Treatment outcome in patients receiving assertive community treatment

Trajectories of patients with severe mental illness in two-year contact with Flexible Assertive Community Treatment teams using Routine Outcome Monitoring data: An observational study

OBJECTIVE

Using outcome data collected routinely over a continuous two-year treatment period, we wished to distinguish homogeneous subgroups of patients with a severe mental illness whose psychosocial problems followed a similar pattern over time. By identifying the effectiveness of health services for different patient groups, this approach allowed us to identify patients at risk of deterioration and those recovering from their symptoms.

METHODS

In total we included 2,660 patients who were in two-year continuous contact with a Flexible Assertive Community Treatment team (FACT). We collected outcome data on psychosocial functioning, needs for care and quality of life. We performed a latent class growth analysis (LCGA).

RESULTS

The LCGA identified six homogenous patient subgroups using trajectories of HoNOS scores. On the basis of the patterns of patients' psychosocial problems over time, we labelled these as follows: 1) stable at a low problem-severity level (N = 709; 27%); 2) stable at a low medium problem-severity level (N = 1,208; 45%); 3) stable at a high medium problem-severity level (N = 528; 20%); 4) stable at a high problem-severity level (N = 116; 4%); 5) amelioration of problems (N = 42; 2%); and 6) deterioration of problems (N = 57; 2%). Patients with stable and a high severity of psychosocial problems had more practical and somatic unmet needs than those in other subgroups, and also had the fewest decrease in the number of unmet needs.

DISCUSSION

After linking patient subgroups with clinical features such as the need for care, we found that, over two years, most patients remained relatively stable in terms of psychosocial functioning, but that their unmet needs decreased over time. However, in terms of needs for treatment during two years of contact with a FACT team, patients in the subgroup with a stable and high problem-severity level tended to derive little or no benefit.

Predictors of Clinical Outcome of Assertive Community Treatment (ACT) in a Rural Area in Denmark: An Observational Study with a Two-Year Follow-Up

Assertive Community Treatment (ACT) is a multidisciplinary team approach to community care treatment, mainly characterised by small caseload and individualised care. The aim of the present study was to identify predictors of clinical outcome in ACT using an observational design. Three ACT Teams were established in The North Denmark Region to treat patients with severe mental illness. The patients were identified and followed in regional and national psychiatric registers, and in social and somatic case registers, 2 years before and 2 years after inclusion. The results showed that the use of psychiatric hospital services decreased significantly for the 240 included patients. Furthermore, the psychopharmacological profile was improved. No significant change occurred in the consumption of the somatic hospitals. Clinical outcome, defined as halving of admissions or bed days, was in a logistic analysis predicted by the patient's psychiatric use of inpatient service prior to inclusion in an ACT Team.

The effects of motivation feedback in patients with severe mental illness: a cluster randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of providing clinicians with regular feedback on the patient's motivation for treatment in increasing treatment engagement in patients with severe mental illness.

DESIGN

cluster randomized controlled trial (Dutch Trials Registry NTR2968).

PARTICIPANTS

adult outpatients with a primary diagnosis of a psychotic disorder or a personality disorder and their clinicians, treated in 12 community mental health teams (the clusters) of two mental health institutions in the Netherlands.

INTERVENTIONS

monthly motivation feedback (MF) generated by clinicians additional to treatment as usual (TAU) and TAU by the community mental health teams.

PRIMARY OUTCOME

treatment engagement at patient level, assessed at 12 months by clinicians.

RANDOMIZATION

teams were allocated to MF or TAU by a computerized randomization program that randomized each team to a single treatment by blocks of varying size. All participants within these teams received similar treatment. Clinicians and patients were not blind to treatment allocation at the 12-month assessment.

RESULTS

The 294 randomized patients (148 MF, 146 TAU) and 57 clinicians (29 MF, 28 TAU) of 12 teams (6 MF, 6 TAU) were analyzed according to the intention-to-treat principle. No statistically significant differences between treatment groups on treatment engagement were found (adjusted mean difference =0.1, 95% confidence interval =-2.2 to 2.3, P=0.96, d=0). Preplanned ancillary analyses showed statistically significant interaction effects between treatment group and primary diagnosis on treatment motivation and quality of life (secondary outcomes), which were beneficial for patients with a primary diagnosis of a personality disorder but not for those with a psychotic disorder. There were no reports of adverse events.

CONCLUSION

The current findings imply that monitoring and discussing the patient's motivation is insufficient to improve motivation and treatment engagement, and suggests that more elaborate interventions for severe mental illness patients are needed.

Changes in individual needs for care and quality of life in Assertive Community Treatment patients: an observational study

BACKGROUND

It is largely unknown which unmet needs in the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS) need to be resolved in order to improve a patients' subjective quality of life (QoL). We therefore investigated the pattern of individual unmet needs over time and its relation to QoL over time.

