Community Ment Health J (2015) 51:171–174 DOI 10.1007/s10597-014-9757-0

BRIEF REPORT

Modified Assertive Community Treatment: Effectiveness on Hospitalization and Length of Stay Salleh Mohd Razali • Mohd Affendi Hashim

Received: 14 June 2013 / Accepted: 6 July 2014 / Published online: 24 July 2014 Ó Springer Science+Business Media New York 2014

Abstract The objective is to assess the efficacy of a modified Assertive Community treatment (ACT). This is a retrospective cross-sectional study with a comparative group. The study group was patients with schizophrenia who had completed modified ACT, while the control group was those who did not receive modified ACT. The final sample comprises 44 patients in each group. There was no significant difference between both groups in number of admissions and average length of stay. However, in the modified ACT group there was a significant reduction in the number of admissions after the intervention. In conclusion readmission rate was significantly reduced following modified ACT intervention. Keywords stay

Modified ACT  Admission rate  Length of

Introduction Since its development in Madison, Wisconsin, USA in the early 1970s, Assertive Community Treatment (ACT) has been disseminated across the nation and overseas (Dixon and Goldman 2003). ACT is a widely investigated treatment model for people with severe mental illness and is recognized as an evidence-based practice (Bond et al. S. M. Razali (&) Discipline of Psychiatry and Behaviour Medicine, Faculty of Medicine, Universiti Teknologi Mara (UiTM), Sungai Buloh Campus, 4700 Sungai Buloh, Selangor, Malaysia e-mail: [email protected] M. A. Hashim Department of Psychiatry, Hospital Sultanah Bahiyah, 05460 Alor Setar, Malaysia

2001). Typical outcome include reduced drop-out rate, hospital stay and hospitalization, higher client and family satisfaction, and increased housing stability (Mueser et al. 1998; Ziguras and Stuart 2000). However, there is little evidence that ACT improves symptomatology, quality of life (QOL), social functioning, or employment (Salyers and Tsemberis 2007). ACT is labor-intensive and an expensive program to administer. It provides service 24 h a day, 7 days a week, 365 days a year. Most developing countries including Malaysia cannot afford to run the standard ACT program due to several constraints and limitations. Even in the developed country such as England, many ACT centres did not have adequate staff to deliver the services (Ghosh and Killaspy 2010). McCrone et al. (2009) found the cost of ACT was higher but not significantly different from usual care. Burns (2010) expressed his doubt on the value of investing in high fidelity ACT because ordinary Community Mental Health Services (CMHS) share most of the organization aspect of ACT and appear to deliver equal outcome with much reduced resources. Since the government introduced the policy of decentralization of psychiatric services and started reducing beds in mental institutions in the early 1960’s, the communitybased psychiatric services in general hospitals in Malaysia have gained in popularity (Razali 2004). The modified ACT service was then started in the form of small pilot projects in the country in the mid-1990s (Ruzanna and Marhani 2008). What has been practiced in Malaysia up to now is a modification of the standard or traditional ACT (modified ACT). However, local studies on modified ACT are very limited (Rahima 2010; Siti Salwa 2008); and not much data is available to evaluate its efficacy. There is also a scanty of research available worldwide on the effectiveness of a modified ACT, as compared with the standard

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ACT, which is claimed as one of the most researched interventions in the United States and elsewhere (Dixon 2000). The objective of this study was to assess the effectiveness of a modified ACT service in relation to the two most consistent outcomes of the intervention: frequency of admission and length of stay.

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diagnosis of substance abuse, alcoholism, and mental retardation (moderate to severe); and serious medical problem were excluded. Homeless patients and the co-morbidities are not common in HSB populations.

Results Modified ACT Services in Sultanah Bahiyah Hospital (HSB) The modified ACT team in HSB, Alor Setar was established in 2000. The operation of the modified ACT services in HSB are similar to those in standard ACT such as sharing case load and providing most of the services directly in the community (no brokered out services); except for a higher ratio of clinical staff-to-patients, of 1:30 instead of 1:15 or less (Stein and Test 1980); and the home care services coverage are not provided 24 h. The services only provided during normal working hours; there are no home care services after office hours, during weekends and on public holidays. However, the medical officer on call and other members of the team are on standby at the call center during these periods. Any patients requiring community interventions will be seen in the next working day.

