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Assertive Community Treatment:

An integrated MH community care model?

Tom Burns Professor of Social Psychiatry

University of OxfordUK

16 August – 5 September 1807

Second battle of Copenhagen

British navy bombards Copenhagen

Walls of the asylum breached and patients escape

Danish community psychiatry begins

Early developments

• Outreach an early feature of UK psychiatry– 1948 NHS consultants’ ‘domiciliary visits’– 1953 First CPNs in Warlingham Park Hospital– 1959 MHA shaped sectorisation and outreach

• Must offer OP follow up of compulsory patients• Social workers involved in admission and support

• ‘Sector/Secteur’ model developed – France and UK in 1960s

Community Mental Health Teams (CMHTs)

• Multidisciplinary CMHTs arise to meet complex needs – Medically led

• CMHTs with CPNs the norm by late 1970s– Social workers, psychologists, occupational

therapists• Responsible for inpatient and community care• Referrals from Primary Care (liaison)

Evidence Based Mental Health Care

• EBM in 1970s

• Evidence (RCTs) > experience and authority

• Internationalization of evidence

• Stein and Test (1980) starting pistol for Mental Health Services Research

PACT - Stein & Test 1980• Project for Assertive Community Treatment• 126 psychotic patients in RCT of:

– Intensive case management (ACT)– Treatment as usual

• Results:• Hospitalisation Reduced >70%• Social Functioning Improved• Symptoms Same/Improved• Employment Enhanced• Costs Equivocal

PACT Clinical Practice• Low case loads 1:10• Frequent contact (weekly to daily)• In vivo (outreach to home and neighborhood)• Daily team meetings • Multidisciplinary work ‘whole team approach’• Flexibility, crisis stabilization, available 24/7• Not time limited

• Emphasis on medication• Emphasis on survival skills and circumstances

–Accommodation, food, money–Social functioning – leisure, work and substance abuse

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ACT research takes off

• Over 50 studies in Meuser’s 1998 review– Of which >30 ACT like– Mueser KT, Bond GR, Drake RE, Resnick SG. Models of community

care for severe mental illness: a review of research on case management. Schizophrenia Bulletin 1998;24(1):37-74.

• Over 90 studies in Catty 2002 review– Of which >60 ACT like– Catty J, Burns T, Knapp M, Watt H, Wright C, Henderson J et al. Home

treatment for mental health problems: A systematic review.

Psychological Medicine 2002;32:383-401

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ACT vs Standard Care Hospital Admissions

Marshall M, Lockwood A. Assertive Community Treatment for people with severe mental disorders (Cochrane Review). The Cochrane Library [3]. 25-2-1998.

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Case Management vs Standard CareHospital admissions

Marshall M, Gray A, Lockwood A, Green R. Case management for severe mental disorders (Cochrane Review). The Cochrane Library [1]. 2001.

Clinical practice extensively described and 300 teams mandated in the UK

Assertive Outreach in Mental HealthA Manual for PractitionersTom Burns and Mike Firn, OUP

Excellent book – available in English, Italian and Swedish

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The intellectual puzzle

• No European study has replicated these findings

• UK700 and PRiSM showed no difference

• This paradox has helped us identify what is needed for effective community care

“When the facts change, I change my opinion. What, sir, do you do?”

John Maynard Keynes, economist

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Two explanations

• Current European (UK) care already achieved low bed occupancy

• UK experimental services did not successfully replicate ACT intensity and skill – ‘poor model fidelity’

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Attempting to answer the question empirically:

Going beyond definitions

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Impact of current bed usage

17Copyright ©2007 BMJ Publishing Group Ltd.

Burns, T. et al. BMJ 2007;335:336

Metaregression of Intensive Case management studiesControl group mean v mean days per month in hospital.

Negative treatment effect indicates reduction relative to control

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Impact of model fidelity (ACT)

Measured using IFACT scale:Organisation

staffing

treatments

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Meta-regression of Fidelity v Reduction in IP days

M-R of Team organisation v Reduction in IP days

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M-R of Team staffing v Reduction in IP days

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Testing for characteristics of home-based care using cluster analysis and regression

20 characteristics of home-based careExperimental services only60 of 90 replied, international response

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Associations between common service components

Smaller caseloads

RegularlyVisiting at home

High % ofContacts at home

Responsible forHealth and social care

PsychiatristIntegrated in team

Multidisciplinaryteams

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Associations between service components & Hospitalisation:

regression analysisSmaller caseloads

RegularlyVisiting at home

High % ofContacts at home

Responsible forHealth and social care

PsychiatristIntegrated in team

Multidisciplinaryteams

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Conclusion: Effective ingredients in community mental health care

• Home visiting• Integrated psychiatrist• Combined health and social care• Multidisciplinarity• Small caseloads (1:20)• Team organisation: not specifics of

staffing

What does not seem necessary?

• Tiny caseloads– ultra-high intensity of contact

• Highly specialized staff– Vocational rehab, drug staff etc

• 24 hour availability• Whole team approach

What have we learnt from ACT?

• Fixed caseloads– Probably 20- 25

• Regularity of meetings• Zoning

– FACT (Functional ACT)• Red – frequent visits• Yellow – routine visits• Green – open to team

Current controversies

• Continuity of care– Separate inpatient and outpatient teams– Highly specialized teams

• Crisis / early intervention / assessment etc.

• Balancing of specialist and generic mental health skills and responsibilities

• Coercion , paternalism, confidentiality

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Thank you for your attentionMange tak