Our study found no evidence of greater clinical efficacy or improvement in social outcomes for recipients of assertive community treatment compared with usual care from community mental health teams.
Our trial tackled the limitations of previous studies7-10
by using a randomised controlled design and testing the standard model for assertive community treatment.4,16
Our assertive community treatment teams had medium to high model fidelity and were representative of such teams in London.18
Our referral criteria were strictly adhered to and only a small number of participants not meeting referral criteria for recent inpatient care were recruited through our panel. Primary outcome data were available for all participants. Our findings therefore seem robust for inner city populations in the United Kingdom.
One important limitation of the study was its non-blindness, although this might have been expected to lead the assertive community treatment teams to resist more admissions than the community mental health teams. Likewise, interviewer bias might have been expected to increase differences between the groups. That this was not the case supports the validity of our findings. A second limitation was the response rate for follow-up interviews at which secondary outcome data on symptoms, needs, quality of life, and satisfaction were collected. However, use of a combination of participant and staff rated measures reduced both interviewer and non-response bias as data from staff rated measures on clinical and social function, substance misuse, compliance with drugs, and adverse events were available for all participants.
The number of days spent in hospital was similar for both groups and our primary hypothesis was therefore not supported. We analysed multiple secondary outcomes of which two achieved nominal significance. Any adjustment for multiple analyses would reduce the degree of statistical significance. Bearing this in mind, our results suggest that patients receiving assertive community treatment were better engaged in terms of both quantity and quality of contact with staff, and fewer clients were lost to follow-up. In addition, greater satisfaction with services was reported by clients assigned to assertive community treatment who agreed to be interviewed. These findings suggest that the assertive community treatment approach may be more acceptable to this difficult to engage client group than the standard community mental health team model. This was not, however, associated with any improvement in social or clinical function.
In the context of the UK government's national policy of strongly encouraging the implementation of assertive community treatment,13,14
our results require further examination. Inpatient mental health services in inner cities are already operating with high admission thresholds, most patients being detained under the Mental Health Act 1983.32
Interventions that aim to prevent or reduce admissions are therefore unlikely to succeed. It may also be that the approach of community mental health teams, particularly in inner cities, already incorporates features of assertive community treatment such as relatively low case loads, dedicated inpatient beds, similar staffing structures, and home visits.12
Another possibility is that because the assertive community treatment teams in our study were new, lack of experience may have reduced their effectiveness. Finally, an 18 month follow-up may not have been long enough to measure positive change: over a longer follow-up, greater engagement and satisfaction might have an effect on other outcomes.
Our findings should encourage policy makers and service planners to consider whether improved engagement and satisfaction for recipients of assertive community treatment justify its implementation. Further investigation is needed as to whether the elements of such treatment that enhance engagement with services could be incorporated effectively into the work of community mental health teams. Certainly this cannot be achieved through a simple reduction in case load.9,10
Assertive community treatment is gaining popularity in Europe, but our results suggest that it cannot be assumed to be preferable to well developed generic community mental health teams.
What is already known on this topic
Assertive community treatment is one of the most widely researched mental health service interventions
International studies have shown positive reductions in length and frequency of admissions
UK studies of other models of intensive community mental health care have found no advantage over usual care yet assertive community treatment has been implemented nationally
What this study adds
Assertive community treatment had no benefit over usual community mental health team care for inpatient admissions and clinical or social outcomes
Satisfaction and engagement with services may be greater for recipients of assertive community treatment