METHODS

Using data gathered from 251 patients in a Routine Outcome Monitoring procedure in Assertive Community Treatment (ACT) teams, we used paired samples tests to analyze differences in QoL total scores and the number of unmet needs between baseline and follow-up data. Ordinal regression was used to analyze the relationship between outcome in individual unmet needs and QoL.

RESULTS

As well as small improvements in QoL over time in patients in contact with ACT, we found a small to moderate decrease in unmet needs over time. While a decreasing number of unmet needs was associated with an increase in QoL, outcomes in QoL and individual unmet needs were weakly related (r ≤ .165). Ordinal regression analysis showed that a better outcome in individual unmet needs related to accommodation and day-time activities was weakly related to a better outcome in QoL.

CONCLUSIONS

Patients receiving ACT make small improvements in their QoL and ACT may help to solve some of their needs. QoL benefits from reducing needs for care, in particular the need for appropriate housing and meaningful daytime activities.

Can assertive community treatment remedy patients dropping out of treatment due to fragmented services?

Previously, many patients with severe mental illness had difficulties to engage with fragmented mental health services, thus not receiving care. In a Dutch city, Assertive Community Treatment (ACT) was introduced to cater specifically for this group of patients. In a pre-post comparison, changes in mental health care consumption were examined. All mental health care contacts, ACT and non-ACT, of patients in the newly started ACT-teams were extracted from the regional Psychiatric Case Register. Analyses of mental health care usage were performed comparing the period before ACT introduction with the period thereafter. After the introduction of ACT, mental health care use increased in this group of patients, although not all patients remained under the care of ACT teams. ACT may succeed in delivering more mental health care to patients with severe mental illness and treatment needs who previously had difficulties engaging with fragmented mental health care services.

The motivation paradox: higher psychosocial problem levels in severely mentally ill patients are associated with less motivation for treatment

PURPOSE

Lack of motivation for treatment makes a subgroup of patients with severe mental illness (SMI) difficult to engage in psychiatric treatment. Such difficult-to-engage patients may also be the most in need of treatment. We hypothesized that the level of psychosocial problems would be inversely related to motivation for treatment.

METHODS

Cross-sectional study in two independent samples. The first sample (n = 294) included SMI patients who participated in a randomized controlled trial and were assessed using the Health of the Nation Outcome Scales (HoNOS) and self-rated and clinician-rated motivation-for-treatment scales. The second sample (n = 1,170) included SMI patients who were treated in Assertive Outreach Teams and were routinely assessed with the HoNOS and a motivation-for-treatment scale. In both samples, patients also self-rated their quality of life.

RESULTS

In both samples, patients with HoNOS scores of 16 and higher had lower motivation scores on all motivation scales than patients with lower HoNOS scores, and also a lower quality of life.

CONCLUSIONS

A motivation paradox seems inherent to this association between higher psychosocial problems levels, less motivation for treatment, and lower quality of life. Such a paradox has clinical relevance, as it may provide an ethical basis for outreach services which aim to engage marginally motivated SMI patients with severe psychosocial problems into mental health care.

Changes in motivation for treatment in precontemplating dually diagnosed patients receiving assertive community treatment

In a population of dually diagnosed patients receiving assertive community treatment we used the theoretical framework of the transtheoretical model to establish (a) the proportions and characteristics of patients who were not motivated for treatment for psychiatric symptoms and substance use, (b) the proportion of patients who moved towards behavioral change after about 1 year, and examine how this change was related with clinical outcome; and (c) the sequence of change processes. Chi square tests and T tests were used to compare the patient characteristics and outcomes of patients who remained in precontemplation with those who progressed. During follow-up, 47 % of the patients came out of the precontemplation phase for treatment of psychiatric symptoms and 38 % for substance use behavior. Those who remained in precontemplation benefited less from treatment. Of those who did move forward, most appeared to become motivated for psychiatric treatment before becoming motivated to reduce substance use.

Flexible Assertive Community Treatment, Severity of Symptoms and Psychiatric Health Service Use, a Real life Observational Study

Background:

Introduction of Flexible Assertive Community Treatment (FACT) may be associated with increased remission rates and changes in patterns of care. The present paper reports on differences in psychosocial functioning and health care use between patients in FACT and two groups of patients not currently provided with a specific model of community service.

Methods:

The ongoing "Pharmacotherapy Monitoring and Outcome Survey" provided routine outcome measures of patients using antipsychotics in the north of the Netherlands. Level of psychosocial functioning was assessed using the Health of the Nations Outcome Scales (HoNOS) and matched with psychiatric health care consumption obtained from the Psychiatric Case Register. Patients who never received FACT, patients ever in FACT but not at assessment date, and patients in FACT were identified. Data were subjected to multilevel linear regression analysis.

Results:

Data showed that most patients in FACT also had non-FACT episodes after the start of FACT. Furthermore, patients in FACT displayed higher levels of psychosocial functioning and used more outpatient care than the other two groups.

Conclusions:

Patients in FACT receive more outpatient care and have better psychosocial functioning. However, causal inferences cannot be derived from these data. In addition, membership of a FACT-team in this setting did not last indefinitely.

