Efficacy and Effectiveness
(See, also, section on "Implementation of ACT as Evidence-Based Practice," below.)

Allness DJ. The Program of Assertive Community Treatment (PACT): The model and its replication. New Direction for Mental Health Services 1997;74:17-26.

Anders SL. Improving community-based care for the treatment of schizophrenia: lessons from native Africa. Psychiatric Rehabilitation Journal 2003;27(1):51-8.

Bond GR, Miller LD, Krumwied RD, Ward RS. Assertive Case management in three CMHCs: a controlled study. Hospital and Community Psychiatry 1988;39(411):418.

Bond GR, Witheridge TF, Dincin T, Wasmer D, Webb J, DeGraaf-Kaser R. Assertive Community Treatment for frequent users of psychiatric hospitals in a large city: a controlled study. American Journal of Community Psychology 1990;18(6):865-91.

Bond GR, McGrew JH, Fekete DM. Assertive outreach for frequent users of psychiatric hospitals: a meta-analysis. Journal of Mental Health Administration 1995;22(1):4-16.

Bond GR, Drake R, Mueser KT, Latimer E. Assertive Community Treatment for people with severe mental illness: critical ingredients and impact on patients. Disease Management and Health Outcomes 2001;9:141-59.

Bond GR, Salyers MP, Rollins AL, Rapp CA, Zipple AM. How Evidence-Based Practices Contribute to Community Integration. Community Mental Health Journal. 2004, 40:569-588.

Burns BJ, Santos AB. Assertive community treatment: an update of randomized trials. Psychiatric Services 1995;46(7):669-75.

Chandler D.  Spicer G. (2002) Capitated assertive community treatment program savings: system implications. Administration & Policy in Mental Health.  30(1):3-19.

 Abstract:   In a California county of one million people, 500 clients, 4% of all those served in 1994, were found to use 38% of publicly funded mental health services. A controlled experiment was designed to test whether a capitated Assertive Community Treatment (ACT) program could produce outcomes that were equivalent or better than "usual services" for a subset of very-high-utilizing clients while reducing costs. Results showed that major challenges in using an ACT program for cost reduction were successfully met. Costs over all 4 years were substantially lower for the experimental group than for a randomly assigned comparison group.

Chue P, Tibbo P, Wright E, Van Ens J. Client and community services satisfaction with an assertive community treatment subprogram for inner-city clients in Edmonton, Alberta. Canadian Journal of Psychiatry 2004;49(621):624.

Dekker J, Wijdenes W,  Koning YA, ardien R, Hermandes-Willenborg L, Nusselder H.(2002) Community Mental Health Journal.  38(5):425-34.

 Abstract :   In Amsterdam in the Netherlands, in 1993, an intensive case management project was initiated. This article describes this well-known Dutch project as it was tested in a randomised clinical trial using regular outpatient and inpatient care as the control conditions. All the patients in this project are very ill and most of them suffer from schizophrenia. The new form of care has the same effect on everyday problems as regular care. The basis of this data is too narrow for the drawing of conclusions about the risk of suicide. Longer follow-up would be advisable in order to improve our understanding of this problem. There has been no drop in compulsory admissions. On the other hand, there has been a spectacular decrease in the number of bed days (a reduction of 66% in the second year of the ACT programme).

Dixon L. (2000) Assertive community treatment: twenty-five years of gold.  Psychiatric Services.  51(6):759-65.

Drake RE, Mueser KT, Brunette MF, McHugo GJ (2004) A Review of treatments for people with severe mental illnesses and co-occurring substance abuse disorders. Psychiatric Rehabilitation Journal, 27(4):360-374.

Herinckx HA, Kinney RF, Clarke GN, Paulson RI. Assertive community treatment versus usual care in engaging and retaining clients with severe mental illness. Psychiatric Services 1997 October;48(10):1297-306.

Holloway F.  Carson J. Case management: an update. International Journal of Social Psychiatry.  47(3):21-31, 2001.

Abstract:  BACKGROUND: Case management in its various forms represents a major innovation in mental health care. Its efficacy remains controversial. AIMS: To update after a decade a previous review article (Holloway, 1991). METHODS: Descriptive literature and controlled trials of case management and its derivative Assertive Community Treatment (ACT) was accessed through four comprehensive and systematic reviews of the literature, repeated Medline and Embase searches and personal contacts. RESULTS AND CONCLUSIONS: The concept of case management has continued to evolve over the past decade. No controlled trial has been published exploring the model of the case manager as a service broker without responsibility for the provision of care. Basic case management principles have frequently been incorporated within routine clinical practice. Published controlled trials of ACT, which were almost exclusively carried out in North America, have shown markedly positive results. However caution is required in extrapolating these findings to routine clinical practice within different systems of health and social care. Case management is not in itself an effective treatment for severe mental illness.  

Hoult J. Comprehensive services for the mentally ill. Current Opinion in Psychiatry 1993;6:238-45.

Joannette, Judith A; Lawson, James S; Eastabrook, Shirley J; Krupa, Terry. Community tenure of people with serious mental illness in assertive community treatment in Canada.  Psychiatric Services. Vol 56(11) Nov 2005, 1387-1393.

