The International Journal of Psychosocial Rehabilitation
Effectiveness of Assertive Community Treatment for Patients Referred under Kendra’s Law: Proximal and Distal Outcomes

Eris F. Perese, MSN
Clinical Associate Professor
University at Buffalo, School of Nursing
716-873-2546
email: perese@buffalo.edu

Yow-Wu Bill Wu, PhD

Associate Professor
University at Buffalo, School of Nursing

Ranganathan Ram, MD
Medical Director of Mental Health Programs

Delaware


  Citation:
Perese, E.F. ,  Wu,  Y.-W. B.,
& Ranganathan R.  (2004).  Effectiveness of Assertive Community Treatment for Patients
Referred under Kendra’s Law: Proximal and Distal Outcomes
  International Journal of Psychosocial Rehabilitation. 9 (1), 5-9.

Acknowledgment:    The authors gratefully acknowledge the assistance and support of Lake Shore Behavioral Health Incorporated and the help of the Assertive Community Treatment team. They wish to express their appreciation to Cathleen Curtin, MSN for data management and to nursing students, Earl Adams and Cheryl Putnam, for assistance in reviewing the records. The study was supported by funds from the Research and Development Fund of the School of Nursing of the University at Buffalo, The State University of New York.

Key words: Assertive Community Treatment, involuntary outpatient commitment, Kendra’s Law, proximal and distal outcomes


Abstract  
This study examined proximal and distal outcomes achieved by 37 patients referred under New York’s Kendra’s Law (Group I) and 19 voluntary patients (Group II) in Assertive Community Treatment. Group I had greater age diversity and less social support on admission. The groups did not differ significantly on admission in rates of hospitalizations, homelessness, dangerousness and arrest/incarcerations. Face-to-face interviews were conducted at baseline, 6 months and 12 months. Among proximal outcomes, psychiatric symptoms, distress, stress and dangerousness to self improved; dangerousness to others did not. There was a trend toward improvement of unmet needs.  Among distal outcomes, health, life satisfaction, psychiatric and medical emergency room visits, medical hospitalizations, homelessness and police contacts/arrests improved. Social support, psychiatric hospitalizations, incarcerations and employment did not. Global functioning improved but specific role functioning did not. Group I was less satisfied with treatment. Group outcomes differed only on psychiatric hospitalizations, with fewer admissions among Group I.


Introduction
Among patients with severe mental illness (SMI), there is a group—the “Revolving Door” patients (Hiday & Scheid-Cook, 1991, p. 83)—who are non-adherent to medications and treatment and high users of psychiatric services (Hafemeister & Banks, 1996; Cuffel, 1997). They also have frequent contact with other community services and agencies such as the police, courts, jails, prisons and emergency medical facilities around episodes of dangerousness and victimization  (Swartz & Monahan, 2001).  In the past, these patients might have been referred for involuntary admission to a psychiatric hospital but now they are likely to be referred for involuntary outpatient treatment (Torrey & Kaplan, 1995).

Although some mental health professionals consider involuntary outpatient commitment to be helpful in engaging in treatment persons with SMI who are at risk for danger to themselves or others but who are unable or unwilling to accept on-going treatment (Muentz, Grande, Kleist & Peterson, 1996; Swartz, et al., 2001; Torrey & Zdanowicz, 2001), others believe that court ordered treatment is the extreme end of a continuum of coercion (Diamond, 1995).  Family members of the National Alliance for the Mentally Ill (NAMI) see involuntary outpatient treatment as a way of getting help for family members before they become so ill that they are a danger to themselves or others (“AOT Update”, 2000).    Consumers of mental health services have a wide range of opinions with one consumer, Frese, (1997) saying that involuntary outpatient treatment

helped him when he was unable to realize that he was ill, but with others expressing concern that involuntary treatment will create fear, destroy trust between consumer and clinician, and cause people to avoid seeking help (Mad Nation, 1999).  Geller (1995, p. 233) views involuntary treatment as a compassionate measure, a compensatory therapeutic intervention for individuals who have biological, psychological and social deficits due to their mental illness or to the residual effects of the illness--a “form of prosthesis for a biopsychosocial deficit”.  Policy makers view involuntary outpatient commitment as a solution for many problems associated with severe mental illness-- homelessness, frequent use of emergency health services, contact with the police/arrests, and violent behaviors (Swartz, et al., 1999; Applebaum, 2001). 

According to Muentz, Grande, Kleist and Peterson (1996) and Appelbaum (2001),
involuntary outpatient commitment is associated with a reduction of hospitalizations, increase in time in treatment, increase in ability to remain in the community  and a reduction of episodes of violence (Torrey & Zdanowicz, 2001).   On the other hand, there are those who believe that availability and provision of appropriate mental health care services would make involuntary outpatient treatment unnecessary (Diamond, 1995).  There have been two large studies that have examined the effect of outpatient commitment on outcome-- the Duke North Carolina Study (Swartz, et al., 2001) and the Bellevue pilot study (Steadman, et al., 2001).  The Duke study did not find any difference in hospitalization between the patients committed for outpatient treatment and the controls at one year but the authors suggest that outpatient commitment is effective in reducing hospital stays and violence as long as the intervention is sustained and combined with a high intensity of community services.  The Bellevue study compared outcomes of patients mandated to receive community treatment and a control group. Both groups received enhanced community services. There was no significant difference in hospitalization and arrests and other outcomes .

