In This Issue: Does ACT Apply in Canadian Inner Cities? - Assessing ACT - Balancing ACT - Featured Tool: Client Contact Log

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Does ACT Apply in Canadian Inner Cities?

Left to right: Margaret Gehrs, Dr. Lorne Tugg, Nicole Kirwan, Don Wasylenki, Michael Higgens, Suzanne Cohen, Nancy Read, and John Langley

A project led by Dr. Donald Wasylenki, Psychiatrist-in-Chief at St. Michael's Hospital in Toronto, is investigating whether the ACT model can be implemented in a Canadian inner city environment and if it is beneficial to clients with severe and persistent mental illness in that setting. The project also seeks to determine if basing ACT in a hospital can help bring hospital and community care closer together. Finally, the study will compare the cost of ACT with another form of intensive community treatment.

This research project will examine the services and outcome of the CONTACT Mental Health Outreach Service, one component of mental health services operated by St. Michael's Hospital. The surrounding community in southeast Toronto is extremely disadvantaged, with high rates of poverty, hospitalisations for mental illnesses, homelessness and substance abuse. Until now, there have been no Canadian studies of the effectiveness of ACT in such an environment. The CONTACT team follows the ACT model and provides community treatment for severely ill individuals. The team consists of nurses, social workers, addictions counsellors, an occupational therapist, peer support workers, a vocational rehabilitation therapist, a social recreation therapist and psychiatrists and operates off the hospital site, near a large park frequented by people who are homeless, mentally ill and using substances.

In this study, clients are randomly assigned to the CONTACT team or to Community Connections, another innovative case management program at St. Michael's Hospital, which links clients with treatment and rehabilitation services in the community. These services include social recreational programming, work programs, supportive housing and volunteer companions. Community Connections staff work closely with outside agencies and play an important role in coordinating and monitoring clients' use of community resources. Clients in the study are assessed prior to the project, nine months later and again at 18 months. During the project, recognized tests used to measure mental health status will document clients' psychiatric symptoms, insight into their illness, satisfaction with the services, sense of hopelessness, housing, suicidal behaviours, thought or intentions, and levels of alcohol or drug use. To date, the researchers have completed 90 percent of the initial assessments and over a third of the two follow-up assessments.

At the same time, the service providers will be monitored to determine the amount of time spent on patient care and the types of services provided. This data will also later permit a detailed analysis of the cost-effectiveness of the program. A "fidelity" scale will be used to rate the operation of the CONTACT team against the ideal concept of an ACT team. In addition, the researchers will survey 25 relevant community agencies to see if the program has increased referrals and collaboration between community agencies and the ACT team. The survey will also address levels of satisfaction with the integration of the service.

In addition, four sub-studies have been initiated, using the project data to examine certain significant factors in more detail. One sub-study is probing the effectiveness of measurements of client "insight" into his/her own mental illness, which may affect willingness to accept or cooperate with care. The other studies will consider suicidal thoughts and actions, an examination of alcohol and drug use in greater detail and the impact of personality factors on community treatment outcomes among people with major mental illness.

The clients participating in this study are among those within the health and social services system at highest risk in many categories, and are heavy users of a range of health and social services, especially inpatient, crisis and emergency services. Determining the effectiveness of these two models for this group will be a valuable addition to our understanding of how to help hard-to-serve and extremely disadvantaged individuals with mental illness.

For more information about this study, see the project description.

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