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RESEARCH: Helen Killaspy, Paul Bebbington, Robert Blizard, Sonia Johnson, Fiona Nolan, Stephen Pilling, and Michael King The REACT study: randomised evaluation of assertive community treatment in north London BMJ 2006; 332: 815-820 [Abstract] [Full text]

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Actual or placebo effect ?

Vivek A Furtado   (12 April 2006)

The Community Intensive Therapy Team

Alka S Ahuja, Gill Salmon, Ahmed Darwish, Liz Steed   (12 April 2006)

Time to reconsider assertive outreach teams

sanjoo chengappa   (20 April 2006)

Too Pessimistic an Outlook

Rachel Upthegrove, Dermot McGovern, Consultant Psychiatrist, Birmingham Early Intervention Service   (1 May 2006)

The problem of clinical outcome measurement

Harry B. Andrews, Michael S. Dennis   (2 May 2006)

Re: The problem of clinical outcome measurement

Linda Hart   (8 May 2006)

Northumberland findings on AOT impact on bed use

Eugene P Moynihan   (10 July 2006)

Actual or placebo effect ? 12 April 2006
Vivek A Furtado, Senior House Officer Leeds Mental Health NHS Teaching Hospital Trust, LS6 4EP Send response to journal: Re: Actual or placebo effect ?	The REACT study was well conducted and it was worthy to note that there was no difference between inpatient admissions between the two groups. However patients assigned to the assertive community group were more satisfied with services as compared to the community mental health group. All patients included in the trial had to have 12 months of follow up by the community mental health team as an inclusion criterion. Some patients do not engage with services due to various reasons. What were the reasons for these patients not to engage with services? Could this satisfaction of services be due to the fact that “another team” is involved rather than the "CMHT" - someone whom the patient would not have liked in the first place during the one year period, than the actual assertive nature of the care provided by the assertive community team? Competing interests: None declared
The Community Intensive Therapy Team 12 April 2006
Alka S Ahuja, Consultant Child and Adolescent Psychiatrist Gwent Healthcare NHS Trust, Newport NP18 3 XQ, Gill Salmon, Ahmed Darwish, Liz Steed Send response to journal: Re: The Community Intensive Therapy Team	The paper by Killaspy et al suggests that assertive community treatment are better at engaging clients and lead to greater satisfaction with services1. We wish to share our experiences of a community assertive team based in the Child and Adolescent Mental Health Services in South Wales. In the past decade, Child and Adolescent Mental Health services (CAMHS) have seen a number of recent developments in the area of intensive community support for children and adolescents. These included the wrap around model2 and the intensive home-based models of psychiatric care 3.The theoretical model behind these approaches is not new but based on the bio-psycho-social model which informs much of child and adolescent psychiatry. A Community Intensive Therapy Team (CITT) based on the wraparound model4 operates in the Pontypridd and Rhondda Trust in South Wales. This team aims to offer a service to children and young people, who need more care than it is usually possible to provide within traditional outpatient settings. The patients served by the team are comparable with patients who might be referred for admission to an in-patient unit and include patients with eating disorders, psychosis, affective disorders, or repetitive self-harm. The philosophy of the team is to work with the child and family in their own environment, titrating the therapy to the needs of all concerned. On average the team receives and discharges one referral a week, thereby having around 52 active cases at any one time. Prior to its in 1998, on average 5-6 patients were admitted to the local adolescent unit from the specialist CAMHS teams serving the area now covered by the team. In addition, other patients were receiving specialist Tier 4 services outside of the region. Since 2001 to date, for the same population area and with input from the CITT, the need for CAMHS inpatient admissions has reduced considerably. Only four CAMHS patients needed admission to an adolescent inpatient from 2001 to date and there have been no referrals to Tier 4 services outside of the region during this period. This model is now being adapted by other CAMHS services in the area. References 1. Killaspy H, Bebbington P, Blizard R, Johnson S, Nolan F, Pilling S, King M. The REACT study: randomised evaluation of assertive community treatment in north London. BMJ. 2006; 332(7545):815-20 (Apr 8). 2. VanDenBerg, J.E & Grealish, E.M. Individualized services and supports through the wraparound process: Philosophy and procedures. Journal of Child and Family Studies, 1996; 5, 7-21. 3. Woolston, J.L., Berkowitz, S.J., Schaefer, M.C. & Adnopoz, J.A. The Child Psychiatrist in the Community, 1998; 7, 615-633. 4. VanDenBerg, J.E. Integration of individualized mental health services into the system of care for children and adolescents. Administration and Policy in Mental Health, 1993; 20, 247-257. Competing interests: None declared
