Community-based Treatment Model Research Articles

Insights from California on Involuntary Commitment for Substance Use.

Involuntary commitment (IC) for the treatment of substance use disorders is a highly controversial and poorly understood practice, with California offering a striking example. The state's involuntary commitment laws, known collectively as Lanterman-Petris-Short, authorized IC for grave disability related to chronic alcoholism. These provisions remain shrouded in obscurity, and data on their usage are lacking. Amid the ongoing debate over the utility of IC as a tool to treat severe substance use disorders and legislation expanding IC for substance use disorders (SUDs) in California and other states, this article highlights the need to better study the use and effectiveness of existing legislation as well as to consider upstream interventions, such as expansion of community-based treatment models.

A conceptual model of how mental health clubhouses impact health and quality of life among individuals with serious mental illness.

People with serious mental illness (PWSMI) experience dramatic disparities in health, quality of life, and longevity. Mental health Clubhouses are a community-based treatment model that can positively affect health and quality of life among PWSMI. However, few studies investigate the processes within Clubhouses and what factors are related to the improvement of health and quality of life among members. To address this gap, this research offers a conceptual model of how Clubhouses contribute to health and quality of life. This conceptual model was created using participatory qualitative methods, combining Photovoice and grounded theory. Forty-two participants (37 Clubhouse members and six staff) from four Clubhouses in Hawai'i were engaged in 22 sessions over the course of 2 years. The conceptual model begins with quality of participation in Clubhouse activities, which refers not only to being present in the Clubhouse but being actively and meaningfully engaged in Clubhouse activities. Engagement in Clubhouse activities and working side-by-side with members and staff led to reciprocal social support. As members were supported and supported others, they gained a sense that they mattered, and they perceived themselves as more capable, more efficacious, and less stigmatized over time. They became a contributing member of a community, which supported health and quality of life directly and indirectly. This work offers a novel conceptual framework of Clubhouse processes that highlights the importance and potential of empowering psychosocial treatment models. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Prevalence and associated risk factors of hepatitis C antibody and RNA among people who inject drugs in Puerto Rico

As a public health crisis, hepatitis C viral infection (HCV) is highly prevalent among people who inject drugs (PWID). We aimed to assess factors associated with HCV antibody (Ab) and HCV ribonucleic acid (RNA) positivity among PWID in Puerto Rico. The study recruited a total of 150 persons in rural and peri-urban community settings through the respondent-driven sampling method and administered a structured questionnaire. We conducted HIV and HCV testing using dried blood spots (DBS). We examined correlates of HCV infection with sociodemographics, drug use patterns, and injection practices using regression in bivariate and multivariable analysis. Of the 150 participants, 89% were male; 11% were female; 72% identified as mixed race; and the median duration of drug injection was 17.8years. The mean age was 43.1years, with 64% of the population being from 23 to 45years old. Among study participants (n=150), the prevalence of HCV Ab was 73%, and HCV RNA was 53%. Factors significantly associated with HCV Ab and RNA included older age, increasing years of injection, incarceration, injecting other people, and identifying as Black. The belief that syringe air blowing reduces HCV transmission was also independently associated with HCV Ab positivity. Our findings regarding risk factors associated with HCV infection show the need to enhance prevention and control strategies for reducing transmission among PWID. Direct-acting antiviral treatment, sustained access to harm reduction, and culturally tailored services will be required to substantially reduce rates of HCV. Community-based treatment models and treatment in correctional settings are needed.