Methodology Patient Selection This study was a retrospective cross-sectional study comparing two groups of patients with schizophrenia; one group received modified ACT (study group) and the other group (control group) did not receive modified ACT because they stayed outside the coverage area. The study was conducted between October 2010 and January 2011 at Psychiatric Clinic, Hospital Sultanah Bahiyah (HSB), in the northern part of Peninsular Malaysia. The study protocol was approved by the Universiti Sains Malaysia Ethical Committees (Human). All patients with schizophrenia (DSM-IV-TR) (American Psychiatric Association 2000) between 23 to 60 years old, who have been enrolled under the modified ACT service of 5 to 10 years visiting the clinic, were screened for the study. The inclusion criteria were the General Assessment of Functioning (GAF) Scale (American Psychiatric Association 2000) scores of 51 to 70 (mild to moderate symptoms) and had at least 2 psychiatric admissions in their lifetime before the study. The same inclusion criteria were applied to the control group with at least 5 years duration of illness, matching for age and sex. The sample was selected by convenience sampling after the screening. Those who refused to sign the informed consent form, homeless patients, and patients with co-morbid

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Demographic and Clinical Profile The final sample comprised 44 patients in each group. The socio-demographic data between the two groups were comparatively similar. The differences were not statistically significant except in terms of duration of illness, where patients in the modified ACT group had a longer duration of illness. Number of Admissions Average Number of Admissions Between the Two Groups The median of admissions in the past two years for the modified ACT group was 0 with IqR of 1. The minimum number of admissions was 0 and the maximum was 3. The median of admissions in the past two years for the control group was 0 with IqR of 1. The minimum number of admissions was 0 and the maximum was 4. There was no significant difference in the average number of admissions in the past two years between the modified ACT group and the control group (Mann–Whitney Test: Z = -1.217, p = 0.223). No. of Admissions Between Pre- and Post-modified ACT Intervention Out of the 44 patients in the modified ACT group, 25 (57 %) had a reduced number of admissions after the intervention, 12 (27 %) had an equal number of admissions before and after the modified ACT service; while seven (16 %) had an increased number of admissions after modified ACT enrolment. The median number of admissions before modified ACT was 2 and the median number of admissions after the intervention was 1. Therefore, the number of admissions after modified ACT intervention was significantly reduced (Wilcoxon Signed-Rank Test: Z = -2.593, p = 0.01). Length of Stay Average Length of Stay (ALOS) Between the Two Groups The median length of stay (ALOS) per admission in the past 2 years for the ACT group was 0 with IqR of 33 days.

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The minimum ALOS per admission in the past two years was 0 and the maximum ALOS per admission was 77 days. The median ALOS per admission in the past two years for the control group was 0 with IqR of 12 days. The minimum ALOS per admission in the past two years was 0 and the maximum ALOS per admission was 143 days. There was no significant difference in ALOS per admission in the past two years between the modified ACT group and the control group (Mann–Whitney Test: Z = -0.867, p = 0.386). Average Length of Stay (ALOS) Between Pre-and Postmodified ACT Intervention Following the modified ACT intervention, ALOS in 21 (48 %) patients was reduced, while in another 23 (43 %) ALOS was increased or the same. The median ALOS before modified ACT was 21.7 with IqR of 23.7 and the median ALOS after modified ACT was 22.1 with IqR of 40.5. The difference in median ALOS per admission in the past two years between pre-and post-modified ACT period was not significant (Wilcoxon Signed-Rank Test: Z = -0.537, p = 0.591).

Discussion An interesting question to ask here is why a modified ACT only managed to reduce the number of admissions after the intervention; but not much difference between the two groups in the rate of admission and length of stay, as was documented in a Cochrane Systemic Review (Marshal and Lockwood 2000). This is partly due to high variability and small differences in group averages. In contrast to our finding, a randomized controlled study on the efficacy of a modified ACT from South Africa (Botha et al. 2010) found the intervention had positive outcomes in hospitalization, psychopathology, and overall level of functioning among patients with SMI. One of the explanations for the failure to produce a positive result is that the standard community care or Community Mental Health Services in this country have improved (Malaysia’s Country Report 2008). Since early 2000’s, the core ingredients of ACT, such as homebased care services, especially acute treatment at home, were provided to all patients with SMI in the community, regardless of whether they were enrolled in the modified ACT programme or not. (Ruzanna and Marhani 2008). The importance of home-based treatment was highlighted by Harvey et al. (2011). They found that the better efficacy of ACT in UK as compared with Australia centre may be due to the differences in the implementation of ‘active components’ of home treatment. Existing fidelity measures may not adequately weight these important elements of the model.

