Psychiatric Services
Psychiatric Services July 1995 Vol. 46 No. 7 669
Assertive Community Treatment: An Update of Randomized Trials
BarbaraJ. Burns, Ph.D. Alberto B. Santos, M.D.
Objective: Results of randomized
clinical trials of assertive commu-
nity treatment for seriously men- tally ill patients published be-
tween 1 990 and 1994 are reviewed to synthesize the state of knowledge
about this research and to clarify
continuing research directions. Methods: Randomized trials of in-
terventions that used treatment principles and practices consistent with the Program for Assertive Community Treatment model or
close adaptations whose results were published since 1990 were identi-
f ied by literature searches using MEDLINE and PsychLit and by
contact with investigators of ongo-
ing trials. Results: Controlled
clinical trials have been conducted with a wide range ofseverely men-
tally illpopulations, including pa-
tients in Great Britain, patients
with recent-onset schizophrenia,
veterans, dually diagnosed clients, and homelesspersons. Methodologi- cal improvements in some studies include increased attention to
Dr. Burns is professor in the de- partment of psychiatry and be- havioral sciences at Duke Univer- sin, Medical Center in Durham, North Carolina. Dr. Santos is pro- fessor in the department of psy- chiatry and behavioral sciences at the Medical University of South Carolina in Charleston. Address correspondence to Dr. Burns at Box 3454, Duke University Medi- cal Center, Durham, North Caro- lina 27710. This paper is part of a special section highlighting re- cent research on assertive com- munity treatment programs.
monitoring the experimental and
comparison interventions, as well
as larger sample sizes and longer duration oftbe clinical trials than in earlier efficacy trials. Strong
positive effects ofassertive commu- nity treatment on hospital days
and on patient and family satis-
f action werefound. Gains infunc- tional outcomes, such as employ- ment, may require interventions
specifically targeted to these out- comes. Conclusions: Questions
about the role ofassertive commu- nity treatment as time-limited treatment, as an adjunct to other
services and treatment, or as a com-
prebensive and continuous service
system for adults with severe men-
tal illness require further research. The growing research base should
provide valuable information on
costs, outcomes, and indications for
assertive community treatment
that can be evaluated by policy-
makers. (Psychiatric Services 46:
669-675, 1995)
The cycling of persons with severe mental illness between inpatient and outpatient settings and providers in the 1960s and early 1970s led clini- cians and investigators to develop a model for continuous, comprehen-
sive, and highly flexible community care (1). Known as the Program for Assertive Community Treatment (PACT), this model calls for provi- sion of a full range of medical, psy- chosocial, and rehabilitation services
by a community-based team that op-
erates seven days a week, 24 hours a day.
The care envisioned by the PACT model is much like hospital-based treatment but is intended to be con- tinued on a long-term basis, so that patients do not lose the benefits of treatment due to changes in settings
or providers or due to inadequate fol- low-up. Missed aftercare appoint- ments are avoided because the com- munity-based team provides out- reach and care adapted to patients’ changing needs. The model’s aggres- sive approach to symptom reduction and relapse prevention is intended to help patients with severe mental ill- ness become reintegrated into the community, to increase their ability to live independently, and to im- prove their quality oflife and that of their families. Patients learn living skills in naturalistic settings rather than in artificial settings such as hos- pitals or sheltered workshops, in- creasing the likelihood that these skills will survive.
The PACT approach is often re- ferred to in the research literature and in state mental health programs as Training in Community Living (2), continuous treatment teams (3),
and assertive community treatment (ACT) (4). Research has been a ball-
mark ofthe development of assertive community treatment programs based on this model.
