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.     

Involuntary admission may support treatment outcome and motivation in patients receiving assertive community treatment

Objective  

Patients with severe mental illness who are treated in assertive community treatment (ACT) teams are sometimes involuntarily admitted when they are dangerous to themselves or others, and are not motivated for treatment. However, the consequences of involuntary admission in terms of psychosocial outcome and treatment motivation are largely unknown. We hypothesized that involuntary admission would improve psychosocial outcome and not adversely affect their treatment motivation.     

Hospital outcome measures following assertive community treatment in Edmonton, Alberta.

OBJECTIVE: To examine hospital outcome measures for individuals with chronic and severe mental illnesses before and after their registration in an assertive community treatment (ACT) program in Edmonton, Alberta. METHODS: Data were collected from Alberta Health on individuals who were registered in ACT from April 1993 to April 1995. For each individual, hospital outcome measures were calculated for the 365 days prior to and 365 days after registration for ACT (thus covering April 1, 1992-March 31, 1996). RESULTS: Data were collected from 295 individuals. Compared with 1 year prior to beginning ACT, there was a 34% reduction in hospital separations for patients with psychiatric diagnoses. The average length of stay (LOS) for each separated patient decreased by 56%, and the hospitalization days for each patient separated also decreased by 39%. The number of emergency visits for psychiatric reasons was reduced by 32%, and the number of clients visiting emergency departments for psychiatric reasons declined by 30%. CONCLUSIONS: In the 1-year period after registration in an ACT program, hospital outcome measures were improved in this cohort of 295 individuals with severe and chronic mental illnesses.     

Ethics of assertive outreach (assertive community treatment teams)

Purpose of review: Assertive outreach, also known as assertive community treatment, is a well established service model in several countries for people with severe and enduring mental health problems who do no engage with psychiatric services. However, it has been criticized for being coercive and paternalistic. The present review considers a number of recent contributions to the debate concerning the ethics of assertive outreach. Recent findings: Assertive outreach brings into sharp focus a number of ethical issues that affect most mental health services, but it also generates new ones, primarily whether delivery of a service to people who are refusing it and are not legally bound to accept it can be justified. Several authors have grappled with these issues, mainly through using traditional principles of ethical treatment based on professional values, and this paper reviews such attempts at resolving those dilemmas. In so doing, it reveals the limitations of such approaches. Summary: In conclusion, the present review suggests an alternative ethical basis for supporting delivery of assertive outreach services to a reluctant client group, which focuses more on the client's values and areas of assistance with which they express genuine appreciation and satisfaction.     

The effectiveness of the assertive community treatment model

This study sought to determine the benefits of an assertive community treatment model (ACT) versus a continuing day-treatment program (CDTP) for the treatment of chronic mentally ill patients. The study utilized a quasi-experimental design with a matched-groups comparison of outcomes achieved by patients in two community mental health centers in the South Bronx area of New York City. The study assessed outcomes regarding hospital readmissions, quality of life, and housing and vocational rehabilitation. The sample size was 60, with 30 subjects in each group. Due to the small size and baseline differences between groups, nonparametric tests were the primary statistical analyses.     

Five-year outcome of first-episode psychosis before and after the implementation of a modified assertive community treatment programme

Objective  

Assertive community treatment programmes are increasingly common worldwide but without much knowledge of their long-term effect. We investigated whether the implementation of such a programme would improve symptomatic and functional outcome 5 years later.     

Perceived stigma and community integration among clients of assertive community treatment

Facilitating the integration of persons with psychiatric disabilities is an important goal of community programs. In addition to limitations such as inadequate housing, poverty, and unemployment, a common barrier to community adjustment identified by people with psychiatric disabilities is their perception of being stigmatized. This study examined the relationships between perceived stigma and community integration in 95 clients of assertive community treatment (ACT) teams, using sequential multiple regression procedures. Findings indicate that despite their physical presence in the community and the intensive support they receive, ACT clients believe other community members will reject them. Moreover, this perception appears to interfere with their sense of belonging, particularly among those who also perceive less social support and who have greater psychosocial skill deficits. In the context of the present study, global self-esteem did not mediate this relationship. In addition to community focused antistigma campaigns, stigma-related issues should also be addressed with ACT clients themselves.     

Employment outcomes in family-aided assertive community treatment

Family-aided assertive community treatment (FACT) was enhanced by adding vocational specialists to help persons with severe mental illness obtain competitive employment. Results were then tested against those of conventional vocational rehabilitation (CVR). The FACT cohort demonstrated significantly better employment rates than did the CVR, while negative symptoms declined in the former and increased in the latter. No evidence was found that competitive work presented a significant risk for relapse.     

