The association between program characteristics and service delivery in assertive community treatment

The authors describe the relationship between service intensity and staffing, organizational, client, and site characteristics in 19 programs based on the Thresholds Bridge adaptation of the assertive community treatment (ACT) model. Pearson correlations were examined between 14 program characteristics and intensity of ACT services. Several staffing and organizational attributes were related to service intensity: larger team size, shared caseloads, greater supervisor involvement in direct client services, and assignment of primary responsibility for the client to the team. The potential facilitating relationship between several aspects of team operation and intensive services is discussed as are implications for local implementation of ACT.     

Program fidelity in assertive community treatment: development and use of a measure

Assertive community treatment (ACT) is a complex community-based service approach to helping people with severe mental disorders live successfully in the community. Effective replication of the model and research on critical elements require explicit criteria and measurement. A measure of program fidelity to ACT and the results of its application to fifty diverse programs are presented.     

Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders

To investigate the possibility of engrafting fetal liver hematopoietic cells by in utero intraperitoneal transplantation, we transplanted donor cells obtained from mouse fetuses at 13, 15 and 17 days of gestation to mouse fetuses at 15, 16 and 17 days of gestation. Engraftment was assessed by Sry gene amplification of DNA extracted from peripheral blood samples of transplanted mice six weeks after birth. In comparison, we performed an in vitro colony-assay of fetal liver cells at 13, 15, and 17 days of gestation. The incidence of engraftment was significantly higher in cells of 15 days of gestation than in cells of 13 or 17 days of gestation, whereas the colony forming activity decreased gradually from 13 to 15 days of gestation. From these results, we suggest that the 15 day liver contains hematopoietic progenitors which have the specific characteristics required for engraftment by intraperitoneal transplantation.     

Mental health teams in the community

This article describes how one community psychiatric nursing service established a forum to clarify the roles and professional boundaries for nurses working within a multidisciplinary team. The author describes the initiative within the context óf the wider issues surrounding mental health care in the community.     

The impact of assertive community treatment on the social relationships of people who are homeless and mentally ill

Two randomized experiments compared the effectiveness of the assertive community treatment (ACT) team against other treatments (outpatient therapy, drop-in center, and brokered case management) in improving the social relationships of individuals who were both homeless and suffered from severe and persistent mental illness. In both studies clients assigned to ACT teams reported having more professionals in their social networks than clients assigned to the other treatments. Clients did not report significant differences between treatment conditions on most of the other social relationship dimensions. Further attention to developing social skills and network interventions within ACT teams are recommended.     

Cost-effectiveness of inpatient substance abuse treatment

OBJECTIVE: To identify the characteristics of cost-effective inpatient substance abuse treatment programs. DATA SOURCES/STUDY SETTING: A survey of program directors and cost and discharge data for study of 38,863 patients treated in 98 Veterans Affairs treatment programs. STUDY DESIGN: We used random-effects regression to find the effect of program and patient characteristics on cost and readmission rates. A treatment was defined as successful if the patient was not readmitted for psychiatric or substance abuse care within six months. PRINCIPAL FINDINGS: Treatment was more expensive when the program was smaller, or had a longer intended length of stay (LOS) or a higher ratio of staff to patients. Readmission was less likely when the program was smaller or had longer intended LOS; the staff to patient ratio had no significant effect. The average treatment cost $3,754 with a 75.0% chance of being effective, a cost-effectiveness ratio of $5,007 per treatment success. A 28-day treatment program was $860 more costly and 3.3% more effective than a 21-day program, an incremental cost-effectiveness of $26,450 per treatment success. Patient characteristics did not affect readmission rates in the same way they affected costs. Patients with a history of prior treatment were more likely to be readmitted but their subsequent stays were less costly. CONCLUSIONS: A 21-day limit on intended LOS would increase the cost-effectiveness of treatment programs. Consolidation of small programs would reduce cost, but would also reduce access to treatment. Reduction of the staff to patient ratio would increase the cost-effectiveness of the most intensively staffed programs.     

Situational determinants of assertive behaviors.