Abstract: OBJECTIVE: This study followed consumers after admission to an assertive community treatment program to determine when the first hospital admission was more likely to occur, which variables predicted community tenure, and, more specifically, whether the availability of within-program hospital beds predicted community tenure. METHODS: Data were gathered from three assertive community treatment programs in southeastern Ontario--the psychosocial rehabilitation program, the community integration program, and the assertive community treatment team program. Only the psychosocial rehabilitation program provided within-program beds. Hospital records of consumers who entered a program between July 1, 1990, and December 1, 1999, were examined prospectively until January 1, 2000, in order to record time to the first admission. Survival analysis based on the life-tables method was used to estimate the probability of remaining out of the hospital at 90-day intervals. Factors associated with time to admission were identified by using the Cox proportional hazards model. RESULTS: A total of 333 consumers were followed: 117 consumers in the psychosocial rehabilitation program, 105 in the community integration program, and 111 in the assertive community treatment team program. Findings indicated that consumers were most likely to be admitted to a hospital in the nine months after entering an assertive community treatment program. A diagnosis of substance use disorder, higher past hospital use, and the availability of within-program beds were associated with an increased risk of admission. CONCLUSIONS: Studies have shown that hospitalization remains a reality for many consumers and therefore warrants further study. The survival model proved advantageous by allowing a more complete and comparable description of consumers' hospitalization patterns that cannot be achieved with previously used methods, and it offered the power of regression analysis.

Jorgensen P,  Nordentoft M,  Abel MB,  Gouliaev G,  Jeppesen P, Kassow P.(2000) Early detection and assertive community treatment of young psychotics: the Opus Study Rationale and design of the trial. Social Psychiatry & Psychiatric Epidemiology.  35(7):283-7.

 Abstract:   BACKGROUND: Recent research indicates that early detection of young persons suffering from psychosis and subsequent intensive intervention enhances treatment response and prognosis, but the data are only preliminary and suggestive. METHOD: We present the rationale and design of the largest study to date to evaluate two major issues in the field of secondary prevention: (1) Does education and intensified collaboration with general practice, social services etc. reduce the duration of untreated psychosis? and (2) Can modified assertive community treatment improve the course and outcome in young persons suffering from psychosis as compared to treatment in community mental health centres? The article aims additionally to put the study in context and assist in designing future studies. RESULTS: Preliminary experiences are described. The findings of the first 312 patients show that modified assertive community treatment results in patients adhering to treatment significantly better than standard treatment in community mental health centres. CONCLUSION: The surge of interest in preventively oriented detection and treatment models for untreated psychosis in young people calls for research programmes and evidence. The obstacles to this are manifold. The initial findings of the OPUS study suggest, however, that better adherence to treatment is possible.

Killaspy H, Bebbington P, Blizaard R, Johnson S, Nolan F, Pilling S, King M. The REACT study: randomized evaluation of assertive community treatment in north London. BMJ, doi:10.1136/bmj.38773.518322.7C (published 16 March 2006).

King R. Intensive Case Management: a critical re-appraisal of the scientific evidence for effectiveness. Adm Policy Ment Health & Ment Health Serv Res. DOI 10.1007/s10488-006-0051-5.

 Knapp M, Beecham J, Koutsogeorgopoulou V et al. Service use and costs of home-based versus hospital-based care for people with serious mental illness. British Journal of Psychiatry 1994 August;165(2):195-203.

Lafave HG, de Souza HR, Gerber GJ. Assertive community treatment of severe mental illness: a Canadian experience. Psychiatric Services 1996 July;47(7):757-9.

Lamberti JS. Weisman R. Faden DI. Forensic assertive community treatment: preventing incarceration of adults with severe mental illness. Psychiatric Services. 55(11):1285-93, 2004 Nov.

Abstract: OBJECTIVE: Persons with severe mental illness are over-represented in jails and prisons in the United States. A national survey was conducted to identify assertive community treatment programs that have been modified to prevent arrest and incarceration of adults with severe mental illness who have been involved with the criminal justice system. METHODS: Members of the National Association of County Behavioral Health Directors (NACBHD) were surveyed to identify assertive community treatment programs serving persons with criminal justice histories and working closely with criminal justice agencies. Programs were identified that met three study criteria: all enrollees had a history of involvement with the criminal justice system, a criminal justice agency was the primary referral source, and a close partnership existed with a criminal justice agency to perform jail diversion. Senior representatives of each program were subsequently contacted, and a telephone survey was administered to gather information about the design and operation of the programs. RESULTS: A total of 291 of 314 NACBHD members (93 percent) responded to the survey. Sixteen programs that met the study criteria were identified in nine states. The primary referral sources for 13 of these programs (81 percent) were local jails. Eleven programs (69 percent) incorporated probation officers as members of their assertive community treatment teams. Eight programs (50 percent) had a supervised residential component, with five providing residentially based addiction treatment. Eleven of the 16 programs have begun operating since 1999. Only three programs have published outcome data on program effectiveness. CONCLUSIONS: Forensic assertive community treatment is an emerging model for preventing arrest and incarceration of adults with severe mental illness who have substantial histories of involvement with the criminal justice system. Further research is needed to establish the structure, function, and effectiveness of this developing model of service delivery.

