Assertive community treatment for people with severe mental illness: the effect on hospital use and costs.

OBJECTIVE: To determine the effect of the Program for Assertive Community Treatment (PACT) model on psychiatric inpatient service use in a population of non-emergency psychiatric patients with severe chronic mental illness, and to test for variations in this effect with program staffing levels and patient characteristics such as race and age. DATA SOURCES/STUDY SETTING: Data are taken from a randomized trial of PACT in Charleston, South Carolina for 144 patients recruited from August 1989 through July 1991. STUDY DESIGN: Subjects were randomly assigned either to one of two PACT programs or to usual care at a local mental health center. Effects on hospital use were measured over an 18-month follow-up period via multiple regression analysis. DATA COLLECTION METHODS: Data were obtained from Medicaid claims, chart reviews, subject, case manager, and family interviews; searches of the computerized patient and financial databases of the South Carolina Department of Mental Health and relevant hospitals; and searches of the hard copy and computerized financial databases of the two major local hospitals providing inpatient psychiatric care. PRINCIPAL FINDINGS: PACT participants were about 40 percent less likely to be hospitalized during the follow-up period. The effect was stronger for older patients. Lower PACT client/staff ratios also reduced the risk of hospitalization. No evidence of differential race effects was found. Given some hospital use, PACT did not influence the number of days of use. CONCLUSIONS: Controlling for other covariates, PACT significantly reduces hospitalizations but the size of this effect varies with patient and program characteristics. This study shows that previous results on PACT can be applied to non-emergency patients even when the control condition is an up-to-date CMHC office-based case management program.

Dissemination of assertive community treatment programs.

OBJECTIVE: The study sought to estimate the number of programs in the U.S. for severely mentally ill adults that used the assertive community treatment model and to describe variations in characteristics of the intervention across programs. METHODS: Assertive community treatment programs identified by state mental health authorities completed a 12-item survey. The survey included questions on caseload, composition of the treatment team, nature of services, and structure of service provision. RESULTS: A total of 303 of 340 programs (89 percent) identified by states responded to the survey. More than 75 percent provided most of their services in the field, delivered medications, included medical staff on the assertive community treatment team, and had caseload ratios of less than 20 consumers for each provider. CONCLUSIONS: Assertive community treatment programs have disseminated quite unevenly across 33 states, with the highest concentrations of programs in midwestern and eastern states.

A community-based public-academic liaison program.

OBJECTIVE: The authors discuss obstacles and incentives associated with successful community-based public-academic liaison activities and illustrate their conclusions by describing their public-academic liaison program, which received the American College of Psychiatrists' first annual Award for Creativity in Psychiatric Education. METHOD: The first 8 years of a state/university collaboration are described in which the parties involved first developed a variety of innovative services designed to fill specific gaps in the public service delivery system and subsequently integrated academic research and training components. RESULTS: The carefully planned and monitored process resulted in the exponential growth of interest in public sector work, the realization of the university's primary goals of developing high quality training and research sites, a substantial increase in the number of graduates accepting positions in the public sector, several projects funded by the National Institute of Mental Health, and two national awards. CONCLUSIONS: These collaborations illustrate the highly complementary relationship of public-academic liaison activities and their potential capacity to improve access to services, substantially improve the quality of these services, generate extramural support for services research, and increase the number of well-trained professionals in the public sector.

A pilot study of assertive community treatment for patients with chronic psychotic disorders.

This study measured hospital utilization and residential status of 51 patients with chronic psychoses before and after a 1-year program of assertive community treatment. Time hospitalized was reduced by 94%, and 82% of the patients previously living in hospitals or group homes attained independent living status, suggesting that this form of clinical management may reduce institutional care and costs to mental health care systems.

Providing assertive community treatment for severely mentally ill patients in a rural area.