Intensive community care services for children and young people in psychiatric crisis: an expert opinion

BackgroundChildren and young people’s (CYP) mental health is worsening, and an increasing number are seeking psychiatric and mental health care. Whilst many CYPs with low-to-medium levels of psychiatric distress can be treated in outpatient services, CYPs in crisis often require inpatient hospital treatment. Although necessary in many cases, inpatient care can be distressing for CYPs and their families. Amongst other things, inpatient stays often isolate CYPs from their support networks and disrupt their education. In response to such limitations, and in order to effectively support CYPs with complex mental health needs, intensive community-based treatment models, which are known in this paper as intensive community care services (ICCS), have been developed. Although ICCS have been developed in a number of settings, there is, at present, little to no consensus of what ICCS entails.MethodsA group of child and adolescent mental health clinicians, researchers and academics convened in London in January 2023. They met to discuss and agree upon the minimum requirements of ICCS. The discussion was semi-structured and used the Dartmouth Assertive Community Treatment Fidelity Scale as a framework. Following the meeting, the agreed features of ICCS, as described in this paper, were written up.ResultsICCS was defined as a service which provides treatment primarily outside of hospital in community settings such as the school or home. Alongside this, ICCS should provide at least some out-of-hours support, and a minimum of 90% of CYPs should be supported at least twice per week. The maximum caseload should be approximately 5 clients per full time equivalent (FTE), and the minimum number of staff for an ICCS team should be 4 FTE. The group also confirmed the importance of supporting CYPs engagement with their communities and the need to remain flexible in treatment provision. Finally, the importance of robust evaluation utilising tools including the Children’s Global Assessment Scale were agreed.ConclusionsThis paper presents the agreed minimum requirements of intensive community-based psychiatric care. Using the parameters laid out herein, clinicians, academics, and related colleagues working in ICCS should seek to further develop the evidence base for this treatment model.

Metacognition and the clubhouse model in treating severe mental illness.

Clubhouses have demonstrated significant positive psychosocial outcomes, in addition to more enduring resiliencies for persons with histories of severe persistent mental illness (SPMI). However, there is a paucity of research investigating the recovery processes impacted by community-based interventions like clubhouse for SPMI. Research into metacognition and its relation to recovery trajectories in SPMI creates a compelling cognitive and intersubjective framework within which to understand the recovery impacts of the clubhouse intervention model of social practice. The present article examines significant areas of conceptual overlap between the clubhouse model of social practice, metacognition, and intersubjective recovery processes. A preliminary research project investigating the metacognitive impacts of community-based interventions for SPMI is presented. An overview of the theoretical and practical relevance of the clubhouse community-based treatment model of social practice to metacognitive recovery processes is presented through a discussion of the resilience observed in clubhouse settings as it relates to the enhancement of intersubjectivity. The clubhouse model of social practice is a unique therapeutic modality with outcomes that can be readily investigated and explained through metacognitive processes relevant to recovery in SPMI. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The effect of flexible assertive community treatment in Denmark: a quasi-experimental controlled study

Flexible assertive community treatment (FACT) is a community-based treatment model for patients with severe mental illness that has been widely implemented despite little evidence for its effectiveness. We aimed to evaluate the effect of FACT on mental health care outcomes compared with treatment from standard community mental health teams (CMHTs) or assertive community treatment (ACT) teams in Denmark. We did a quasi-experimental, propensity-score matched, controlled study in five FACT teams, four ACT teams, and five CMHTs in the Capital Region of Denmark. The FACT teams were established on May 1, 2016 (the index date). Patients were identified through the Danish Psychiatric Register and the study population consisted of all patients receiving care from any of these teams on the index date. Assignment to treatment was based on administrative considerations and was not done by the researchers. Patient data were collected from Danish registers. The primary outcome was analysed in the intention-to-treat population and compared mental health care outcomes (psychiatric admissions and bed days, outpatient contacts, self-harm, coercion, and death by any cause) for patients under the care of CMHTs or ACT teams that were reconfigured to FACT teams (CMHT-FACT or ACT-FACT) with patients who remained under the care of CMHTs and ACT teams. Patients who received FACT were matched using propensity scores with control patients from CMHTs and ACT teams to balance differences in baseline characteristics. On May 1, 2016, 2034 individuals (887 in the CMHT-FACT group, 887 in the matched CMHT group, 130 in the ACT-FACT group, 130 in the matched ACT group) were enrolled and were followed up from Nov 1, 2016, to Nov 1, 2018. The number of outpatient contacts was higher for patients receiving FACT than for those in the control groups (CMHT-FACT vs CMHT: incidence rate ratio 1·15; 95 % CI 1·10-1·20; ACT-FACT vs ACT: 1·15; 1·03-1·29). Patients receiving FACT had fewer admissions than those in the control groups (CMHT-FACT vs CMHT: 0·84; 0·76-0·92; ACT-FACT vs ACT: 0·71; 0·59-0·85). However, there were no significant differences in total inpatient days, use of coercion, episodes of self-harm, or deaths. To our knowledge, this is the first study to investigate the effect of FACT compared with treatment from a CMHT or ACT team. Our results suggest that FACT can provide a more intensive approach in terms of increased outpatient contacts than CMHT care or ACT. FACT requires further evaluation through randomised controlled trials that include a cost-effectiveness component before wider implementation. Mental Health Services in the Capital Region of Denmark.