The initial studies of the PACT model in Madison, Wisconsin, were designed as randomized clinical tn- als, allowing comparison of out- comes for clients who received asser- tive community treatment with those for clients who received the community’s standard hospital and aftercare services ( 1 ,5-7). The PACT approach demonstrated benefi ts in clinical status, independent living, social functioning, employment status, medication compliance, and quality oflife, as well as reduced use of inpatient services and cost-effec- tiveness (1 ,5 ,6). Further, the burden on families and society associated with assertive community treatment was no greater than that associated with the control conditions (7). These early studies set the standard
670 Psychiatric Services July 1995 Vol. 46 No. 7
Table 1 Recent studies involving randomized trials ofassertive community treatment and their outcome findings
Study popula- tion or focus Study
Outcome
Clinical status
Functional status
Social Work
Inde-
pendent living
Satisfac-
tion with services
Reduced
hospital use
Lower costs
Great Britain Marks et al. , 1 994 (1 8) + + – nr + + nr Great Britain Audini et al., 1994 (19) – nr + – nr Great Britain Merson et al., 1992 (20) + – nr nr + + nr Patients with Test, 1992 (2) nr nr nr + nr + nr
recent-onset schizophrenia
Veterans Rosenheck et al. , 1 994 (23)
+ + – + + + +
Homeless persons Morse et al., 1992 (27) – – nr + + nr nr Dually diagnosed Bond et al., 199 1 (3 1) – nr nr nr nr – nr
clients Assertive commu- McFarlane et al., 1992 + nr + nr nr – nr
nity treatment (35) with family psychoeducation
+ = Evidence ofstatistically significant benefit in flivor ofassertive community treatment or experimental intervention (p<.O5)
– = No evidence ofstatistically significant benefit in fiuvor ofassertive community treatment or experimental intervention
nr = Outcome not reported
for both the operational elements of the intervention and the research methods for subsequent clinical tn- als, including measurement of a range ofclinical and functioning do- mains, service utilization, and costs.
Assertive community treatment is the only full-service intervention for persons with severe mental illness that has been tested in multiple ran- domized clinical trials. In addition to the early efficacy trials conducted in Wisconsin ( 1 ,5-7), and the Austra- han study by Hoult and colleagues reported in 1983 (8), three addi- tional controlled trials had been completed in the United States by 1990 (9-1 1). Numerous other ran-
domized clinical trials are now under way (12).
Two pivotal reviews ofresearch on assertive community treatment have been completed, one by Olfson (13) in 1990 and a second by Test (2) in
1992. Based on somewhat mixed findings in replications of PACT outside Madison, Olfson concluded that further research was needed to identify conditions under which pa- tients receiving assertive community treatment might achieve superior outcomes.
Although Test acknowledged the
extensive empirical support for asser- tive community treatment, she cx- pressed concern about the future of
this intervention within the broader
system of community-based care.
She found that studies of programs viewed as adaptations of the PACT model-for example, the Bridge’s
adaptation in which clients used other mental health services instead ofthose provided directly by a single team ( 1 0, 14)-showed fewer favor-, able psychosocial outcomes than did
studies of the original program. Test is currently conducting a 12-year
prospect ive controlled study, com- paring use ofassertive community
treatment as a self-contained system
of care and its use as one of many
components in a well-integrated sys- tem ofcare, with both conditions of-
fening high-quality clinical and reha- bilitative services.
The issues identified by Olfson
and Test-the need to determine de-
sired functional outcomes of asser-
tive community treatment and the place of assertive community treat- ment within a system of care-were used to focus this review ofreports of randomized trials of assertive corn- rnunity treatment that have been
published since 1990. These trials were identified by literature searches using MEDLINE and PsychLit and by contact with investigators known to be conducting such studies (12).
We included studies of programs that were consistent with assertive community treatment principles and practices or that were close adap- tations, such as the Bnidge model.
Recent randomized trials Randomized clinical trials of asser- tive community treatment that were published since previous reviews (2,4,13) used methods similar to
those used in earlier studies but in- cluded a wider variety of popula- tions. Recent studies have examined use of assertive community treat- ment in Great Britain and with sub- groups of patients with severe men- tal illness in the U.S., including pa- tients with recent-onset schizophre- nia, veterans, dually diagnosed cli- ents, and inner-city homeless per- sons. In addition, integration of in- novative adjunctive treatments, such as family psychoeducation, into as- sertive community treatment has been studied. Table 1 presents se- lected findings from these recent studies.
