Community tenure of people with serious mental illness in assertive community treatment in Canada.

OBJECTIVE: This study followed consumers after admission to an assertive community treatment program to determine when the first hospital admission was more likely to occur, which variables predicted community tenure, and, more specifically, whether the availability of within-program hospital beds predicted community tenure. METHODS: Data were gathered from three assertive community treatment programs in southeastern Ontario--the psychosocial rehabilitation program, the community integration program, and the assertive community treatment team program. Only the psychosocial rehabilitation program provided within-program beds. Hospital records of consumers who entered a program between July 1, 1990, and December 1, 1999, were examined prospectively until January 1, 2000, in order to record time to the first admission. Survival analysis based on the life-tables method was used to estimate the probability of remaining out of the hospital at 90-day intervals. Factors associated with time to admission were identified by using the Cox proportional hazards model. RESULTS: A total of 333 consumers were followed: 117 consumers in the psychosocial rehabilitation program, 105 in the community integration program, and 111 in the assertive community treatment team program. Findings indicated that consumers were most likely to be admitted to a hospital in the nine months after entering an assertive community treatment program. A diagnosis of substance use disorder, higher past hospital use, and the availability of within-program beds were associated with an increased risk of admission. CONCLUSIONS: Studies have shown that hospitalization remains a reality for many consumers and therefore warrants further study. The survival model proved advantageous by allowing a more complete and comparable description of consumers' hospitalization patterns that cannot be achieved with previously used methods, and it offered the power of regression analysis.

How do people who receive assertive community treatment experience this service?

Using a participatory research approach this study examined Assertive Community Treatment as experienced by service recipients. Overall participants were positive about their involvement with ACT and their experiences reflected critical ingredients of the model. The analysis revealed seven ways the ACT promoted community adjustment. Unhelpful aspects of the experience included staff requiring more training in particular service areas, conflicts over money and medications, stigmatizing aspects of the service, and authoritative practices of individual staff. Services promoting community participation were less well-developed than clinical approaches. Tensions inherent in receiving ACT services were related to the participants' negotiation of personal and social consequences of mental illness while striving for autonomy, community participation and inclusion.

An outcome in need of clarity: building a predictive model of subjective quality of life for persons with severe mental illness living in the community.

PURPOSE: The study purpose was to construct a predictive model of subjective quality of life for persons with severe mental illness living in the community with particular attention to participation in occupations. METHOD: Persons with severe mental illness (N=154) rated their subjective quality of life. Several measures for each of the following categories of variables were completed: demographics, clinical, social participation, and self-measured well-being. Regression analysis was used to determine the significant predictors for each category and then to build the predictive model from these significant variables. RESULTS: Symptom distress accounted for the most variance (33%) in subjective quality of life, followed by psychological integration (3%) and physical integration (2%). CONCLUSIONS: The study suggests that occupational therapists should attend to subjective experience of symptoms to influence quality of life. Therapists are also in a good position to address their clients' sense of belonging to their communities and to enable community participation.

Prevalence and characteristics of parenting among people served by Assertive Community Treatment.

This study examines the prevalence and the characteristics of parenting among people served by Assertive Community Treatment (ACT). Four semi-rural ACT teams in southeastern Ontario were surveyed. The findings suggest that a significant minority (38%) of persons receiving ACT services are parents, although most (84%) do not live with their children and many rarely see their children. These findings are surprising considering the lack of discussion in the literature about parenting among recipients of ACT services. The results are discussed in terms of the meaning for ACT services.

Challenges faced by service providers in the delivery of Assertive Community Treatment.

This qualitative study examined the delivery of Assertive Community Treatment from the perspective of service providers of 4 ACT teams in southeastern Ontario. Overall, providers were positive about their involvement with ACT. Eight tensions experienced in the context of delivering services emerged: negotiating governance structures; providing 24-hour coverage; balancing the clinical-administrative responsibilities of team leaders; accessing hospital beds; meeting local population needs; integrating treatment and rehabilitation; changing services to meet changes in the population being served; and implementing ambiguous ACT standards. Framing these challenges in the context of ACT structures and the broader community mental health system, the study suggests possibilities for the ongoing development of the model to facilitate the realization of the ACT vision.