Perceptions of assertive community treatment in the UK and Lithuania

BACKGROUND: There is current uncertainty over the future of assertive community and outreach teams in view of recent evidence suggesting that they no longer reduce hospital admissions. Despite this, assertive teams remain popular among practitioners. AIMS: To examine the views of assertive community team members and other mental health professionals in London (UK) and Vilnius (Lithuania) to determine important differences in attitudes. METHOD: A questionnaire, involving the assessment of statements giving common opinions on assertive community teams, was given to 62 staff in Vilnius, Lithuania and West London, UK, 33 from assertive community or outreach teams and 29 from other mental health professionals. RESULTS: The results of the questionnaire showed that personnel in experienced assertive outreach teams in London believed that they gave more intensive care (p < 0.001), felt it of greater value to see patients in the community (p < 0.001) and were not just well-resourced community teams with low caseloads (p < 0.01) than did other groups, but they placed lower value on assertiveness (p = 0.04) and comprehensive care (p < 0.04). These differences were less marked in Lithuania where staff regarded home treatment as similar to clinic treatment and were more supportive of comprehensive care. CONCLUSION: The results suggest that in experienced community teams the notion of assertiveness has become less important in planned intensive community care and so the term ACT may be outmoded. However, for countries such as Lithuania, somewhat similar to the United States in 1972 when ACT began, the original principles are still appropriate and 'assertive' is a major component of their effectiveness.     

Moving assertive community treatment into standard practice

This article describes the assertive community treatment model of comprehensive community-based psychiatric care for persons with severe mental illness and discusses issues pertaining to implementation of the model. The assertive community treatment model has been the subject of more than 25 randomized controlled trials. Research has shown that this type of program is effective in reducing hospitalization, is no more expensive than traditional care, and is more satisfactory to consumers and their families than standard care. Despite evidence of the efficacy of assertive community treatment, it is not uniformly available to the individuals who might benefit from it.     

Measuring client satisfaction with assertive community treatment

OBJECTIVE: A mailed survey was used to measure satisfaction of seriously mentally ill clients with services provided by an assertive community treatment team. METHODS: A detailed 35-item questionnaire was mailed in 1995 to all 174 clients of the Brockville (Ontario) Psychiatric Hospital's assertive community rehabilitation program. RESULTS: The rate of return was 51 percent. Compared with clients who did not return the survey, the respondent group had significantly fewer males and fewer clients with a diagnosis of schizophrenia; respondents had been associated with the program for less time. Factor analysis of the survey responses revealed three principal components accounting for 46 percent of the total variance in responses. The factors were interpersonal aspects of care, client involvement in treatment, and medication and treatment issues. Respondents were generally satisfied with service from the program, but they were dissatisfied with side effects of medication and the amount of medication they were taking. CONCLUSIONS: A mailed survey appears to be an efficient and nonintrusive way to collect satisfaction data anonymously from persons with serious mental illness who are clients of an assertive community treatment team. The results highlight areas of need that the team can address.     

国外主动性社区治疗的研究现状与启示

1概述欧洲学者将社区精神卫生服务近20余年发展描述为“个案管理的巨大成就（TriumphofCaseManagement）[1]。1900年美国马里兰大学精神病学系的Lisa在评述个案管理为基础的“主动性社区治疗（AssertiveCommunityTreatment,ACT）”在全美的发展历程时,誉之为25年的黄金岁月[2]。     

Direct and indirect time inputs and assertive community treatment

Assertive Community Treatment (ACT) is an appealing community program model because it proposes to provide individuals with coping skills that allow them to maintain independent lives in their communities and it offers the potential to decrease inpatient stays and increase community tenure. But, it is not without its limitations. Critics point out that ACT's unique elements also make it a potentially very resource intensive program—an important consideration in times of fiscal constraints. Though the charge may be justified, there is little in the literature that actually quantifies the intensity of resources used. The process through which it achieves outcomes is not frequently described. Using ACT team workload information, we examine the time trade-offs—direct for indirect time—involved with implementing this model. In addition, we describe the specific activities that make up the direct and indirect time inputs that go into supporting clients in the community through assertive team oriented case management.     

Clinical significance of assertive community treatment among adolescents

Social Psychiatry and Psychiatric Epidemiology - The efficacy of assertive community treatment for children and adolescents is proven in the United States, but remains controversial in Europe....