Psychiatric Services July 1995 Vol. 46 No. 7 671
Great Britain. In one 20-month trial in London, 189 patients facing emergency hospital admissions were randomly assigned to assertive corn-
munity treatment or to standard hospital and community care (15- 1 8). Significant differences favoring assertive community treatment were found for symptoms, social function- ing, and patient and family satisfac- tion. Further, reduced inpatient days
were reported during the 18-month follow-up, when the assertive com-
munity treatment team had control over hospital admissions and dis- charges. Patients who received asser- tive community treatment spent fewer days in the hospital. Neverthe- less, no differences were found be- tween costs for assertive community treatment and standard care.
These patients were followed in a longer-term study spanning 45 months. Patients who had formerly
received assertive community treat- nient were randomly assigned to continue that treatment or to receive standard care. Patients originally as- signed to standard care were also fol- lowed. The study found few differ-
ences in favor ofassertive community treatment, with the exception of in- creased family and patient satisfac- tion (19). Lack ofmore robust results was associated with poor staff morale
and reduced staff resources, a conse- quence of extensive publicity sun- rounding several unfortunate events, including suicides and a murder by patients in assertive community treatment (although suicide oc- curred at a similar rate among other patient groups). Thus the promising results through 20 months of follow- up were not sustained in the longer follow-up period, during which the capacity of assertive community treatment teams was severely ham- pered.
In a second British study, 100 pa- tients presenting to a psychiatric emergency service were randomly as- signed to an ACT-like team, de- scribed as such because 24-hour cov- erage was not provided, or to the usual hospital-based services. After three months of treatment, patients assigned to assertive community treatment showed greater improve- ment in symptoms, more satisfaction
with services, and fewer hospital days, an average of 1 .2 days versus 9.3 days for patients in the control
group. There was no experimental
effect for social functioning at the three-month follow-up. Noteworthy in this study was the difference be- tween groups in loss to follow-up- three of48 patients in the assertive community treatment group corn- pared with 1 5 of 5 2 in the control
group-and the limited clinical in- tensity ofassertive community treat-
ment, with contacts averaging less than one a week (20).
Recent-onset schizophrenia. Pre- liminary findings from Test’s 12-year prospective controlled study of asser- tive community treatment in Wis- consin have been reported (2). The
study includes 115 young adults with recent-onset schizophrenia or related disorders.
Unlike earlier studies in this set- ting, in which the control condition
was usual hospital and community aftercare, patients in the control
group in this study receive services from the Dane County mental health
agency, nationally recognized as a progressive and well-integrated sys- tern of care. The agency’s service components include psychosocial day programs, a medication clinic, a 24-hour mobile emergency service, and an ACT-like team that is used with discrimination for patients who
drop out of treatment (2 1 ). Consis- tent with earlier findings, Test’s pre- liminary findings suggest that over’a two-year period patients in assertive community treatment had fewer hospital days (5.24 days, compared
with 44. 17 for patients in the control group), a lower rate ofhospital ad- missions (19.4 percent compared with 56.1 percent), and more time living in an apartment and less time living with family members.
Veterans. Rosenheck and col- leagues (22,23) conducted the larg- est randomized study of assertive community treatment to date, in- volving nearly 1,000 frequent users of inpatient services at ten Veterans Affairs (VA) sites in the Northeast. Subjects were assigned on discharge to assertive community treatment or to standard aftercare and were fol- lowed for two years. The sample in-
cluded patients in neuropsychiatric hospitals who had a history of either 180 hospital days in the previous
year or four or more psychiatric ad- missions and patients in general
medical and surgical hospitals who
had 40 or more hospital days in the previous year or two or more pre- vious psychiatric ad�nissions.
