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eLetters: Electronic letters published:
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3-year outcomes for Assertive Community Treatment teams
- Panthratan S Grewal, Colin Cowan, Consultant Psychiatrist, Sandwell Mental Health Foundation Trust (30 September 2009)
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Focus on recovery needed
- Adarsh Shetty (30 September 2009)
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Active outreach
- David H Yates (28 October 2009)
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Panthratan S Grewal, ST5 Birmingham & Solihull Mental Health NHS Foundation Trust, Colin Cowan, Consultant Psychiatrist, Sandwell Mental Health Foundation Trust
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psgrewal{at}doctors.org.uk Panthratan S Grewal, et al.
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We read with interest the 3 year outcomes for Assertive Community Teams (ACTs) in North London reported by Killaspy et al (2009). Their longer term follow up to the REACT study (Killaspy et al, 2006) replicated their original finding that ACTs had no advantage over CMHTs in reducing in-patient care and concluded by questioning further investment in ACT in the UK. We found this interesting because we have evidence for a reduction in inpatient bed use locally, albeit using a different methodology. The Sandwell Assertive Outreach Team (AOT) has been operating for over 5 years, serving an ethnically and socioeconomically diverse urban population of approximately 280,000. The team has remained compliant with the Department of Health Policy Implementation Guide (2001) and has a mean score of 3.7 on the Dartmouth Assertive Community Treatment Scale (Teague et al, 1998). We retrospectively reviewed our performance in terms of number of admissions and bed days for all 73 patients who have been with our service for over 3 years. We compared these results with data for the same population in a similar period prior to transfer of care to our team. The results are summarised in table 1. We are conscious of a local trend for referrals to our service to be initiated as patients relapse and therefore transfer of care often occurs on discharge from hospital. Improvements seen in 1 year figures may be due a period of remission in keeping with the natural history of the illness but the fact that improvements are maintained over 3 years in patients with frequent relapses would suggest that this is less likely to be a significant factor. A possible explanation for the reduction in bed use might be that our Assertive Outreach team offers daily home treatment for patients in relapse and at risk of admission instead of involving the Crisis and Home Treatment Team. We are not aware of this aspect of assertive outreach being reported elsewhere in the literature about UK services and suggest it produces better outcomes by preventing patients with a history of disengaging from mental health services having to develop a therapeutic relationship with a new team at a time of crisis. We feel that these before and after findings provide evidence to suggest that assertive outreach was locally responsible for reducing bed usage over several years in a population previously characterised by poor engagement and multiple admissions. Burns et al (2007) found that fidelity to ACT staffing practices did not explain variation in outcome between trials and concluded that we should research the practices of teams. It would be interesting to know whether other services report a reduction of inpatient bed use and whether a programme of active daily visiting with medication in relapse played a part. We suggest that this aspect of assertive outreach could be incorporated in future research into effective components of the model.
Table 1: Comparing bed usage in 73 Sandwell AOT patients before and after transfer to AOT Declaration of Interests: None References: Burns T, Catty J, Dash M, Roberts C, Lockwood A & Marshall M (2007). Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression. BMJ, 335(7615) p336 Department of Health (2001) The Mental Health Policy Implementation Guide. London: Department of Health. Killaspy H, Kingett S, Bebbington P, Blizzard R, Johnson S, Nolan F, Pilling S & King M (2009) Randomised evaluation of assertive community treatment: 3-year outcomes. British Journal of Psychiatry, 195(1) p81-2 Killaspy H, Bebbington P, Blizard R, Johnson S, Nolan F, Pilling S & King M (2006) The REACT study: randomised evaluation of assertive community treatment in north London. BMJ, 332(7545) p815-20 Teague G, Bond G & Drake R (1998) Program fidelity in assertive community treatment: Development and use of a measure. American Journal of Orthopsychiatry, 68 p216-232 |
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Adarsh Shetty, Consultant Psychiatrist in Rehabilitation and Assertive Outreach Cwm Taf Health Board, St. Tydfil's Hospital, Merthyr Tydfil CF47 0SJ.