Administered 32 assertive situations that varied in social-interpersonal context to 60 male 21-67 yr old hospitalized psychiatric patients via role playing. Half of the role-played situations required the expression of negative (hostile) assertiveness, and the other half required positive (commendatory) assertive expression. Situational context was varied by having Ss respond to male and female interpersonal partners who were either familiar or unfamiliar to Ss. Responses were videotaped and rated on 5 measures of speech content and 7 measures of nonverbal behavior. Additionally, groups of high- and low-assertive patients were identified from the total sample using a behavioral measure of global assertiveness and a self-report instrument. Results indicate that interpersonal behavior in assertive situations varied as a function of social context. Further, high- and low-assertive Ss were differentiated on the basis of 9 of the 12 measures of interpersonal behavior. Support for a stimulus specific theory of assertive behaviors and implications for assertive training are discussed. (21 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cost-effectiveness model of adjunctive lamotrigine for the treatment of epilepsy

OBJECTIVE: To predict the cost-effectiveness of lamotrigine by evaluating the costs and health outcomes in treated patients. BACKGROUND: Lamotrigine adjunctive therapy has been found to be associated with decreased seizure frequency and severity in patients who are refractory to treatment with the older antiepileptic drugs (AEDs). METHODS: We used a cost-effectiveness clinical decision analysis framework to assess the impact of these clinical benefits on patient health care use. The measure of effectiveness was seizure-free days gained. The measures of health care resource use included hospitalizations, outpatient and emergency department visits, surgery, and AEDs. Medical care use and cost estimates were derived from clinical trial data and published sources. Costs and effectiveness (incremental costs per seizure-free days gained) of lamotrigine adjunctive therapy versus older AEDs were compared in patients refractory to previous treatment during three time periods: the start-up year, the second year when decisions about surgery were made, and all subsequent years. RESULTS AND CONCLUSIONS: The model predicts that use of lamotrigine would be associated with an overall reduction in use of other direct medical care resources (hospitalizations, outpatient visits, diagnostic and laboratory tests, and surgery). For a 10-year time horizon, the estimated cost-effectiveness ratio is $6.9 per seizure-free day gained. The model provides a flexible framework to analyze the effect of new antiepileptic drugs.     

Toward a task analysis of assertive behavior

Conceptualized assertiveness problems in terms of a task analysis of the topography of competent responding. 47 male and 54 female undergraduates who ranged from extremely nonassertive to highly assertive (according to their scores on the Conflict Resolution Inventory) responded to 3 sets of situations requiring refusal of an unreasonable request. Content knowledge of an assertive response, delivery of the response under 2 conditions, heart rate, self-perceived tension, and the incidence of positive and negative self-statements were assessed. Differences on these variables between low-assertive (LA), moderate-assertive (MA), and high-assertive (HA) groups were analyzed to determine the nature of the response deficit in nonassertive Ss. LA Ss differed from MA and HA Ss on role-playing assessments requiring them to deliver an assertive response, but they did not differ from MA and HA Ss on their knowledge of a competent response or on hypothetical delivery situations. No significant differences in heart rate were observed between LA, MA, and HA Ss; however, higher self-perceived tension was found in LA compared to MA and HA Ss. A greater number of negative and fewer positive self-statements were reported by LA compared to MA and HA Ss. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cost-effectiveness of guided self-help treatment for recurrent binge eating.

Objective: Adoption of effective treatments for recurrent binge-eating disorders depends on the balance of costs and benefits. Using data from a recent randomized controlled trial, we conducted an incremental cost-effectiveness analysis (CEA) of a cognitive–behavioral therapy guided self-help intervention (CBT–GSH) to treat recurrent binge eating compared to treatment as usual (TAU). Method: Participants were 123 adult members of an HMO (mean age = 37.2 years, 91.9% female, 96.7% non-Hispanic White) who met criteria for eating disorders involving binge eating as measured by the Eating Disorder Examination (C. G. Fairburn & Z. Cooper, 1993). Participants were randomized either to treatment as usual (TAU) or to TAU plus CBT–GSH. The clinical outcomes were binge-free days and quality-adjusted life years (QALYs); total societal cost was estimated using costs to patients and the health plan and related costs. Results: Compared to those receiving TAU only, those who received TAU plus CBT–GSH experienced 25.2 more binge-free days and had lower total societal costs of $427 over 12 months following the intervention (incremental CEA ratio of ?$20.23 per binge-free day or ?$26,847 per QALY). Lower costs in the TAU plus CBT–GSH group were due to reduced use of TAU services in that group, resulting in lower net costs for the TAU plus CBT group despite the additional cost of CBT–GSH. Conclusions: Findings support CBT–GSH dissemination for recurrent binge-eating treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A factor analysis of assertive behaviors.

Factor analyzed the data from 5 objective measures of interpersonal behavior, presumed to be tapping "assertiveness," administered to 55 male alcoholic inpatients. In addition, each behavioral measure was correlated with a subjective global rating of assertiveness. Four of the behavioral measures loaded highly on a general factor of assertiveness. The fifth behavioral measure loaded highly on a separate factor, Response Latency. All behavioral measures with the exception of response latency evidenced significant correlations with the subjective rating of global assertiveness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of conceptual complexity on assertive behavior.

