Perspective.

Assertive community treatment makes sense for "high maintenance" mentally ill patients. In fact, it is unethical to treat such patients without providing a support system that is going to assertively case-manage housing, income, nontoxic leisure activities, and monitor drug use, advocacy, and employment--if possible.

One of the basic public health principles of primary or secondary prevention is monitoring behavior and assertive community treatment. Such strategies provide closer supervision of patients who for various reasons are not compliant with treatment demands. It has been proven particularly effective with chronic schizophrenia patients who have a high hospital recidivism rate, dually diagnosed substance abusing and psychotic patients, and patients who have a difficult time keeping out of the criminal justice system secondary to their mental illness.

A benefit of ACT is that it allows for a greater capacity for meeting patients' individual needs. Also, because the patient/therapist relationship is so intense, if there is a good match, there is a good opportunity for a therapeutic relationship that is extremely culturally sensitive. Furthermore, maintaining a patient in the community without frequent disruptions to trips to the hospital or jail, enhances the likelihood of recovery.

The biggest challenge to treating seriously and persistently mentally ill patients is compliance with treatment plans. Fortunately, much of the time, the problem is not attributable to paranoid suspiciousness or just plain grouchy, uncooperativeness, but rather cognitive confusion. Constant and persistent follow-up can correct this problem.

The biggest obstacle to the success of ACT is that mental health is under-funded and not given the respect of insurance parity. Unfortunately, states have made huge investments in hospitals and correctional facilities and are hard pressed to get rid of those good state jobs that get governors reelected. As a result, the idea of putting enough community supports in place to keep the severely mentally ill out of the hospital or corrections is onerous.

BY CARL C. BELL, M.D.

DR. BELL is chief executive officer and president of Community Mental Health Inc. in Chicago and serves as director of public and community psychiatry at the University of Illinois at Chicago.