Andrew Molodynski and Tom Burns
Introduction
Assertive Community Treatment (ACT) is probably the most researched form of mental health service delivery. Over 90 randomised and non randomised trials have been published throughout the world over a timescale of more than 30 years, since its inception in North America (Marshall & Lockwood, 1998; Burns, 2007). There has also, particularly recently, been a good deal of qualitative research attempting to capture and examine the personal experiences of patients and families in an attempt to understand what it is about ACT that is attractive to many patients and leads to greater engagement.
It may be thought that this wealth of research has brought understanding and a degree of clarity to the area, but for a variety of reasons this has not been the case. The findings of much of the research have been contradictory or of sub optimal quality, reflecting the difficulty of this type of research and of assigning meaning to the findings. These issues are compounded by uncertainty about the terminology used, with Assertive Community Treatment (ACT) being used in the United States (US) and most of the research literature, and assertive outreach and intensive case management often being used interchangeably in the United Kingdom (UK) and the rest of Europe. More recently some consensus has begun to emerge about what may constitute the ingredients of successful care, judged in terms of acceptability and social and clinical outcomes. This chapter presents some of the most important research in the area and derives potential ways forward in both clinical practice and in research.
The rise of a new model
In the mid 1970s in Madison, in the Midwest of the US, a decision was made to close a psychiatric ward. The ward staff was trained to look after people in the community instead in a project labelled Training in Community Living (TCL). This was the first example of what has come to be called ACT. The programme aimed to address comprehensively the various factors that led to an inability to manage in the community that conventional care did not address adequately. These factors are shown in Table 1.1.
The fledgling service that was based upon these admirably clear principles was the subject of a randomised controlled trial (RCT), with 126 patients assigned either to TCL or hospital based care and rehabilitation. Patients were followed up for 14 months in the TCL programme and then for a similar period after it ended. The results were remarkable (Stein & Test, 1980). Rates of psychiatric readmission (to become the measure of choice in ACT studies) were 58% in the control group and 6% in the TCL group, with average time spent in hospital 20 and 9 days respectively. The TCL group also spent less time unemployed and more time in independent accommodation, and rated higher on measures of self esteem and activities. An economic analysis was favourable and an examination of family and community burden showed no increase in the TCL group. Most gains were lost when the subjects were followed up some months after the end of the programme, highlighting a need for ongoing or indefinite intervention in some cases. As might have been expected, these findings stimulated much interest in North America and overseas. The introduction of teams, however, was far from rapid.
In 1983, these results were replicated in a further RCT in Sydney, Australia (Hoult et al., 1983). The community treatment was home based and offered 24 hour availability from a multi-disciplinary team. It included medication, support, counselling, and social and life skills training along with family support and education. Again results were impressive, with highly statistically and clinically significant reductions in hospital use. Those receiving hospital based care spent on average 53.5 days in hospital over the course of a year compared with just 8.4 days in the project group. In addition to this, patients reported positively about their experience of the community intervention as compared to standard care and there were no significant differences in measures of community burden such as police involvement. A costing study found average direct and indirect treatment costs of A$4489 for intervention patients and A$5669 for control patients. The authors concluded that the majority of psychiatric patients could be treated more effectively and more economically outside hospital.
Adoption of the model
Because these two influential studies both found such clear benefit with an assertive community focussed treatment built on basic principles they led to widespread clinical and research replication in several countries. There was extensive commissioning of ACT teams in the US and the introduction of mobile treatment teams in Australia, run along very similar principles. The UK led their introduction in Europe, though initially this was mainly limited to large urban areas. Researchers in South London reported that an intensive community support programme, the Daily Living Project, showed encouraging results early on in terms of symptoms, functioning and hospital use but most gains were lost towards the end of the study period (Marks et al., 1994). The study was compromised by a high profile homicide by an experimental group patient. Control over hospital discharges was withdrawn in the experimental group as a result, diminishing its flexibility.
A large multi-centre study in the US (Rosenheck et al., 1995), the largest ever conducted with 873 participants, showed that intensive psychiatric community care (IPCC) programmes reduced bed use by 89 days (33%) over a 2-year period. In contrast to the earlier studies, they found intensive community care to be marginally more expensive despite the reductions in bed use. This study lent further support to the adoption of ACT as a mainstay of the community care of the severely mentally ill.
