment in Norway: a sequential mixed-methods study

BackgroundAssertive 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.MethodsTo 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.ResultsThe 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.ConclusionThe 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.

Long-term effects of rent supplements and mental health support services on housing and health outcomes of homeless adults with mental illness: extension study of the At Home/Chez Soi randomised controlled trial

Housing First is increasingly implemented for homeless adults with mental illness in large urban centres, but little is known about its long-term effectiveness. The At Home/Chez Soi randomised controlled trial done in five cities in Canada showed that Housing First improved housing stability and other select health outcomes. We extended the At Home/Chez Soi trial at the Toronto site to evaluate the long-term effects of the Housing First intervention on housing and health outcomes of homeless adults with mental illness over 6 years. The At Home/Chez Soi Toronto study was a randomised, controlled trial done in Toronto (ON, Canada). Here, we present the results of an extension study done at the same site. Participants were homeless adults (aged ≥18 years) with a serious mental disorder with or without co-occurring substance use disorder. In phase 1, participants were stratified by level of need for mental health support services (high vs moderate), and randomly assigned (1:1) using adaptive randomisation procedures to Housing First with assertive community treatment (HF-ACT), Housing First with intensive case management (HF-ICM), or to treatment as usual (TAU). Participants with moderate support needs were further stratified by ethnoracial status. Considering the nature of the Housing First intervention, study participants and study personnel were not masked to group assignment. Phase 1 participants could choose to enrol in the extension study (phase 2). The primary outcome was the rate of days stably housed per year analysed in the modified intention-to-treat population, which included all randomly assigned participants who had at least one assessment for the primary outcome. Participants contributed data to the study up to the point of their last interview. Multilevel multiple imputation was used to handle missing data. The trial was registered with ISRCTN, ISRCTN42520374. Between Oct 1, 2009, and March 31, 2013, 575 individuals participated in phase 1 of the Toronto Site At Home/Chez Soi study (197 [34%] participants with high support needs and 378 [66%] with moderate support needs). Of the 378 participants with moderate support needs, 204 were randomly assigned to receive the HF intervention with ICM or with ethnoracial-specific ICM services (HF-ER-ICM; HF-ICM or HF-ER-ICM groups) and 174 were randomly assigned to TAU. Of the 197 participants with high support needs, 97 were randomly assigned to receive the HF intervention with ACT (HF-ACT treatment group) and 100 were randomly assigned to TAU group. Between Jan 1, 2014, and March 31, 2017, 414 (81%) of 575 phase 1 participants participated in the extended phase 2 study. The median duration of follow-up was 5·4 years (IQR 2·1-5·9). Among phase 2 participants, 141 had high support needs (79 participants in the HF-ACT group; 62 participants in the TAU group), and 273 had moderate support needs (160 participants in the HF-ICM or HF-ER-ICM group; 113 participants in the TAU group). 187 high support needs participants (93 participants in the HF-ACT group, 94 participants in the TAU group), and 361 moderate support needs participants (201 participants in the HF-ICM or HF-ER-ICM group, 160 participants in the TAU group) were included in the modified intention-to-treat analysis for the primary outcome. The number of days spent stably housed was significantly higher among participants in the HF-ACT and HR-ICM or HF-ER-ICM groups than participants in the TAU groups at all timepoints. For participants with moderate support needs, the rate ratio (RR) of days stably housed in the Housing First group, compared with TAU, was 2·40 (95% CI 2·03-2·83) in year 1, which decreased to 1·13 (1·01-1·26) in year 6. The RR of days stably housed for participants with high support needs, compared with TAU, was 3·02 (2·43-3·75) in year 1 and 1·42 (1·19-1·69) in year 6. In year 6, high support needs participants in the Housing First group spent 85·51% of days stably housed compared with 60·33% for the TAU group, and moderate needs participants in the Housing First group spent 88·16% of days stably housed compared with 78·22% for the TAU group. Rent supplements and mental health support services had an enduring positive effect on housing stability for homeless adults with mental illness in a large, resource-rich urban centre, with a larger impact on individuals with high support needs than moderate support needs. Mental Health Commission of Canada, Ontario Ministry of Health and Long-Term Care, and the Canadian Institute of Health Research.