Latimer E (2005) Economic considerations associated with assertive community treatment and supported employment for people with severe mental illness. J Psychiatry Neurosci 30(5):355-9

Abstract: This article discusses economic considerations associated with evidence-based practices for people with severe mental illness that involve grouping treatment and rehabilitation staff into a single team. The article includes a brief review of the evidence and arguments that both assertive community treatment and supported employment are effective in promoting recovery, as well as having other favourable outcomes. In terms of cost, assertive community treatment appears to allow flexible deployment of resources such that the number of days in hospital is reduced, which means that in many cases this form of treatment pays for itself. Evidence for a similar cost offset with supported employment is much more limited. Even when such practices increase overall costs, they appear to be more cost-effective than the alternatives with which they have been compared. Consideration of these findings together suggests that improved synthesis and use of individual-level clinical information, which are more easily achieved by a team, are key to more cost-effective service delivery for people who need the expertise of different kinds of professionals.

Lehman AF, Dixon LB, Kernan E, DeForge BR, Postrado LT. A randomized trial of assertive community treatment for homeless persons with severe mental illness. Archives of General Psychiatry 1997 November;54(11):1038-43.

Lehman AF. Buchanan RW. Dickerson FB. Dixon LB. Goldberg R.Green-Paden L. Kreyenbuhl J. (2003) Evidence-based treatment for schizophrenia. Psychiatric Clinics of North America. 26:939-54. 

Abstract:   Taken together, the research on what treatments help people with schizophrenia point to the value of treatment programs that combine medications with a range of psychosocial services. Provision of such packages of services likely reduces the need for crisis-oriented care hospitalizations and emergency room visits and enables greater recovery. For most people with schizophrenia, the combination of psychopharmacological and psychosocial interventions improves outcomes. Several psychosocial treatments have demonstrated efficacy. These include family intervention, supported employment, assertive community treatment, skills training, and CBT. In the same way that psychopharmacologic management must be tailored individually to the needs and preferences of the patient, so too should the selection of psychosocial treatments. At the very least, all people with schizophrenia should be provided with education about their illness. Beyond illness education, all of the recommended psychosocial interventions would be used rarely during any one phase of illness for an individual. Some psychosocial treatments share treatment components, and patients have different clinical and social needs at different points in their illness course. Knowledge regarding how best to combine treatments to optimize outcomes is scarce.

Lehman AF, Kreyenbuhl J, Buchanan RW et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophrenia Bulletin 2004;30(2):193-217.

Macias C, Rodican CF, Hargreaves WA, Jones DR, Barreira PJ, Wang Q. (2006) Supported Employment Outcomes of a Randomized Controlled Trial of ACT and Clubhouse Models. Psychiatric Services; 57:1406-1415.

Marks IM, Connolly J, Muijen M, Audini B, Mcnamee G, Lawrence RE. Home-Based Versus Hospital-Based Care for People with Serious Mental-Illness. British Journal of Psychiatry 1994 August;165:179-94

Marshall M, Lockwood A. (2000) Assertive community treatment for people with severe mental disorders. (Cochrane Review) In: The Cochrane Library, Issue 3, 2000. Oxford.

Abstract :  BACKGROUND: Assertive Community Treatment (ACT) was developed in the  early 1970s as a response to the closing down of psychiatric hospitals. CT is a team-based approach aiming at keeping ill people in contact ith services, reducing hospital admissions and improving outcome, specially social functioning and quality of life. OBJECTIVES: To determine the effectiveness of Assertive Community Treatment (ACT) as an alternative to i. standard community care, ii. Traditional hospital-based rehabilitation, and iii. case management. For each of the three comparisons the main outcome indices were i. remaining in contact with the psychiatric services, ii. extent of psychiatric hospital amissions, iii. clinical and social outcome and iv. costs. SEARCH STRATEGY: Electronic searches of CINAHL (1982-1997), the Cochrane Schizophrenia Group's Register of trials (1997), EMBASE (1980-1997), MEDLINE (1966-1997), PsycLIT (1974-1997) and SCISEARCH (1997) were undertaken. References of all identified studies were searched for further trial citations. SELECTION CRITERIA: The inclusion criteria were that studies should i. Be randomised controlled trials, ii. have compared ACT to standard community care, hospital-based rehabilitation, or case management and iii. have been carried out on people with severe mental disorder the majority of whom were aged from 18 to 65. Studies of ACT were defined as those in which the investigators described the intervention as "Assertive Community Treatment" or one of its synonyms. Studies of ACT as an alternative to hospital admission, hospital diversion programmes, for those in crisis, were excluded. The reliability of the inclusion criteria were evaluated. DATA COLLECTION AND ANALYSIS: Three types of outcome data were available: i. categorical data, ii. numerical data based on counts of real life events (count data) and iii. numerical data collected by standardised instruments (scale data). Categorical data were extracted twice and then cross-checked. Peto Odds Ratios and the number needed  to treat  (NNT) were calculated. Numerical count data were extracted twice and cross-checked. Count data could not be combined across studies for technical reasons (the data were skewed) but all relevant observations based on count data were reported in the review. Numerical scale data were subject to a quality assessment. The validity of the quality assessment was itself assessed. Numerical scale data of suitable quality were combined using the standardised mean difference statistic where possible, otherwise the data were reported in the text or 'Other data tables' of the review. MAIN RESULTS: ACT versus standard community care Those receiving ACT were more likely to remain in contact with services than people receiving standard community care (OR 0.51, 99%CI 0.37-0.70). People allocated to ACT were less likely to be admitted to hospital than those receiving standard community care (OR 0.59, 99%CI 0.41-0.85) and spent less time in hospital. In terms of clinical and social outcome, significant and robust differences between ACT and standard community care were found on i. accommodation status, ii. employment and iii. patient satisfaction. There were no differences between ACT and control treatments on mental state or social functioning. ACT invariably reduced the cost of hospital care, but did not have a clear cut advantage over standard care when other costs were taken into account. ACT versus hospital-based rehabilitation services Those receiving ACT were no more likely to remain in contact with services than those receiving hospital-based rehabilitation, but confidence intervals for the odds ratio were wide. People getting ACT were significantly less likely to be admitted to hospital than those receiving hospital-based rehabilitation (OR 0.2, 99%CI 0.09-0.46) and spent less time in hospital. Those allocated to ACT were significantly more likely to be living independently (OR (for not living independently) 0.19, 99%CI 0.06-0.

