What matters when implementing Flexible Assertive Community Treatment in a Swedish healthcare context: A two-year implementation study

Despite the lack of scientific evidence for the effectiveness of Flexible Assertive Community Treatment (Flexible ACT), the model disseminates rapidly in the mental health services in a number of countries. This is in contrast to many evidence-based practices that often face comprehensive implementation barriers. Knowledge is needed on the dissemination of Flexible ACT to understand the relative success. The aim of this study was to explore program fidelity and factors influencing the implementation of Flexible ACT in a Swedish healthcare context over a 2-year period. Seven mental healthcare teams who decided to implement Flexible ACT were included in the study. Interviews were conducted regularly with project leaders and team leaders, and steering group meeting notes and implementation progress reports were collected during a 2-year period. Flexible ACT fidelity assessments were conducted 6 and 18 months after implementation started. Data was analysed using conventional and directed content analysis and the Sustainable Implementation Scale. All teams reached at least good fidelity 6 months after implementation, and the fidelity scores remained stable over an 18-month period. An active national initiative and support to implement Flexible ACT, as well as a willingness among managers and staff to implement the model, contributed to the seemingly swift and easy implementation. Despite the highly sectored Swedish healthcare context, implementation of high fidelity Flexible ACT was possible. Positive mental health professional attitudes, belief in the practice, and desire to offer the practice appear to have central roles when implementing new practice models in mental healthcare.     

The effect of Assertive Community Treatment in Japan

Ito J, Oshima I, Nishio M, Sono T, Suzuki Y, Horiuchi K, Niekawa N, Ogawa M, Setoya Y, Hisanaga F, Kouda M, Tsukada K. The effect of Assertive Community Treatment in Japan. Objective: The aim of this study was to evaluate the effects of the Assertive Community Treatment (ACT) program in a Japanese mental health service setting. Method: This study was a randomized controlled trial. ACT was the intervention condition (n = 59), and the usual hospital‐based rehabilitation program was the control condition (n = 59). Outcome indicators include in‐patient days, psychiatric symptoms, social functioning, quality of life, and client satisfaction. The follow‐up period was 12 months after the intervention. Results: We found a significant reduction of in‐patient days for the ACT group demonstrated by t‐test (t = 2.33, P = 0.02). However, the results of ancova did not show significant differences for in‐patient days between the two groups (F = 1.85, P = 0.18). The depression score for Brief Psychiatric Rating Scale for the ACT group was significantly lower than the control group at the 12‐month follow‐up assessment (F = 5.57, P = 0.03). According to the t‐test, the ACT group had a higher client satisfaction than the control group (t = 2.08, P = 0.05). Conclusion: We concluded that ACT had a positive influence, as evidenced by a reduction of in‐patient days, lower depressive symptoms, and higher client satisfaction.     

Assertive community treatment versus standard treatment for severely mentally ill patients in Denmark: a quasi-experimental trial

Background: The future of assertive community treatment is uncertain, and studies have questioned whether it continues to provide a more effective treatment model for severely mentally ill patients in a modern mental health context. Studies conducted in new settings can contribute to the debate.

Methods: This Danish study compares treatment from assertive community treatment with treatment by standard community mental health teams, using a non-blinded quasi-experimental multi-center trial. Outcomes included contact with mental health services, days of admission, days of involuntary admission, number of outpatient contacts, adherence to antipsychotic medication, social functioning, user satisfaction, and psychopathology.

Results: A total of 366 patients receiving treatment from assertive community treatment (n?=?213) or continuation of care from community mental health teams (n?=?153) were included in the trial. Assertive community treatment was significantly better in sustaining contact with patients. At 2-year follow-up, 16 (8%) of patients receiving assertive community treatment versus 22(14%) receiving care from standard treatment had lost contact with treatment. Patients who received assertive community treatment had a larger reduction in inpatient service-use, increased adherence to antipsychotic medication, improved social functioning, and higher user satisfaction. No differences in days of involuntary admission and psychopathology were found.

Conclusions: The results suggest that a high fidelity assertive community treatment may be a valuable tool to strengthen contact between severely mentally ill patients and the treatment staff and may contribute to improving outcomes in a modern Danish mental health context.     

ACT and Recovery: Integrating Evidence-Based Practice and Recovery Orientation on Assertive Community Treatment Teams

We examine whether Assertive Community Treatment (ACT), a widely implemented and rigorously studied practice, can successfully incorporate a recovery-oriented approach while continuing to retain program fidelity. We briefly review the effectiveness of ACT as an evidence-based practice, with a focus on adaptations to changing populations and contexts. We explore philosophical similarities and differences between ACT and recovery and examine how fidelity standards, a widely used indicator of how ACT teams operate, support or interfere with the adoption of a recovery-oriented practice. Finally, we provide recommendations on how best to incorporate a recovery orientation into existing ACT teams. Dr. Salyers is Co-Director of the ACT Center of Indiana, Associate Research Professor, Department of Psychology, IUPUI, and Research Scientist, VA HSR&D Center on Implementing Evidence-based Practice, Roudebush VAMC and Regenstrief Institute, Inc. Dr. Tsemberis is Founder and Executive Director of Pathways to Housing, Executive Director of the New York State Institute for ACT and Recovery Based Training, and Assistant Professor, Department of Psychiatry, NYU Medical Center.     

