Assertive community treatment in the Netherlands

Sytema et al. (1) conducted an important Assertive Community Treatment (ACT) study because their randomization procedure – informed consent after randomization – makes their research population fairly similar to daily mental health practice. They conclude that ACT is significantly better than standard care in maintaining contact only, but does neither significantly reduce the use of in-patient care facilities nor lead to important clinical or functional gains. Some comments may be passed on study design and conclusions. First, different from the comparison made in Table 1 in Sytema et al.’s article (1), Dutch community mental health (CMHC) teams discuss patients in weekly team meetings. However, differences between ACT and CMHC teams may exist in routinely discussing each patient in care of the team and the amount of time dedicated per patient. Second, smaller caseload allows for more contacts per patient per time. Hence, it cannot be excluded that positive results of ACT depend more on differences between arms in the size of the caseload than on the ACT approach. Further research on the impact of caseload-size is warranted. Third and more important is the skills issue. Authors argue that all skills are available in the ACT team. This may be questioned for several reasons. Even in ACT teams, everyday practice prevents all skills to be available at any time for each patient. Access of patients to available skills depends on treatment indication, work schedule and mere luck. Only, latter two factors are in favour of ACT due to smaller caseload while treatment indication and allocation to discipline may not have been different in both treatment arms. Another reason for questioning the validity of the availability statement is that disciplines are similar in both the ACT and the CMHC team, except for the ACT client worker. It is assumed that the ACT team daily meetings sufficiently result in transferring knowledge and skills among team members. Didactic literature does not support this assumption. Transference of knowledge may happen, although evidence for this is scarce. However, transference of skills requires more than daily sharing knowledge. Moreover, the authors implicitly equate discipline with skills which is certainly not the case in Dutch mental health care, and probably also not in other countries. In addition, a mutual frame of reference regarding treatment is not the standard in Dutch mental health care teams. When such frame is lacking, availability of all skills may become more confusing than when only few skills are present. This is certainly true in schizophrenic patients who due to cognitive deficits have difficulties in confining themselves to main facts. One may assume chances of triggering their deficits in verbal memory and face recognition being less in the CMCH teams that offer one-to-one therapeutic relationships than in ACT teams that offer diluted relationships. In other words, negative aspects of the ACT-construct may level the positive ones, not to consider former ones to exceed the latter. Last but not least, the all-skills-available-in-ACT claim may be doubted. Recent meta-analyses have shown a significant superiority of combination therapies over mono-therapies (2). In the severely mentally ill combinations of medication, cognitive behaviour therapy and problem solving oriented family treatment have proved superior in reducing symptoms, relapse and admission rate as well as in improving quality of life and social functioning (3, 4). Enduring effectiveness of cognitive behaviour therapy for delusions (5, 6) and of Hallucination focused Integrative Treatment (HIT) for auditory vocal hallucinations (7–10) have been proved. At best, staff of few Dutch ACT teams has been trained in motivational interviewing, Cognitive Behavioural Therapy (CBT), HIT and family treatment, but even this may be doubted. One may expect that combining availability of these skills with a mutual frame of treatment reference may give significantly better results than standard care in various clinically relevant domains. Effectiveness of such a programme – a precursor of ACT – has been demonstrated some 20 years ago (11). Compared with standard care, this precursor programme resulted in a significant reduction of psychiatric admissions per year. Finally this study raises questions about the value of continuity of care. Is it a panacea, good for everyone? Should it be restricted to specific disorders because of the risk of possible side-effects such as dependency and learned helplessness? Which increased yield should the continuity of care paradigm achieve and what evidence exists for its effectiveness in attaining this? Should ACT be widely implemented when increased number of contacts is the only significant surplus value of optimal accessibility to therapists with small caseloads who assertively deliver outreach services? I guess not. However, present knowledge precludes the drawing of well-founded conclusions on the subject. Further research with follow-up periods of at least 2 years is warranted to study who are benefited in which domains by assertive offering continuity of care. Sound decisions need an array of parameters and should be based on (cost-) effectiveness on burden (on patient, family as well as society), clinical improvements (symptoms, quality of life and social functioning), relapse and rehospitalization.