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Is the ACT model effective in a contemporary Danish psychiatric setting?

Preliminary Results from a Danish Multi-centre Trial of Assertive Community Treatment vs. Standard Psychiatric Treatment

Marie Høgh Thøgersen, Bispebjerg Psychiatric Dep. Gøteborg 2007

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Assertive Community Treatment (ACT)In Denmark

2003: wide-scale Implementation

Debate on ethical issues in relation to ACT

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Dilemma in Psychiatry

Paternalisme

Autonomy

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Deinstitutionalisation was associated with less paternalism and more autonomy

Paternalism

Autonomy

Is Assertive Community Treatment associated with more paternalism and less

autonomy?

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Study Design

ACT-Team I Control I ACT-Team II Control II

ACT-team

dropout dropout

2 YEAR FOLLOW UP

ASSESSMENT

ACT-team Control

BASELINE

Register Data (1)Medical Records (2)

Register Data (1)Medical Records (2)

Interviews (3)

N= 213 N= 153

Control Level 1 = 5 Level 2 = 20 Level 3 = 66

Level 1 = 8Level 2 = 6

Level 3 =110

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Inclusion Criteria

• Age 18-65 • Address in catchment area• Chronic mental illness

• At least 4 admissions or 40 days at hospital within the last 2 years

• Dual diagnoses • Difficult to engage with services

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Model Fidelity: How do we know that the danish ACT teams follow

the ACT principles?

Assessment of adherence to model

(IF-ACT) = 17-item Index of Fidelity to Assertive Community Treatment scale

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TREATMENT ACT TEAM STANDARD TREAT.

• 1:10

• Weekly

• Home

• Yes

• Generally

• Yes

• 1:20 / 1:30

• Varies

• CMHC

• No

• No

• No

Case load

Staff

Frequency of contact

Place of visits

Contact at hospital

Crisis plan

Contact outside office hours

PsychiatristPsychologistPsychiatric nurseSocial workerOccupational therapist

Psychiatrist Psychiatric nurse (Social worker)

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Results

Level 1 (Registerdata)

Level 2 (Medical Records)

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ACTn=213

CONTROLn=153

P value of Difference

Male 126 (59) 95 (62) 0.7

Mean (SD) age (years) 42,6 (11) 43,5 (11) 0.4

Ethnicity other than Danish 62 (29,1) 37 (24,2) 0.4

Completed high school education 40 (20) 35 (23) 0.4

Having children 64 (33) 52 (36) 0.7

Living conditions

Married or living with partner 26 (13) 15 (10) 0.4

Living independently 163 (78) 119 (78) 0.3

Living in supervised setting 10 (5) 6 (4) 0.3

Living with parents or family 12 (6) 15 (10) 0.3

Homeless 25 (12) 12 (8) 0.3

Sociodemographic characteristics at baseline

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Clinical characteristics at baseline

ACTn=213

CONTROLn=153

P value of Difference

Social functioning GAF function 34,21 (10,5) 34,99 (10,9) 0.52

Health service use

Mean (SD) days in hospital Mean (SD) days of involuntary admission

48,4 (71,9)

23,2 (45,8)

44,6 (71,2)

30,4 (60,8)

0.84

0.03

Diagnosis

Schizophrenia

Other

198(95)

9 (4)

142 (93)

10 (6)

Comorbidity:Substance abuse 118 (57) 72 (47) 0.07

Level of Drug dependence Mean DTES (SD) 3,71 (2,6) 3,23 (2,5) 0.10

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Clinical outcomes at 2 year follow-up

ACTn=213

CONTROLn=153

P value of Difference

Health service use Mean (SD) days in hospital Mean (SD) days of Involuntary admission

16 (43,8)

5,3 (20,3)

36,8 (69,9)

18,1 (44,8)

0.00

0.00

Level of Drug dependence: Mean DTES (SD) Difference from DTES score at inclusion

3,57 (2,5)

-0.19 (2,1)

3,55 (2,6)

0,25 (2,0)

0.54

0.06

Social functioning GAF (function) 38,47 (10,8) 35,15 (10,8) 0.01

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Results

Level 3 (Patient Interviews)

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Interviews

Are mentally ill people a credible source of information?– Drop out– Missing data – Ambigious reply’s

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Place of Interviews

57%

17%

9%

17%Home ofPatient

TreatmentCenter

ResearchOffice

Other

N = 183

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User satisfaction and quality of life

ACTn=101

CONTROLn=86

P value of Difference

User satisfactionClient Satisfaction Questionnaire

24,25 (5,86) 21,89 (5,27) 0.01

Quality of LifeMANSA*

57,12 (11,85) 55,96(9,75) 0.57

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Do patients experience the assertive approach in the two Danish ACT teams as coercive?