Contexts of Social Relationship Development Among Assertive Community Treatment Clients

This exploratory qualitative study examined contexts and processes of social relationship development as experienced by adults with schizophrenia participating in assertive community treatment (ACT) programs. Semistructured interviews with 20 ACT clients diagnosed with schizophrenia-spectrum disorders and 2 ACT staff members were analyzed using grounded theory analysis methods. Results showed that aside from contacts with family members and providers, participants' interactions with fellow mental health clients tended to dominate social interactions, and that this pattern appeared to be influenced by both the concentration of social opportunities in daily activities of service utilization and the ACT program emphasis upon facilitating relationships between clients. Participants described their relationships with other mental health clients in primarily positive terms, yet several participants expressed dissatisfaction and desired greater integration into mainstream social networks. Implications for mental health service delivery are discussed.     

Comparison of Assertive Community Treatment Programs in Urban Massachusetts and Rural North Carolina

In this pilot study, we compared teams in rural North Carolina (NC) and urban Massachusetts (MA) to examine the how sites vary the implementation of the Assertive Community Treatment (ACT) model to respond to state and local circumstances. We analysed and compared data on: client characteristics using the NC-TOPPS and a modified survey in MA; Regional Demographics and; Team Characteristics. Issues such as driving distances, lack of qualified clinical staff, scarcity of physicians, and more limited oversight created impediments to fidelity in rural NC, despite higher per patient funding. ACT is now national, but variability in implementation of the model remains. This paper was originally presented as a poster at the 59th Institute on Psychiatric Services in New Orleans, October 2007.     

Needs assessed by psychiatric health care and social services in a defined cohort of clients with mental disabilities

Background The identification of needs for support and service in clients with long–term mental disabilities is usually not done by staff personnel from both psychiatric care and social services. However, such a process is probably necessary in order to provide adequate psychiatric care and social services. Aims To estimate the prevalence of mentally disabled clients and investigate whether staff from psychiatric care and social services identified the same individuals and the same number of needs in the same areas. Methods Clients from a defined catchment area were identified during a three–month period. A questionnaire was developed to collect socio–demographic information and to assess needs for support and service. Results The study identified 1,290 clients with needs with a prevalence of 5.72/1000 inhabitants. More than half of the clients needed support in activities of daily living. Only 18.1% of the clients were identified by both organizations. In general, the staff from psychiatric care and social services identified the same needs at a group level. However, at the individual level, agreement was quite low. Conclusions The staffs from both psychiatric care and social services are necessary to evaluate the needs of support and services in clients with mental disabilities.     

A Meta-analysis of Cognitive Remediation for Schizophrenia: Efficacy and the Role of Participant and Treatment Factors

The number of randomized, controlled studies of cognitive remediation (CR) for schizophrenia, a therapeutic approach designed to improve cognitive skills and function, has grown substantially over the past 20 years. Active elements of CR treatment, however, remain unknown. The current meta-analysis investigated treatment, study, and participant factors in the size of observed treatment effects. Electronic databases were searched up to May 2020 using variants of the key words “cognitive remediation,” “clinical trials,” and “schizophrenia.” This search produced 73 unique, randomized, controlled trials. Data were independently extracted by 3 reviewers with excellent reliability. Random-effects models were used to assess primary cognitive and secondary symptom and functional outcomes. Moderator analyses investigated the role of a variety of treatment, study, and participant factors. The meta-analysis (4594 participants) revealed that CR produced significant small-to-moderate size improvements in all domains of cognition studied (Hedge’s gs = .19–.33). and a significant small improvement in function (Hedge’s g = .21). CR programs that included a discussion (“bridging”) group to help apply acquired cognitive skills to everyday life produced larger effects on global cognition and verbal memory. CR programs with strategy-coaching produced larger effects on episodic memory. Sample age, gender, positive, negative, and overall symptoms, and medication dose did not serve as barriers to treatment gains. CR produces small-to-moderate improvements in cognition and function in schizophrenia. Programs of CR that utilize bridging groups and strategy-coaching are more cognitively potent. Future research should focus on ways to modify CR to bolster generalization of cognitive improvements to function.     