Time to reconsider assertive outreach teams 20 April 2006
sanjoo chengappa, SHO in Psychiatry Queen Marys Hospital, Roehampton, London, (SW London and St Georges Mental HealthNHS Trust) sw15 5pn Send response to journal: Re: Time to reconsider assertive outreach teams	As the authors have concluded this study and previous studies have questioned the benefits of intensive assertive teams over generic Community Mental Health Teams (CMHTs). The better results in terms of more satisfaction with services and better engagement could be explained by the composition of the assertive outreach services. They are made up of better motivated, experienced staff. This probably is not just because of the novelty of these teams but also because they are better resourced units. However the worry is that in due course of time when these teams become well established, the novelty fades and they become no so well resourced as now their composition would become similar to the CMHTs and then the modest differences in outcomes will disappear. Also these teams draw away experienced skilled staff from already overburdened CMHTs. They have been modelled on similar services in United States and Australia; however the different demographics and geography, differences in the structure of the generic CMHTs between UK and in these countries must be kept in mind when considering their success there. Competing interests: None declared
Too Pessimistic an Outlook 1 May 2006
Rachel Upthegrove, Consultant Psychiatrist Birmingham Early Intervention Service, Harry Watton House, Church Lane, Aston, Birmingham B65ug, Dermot McGovern, Consultant Psychiatrist, Birmingham Early Intervention Service Send response to journal: Re: Too Pessimistic an Outlook	We believe the authors’ conclusions about the lack of effectiveness of AO are too pessimistic. More emphasis should be given to the significantly fewer patients lost to Assertive Community Treatment (ACT) teams. If suicides are included 13 (10%) were lost from Community Mental Health Teams (CMHTs) compared with 3 (2%) from the ACT teams (equating to 43 (34% ) vs 10 (7%) over 5 years!). Even if there is no difference in the clinical outcomes of CMHTs and ACT teams, patients who are lost can benefit from neither. It should also be remembered that one of the main drivers in developing ACT in the UK was the Clunis homicide inquiry which emphasized the dangers of lost contact. The authors acknowledge that the clinical gains of ACT may take longer to be realized than the 18 month study period. The ACT patients were new, being taken from the CMHTs. The Pan London ACT study shows that newly accepted patients were hospitalized significantly more often than “established” patients (Priebe et al 2003). An 18 month time frame when treating such challenging patients may well be too short to reveal differences. We believe that a different conceptual approach would be more helpful. ACT is not actually a treatment per se; the model describes the structure rather than the content of a service. This structure facilitates patient engagement so that treatment can be offered. In the very challenging group of patients under study, the better contact and greater satisfaction achieved by ACT is fundamental to successful treatment. The fact that the treatments offered by ACT have not produced better outcomes provokes questions about what treatments are used and how they are implemented. This should be the focus of further study. Meanwhile we believe that any assumption that ACT can provide no clinical advantage over CMHTs is premature and overly pessimistic. Finally the claim that other intensive models of care in the UK have shown no advantage over usual care is misleading. Recent studies of Early Intervention (Craig et al 2004) and Crisis Resolution Services (Johnson et al 2005 have shown superior clinical outcomes . • Report of the inquiry into the care and treatment of Christopher Clunis. London: HMSO, 1994. • PRIEBE S, FAKHOURY W, WATTS J et al Assertive outreach teams in London: patient characteristics and outcomes: Pan-London Assertive Outreach Study, Part 3 Br. J. Psychiatry, Aug 2003; 183: 148 - 154. • Johnson S, Nolan F, Pilling S et al Randomised Controlled Trial of acute mental health care by a crisis resolution team: the North Islington Crisis Resolution Team BMJ 235;331;599 • Craig T, Garety P, Power P, et al The Lambeth Early Onset (LEO) Team: randomized controlled trial of the effectiveness of specialized care for early psychosis. BMJ 2004,329,1067 Competing interests: None declared
The problem of clinical outcome measurement 2 May 2006