With the passage of Kendra’s Law, Assisted Outpatient Treatment (AOT), in 1999, New York joined the 40 states and the District of Columbia that have some form of involuntary outpatient commitment laws (Applebaum, 2001).The New York State Office of Mental Health assumed responsibility for AOT and delegated implementation to the counties.  Across the state, from the cosmopolitan New York City area to the dormant steel towns of Western New York, counties with varying resources faced the task of providing treatment with limited information about the effectiveness of different treatment modalities under usual practice conditions to guide them (Holloway, Szmukler & Sullivan, 2000).  Counties often used existing programs such as Assertive Community Treatment (ACT) (Swanson, et al., 1997).  Extensive studies of ACT for voluntary patients have shown that ACT reduces hospital readmissions, use of emergency services, legal problems, and homelessness and improves global functioning and clinical symptoms (Scott & Dixon, 1995; Lehman, et al., 1999). There is less evidence that ACT improves social functioning and employment (Mueser et al., 1998). ACT programs are widely accepted as the “gold-standard” of treatment for persons with SMI who are frequent users of inpatient psychiatric care and emergency psychiatric services (Burns & Santos, 1995; Lehman, et al., 1999; Phillips et al., 2001) but there is little information about effectiveness of ACT in providing care for patients who have been court-ordered to receive treatment or as a “jail diversion program” (Phillips, et al., 2001, p.772). Arboleda-Florez (1999, p. 4) writes that ACT “is not better than standard community care on imprisonment, arrests or police contacts”.    Mays (1995) questions the effectiveness of ACT for those high users of emergency psychiatric services who deny their need for on-going care and reject efforts of ACT staff to develop a trusting, cooperative relationship with them.   Mueser, et al. (1998) raise the question of the need to modify ACT to meet the needs of patients with SMI who have high rates of illegal behaviors. 

This study examines the effectiveness of ACT in providing care for patients
referred for treatment under Kendra’s Law. Because severe mental illness affects many aspects of a person’s life, Lehman (1999, p. 30) recommends that measures of treatment effectiveness include a broad range of outcomes—“ clinical, rehabilitative, humanitarian and public welfare domains”; and, that both proximal and distal outcomes be considered.  Based on Lehman’s suggestions, the following research questions were posed:  1. Was there improvement of proximal outcomes –basic needs, psychiatric symptoms, psychological distress, stress, and dangerousness to self and to others---after six months of ACT?  2. Was there improvement of distal outcomes –health, functioning, social support, life satisfaction, employment, homelessness, police contacts, arrests/incarcerations and use of psychiatric and non-psychiatric emergency rooms and hospitals-- after one year of ACT?   3. How satisfied were the patients with treatment? 4. Was there a relationship between patients’ status—voluntary or referred for involuntary outpatient treatment-- on admission to ACT and outcomes and satisfaction with treatment?

Proximal and Distal Outcomes
The terms proximal and distal outcomes carry the meaning of cause and time relationships to the treatment intervention.  In comparison to distal outcomes that are broad and tend to be evidenced at a greater distance of time, the effect of the intervention is more likely to be stronger or more direct on proximal outcomes and to occur close in time to the intervention (Lehman, 1996). Because of the course of severe mental illness,  psychiatric symptoms and residual disabilities, persons with SMI often have impaired functioning, inability to tolerate stress, limited social skills and compromised judgment (National Institute of Mental Health, 1991) that result in unmet needs (Arvidsson, 2003), poor health (Massaro, 1992), poverty, homelessness and victimization (Steinwachs, Kaspser & Skinner, 1992), increased contact with the police, arrests and incarcerations (Schellenberg, Wasylenki, Webster & Goering, 1992), high rates of unemployment (Anthony & Blanch, 1987; Mueser, Drake & Bond, 1997), lack of social support (Cohen & Farkas, 1986; Estroff, Zimmer, Lachicotte & Benoit, 1994; Shankar &  Collyer, 2002) and diminished quality of life, (Mueser, Drake & Bond, 1997).  In addition to having increased rates of medical problems, persons with SMI often lack the ability to access health care, including preventive care, and the ability to modify unhealthy life-style practices (NIMH, 1991; Felker, 1996; Hutchinson, 1996; Getty, Perese & Knab, 1998; Berren, 1999; Brown, 1999).  Evaluation of effectiveness of treatment for persons with SMI must consider the intervention’s ability to bring about change for these multiple problems  

Proximal outcomes
In this study, proximal outcomes include perceived basic needs, psychiatric symptoms, psychological distress, stress, and dangerousness to self or others.   Basic needs.  Malm, May and Dencken (1981) identified the needs of persons with SMI as: medical care, human relationships, material supplies (housing, clothing food), work and employment opportunities, safety, leisure activities, communication and transportation, and inner experiences such as a sense of purpose. In Buffalo, New York, located in the western part of New York State and the setting of this study, when 73 members of a chapter of (NAMI) who had SMI were surveyed about basic needs, the needs identified as unmet by more than half of the respondents were:  a friend (62%), a role-in-life [a job] (60%), a group to belong to (56%), a sense of self-identity (55%), and information about mental illness for others [experienced stigma] (53%) (Perese, 1997).

 In another Buffalo study, among 34 patients with SMI who were psychosocial club members, the most frequently identified unmet needs were: role in life (job), self-identity, financial resources, a friend and a group to belong to (Perese, Getty & Wooldridge, unpublished). A Swedish five-year study of 377 persons with SMI receiving treatment in the community found similar unmet needs.  The overall unmet needs improved over a five year period but there was no change in unmet needs for work and social contact with friends and relatives (Arvidsson, 2003).  Psychiatric symptoms and Psychological distress.  Even when receiving treatment, many persons with SMI continue to experience psychiatric symptoms (Clinton, Lunney, Edwards, Weir & Barr, 1998; Mueser, Bond, Drake & Resnick, 1998).  In studying subjective distress of patients with SMI, Bradshaw and Brekke (1999) found that distress was influenced not only by high levels of psychiatric symptoms but also by  patients’ perception that people were angry with them. Stress. 

