Health and Social Security Services for People with Down’s Syndrome in Denmark

To promote the recovery of people with mental illness, outreach services in psychiatric rehabilitation is an effective treatment. In Japan, deinstitutionalization has been delayed, and outreach services were not developed until recently. However, Japan's Ministry of Health, Labor, and Welfare announced in its 2004 report Mental Health and Medical Welfare Vision of Reform that the national policy of mental health must shift from hospital-oriented treatments to community-oriented treatments. As a result, many pioneering outreach activities are beginning to appear. In this article, we review outreach services in Japan of assertive community treatment (ACT), psychiatric home-visit nursing (PHVN), and the welfare-based outreach program known as home-visit life skills coaching. To provide outreach services of all types to people with mental illness, the separate roles of ACT, PHVN, and home-visit life skills coaching must be clearly defined. However, few agencies provide outreach services to people with mental illness in the Japanese psychiatric system. Thus, we must promote studies and activities that demonstrate the effectiveness of such services and change the culture of psychiatric services from hospital oriented to community oriented.     

The current research on support skills on ACT team

The author describes the support skills of Assertive Community Treatment (ACT) based on the activities of community mental health teams such as the Assertive Outreach Team (AOT) from Birmingham, Britain; ACT/PACT teams from the states of Indiana and Washington in the U.S.; and three ACT (primarily ACT-K) teams from Japan. The author contrasts skills used in Britain and the United States with those used in Japan. Japanese ACT teams have demonstrated effectiveness using skills considered to be taboo in conventional psychiatric hospitals, and the author illustrates examples of such skills. Finally, the author qualitatively analyzes and explains the skills utilized by psychiatrists on ACT teams.     

Preliminary outcome study on assertive community treatment in Japan

Aims: The beneficial effects of assertive community treatment (ACT), which has been widely acclaimed as being successful in several foreign countries, must also be objectively evaluated with respect to the transition from inpatient to community‐based mental health treatment in Japan. This was the first study that examined effects of the ACT program in Japan using pre/post design data of the pilot trial of the ACT program in Japan project. Methods: The study included 41 subjects hospitalized at Kohnodai Hospital, National Center of Neurology and Psychiatry between May 2003 and April 2004 for severe mental illness and who met inclusion criteria for entry regarding age, diagnosis, residence, utilization of mental health services, social adjustment, and ability to function in daily activities. All subjects provided informed consent for study participation and were followed for 1 year after hospital discharge. Results: Comparison of the number of days and frequency of inpatient psychiatric hospitalization and frequency of emergency psychiatric visits between the 1‐year period before hospitalization and 1‐year period after hospital discharge showed a significant decrease in number of days and frequency of hospitalization. Comparison at 1 year after discharge with baseline showed no change in satisfaction with overall quality of life or Brief Psychiatric Rating Scale scores, but the Global Assessment of Functioning score significantly increased, and the antipsychotic dose (chlorpromazine equivalent) significantly decreased. Conclusion: Despite some limitations in methodology and conclusions, this study suggests that ACT enables persons with severe mental illness to live for longer periods in the community, without worsening of symptoms, decreased social function, or deterioration in quality of life.     

A comprehensive treatment program for schizophrenia and chronic mental illness

The failure of deinstitutionalization and the community mental health movement to improve the treatment of chronic psychiatric patients, particularly schizophrenics, is described. Problems with the current treatment paradigm include unrealistic expectations concerning the rehabilitative effects of antipsychotic medications, inadequate funding of the community mental health system, and the predominance of the "infectious disease model," rather than the more appropriate "chronic disease model" of mental illness. A model for the comprehensive treatment of chronic mental illness is proposed that includes: treatment, rehabilitation, social services, and continuity of care. The need for an integrated community approach to rehabilitating chronic psychiatric patients is stressed, and some of the specific ingredients essential to such a program are identified.     

