1 Assertive Community Treatment: An integrated MH community care model? Tom Burns Professor of Social Psychiatry University of Oxford UK

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: HospitalisationReduced >70% Social FunctioningImproved SymptomsSame/Improved EmploymentEnhanced CostsEquivocal

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

8 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): 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:

9 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]

10 Case Management vs Standard Care Hospital admissions Marshall M, Gray A, Lockwood A, Green R. Case management for severe mental disorders (Cochrane Review). The Cochrane Library [1]

Clinical practice extensively described and 300 teams mandated in the UK Assertive Outreach in Mental Health A Manual for Practitioners Tom Burns and Mike Firn, OUP Excellent book – available in English, Italian and Swedish

12 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 13

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’

15 Attempting to answer the question empirically: Going beyond definitions

16 Impact of current bed usage

17 Copyright ©2007 BMJ Publishing Group Ltd. Burns, T. et al. BMJ 2007;335:336 Metaregression of Intensive Case management studies Control group mean v mean days per month in hospital. Negative treatment effect indicates reduction relative to control

18 Impact of model fidelity (ACT) Measured using IFACT scale: Organisation staffing treatments

19 Meta-regression of Fidelity v Reduction in IP days

M-R of Team organisation v Reduction in IP days 20

21 M-R of Team staffing v Reduction in IP days

22 Testing for characteristics of home-based care using cluster analysis and regression 20 characteristics of home-based care Experimental services only 60 of 90 replied, international response

23 Associations between common service components Smaller caseloads Regularly Visiting at home High % of Contacts at home Responsible for Health and social care Psychiatrist Integrated in team Multidisciplinary teams

24 Associations between service components & Hospitalisation: regression analysis Smaller caseloads Regularly Visiting at home High % of Contacts at home Responsible for Health and social care Psychiatrist Integrated in team Multidisciplinary teams

25 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 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

29 Thank you for your attention Mange tak