Marshall M, Gray, A, Lockwood A, Green R.(2000) Case management for people with severe mental disorders. Cochrane Database of Systematic Reviews. 

Abstract:   BACKGROUND: Since the 1960s, in many parts of the world, large psychiatric were closed down and people were treated in outpatient clinics, day centres or community mental health centres. Rising readmission rates suggested that this type of community care may be less effective than anticipated. In the 1970s case management arose as a means of co-ordinating the care of severely mentally ill people in the community. OBJECTIVES: To determine the effects of case management as an approach to caring for severely mentally ill people in the community. Case management was compared against standard care on four main indices: (i) numbers remaining in contact with the psychiatric services; (ii) extent of psychiatric hospital admissions; (iii) clinical and social outcome; and (iv) costs. SEARCH STRATEGY: Electronic searches of CINAHL (1997), the Cochrane Schizophrenia Group's Register of trials (1997), EMBASE (1980-1995), MEDLINE (1966-1995), PsycLIT (1974-1995) and SCISEARCH (1997) were undertaken. References of all identified studies were searched for further trial citations. SELECTION CRITERIA: The inclusion criteria were that studies should be randomised controlled trials that (i) had compared case management to standard community care; and (ii) had involved people with severe mental disorder mainly between the ages of 18-65. Studies of case management were defined as those in which the investigators described the intervention as 'case' or 'care' management rather than 'Assertive Community Treatment' or 'ACT'. DATA COLLECTION AND ANALYSIS: A study was carried out to test the reliability of the inclusion criteria. Categorical data were extracted twice and then cross-checked, any disagreements being resolved by discussion. Odds ratios and the number needed to treat were estimated. Continuous data collected by a measuring instrument was only included if the instrument(i) had been described in a peer-reviewed journal; (ii) was a self-report or had been completed by an independent rater; and (iii) provided a summary   score for a broad area of functioning. Normally distributed continuous data were included if means and standard deviations were available. Non-normal data were included if analysed either after transformation or using non-parametric methods. Tests for heterogeneity were conducted. MAIN RESULTS: Case management increased the numbers remaining in contact with services (for case management odds ratio = 0.70; 99%CI 0.50-0. 98; n=1210). Case management approximately doubled the numbers admitted to psychiatric hospital (OR 1.84; 99% CI 1.33-2.57; n=1300). Except for a positive finding on compliance, from one study, case management showed no significant advantages over standard care on any psychiatric or social variable. Cost data did not favour case management but insufficient information was available to permit definitive conclusions. REVIEWER'S CONCLUSIONS: Case management ensures that more people remain in contact with psychiatric services (one extra person remains in contact for every 15 people who receive case management), but it also increases hospital admission rates. Present evidence suggests that case management also increases duration of hospital admissions, but this is not certain. Whilst there is some evidence that case management improves compliance, it does not produce clinically significant improvement in mental state, social functioning, or quality of life. There is no evidence that case management improves outcome on any other clinical or social variables. Present evidence suggests that case management increases health care costs, perhaps substantially, although this is not certain. In summary, therefore, case management is an intervention of questionable value, to the extent that it is doubtful whether it should be offered by community psychiatric services. It is hard to see how policy makers who subscribe to an evidence-based approach can justify retaining case management as 'the cornerstone' of community mental health services.

Marx AJ, Test MA, Stein LI. Extrahospital management of severe mental illness. Feasibility and effects of social functioning. Archives of General Psychiatry 1973 October;29(4):505-11.

McGrew JH, Bond GR. Critical ingredients of assertive community treatment: judgments of the experts. Journal of Mental Health Administration 1995;22(2):113-25.

Mechanic D. Challenges in the provision of mental health services: some cautionary lessons from US experience. Journal of Public Health Medicine 1995 June;17(2):132-9.

Morse GA, Calsyn RJ, Klinkenberg WD et al. An experimental comparison of three types of case management for homeless mentally ill persons. Psychiatric Services 1997 April;48(4):497-503.

Mueser KT, McGurk SR. Schizophrenia. Lancet, 2004; 363:2063-2072.

Muijen M, Cooney M, Strathdee G, Bell R, Hudson A. Community psychiatric nurse teams: intensive support versus generic care. British Journal of Psychiatry 1994 August;165(2):211-7.