In a study of 34 persons with SMI, the stress level was found to be 6.67 on a scale of 1 to 10 with nearly half (42%) reporting high levels (8, 9 or 10). The subjects identified daily hassles as:  being criticized, problems getting along with others, family relations, physical health problems and financial worries; and major events as:  acute episodes of physical illness, surgery, death of a family member or friend, homelessness, being robbed, and problems with housing (Perese, Getty & Wooldridge, 2003).  Dangerousness.  In comparison to the general population, there is an increased risk of violent behavior among a subgroup of persons with SMI who have a prior history of violence and substance abuse disorder or antisocial personality disorder (Eronen, Angermeyer & Schulze, 1998). The risk is further increased when these patients are non-compliant with medication (Swartz, et al., 1998).  Hiday and Wales (2003) say that, if violence is defined broadly to include being in a fight, the proportion of persons with SMI who are violent is about 50%. 

Distal outcomes
Health -  Over all, persons with SMI have poorer health than the general population (Lehman, 1996). The effects of their illness and the residual disabilities further compromise their health by limiting their ability to maintain health and prevent health problems from occurring (Hutchinson, 1996).  In addition, high rates of unhealthy lifestyle practices, poverty, victimization and stigma negatively affect their health (Felker, Yazel & Short, 1996; Berren, Hill, Merikle, Gonzalez & Santiago, 1999; Brown, Birtwistle, Roe & Thompson, 1999).  Although about 70% of people with SMI who report health problems receive treatment, only half of those with dental problems receive treatment (Dixon, Postrado, Delahanty, Fischer & Lehman, 1999).   Use of health care services by persons with SMI has been found to be inefficient and costly (Felker, 1996; Berren, et al., 1999), with high rates of non-urgent use of emergency services linked to perceived unavailability of other sources of care and psychosocial factors such as lack of social support (Padgett & Brodskky, 1992) and limited knowledge and capacity for self-care (Getty, Perese & Knab, 1998).

Functioning -  Among persons with SMI, impaired functioning often results in problems in carrying out a role in life such as a worker, homemaker or student; problems with relationships; problems with leisure or social activities and problems with caring for oneself including managing mental and physical health problems (Pratt & Mueser, 2002).

Social Support - In 1988, House, Landis and Umberson described a link between lack of social support and higher mortality rates and higher rates of physical and psychiatric illnesses in the general population; and, in 1994, Berren et al. reported similar findings among persons with SMI.  In addition to social support’s influence on health, Clinton et al., 1998, found that social support plays an important role in helping persons with SMI adjust to living in the community.    Among the general population, social support was 5.4 when measured with the Social Support Index that has a range of 0-8 (Bell, LeRoy & Stephenson, 1982).  In  Buffalo, among 34 persons with SMI, social support was 4.6  (Perese, et al., 2003). Lack of treatment effect on social support among patients with SMI was found by Walsh (1996) and Getty, Perese and Wooldridge (unpublished).

Life satisfaction - In the general population, the mean life satisfaction score as measured with Lehman’s (1988) General Life Satisfaction Scale (GLSS) was 5.4.  That is between mostly satisfied and pleased (Sullivan, Wells & Leake, 1991).  Among persons with SMI living in the community, life satisfaction was 4.4 (Lehman, Ward & Linn, 1982).  A similar rate (4.2) was found among persons with SMI who were NAMI members (Perese, 1997) but a lower rate (3.8) was found among psychosocial club members, (Perese, et al., 2003).

Homelessness -  Approximately one-third of the homeless population has severe mental illness; and, among this population there is a high rate of co-existing medical problems, substance abuse, relationship problems, contact with law enforcement agencies and limited education (Shern, et al., (2000). In Buffalo, the two year rate of homelessness or “on-the –streets” varied dramatically from 17.8% among NAMI members (Perese, 1997) to 26.5% among psychosocial club members (Perese, et al., 2003).

Psychiatric emergency room visits -   Psychiatric emergency rooms are the first line of care for many persons with severe mental illness in crisis; and for some, the only source of mental health care (Arfken, Zeman, Yeagaer, Mischel & Amirsadri, 2002).  About one-third of the visits are accounted for by repeat visitors (Ellison, Blum & Barsky, 1986). In an early study, Munves (1983) reported that the rate of repeat emergency room visits among persons with chronic mental illness was 20% in one year.  In Buffalo, the two-year rates were 45% (Perese, 1997) and 39% (Perese, et al., 2003).

Readmission to psychiatric hospital -  Hafemeister and Banks (1996), who examined re-hospitalization rates in six New York State hospitals, predicted that 32-57% would be readmitted at one year and 43-64% at two years.  In Buffalo, two-year readmission rate was 64%  (Perese, 1997) and one-year rate was 32% (Perese, et al., 2003). Interestingly, reduction of hospitalizations is believed by clinicians to be related to decreased substance use and, by consumers, to be related to improvement in social support and finances (Lang, et al., 1999).   Police contact, arrests and incarceration.   Because of diminished ability to manage crises and limited skills for surviving in the community, persons with SMI are likely to have more encounters with the police than the general population (Lamb, Weinberger & DeCuir, 2002). With a duty to protect both the welfare of the community and individuals with disabilities who cannot manage on their own, police often try to settle crises, for non-mentally ill as well as for mentally ill, by defusing the situation.  If they are not able to resolve the crisis, they decide whether the person will be arrested or taken to a psychiatric evaluation setting (Hiday & Wales, 2003).  According to Schellenberg et al., (1992), between 33% and 50% of psychiatric patients have a history of being arrested; and, they say that, even after engagement in treatment, one in thirteen patients will be arrested.  Factors that predict increased risk of arrest are: being young, male, nonwhite, homeless, substance abusing and having a history of prior arrests. Persons with SMI who are arrested tend to be charged with nuisance crimes such as trespassing, failure to pay for meals, vandalism, loitering and disorderly conduct; or with shoplifting and theft. They are more likely to threaten harm than to use weapons or to cause injury. 