Parents Served by Assertive Community Treatment: Parenting Needs, Services, and Attitudes

OBJECTIVE

Assertive Community Treatment (ACT) is an evidence-based practice for individuals with severe mental illness. Although at least half of all people with severe mental illness are parents, little is known about their experiences as parents and as recipients of mental health interventions like ACT. The purpose of the current study was to examine the experiences of parent consumers served by ACT.

METHOD

Seventeen parents being served by ACT teams were interviewed about parenting, parenting needs, severe mental illness, satisfaction with ACT services, and suggestions for improved parent-focused treatment services.

RESULTS

All parents identified at least one positive aspect of parenting and most parents (77%) also identified negative aspects of parenting. Loss of custody emerged as a significant parenting problem, with most parents (88%) experiencing custody loss at least once. Parents expressed interest in numerous parent-focused services, including family therapy, parenting skills, communication skills training, resources for children, and peer support groups. Most participants with adult children (88%) reported having no unmet parent-related needs and high satisfaction (4.63 of 5) with ACT services, whereas parents with young children (78%) reported having several unmet parenting needs and relatively lower satisfaction (3.78 out of 5) with ACT services.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The ACT treatment model may not be adequately serving parents of young, dependent children. Findings suggest the need for more attention and focus on parent consumers, including identification of parental status and improved parent-related treatment services and support.

Effects of an assertive community program in patients with severe mental disorders and impact on their families

AIMS

Assertive community treatment (ACT) is known to have a positive impact on the number and length of inpatient stays. However, recent studies have shown little or no effect of such programs in European settings. This paper aims to describe the impact of a newly implemented ACT program on patients and their families' burden. Predictive factors have also been examined.

METHOD

Fifty-five patients characterized by heavy use of psychiatric care, numerous hospitalizations, or failure to link with outpatient psychiatric care and their relatives were followed. Data were gathered on patients before and after follow up as well as on relatives' burden and costs. The number and domains of clinician interventions have been detailed.

RESULTS

The ACT program had a positive effect on symptoms, psychosocial adaptation and quality of life. Age was the most significant predictor of changes. Older patients, most of them suffering from delusional disorders, showed no improvement or even some impairment. Finally, the program appeared to have a marked effect on easing families' burden in domains such as assistance in daily life activities and costs.

CONCLUSIONS

ACT appears to be recommended for patients with poor outcome when treated in other settings. Early intervention seems to be justified as highlighted by younger age being the best predictor of positive changes. Families can be helped considerably, particularly those confronted with patients with persistent disturbing symptoms which do not, however, warrant hospitalization. Finally, the fact that patients with delusional disorder do not seem to improve warrants further research.

The characteristics of consumers receiving case management in the community: a review of literature

Mental health nurses increasingly provide care for consumers in the community who once would have received treatment in psychiatric inpatient units. The purpose of this review is to determine the characteristics of these consumers. We searched electronic databases and obtained information on some of the characteristics of community mental health consumers. For some nurses, over half of their caseloads are consumers with schizophrenia. Up to about one-third of consumers may be involuntary, but this proportion varies considerably. Impairments of health and social functioning appear common among consumers of community mental health services. This study identifies the need for greater interrogation of national databases to enhance understanding of community caseloads.

Duration of assertive community treatment and the interpretation of routine outcome data

OBJECTIVE

Statistical inferences based on routine outcome monitoring data are susceptible to biases. Because this process may be influenced by differences in attrition and treatment duration, we wished to gain an insight into the relationship between treatment duration and clinical outcome.

METHOD

We enrolled 569 assertive community treatment (ACT) team patients. As part of a six-monthly routine outcome monitoring (ROM) procedure, we used the Global Assessment of Functioning (GAF) scale, the Health of the Nation Outcome Scales (HoNOS), and a scale to assess their treatment motivation and satisfaction with services. Duration of ACT showed that treatment duration was short for 292 patients [≤ three ROM assessments; 11.6 months (SD = 6.1)], medium for 191 [four to six ROM assessments; 26.9 months (SD = 7.3)], and long for 86 [≥ seven ROM assessments; 44.06 months (SD=7.1)]. Chi-square and ANOVA were used to compare patient characteristics and baseline values across different treatment duration groups, and structural equation modelling was used to unravel interdependencies between the baseline and outcome variables.

RESULTS

More patients receiving long-term ACT were diagnosed with a psychotic disorder and/or substance abuse than those whose treatment was shorter. Patients whose treatment lasted longer had worse baseline GAF and HoNOS scores than those whose treatment was shorter. Structural equation modelling showed that the interdependencies between determinants and outcome variables (concerning the relationships between both identical and non-identical variables over time) were different for each of the treatment duration categories.

CONCLUSIONS

Patients in ACT teams with different treatment durations constitute distinguishable groups with different outcomes. This should be taken into account when using outcome data for benchmarking purposes.