The major findin�s were in the ar- eas ofutilization of inpatient services
and hospital costs. Patients in asser- tive community treatment used an
average of89 days ofinpatient treat- ment over the two-year period, one-
third less than the control group. The average total cost ofcare, includ- ing inpatient and outpatient 5cr-
vices, was 20 percent less for patients in assertive community treatment.
Cost savings were associated with assertive community treatment for patients discharged from neuropsy- chiatric hospitals. However, costs in-
creased for the less chronic patients assigned to assertive community treatment after discharge from gen-
era! medical and surgical hospitals. These patients typically had used
much less inpatient care than those discharged from neuropsychiatnic hospitals and thus had accrued lower costs for care before the study began. Comparisons among subgroups of patients in assertive community treatment showed lower costs for two subgroups-veterans over 45
years old and veterans with higher levels of previous use of inpatient
services. Client-level outcomes differed
slightly by the type of hospital from which patients had been discharged. Patients in assertive community treatment discharged from both types ofhospitals reported more days in independent living situations and were more satisfied with services. Among patients discharged from general medical and surgical hospi- tals, patients in assertive community treatment differed from patients in the control group in reduction of anxiety and depression symptoms, total Brief Psychiatric Rating Scale score, and increased community skills.
With its large sample size and ample power to test differences, this study provided strong evidence of
672 Psychiatric Services July 1995 Vol. 46 No. 7
the effectiveness ofassertive commu- nity treatment in reducing use of in-
patient services among more chronic patients with a history of high levels of service use but provided stronger evidence ofclinical benefit for more acute patients with lower levels of previous service use.
Rosenheck and colleagues also re- ported differences in implementa- tion of assertive community treat-
ment across the ten sites that are reminiscent ofthe findings of Bond
and associates (1 0) in their compari- son of three community mental
health centers. These differences highlight that clinical trials in natu- ralistic settings are subject to mixed responses from providers who are
called on to change their practice style. Stein (24) identified this prob- 1cm as “swimming against a tidal
wave” in his description of introduc- i ng assert ive community treatment
to clinicians trained to practice in in- stitutional settings. In the VA study,
differences in the implementation of assertive community treatment at the various sites were readily de- tected through recommended ap- proaches for monitoring fidelity to the model (25,26). These data are
available for comparison with studies of assertive community treatment in other populations.
Homeless persons with severe mental illness. The first published
trial of assertive community treat- ment for homeless persons with se- vere mental illness was conducted by Morse and colleagues in St. Louis, Missouri (27). Individuals were screened at local shelters, and 178 subjects were randomly assigned to three treatment conditions-a drop- in center, outpatient treatment, and
assertive community treatment. Cli-
ents were assessed at baseline and at 12-month ��llow-up. Forty-two per- cent of all subjects in the study were lost to follow-up, and the rate of at- trition was even higher for some con- ditions, for example, it was 52 per- cent for the group assigned to the
drop-in center. These high rates were not unexpected for a transient popu- lation receiving minimal treatment.
Improvement in symptoms, in-
come, adjustment, and self-esteem and a reduction in number of days
homeless were observed across all three groups. An experimental effect
for assertive community treatment was evident in satisfaction with the program, fewer days homeless, and increased use ofcommunity resources. Despi te its methodological ii mita- tions, this study established the fea- sibility of reducing homelessness
(from 25 days per month to three days per month) and represented an
important accomplishment at a time when no evidence existed that home-
lessness among mentally ill persons could be altered. Reports of further trials of assertive community treat- ment assessing a range of outcomes with homeless mentally ill persons are forthcoming (28).