Employment -  Anthony and Blanch (1987) report that less than 15% of patients with severe mental illness are competitively employed. Barriers to employment include the residual disabilities of mental illness (Mueser, et al., 1997; McGurk & Mueser, 2003), lack of economic incentives, such as fear of losing social insurance program benefits and treatment programs that emphasize prevocational goals rather than competitive employment (Drake, McHugo, Becker, Anthony & Clark, 1996).

Satisfaction with Treatment -  Howard, et al., (2001) emphasize the need for consumers’ evaluation of their satisfaction with service, quality of care and effectiveness of treatment as a vital part of evaluating the effectiveness of a treatment option.  In measuring client satisfaction with Assertive Community Treatment, Gerber and Prince (1999) found that 80% of the clients indicated overall satisfaction with the treatment.  They were less satisfied in the areas of medications and their ability to influence treatment choices.

Method
Setting and Subjects
The setting was an ACT program provided by a not-for-profit Behavioral Health Services Organization.   After obtaining approval from the University at Buffalo’s Institutional Review Board and the agency’s clinical director, the 71 patients in the ACT program were invited to join the study. Fifty-six (79%) agreed to participate and signed consent forms.  There was no significant difference in age, race, marital status, living situation, employment, dangerousness, arrests/incarcerations, hospital readmissions, and functioning between patients who agreed to participate and those who refused. They differed significantly on three items. Women were more likely to refuse, as were patients with higher levels of educational achievement and patients with lower rates of alcohol and substance abuse.

Study Design
This comparative study was conducted between November 2000 and March 2002.  Data were obtained using record review, face-to-face interviews and staff observations.  Record review carried out by trained research assistants provided information about demographic characteristics and about hospital admissions, arrests, incarcerations, employment and homelessness for the year prior to admission to the ACT program and for the year following admission to the program.  Proximal outcomes and distal outcomes were obtained in face-to-face interviews conducted by the PI and, for three patients, by a Spanish speaking agency member.  ACT staff completed standard scales that related to severity of psychiatric symptoms and level of functioning based on their observations.  At the end of the study, patients completed a questionnaire that measured their degree of satisfaction with the program in an interview with research assistants or on their own if they preferred.

Intervention
The ACT program provides 24-hour, 7 day a week services by a multidisciplinary team that includes a psychiatrist, a nurse, case managers, substance abuse and vocational specialists and peer counselors.  It collaborates with other agencies such as housing, transportation and social services and has an agreement with a primary care clinician to provide medical care.  In a study that used The Dartmouth Asssertive Community Treatment Scale (DACTS) (Winter & Calsyn, 2000) to evaluate the fidelity to the ACT model of 28 ACT programs in New York State, the Buffalo ACT program had the highest rating of fidelity, a score of 3.81 out of a possible 5 (Laughlin, C., personal communication, March 21, 2002).  Priority for admission to ACT is given to patients who are non-responsive to treatment, homeless, recently incarcerated, at risk of danger to themselves or others, frequent users of psychiatric emergency services and to patients with repeated hospital admissions.  Patients are admitted to ACT voluntarily, often upon discharge from the hospital; or, as referrals from the AOT committee for enhanced outpatient treatment.  If patients are found by the AOT committee to be in need of AOT, they are given the choice of agreeing to a voluntary  enhanced outpatient treatment plan, the AOT diversion agreement, or facing a court order to follow a recommended treatment plan.  In Erie County, the proportion of people who accepted the diversion agreement from passage of Kendra’ Law in the fall of 1999 through February 2003 is much higher (83%) than the rate for all of New York State (39%) (“Western New York Assisted Outpatient Treatment Report”, 2003).  In Erie County, during the time of the study, 90% of individuals referred to AOT chose the diversion agreement (The Challenger, 2000). 

Instrumentation                                               
The Buffalo Client Assessment Inventory (BCAI), developed by the authors and used to obtain data, includes structured questions and research instruments—10 brief self-report instruments and 3 instruments that used observation- based ratings.  For this study, psychiatric diagnosis was the diagnosis entered in the patient’s record by the ACT team psychiatrist on enrollment in ACT and was based on longitudinal data, an extensive psychiatric evaluation and data available from collateral sources. Data relating to readmissions to a psychiatric hospital, police contact, arrests, and incarcerations during the year preceding admission to ACT were obtained from the record.  Legal status was obtained from the record review and, for the purpose of this study, is represented by AOT status and includes AOT diversion agreement and court petitions, the Group I patients,  and voluntary status, the Group II patients.  Among proximal outcomes, basic needs (food, clothing, transportation, medical care, dental care, housing and finances) were measured using the Meeting Basic Needs scale, a subscale of The Colorado Client Assessment Record (Ellis, Wilson & Foster, 1984), that was modified to include medical and dental needs. The scale has a range of 7 to 28 with higher scores indicating more unmet needs.  Psychiatric symptoms were assessed with the Brief Psychiatric Rating Scale (BPRS) (Overall & Gorham, 1962), score range of 18 to 126 with higher scores indicating greater severity of symptoms.  Psychological distress was measured with the Six-Item Indexes of Psychological Distress (Rosen, Drescher, Moos, Finney & Murphy, 2000), score range of 6 to 30 with higher scores indicating more psychological distress.  The scale asks the patients to indicate on a scale of 1 (not at all) to 5 (extremely distressed) how distressed they are by certain feelings or ideas. Stress was measured with the Modified Stress Ladder (Duffy et al., 1992), score range of 1 to 10 with higher scores indicating more stress.  Dangerousness was measured with the Violent Behavior Scale (Neale & Rosenheck, 2000) that elicits patients’ history of dangerous behaviors. The scale consists of eight questions about thoughts, discussions, threats or actions, four relating to self and four to others. The patient responds with a yes or no.  Each yes response counts as one.  Score range is 0 to 8 for the total scale or 0 to 4 for danger to self and 0-4 for danger to others with higher scores indicating greater risk for dangerous behavior. 