Daily time use as a measure of community adjustment for persons served by assertive community treatment teams.

PURPOSE: The purpose of the study was to examine daily time use of clients of Assertive Community Treatment (ACT) as a measure of their community adjustment and well-being. The actual daily time use of ACT clients in the four categories of personal care, productivity, leisure, and sleep were compared to the data for Canadian population norms. METHOD: Daily time use data were collected from 27 adult clients from two Assertive Community Treatment Teams in southeastern Ontario using recall time diaries of two weekdays. The data were coded using the Statistics Canada (1999) coding scheme. Descriptive statistics were used to determine time in the major categories of time use and z scores were used to compare the study sample to the adult Canadian population. The percentages of time spent in specific subcategories of activity were also compared. RESULTS: The results indicated an imbalance in occupation with time use dominated by leisure and sleep activities. Study participants spent significantly more time in passive leisure compared to active leisure and socialization. CONCLUSION: The activity patterns of ACT clients were not consistent with those associated with community adjustment, health, and well-being. Occupational therapists working in ACT are in a good position to contribute to the literature regarding occupational performance and mental illness and to lead ACT teams in discussions and practices that may promote health through activity.

Substance abuse in a Canadian population of Assertive Community Treatment (ACT) clients: implications for service planning and delivery.

This brief paper reports on a study that used diagnosis, client self-reports, and clinician ratings to estimate the prevalence of drug, alcohol, and tobacco abuse among a random sample of 174 clients of 4 Assertive Community Treatment (ACT) teams in southeastern Ontario, Canada. Drug and alcohol abuse rates were lower that those reported in the literature, while high rates for tobacco use were consistent with published reports. ACT service delivery is guided by formal standards that assume high rates of substance abuse. It is argued that local population profiles should be monitored and considered in the development of ACT intervention practices.

Aging women with schizophrenia.

The purpose of this study was to describe the aging experiences of women with schizophrenia. The research focused on how participants viewed their own aging with schizophrenia, their perceived worries and concerns and how they were coping with aging with the disorder. Using a qualitative approach, data were collected using multiple in-depth interviews with six participants selected purposefully from the client list of a community mental health center. Interview transcriptions were coded and analyzed according to the study questions using QSR Nudist 4 software. Several categories and sub-categories emerged. These included the improvement in the illness over time; physical and daily living activity limitations; specific positive and negative changes that the women report have accompanied aging; the profound losses experienced by the participants when they were younger as a result of having schizophrenia; and how these losses have affected their present lives in terms of limiting available informal support, creating dependency on formal programs and services, and participants' fears of the future. Based on the study findings, implications for mental health practice and services are considered and suggestions are made to guide future research.

Direct and indirect time inputs and assertive community treatment.

Assertive Community Treatment (ACT) is an appealing community program model because it proposes to provide individuals with coping skills that allow them to maintain independent lives in their communities and it offers the potential to decrease inpatient stays and increase community tenure. But, it is not without its limitations. Critics point out that ACT's unique elements also make it a potentially very resource intensive program--an important consideration in times of fiscal constraints. Though the charge may be justified, there is little in the literature that actually quantifies the intensity of resources used. The process through which it achieves outcomes is not frequently described. Using ACT team workload information, we examine the time trade-offs--direct for indirect time--involved with implementing this model. In addition, we describe the specific activities that make up the direct and indirect time inputs that go into supporting clients in the community through assertive team oriented case management.

Substance use among persons with serious mental illness in eastern Ontario.

One hundred and eighty persons with serious mental illness (SMI) in eastern Ontario, receiving services from assertive community treatment teams in Brockville and Kingston were interviewed about substance use. Data were compared to survey findings for the Ontario population. Tobacco use was higher among both men and women in the SMI sample, but use of alcohol and drugs in the past 12 months was lower than population data. The frequency of alcohol use was significantly greater than drug use among the SMI sample.