Assertive outreach in Denmark. Professor Merete Nordentoft Psychiatric Center Copenhagen, Copenhagen University

Transcription

1 Assertive outreach in Denmark Professor Merete Nordentoft Psychiatric Center Copenhagen, Copenhagen University

2 Marie Hoegh Thoegersen, Ph.D. Social Service Administration, Copenhagen Municipality

3 The needs of the group of reluctant patients with severe mental illness remain difficult to meet We need to find an effective approach for managing this group of patients for whom psychiatric care is essential 3

4 Assertive Community Treatment has been broadely implemented in Denmark OPUS - Early intervention Assertive Community Treatment for people with severe mental illness, age + 35

5 The Danish OPUS Trial: A two-site randomised clinical trial of assertive specialised psychiatric treatment First episode psychosis Five- and ten-year follow-up

6 Specialised Assertive Intervention by OPUS team Assertive Community Treatment (staff: patient ratio1:10) Psychoeducational multi family groups Social skills training

7 The OPUS team (8-12 staff members) Psychiatrist Psychiatric nurse Psychologist Social worker Occupational therapist Labour market/ educational guide

8 Assertive Community Treatment Multidisciplinary team, caseload 1:10 Team follows the patients during in and outpatient treatment Flexible frequency of contact (weekly) Home visits Coordinate different institutions involved in the treatment of the patient. GP, somatic department, creditors and social services.

9 Can contact be established?

10 For instance how to respond to an unpleasant official letter

11 Or how to respond when neighbours complain about too much wornout furniture placed in the corridor

12 The OPUS Program for involving the family: Consequently involving families Workshops for relatives Single family sessions McFarlanes model for psychoeducational multifamily groups, every second week for 1½ year. On going possibility for contact to the patient s primary team member

13 Out-patient contacts and family intervention during the two-year intervention periode OPUS Out-patient contacts Family groups Standard % 27 2%

14 Satisfaction with treatment 2 y

15 Drop-out No out-patient treatment Petersen et al, BMJ 2005

16 Substance abuse Comorbid substance abuse (%) P = 0.03 P=0.04 P=0.49

17 Use of beddays during and after the OPUS-trial Bertelsen et al, Arch Gen Psych 2008

18 Use of supported housing Living in an institution

19 The Danish OPUS Trial Conclusion: Psychotic and negative symptoms and substance abuse was significantly better after two years of intervention. Difference disappeared when patients in OPUS treatment were transferred to standard treatment after two years

20 The Danish OPUS Trial Conclusion: Significant more satisfaction with treatment in OPUS-team treated group after two-years Significantly better adherence in OPUSteam treated group Low dose strategy succesfully implemented in OPUS (20 percent lower dosage antipsychotic medication)

21 The Danish OPUS Trial Conclusion: O PUS is c he Me an Number of bedadays was reduced with 22 p s e a r angroup vingin:opus team and 5 percent compared with d b 3 0 dstandard ett e r 9 bed ays in treatment d a y Even aftersu the end of the experimental s p ( 2 p thperiode, 0 o %) still e fivepatients inrtintegrated treatment e d h ou(17 yeuse had a lower of bed days sinpercent ar p e g in riod lower) Fewer in the OPUS-treated group stayed in supported housing after five years OPUS treatment was cheaper and better than standard treatment

22 Summary of evidence for EIS Nice, Schizophrenia 2009: Offer early intervention services to all people with first episode psychosis. Provide comprehensive range of treatments Cochrane, Early intervention in psychosis 2011: Some support for specialised early intervention services, but further trials would be desirable, and there is a question of whether gains are maintained Port, Schizophrenia, 2009: Current evidence does not support any evidence-based treatment recommendations at this time, primarily due to small numbers of studies for any given intervention and some inconsistencies among the findings

23 16 OPUS/ Early intervention teams

24 Early Intervention Services in Europe

25 Assertive Community Treatment in Denmark for people with severe mental illness

26 Background ACT Stein & Test s original study (1980) Reduced days at hospital Improved clinical outcome, social functioning, likelihood of employment, adherence to antipsychotic medication, quality of life Australian study by (Hoult.et.al 1983) ACT began to gain influence on international service development Cochrane Review (Marshall & Lockwood1998)

27 Background Recent studies do not confirm the positive results of earlier studies ACT no longer reduces inpatient serviceuse Metaregression Burns et al ACT has no demonstrated effect on hospitalisation 30

28 Why this difference? THE CONTROL GROUP? A clinical successful outcome is determined just as much by the control group as by the intervention group

29 CONTROL ACT

30 End of road for treatment-as-usual studies? BMJ, Burns 2009

31 ACT no longer seems to reduce inpatient service use ACT continues to improve engagement with services and user-satisfaction More studies in other European countries with modern mental health services are needed to illuminate whether the UK findings are representative

32 Effect of ACT in two community mental health teams in Copenhagen

33 Characteristics of Interventions Team size pts Case load of max. 10 patients Extended hours Assertive Home visits Community No drop out policy Treatment make contact Team approach Frequent team meetings Team Team size 300 pts Case load of 30 patients Office hours only Community MainlyMental office based Health Discharge if unable to Teams Case-management Weekly/monthly meetings Referral to outside agencies

34 MODEL FIDELITY CMHT 41% ACT 91% Assessment of adherence to model (IF-ACT) = 14-item Index of Fidelity to Assertive Community Treatment scale

35 RESULTS: TWO YEAR FOLLOW-UP Number of patients lost to treatment Chart Title % of patients lost to treatment 8 P= ACT 38 CONTROL

36 RESULTS: TWO YEAR FOLLOW-UP Inpatient service-use 50 CONTROL 45 ACT P =0.31 Patients in ACT = 22.5 P hospital per year 25 fewer days in the Avg. no. = days of inpatient service-use per year P = b-line 1 year 392 year

37 RESULTS: TWO YEAR FOLLOW-UP User satisfaction (CSQ) CONTROL ACT Score on CSQ (0-25) P

38 Study I: In Summary ACT was more effective than standard treatment in regards to: Engaging patients Reducing hospitalisation Improving user satisfaction Improving social functioning Improving adherence to antipsychotic medication 41

39 Summary of Evidence for ACT Cochrane, ACT for those with severe mental disorder, 1998: Clearly favours ACT NICE, Schizophrenia, 2009: Not mentioned PORT, Schizophrenia 2009: Systems of care serving persons with schizophrenia should include a program of ACT. This intervention should be provided to individuals at risk for repeated hospitalizations or homelessness

40 Assertive Outreach in Europe?

41 Thank you for your attention