Psychiatric Hospitalizations,Arrests, Emergency Room Visits,and Homelessness of Clients with Serious and Persistent Mental Illness: Findings from a Randomized Trial of Two ACT Programs vs. Usual Care

Objective: This investigation examined several adverse outcomes in clients with serious mental illness in a randomized trial of Assertive Community Treatment (ACT) versus usual care. Method: 163 subjects were randomized to one of two ACT experimental conditions (staffed by consumers or non-consumers) or usual community care. Conditions were compared on psychiatric hospitalization, emergency room visit, arrest, and homelessness, within the two-year study period. Demographic, program, and client variables were examined for significant associations with outcomes. Results: Significant differences were found between ACT and usual care in time to first arrest, but not hospitalization, homelessness or ER visits. Shorter time to first hospitalization was associated with male gender, diagnoses other than schizophrenia, high psychiatric symptomatology and lower provider case load. ER visits were associated with increased client symptomatology. Shorter times to homelessness were predicted by poorer therapeutic alliance between case manager and clients. Shorter time to first arrest was predicted by client minority status and enrollment in usual care. Conclusions: The paucity of significant main effects may have been due to a prolonged start-up phase of the ACT programs, poor ACT implementation, restricted availability of psychiatric hospital beds, or changes in usual care services delivered over the study period.     

Community Integration in the Early Phase of Housing Among Homeless Persons Diagnosed with Severe Mental Illness: Successes and Challenges

The present investigation used qualitative methods to explore the response to housing and experience of community integration of formerly homeless individuals diagnosed with severe mental illness recently housed in both independent and staffed residential settings. Findings indicate that entering into housing after a long period of homelessness is associated with improvements in community integration for most individuals diagnosed with severe mental illness. However, for a meaningful minority, the adaptation to housing may also be associated with challenges that can complicate the integration process. Implications of findings are discussed in the context of how best to tailor programs to meet the complex needs of persons diagnosed with severe mental illness and to maximize community integration.     

Reconceptualizing the Case Management Relationship in Intensive Treatment: A Study of Staff Perceptions and Experiences

The helping relationship or alliance is theorized to be an important process variable in case management services for people with serious mental illness. Previous studies of the case management relationship borrow concepts and measures from psychotherapy research and therefore may overlook important differences in tasks, settings, and clinical roles across settings. A study of client–provider relationships as perceived by case managers, based on a qualitative study of two intensive case management (ICM) teams, is presented. The findings, which delineate positive and negative experiential elements, may be used to improve measurement of the case management relationship in future research.     

How states of mind change in psychotherapy: An intensive case analysis of Lisa's case using the Grid of Problematic States

Abstract

This study uses the Grid of Problematic States (GPS) to examine Lisa's case, one of the most successful in the York Psychotherapy Depression Project. This study tried to assess whether the contents of mental experience form stable clusters consistent with a diagnosis of depression. It was possible with the GPS to pinpoint problematic states typical of depression and trace the transitional states occurring in Lisa between two different mental states: depressive and well-being. The GPS analysis suggested that the treatment successfully managed to deal with symptoms and to change the patient's thought themes and emotions. At the end of treatment, Lisa was less sad and displayed some anger, and a state of being nurtured emerged.     

An intensive case analysis of client metacognition in a good-outcome psychotherapy: Lisa's case

Abstract

The authors analyzed the successful case of Lisa, a client with major depression, using the Metacognitive Assessment Scale (MAS). Consistently with the literature on depression, the authors hypothesize that Lisa's ability to reflect on mental states—here metacognition—is marginally affected. The authors found that Lisa was better at describing her own mind rather than understanding the mind of the others. Furthermore, the most severe impairment was in using metacognition to cope with mental state source of distress and to enact strategies to solve interpersonal problems. During the therapy such difficulties improved progressively. Limitations and implications of these findings are discussed.     

Mental health outcomes for those who have offended and have been given a Mental Health Treatment Requirement as part of a Community Order in England and Wales

Background

Growing evidence of mental disorders among people going through the criminal justice system suggests the potential benefit of courts adding a Mental Health Treatment Requirement (MHTR) when sentencing an offender to a Community Order (sentence) in England and Wales. Although available since 2003, MHTRs have not been widely used, and there is little evidence on outcomes.

Aim

To conduct the first large-scale evaluation of mental health outcomes of people with an MHTR as part of their community sentence across multiple sites in England and Wales.

Methods

Data were collected from 14 sites in England and Wales about individuals who were given an MHTR as part of a community sentence. They were assessed before and after this. During the MHTR, they received a psychotherapeutic intervention by assistant psychologists in a primary care framework. Measures of psychological distress (Clinical Outcomes in Routine Evaluation—Outcome Measure), anxiety (Generalised Anxiety Disorder-7) and depression (Patient Health Questionnaire) were completed before the MHTR was implemented and after completion.

Results

Where paired sample t-tests and Wilcoxon signed ranked tests were used, with samples ranging between 309 and 447 individuals, clinically significant changes were obtained for all measures. Most individuals (63%) were identified as experiencing a reliable change in at least two out of the three scales. Finally, a negative linear relationship, between measures at the start of the intervention and reliable change, was identified with higher pre-measures, indicating that more initial distress, anxiety and/or depression were associated with more sizeable changes.

Conclusions

This paper provides the first substantial evidence in support of the MHTR within a primary mental healthcare framework as an effective pathway to reduce mental health problems among individuals under probation supervision as part of a sentence after conviction for a criminal offence. This supports the expansion of the provision across England and Wales. Future research should take account of the non-completers and explore the relationship between the MHTR, mental health improvements and reoffending.