Study Of Assertive Community Treatment Research Articles

Carer involvement in the assessment of personal recovery: A naturalistic study of assertive community treatment in Norway.

The user and carer movements have come a long way in becoming embedded in mainstream mental health services for individuals with serious mental illness. However, implementing recovery-oriented practice continues to be plagued by an individualistic clinical focus. The carers do not feel integrated despite policies and best intentions. The implementation of Assertive Community Treatment (ACT) provided an opportunity to involve the carers and compare their assessment of personal recovery with the users. The aims of this study were to examine (i) how family carers and users differed in their assessment of personal recovery, (ii) whether familial and personal relationships influenced how carers assess personal recovery of users, and (iii) if the experience of family carers with the ACT team was associated with personal recovery. The naturalistic, explorative study recruited 69 users and 36 family carers from 12 Norwegian ACT teams. The users and carers assessed the user's personal recovery. Family carers also reported their experience and satisfaction with the ACT teams. Analyses included independent and paired sample T-tests and correlation analysis. Family carers were significantly more conservative than the users' assessment of the intrapsychic and interpersonal subscales of personal recovery. The pattern held true whether the family carers were matched to the users or part of the total sample. Lastly, there was a significant negative correlation between the family carer's experience of cooperation with the ACT team and their assessment of the user's intrapersonal process of recovery. The results of our study were consistent with previous research on carer involvement in MHS. However, it is the first study that engaged carers and assessed personal recovery of the users of ACT services. Discrepancy between carers and users is the rule. Clinicians are encouraged to embrace the discrepancy and diversity carers bring and learn the methodology of multi-informant assessments. There also is a need to address, update, and integrate the personal, familial, and relational aspects of recovery. Modification of recovery measures such as QPR and their creative use with carers has the potential to generate valuable third-party information and to involve them meaningfully in mental health services.

A 10-year service evaluation of an assertive community treatment team: trends in hospital bed use

Background: Studies of assertive community treatment (ACT) have shown various benefits, including reduced hospital bed use. In the UK, this finding was not replicated by randomised controlled trials (RCTs), which lacked fidelity to the model. Conversely, observational studies, while limited by their inherent weakness in implying causality, have shown lower bed use. Against this background many ACT teams are being disestablished in the UK.Aims: To observe the long-term effect of ACT on bed use, incorporating methods of analysis which mitigate against some weaknesses of observational design.Methods: Bed use was compared for equal periods of time either side of starting support from an ACT team.Results: Ninety-three people were followed for up to 10.5 years after starting ACT. Hospital bed use was compared for each person, showing a reduction from a mean of 72 d per year prior to ACT to 44 d per year during ACT (p = 0.0018).Conclusions: The results demonstrate that ACT is associated with reduced bed use in the UK and that it is possible to use an observational design with enhanced analysis techniques to increase evidence for causality. These techniques may have value in other service evaluations.

The effectiveness of assertive community treatment for elderly patients with severe mental illness: a randomized controlled trial

BackgroundDue to fragmented mental, somatic, and social healthcare services, it can be hard to engage into care older patients with severe mental illness (SMI). In adult mental health care, assertive community treatment (ACT) is an organizational model of care for treating patients with SMI who are difficult to engage. So far all outcome studies of assertive community treatment have been conducted in adults.MethodsIn a randomized controlled trial design we compared the effectiveness of ACT for elderly patients with that of treatment as usual (TAU). Sixty-two outpatients (60 years and older) with SMI who were difficult to engage in psychiatric treatment were randomly assigned to the intervention or control group (32 to ACT for elderly patients and 30 to TAU). Primary outcomes included number of patients who had a first treatment contact within 3 months, the number of dropouts (i.e. those discharged from care due to refusing care or those who unintentionally lost contact with the service over a period of at least 3 months); and patients’ psychosocial functioning (HoNOS65+ scores) during 18 months follow-up. Secondary outcomes included the number of unmet needs and mental health care use. Analyses were based on intention-to-treat.ResultsOf the 62 patients who were randomized, 26 were lost to follow-up (10 patients in ACT for elderly patients and 16 in TAU). Relative to patients with TAU, more patients allocated to ACT had a first contact within three months (96.9 versus 66.7%; X2 (df = 1) = 9.68, p = 0.002). ACT for elderly patients also had fewer dropouts from treatment (18.8% of assertive community treatment for elderly patients versus 50% of TAU patients; X2 (df = 1) = 6.75, p = 0.009). There were no differences in the other primary and secondary outcome variables.ConclusionsThese findings suggest that ACT for elderly patients with SMI engaged patients in treatment more successfully.Trial registrationNTR1620