Consumers as Staff in Assertive Community Treatment Programs

The last decade has witnessed the increasing importance of consumers as providers of mental health services. Assertive Community Treatment (ACT) teams and ACT variants, with their emphasis on rehabilitation and support in the client's natural environment, have hosted consumer-professional collaborations. The authors discuss one such program in which an ACT program for homeless mentally ill adults employed consumer advocates (CAs). Consumer advocates were found to have a service profile similar to other staff. Further, there is suggestive evidence that the employment of CAs created a more positive attitude toward persons with mental illness. Issues of role definition, boundaries, support with supervision and the importance of CAs' experiences with mental illness are discussed.     

Exploring Primary Care Activities in ACT Teams

People with serious mental illness often receive inadequate primary and preventive care services. Federal healthcare reform endorses team-based care that provides high quality primary and preventive care to at risk populations. Assertive community treatment (ACT) teams offer a proven, standardized treatment approach effective in improving mental health outcomes for the seriously mentally ill. Much is known about the effectiveness of ACT teams in improving mental health outcomes, but the degree to which medical care needs are addressed is not established. The purpose of this study was to explore the extent to which ACT teams address the physical health of the population they serve. ACT team leaders were invited to complete an anonymous, web-based survey to explore attitudes and activities involving the primary care needs of their clients. Information was collected regarding the use of health screening tools, physical health assessments, provision of medical care and collaboration with primary care systems. Data was analyzed from 127 team leaders across the country, of which 55 completed the entire survey. Nearly every ACT team leader believed ACT teams have a role in identifying and managing the medical co-morbidities of their clientele. ACT teams report participation in many primary care activities. ACT teams are providing a substantial amount of primary and preventive services to their population. The survey suggests standardization of physical health identification, management or referral processes within ACT teams may result in improved quality of medical care. ACT teams are in a unique position to improve physical health care by virtue of having medically trained staff and frequent, close contact with their clients.     

Therapeutic Agents of Assertive Community Treatment

The goal of this study was to learn how assertive community treatment (ACT) contributes to the improvement of those with serious mental illness in order to contribute to the growing clinical literature regarding the therapeutic agents of ACT teams. Methods included reviewing the case records of three ACT clients who have improved significantly, as well as interviewing the clients themselves and their clinicians. The results indicated that there was significant agreement among the case records, the clients, and their clinicians in identifying the most useful aspects of assertive community treatment. Primary among these factors were the persistence demonstrated by ACT clinicians in engaging their clients, the trust that clients developed in their clinicians, and as a result, the process by which their clinicians became guides to the world of psychiatric and social services that further facilitated their clients' community adjustment. In closing, we consider implications from these findings both for staff development for ACT team members, and for suggestions toward the development of a model of recovery from serious mental illness.     

Soins intensifs à domicile : modèles internationaux et niveau de preuve

Introduction

Despite recent legislation favouring home treatment services, international literature contrasts with its development in France, where those programs stay rare. They were implemented since the deinstitutionalization movement of the 1970s, to provide care to severe mentally ill outpatients, who used to stay in long-term inpatient wards. Those home treatment programs can be divided in two groups: Assertive Community Treatment and crisis interventions teams.

Objectives

This article first aims to describe those two types of programs, and then to review their evidence level. Finally, we will discuss the actual controversy about effectiveness of home treatment.

Method

This article is a literature review of international research about home treatment programs for adults’ severe mental illness. It excluded children psychiatry, addictology and elderly psychiatry. We selected reviews and research articles taken from international publications, using a PubMed research.