Co-occurring substance abuse. The early studies ofassertive com- munity treatment were careful not to
select clients with a primary diagno- sis ofsubstance abuse. However, in a longitudinal study of young adults with schizophrenia who received as- sertive community treatment, Test and colleagues (29) identified a group of “significant users” with
long histories and deeply entrenched
patterns of multiple substance use. One trial in Delaware targeted pa-
roled intravenous drug users whose history of mental illness was not
specified (30). The study did not specify either the changes made in assertive community treatment to
adapt the program for this popula- tion or whether staff members were trained for community outreach.
Further, the randomization was compromised by requirements re- lated to federal law that prohibited
coercion of or withholding of bene- fits from study participants. As a re-
sult, the study was subject to selec- tion factors, including differences in
the extent ofcriminal history among clients in assertive community treat- ment, limited participation in the
experimental and control interven- tions, and a high study attrition rate of 50 percent among 135 subjects. Although these limitations resulted
in a failed trial, the study was one of the first efforts to use assertive com- munity treatment with a substance- abusing population, and it provided examples of the problems that can occur in naturalistic trials.
In their study of three CMHCs, Bond and colleagues ( 1 0) reported
serendipitous findings of reduced hospital days for clients with sub- stance abuse in assertive community treatment. However, efforts to repli-
cate this finding in a subsequent se- ries of studies were not successful (3 1 ). In those studies, 97 young adults with severe mental illness and substance abuse were randomly as-
signed to an experimental condition or to a control condition. Once iden-
tified as experimental subjects, they were then assigned either to assertive
community treatment or to a refer- ence group who received drug and a!- cohol education, resulting in a final design that was quasi-experimental. This study was also compromised by
failure to implement the randomized
design at all three sites and by high dropout rates. The study did not de- scribe any specialized training in substance abuse treatment for asser- tive community treatment team
staff.
Results from a group of investiga- tors in New Hampshire were more encouraging. They developed a treatment model that integrated substance abuse and mental health interventions for dually diagnosed
persons with severe mental illness (32). In their pilot study of outpa-
tients with schizophrenia and alco- holism, more than halfofthe sub-
jects achieved stable remission from alcoholism at four years, with a mean
duration of abstinence of 26.5 months (33). This integrated treat- ment model has been tested in a mu!- tisite study ofassertive community treatment in New Hampshire, and results are promising (34).
lntegratingfamily psychoedu-
cation. Although research focusing on the separate components of asser- tive community treatment may be needed to determine the mecha- nisms of its effectiveness, McFarlane and colleagues (35) instead took the approach of enhancing assertive
community treatment by adding a family intervention for which effi- cacy had been established (36). Fam- ily education and close collaboration
between family members and the as- sertive community treatment team in relapse prevention and rehabilita-
Psychiatric Services July 1995 Vol. 46 No. 7 673
tion has not always been considered a
crucial part of assertive community
treatment. Alternatively, many fam- ily interventions have not dealt ade- quately with patients’ needs for reha-
bilitation. In the study in New York State by
McFarlane and colleagues (3 5), 72
patients in assertive community treatment were randomly assigned
to the experimental condition in which psychoeducation was pro-
vided in three sessions in a multiple
family group or to a control condi- tion in which crisis intervention for families was provided as needed. At a preliminary follow-up after 12
months in the study, patients in the
experimental condition had a lower rate ofrelapse (22 percent, compared with 40 percent for the control
group) and a higher rate of employ- ment (37 percent, compared with 15
percent for the control group). There was no difference between the groups
in hospital use. The favorable differ-
ence between groups in employment
rate was also found in subsequent fol- low-ups (McFarlane WR, personal
communication, 1994).