Muijen M. Rehabilitation and care of the mentally ill. Current Opinion in Psychiatry 1994;7:202-6.

Olfson M. Assertive community treatment: an evaluation of the experimental evidence. Hospital and Community Psychiatry 1990 June;41(6):634-41.

Phillips SD.  Burns BJ.  Edgar ER.  Mueser KT.  Linkins KW.  Rosenheck RA.  Drake RE.  McDonel Herr EC. (2001)  Moving assertive community treatment into standard practice.  Psychiatric Services.  52(6):771-9,

Abstract: 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.

Ontario Ministry of Health and Long Term Care. Ontario Program Standards for ACT Teams. Second Edition October 2004, Updated January 2005.  Full text of standards (41 pages) available free from the Ontario MOHLTC website.

Quinlivan R, Hough R, Crowell A, Beach C, Hofstetter R, Kenworthy K. Service utilization and costs of care for severely mentally ill clients in an intensive case management program. Psychiatric Services 1995 April;46(4):365-71.

Rosen A.  Teesson M. (2001) Does case management work? The evidence and the abuse of evidence-based medicine. Australian & New Zealand Journal of Psychiatry.  35(6):731-46 .[erratum appears in Aust N Z J Psychiatry 2002 Apr;36(2):288 

 Abstract:  OBJECTIVES: This study reviews typologies of psychiatric case management and then discusses the efficacy, effectiveness and cost effectiveness of psychiatric case management, with particular focus on evidence from Australia and the UK. Subsequently, it aims to examine the way such evidence has been interpreted in the context of UK psychiatric research and services. Finally it examines the ways in which, by the selective reviewing or editorializing of evidence, case management has been brought into disrepute in the UK. METHOD: This study reviews literature of the recent evidence for case management, and asks three questions of case management: has it been shown to be efficacious in controlled research, is it effective in applied settings, and is it cost effective? An examination is then made of the concurrent representations of the UK evidence in both the academic literature and the media. RESULTS: There is strong evidence for the efficacy effectiveness and cost-effectiveness of case management in psychiatry, the closer it conforms to active and assertive community treatment models. It appears, however, that studies and evidence-based reviews of case management have possibly been misused and misrepresented in a highly charged atmosphere of professional media debate. The potential for this abuse is not limited to psychiatry and remains a challenge for all evidence-based practice. CONCLUSION: On the evidence, assertive community treatment case management is one of the most effective interventions in psychiatry today. Despite improving the evidence base for practice (e.g. as has occurred for case-management in psychiatry), evidence-based medicine (EBM) is still susceptible to compromise and misrepresentation, due to unexamined or undeclared bias. Unless this potential for abuse is recognized and checked, EBM in psychiatry is in danger of being discredited at the hand of some of its own proponents. There is a need for more rigorous pursuit of evidence-based psychiatry, including more systematic declaration of bias in all research, whether quantitative or qualitative in design. 

Scott JE, Dixon LB. Assertive community treatment and case management for schizophrenia. Schizophrenia Bulletin 1995;21(4):657-68.

 Stein LI, Test MA, Mars AJ. Alternatives to the hospital: a controlled study. American Journal of Psychiatry 1975;132(5):517-22.

 Stein LI, Test MA. Alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry 1980 April;37(4):392-7.

Test MA, Stein LI. Training in community living: research design and results. In: Stein LI, Test MA, editors. Alternatives to Mental Hospital Treatment. New York: Plemum Press; 1978.

Thompson KS, Griffith EE, Leaf PJ. A historical review of the Madison model of community care. Hospital and Community Psychiatry 1990 June;41(6):625-34.

Udechuku, Adaobi; Olver, James; Hallam, Karen; Blyth, Frances; Leslie, Melissa; Nasso, Marina; Schlesinger, Paul; Warren, Lorraine; Turner, Miles; Burrows, Graham. Assertive community treatment of the mentally ill: Service model and effectiveness. Australasian Psychiatry. Vol 13(2) Jun 2005, 129-134.

Abstract:  OBJECTIVE: To provide a description of the service delivery model of an assertive community treatment (ACT) team in the management of a group of severely mentally ill patients and examine the effectiveness of this team in reducing readmissions to a psychiatric inpatient service. METHOD: A clinical case audit was performed on a single day in September 2001. Admission episodes and duration were collected for patients registered with the team in the 12 month period prior to ACT and for a period of 12 months ending on the day of the audit. Forty-three patients were registered with the team at the time of data collection. The majority (79%) were diagnosed with schizophrenia and there were high rates of comorbidity (76%) and disability (mean Global Assessment of Functioning score 45.9). The main outcome measures were the number of readmissions and readmission days before and after the institution of ACT. RESULTS: The mean number of readmission days reduced from 70.9 to 10.2 (p < 0.05) following the institution of ACT. CONCLUSION: Assertive community treatment conducted in a naturalistic clinical environment is effective in significantly reducing the number of readmission days in a group of patients suffering from long-term and persistent severe mental illness. (PsycINFO Database Record (c) 2005 APA, all rights reserved) (journal abstract).

Wright C, Burns T, James P et al. Assertive outreach teams in London: models of operation - Pan-London Assertive Outreach Study, Part I. British Journal of Psychiatry 2003 August;183:132-8.