Bazelon Center issues guidance to reduce incarceration of people with MI

Investments in supported housing, mobile crisis services and assertive community treatment (ACT) are key in helping to reduce incarceration of people with psychiatric disabilities, according to a report released Oct. 1 by the Bazelon Center for Mental Health Law. The services are essential and effective and should be a part of every community's mental health system, officials stated.

Assisted outpatient treatment orders and the therapeutic relationship in Assertive Community Treatment: a mixed-methods study

ABSTRACTBackground: A large proportion of clients served by Assertive Community Treatment (ACT) teams in New York City (NYC) are referred through “Assisted Outpatient Treatment” (AOT), which involves civil commitment to outpatient services. Research indicates that clients perceive AOT to be coercive, but it is unclear how this impacts the therapeutic relationships with ACT teams. We used mixed-methods to examine and compare perceptions of the therapeutic relationship and associated factors between ACT clients who were, and were not, referred through AOT.Method: Thirty persons receiving ACT services in NYC (15 AOT, 15 non-AOT) completed qualitative interviews about perceptions of treatment and referral, as well as measures of therapeutic alliance, procedural fairness, experienced coercion, shared decision-making, and self-stigma.Results: Quantitative findings revealed no differences in measures between AOT and non-AOT participants, with the exception being perception of “negative pressures” in the referral process, which was higher in the AOT group. However, qualitative findings were more mixed, with a notable subgroup of AOT-participants endorsing themes of paternalism and coercion in the referral and treatment decision-making process.Discussion: Findings indicate that the impact of AOT-referral on perceptions of ACT services is complex, and that AOT referrals impact treatment relationships in a subset of clients.

Psychometric Properties of Scale to Assess the Therapeutic Relationship-JapaneseVersion (STAR-J).

Background: A good therapeutic relationship between patient and psychiatrist is vital for effective mental health care. However, no instruments to assess this relationship are available in Japan. This study aimed to develop a Japanese version of a Scale To Assess Therapeutic Relationship (STAR-J), which measures such relationships from the viewpoints of both the patient (STAR-J-P) and clinician (STAR-J-C). We examined the tool’s psychometric properties, including factor structure, internal consistency, convergent validity, and test-retest reliability among psychiatric outpatients and psychiatrists. Methods: Study participants comprised 139 outpatients and 10 psychiatrists. Exploratory factor analysis was conducted to investigate factor structure; to confirm cross-validity, confirmatory factor analysis was conducted using a different sample constituting 195 participants in an assertive community treatment program and their 91 case managers. Cronbach’s alpha was used to assess internal consistency. For STAR-J-P only, the intra-class correlation coefficient (ICC) was computed for 17 patients to determine test-retest reliability. Spearman’s correlation coefficients were calculated to examine convergent validity with service satisfaction, empowerment, and medication adherence. Results: We identified a two-factor structure for STAR-J-P and a one-factor structure for STAR-J-C. Cronbach’s alphas for the two STAR-J-P factors were 0.897 and 0.645, and that for the STAR-J-C factor was 0.949. The ICCs for STAR-J-P factors 1 and 2 were 0.765 and 0.630, respectively. STAR-J-P and STAR-J-C were not significantly correlated. STAR-J-P factors 1 and 2 showed significant correlations with service satisfaction (factor 1: ρ = 0.648, p < 0.001; factor 2: ρ = 0.238, p = 0.005) and medication adherence (factor 1: ρ = 0.508, p < 0.001; factor 2: ρ = 0.347, p < 0.001), but only factor 1 showed a significant relationship with empowerment (ρ = 0.283, p = 0.001). STAR-J-C was significantly correlated only with empowerment (ρ = 0.207, p = 0.017). Conclusions: STAR-J appears to be a useful instrument for assessing therapeutic relationships in the Japanese psychiatric outpatient setting. Further studies should test its validity and applicability in different mental health service settings.