Lower Mortality in Persons Infected with HIV Receiving Antiretroviral Treatment in a Hospital-Based Model: An Observational Cohort Study

ABSTRACT: Aim: Although the National Free Antiretroviral Treatment Program (NFATP) is effectively administered through a community-based treatment model in China, there are some limitations in this model. No-one has reported the outcomes of highly active antiretroviral therapy as part of a hospital-based HIV treatment model in China. Methods: This study was a retrospective analysis of mortality and viral responses in HIV-positive patients taking highly active antiretroviral therapy regimens in a cohort registered in Ditan Hospital, Beijing, China, the largest infectious disease hospital in North China. Results: This study demonstrated low mortality (3.4% of patients died in a median follow-up of 19 months, with a mortality of 1.7 per 100 person-years) from 2005 to 2010 in Ditan Hospital. In an adjusted Cox proportional hazards regression analysis, CD4 cell counts less than 50 cells/μl (adjusted hazard ratio of 5.95 [95% CI: 1.3–28.2]) was the strongest risk factor for death, and switching regimens during treatment was associated with lower risk of death. The study also demonstrated 93.4% of patients were adequate viral suppression, 3% were definite virologic failure, 2% were probable virologic failure and 1.3% were indeterminate. In logistic regression analysis, the strongest risk factors for inadequate viral suppression or failure were single, divorced or widowed (adjusted odds ratio: 4.2; 95% CI: 1.2–14.9) and baseline alanine aminotransferase >100 U/l (adjusted odds ratio: 6.2; 95% CI: 1.5–26.1). Conclusion: The hospital-based HIV treatment model appeared to be successful in improving patient survival and should be considered as an important alternative to the community-based treatment models commonly applied in China.

Outcomes of Multidrug-Resistant Tuberculosis Treatment with Early Initiation of Antiretroviral Therapy for HIV Co-Infected Patients in Lesotho

BackgroundAlthough the importance of concurrent treatment for multidrug-resistant tuberculosis (MDR-TB) and HIV co-infection has been increasingly recognized, there have been few studies reporting outcomes of MDR-TB and HIV co-treatment. We report final outcomes of comprehensive, integrated MDR-TB and HIV treatment in Lesotho and examine factors associated with death or treatment failure.MethodsWe reviewed clinical charts of all adult patients who initiated MDR-TB treatment in Lesotho between January 2008 and September 2009. We calculated hazard ratios (HR) and used multivariable Cox proportional hazards regression to identify predictors of poor outcomes.ResultsOf 134 confirmed MDR-TB patients, 83 (62%) were cured or completed treatment, 46 (34%) died, 3 (2%) transferred, 1 (1%) defaulted, and 1 (1%) failed treatment. Treatment outcomes did not differ significantly by HIV status. Among the 94 (70%) patients with HIV co-infection, 53% were already on antiretroviral therapy (ART) before MDR-TB treatment initiation, and 43% started ART a median of 16 days after the start of the MDR-TB regimen. Among HIV co-infected patients who died, those who had not started ART before MDR-TB treatment had a shorter median time to death (80 days vs. 138 days, p = 0.065). In multivariable analysis, predictors of increased hazard of failure or death were low and severely low body mass index (HR 2.75, 95% confidence interval [CI] 1.27–5.93; HR 5.50, 95% CI 2.38–12.69), and a history of working in South Africa (HR 2.37, 95% CI 1.24–4.52).ConclusionsFavorable outcomes can be achieved in co-infected patients using a community-based treatment model when both MDR-TB and HIV disease are treated concurrently and treatment is initiated promptly.