Ziguras SJ.  Stuart GW.  (2000) A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatric Services.  51(11):1410-21.

 Abstract :   OBJECTIVE: Meta-analytical methods were used to investigate the effectiveness of case management and to compare outcomes for assertive community treatment and clinical case management. METHODS: Controlled studies of case management published between 1980 and 1998 were identified from reviews and through database searches. The results were quantitatively combined and compared with results of studies of mental health services without case management. Combined effect sizes and significance levels for 12 outcome domains were calculated. Analysis of homogeneity was used to explore differences between models. RESULTS: Forty-four studies were analyzed; 35 compared assertive community treatment or clinical case management with usual treatment, and nine directly compared assertive community treatment with clinical case management. Both types of case management were more effective than usual treatment in three outcome domains: family burden, family satisfaction with services, and cost of care. The total number of admissions and the proportion of clients hospitalized were reduced in assertive community treatment programs and increased in clinical case management programs. In both programs the number of hospital days used was reduced, but assertive community treatment was significantly more effective. Although clients in clinical case management had more admissions than those in usual treatment, the admissions were shorter, which reduced the total number of hospital days. The two types of case management were equally effective in reducing symptoms, increasing clients' contacts with services, reducing dropout rates, improving social functioning, and increasing clients' satisfaction. CONCLUSIONS: Both types of case management led to small to moderate improvements in the effectiveness of mental health services. Assertive community treatment had some demonstrable advantages over clinical case management in reducing hospitalization.

Zygmunt A.  Olfson M.  Boyer CA.  Mechanic D. (2002) Interventions to improve medication adherence in schizophrenia. American Journal of Psychiatry.  159(10):1653-64, 

Abstract:   OBJECTIVE: Although nonadherence with the antipsychotic medication regimen is a common barrier to the effective treatment for schizophrenia, knowledge is limited about how to improve medication adherence. This systematic literature review examined psychosocial interventions for improving medication adherence, focusing on promising initiatives, reasonable standards for conducting research in this area, and implications for clinical practice. METHOD: Studies were identified by computerized searches of MEDLINE and PsychLIT for the years between 1980 and 2000 and by manual searches of relevant bibliographies and conference proceedings. Key articles were summarized. RESULTS: Thirteen (33%) of 39 identified studies reported significant intervention effects. Although interventions and family therapy programs relying on psychoeducation were common in clinical practice, they were typically ineffective. Concrete problem solving or motivational techniques were common features of successful programs. Interventions targeted specifically to problems of nonadherence were more likely to be effective (55%) than were more broadly based treatment interventions (26%). One-half (four of eight) of the successful interventions not specifically focused on non-adherence involved an array of supportive and rehabilitative community-based services. CONCLUSIONS: Psycho-educational interventions without accompanying behavioral components and supportive services are not likely to be effective in improving medication adherence in schizophrenia. Models of community care such as assertive community treatment and interventions based on principles of motivational interviewing are promising. Providing patients with concrete instructions and problem-solving strategies, such as reminders, self-monitoring tools, cues, and reinforcements, is useful. Problems in adherence are recurring, and booster sessions are needed to reinforce and consolidate gains.

 
Implemention of Act as Evidence-Based Practice

Allred CA. Burns BJ. Phillips SD. The assertive community treatment team as a complex dynamic system of care. Administration & Policy in Mental Health. 32(3):211-20, 2005 Jan.

Abstract: This paper presents a dynamic systems view of assertive community treatment (ACT), a recognized evidence-based treatment for adults with severe and persistent mental illness (SPMI). It is argued that because an ACT team operates as a complex adaptive system (CAS), it engages in the organizational processes of "sensemaking" and self-organization, which help to bring order to the actions of team members and sustainability of the intervention itself. Consequently, successful implementation of ACT requires that management technologies such as meaning-creation and design are used in conjunction with traditional "command and control" technologies of policies, procedures, processes, and structures.

Angell B.(2003) Contexts of social relationship development among assertive community treatment clients.  Mental Health Services Research.  5(1):13-25.

Abstract:   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.

Corrigan, PW; Steiner, L; McCracken, SG; Blaser, B; Barr, M (2001) Strategies for Disseminating Evidence-Based Practices to Staff Who Treat People With Serious Mental Illness. Psychiatric Services, Vol. 52, No. 12, pp.

Drake RE.  Mueser KT.  Torrey WC.  Miller AL.  Lehman AF.  Bond GR. Goldman HH.  Leff HS. (2000) Evidence-based treatment of schizophrenia. Current Psychiatry Reports.  2(5):393-7.

Abstract:  People with schizophrenia can be helped greatly with pharmacologic and psychosocial interventions that are known to be effective. Several interventions are now supported by research: use of medications following specific guidelines, training in illness self-management, case management based on principles of assertive community treatment, family psychoeducation, supported employment, and integrated substance abuse treatment. However, few patients actually receive these evidence-based interventions because they are not provided in routine mental health settings. Therefore, implementing effective treatments in mental health treatment programs is a critical challenge for the field. We review the six areas of evidence-based treatment of schizophrenia, as well as knowledge regarding implementation of mental health programs in routine practice settings.

Drake RE, Goldman HH, Leff HS, Lehman AF, Dixon L, Mueser KT, Torrey WC. (2001) Implementing evidence based practices in routine mental health service settings. Psychiatric Services 52:179-182.

