1. 1 Is the ACT model effective in a contemporary Danish psychiatric setting? Preliminary Results from a Danish Multi-centre Trial of Assertive Community Treatment vs. Standard Psychiatric Treatment Marie Høgh Thøgersen, Bispebjerg Psychiatric Dep. Gøteborg 2007

2. 2 Assertive Community Treatment (ACT) In Denmark 2003: wide-scale Implementation Debate on ethical issues in relation to ACT

3. 3 Dilemma in Psychiatry Paternalisme Autonomy

4. 4 Deinstitutionalisation was associated with less paternalism and more autonomy Paternalism Autonomy Is Assertive Community Treatment associated with more paternalism and less autonomy?

5. 5 Study Design ACT-Team IControl I ACT-Team II Control II ACT-team dropout 2 YEAR FOLLOW UP ASSESSMENT ACT-team Control BASELINE Register Data (1) Medical Records (2) Register Data (1) Medical Records (2) Interviews (3) N= 213N= 153 Control Level 1 = 5 Level 2 = 20 Level 3 = 66 Level 1 = 8 Level 2 = 6 Level 3 =110

6. 6 Inclusion Criteria Age 18-65 Address in catchment area Chronic mental illness At least 4 admissions or 40 days at hospital within the last 2 years Dual diagnoses Difficult to engage with services

7. 7 Model Fidelity: How do we know that the danish ACT teams follow the ACT principles? Assessment of adherence to model (IF-ACT) = 17-item Index of Fidelity to Assertive Community Treatment scale

8. 8 TREATMENT ACT TEAM STANDARD TREAT. 1:10 Weekly Home Yes Generally Yes 1:20 / 1:30 Varies CMHC No Case load Staff Frequency of contact Place of visits Contact at hospital Crisis plan Contact outside office hours Psychiatrist Psychologist Psychiatric nurse Social worker Occupational therapist Psychiatrist Psychiatric nurse (Social worker)

9. 9 Results Level 1 (Registerdata) Level 2 (Medical Records)

10. 10 ACT n=213 CONTROL n=153 P value of Difference Male126 (59)95 (62)0.7 Mean (SD) age (years)42,6 (11)43,5 (11)0.4 Ethnicity other than Danish62 (29,1)37 (24,2)0.4 Completed high school education40 (20)35 (23)0.4 Having children64 (33)52 (36)0.7 Living conditions Married or living with partner26 (13)15 (10)0.4 Living independently163 (78)119 (78)0.3 Living in supervised setting10 (5)6 (4)0.3 Living with parents or family12 (6)15 (10)0.3 Homeless25 (12)12 (8)0.3 Sociodemographic characteristics at baseline

11. 11 Clinical characteristics at baseline ACT n=213 CONTROL n=153 P value of Difference Social functioning GAF function34,21 (10,5)34,99 (10,9)0.52 Health service use Mean (SD) days in hospital Mean (SD) days of involuntary admission 48,4 (71,9) 23,2 (45,8) 44,6 (71,2) 30,4 (60,8) 0.84 0.03 Diagnosis Schizophrenia Other 198(95) 9 (4) 142 (93) 10 (6) Comorbidity: Substance abuse118 (57)72 (47)0.07 Level of Drug dependence Mean DTES (SD)3,71 (2,6)3,23 (2,5)0.10

12. 12 Clinical outcomes at 2 year follow-up ACT n=213 CONTROL n=153 P value of Difference Health service use Mean (SD) days in hospital Mean (SD) days of Involuntary admission 16 (43,8) 5,3 (20,3) 36,8 (69,9) 18,1 (44,8) 0.00 Level of Drug dependence: Mean DTES (SD) Difference from DTES score at inclusion 3,57 (2,5) -0.19 (2,1) 3,55 (2,6) 0,25 (2,0) 0.54 0.06 Social functioning GAF (function) 38,47 (10,8)35,15 (10,8)0.01

13. 13 Results Level 3 (Patient Interviews)

14. 14 Interviews Are mentally ill people a credible source of information? –Drop out –Missing data –Ambigious reply’s

15. 15 Place of Interviews N = 183

16. 16 User satisfaction and quality of life ACT n=101 CONTROL n=86 P value of Difference User satisfaction Client Satisfaction Questionnaire 24,25 (5,86) 21,89 (5,27)0.01 Quality of Life MANSA* 57,12 (11,85)55,96(9,75)0.57

17. 17 Do patients experience the assertive approach in the two Danish ACT teams as coercive?

18. 18 Preliminary Results: Experience of Coercion Do you experience that: That you can make yourself understood in relation to your case manager? That your case manager respects your rights as a patient and keeps his/her confidentiality? That you can ask your case manager to leave, during home visits, if you want him/her to leave? 12 Qualitative Interviews 5. 1. 2. 3. 4. 4-5 = Yes 3 = Neutral 1-2 = No No, Definitely not Yes, definitely

19. 19 Does your case manager respect your rights as a patient and keep his/her confidentiality? % of total N= 149 P= 0,54

20. 20 Can you make yourself understood in relation to your case manager? N= 165 P= 0,056 % of total

21. 21 Can you ask your case manager to leave during home visits, if you want him/her to leave? % of all N= 70/96 P= 0,000**

22. 22 Patient experiences of medication

23. 23 Have you taken antipsychotic medication within the last year? N= 165/183 P= 0,375

24. 24 Can you decide for yourself, whether or not to take your medication? N= 152/183 P= 0,035*

25. 25 In your opinion, does your case manager encourage you to get started with some of the things you would like to do? % of total N= 145 /183 P= 0,020*

26. 26 In your opinion, is your Case Manager a collaborator? N= 156 /183 P= 0,009*

27. 27 Is the ACT model effective in a contemporary Danish psychiatric setting?

28. 28 In the light of the results from this study, the answer seems to be yes.

29. 29 CONCLUSION Signficantly fewer days spendt at hospital Significantly fewer days of involountry admission Significantly higher level of social functioning (GAF) Signficiantly higher improvement in level of drug abuse (DTES) Significant higher level of user satisfaction At 2 year follow-up,patients in the ACT teams were characterised by:

30. 30 CONCLUSION - continued Patients do not experience the assertive outreach in the Danish ACT Teams as coercive - the contrary appears to be the case Patients in the ACT Teams experience a higher degree of influence on medication Danes with other ethnic background differ significantly in their experience of coercion The patient perspective is important

31. 31 Thank you for your attention. Good Afternoon!

32. 32 Ethical Dilemma Paternalism: Autonomy: Hippokrates: to do what the doctor considered good for the patient with or without accept from the patient to give priority to patient’s autonomy even if it was harmful to patient’s health

33. 33

34. 34 Average length of meetings with case manager N= 183 P= 0,000** % of total

35. 35 Frequency of meetings with case manager N= 183 P= 0,000** Number of times per week /month

36. 36 Does your Case Manager think that you can not get on without his/her help? N= 134 /183 P= 0,022*