A preliminary evaluation: Demographic and clinical profiles and changes in functioning in children receiving psychosocial rehabilitation

The present study is the first to examine the demographic and clinical profiles at intake of children, ages 4 to 18 years, who received Child Psychosocial Rehabilitation (CSPR), a relatively new community-based treatment model for children with emotional disturbance. In addition, the relationship between the relative change in psychosocial, emotional, and behavioral functioning as measured by CAFAS (Hodges, 1989, 1994, 2000) and PECFAS (1994, 2000) scores and the children's age, gender, ethnicity, current living arrangement, internalizing and externalizing behaviors, and severity of impairment at intake were evaluated. Fifty-three children received CPSR for a minimum of six months from a for-profit outpatient child and adolescent mental health clinic located in southwestern Idaho. Significant improvement in the children's overall functioning was found after six months of treatment. Middle or high school age children demonstrated significantly more impairment at intake compared with their younger counterparts. No significant differences in overall functioning were revealed considering the characteristic of gender, living arrangement and clinical profiles at intake.

Long-term effect of community-based treatment: Evidence from the adolescent outcomes project

A growing literature on adolescent drug treatment interventions demonstrates the efficacy of "research therapies," but few rigorous studies examine the effectiveness of community-based treatments that are more commonly available to and utilized by youths and their families, the criminal justice system and other referring agencies. Even less is known about the long-term effects of these community-based treatments. This study evaluates the effects 72-102 months after intake to a widely disseminated community-based treatment model, residential therapeutic community treatment, using data from RAND's Adolescent Outcomes Project. Weighting is used to control for pre-existing differences between adolescent probationers disposed to Phoenix Academy and those assigned to one of six alternative group homes serving as the comparison conditions. Although Phoenix Academy therapeutic community treatment had positive effects on substance use and psychological functioning during the first 12 months following intake, we find no evidence of positive long-term effects on 16 outcomes measuring substance use and problems, criminal activity, institutionalization, psychological functioning and general functioning. We discuss the implications of these findings and the failure to maintain the effects observed during the first year follow-up.

Early Outcomes of MDR-TB Treatment in a High HIV-Prevalence Setting in Southern Africa

BackgroundLittle is known about treatment of multidrug-resistant tuberculosis (MDR-TB) in high HIV-prevalence settings such as sub-Saharan Africa.Methodology/Principal FindingsWe did a retrospective analysis of early outcomes of the first cohort of patients registered in the Lesotho national MDR-TB program between July 21, 2007 and April 21, 2008. Seventy-six patients were included for analysis. Patient follow-up ended when an outcome was recorded, or on October 21, 2008 for those still on treatment. Fifty-six patients (74%) were infected with HIV; the median CD4 cell count was 184 cells/μl (range 5–824 cells/μl). By the end of the follow-up period, study patients had been followed for a median of 252 days (range 12–451 days). Twenty-two patients (29%) had died, and 52 patients (68%) were alive and in treatment. In patients who did not die, culture conversion was documented in 52/54 patients (96%). One patient had defaulted, and one patient had transferred out. Death occurred after a median of 66 days in treatment (range 12–374 days).Conclusions/SignificanceIn a region where clinicians and program managers are increasingly confronted by drug-resistant tuberculosis, this report provides sobering evidence of the difficulty of MDR-TB treatment in high HIV-prevalence settings. In Lesotho, an innovative community-based treatment model that involved social and nutritional support, twice-daily directly observed treatment and early empiric use of second-line TB drugs was successful in reducing mortality of MDR-TB patients. Further research is urgently needed to improve MDR-TB treatment outcomes in high HIV-prevalence settings.

