Assertive community treatment.

Is delivering psychiatric services to people who need them but might not want them effective outreach or coercion?

The "in your face" mental health service-delivery model, called assertive community treatment, aims to get the most seriously mentally ill people into treatment and keep them out of state psychiatric hospitals and jails. Yet many of the people most in need of such services have limited or no awareness of their illness.

Opponents of aggressive mental health interventions argue that pushing treatment where it's not wanted is an affront to an individual's right to liberty. Proponents counter that withholding treatment denies people their right to equality and justice--particularly if they end up in prison because their illness has led to criminal behavior.

In its purest form, the assertive community treatment (ACT) model is about opportunity and treatment accessibility, "not coercion," according to Mary Ann Test, Ph.D., of the University of Wisconsin-Madison School of Social Work, who codeveloped the model in the 1970s with Arnold Marx, M.D., and Leonard Stein, M.D. From the outset, the ACT model "focused on service delivery mechanisms such as a single, integrated team and use of outreach to deliver services, supports, and rehabilitation to maximize the possibility that even the most disabled consumers would remain in the community and have a decent quality of life," Dr. Test explained.

Specifically, the ACT model targets individuals with the most intractable symptoms of severe mental illness, whose conditions may significantly impair their ability to keep themselves safe, maintain adequate housing, acquire employment, avoid violence, and access community services. Typically, such individuals are heavy users of inpatient psychiatric services.

Such individuals are often written off, but assertive community treatment strives to provide help and hope. It seeks to do this by replacing crisis-oriented care with continuous, intensive, mobile treatment, rehabilitation and support in community settings.

The hallmark of ACT is its intensity. Typically, a "transdisciplinary" team of 10-12 specialists provides oversight, treatment, and services on an outpatient basis for about 100 people with severe, persistent mental illness--many of whom have been in and out of hospitals and possibly prison. The team shares responsibility for bringing services to its clients, wherever they might be and whenever the clients might need them.

The service menu may involve counseling and medication support, as well as help with daily activities, family life, housing, employment, education, physical health care, substance abuse management, and whatever other services are needed to help maintain and support these individuals in the community.

The high ratio of staff to clients--typically, ACT programs have 1 staff member for every 10 clients--allows much-needed flexibility in client-management plans. The management team meets daily to discuss the status of each client and, if necessary, to adjust services based on changing needs and circumstances. Two other cornerstones of the model that set it apart from other service-delivery paradigms is the availability of crisis services 7 days a week, 24 hours a day and the fact that treatment and rehabilitative services are provided as long as clients need them, rather than based on an arbitrary timeline.

To date, the model has been implemented in more than 30 U.S. cities as well as in other countries, including Australia, Sweden, and the United Kingdom. The U.S. Veterans Health Administration has also developed and implemented on a large scale a service-delivery system based on the ACT paradigm. (See sidebar.)

The ACT program has been the subject of more than 25 controlled trials linking it to significant reductions in inpatient hospital admissions and length of stay, as well as reductions in psychiatric symptoms and disability. Patient and family satisfaction ratings are consistently high, and cost analyses have shown it to be no more expensive than standard care--thanks to the associated reduction in hospital bed-days, use of ambulatory services, and involvement with legal and social services (Cochrane Database Syst. Rev. 1998; Article No.: CD001089. DOI: 10.1002/14651858.CD001089).

Despite the efficacy of ACT, the demand for such services far outpaces the supply. The National Institute of Mental Health estimates that on any given day, 40% of the 2.3 million American adults with bipolar disorder and the 2.2 million with schizophrenia in a given year do not get treatment for their conditions. Lack of public awareness about effective treatment, inadequate provider training, failures of the community mental health and judicial systems, and lack of adequate funding keep evidence-based practices from widespread community implementation.

And as former U.S. Surgeon General David Satcher, M.D., emphasized in his 1999 landmark report on mental health, "Stigma remains the single most significant barrier to people getting the help they need." Until those barriers are addressed and removed, the promise of ACT will never be fully realized.

RELATED ARTICLE: Approach Proves Effective for Veterans

By the late 1980s, nearly 70% of the Veterans Health Administration budget was earmarked for inpatient health care, and most mental health services for veterans with severe mental disorders were provided on an inpatient basis. Since that time, the agency has reduced the proportion of inpatient beds by 80% by shifting to outpatient and community-based alternatives.

For some veterans with the most severe mental illness, the alternative to repeat hospitalization has been the receipt of services through Mental Health Intensive Case Management (MHICM) programs, which began as a clinical trial of the ACT model. "We did a rigorous evaluation to see if ACT would work in the VHA, and the evidence supported its effectiveness," said Robert Rosenheck, M.D., director of the Veterans Administration's Northeast Program Evaluation Center in West Haven, Conn.

Designed to serve veterans with severe mental illness, MHICM teams comprise 4-6 health care providers (including some combination of psychiatrists, nurses, social workers, psychologists, and peer specialists) who together provide treatment and rehabilitation services. The teams work closely with VHA emergency departments and inpatient units to develop and coordinate care, and they work with the veterans in real-world settings, providing support for all aspects of daily living.

Criteria for MHICM include a primary diagnosis of a severe, debilitating mental illness that precludes maintenance of a normal lifestyle in the community and a history of high inpatient and outpatient mental health service use. A VHA performance monitoring report published in 2002 stated that 90.7% of MHICM veterans had a diagnosis of psychotic illness at entry and had spent an average of 96 days in the hospital in the year before entry.

Ongoing evaluations demonstrate the benefits and cost-effectiveness of the more than 80 MHICM programs currently available, but a large number of veterans who meet the entry criteria are not getting services.

In testimony for the American Psychiatric Association to the U.S. of House of Representatives in 2003, Joseph T. English, M.D., chairman of St. Vincent's Catholic Medical Centers in New York, estimated that 25,000-35,000 veterans needed MHICM, but the 80 programs in operation served slightly more than 8,000 veterans, according to a 1998 VA survey by the Committee on Care of Severely Chronically Mentally Ill (SCMI) Veterans.

For MHICM to meet its potential, it needs more financial and administrative support from the government, according to Dr. English, "to provide the essential number of new intensive case management teams and to fully staff existing teams so that our nation's most vulnerable veterans receive appropriate and coordinated care."

BY DIANA MAHONEY

New England Bureau