OBJECTIVE: The authors' goals were to describe an assertive community treatment program developed for patients in rural South Carolina and to evaluate the effect of the program on rates of hospital utilization and cost of care. METHODS: Twenty-three patients with chronic psychotic disorders living in rural areas of South Carolina were assigned to an assertive community treatment program. The patients' average number of days per year in the hospital, length of stay per admission, number of admissions per year, and estimated annual cost of care during the five years before assignment to the program and during a period from four to 26 months after assignment were compared. RESULTS: The intervention was associated with a 79 percent decrease in hospital days per year, a 64 percent decrease in the number of admissions per year, a 75 percent decrease in the average length of stay per admission, and a 52 percent reduction in estimated direct cost of care. CONCLUSIONS: Although the methods of assertive community treatment may need to be modified to suit the travel requirements and other characteristics of rural settings, the study results suggest that the model can be successfully used in rural areas.

Oral contraceptives and panic disorder.

BACKGROUND: There are no published reports of an association between triphasic oral contraceptives and the development of panic disorder. METHOD: The authors describe two cases in which the use of triphasic oral contraceptives in women appear to have precipitated panic disorder. Treatment with the triphasic oral contraceptives was stopped and the patients were followed for 2 years. RESULTS: Both subjects had rapid and total resolution of their panic disorder symptoms following cessation of triphasic oral contraceptive medications. CONCLUSION: Triphasic oral contraceptives in some predisposed women may lead to precipitation of panic disorder.

PIP: Panic disorder, a severe anxiety disorder, affects 1-2% of the general population, mostly women 20-40 years old. A 29-year-old married white women with no children presented with an 18-month history of panic attacks. Episodes of abrupt anxiety lasted 5-20 minutes and occurred 3-4 times per week accompanied by rapid heart rate, shortness of breath, dizziness, and a fear of losing control. She was evaluated by a cardiologist several months earlier for episodic tachycardia, but the tests were normal. She was taking .5 mg of lorazepam po 2-3 times per month, which relieved her anxiety. Her only other medication was 1 tablet/day of Triphasal oral contraceptive (OC). She was started on treatment with desipramine 10 mg, and the dose gradually increased to 60 mg/day which she was unable to tolerate because of marked anorexia; lorazepam .5 mg bid and 10.5-mg tablet p.r.n. was continued to address excess activation secondary to the tricyclic depressant. She had changed from a constant dose OC (Lo/Ovral) to a triphasic preparation (Triphasil) 6 months prior to the onset of her panic attacks. The OC was halted, and she has experienced no subsequent panic attacks or avoidance behaviors during 2 years of follow-up. In the 2nd case a 39-year-old married white woman with 3 children presented with a 3-year history of panic attacks. She was given Ortho-Novum 7/7/7 1 tablet/day for about 8 months prior to her 1st panic attack, which occurred while she was driving. Her medications were clorazepate 3.75 mg b.i. d. and Ortho-Novum 7/7/7 1 tablet g.d. for 21 days of each month; she had been taking both since October 1984. Her father and brother had exhibited some driving avoidance behaviors. Because the triphasic OC preparation possible precipitated her panic disorder with agoraphobia, she was changed to Ortho-Novum 1/35 OC which has markedly improved her anxiety for 2 years now.

Computer prediction of serum theophylline concentrations in ambulatory patients.

This study assessed the ability of a computer program Simulated Kinetics (SIMKIN) to predict serum theophylline concentrations in ambulatory patients receiving oral theophylline. Data were collected by retrospective review of prospectively obtained data. A total of only 20 measured serum theophylline concentrations could be included in the study, although records of 195 patients were reviewed. An estimated patient compliance of 90-110% was required and was computed using prescription refill information. Predicted serum theophylline concentrations were generated for each patient by entering into the SIMKIN program the characteristics pertinent to theophylline disposition and the patient's theophylline dosing regimen. Actual and SIMKIN-predicted theophylline concentrations were compared by using simple linear regression and by constructing a 95% confidence interval around the mean prediction error and root mean squared error. The ability of SIMKIN to predict therapeutic category, i.e., subtherapeutic, therapeutic, or toxic, was assessed using Fisher's exact test. SIMKIN predictions of individual theophylline concentration were insufficiently accurate to replace confirmatory followup monitoring of actual levels. However, SIMKIN was able to predict the therapeutic category with 70% accuracy. We conclude that SIMKIN may be useful for categorizing a dose regimen of theophylline as therapeutic, but that it is of little use in predicting individual concentrations in outpatients when literature-averaged pharmacokinetic parameters are the sole criteria for prediction, and compliance cannot be accurately assessed.