Postulated that information-processing style is an important cognitive skill for effective assertive behavior and identified conceptual complexity (CC) as the variable that defined Ss' information-processing approach. In 2 studies, 146 undergraduates differing in CC were compared in their performance on various measures relevant to competent assertive behavior (e.g., Assertiveness Knowledge Inventory, the Hypothetical Behavior Role-Playing Assertion Test, and the Assertiveness Self-Statement Test). In Exp I, high CC Ss (e.g., those who possessed abstract schema for processing social information) demonstrated greater content knowledge, direct delivery skill, and fewer negative self-statements that inhibit assertiveness. Exp II involved the testing of various hypotheses about the specific role of CC in assertive encounters. High vs low CC females were more assertive in difficult situations (e.g., interaction with close friends) but did not differ in simple situations. High CC Ss were more assertive in extended interaction tests, expressed consideration of the needs of others, and were more flexible in sex-role orientation. (22 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive, assertive, and insight-oriented group therapies in the treatment of reactive depression in women.

33 nonpsychotic, nonsuicidal women (mean age 35.1 yrs) who scored between 15 and 31 on the Beck Depression Inventory (BDI) and whose depression was situationally related were assigned to 6-wk cognitive, assertive, or insight-oriented group therapy. Ss were administered a standardized interview, BDI, Rathus Assertiveness Schedule, Personality Data Form, and 4 tape-recorded scenes requiring an assertive response before and after the groups and at a 2-mo follow-up. Results show all groups improved significantly in depression, rationality, and assertiveness. Assertive and insight groups improved significantly more in rationality regarding acceptance than the cognitive group. At follow-up, none of the assertive groups, 18% of the cognitive group, and 45% of the insight group had sought further treatment. Additionally, the assertive group was significantly more rational regarding frustrating events and self-worth. The assertive and insight groups made significantly more gains and were more assertive than the cognitive group. A 3 (change in depression) by 3 (treatment group) ANOVA showed high-depression-change and medium-depression-change Ss changed significantly more in assertiveness and rationally than low-depression change Ss. (36 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On the decision to be assertive.

Examines the applicability of an expectancy/decision model to assertiveness in a nonclinical population of 111 college students. Assertiveness, defined as refusal to comply with an unreasonable request, has been researched extensively from the viewpoint of behavior theory, which prescribes anxiety reduction and skill acquisition for the training of assertive behaviors. However, little has been done to investigate the reasons why assertive behavior occurs in one situation and not in another. Results suggest that the Ss, irrespective of their scores on standard measures of assertiveness and of anxiety (Rathus Assertion Inventory and the State–Trait Anxiety Inventory Trait Scale), considered the consequences of being assertive when making a decision about how to behave. Moreover, it was found that the difference between Ss who chose an assertive response and those who did not lies in the formers' assessments of the probabilities that bad consequences will occur and good consequences will not rather than in their evaluations of how bad or how good those consequences would be. Results imply that training programs should take into account the participant's perceptions of the risks involved in being assertive and that the focus should be on changing these perceptions rather than on attempting to change his or her values or focusing solely on specific assertive behaviors. (22 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On the wisdom of assertive job-seeking behavior.

Employer ratings of 16 frequently advocated assertive job-seeking behaviors were summarized in terms of whether or not each would enhance or diminish the applicant's chances for being offered employment. These ratings were further subjected to an Applicant Sex?×?Industry Size MANOVA. Data were derived from 272 employers listed as business or industrial organizations in the 1981 College Placement Annual. Some behaviors were clearly adaptive; others appeared to be self-defeating. The applicant's sex proved irrelevant to hiring decisions; however, company size influenced the employment potential of 5 assertive behaviors. (21 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cost-effectiveness analysis

When different health care interventions are not expected to produce the same outcomes both the costs and the consequences of the options need to be assessed. This can be done by cost-effectiveness analysis, whereby the costs are compared with outcomes measured in natural units--for example, per life saved, per life year gained, and per pain or symptom free day. Many cost-effective analyses rely on existing published studies for effectiveness data as it is often too costly or time consuming to collect data on cost and effectiveness during a clinical trial. Where there is uncertainty about the costs and effectiveness of procedures sensitivity analysis can be used, which examines the sensitivity of the results to alternative assumptions about key variables. In this article Ray Robinson describes these methods of analysis and discusses possibilities for how the benefits of alternative interventions should be valued.