Integration of Illness Management and Recovery Within ACT
Condition: Severe Mental Illness; Schizophrenia; Bipolar Disorder
MeSH terms: Schizophrenia; Bipolar Disorder; Mental Disorders
Study type: Interventional

Summary: 
      Integrating Illness Management and Recovery (IMR) into Assertive Community Treatment (ACT)
      has great promise for improving the symptomatic, functional, and recovery outcomes for people
      with Serious Mental Illness (SMI), especially those individuals who have the greatest needs.
      In addition to these positive consumer outcomes, system benefits may also accrue due to more
      rapid graduation of consumers from ACT (with IMR) programs to less intensive levels of care.
      However, before these benefits can be realized, research and development are needed to design
      and pilot test a treatment manual that is feasible and acceptable to consumers and staff for
      integrating IMR and ACT.
    

Detailed description: 
      Despite significant advances in pharmacological treatments, many individuals with severe
      mental illnesses (SMI) such as schizophrenia and bipolar disorder continue to experience
      significant impairments in crucial life areas such as employment, housing, social
      functioning, and daily living skills. In addition, many of these individuals have significant
      levels of psychotic, mood, or negative symptoms, and are prone to frequent relapses and
      re-hospitalizations. Psychosocial treatments are needed to improve illness management and
      functioning beyond the limited effects of medication. However, relatively few psychosocial
      evidence-based practices (EBPs) exist for people with SMI and only a small percentage of
      people who could benefit from these treatments actually receive them. At the federal level,
      the implementation and dissemination of EBPs for people with SMI is a major policy priority
      and research objective.

      Assertive Community Treatment (ACT) Overview. ACT is one of five psychosocial treatments for
      people with SMI designated as an EBP by SAMHSA. Since its inception, ACT has grown from a
      single, experimental research treatment program to an essential element within the service
      continuum of most public mental health systems for people with SMI. ACT programs typically
      serve consumers with the most severe symptoms who have the greatest disability and support
      needs (e.g., high rates of homelessness and hospitalizations), and who are most difficult to
      engage and retain in standard outpatient programs.

      Research on ACT is extensive, with more than 25 RCTs. Literature reviews consistently
      conclude that ACT is more effective than standard community mental health services with
      demonstrated effectiveness in reducing psychiatric hospitalizations, and improving community
      tenure, retention in treatment, and high consumer and family satisfaction with services.
      However, ACT is less effective at improving symptom management, social functioning, and other
      functional outcomes, and needs to be adapted to better facilitate recovery. ACT is
      cost-effective compared to standard case management and has been widely disseminated with
      more than 300 ACT programs in at least 41 states.

      Illness Management and Recovery (IMR) Overview. The Illness Management and Recovery (IMR)
      program is well-suited for enhancing outcomes in those areas less effectively addressed by
      ACT: symptom management and community functioning. IMR is also one of five psychosocial EBPs
      identified by SAMHSA for adults with SMI. IMR programs have been widely implemented across
      the U.S. and other countries, and researchers have conducted a number of open clinical trials
      and quasi-experimental studies. Recently, three RCTs were conducted, supporting the
      effectiveness of group-based IMR implemented in outpatient mental health clinics and
      supported housing. These studies show significant positive outcomes with IMR, including
      symptom reduction, improved functioning, increased knowledge about mental illness, and
      progress toward personal recovery goals.

      Although these positive results support the effectiveness of IMR, several gaps and
      limitations are apparent in this growing area of practice and research. First, although IMR
      has been implemented clinically with very symptomatic consumers, such as inpatient and
      residential settings, controlled research on IMR has focused on outpatient settings,
      involving consumers who tend to be less symptomatic and higher functioning than those
      typically served on ACT teams. Second, providing IMR in outpatient clinics restricts the
      ability of clinicians to teach consumers skills in more natural community venues, which could
      improve the acquisition of new skills and related functional gains. Third, research on IMR
      has been mainly limited to the group modality, and hence, little is known about the effects
      of IMR provided in both individual and group formats.

      Integrating IMR with ACT. Several characteristics of ACT suggest it will be an excellent
      platform for integrating and implementing the IMR program. By design, ACT programs serve
      people with the greatest needs who tend to drop out of standard outpatient programs; thus,
      integrating IMR into ACT has the potential to improve illness self-management in those
      consumers who need it most. The individualized and assertive outreach nature of ACT services
      will also allow IMR to be delivered in both individual and group modalities, and the in vivo
      practice of ACT will empower consumers to learn and practice IMR skills in their natural
      settings. Finally, the ACT principle of working with families and natural supports will
      facilitate the involvement of those supports in helping consumers to better manage their SMI
      and to achieve their recovery goals.