Distal outcomes--health, social support and life satisfaction--were measured respectively with the Self-rated Health Scale (Stewart, Hays & Ware, 1992), an eight item scale that has a score range 1-5, lower score indicates better health  (not reported in this article) and the Self-reported Health scale (Idler & Angel, 1990), a one-item scale that has a score range of 1-5 with lower score indicating better health; the Social Support Index (SSI) (Bell, et al., 1982) that has a score range of 0-8 with higher scores indicating greater support and  the General Life Satisfaction Scale (GLSS) (Lehman, 1988), that has a score range of 1, terrible, to 7, delighted.   Functioning was measured with two instruments, the Role Functioning Scale (RFS) (Goodman, Sewell, Cooley & Leavitt, 1993) and the Global Assessment of Functioning (GAF) (DSM-IV, 1994). The Role Functioning Scale (RFS) was used to measure overall level of functioning and functioning in four domains-- working/productivity; independent living/self-care; immediate social relationships and extended social relationships. The RFS is considered to be a reliable scale for measuring functioning among persons with SMI (Green & Gracely, 1987). The RFS score range for individual domains is 1 to 7 and for overall functioning, 7 to 28. Higher score indicates better functioning.  The GAF (DSM-IV, 1994) has a score range from 0 to 100.  Higher scores reflect better functioning, with scores of 50 to 41 indicating serious distress and dysfunction, 40 to 31, severe distress and dysfunction, 30-21, inability to function in most areas, and 20-11, danger to self or others (Rosse & Deutsch, 2000). All members of the ACT team received training in use of the GAF before the research study was initiated.  Satisfaction with treatment was measured with the Client Evaluation of Services (CSQ-8) (Nguyen, Attkisson & Stegner, 1983), an eight-item scale with a score range of 8 to 32.  Higher scores indicated greater satisfaction.  
 
Analysis of data
A repeated measures analytical approach was used to answer our research questions. Descriptive statistics were used to present demographic characteristics. Chi-square analysis was used to examine demographic characteristics between patients referred by AOT and voluntary patients.  Paired t-tests were used to compare the effectiveness of the intervention between prior year or baseline and 6 months for proximal outcomes.     For distal outcomes, paired t-tests were used to compare the effectiveness of the intervention between prior year or baseline and 12 months.  To manage missing data, existing time one data was used to create a regression equation.  Based on the parameters estimated by these regression equations, we substituted the missing values.  Chi-square and independent t-tests were also used to compare outcomes of Group I and Group II.  Statistical significance level was set at .05 level and 1-tailed test was used. 

Results
Demographic characteristics
As shown in Table 1, the majority of the 56 participants were male (77%) and African-American (59%). Twenty-four (44%) had not completed high school.  Most common clinical diagnosis was schizophrenia.  According to admission data in the record, 30 (54%) had a diagnosis of alcohol abuse and 32 (57%), drug abuse; 51 (91%) had been hospitalized at least once in the prior year; and 13 (31%) of the 41 participants with available data had exhibited dangerousness to others. Nineteen (34%) lived in unstable situations (emergency housing, shelters or “staying with friends”) and nineteen (34%) had been homeless at least once during the prior year. Thirty-seven  had been referred by AOT. Nineteen were voluntary admissions to ACT.

Table 1.  Demographic, Clinical and Community Adaptation Characteristics of

Patients on Admission to ACT

N=56                                                                                      

 

Demographic Characteristics

                                                                         n         %         

Gender

 

            Male                                                    43      77.0                                          

 

Female                                                             13      23.0

Age

 

            18-29                                                     9      16.1

 

            30-49                                                   39      69.6

 

50-69                                                                 8      14.3

Race

Caucasian                                                         19       34.0

            African American                                  33       59.0

            Latino                                                     3        5.0

            Pacific Rim                                             1        2.0

Marital Status

            Divorced                                              11        20.0

            Single                                                   45        80.0

Education

            Less than high school                            24        44.0

            High school                                          22        41.0

            Some college                                          5          9.0

            College degree                           3          6.0

Employment

            Unemployed                                         18        32.0

            Employed                                               5          9.0

            Total disability                                       33        60.0

Living situation (n=50)

            Stable housing                                     31        55.4                    

(house, apartment,

room, group home,

            board and care)                                     

Unstable housing                                             25       44.6

(shelter, motel, friend, homeless)

 

