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Feasibility and usefulness of training assertive community treatment team in CBT
This article evaluated the impact of training one ACT team in CBT techniques. This retrospective study found an ACT team who was trained in CBT would utilize CBT interventions with their clients, even after training. However, CBT interventions did not increase medication adherence or result in reductions in crisis visits and hospitalizations. Staff reported that the training was helpful in helping them better understand clients’ problems, increasing their self-confidence in dealing with clients’ problems, and improving their interventions with clients. However, they also identified several barriers to the use of CBT interventions, and these were: (a) the change in individual caseloads for some team members over time, (b) having to play multiple roles, such as driving, being an advocate, helping with shopping, and being a therapist, and (c) having to deal with crises and unexpected issues and not being able to focus on one problem. Another challenge mentioned was that clients had multiple needs and different team members were addressing different needs and this interfered with the continuity of therapy. The ACT psychiatrist and certified cognitive therapist, trained the rest of the ACT team in CBT techniques. Training consisted of 13 h of didactic and experiential training spread over a 6-month period. The training was based upon an unpublished CBT manual for case managers. The didactic training consisted of introduction to cognitive theory, cognitive case conceptualization, adapting cognitive therapy for SMIs and incorporating techniques into routine practice. The experiential training included learning various techniques, such as Socratic questioning, identifying and enhancing coping skills for positive psychotic symptoms, role-playing, and cost-benefits analysis. In addition to the didactic training, individual supervision was provided as needed and amounted to an hour every 2 weeks during the course of the study period.
Pinninti, N.R., Fisher, J., Thompson, K., & Steer, R. (2010). Feasibility and usefulness of training assertive community treatment team in cognitive behavioral therapy. Community Mental Health Journal, 46, 337-341. doi: 10.1007/s10597-009-9271-y
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Assertive community treatment and the physical health needs of persons with severe mental illness: issues around integration of mental health and physical health.
This article involves a qualitative study that included five ACT teams and the level that they integrate mental health and physical health. The results of this qualitative study show three main themes (1) all ACT teams recognized serious and chronic physical health problems among consumers they served, (2) ACT teams took a variety of roles to address the physical health problems of their consumers, and (3) there were a number of challenges to integrating primary and mental health care within an ACT setting. The main conclusion is that ACT is well positioned to integrate physical health and mental health care and ACT staff expressed the need, desire, and willingness to integrate physical health care with mental health care.
Shattell, M., Donnelly, N., Scheyett, A., & Cuddeback, G. (2011). Assertive community treatment and the physical health needs of persons with severe mental illness: Issues around integration of mental health and physical health. Journal of the American Psychiatric Nurses Association, 17 (1), 57-63. doi: 10.1177/1078390310393737
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NPACT: Enhancing programs of assertive community treatment for the seriously ill.
This two-group community comparison design study examines the impact on psychiatric and physical outcomes through enhancing a standard Program of Assertive Treatment (PACT) with Advanced Practice Psychiatric Mental Health Nurses (APNs) and stabilized consumer peer providers (NPACT). Evaluations were conducted at baseline and at 6 months to assess six outcome variables: psychiatric symptoms, community adjustment, disability, physical symptoms, health promotion orientation, and consumer satisfaction. Significant improvements over time were demonstrated for both groups on all variables. However, treatment effects for NPACT over PACT were demonstrated for psychiatric symptoms, community functioning, and consumer satisfaction. NPACT subjects endorsed more medical problems at baseline than did PACT subjects. This may be due to subjects being more likely to disclose physical health symptoms to nurses. In conclusion, enhancements for PACT using advanced practice nurses and consumer peer providers have the potential to address both health and mental health problems of the seriously mentally ill.
Kane, C.F., & Blank, M.B. (2004). NPACT: Enhancing programs of assertive community treatment for the seriously ill. Community Mental Health Journal, 40 (6), 549-559.
Assertive community treatment: Evidence based hope for the seriously mentally ill.
This editorial summarizes the overall evidence of ACT, including a paragraph about primary care (i.e., access to primary care and early evidence-based studies that describe the scope of the problem) . The overall conclusion of the editorial is that there is hope for those suffering from serious mental illness with ACT.
Rice, M.J. (2011). Assertive community treatment: Evidence based hope for the seriously mentally ill. Journal of the American Psychiatric Nurses Association, 17(1), 13-15. doi: 10.1177/1078390310396708
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The inextricable nature of mental and physical health: Implications for integrative care.
This article provides evidence that physical health problems are caused and exasperated by psychological factors and psychological distress leads to physical disease. It argues that new approaches are needed to assure adequate professional knowledge of behavioral health at basic licensure, to increase the use of advanced practice psychiatric–mental health nurses in primary care set¬tings, to identify and teach behavioral competencies for primary care providers, and to fund the design and evaluation of integrative models of care.