Results

This article concerns home treatment programs, belonging to “mobile teams”, which is a group of psychiatric teams including varied goals: Improving continuity of care, community assessment, avoiding admissions to psychiatric hospital, improving skills in community living, and supporting families. Those programs practice assertive outreach. Some provide care and others only assess and direct people to other services. Only the first ones are concerned by this article. We distinguish two types of home treatments: Assertive Community Treatment (ACT) and Crisis Intervention teams. Assertive Community Treatment, also named Assertive Outreach teams or Intensive Case Management, is a very well described model which aims to keep people with severe mental illness in the community. It is an intensive kind of Case Management. It is specially addressed to high services users, with frequent admissions. ACT consists in visiting people at home, providing cares and social support, developing skills to cope with daily living. It is provided by a 24-hour available multidisciplinary team, in an unlimited time. The first Stein and Test study showed benefits compared to standard treatment, but more recent trials failed in improving hospital use or clinical and social outcomes. Some even show and increased hospitalization rate. This variation can be explained by an improvement of standard care with time, and international heterogeneity. A higher fidelity to the original model could decrease bed use. Fidelity scales have been developed to compare different programs. ACT seems to be useful to improve engagement in care for people with a high level of needs, and to maintain them in housing. Studies also show a dilution of the effectiveness of ACT in routine practice. Those results limit its implementation. The second group of home treatments is crisis intervention and home treatment teams, also called crisis assessment teams. Those teams aim to treat crisis at home for severe mentally ill people. Crisis is defined as a symptomatic exacerbation in severe mental illness. Treatment is provided by a 24 hours available multidisciplinary team which assesses the situation, directs the patient and programs a crisis intervention. The intervention is time limited, about six weeks. It helps people to resolve crisis in the community. It could avoid 50% of psychiatric admissions, without increasing readmission rates. A recent study shows it could reduce the suicide rate. It also improves satisfaction with care and engagement.

Conclusions

Despite the controversy, home treatment services can be useful to improve engagement in care, user's satisfaction, and to avoid psychiatric admissions. Visiting patient at home and associating social interventions with medical treatment improve bed use outcomes. Less intensive but well organized community teams can also bring benefits. In the French context, the lack of visibility of home treatment teams can be explained by several hypotheses. We can cite the lack of systematic evaluation of care programs, the persistence of more inpatient beds than in other countries, the difficulty to implement home treatment in rural areas or the cultural use of hospital.     

Can Assertive Community Treatment Remedy Patients Dropping Out of Treatment Due to Fragmented Services?

Previously, many patients with severe mental illness had difficulties to engage with fragmented mental health services, thus not receiving care. In a Dutch city, Assertive Community Treatment (ACT) was introduced to cater specifically for this group of patients. In a pre–post comparison, changes in mental health care consumption were examined. All mental health care contacts, ACT and non-ACT, of patients in the newly started ACT-teams were extracted from the regional Psychiatric Case Register. Analyses of mental health care usage were performed comparing the period before ACT introduction with the period thereafter. After the introduction of ACT, mental health care use increased in this group of patients, although not all patients remained under the care of ACT teams. ACT may succeed in delivering more mental health care to patients with severe mental illness and treatment needs who previously had difficulties engaging with fragmented mental health care services.     

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.     

How many assertive community treatment teams do we need?

OBJECTIVE: Assertive community treatment (ACT) reduces hospitalizations for persons with severe mental illness. However, not everyone who needs ACT receives it. Without empirical guidelines for ACT planning, communities are likely to underestimate or overestimate the number of teams they need; thus the capacity of the programs will not meet current needs. In this study, administrative data were used to develop empirical estimates for the number of required ACT teams. These estimates were then used to examine current conceptual guidelines for developing the number of ACT teams that communities need. METHODS: Administrative data from a large, urban county were used to enumerate all persons with a severe mental illness who had three or more hospitalizations within one year (ACT eligible). RESULTS: Fifty-one percent of persons with a severe mental illness were found to be eligible for ACT (743 of 1,453 persons). This figure represents 2.2 percent of the county's mental health users and .06 percent of its adult population. CONCLUSIONS: Communities should develop enough ACT teams to serve approximately 50 percent of their populations of persons with severe mental illness or roughly .06 percent of their adult populations.     