Legal status

            AOT                                                    37        66.1

            Non-AOT                                            19        33.9

Clinical Characteristics

Psychiatric diagnosis

            Schizophrenia                                       40        71.4                

            Schizoaffective                                       7        12.5

            Unipolar disorder                                   2          3.6

Bipolar disorder                                                 3          5.4

Anxiety Disorder                                                1          1.8

            Alcohol abuse   alone                              7        12.5

            Drug abuse alone                                    8        14.2

            Alcohol & drug abuse                           22        39.2

            Psychosis NOS                                      2          3.6

            Borderline Personality Disorder              2          3.6

            Antisocial Personality Disorder               7        12.5

            Personality Disorder NOS                      3          5.4

 

Danger to self (n=43)

(year prior to ACT enrollment)

                        0                                              39        91

                        1-3 times                                    4           9

Danger to others (n=41)

(year prior to ACT enrollment)

                        0                                              29        69

                        1-3 times                                    9        21

                        more than 3 times                       4        10

 

Hospital admissions

(year prior to ACT enrollment)

                        0                                                5          9

                        1-3 times                                  36        65

                        more than 3 times                     14        26

 

Community Adaptation Characteristics

(year prior to ACT enrollment)

                        Contact with police (n=34)      

                                    0                                  14        41

                                    1-3 times                      14        41

                        more than 3 times                       6        18

                        Arrests (n=48)

                                    0                                  30        63

                                    1-3 times                      13        27

                                    more than 3 times           5        10

            Incarcerations (n=40)

                        0                                              29        73

                        1-3 times                                  11        27

                        more than 3 times           0


Chi square analysis indicated that there was no significant difference in gender, race, marital status, education, housing, diagnosis, alcohol and substance abuse, arrest/incarcerations, dangerousness or hospital admissions between Group I and Group II on admission.  There was a difference in age  (2=6.28, df=2, p=.043). Among 37 patients in Group I, 22 (59.5%) were 30 to 49 years old and there were nearly equal numbers of younger patients (7 or 18.9%) and older patients (8 or 21.6%).  Among 19 patients in Group II, 17 (89.5%) were in 30 to 49 years old and two younger than 30. The statistical difference in employment status (2=7.73, df=2, p=.02) was of little clinical importance; e.g. four (10.8%) Group I patients employed and one (5.3%) in Group II..  Social support (score range 0-8) among Group I patients (3.35, s.d.=2.1) was significantly lower than among Group II patients, (4.77 , s.d.=2.1, df=2, p=.021).  (Test result is t (54)=1.71, p=.046.)

Research question 1:  Was there improvement of proximal outcomes?
Table 2 summarizes the pre-post comparisons of proximal outcomes. Basic needs.  
The overall rating of needs at the initial assessment was 12.68; e.g., the patients perceived their needs as met between “most of the time” and “some of the time”.  (Data obtained by asking patients about their unmet needs for the year prior to admission to ACT are not included in the measurement of the effect of treatment from baseline to 6 months; however, the total rating of needs for the prior year was 14.0, significantly more unmet needs than at the initial assessment.)  At initial assessment, the three needs most frequently rated as unmet were transportation, housing and dental care.  There was no significant change in patients’ perception of needs met between initial assessment and six months. Patients’ comments included: “If I want to go somewhere, I still have to walk”; “ I have a place to stay but it is not what I want; and, “I am afraid to go to the dentist”.    

 

 

Table 2.  Proximal Outcomes of Patients in ACT

 

                                                              Initial  Assessment                 6 month  Assessment

                                                              M           sd          n                      M          sd         n                                       

Total Basic Needsa                        12.68        5.39    50                   11.74     3.21     50

                                   

Psychiatric Symptoms

BPRS b                                                40.80      16.35    50                   32.7*   10.47     50

                                                     

Psychological   Distress         12.21        5.54    56                   10.86*   5.27        56

SCL-6c                                                             

 

Stress                                                   4.98         2.37   53                     3.94*    2.27    53

 Stress Ladderd                                                                             

                                   

Dangerousness

Violent Behavior Scalee

Toward self                                              .25          .76   43                        .07*     .46     43

(score range 4-8) 

 

Toward others                                          .21          .66    39                       .21       .52     3

 (score range 4-8 *significant at .05 (one-tail)

a  Meeting Basic Needs scale  (Ellis, Wilson & Foster, 1984) score range 7-28, higher score indicates more unmet needs
b  Brief Psychiatric Rating Scale (Overall & Gorham, 1962), score range 18-126, higher score indicates greater severity
c  Six-Item Indexes of Psychological Distress (Rosen, Drescher, Moos, Finney & Murphy, 2000), score range 6-30, higher score indicates greater psychological distress
d  Modified Stress Ladder, (Duffy et al. 1992), score range 1-10, higher score indicates greater stress
e Violent Behavior Scale (Neale & Rosenheck, 2000), score range 8-24, higher score indicates greater violence. Subscale danger to self, score 4-12; danger to  others, score 4-.

                                                                     
Psychiatric symptoms, Psychological distress, Stress and Dangerousness.  
There was a significant improvement of psychiatric symptoms that were rated by the ACT team and also a significant improvement of psychological distress that was rated by the patients.  On initial assessment of distress, feelings such as depression, fear, anxiety,  hopelessness and thoughts such as there is something wrong with your mind were rated in the moderately distressful range and at one year they were rated in the range of little distress.    Perceived stress showed significant improvement, decreasing one point.  There was a dramatic decrease in dangerousness toward self; but there was no significant change in dangerousness toward others.  In responding affirmatively to the questions of whether they talked about hurting or striking someone or threatened to do so, patients often added comments indicating that those actions were required to protect themselves in the community.   Of the six proximal outcomes, five (86%) showed significant improvement.