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dradarshshetty{at}yahoo.co.in Adarsh Shetty
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Killaspy et al (2009) present disappointing results from their randomised controlled trial examining the effectiveness of Assertive Community Treatment (ACT).(1) They found that ACT did not reduce admissions and bed usage. However, as Professor Burns' editorial in the same issue (2009) points out, this finding should not come as any great surprise to us.(2) ACT has never really been shown to be effective in reducing admissions in the UK. Professor Burns avers that this is because of Community Mental Health Teams (CMHTs) actually being active comparators rather than Treatment As Usual (TAU). I think there is another important reason. UK Assertive Outreach (AO) teams have always had engagement as their primary focus. This is understandable in view of their client group, a group that has not engaged with traditional CMHTs. Thus, innovative approaches to engagement, such as meeting in less stigmatizing settings, have been the hallmark of UK AO teams, along with providing practical support. However, the key question is, what happens once the patient is engaged? I believe the focus of the team should then swiftly move towards recovery and social inclusion. The most important characteristics of this would include a strong strengths-based approach and a focus on helping patients back to employment, whether voluntary or paid. Other characteristics would include a clear relapse prevention plan made in collaboration with the patient and a strong network of supported accommodation. Occupational therapists (OTs) are invaluable in promoting such approaches in psychiatric care, both in terms of social inclusion and potentially in leading on return to work initiatives.(3) Similarly, strong links with the local authority are important in ensuring a good network of supported accommodation. This is facilitated by the presence of social workers with such links within the team. However, it is interesting that in surveys done of AO team composition, it is the nursing profession that predominates.(4) OT and social work input remains limited, while psychology input is concerningly rare. AO as an intervention has worked well abroad but needs to be modified to suit the needs of the UK population. The modification required, in my opinion, is a stronger focus on recovery and rehabilitation. This can be facilitated by ensuring that Occupational Therapists and Social Workers are an integral part of AO teams. It intuitively makes sense that a strong recovery approach, clear relapse prevention plans and good supported accommodation that is available for the patient who needs it, should together reduce admissions and bed usage. This is the AO model that needs to be evaluated in well-designed randomized controlled trials. 1 Killaspy H, Kingett S, Bebbington P, Blizard R, Johnson S, Nolan F, et al. Randomised evaluation of assertive community treatment: 3-year outcomes. Br J Psychiatry 2009; 195: 81–2. 2 Burns T. End of the road for treatment as usual studies? Br J Psychiatry 2009; 195: 5-6. 3 College of Occupational Therapists (COT). The value of occupational therapy and its contribution to adult social service users and their carers. COT, 2008. http://www.cot.org.uk/MainWebSite/Resources/Document/The%20value%20of%20OT%20and%20its%20contribution.pdf 4 Wright C, Burns T, James P, Billings J, Johnson S, Muijen M, et al. Assertive community treatment teams in London: models of operation. Pan London Assertive Community treatment Study Part I. Br J Psychiatry, 2003, 183: 132 –8. |
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David H Yates, Retired Psychiatrist Family carer
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davidmet{at}ticali.co.uk David H Yates
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Your letter about Assertive outreach [ I prefer Active outreach, it's more peaceful and is easier to see that often it is inactive ] having to go further for subsequent recovery, going on with keeping contact and providing a Recovery programme of activities, is very pertinent. It resonates with the alarm at the unexpected and unsettling rise in the rate of homicides down to schizophrenia. A problem in providing and delivering this aftercare for schizophrenai is that most with schizophrenia will not meet the current preference in funding agencies for getting people back into fulltime work. Those with residual schizophrenia do still need to have a programe in the week which mediates for them, at their level of experience and educaton, a regular routine of some activity in the week ahead, - training, education, interest pursuits, which hold them onto outside engagement and into some approriate company. The National Service Farmework [NSF}standards end this month. The service to the other serious and enduring mental illnesses have much improved. It may be that in some replacment statement they should lose the priority that the NSF afforded to them hitherto. But there is no such improvement in service to schizophrenia. It should remain as the unfinished priority for commissioning and delivery. The national service to the illness must receive a more prominent oversight, and awaits an ovedue urgent and continuing review from the National Director and the Royal College D H Yates FRC Psych family carer |
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