A four-year retrospective study of Assertive Community Treatment: Change to more frequent, briefer client contact

The authors explored the feasibility of providing frequent, brief client contact as a strategy for reallocating Assertive Community Treatment (ACT) staff time to new clients, while preserving relationships with current clients and ACT program fidelity standards. A retrospective analysis of 4 years of service records for a high-fidelity ACT team revealed gradual increases in staff-client contact frequency, and corresponding decreases in contact duration. During these years, fidelity to ACT standards remained moderately high, and clients' employment and hospitalization outcomes improved.

The Coproduction of Moral Discourse in U.S. Community Psychiatry

Anthropologists often criticize the discipline of bioethics because its remote, abstract theories fail to capture how front-line clinicians experience and resolve moral uncertainty. The critique overlooks, however, the ways that everyday, emergent moral discourse is influenced--over time and through several mediations--by formal ethical notions. High-order ethical pronouncements become sedimented into the conditions of work, illustrated in this article by a two-year ethnographic study of Assertive Community Treatment (ACT), a popular mode of outpatient psychiatric services. ACT clinicians' moral unease when they break the confidentiality of patients is connected to high-order debates, dating back 35 years, about ensuring patients' autonomy without abandoning them. These debates originally spurred the invention of ACT, and they get braided into today's moral discourse through several mediations: regulatory paperwork, the mandates and micropolitics of staff-patient interactions, and the idealized self-image of front-line staff. This article shows how everyday moral talk is coproduced by both the immediate contexts of clinical work and the categories of formal bioethics.

A Comparison of Assertive Community Treatment and Intensive Case Management for Patients in Rural Areas

A Comparison of Assertive Community Treatment and Intensive Case Management for Patients in Rural Areas

An exploratory study of assertive community treatment for people with intellectual disability and psychiatric disorders: conceptual, clinical, and service issues

Assertive community treatment (ACT) has been applied to a number of disorders in the adult population, such as schizophrenia, with some degree of success; its use in the treatment of people with intellectual disability (ID) and mental illness has received little attention. Despite the high costs of ID in health and social care, there has been very little evidence-based practice for people with ID and mental illness, and it remains a neglected area of research. Aims The aims of this study were an exploratory comparison of the effectiveness of an ACT model for the treatment of mental illness in people with ID (ACT-ID) with a standard community treatment (SCT-ID) approach. A Randomized controlled trial design was adopted and allocation was made by stratified randomization by an independent statistician. The prognostic factors used in the randomization were gender and psychiatric diagnosis (psychosis vs. affective). Service users were randomly allocated to either ACT-ID or SCT-ID. There were no statistically significant differences between ACT-ID and SCT-ID in terms of the level of unmet needs, carer burden, functioning and quality of life, but borderline evidence of a difference between treatment groups in quality of life in favour of SCT-ID. Both SCT-ID and ACT-ID groups decreased level of unmet needs and carer burden, and increased functioning. SCT-ID also led to a small increase in quality of life.

A Method for Analyzing Longitudinal Outcomes with Many Zeros

Health care utilization and cost data have challenged analysts because they are often correlated over time, highly skewed, and clumped at 0. Traditional approaches do not address all these problems, and evaluators of mental health and substance abuse interventions often grapple with the problem of how to analyze these data in a way that accurately represents program impact. Recently, the traditional 2-part model has been extended to mixed-effects mixed-distribution model with correlated random effects to deal simultaneously with excess zeros, skewness, and correlated observations. We introduce and demonstrate this new method to mental health services researchers and evaluators by analyzing the data from a study of assertive community treatment (ACT). The response variable is the number of days of hospitalization, collected every 6 months over 3 years. The explanatory variable is group: ACT vs. standard case management. Diagnosis (schizophrenia vs. bipolar disorder), time, and the baseline values of hospital days are covariates. Results indicate that clients in the ACT group have a higher probability of hospital admission, but tend to have shorter lengths of stay. The mixed-distribution model provides greater specification of a model to fit these data and leads to more refined interpretation of the results.

Using discrete-time survival analysis to examine patterns of remission from substance use disorder among persons with severe mental illness.

