Assertive Community Treatment

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Special arrangements to provide rapid response have been described by Stein and Test (1980) working in the USA . In this approach, called Assertive Community Treatment (ACT), patients with acute psychiatric disorder, who would otherwise be admitted to hospital, are cared for instead by a well-staffed community team. The special features of ACT are:

•  Staff work with patients as required instead of having individual case lists;

•  Generous staffing, about one staff member to 10 patients;

•  A psychiatrist working specifically with the team;

•  Services provided in the patients home, or when appropriate, place of work;

•  24-houravailability.

ACT has been described in detail and scales are available to measure the fidelity of a replication to the model (Teague et at. 1998).

Stein and Test (1980) compared ACT with standard treatment in which acutely ill patients were admitted to hospital. Over 14 months, symptoms, social functioning, and satisfaction were better in the community group, and bed use was reduced. In Australia , Hoult et al. (1983) obtained comparable results with a similar kind of intensive community treatment, and reported that this treatment was less costly than hospital treatment. In the UK ,

Marks et at. (1994) compared routine hospital care with a form of intensive community treatment, which they called the daily living program. The' study lasted for 3 years, and was concerned with acutely ill patients who had not previously been admitted to hospital. About three-quarters of the community treatment group required an initial brief admission to hospital (average 6 days) before they could be managed in the community. Their stay in hospital was significantly less than that of the control group (average 53 days), and the outcomes for symptoms and social adjustment were slightly better. Deaths from self-harm were not reduced.

A meta-analysis of five randomized trials of ACT or closely similar approaches by Joy et at. (1999) showed that compared with standard care, ACT reduced admission to hospital by about 40% over 1 year without worsening clinical and social outcomes. Burden on families was reduced, One trial reported a homicide by a patient and there was insufficient evidence from the other trials to form a certain assessment of the safety of the approach. Overall costs associated with ACT were less than those of standard care.