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Preliminary Results: Experience of CoercionDo you experience that: • That you can make yourself

understood in relation to your case manager?

• That your case manager respects your rights as a patient and keeps his/her confidentiality?

• That you can ask your case manager to leave, during home visits, if you want him/her to leave?

12 Qualitative Interviews

5.

1.

2.

3.

4.4-5 = Yes

3 = Neutral

1-2 = No

No, Definitely not

Yes, definitely

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Does your case manager respect your rights as a patient and keep his/her

confidentiality?

0102030405060708090

100

ACT Team Control

Yes (4-5)

Neutral (3)

No (1-2)

% o

f to

tal

N= 149 P= 0,54

200

10

20

30

40

50

60

70

80

ACT Team Control

Yes (4-5)

Neutral (3)

No (1-2)

Can you make yourself understood in relation to your case manager?

N= 165 P= 0,056

% o

f to

tal

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Can you ask your case manager to leave during home visits, if you want him/her to

leave?

0

10

20

30

40

50

60

70

80

ACT-Team

Yes (4-5)

Neutral (3)

No (1-2)

% o

f al

l

0102030405060708090

Danish Ethnicbackgroundother than

danish

Yes (4-5)

Neutral(3)

No(1-2)

N= 70/96 P= 0,000**

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Patient experiences of medication

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Have you taken antipsychotic medication within the last year?

0

10

20

30

40

50

60

70

80

90

100

ACT Team Control

Yes

No

N= 165/183 P= 0,375

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Can you decide for yourself, whether or not to take your medication?

0

10

20

30

40

50

60

ACT Team Control

Yes

No

N= 152/183 P= 0,035*

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In your opinion, does your case manager encourage you to get started with some of the

things you would like to do?

0

10

20

30

40

50

60

70

80

90

ACT team Control

Yes

No% o

f to

tal

N= 145 /183 P= 0,020*

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In your opinion, is your Case Manager a collaborator?

0

10

20

30

40

50

60

70

80

90

100

ACT Team Control

Yes

No

N= 156 /183 P= 0,009*

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Is the ACT model effective

in a contemporary Danish

psychiatric setting?

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In the light of the

results from this study,

the answer seems to be yes.

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CONCLUSION

Signficantly fewer days spendt at hospital

Significantly fewer days of involountry admission

Significantly higher level of social functioning (GAF)

Signficiantly higher improvement in level of drug abuse (DTES)

Significant higher level of user satisfaction

At 2 year follow-up,patients in the ACT teamswere characterised by:

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CONCLUSION - continued

Patients do not experience the assertive outreach in the Danish ACT Teams as coercive - the contrary appears to be the case

Patients in the ACT Teams experience a higher degree of influence on medication

Danes with other ethnic background differ significantly in their experience of coercion

The patient perspective is important

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Thank you for your attention.

Good Afternoon!

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Ethical Dilemma

Paternalism: Autonomy:

Hippokrates: to do what the doctor considered good for the patient

with or without accept from the patient

to give priority to patient’s autonomy

even if it was harmful to patient’s health

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2 year follow up, 1*, 2*+3*

Baseline 1* + 2* Baseline 1* + 2*

ACT Group 1n = 121

ST Group1n = 86

ST Group 2n = 67

ACT Group 2n = 92

Dropout-2level 1: n =8level 2: n =16

level 3: n =110

Dropout-2level 1: n =5

level 2: n =20level 3: n =66

Dropout-1level 1: n =1level 2: n=12

ExcludedPt’s

N = 9

Excluded Pt.'s.1N = 5

Excluded Pt.'s.1N = 2

Excluded pt.'s.1N =3

Dropout-1level 1: n =2level 2: n=15

2 year follow up, 1*, 2*+3*

ACTN = 213

CONTROLN = 153

assesmentassesment

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Average length of meetings with case manager

0

10

20

30

40

50

60

70

80

ACT Team Control

≤ 10 min.

½-1 hrs.

≥ 1.5 hrs.

N= 183 P= 0,000**

% o

f to

tal

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Frequency of meetings with case manager

0

10

20

30

40

50

60

ACT Team Control

≤1 month

1 month

2-3 week

1 week

>1 week

N= 183 P= 0,000**

Number of times per week /month

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Does your Case Manager think that you can not get on without his/her help?

0

10

20

30

40

50

60

70

80

90

ACT- team Control

Yes

No

N= 134 /183 P= 0,022*