Discussion Recent studies of assertive commu-
nity treatment continue to show a
stmng experimental effect of the in- tervention on psychiatric hospitali-
zation (2,18,20,22). This effect is
stronger on the number of days hos- pitalized than on the number of hos-
pita! admissions. Functional outcomes. The ab-
sence of an experimental effect on functional outcomes in most studies
is also consistent with the findings of previous research and may be related to the limited statistical power of many studies. Changes in functional
status were demonstrated in the large sample in the VA study (22)
but not in a meta-analysis of nine
studies by Bond and colleagues (37). Although the lack of findings has
been attributed to problems in mea-
suring functional outcomes, the measures themselves may be ade- quate because improvement in symptoms, functioning, and quality
of life is generally reported both for patients in assertive community
treatment and for patients in control
groups. Difficulty achieving an cx-
perimental effect may be due to the
limited gains that can be achieved by
patients with severe mental illness,
particularly within the short study periods, which typically have ranged
from three months to two years. Furthermore, in recent years, the
“usual-care” comparison conditions
have improved with dissemination of the community support philosophy,
increased sophistication about case
management, and providers’ willing-
ness to engage in the delivery of field-
based services. Despite these changes,
reduced use of inpatient treatment
services is generally not observed in
studies ofthe “broker” model of case management (38-40), with the cx-
ception ofone study that used inten-
sive case management (41). Thus some aspect of assertive
community treatment decreases hos- pita! use more effectively than other
state-of-the-art case management in-
terventions. It is unclear whether
this decrease in hospital use is attrib-
utable to improved medication corn- pliance (still rarely reported), inten-
sity ofservices, site ofservices, conti-
nuity of caregivers, assertive out-
reach, 24-hour coverage, the pro-
gram philosophy, the therapeutic a!-
liance (42), team care, or a combina-
tion of the preceding factors. How-
ever, this highly consistent finding of reduced hospitalization requires fur-
ther investigation.
The value of decreased hospital
use does not eliminate the need to
strive for more consistent improve- ment in other outcomes. For exam- pie, employment gains have been
demonstrated in just two ofthe older
trials of assertive community treat-
ment (1,5) and only one ofthe more
recent trials (35). Improvement in
independent living, without in-
creased use of community place-
ments such as group homes or nurs-
ing homes, was reported in three re-
cent trials (2,22,27). Improved clini- cal status was reported in another four studies (18,20,22,35). Further
gains will require both interventions
targeted toward specific outcomes
and reimbursement for vocational re-
habilitation, substance abuse treat- ment, and housing services.
High rates ofpatients’ persistence
in treatment (37) and consistently
high rates ofpatient and family satis-
faction associated with assertive
community treatment (18,19,20,
22,27) merit further attention in
qualitative research to increase un-
derstanding of the meaning of such findings. Perhaps even more critical
than the amount oftreatment pro-
vided (20) may be the perceived
availability of community-based
staffteams in increasing patients’ en- gagement in treatment. The stand-
ard research measures of effectiveness
used in these clinical trials do not as-
sess the often intense, respectful, and rewarding aspects of the relation-
ships between clinicians and pa-
tients, but these factors may be criti- cal for the success of long-term reha-
bi!itative interventions. For example, National Alliance
for the Mentally Ill (NAMI) director
Laurie Flynn has stated that assertive
community treatment programs
provide families “security and peace
ofmind. . . . The family for the first time knows that there’s going to be a real safety net around their relative;
no matter what the problem , no mat- ter what the service need, someone
can be reached and someone will re-
spond” (43). . Assertive community treatment
in the system ofcare. The studies re- viewed here have not contributed
substantial data to inform the issue raised by Test (2)ofthe place of asser-
tive community treatment in a sys- tern of care. These studies reveal an
experimental trend suggesting that highly targeted interventions are
necessary to achieve more challeng-
ing but desired outcomes such as re-
duced homelessness, substance abuse, and unemployment. Further
research is needed to answer the
question of whether to reserve asser- tive community treatment as a last
resort for highly noncompliant pa- tients, as in the Dane County model
(2 1 ), to provide it as the standard ser- vice for most patients with severe
mental illness, or to use it in some
other intermediate option.