      IMR also serves as an important potential service partner for ACT. ACT has been criticized by
      some as not being recovery-oriented. The integration of IMR may further enhance the growing
      recovery philosophy of ACT teams by providing a specific approach to promoting illness
      self-management and recovery that can be integrated into routine services. IMR can also
      improve the limited effectiveness of ACT teams at reducing symptoms and improving social and
      independent functioning. We also speculate (and plan to test in the subsequent, larger R01
      research program) that providing IMR will accelerate the graduation of consumers from ACT,
      thereby increasing the number of slots available for new consumers in need of this scarce
      resource, further enhancing its cost-effectiveness. Thus, the integration of ACT and IMR has
      the potential to significantly benefit consumers with SMI, and increase the efficiency of the
      ACT model.

      Despite these potential benefits, there are substantial challenges to integrating IMR into
      ACT teams. IMR has been developed and used primarily in traditional treatment settings, not
      in mobile community treatment approaches (e.g. ACT). In practice, many ACT clinicians find
      that their time is devoted to responding to daily crises and acute case management needs; ACT
      staff members often have difficulty making time and learning how to implement more
      learning-based and recovery-oriented interventions. Most critically, there are no
      standardized guidelines for implementing IMR within ACT, making the integration of the two
      EBPs even more challenging.

      A few ACT teams, however, have foreseen the promise of integrating IMR into ACT. Using a
      nonequivalent group design, Garfinkle and Storch found that ACT consumers in IMR treatment
      showed a number of positive outcomes compared to ACT consumers without IMR services over 11
      months, including lower hospitalization rates, improved retention of housing and competitive
      employment, and more work toward personal recovery goals. Salyers and colleagues conducted a
      small single group, pre-post pilot study to evaluate the feasibility of using peer
      specialists trained in IMR on ACT teams, and found that consumers who received IMR improved
      significantly on a measure of recovery, with a trend toward increased knowledge of mental
      illness, and consumer and staff satisfaction with IMR services. In a second study, Salyers
      and colleagues randomly assigned two of four ACT teams to IMR training and services (using
      only peer and mental health specialist staff for IMR service delivery). They reported that
      over the two-year period, ACT+IMR teams achieved moderate fidelity to IMR, but that rates of
      penetration were low, with only 25% of consumers having any exposure to IMR. However,
      secondary analyses found that ACT consumers who received IMR showed significant reductions in
      hospitalizations and incarcerations, and improvements in illness self-management.

      The lack of well developed guidelines for implementing IMR undoubtedly limited the
      effectiveness of the program in the Salyers' project. Fortunately, lessons learned from this
      study, as well as the SAMHSA EBP study on IMR and the present project team's practice and
      research experience with both ACT and IMR, suggest that with a number of adaptations IMR can
      be successfully integrated into ACT services. We plan to develop and implement the following
      promising strategies for integrating these two EBPs in this project: (1) develop an adapted
      manual, training resources, and fidelity scale specific to implementing IMR within ACT, (2)
      provide intensive initial and follow-up booster clinician training, (3) provide regularly
      scheduled clinical supervision of IMR within the ACT team, in addition to regularly scheduled
      outside consultation by IMR+ACT experts during project startup, (4) create an organizational
      culture that supports and champions the integration of IMR within ACT, (5) cross-train all
      ACT staff to support the consumer's participation in IMR, and (6) create several specific,
      strategic adaptations to ACT team operations and protocol to facilitate the practice of IMR
      within daily ACT service activities. We expect these implementation strategies to result in
      an integrated IMR+ACT program that yields positive outcomes both to consumers and mental
      health service delivery systems.
    

Intervention name(s): Assertive Community Treatment (ACT) + Illness Management and Recovery (IMR)
Intervention type(s): Behavioral
Intervention description(s): The integrated ACT+IMR model was developed and manualized prior to the start of this evaluation (27). The model incorporates the following key features: a) ACT staff provide IMR in office-based group and/or individual sessions in office or community settings; b) regular community follow-up by ACT staff to assist clients with practicing IMR skills and achieving their goals; c) regular communication within ACT team (e.g., during daily meetings) on IMR client goals and progress; and d) supervision and consultation on IMR within ACT.
Other intervention name(s): ACT+IMR
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: A pilot, cluster randomized controlled trial was conducted in which ACT teams were randomized to provide either IMR within ACT (ACT+IMR) or standard ACT treatment (ACT-only). The impact of ACT+IMR vs. ACT-only on illness management and recovery outcomes was based on assessments conducted on a subset of randomly selected clients from each team, conducted at baseline, six months, and one year. Randomization to ACT+IMR or ACT-only was stratified by state and by team size, resulting in one large team and one small team assigned to each condition in each state.
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Assertive Community Treatment (ACT) Only; Assertive Community Treatment (ACT) + Illness Management and Recovery (IMR)