Investigators in mental health research are often interested in examining critical events such as onset, relapse, and recovery from illness, including substance use disorders. As data on these critical events are often collected at discrete-time intervals (e.g., weekly, monthly, or yearly), discrete-time survival models are more appropriate than well-known continuous-time methods. In this paper, we present discrete-time survival analysis methods at an introductory level. Using data collected every 6 months from a 3-year study of assertive community treatment in New Hampshire, we show that discrete-time survival models can be used to analyze patterns of remission from substance use disorder among clients with severe mental illness. The main questions investigated are (1) when are remissions more likely to occur? and (2) what variables predict remission? The results indicate that remission is more likely to occur in the first 6 months and in the 3rd year of the study. Gender, age, baseline use of substances, and diagnosis are strong predictors of remission.

A Critique of the Effectiveness of Assertive Community Treatment

Back to table of contents Previous article Next article LettersFull AccessA Critique of the Effectiveness of Assertive Community TreatmentMary Ann Test, Ph.D., and Leonard I. Stein, M.D.Mary Ann TestSearch for more papers by this author, Ph.D., and Leonard I. SteinSearch for more papers by this author, M.D.Published Online:1 Oct 2001https://doi.org/10.1176/appi.ps.52.10.1396AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: As codevelopers of the assertive community treatment model, we believe it is important to clarify several issues raised by Dr. Gomory in his letter, in which he contends that it is premature to move assertive community treatment into standard practice as discussed in the article by Ms. Phillips and her colleagues. These authors asked us if we wished to respond to the letter from Dr. Gomory.Dr. Gomory calls for further discussion of issues such as "the therapeutic value of the coercion on which assertive community treatment is based." The assertive community treatment approach never was, and is not now, based on coercion. Quite the opposite is the case. We developed assertive community treatment in the 1970s on the basis of our belief that persons suffering from even very disabling mental illnesses can live freely in the community and experience a satisfying quality of life if they receive adequate supports and assistance (1). Other community treatment efforts at that time were failing because the system was highly fragmented and providers demanded that even very ill clients visit offices or program settings to receive services.Assertive community treatment focused on service delivery mechanisms such as a single integrated team and use of outreach to deliver services, supports, and rehabilitation to maximize the possibility that even the most disabled consumers would remain in the community and have a decent quality of life. Our own conclusion from the literature, when we consider the most rigorous studies and the programs that have high fidelity to the model, is that assertive community treatment is successful in reaching these goals. The willingness to deliver services to clients should not be equated with coercion. Coercion is not part of the model, and if programs that call themselves assertive community treatment programs appear to be using coercion, they should be closely scrutinized and modified.Meanwhile, we believe it is fair to say that many of our earlier efforts were overly paternalistic. Although we differed with many in that era in that we espoused the rights and abilities of persons with severe mental illness to live in the community—indeed, in the same settings as other citizens (2), we shared the prevailing view that staff "knew best" what clients needed. Hence our treatment plans were typically staff derived. Fortunately, the courageous voices of consumers, along with years of experience, have led us to see the enormous strengths of persons with mental illness. The assertive community treatment model has evolved into one of ongoing collaboration with consumers in making and reviewing decisions about goals and methods. The model will continue to improve only when we work in partnership with consumers.Dr. Gomory also points to the shortage of evidence about the effects of assertive community treatment beyond the well-documented reductions in hospitalization, and he accurately notes that we have not yet published data on psychosocial outcomes from a long-term study of assertive community treatment whose early (two-year) findings on hospitalization were reported in 1991 (3). Progress on this study for a number of years was substantially slowed, partly because of the need for the principal investigator (MAT) to assume family caregiving responsibilities and also by the need to devote all resources to the continued collection of the long-term data. Data analyses and writing are now our primary focus, and readers can be assured that all dimensions of the findings will be published as soon as this work is completed.Dr. Test is professor in the School of Social Work and affiliate professor in the department of psychiatry at the University of Madison, Wisconsin. Dr. Stein is professor emeritus of psychiatry at the University of Wisconsin, Madison, Medical School and director of research and education at the Mental Health Center of Dane County, Inc., in Madison.

A pilot study of assertive community treatment for patients with chronic psychotic disorders

This study measured hospital utilization and residential status of 51 patients with chronic psychoses before and after a 1-year program of assertive community treatment. Time hospitalized was reduced by 94%, and 82% of the patients previously living in hospitals or group homes attained independent living status, suggesting that this form of clinical management may reduce institutional care and costs to mental health care systems.