Integrating Assertive Community Treatment and Illness Management and Recovery for Consumers with Severe Mental Illness

This study examined the integration of two evidence-based practices for adults with severe mental illness: Assertive community treatment (ACT) and illness management and recovery (IMR) with peer specialists as IMR practitioners. Two of four ACT teams were randomly assigned to implement IMR. Over 2 years, the ACT–IMR teams achieved moderate fidelity to the IMR model, but low penetration rates: 47 (25.7%) consumers participated in any IMR sessions and 7 (3.8%) completed the program during the study period. Overall, there were no differences in consumer outcomes at the ACT team level; however, consumers exposed to IMR showed reduced hospital use over time.     

Staff Turnover in Statewide Implementation of ACT: Relationship with ACT Fidelity and Other Team Characteristics

Staff turnover on assertive community treatment (ACT) teams is a poorly understood phenomenon. This study examined annual turnover and fidelity data collected in a statewide implementation of ACT over a 5-year period. Mean annual staff turnover across all observations was 30.0%. Turnover was negatively correlated with overall fidelity at Year 1 and 3. The team approach fidelity item was negatively correlated with staff turnover at Year 3. For 13 teams with 3 years of follow-up data, turnover rates did not change over time. Most ACT staff turnover rates were comparable or better than other turnover rates reported in the mental health and substance abuse literature.     

Mental health services in Asia: International perspective and challenge for the coming years

In contrast to European countries and the United States of America, there has been a steady increase in the psychiatric inpatient population in Japan between 1960 and 1993. Japan has the biggest number of psychiatric beds in the world, both in absolute and relative numbers per population. However, Japan now focuses on community based services and the human rights of patients. In other Asian countries, the number of psychiatric beds is relatively small; however, the numbers are increasing each year in China, the Republic of Korea, Philippines, Indonesia and in many other countries in Asia. These countries are still facing the challenge of increasing psychiatric services and to improve the quality of care with scarce mental health resources. Should Asian countries take the similar path to European countries and develop mental health services? This review provides an overview of Asian mental health services and discussing the following issues: how many psychiatric beds do we need in Asia?; public vs private psychiatric services?; financing scheme to promote community based care in Asia; mental health services in primary health care; family education and user involvement in Asia; and the challenge for psychiatrists in Asia.     

Who uses consumer-run self-help organizations?

A multisite evaluation of community mental health services is used to answer two questions: (a) How do diagnosis, functioning, and self-assessments of consumer/survivor initiative (CSI) and assertive community treatment (ACT) participants compare?, and (b) What other supports/services are CSI and ACT participants using? The sample is from an Ontario evaluation of consumer/survivor peer initiatives in four communities (n=73). The reference group is new (n=48) and ongoing (n=134) clients of four ACT teams. Self-help organizations are serving a broader population of individuals who include a significant subgroup of persons with severe mental illness along with others with a mixed picture of higher functioning and greater instability. There is little overlap in the use of these modes of service delivery, which suggests that maintaining options within systems of care is critical to ensuring coverage and access for the broader population.     

Evaluating the Quality of Rural Intensive Case Management Services using Administrative Data: an Exploratory Study

Assertive Community Treatment (ACT) for people with severe mental illness is an effective approach that is increasingly implemented in rural areas. Low-cost methods of evaluating fidelity to program models are needed to assure services are delivered as intended. In 2007, the Veterans Health Administration implemented an ACT-like Mental Health Intensive Case Management (ACT/ICM) program for SMI veterans in rural areas. This study demonstrates the use of administrative data, reflecting patient characteristics and intensity of service delivery, to characterize services delivered by these programs, to compare them to general mental health programs at the same VA medical centers, and to each other. A total of 298,509 veterans received mental health services at VA medical centers that also operated a rural ACT/ICM program in FY 2012. Altogether 854 (0.29%) received ACT/ICM services for 1 year or more (long term participants) and 259 (.09%) received them for less than 1 year (new entrants). Logistic regression showed ACT/ICM patients were distinguished by diagnoses of schizophrenia, bipolar disorder, and major depression; larger numbers of psychiatric or substance abuse visits; and use of 3 or more classes of psychotropic medication. The model had a high c statistic of 0.91. Propensity scores allowed clear identification of programs most and least conforming to the profile of a “typical” rural ACT/ICM program. Low cost administrative data can be used to identify programs successfully conforming to an empirically derived rural model of ACT/ICM. Further validation of this approach is needed.     