Research question 2: Was there improvement of distal outcomes?
Table 3 summarizes the results from pre-post comparisons of distal outcomes. Health.  There was a significant positive change in perception of general health; e.g., patients perceived their health as improved from time of admission.  Functioning.  There was significant improvement of one measure of functioning, the GAF that includes psychiatric symptoms but no improvement in functioning as measured by the RFS that does not include psychiatric symptoms.   Social support.  There was no significant change in perceived social support. Data obtained by asking the patients about their perceived social support for the year prior to admission to ACT showed that social support was 3.69 s.d. 2.1, considerably lower than the score obtained on the initial assessment, with patients referred for Assisted Outpatient Treatment having significantly lower social support, (3.4, s.d. 2.1) than voluntary patients (4.4, s.d. 2.1).  Life satisfaction.   There was significant improvement in life satisfaction.  Employment.  There was no significant increase in employment.  Arrests/incarcerations.  There was significant decrease in police contacts and arrests but no significant decrease in incarcerations. Use of medical and psychiatric emergency rooms and hospitals.  There was significant decrease in medical emergency room visits, medical hospital admissions and psychiatric emergency room visits.  The change was striking with the rates cut nearly in half. There was no decrease in psychiatric hospital admissions. Of the 13 distal outcomes examined, 8 (62%) showed improvement.

 

Table 3.  One-year distal outcomes of patients in ACT

                                          1 year prior            Initial Interview          12 month Interview

                                           M      sd       n          M      sd         n          M        sd         n         

Health

Self-rated Healtha                                             2.98   1.12       40        2.63*   1.21     40

Functioning                                                                                                    

1) RFSb                                                          13.35   4.59       53        13.67   3.31     53                

2) GAFc                                                         29.35   4.25       56        31.72* 3.96     56

Social                                                             4.13   2.12       40          4.30   1.80     40

Support

SSId                                                                   

Life

Satisfaction                                                       4.43   1.27     40        4.97* 1.27      40

GLSSe                                                                                                                                     

Medical                      .47   .84    32                                                      .19*  .54       32

Hospital                                             

Admissions    

Medical                      .86    1.3   36                                                      .47*  .91     36

Emergency                                                                                        

Room visits                           

 

Psychiatric                  1.33    7.98  40                                                             1.10  1.84   40

Hospital                                                                                             

Admissions                

 

Psychiatric                  1.91  1.90  32                                                              .81*  2.22    32

Emergency Room                                                                             

Visits                                      

Police contact             .84    .75    25                                                              .40*   .58    25

Arrests                        .59    .80    32                                                              .34*   .55    32

Jail                              .40     .71   25                                                              .28      46    25

                                               

Number

Employed                     5 [9%]    56                                                             

                                                                                   

Number  Homelessness

                             19  [38%]  50                                                                 5     [9%]   56

                                                                                                                       

Patient Satisfaction

With treatment                                                                                      28.71  4.09  35

(CES score range 8-32)        


a Self-rated Health, Idler & Angel, 1990), score range 1-5.  Higher score indicates better health.
  b Role Functioning Scale (RFS), (Goodman, Sewell, Cooley & Leavitt, 1993), score range 4 to 28.  Higher score indicates more positive functioning.
  cGlobal Assessment of functioning (GAF), DSM_IV based on GAS (Endicott, Spitzer, Fleiss & Cohen, 1977), score range 1-100. Higher score indicates more positive
 functioning.
  dSocial Support Index (SSI), (Bell, LeRoy & Stephenson, 1982), score range 0-8.  Higher score indicates greater social support.
  eGeneral Life Satisfactioin Scale, (Lehman, 1988), score range 1 (terrible) to 7 (delighted).
  fClient Evaluation of Services (CSQ-I), (Nguyen, Aattkisson & Stegner, 1983), score range 8 to 32.  Higher score indicates greater satisfaction.



Research question 3:  Were the patients satisfied with treatment?
The majority of the patients, 88%, were satisfied with treatment.  There was a significant difference in satisfaction between those referred by AOT (Group I) (mean= 27.78, s.d.= 4.72) and voluntary patients (Group II)  (mean=30.50, s.d.=1.38). 

Research question 4:
Was there a relationship between status on admission to ACT; e.g., being referred by AOT (Group I) or being a voluntary patient (Group II) and outcomes?  Table 4 summarizes the differences between distal outcomes of Group I and Group II patients. There were no significant differences of outcomes with one exception. There was a significant difference in readmissions to psychiatric hospitals with Group I having fewer psychiatric hospital readmissions.   

 

Table 4.  Distal Outcomes of Group I and Group II 

                                                      Group I                                   Group II                       t

M         sd         n                      M         sd         n                                            

Health a                                   

Baseline                                    2.9      1.2       37                    2.8       1.4       19            - .29    

    12-months                            2.6      1.2       27                    2.7       1.3       13              .24

RFSb

    Baseline                                13.1     4.6       37                   13.3     4.7       19             .20 

     12-months                           12.0     4.3       30                    14.2    4.3       14              .92

GAFc                                              

    Baseline                                29.3     3.8       37                    29.0     4.6       19            -.28 

    12-months                            31.0     4.7       20                    33.5     6.6       10            1.23 SSId

Baseline                                    3.62     2.24     37                     4.74    2.02     19           1.82*   

12-months                                4.2       1.8       26                     4.5      1.9       13              .50

GLSSe

Baseline                                    4.5       1.5       37                     4.2      1.4       19             -.80      12-months                           4.9       1.4       27                     5.3      1.6       13              .79

 