Goldman HH, Ganju V, Drake RE, Gorman P, Hogan M, Hyde PS, Morgan O (2001) Policy implications for implementing evidence-based practices. Psychiatric Services, 52: 1591-1597.

Harai E. (2001) Whose evidence? Lessons from the philosophy of science and the epistemology of medicine. Australian and New Zealand Journal of Psychiatry. 35:724-730.

Krupa T. Eastabrook S. Beattie P. Carriere R. McIntyre D. Woodman R. (2004) Challenges faced by service providers in the delivery of Assertive Community Treatment. Canadian Journal of Community Mental Health. 23(1):115-27.

Abstract: This qualitative study examined the delivery of Assertive Community Treatment from the perspective of service providers of 4 ACT teams in Canada (Southeastern Ontario). Overall, providers were positive about their involvement with ACT. Eight tensions experienced in the context of delivering services emerged: negotiating governance structures; providing 24-hour coverage; balancing the clinical-administrative responsibilities of team leaders; accessing hospital beds; meeting local population needs; integrating treatment and rehabilitation; changing services to meet changes in the population being served; and implementing ambiguous ACT standards. Framing these challenges in the context of ACT structures and the broader community mental health system, the study suggests possibilities for the ongoing development of the model to facilitate the realization of the ACT vision.

Latimer E. Community-based care for people with severe mental illness in Canada. International Journal of Law and Psychiatry 28 (2005) 561-573. Available online at www.sciencedirect.com.

Latimer E. Organizational implications of promoting effective evidence-based interventions for people with severe mental illness. Canadian Public Policy. Vol XXXI. Special electronic supplement on Mental Health Reform for the 21st Century in partnership with the School of Policy Studies and the Centre of Excellence for Health Services and Policy Research. Queen’s University, Kingston, Ontario. http://economics.ca/cpp/en/specialissue.php.

Lavis JN, Posada FB, Haines A, Osei E. Use of research to inform public policymaking. Lancet, 2004; 364:1615-21.

Lehman AF.  Steinwachs DM.  Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations.  Schizophrenia Bulletin.  24(1):1-10, 1998.

Abstract:  Beginning in 1992, the Agency for Health Care Policy and Research and the National Institute of Mental Health funded the Schizophrenia Patient Outcomes Research Team (PORT) to develop and disseminate recommendations for the treatment of schizophrenia based on existing scientific evidence. These Treatment Recommendations, presented here in final form for the first time, are based on exhaustive reviews of the treatment outcomes literature (previously published in Schizophrenia Bulletin, Vol. 21, No. 4, 1995) and focus on those treatments for which there is substantial evidence of efficacy. The recommendations address antipsychotic agents, adjunctive pharmacotherapies, electroconvulsive therapy, psychological interventions, family interventions, vocational rehabilitation, and assertive community treatment/intensive case management. Support for each recommendation is referenced to the previous PORT literature reviews, and the recommendations are rated according to the level of supporting evidence. The PORT Treatment Recommendations provide a basis for moving toward "evidence-based" practice for schizophrenia and identify both the strengths and limitations in our current knowledge base.

Latimer E (2005) Organizational Implications of promoting effective evidence-based interventions for people with severe mental illess. Special Electronic Supplement on Mental Health Reform for the 21st Century. S47-S52.   http://economics.ca/cpp/en/specialissue.php.

Mueser KT.  Torrey WC.  Lynde D.  Singer P.  Drake RE. (2003) Implementing evidence-based practices for people with severe mental illness. Behavior Modification.  27(3):387-411

 Abstract:  Persons with severe mental illnesses (SMI) often lack access to  effective treatments. The authors describe the Implementing Evidence-Based Practices (EBPs) Project, designed to increase access for people with SMI to empirically supported interventions. The EBP Project aims to improve access through development of standardized implementation packages, created in collaboration with different stakeholders, including clinicians, consumers, family members, clinical supervisors, program leaders, and mental health authorities. The background and philosophy of the EBP Project are described, including the six EBPs identified for initial package development: collaborative psychopharmacology, assertive community treatment, family psychoeducation, supported employment, illness management and recovery skills, and integrated dual disorders treatment. The components of the implementation packages are described as well as the planned phases of the project. Improving access to EBPs for consumers with SMI may enhance outcomes in a cost-effective manner, helping them pursue their personal recovery goals with the support of professionals, family, and friends.

Nixon J.  Phipps K.  Glanville J.  Mugford M.  Drummond M. (2002) Using economic evidence to support decision making: a case study of assertive community treatment within the UK National Service Framework for Mental Health.   Applied Health Economics & Health Policy.  1(4):179-90.

Abstract:   This study illustrates a process of accessing and utilising clinical and economic evidence in health care decision making. The scenario examined was that of a UK Health Authority evaluating evidence prior to the introduction of assertive community treatment (ACT), as part of guidance from the UK National Service Framework for Mental Health. The consistency between clinical and cost evidence from a number of sources (Cochrane Database of Systematic Reviews (CDSR), Database of Reviews of Effectiveness (DARE), HTA database, NHS Economic Evaluation database (NHS EED) was also addressed, as was the usefulness of structured abstracts on NHS EED. The findings showed that within specified caveats ACT tends to be more effective and also less costly than alternative interventions; there is general agreement between sources principally reporting effectiveness and economic evaluations; and NHS EED abstracts are useful in the decision making process where information gaps exist. In terms of health care policy in the health authority examined, two ACT teams were subsequently introduced in the city of Leicester. Although systematic reviews and appraisals of evidence are arguably the gold standard in health care decision making, the study illustrates how the use of databases of structured abstracts can assist in making optimal choices in real life decision making scenarios.

