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Discuss the evidence for the effectiveness of Assertive Community Treatment

Introduction

• most of us probably work in, and have received the bulk of our training within hospitals
• but are hospitals the best place to treat the mentally ill?
• in the last 50 years or so, there has been a shift away from large institutional care, to treating people within a community setting, and placing emphasis on the supports in someone's community, without burdening them with the stigma of a mental hospital admission
• in this essay, I will look firstly at some of the factors that have influenced this change in practice. I will then look at what we mean by Assertive Community Treatment (ACT) and at some of the major studies that have supported its use
• I then hope to discuss some of the evidence for and against ACT before looking at what the future may have in store

History

• the role of mental hospitals in prolonging the disabilities caused by mental disorders has been raised by a number of authors, including Russell Barton's Institutional Neurosis (1965), and Goffman's book Asylums (1961) — the latter introducing the concept of institutionalization and total institutions
• both of these books occurred during the time that phenothiazines were changing the face of psychiatry forever, and since the 1950s bed occupancy rates in psychiatry have been falling
• the Mental Health Act 1959 emphasized the shift away from institutional care, with more and more patients being cared for in the community — local authorities were given a duty of care in the community and extra powers to do this
• the steady process of deinstitutionalization (Thornicroft and Bebbington, 1989) continued throughout the 1960s, with added impetus from the antipsychiatry movement (Laing, Szasz)

What is ACT?

• Assertive Community Treatment, has been tested under a number of varying guises, which all have a number of factors in common
• some criteria for ACT have been laid down by Deci et al, 1995:

1. services are provided 24 hours a day, 7 days a week
2. team members can deliver medication daily if necessary
3. the team includes psychiatrists and nurses
4. the average percentage of team activity that takes place in the community should be 80%
5. patients can graduate to less intensive interventions or be discharged from the programme
6. the team arranges or directly manages patients' finances

• Teague et al (1998) also lays out some criteria which include:

1. small caseload
2. team case-working
3. time-unlimited services
4. “no drop-out” policy
5. assertive engagement
6. substance misuse treatments within the team
7. team has responsibility for crises, admissions, and discharge planning

Major studies on Community Care

• there has been a gradual accumulation of evidence in support of community treatment, with the majority showing that it is at least equal to, if not better than standard hospital care

Training in Community Living, Madison, USA (Stein and Test, 1980)

• the model used introduced the concept of PACT (Programmes in Assertive Community Treatment) and also assertive case management delivering the service to people wherever they are, and actively maintaining their engagement
• 130 patients (half had a diagnosis of schizophrenia) were each allocated a key worker who coordinated a 24 hour, individually tailored treatment programme
• over 14 months, only 12 of the 65 controls were readmitted compared to 58 of the 65 controls
• the users of the programme were more likely to be employed and were more satisfied with their quality of life; they displayed fewer symptoms and medication compliance was higher in the TCL group
• when the service was stopped at the end of the trial, all benefits were lost with a return to baseline

The Community Treatment Team, NSW, Australia (Hoult, 1986)

• Hoult replicated the TCL model in Sydney, which is 10 times larger than Madisonover the 1 year study period, CTT users spent significantly less time in hospital, with a reduction in symptomatology, and increased satisfactionthe control (standard care) was 26% more expensive than CTT

The Daily Living Programme, Camberwell, London (Muijen et al. 1992)

• this was a replication of the Stein and Test model at the Maudsley hospital in Londonthey found that more patients spent less time in hospital with improved satisfaction, and some clinical benefit

Home-based Acute Psychiatric Services (Burns et al. 1993)

• patients were allocated to the ACT group or standard care group at the point of referral, rather than admissionthis study found that the community model had significant cost savings (mainly due to reduced admission rates) but no benefits in terms of symptoms, social functioning, or satisfaction