Harbinger II: Deployment and Evolution of Assertive Community Treatment in Michigan

Assertive Community Treatment (ACT) is now recognized as the model proven to be most successful in working with clients with long-term, severe mental illness. The first documented research replication study of ACT was Harbinger of Grand Rapids, in Kent County, Michigan. The Harbinger program influenced significant programmatic changes throughout the public mental health system in Michigan. This paper describes this evolution in community mental health locally and why these changes came about. The state-level strategy to implement replications of Harbinger is described, as well as funding and monitoring mechanisms that have now resulted in over 100 successful ACT programs in Michigan. For mental health administrators, the implications discussed include the future of ACT promotion and implementation, within the reality of a managed care framework.     

Twenty Years of Mental Health Policies in Chile

Over the last 20 years, Chile has increased the mental health share of its public health budget and implemented policies that radically transformed psychiatric services in the country. Both national and international factors have contributed to this process. The implementation of two national mental health plans has led to downsizing mental hospitals and developing community alternatives, such as primary health care, community mental health teams, day hospitals, acute psychiatric beds in general hospitals, and group homes. The annual number of new persons starting treatment for mental disorders in the public sector has increased by 343 percent between 2004 and 2007, with depression being the condition that motivates the highest frequency of visits. The Chilean experience has been successful in terms of increasing availability and accessibility of services and demonstrating that with a modicum of political support, it is possible to implement an effective and efficient community-based network of primary and secondary care facilities. Notwithstanding the progress made in this country, the mental health treatment gap is still significant.     

The differential effectiveness of psychosocial and biogenetic causal explanations in reducing negative attitudes toward "mental illness"

Given the apparent failure of the "mental illness is an illness like any other" approach to reducing negative stereotypes of people with mental health problems, the differential effects of biogenetic and psychosocial explanations of psychiatric symptoms were evaluated. Attitude measures were administered to young New Zealand adults before and after a video portraying a young man with psychotic symptoms followed by either biogenetic or psychosocial explanations. Consistent with previous studies, the "medical model" approach significantly increased perceptions of dangerousness and unpredictability. Following the psychosocial explanation there was a slight but statistically insignificant improvement in attitudes. Participants who knew users of psychiatric services, or who had used services themselves, had more positive attitudes than other participants. It is recommended that destigmatization programs minimize efforts to persuade the public that mental health problems are biogenetic illnesses, and focus instead on increasing exposure to users of mental health services. Further research is required to determine whether such exposure should include life histories, so as to highlight the psychosocial causes of mental health problems.     

Employment services as an early intervention for young people with mental illness

Aim: To examine the service characteristics and effectiveness of a segregated employment service assisting young clients with mental illness in New Zealand. Methods: The service assisted both youth and adults with severe mental illness to find and keep competitive employment. A retrospective case study method was used to examine service effectiveness with respect to employment outcomes attained by 49 clients aged 16–25 years over a 2-year period (2005–2007). These results were compared with recent national and international benchmarks. Results: As a service segregated from public mental health services, there were no formal arrangements with local mental health teams, limiting coordination of services and reducing fidelity to evidence-based practices in supported employment. Despite an inability to collaborate closely with local community mental health services and a contract not specifically targeting youth, the service was high performing on a range of employment outcome variables. Conclusions: Subject to some study design and benchmarking limitations, these results support the continuing use of evidence-based practices in supported employment and supported education as important early interventions for young people with mental illnesses.