ElderLynk: A Community Outreach Model for the Integrated Treatment of Mental Health Problems in the Rural Elderly

In 2000, a rural consortium of health care education and service providers established a geriatric mental health outreach program (ElderLynk) for the underserved elderly (aged 65 and older) in ten rural counties in northeast Missouri. ElderLynk evaluated the efficacy of an integrated community-based treatment model through the creation and evaluation of a clinical database. Ten rural counties in northeast Missouri were chosen because they were designated as mental health shortage areas (MHSAs) and because their elderly population approximates the projected level of elderly in the USA in 2020. All patients were managed by a geriatric nurse with treatment planning and oversight provided by a community-based interdisciplinary team which included a psychiatrist, geriatrician, psychologist, and social worker. Using the Geriatric Depression Scale (GDS); the Government Performance and Results Act data (GPRA) to assess life satisfaction, independence/autonomy, psychosocial functioning, and overall health; the Instrumental Activities of Daily Living (IADL); the Mini-Mental Status Examination (MMSE); and patterns of service usage (number of hours of case management and number of counseling sessions), ElderLynk patients improved significantly in overall psychological functioning, level of depression, and reported life satisfaction despite significant declines in mental status, daily function, and overall health.

Characteristics, experience, and treatment of schizophrenia in China

Assessment of differences in the characteristics, experience, and treatment of schizophrenia between China and the West highlights the importance of the interaction of biological and sociocultural factors in the onset and course of the disorder. China reports a much higher prevalence of schizophrenia in urban areas than in rural areas and, surprisingly a higher prevalence in women than in men. Despite differences in the diagnostic criteria for schizophrenia, the pattern of positive, negative, and cognitive symptoms is similar to that seen in the West. Almost ail medical treatment for schizophrenia is provided from specialized psychiatric hospitals, most of which are situated in urban centers. Antipsychotic medication (often the generic clozapine) is the mainstay of inpatient treatment. China developed a variety of innovative community-based treatment models in the 1980s, but the social and economic changes of the 1990s have made ii difficult to generalize these models. Overall, approximately 70% of the estimated 4.8 million persons with schizophrenia in China do not receive regular treatment.

Treatment Foster Care

Currently, there is a severe lack of midrange community-based treatment models for adolescents with severe emotional and behavioral disorders (SED) (Wells&Whittington, 1990). The Treatment Foster Care (TFC) program has the potential to expand the development of such models for these youths. The aim of TFC is to provide a community-based, relatively nonrestrictive treatment in a setting where youths are not separated from nondisabled peers or isolated from their own families. TFC can be used before youths with emotional and behavioral disorders (EBD) are placed in more restrictive institutional treatment settings. In addition, TFC appears to be a promising model to include when out-of-home and/or out-of-community placements are considered for children and adolescents with EBD. This article presents the program components and research direction of the Oregon Social Learning Center's TFC program for adolescents who have SED and need out-of-home care. The article concludes with a case study of a typical program intervention in an educational setting.

Achievement Place

In recent years there has been a move away from the traditional institutionalization of deviant members of society and a step toward community-based treatment models. The present paper summarizes and analyzes one such community-based treatment facility for predelinquent boys. Three distinguishing features of the Achievement Place program are elaborated on in some detail: (1) the utilization of a token economy point system as a primary therapeutic tool, (2) the development of a series of well-controlled experiments enabling the establishment of functional relationships across behaviors, and (3) the training of teaching-parents. A variety of target behaviors are systematically reviewed. Overall evaluation of the Achievement Place program is undertaken in light of a number of issues considered relevant to scientific investigation. Recommendations are made for continued research to define more clearly the parameters of the existing model.