CSQ-8f                                               28        4.7       23                    30.5     1.4       12             2.6*               

                                         Group I                        Group II                                   z

Hospital admissions

      Year prior                  34/37 [.91]                    16/18 [.89]                              .24
     
12-months                 17/30 [.57]                    15/16 [.94]                           -3.42*

 

Arrests

     Year prior                 15/33 (.45)                     3/15 (.20)                              1.85

     12-months                  8/30 (.27)                     8/16 (.50)                             -1.54

 

Incarcerations

    Year prior                    9/27 (.33)                     2/13 (.15)                             1.34

    12-months                   9/30 (.30)                     6/16 (.38)                              -.54

                                   

 Employment

    Year prior                   4/36 (.11)                    1/19 (.05)                                .83

    12-months                   5/30 (.17)                    2/16 (.13)                               .3

*significant at .05

a Self-rated Health, Idler & Angel, 1990), score range 1-5.  Higher score indicates better health.
b Role Functioning Scale (RFS), (Goodman, Sewell, Cooley & Leavitt, 1993), score range 4 to 28.  Higher score indicates more positive functioning.
cGlobal Assessment of functioning (GAF), DSM_IV based on GAS (Endicott, Spitzer,
Fleiss & Cohen, 1977), score range 1-100. Higher score indicates more positive functioning.
dSocial Support Index (SSI), (Bell, LeRoy & Stephenson, 1982), score range 0-8.  Higher score indicates greater social support.
eGeneral Life Satisfaction Scale, (Lehman, 1988), score range 1 (terrible) to 7 (delighted.
fClient Evaluation of Services (CSQ-I), (Nguyen, Attkisson & Stegner, 1983), score range 8 to 32.  Higher score indicates greater satisfaction.


Discussion
The ability to generalize the findings of the study is limited by the small sample size and the characteristics of the setting--a poor, close-knit community with few entry level jobs but with available low-cost housing and established informal networks between the ACT team, other care providers and community agencies.  That there were few significant differences between demographic characteristics of Group I and Group II indicates that both groups came from the same pool of patients—frequent users of psychiatric and community services with high levels of psychiatric symptoms, substance abuse, dangerousness to others and impaired functioning and low levels of social support, employment, and education.  The fact that Group I had more younger and older patients may reflect the community’s acceptance of AOT as a vehicle for obtaining treatment for younger patients who might otherwise not access treatment or who, without needed treatment, might be incarcerated and for older patients who have fallen through the cracks and are no longer receiving needed care.  The lower initial assessment of social support among Group I suggests that these patients may lack people in their lives who could provide assistance or urge them to seek treatment.  Without such help, the likelihood of referral to AOT may have been increased.

It is likely that within the intervention, Assertive Community Treatment (ACT), the ACT team’s ability to: 1) develop a strong alliance with the patients; 2) engage them in treatment that often included monitoring their medications, counseling and substance abuse group interventions; 3) reduce their unmet needs from the status prior to admission to ACT ( even though improvement did not continue) and 4) resolve conflicts with families, landlords, police and entitlement programs contributed directly to improvement of proximal outcomes e.g., reduction of psychiatric symptoms, distress, stress and self-harm.   Because the measurement of dangerousness to others was broad, including thinking about hurting someone, talking about it, threatening it as well as actually striking or injuring someone, lack of improvement of dangerousness may represent continuing use of threats as a community survival strategy as well as actual acts of dangerousness toward others.                                     

ACT team’s expertise in mobilizing community resources and strong community networking skills likely influenced the evolvement of certain distal outcomes. For example, the ACT team’s ability to access health care for patients undoubtedly influenced their perception of improved health and also led to the striking reduction of  the number of visits to medical and psychiatric emergency rooms and medical hospitalizations.  In addition to influencing proximal outcomes such as stress and distress, ACT team’s involvement in helping patients resolve conflicts likely contributed to the reduction of homelessness, police contacts and arrests.   Improvement of functioning when measured with the GAF scale that includes psychiatric symptoms suggests that ACT team’s influence on functioning may have been due, at least in part, to their emphasis on adherence to medication.   Lack of improvement of role functioning in specific domains, of social support and of employment may be related to short exposure to Assertive Community Treatment, insufficient intensity of treatment or lack of treatment activities targeted to these specific outcomes. It may also be related to patient attributes such as limited education, lack of previous work experience and co-occurring substance abuse. 

Conclusion
ACT is effective in providing treatment for patients referred for Assisted Outpatient Treatment.    The findings suggest that Kendra’s Law did not add to outcomes.   The findings do suggest that Kendra’s Law served as a compensatory intervention for patients who lacked social support that might otherwise have prompted them to seek treatment and stay in treatment.   Lack of a decrease of incarcerations may be related to lack of improvement of dangerousness to others and also to some patients’ being sent directly to jail when they violated the diversion agreement.  That there was no reduction of psychiatric hospitalizations may be due to patient attributes such as substance use, non-adherence to medications, unmet needs and lack of social support.  However, it may paradoxically, indicate ACT effectiveness.  That is, the ACT team sought hospitalization for patients at high risk of becoming a danger to themselves or others. The lack of effectiveness of ACT in improving certain outcomes-- role functioning, social support and employment—is consistent with findings of other studies. The only treatment outcome difference between the groups, fewer psychiatric hospitalizations among Group I, is difficult to interpret.  Because of their greater lack of natural occurring social support, they may have been more responsive to the support and assistance provided by the ACT team.  Further study is needed to examine the influence of patient attributes, length of exposure to ACT and intensity and specificity of components within ACT on patient outcomes.        


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