Weaknesses in the literature

• as with most major studies, there are a number of problems which can affect the generalisability of these models:
• charismatic leaders - affects the motivation of all team members and increases the likelihood of an artificial benefit
• all studies were looked at in the first year of their practice, so it is unknown if the models will continue to produce benefits over time
• it has been argued that the control groups are of poor quality
• there is the Hawthorne effect of a major study
• the teams have usually been assembled specifically for the purpose of the study and so motivation is maximal, and morale is high
• as time has gone on, it seems to be increasingly difficult to demonstrate large advantages to the community model compared to the standard services - it is likely that these standard services have increased in quality, thus reducing any differences
• studies are now having to focus on a narrower range of outcome measures if differences are to be demonstrated

The PRiSM study

• Thornicroft et al 1998
• it was a prospective non-randomized controlled trial of two types of community mental health service (intensive sector made up of a PACE team and a PACT team; the standard sector made up of a “generic” community team)
• the two sectors were areas in Camberwell in London which, it is claimed, very closely match in terms of population characteristics most associated with psychiatric morbidity
• only looked at psychosis, since this was their interpretation of “severe mental illness”
• out of 514 people identified with psychotic illness, 302 were randomly allocated for interview
• diagnosis was obtained using OPCRIT and SCAN to establish psychotic cases
• a number of scales were used, including the BPRS, GAF, and other scales measuring social functioning primarily
• follow-up period was 2 years
• the main findings were:
• no clear evidence of differences in adverse between the two sectors
• no clear evidence of effects on symptoms or disability between the two models, despite reduction in hospital admission in the intensive sector
• higher costs for the intensive sector, with a small number of services accounting for a large proportion of costs in particular, there was a higher proportion of supported accommodation utilized in the intensive sector
• there was no difference between carer satisfaction or demands between the two sectors
• no strong support for increased quality of life in the intensive sector, and in both models QOL was poor and changed little over time

Criticisms of the PRiSM study

• there have been numerous criticisms about the PRiSM study
• a number of authors of previous studies have written a paper expressing significant doubt over the conclusions made by the authors of the PRiSM study
• their main criticisms were:

1. there was significant intermingling between the two models of care which makes it difficult to make definitive statements about either
2. neither of the two models is related to models of care that have been evaluated in efficacy studies. For example, the PACT team does not seem to bear a close resemblance to the PACT teams described by Stein and Test in 1980. The actual size and constituents are not described.
3. The intensive intervention was not significantly different from ordinary clinical care
4. Inclusion criteria were those with psychotic illnesses, with little reference to the degree of disability or social handicap
5. There were significant baseline differences (including service provision) in the two sectors making interpretation difficult
6. Both sector services were evolving throughout the study period
7. The two data collection periods were one year apart, thus meaning that history could be a confounding variable

The future

• the general consensus of evidence is that community models are at least as good as standard models, and by reducing hospital admission they can reduce overall healthcare costs
• perhaps more importantly, most show that symptoms reduce and social functioning improves, and the satisfaction with the mental health service increases
• so what are the impediments to prevent this model from becoming the predominant model of mental healthcare provision in the UK
• Firstly, in the current sociopolitical climate, there is an increasing zeitgeist against having the mentally ill in the community. A few highly politicized cases have permeated the media, creating the impression that all mentally ill people are dangerous, homicidal maniacs who you certainly don't want near your school or nursery. This is clearly a fallacy and woefully incorrect, but one does wonder whether we will find that the public (who have an indirect role in the creation of legislation) will become increasingly hostile to the idea that the vast majority of mentally ill people are going to be treated in the community. I think that the public like the idea that those who are deemed to be “mad” are kept somewhere separate to the rest of society.
• Secondly, there is always going to be a place for hospital care. There will always be those who are so unwell and are a danger to themselves or others, that will have to be looked after in a more structured, and secure environment.
• Thirdly, for those people whose environment plays a significant role in the causation or perpetuation of their illness, a setting where they can receive care away from stressors will be an important factor in their recovery.
• I don't think that we will see the end of hospitals, but we will probably see a shift away from large psychiatric institutions, with an increasing awareness that people prefer to receive help in the community. Perhaps, as the concept of “community” becomes more and more distant from what most people experience in their everyday lives, and as we all become insular and distant from others, we will find ourselves once again having to offer asylum to those in need.