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Aims: The beneficial effects of assertive community treatment (ACT), which has been widely acclaimed as being successful in several foreign countries, must also be objectively evaluated with respect to the transition from inpatient to community-based mental health treatment in Japan. This was the first study that examined effects of the ACT program in Japan using pre/post design data of the pilot trial of the ACT program in Japan project.
Methods: The study included 41 subjects hospitalized at Kohnodai Hospital, National Center of Neurology and Psychiatry between May 2003 and April 2004 for severe mental illness and who met inclusion criteria for entry regarding age, diagnosis, residence, utilization of mental health services, social adjustment, and ability to function in daily activities. All subjects provided informed consent for study participation and were followed for 1 year after hospital discharge.
Results: Comparison of the number of days and frequency of inpatient psychiatric hospitalization and frequency of emergency psychiatric visits between the 1-year period before hospitalization and 1-year period after hospital discharge showed a significant decrease in number of days and frequency of hospitalization. Comparison at 1 year after discharge with baseline showed no change in satisfaction with overall quality of life or Brief Psychiatric Rating Scale scores, but the Global Assessment of Functioning score significantly increased, and the antipsychotic dose (chlorpromazine equivalent) significantly decreased.
Conclusion: Despite some limitations in methodology and conclusions, this study suggests that ACT enables persons with severe mental illness to live for longer periods in the community, without worsening of symptoms, decreased social function, or deterioration in quality of life.
COMMUNITY MENTAL HEALTH care in Japan is undergoing a transition from hospital-based to community-based care. We are now in an era of evidence-based medicine emphasizing scientific principles. Assertive community treatment (ACT) programs, with deinstitutionalization of care, have been successful in other developed countries and have now been introduced in Japan with the hope of promising results.
ACT is a community-based program to help patients with severe mental illness who have required frequent or lengthy hospitalizations to live a decent life outside a hospital setting. Staff members comprise a team of experts in various disciplines that visit patients to provide most services. ACT is an intensive and comprehensive care management model to help persons with mental illness live in the community. Stein et al. have shown that an ACT program in the state of Wisconsin in the USA has significantly decreased hospital stays, stabilized living conditions, and increased satisfaction with services provided.1,2 Based on this success, several countries have introduced ACT programs into their community mental health care systems.3–12
This paper reports the beneficial effects experienced by patients in the pilot stage of the first ACT model program in Japan (ACT-J) started in May 2003 in the region covered by the Kohnodai Hospital National Center for Neurology and Psychiatry.
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As shown in Table 2, all the values decreased. For number of days and frequency of inpatient hospitalization, the Wilcoxon signed rank test showed significant changes.
Table 2. Values of outcome measures at 1 year after discharge compared with those at 1 year before hospitalization
|Outcome measure||1 year before hospitalization||1 year after hospital discharge||Z value||P|
|No. of days of inpatient hospitalization||115.95||102.76||56.66||98.42||−3.25||0.001|
|Frequency of inpatient hospitalization||1.68||1.64||1.27||2.04||−2.12||0.034|
|Frequency of emergency psychiatric visits||3.20||7.16||1.85||3.71||−1.45||0.147|
Table 3 compares other outcome results between baseline and 1 year after hospital discharge. The Wilcoxon signed rank test showed significant changes in GAF, BPRS positive and negative symptoms, and CP equivalent. For other BPRS and drug-therapy-related parameters, there were no significant changes. The mean scores on the QOLI (scale of 1–7) for life satisfaction were similar at baseline and after 1 year, with no significant changes.
Table 3. Values of outcome measures at 1 year after discharge compared with those at 2 weeks after discharge
|Outcome measure||2 weeks after hospital discharge||1 year after hospital discharge||Z value||P|
|GAF (n = 38)||46.66||8.15||50.11||6.62||−3.06||0.002|
|BPRS score (n = 37)||16.05||6.39||16.35||7.05||−0.17||0.87|
|BPRS positive symptoms (n = 37)||5.41||3.63||6.73||3.60||−2.51||0.012|
|BPRS negative symptoms (n = 37)||3.03||2.90||2.03||2.66||−2.91||0.004|
|BPRS manic (n = 37)||0.22||0.63||0.41||0.69||−1.54||0.124|
|BPRS mood (n = 37)||5.11||2.40||4.84||2.50||−0.74||0.459|
|BPRS hypochondriasis (n = 37)||2.38||1.46||2.43||1.43||−0.03||0.975|
|QOLI overall satisfaction (n = 37)||4.05||1.61||4.07||1.68||−0.27||0.789|
|No. of psychotropic drugs||5.15||2.04||5.00||2.31||−0.63||0.53|
|No. of antipsychotic drugs||1.90||0.89||1.83||0.95||−0.55||0.58|
Comparison of employment status showed that during the 1-year period before baseline, three persons were regularly employed (defined as at least 5 h per week, at least minimum wage, in a public workplace), and two were engaged in social work activities. At 1 year after hospital discharge, four persons were regularly employed (defined by the conditions above), three were employed (but hours and salary did not meet above conditions), one was attending school, and one was engaged in social work activities.