Two Cochrane Collaboration systematic reviews (Marshall et al., 1998 and Marshall & Lockwood, 1998) concluded that, while case management was not effective and actually increased admissions to hospital, ACT was clearly superior to standard care in maintaining contact with services and reducing hospital use, while improving satisfaction with services. They concluded that ACT was `a clinically effective approach to managing the care of severely mentally ill people in the community' (Marshall & Lockwood, 1998: 2). There were also significant improvements in subjects' accommodation and employment status.
These two reviews taken together had an important effect on policy makers and less than a year later ACT teams were specifically prescribed as an essential element of mental health services in the National Service Framework for England (Department of Health, 1999). Funding was provided to start up ACT services and NHS mental health trusts were penalised if they were not established. Targets were introduced for the size of teams and number of patients, but not the exact nature of practice or the quality of care (see Chapter 13).
The dawning of doubt
Despite their huge influence, there were significant limitations in the methodology of the Cochrane reviews that could have influenced their results. One problem was that the designation of what was or wasn't ACT or case management was largely based upon the description by the original study authors, rather than being determined independently. ACT teams were introduced in the UK through the 1990s. Around the time of the Cochrane review several studies were underway that would come to cast substantial doubt on the ability of ACT to improve symptoms and functioning while reducing hospital use.
The first of these to be published was the PRiSM study in London (Thornicroft et al., 1998), which attempted to differentiate between the efficacy and effectiveness of an assertive approach to managing those with severe mental illnesses. The authors defined efficacy as the measurable differences in experimental circumstances, and effectiveness as the usefulness in routine, large scale clinical services for real populations. The design was extremely ambitious and wide ranging and consequently some of the results are hard to interpret. PRiSM found a reduction in bed use in the experimental services compared to standard care, but of a much lower magnitude; their explanation was the dilution of research effects in real world settings with other pressures coming to bear. At the same time, a smaller RCT was conducted by Holloway in London which found no significant differences between standard and intensive case management (Holloway & Carson, 1998): however, numbers were probably too small to positively exclude an effect (35 patients in each group).
The UK700 study (Burns et al., 1999) was a large multi-centre study in which 708 patients in London and Manchester were randomly assigned to intensive case management (ICM, caseloads of 10–15) or standard case management (SCM caseloads of 30–35) and followed up for two years. The primary outcome measure, overall hospital use, was exactly equal in the two groups, a mean of 72 days over 2 years. The conclusion from the study was that reducing workers' caseloads to allow them to work more intensively with people did not affect outcome substantially. It was also suggested that the ability of ACT to reduce bed usage may not be as great in healthcare systems that were already community focussed and using relatively few hospital beds. These results were far from those expected by the authors and generated a vigorous debate.
These negative findings have continued to be replicated. The REACT study (Killaspy et al., 2006) found no reduction in bed use with ACT in standard UK settings. REACT randomly assigned 251 people with psychotic illnesses who were high users of inpatient care to ACT or continuation of Community Mental Health Team (CMHT) follow up and monitored outcome over an 18 month period. The authors concluded that standard UK community mental healthcare was generally capable of supporting people with severe mental illnesses, but that ACT may be better at engaging clients and may lead to greater satisfaction with services.
Further support for this now seemingly robust finding of no difference in bed use has come from a study examining bed usage in a large number of mental health trusts across the UK after the introduction of Crisis Resolution Teams (CRTs) and ACT teams (Glover et al., 2006). Admissions were compared over the time period 1998–2004. While the overall rate of admission declined in most areas (as would be expected) it fell significantly more in areas with early introduction of CRTs but not where these were introduced late. However, the introduction of ACT demonstrated no reduction in admissions. While there are clearly wider factors influencing bed use, the authors considered their findings robust enough to conclude that crisis services reduced bed use but that ACT did not. With the state of current findings it must be concluded (at least in a contemporary UK setting) that ACT does not reduce hospital bed use.