Harry B. Andrews, Consultant psychiatrist Treatment and Recovery Services, Troon Way Business Centre, Humberstone Lane, Leicester LE4 9HA, Michael S. Dennis Send response to journal: Re: The problem of clinical outcome measurement	This further confirmation of a lack of difference in clinical outcome from assertive comunity team provision for psychotic patients suggests that clinicians and policy-makers are looking at the wrong things over too -short timescales in their search for desirable change. In Leicestershire, the Treatment and Recovery (T&R) service was established 13 years ago to provide alternative to acute ward/general community team care for the 10% of schizophrenia patients with the poorest prognosis. A comprehensive study of suicide in Leicestershire (Dennis et al., 2001) established the suicide frequency for that diagnosis over the 6 years preceding T&R service formation at 4 per year. 571 schizophrenia patients contributed 4,670 patient years of service contact in T&R during those 13 years, and the proportionate rate of suicide in this 10% of all schizophrenia cases was less than half what would have been expected in the absence of such a service. The clinical characteristics of schizophrenia patients taken into T&R over the period include many associated with higher rates of suicide (Hawton et al. 2005), so the rate reduction as a clinical service impact is likely to be greater than this. The overall suicide rate reduction in Leicestershire over the period was approximately 10%, largely due to reduction in male suicide over the past 6 years. In keeping with, and as a partial explanation of, this reduced schizophrenia suicide rate in T&R, we found that the relapse readmission rate from first T&R discharge from any of these non-acute settings over the following 5 years was only 50%. This degree of social stability, and consequential bed usage reduction, could likely only have been achieved by a service design which integrated inpatient therapy and community team support with supported accommodation and supported housing providers, and likely not with a service reconfiguration of only one part. Further details of T&R in Leicestershire can be found at http://www.troutcomes.org.uk. Dennis, M., Read, S., Andrews, H. et al. (2001) Suicide in a single health district: Epidemiology, and involvement of psychiatric services Journal of Mental Health 10: 673-682 Hawton, K., Sutton, L., Haw, C. et al. (2005) Schizophrenia and suicide: systematic review of risk factors British Journal of Psychiatry 187: 9-20 Competing interests: None declared
Re: The problem of clinical outcome measurement 8 May 2006
Linda Hart, Inpatient in Leics T & R Hospital LE5 0LE Send response to journal: Re: Re: The problem of clinical outcome measurement	Although Dr. Harry Andrews et al says the problems of clinical outcome measurements have obvious flaws because the people doing them are looking at the wrong things over the wrong time scale, I would add, as a patient in the Treatment & Recovery Service, that he too is in danger of doing the same thing. I know from experience and the experiences of many others, that had it not been for this specialist service, which proves to be an excellent one in its day to day interactions and care of us mad people, we'd either be dead, homeless, in prison or causing a nuisance to others. Most of us have no other place in which to live, are very difficult to 'place' elsewhere, and above all we are people with feelings, personalities and faces. We are not just numbers to be swivveled around a ouji board hoping to save The Trust money. Dr Andrews may be right to say that the suicide numbers have decreased, but he does himself a disservice in that the consideration he gives to all his patients is exemplary and that is why our quality of life has improved, our horizons broadened and we have a few more goals to aim at rather than suicide. Competing interests: None declared
Northumberland findings on AOT impact on bed use 10 July 2006
Eugene P Moynihan, Manager of Assertive Outreach Team St George's Park, Morpeth. NE61 2NU Send response to journal: Re: Northumberland findings on AOT impact on bed use	The results of the REACT study into Assertive Outreach Teams is disappointing. It is reasonable to expect, on the evidence of previous research in the States and Australia that a fully functioning Assertive Outreach Team would have some impact on the number of days its clients spend in hospital, if not on the actual number of admissions. However, in order to achieve this the Assertive Outreach Team needs to have certain core skills within the team, for example; PSI, Cognitive Behaviour Therapy and Dual Diagnoses specialism. The composition of the team is also important and they need to be truly multi-disciplinary with Social Workers, Nurses, OT’s, Psychiatrists as well as people who don’t possess professional qualifications but bring a number of life experiences to the team. In order to produce the best outcome of reducing admissions the team needs to retain responsibility for their clients following admission to hospital with the Psychiatrist remaining the RMO for the patient. Teams also need to have good balance between social and healthcare. Model fidelity is an import factor to be examined when evaluating Assertive Outreach Teams and the article measured this as medium to high. However, after working in Assertive Outreach for over five years now I am convinced that certain aspects of the model are more crucial than others. Whole team working is one of the most crucial and most Assertive Outreach Teams claim to implement this aspect of the model, however in reality it is often the case that what they actually do is a modified version of whole team working which can pass on model fidelity scales as conforming to the model when in fact it is not. A whole team approach requires that all members of staff be equally responsible for the care of all of