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Previous ACT studies, primarily conducted in the USA, have demonstrated beneficial results, including a reduction in the number of days of inpatient hospitalization, an increase in client satisfaction with services, and a more stable living situation.11,12
This ACT-J pilot study also showed a significant reduction in number of days and frequency of inpatient psychiatric hospitalization at 1 year after index hospital discharge. It may be premature to speculate about the relation between decrease in number of days of hospitalization and effects on quality of life. However, the outcome results in this study suggest stabilization of psychiatric symptoms, a similar level of quality of life, and a small but significant improvement in social functioning. In addition, the number of patients engaged in regular employment tended to increase, and the dose of medication required (CP equivalent) significantly decreased. Therefore, our findings suggest that ACT can reduce the utilization of inpatient psychiatric care without degrading quality of life of patients living in the community.
It seems difficult to completely deny the existence of a relation between the exacerbation of positive symptoms in BPRS and the significant CP equivalent decrease at 1 year after index hospital discharge. However, the correlation coefficient between the difference in the BPRS score baseline and after 1 year and the difference in the CP equivalent dose baseline and after 1 year was low (Spearman: −0.187) and not significant (P = 0.268). Furthermore, the exacerbation of positive symptoms was not unexpected due to the definition of baseline (2 weeks post-hospital-discharge), the relatively low BPRS positive symptoms score baseline (5.41) and the patient characteristics (frequent users of psychiatric care).
In contrast, the activities of the ACT team, which included frequent medical assessment outreach services to support users living independently, and direct emotional support for relatives, might have led to the reduction in the major tranquilizer dose, which was administered to sedate psychomotor excitation due to ‘high expressed emotion’ in the families.
In addition, the BPRS indicated significant exacerbation of positive symptoms and improvement of negative symptoms. This suggests that ACT services may have some ‘activation effects’ on patients. It is possible that this is due to some sort of stimulus, such as assertive outreach and social support.
During the 1-year period after hospital discharge, there were few patients who participated in social work activities, such as day care treatment and sheltered workshops. One reason for this is because our entry criteria focused on patients who were originally reluctant to use traditional rehabilitation facilities. Another reason is because the clinical philosophy in ACT, such as ‘recovery’ and ‘strength model’, emphasizes the importance of competitive employment rather than pre-employment training.
The all-around cost for ACT is not significantly cheaper than that of inpatient care, because of the intensive support for each patient.17 Therefore, this model focuses on the care of patients with severe mental illness, and specific entry criteria have been established. These criteria should also reflect the target goals of each ACT team, such as support for dual diagnosis patients. In conducting the ACT program on a research basis, we realized that Kohnodai Hospital is a general public hospital that serves the community in providing emergency psychiatric care and treatment of complications in a minimum number of inpatient days, and that by focusing on patients requiring long-term hospitalization, it might not be possible to recruit a sufficient sample size. Therefore, patients with severe mental illness who required frequent readmissions due to severe symptoms were considered for the study. To target patients with severe mental illness who were frequent users of psychiatric care, we selected patients hospitalized at Kohnodai Hospital at the time of program entry, and we also established inclusion criteria that had to be met regarding frequency of use of psychiatric services, social adjustment, and ability to function in daily activities.
Patient characteristics in this study included a relatively young mean age (in their 30s) and the fact that about 70% lived with their families. As compared to long-term patients of middle age with parents who have already died, this indicated more patients needing family support. Reports of ACT programs overseas have also emphasized family support.18 This suggests that when targeting high users of psychiatric care, family support of patients must be taken into consideration in establishing ACT programs in Japan.
The baseline survey indicated relatively good results for the BPRS, GAF, and QOLI. The mean BPRS score was low at 16 and the mean GAF score was relatively high at 46. In selecting patients with frequent hospitalizations, the inclusion criteria may have reflected medication or treatment discontinuation, thus resulting in the registration of many patients whose symptoms tended to improve even with relatively short hospitalization.
In addition, more so than the effects of inpatient treatment, this study was designed to evaluate the effects of ACT when the patient is living in the community. The baseline for resumption in community life was defined as 2 weeks after hospital discharge. Thus, when the patients were evaluated, they already had some improvement in psychiatric symptoms and ability to function in society. This factor probably contributed to the relatively good results on baseline evaluation.
The high overall life satisfaction indicated by the QOLI probably reflects the added relief felt by patients in being able to leave the hospital. The fact that ACT case managers began a relationship with patients while still in the hospital to assist them in living independently after hospital discharge probably also had an effect, although that is just an inference. Detailed analysis of the effects of ACT on patients while still hospitalized is an issue for further investigation in a controlled study.
The results of this study require careful interpretation in light of a before and after comparison without a control group, a relatively small number of patients analyzed for treatment effects, and the special clinical conditions under which the study was conducted by a project team.19
However, even with a sample size of about 40 patients, there was a reduction in number of inpatient days, which was statistically significant at a level of 1%. For patients enrolled in this study, during the 1-year period prior to ACT entry, the mean number of days of hospitalization was about 120, and the mean number of hospitalizations was slightly less than 2. This indicates a group of patients with episodes of symptoms requiring inpatient treatment about once every 6 months. The good outcomes 1 year later, including improved social functioning and decreased CP equivalent, are probably not merely due to the spontaneous course of disease after hospital discharge, but also due to the beneficial effects of ACT intervention.
This paper has reported outcomes in patients at 1 year after hospital discharge in an ACT-J pilot study. The methodology of this study as a before and after comparison has some limitations, but our findings suggest that ACT can reduce the utilization of inpatient psychiatric care without degrading the quality of life of patients living in the community. Further investigations should be conducted to confirm the beneficial effects of the ACT program model.