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

Abstract

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.

Clinical and Functional Outcome of Assertive Outreach for Patients With Schizophrenic Disorder: Results of a Quasi-Experimental Controlled Trial

“…Previous studies demonstrating positive effects of assertive models on medication adherence included patients with first-episode schizophrenia, patients with a history of medication non-adherence, or patients with dual diagnosis [25,27]. In contrast, studies such as ours that do not showing such effects [18,31], typically use less stringent inclusion criteria regarding the risk of non-adherence. Therefore, it might be beneficial to define patients at risk for non-adherent behaviour and target interventions more precisely.…”

“…Despite the comparably large evidence base, the clinical meaning of the significant, yet relatively small changes is unclear [14]. Current evidence on psychopathology is also mainly in support of assertive models [3,6,15,18,25,42], yet conflicting results exist [1,48,46]. Finally, the last outcome parameter relevant in the present study, pharmacological adherence, was found to be a clinically important aspect, yet it is typically neglected in studies [14].…”

“…Finally, the last outcome parameter relevant in the present study, pharmacological adherence, was found to be a clinically important aspect, yet it is typically neglected in studies [14]. The few existing investigations show mixed results [4], some favouring assertive community-based models [25,42], whereas others do not [18,31]. Conflicting results were often explained by differences within design, setting, intervention, and control condition; namely treatment as usual within a specific region [9,23].…”

“…Assertive community-based models were developed in the 1970s in the US and subsequently implemented and evaluated in the US and the UK. Recently, nation-wide implementation processes have begun in The Netherlands and in Denmark [34,48], whereas for other parts of continental Europe only a few projects have been studied and reported on [7,18,22]. The latter holds true for Germany, where even though assertive community-based models are guideline recommended, care reality is dominated by a fragmented health care system consisting of independently working psychiatrists within the outpatient care [13].…”

“…Among the subjective parameters, functioning and psychopathology are among the most frequently studied. Regarding functioning, reviews and recent single studies favour assertive community-based models [6,14,18,25,42,48]. Despite the comparably large evidence base, the clinical meaning of the significant, yet relatively small changes is unclear [14].…”