A comparison of experts' perspectives on assertive community treatment and intensive case management

This study compared experts' views on the critical ingredients of assertive community treatment and intensive case management. Twenty experts on assertive community treatment and 22 experts on intensive case management rated the importance of 40 elements common to each treatment approach. The assertive community treatment experts gave higher importance ratings than the intensive case management experts to 37 of the 40 items; for 21 of these items, the ratings were significantly higher. Differences in importance ratings were greatest for organizational and structural elements and smallest for treatment goals. The results of this study indicate that although intensive case management resembles assertive community treatment in most respects, assertive community treatment may be a more clearly articulated model overall.     

A review of the literature on the effectiveness of housing and support, assertive community treatment, and intensive case management interventions for persons with mental illness who have been homeless

A review of 16 controlled outcome evaluations of housing and support interventions for people with mental illness who have been homeless revealed significant reductions in homelessness and hospitalization and improvements in other outcomes (e.g., well-being) resulting from programs that provided permanent housing and support, assertive community treatment (ACT), and intensive case management (ICM). The best outcomes for housing stability were found for programs that combined housing and support (effect size = .67), followed by ACT alone (effect size = .47), while the weakest outcomes were found for ICM programs alone (effect size = .28). The results of this review were discussed in terms of their implications for policy, practice, and future research.     

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.     

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.     

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.     

Best practices: A systematic approach to the management of patients who refuse medications in an assertive community treatment team setting

A significant proportion of patients of assertive community treatment (ACT) teams will adamantly refuse medication. Whether the team should continue to encourage medication or put a hold on advocating for medication is a clinical and ethical dilemma. On the basis of their clinical experiences, the authors propose best-practices criteria that ACT teams can consider in deciding whether medications may be temporarily discontinued when a patient refuses them. The authors suggest that in some circumstances stopping medications in such a case may help in the development or repair of a therapeutic alliance over the long term.     

New directions in research on assertive community treatment

Evaluation of assertive community treatment programs has demonstrated that they are highly effective in reducing the need for psychiatric hospitalization of chronic mentally ill patients. However, the programs also tend to cost more than traditional outpatient care, and their impact on other areas of patient functioning is not clear. The authors believe more rigorous studies of the programs are needed before policymakers can properly evaluate their role in the overall mix of services. Future studies should extend previous research by comparing the programs to current state-of-the-art treatment in community mental health centers or county mental health programs; assessing the total system costs of assertive community treatment programs, as well as the amount of cost shifting by payers; analyzing outcomes of clients in mature programs over longer time periods; standardizing the measurement of various client outcomes; and determining the impact of individual program elements--alone and in combination--on different subgroups of clients.     

Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness

Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p < .001, effect size [ES] = 0.38) and earned more income (median [Mdn] = 549 US dollars, interquartile range [IQR] = 0-5,145 US dollars, versus Mdn = 0 US dollars, IQR = 0-40 US dollars; p < .001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.     

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.     

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]。