An alternative way of looking at ACT
While the UK700 study, along with the later studies above, found that ACT did not significantly affect outcome, it encouraged a different way of thinking about ACT (and indeed mental health services in general) in the UK. The key question seemed to be: If the overall service does not make a difference is it individual components of care, alone or cumulatively, that influence outcome? This prompted a second question: If this is the case, can we measure the effects of specific aspects of care in a robust and meaningful way?
These questions were not entirely new and in North America attempts to measure fidelity to the ACT model had been made for some years (McGrew, 1994; Teague, 1998). Such attempts were an explicit acknowledgement that specific components of care were important and that ACT teams were not uniform. Such variability is probably greater in the UK as contracting arrangements tend to be less specific. McGrew, in 1994, noted that both research in the field and the implementation of new programmes were being significantly hampered by a lack of information on ACT teams and what they did. He and colleagues were concerned that newly introduced services could `drift' away from the original models in the successful early studies by Stein and Test and Hoult and, thus, not provide such effective treatment. His group attempted to identify the most important characteristics of ACT. They started by interviewing 22 recognised experts in the field and refined their answers to a list of criteria to judge fidelity. This Index of Fidelity of Assertive Community Treatment (IFACT) included such things as client to staff ratios, a psychiatrist on the team, daily team meetings, twenty four hour availability, home based care and a team approach. These could be operationalised and the score indicated fidelity to the theoretical model.
Later work by Teague and colleagues in New Hampshire (Teague et al., 1998) used a similar approach utilising expert opinion and literature reviews to identify potentially important components. Their final list of twenty-eight components comprised three domains, were operationalised and had a scoring system evolved. The three domains were the structure and composition of the team (H), its organisational boundaries (O) and the nature of what went on (S). They were made explicit to reflect the fact that important components lay in different areas. Table 1.2 shows the 28 final components of the Dartmouth ACT scale (DACTS) which has been widely used in service planning.
Despite general consensus amongst practitioners and researchers on the core elements of a successful assertive outreach service, variability persists in provision and in working practices. The Pan-London Assertive Outreach (PLAO) Study (Wright et al., 2003) undertook to characterise ACT teams across London, including measures of their fidelity to the models above. The PLAO study discovered wide variation in practice, particularly in services provided in the voluntary sector and those addressing groups such as the homeless or those from ethnic minorities. They found that (out of 24 teams studied) four rated as 'high fidelity' and three as 'low fidelity' to the ACT model as measured by the DACTS, with the rest in between.
Such differences do not always seem to reflect the deliberate adherence to or deviation from a theoretical model but are more naturalistic and dependent upon external factors. There are variations in size of team and whether there is direct medical input, in working practices such as availability outside of standard office hours, the use of the team approach and the thorny issue of responsibility for inpatients. There are significant variations in the availability of support work, psychological input and family intervention between teams. It appears that, if anything, this variability is increasing with time in the UK. The reasons for this are unclear, but may reflect the fact that individual health trusts are more autonomous than previously and also that ACT services are less important for their ratings so that more flexibility of approach is permitted. This will lead to innovative solutions to local issues in some places but there is a danger that drift from successful models may reduce clinical effectiveness.
A way forward
It is perhaps more useful to consider the elements of ACT that may make it successful rather than focussing on the services, with all their heterogeneity. The IFACT and DACTS were first steps on this path, but more recent empirical work, both qualitative and quantitative, has advanced our knowledge further.
A Health Technology Assessment (HTA) for the Department of Health (Burns et al., 2001) and a systematic review by Catty and colleagues (Catty et al., 2002) examined the evidence for home treatment as a whole in contrast to the reviews by Marshall and Lockwood, which discriminated between different models prior to analysis. Marshall's approach could theoretically generate 'purer' results, but ran the risk of misidentifying services given the lack of evidence for their classification. By avoiding this potential pitfall, Catty and colleagues could examine a large body of evidence and investigate which components of care were most common and test which might make a difference (Wright et al., 2004). Hospital use, the most consistently reported outcome measure, was used as the benchmark for comparison. The analysis showed a group of related factors that characterised home treatment services and (using cluster analysis) their association (see Figure 1.1).
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