Weiss, S., Haber, J., Horowitz, J., Stuart, G., & Wolfe, B. (2009). The inextricable nature of mental and physical health: Implications for integrative care. Journal of the American Psychiatric Nurses Association, 15(6), 371–382. doi: 10.1177/1078390309352513
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Program fidelity in Assertive Community Treatment: development and use of a measure.
Describes the development of the Dartmouth Assertive Community Treatment Scale (DACTS) and the results of applying it to 50 diverse programs.
Teague, G. B., Bond, G. R., & Drake, R. E. (1998). Program fidelity in Assertive Community Treatment: development and use of a measure. American Journal of Orthopsychiatry, 68, 216-232.
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Cognitive behavioural therapy for major psychiatric disorder: does it really work? A meta-analytical review of well-controlled trials.
This meta-analytical review of the CBT for major psychiatric disorders states that although cognitive behavioural therapy (CBT) is claimed to be effective in schizophrenia, major depression and bipolar disorder, there have been negative findings in well-conducted studies and meta-analyses have not fully considered the potential influence of blindness or the use of control interventions. In the current meta-analysis it found that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates.
Lynch, D., Laws, K. R., & McKenna, P. J. (2010). Cognitive behavioural therapy for major psychiatric disorder: does it really work? A meta-analytical review of well-controlled trials. Psychological medicine, 40(01), 9-24. doi:10.1017/S003329170900590X
From the hospital to the community: a shift in the primary locus of care.
A community-based mental health team assertively providing a variety of support services to both the patient and the community can effectively treat the patient, substantially reduce use of the hospital, and virtually eliminate the revolving-door syndrome
Stein, Leonard, I., and Test, Mary Ann. (1979) From the hospital to the community: a shift in the primary locus of care. New Directions for Mental Health Services, 1, 15-32.
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Cost-effectiveness of Assertive Community Treatment versus standard case management for persons with co-occurring severe mental illness and substance use disorders.
Examines the cost-effectiveness of ACT in comparison to standard case management.
Clark, R. E., Teague, G. B., Ricketts, S. K., Bush, P. W., Xie, H., McGuire, T. G. et al. (1998). Cost-effectiveness of Assertive Community Treatment versus standard case management for persons with co-occurring severe mental illness and substance use disorders. Health Services Research, 33, 1285-1308.
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Assertive Community Treatment Literature Review.
Provides a detailed overview of ACT and the outcomes associated with the evidence-based practice. The implementation issues are also discussed in great detail, with particular attention to issues related to staffing, financing, and geographical differences in implementing ACT.
Linkins, K., Tunkelrott, T., Dybdal, K., & Robinson, G. (2000, April 28). Assertive Community Treatment Literature Review. Falls Church, VA: Lewin Group, Inc.
Assertive Community Treatment: An update of randomized trials.
Reviews outcomes of randomized controlled trials of ACT including studies of special populations (i.e., homeless, dual diagnoses).
Burns, B. J. & Santos, A. B. (1995). Assertive Community Treatment: An update of randomized trials. Psychiatric Services, 46, 669-675.
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Moving Assertive Community Treatment into standard practice
Describes ACT, summarizes its effectiveness for different client populations, and discusses cost effectiveness. This article also discusses the critical components of ACT and how it has been adapted locally. Additionally, the authors outline issues that mental health system administrators, ACT staff, and consumers are likely to face when implementing ACT.
Phillips, S., Burns, B., Edgar, E., Mueser, K. T., Linkins, K. W., Rosenheck, R. A. et al. (2001). Moving Assertive Community Treatment into standard practice, Psychiatric Services, 52 (6), 771-779.
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Economic impacts of Assertive Community Treatment: A review of the literature.
Focuses on economic impact of ACT on hospital use, emergency-room use, use of outpatient services, housing costs.
Latimer, E. (1999). Economic impacts of Assertive Community Treatment: A review of the literature. Canadian Journal of Psychiatry, 44, 443-454.
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Assertive Community Treatment for people with severe mental illness: Critical ingredients and impact on patients.
Summarizes the results of 25 studies of the effectiveness of ACT. Includes information on cost-effectiveness and fidelity.
Bond, G. R., Drake, R. E., Mueser, K. T., & Latimer, E. (2001). Assertive Community Treatment for people with severe mental illness: Critical ingredients and impact on patients. Disease Management & Health Outcomes, 9, 141-159.
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Cost effectiveness of intensive psychiatric community care for high users of inpatient services.
Evaluates the costs of 10 intensive psychiatric community care programs at U.S. Department of Veterans Affairs medical centers in the northeastern United States.
Rosenheck, R., & Neale, M. (1998). Cost effectiveness of intensive psychiatric community care for high users of inpatient services. Archives of General Psychiatry, 55, 459-466.
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