674 Psychiatric Services July 1995 Vol. 46 No. 7
Whether assertive community
treatment is used for particular pa-
tients on a part-time, time-limited,
or continuous basis is critical to the
cost ofservices. Decisions about du- ration of assertive community treat-
ment may be based on patient char-
acteristics such as patients’ historical
level of service use, availability of
other after-hours crisis back-up ser- vices, or stage of treatment. Al-
though early research in Wisconsin
warned ofa loss in clinical gains with
termination ofassertive community
treatment (1), methods to reduce the intensity of services once goals are
achieved also need to be explored,
perhaps using the criteria suggested
by Dixon and associates (28). In the
current Dane County model, in con- trast to the model ofcontinuous as-
sertive community treatment being studied by Test (2), clients are gradu-
ally transferred to medication clinic
services or to other psychosocial re-
habilitation programs after a period
ofcare in assertive community treat-
ment (Stein LI, personal communi-
cation, 1993). Efforts to streamline costs under
health care reform in states will lead
to adaptations of the model, as will local variation in patient charac-
teristics, other available resources,
and desired outcomes. For example,
in rural areas, the assertive commu-
nity treatment team and the caseload may be smaller, contact with pa-
dents may be less frequent, and fam- ily members may have a greater role
in treatment than in urban areas (44).
The use of trained volunteers and
consumers as staff has been recom-
mended (45). Clearly, the potential
for more efficient assertive commu-
nity treatment models has not been
fully examined. The findings of such
studies could be used to decrease the
cost of community care.
Finally, the issue of adequate pro-
fessional resources or practice style in
assertive community treatment will
be influenced largely by financing
policy. If fiscal incentives to hospital-
ize patients persist, provider organi- zations will value this alternative and
will favor hospitals as a location of
professional training. If policymak-
ers understand that high-quality treatment in the community is no
more expensive than hospital-based
treatment and is more satisfactory to
patients and families, a shift in finan-
cial incentives in favor of community care may be possible. At such a time, academic institutions will necessar- ily change their principal training
focus from a team-oriented institu- tional approach to a team-oriented
approach in the community.
Conclusions Research on assertive community treatment has advanced since the re- views by Olfson (13) and Test (2) largely by providing further cvi-
dence of the positive effects of asser- tive community treatment in reduc-
ing hospital use and increasing pa-
tient and family satisfaction; by test- ing assertive community treatment
in a �wider range of populations, in-
cluding patients with recent-onset
schizophrenia, veterans, dually diag-
nosed clients, and homeless persons;
and by studying the integration of other empirically validated methods
such as family psychoeducation into
assertive community treatment. Evidence ofdifferential effects of
assertive community treatment on
client-level outcomes are incre- mental rather than dramatic. Several factors may have contributed to the limited findings. They include the brief duration of most studies, en-
riched control interventions, and
problems in implementing the stud- ies, including difficulties estab-
lishing the assertive community
treatment condition , retai ning sub- jects, and measuring outcomes. The
findings ofsuch studies may be al-
tered by future studies with longer
duration, better monitoring of im- plementation (46), and increased tar-
geting of interventions by assertive
community treatment teams, par-
ticularly in the areas of substance
abuse treatment and functional reha- bilitation, including employment. This second generation of replica-
tions of assertive community treat- ment illustrates some of the chal- lenges involved in establishing ex-
ternal validity, including the real- world effects of regulations (30),
public policy and opinion (19), and provider and system incentives to
change clinical practice (22). Additional research attention
should also be directed toward quali- tative issues such as the nature of provider-consumer relationships and
toward adaptations of assertive com-
munity treatment that use resources
with increased efficiency. Many of these and other issues, such as the
differential effectiveness of assertive
communi ty treatment for selected patient subgroups, may be examined
without expensive new studies by us-
ing meta-analytic techniques.
Acknowledgments
This work was supported by grants
MH-46624 and MH-514l0 from the National Institute of Mental Health. The authors thank Linda Maultsby, H. Ryan Wagner, Ph.D., Anne McKee, and Michelle Wetherby.
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