the clients and not just the responsibility of the individual Care Co- ordinators. Care plans need to be discussed and agreed by the entire team and not just decided by an individual Care Co-ordinator. Unfortunately on the model fidelity scales that I have seen compliance to this aspect of the model is not easy to determine. Also in order to reduce the number of days Assertive Outreach Team clients spend in hospital it has been established it is crucial that the team has a dedicated Psychiatrist who continues to look after clients during hospital admissions. Finally, eighteen months is too short a timescale to adequately evaluate an Assertive Outreach Team service. The Northumberland Assertive Outreach Team has been operational for five and a half years now and following publication of this article they decided to investigate the impact they have had on hospital admissions. They counted the number of days spent in hospital pre and post Assertive Outreach and made the count proportional to the amount of time the clients have been in the Assertive Outreach Team service. For example, for clients who have been in the service for 5 years the days spent in hospital for the 5 years preceding transfer to Assertive Outreach were counted and measured against the number of days following transfer to Assertive Outreach. Similarly for those who have been with the service for 3 years and 2 years. The results show an overall reduction in the number of bed days in hospital from 20,878 pre AOT to 10,486 post AOT. This reduction of over 50% is in stark contrast to the findings of the REACT Study and demonstrates the need for cautious interpretations of the findings and also the need for further research to AOT in the UK. The results of the REACT study into Assertive Outreach Teams is disappointing. It is reasonable to expect, on the evidence of previous research in the States and Australia that a fully functioning Assertive Outreach Team would have some impact on the number of days its clients spend in hospital, if not on the actual number of admissions. However, in order to achieve this the Assertive Outreach Team needs to have certain core skills within the team, for example; PSI, Cognitive Behaviour Therapy and Dual Diagnoses specialism. The composition of the team is also important and they need to be truly multi-disciplinary with Social Workers, Nurses, OT’s, Psychiatrists as well as people who don’t possess professional qualifications but bring a number of life experiences to the team. In order to produce the best outcome of reducing admissions the team needs to retain responsibility for their clients following admission to hospital with the Psychiatrist remaining the RMO for the patient. Teams also need to have good balance between social and healthcare. Model fidelity is an import factor to be examined when evaluating Assertive Outreach Teams and the article measured this as medium to high. However, after working in Assertive Outreach for over five years now I am convinced that certain aspects of the model are more crucial than others. Whole team working is one of the most crucial and most Assertive Outreach Teams claim to implement this aspect of the model, when in reality it is often the case that what they actually do is a modified version of whole team working which can pass on model fidelity scales as conforming to the model when in fact it is not. A whole team approach requires that all members of staff be equally responsible for the care of all of the clients and not just the responsibility of the individual Care Co-ordinators. Care plans need to be discussed and agreed by the entire team and not just decided by an individual Care Co-ordinator. Unfortunately on the model fidelity scales that I have seen compliance to this aspect of the model is not easy to determine. Also in order to reduce the number of days Assertive Outreach Team clients spend in hospital it has been established it is crucial that the team has a dedicated Psychiatrist who continues to look after clients during hospital admissions. Finally, eighteen months is too short a timescale to adequately evaluate an Assertive Outreach Team service. The Northumberland Assertive Outreach Team has been operational for five and a half years now and following publication of this article they decided to investigate the impact they have had on hospital admissions. They counted the number of days spent in hospital pre and post Assertive Outreach and made the count proportional to the amount of time the clients have been in the Assertive Outreach Team service.So for example, clients who have been in the service for 5 years the days spent in hospital for the 5 years preceding transfer to Assertive Outreach were counted and measured against the number of days following transfer to Assertive Outreach. Similarly for those who have been with the service for 3 years and 2 years. The results show an overall reduction in the number of bed days in hospital from 20,878 pre AOT to 10,486 post AOT. This reduction of almost 50% is in stark contrast to the findings of the REACT Study and demonstrates the need for cautious interpretations of their findings and also the need for further research into AOT in the UK. Competing interests: None declared