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The second possible explanation is that some of the aspects of modified ACT services, such as the bigger staff– patient ratio and lack of home treatment during the weekends, may influence the outcome of the intervention. The patients may be unnecessarily admitted during this period when other alternatives are not available. A high case load will increase the burden of the clinical staff and subsequently jeopardised patients care to some extend as the team members need to look after a larger number of cases, which may predisposed to premature relapse or readmission. All these factors will contribute to negative outcomes of the study, especially when the control group is stonger. Although the intervention did not produce many positive results, the negative results are still credible and important. Part of the failure to produce some positive results are due to small sample size with diverse group of samples which contributed to low statistical power and type II error. Retrospective comparative studies such as this have a very weak study design and require strict matching processes. Ideally, to construct a study that looks at the differences between two groups, a randomized controlled study or a prospective controlled study would be the study design of choice. In this study there is an obvious weakness in part of the design where the possibility that group selection was systemically biased; there is likely that the control group was somehow stonger than the study group. Other confounding factors related to the hospitalization, such as the strength of support provided, compliance with medication, co-morbidities, how the illness was handle, the severity and disabilty of illness are also need to be controlled.

References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorder (4th ed.) text revision (DSM-IVTR). American Psychiatric Association: Washington, DC. Bond, G. R., Drake, R. E., Mueser, K. T., & Latimer, E. (2001). Assertive treatment for people with severe mental illness. Disease Management & Health Outcome, 9, 141–159. Botha, U. A., Koen, L., Joska, J. A., Hering, L. M., & Oosthuizen, P. P. (2010). Assessing the efficacy of a modified assertive community-based treatment programme in a developing country. BMC Psychiatry, 10, 73. Burns, T. (2010). The rise and fall of assertive community treatment. International Review of Psychiatry, 22, 130–137. Dixon, L. B. (2000). Assertive community treatment: twenty-five years of gold. Psychiatric Services (Washington, D. C.), 51, 759–765. Dixon, L. B., & Goldman, H. H. (2003). Forty years of progress in community mental health: The role of evidence-based practices. Australian and New Zealand Journal of Psychiatry, 2003, 668–673. Ghosh, R., & Killaspy, H. (2010). A national survey of assertive community treatment services in England. Journal of Mental Health, 19, 500–508.

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174 Harvey, C., Killaspy, H., Martino, S., White, S., Priebes, S., Wright, C., et al. (2011). A comparison of the implementation of assertive community treatment in Melbourne, Australia and London, England. Epidemiology Psychiatric Sciences, 20, 151–161. Malaysia’s Country Report. (2008). Malaysia’s country report: AsiaPacific community mental health development project. http:// www.aamh.edu.au.html. Marshall, M., & Lockwood, A. (2000). Assertive community treatment for people with severe mental disorders (review). Cochrane Database of Systematic Reviews (2), CD001089. McCrone, P., Killaspy, H., Bebbington, P., Johnson, S., Nolan, F., Pilling, S., et al. (2009). The REACT study: Cost-effectiveness analysis of assertive community treatment in North London. Psychiatric Services (Washington, D. C.), 60, 908–913. Mueser, K. T., Bond, G. R., Drake, R. E., & Resnick, S. G. (1998). Model of community care of severe mental illness: A review of research on case management. Schizophrenia Bulletin, 24, 37–74. Rahima, D. (2010). Rehospitalization, functioning level and quality of life among patients with schizophrenia receiving ACT in Hospital Kuala Lumpur. Dissertation submitted for Master of

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Community Ment Health J (2015) 51:171–174 Medicine (Psychiatry), Universiti Kebangsaan Malaysia, Kuala Lumpur. Razali, S. M. (2004). Deinstitutionalisation and community mental health services in Malaysia: An overview. International Medicine Journal, 11, 29–35. Ruzanna, Z., & Marhani, M. (2008). Assertive community treatment (ACT) for patients with severe mental illness: Experiences in Malaysia. Malaysian J Psychiatry, 17, 1–7. Salyers, M. P., & Tsemberis, S. (2007). Assertive Community Treatment and recovery: Integrating evidence-based practice and recovery orientation on Assertive Community Treatment team. Community Mental Health Journal, 43, 619–641. Siti Salwa, R. (2008). Quality of life and psychological well being of caregivers of patients with schizophrenia receiving ACT—A cross-sectional study. Dissertation submitted for Master of Medicine (Psychiatry), Universiti Kebangsaan Malaysia, Kuala Lumpur. Stein, K. I., & Test, M. A. (1980). Alternative to mental hospital treatment. Archives of General Psychiatry, 37, 392–397. Ziguras, S. J., & Stuart, G. W. (2000). A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatric Services (Washington, D. C.), 51, 1410–1420.

Modified assertive community treatment: effectiveness on hospitalization and length of stay.

The objective is to assess the efficacy of a modified Assertive Community treatment (ACT). This is a retrospective cross-sectional study with a compar...
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