Rosenheck, RA. (2001) Organizational process: A missing link between research and practice.  Psychiatric Services, Vol. 52, No. 12, pp 1607-1612.

Rosenheck RA. Neale MS. Therapeutic limit setting and six-month outcomes in a Veterans Affairs assertive community treatment program. Psychiatric Services. 55(2):139-44, 2004 Feb.

Abstract: OBJECTIVE: This study examined the relationship of limit-setting interventions and six-month outcomes in assertive community treatment. METHODS: Case managers from 40 Veterans Affairs assertive community treatment teams at 40 different sites documented their use of 25 limit-setting activities with 1564 clients during the first six months of treatment. Five scales were constructed representing different types of limit-setting activities: withholding certain types of assistance until the client curtailed certain behaviors; behavioral contracting in which specific goals were identified and linked to reinforcers if the goals were achieved; invocation of external authorities, such as a probation officer; seeking a declaration of incompetence to manage funds or initiation of a request for a payee; and forced hospitalization through civil commitment. Structured interviews conducted at baseline and six months documented changes in clinical status and community adjustment. Multiple regression analysis was used to examine the relationship between limit-setting interventions and outcomes at both the level of the individual client and at the level of the team, adjusting for potentially confounding baseline client characteristics. RESULTS: All five measures of specific limit-setting activities were associated with poorer outcomes on four to six of the eight outcome measures. The site-level comparison of outcomes showed more violent behavior at sites that made more extensive use of these interventions but also greater employment. CONCLUSIONS: After the analysis controlled for potentially confounding factors, clients exposed to limit-setting interventions had poorer outcomes than others on many measures, suggesting that within the limits of a non-experimental study, such interventions do not appear to prevent adverse outcomes.

Salyers MP.  Bond GR.  Teague GB.  Cox JF.  Smith ME.  Hicks ML.  Koop JI.(2003) Is it ACT yet? Real-world examples of evaluating the degree of implementation for assertive community treatment.  Journal of Behavioral Health Services & Research.  30(3):304-20.

 Abstract:   Despite growing interest in assessment of program implementation, little is known about the best way to evaluate whether a particular program has implemented the intended service to a level that is minimally acceptable to a funding source, such as a state mental health authority. Such is the case for assertive community treatment (ACT), an evidence-based practice being widely disseminated. Using an exploratory, actuarial approach to defining program standards, this study applies different statistical criteria for determining whether or not a program meets ACT standards using the 28-item Dartmouth Assertive Community Treatment Scale. The sample consists of 51 ACT programs, 25 intensive case management programs, and 11 brokered case management programs which were compared to identify levels of fidelity that discriminated between programs, but were still attainable by the majority of ACT programs. A grading system based on mean total score for a reduced set of 21 items appeared to be most attainable, but still discriminated ACT programs from other forms of case management. Implications for setting and evaluating ACT program standards are discussed.

Schaedle R.  McGrew JH.  Bond GR.  Epstein I. (2002)  A comparison of experts' perspectives on assertive community treatment and intensive case management. Psychiatric Services.  53(2):207-10

Abstract:   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.

Thornicroft G.(2000) Testing and retesting assertive community treatment. Psychiatric Services.  51(6):703.

Thornicroft G.  Tansella M. (2004) Components of a modern mental health service: a pragmatic balance of community and hospital care: overview of systematic evidence. British Journal of Psychiatry.  185:283-90

 Abstract:   BACKGROUND: There is controversy about whether mental health services should be provided in community or hospital settings. There is no worldwide consensus on which mental health service models are appropriate in low-, medium- and high-resource areas. AIMS: To provide an evidence base for this debate, and present a stepped care model.  METHOD: Cochrane systematic reviews and other reviews were summarised. RESULTS: The evidence supports a balanced approach, including both community and hospital services. Areas with low levels of resources may focus on improving primary care, with specialist back-up. Areas with medium resources may additionally provide out-patient clinics, community mental health teams (CMHTs), acute in-patient care, community residential care and forms of employment and occupation. High-resource areas may provide all the above, together with more specialised services such as specialised out-patient clinics and CMHTs, assertive community treatment teams, early intervention teams, alternatives to acute in-patient care, alternative types of community residential care and alternative occupation and rehabilitation. CONCLUSIONS: Both community and hospital services are necessary in all areas regardless of their level of resources, according to the additive and sequential stepped care model described here.

Schoenwald, SK; Hoagwood, K.  Effectiveness, Transportability, and Dissemination of Interventions: What Matters When?  (2001) Psychiatric Services, Vol. 52, No. 12, pp. 1190-1197

Torrey WC, Drake RE, Burns BJ, Flynn L, Rush AJ, Clark RE, Klatsker D. (2001) Implementing evidence-based practices for person with severe mental illnesses.  Psychiatric Services, 52:45-50.