To the Editor: There is no consensus on whether assertive community treatment (ACT) for people with intellectual disabilities who also have mental health problems should be identical to ACT for people with mental illnesses.
Two studies have evaluated ACT for people with intellectual disabilities and coexisting mental health problems (1,2). However, they used versions that were significantly different from each other and from the original ACT model (3). To evaluate the suitability of this model for this population, characteristics of ACT that are necessary for people with intellectual disabilities need to be identified. We therefore report the results of a study that explored the opinions of specialist health staff.
The participants were 21 staff from four sites in the United Kingdom that deliver ACT-type services to people with intellectual disabilities. Participants included psychiatrists, psychologists, intellectual disability nurses, support workers, and occupational therapists. In-depth structured interviews were carried out in 2006 by two experienced clinicians. Participants were asked to express their opinion about each of 26 statements about ACT derived from the Dartmouth Assertive Treatment Scale (4). After complete description of the study, written informed consent was obtained from all participants. Ethical approval was obtained from Guy's Research Ethics Committee.
In general, participants' opinions were similar, although some disagreement was noted. Participants believed that ACT for people with intellectual disabilities should include most of the structural and human resource features of the original model, including a shared caseload, regular team meetings, a practicing team leader, continuity of staff, and a vocational specialist on staff. They also thought that there should be more than one psychiatrist and more than two nurses per 100 service users. In regard to organizational boundaries, they believed that there should be explicit admission criteria, but having a low intake rate, 24-hour coverage, and a rule about not closing any cases were seen as unnecessary, unrealistic, or inappropriate for this population. Participants indicated that hospital admissions and discharge planning should involve personnel from the ACT service, but it was not agreed whether these personnel should take responsibility for such planning.
There was disagreement about whether the ACT service should have full responsibility for treatment services, particularly housing support, employment, and rehabilitation. Participants agreed that the nature of the ACT service should be similar to that of the original model, including community delivery of services, involvement of service users' support networks, and a stagewise treatment model for those who misuse substances. There was disagreement on whether a no-dropout policy or high levels of service time and contacts were realistic or necessary. Participants did not support direct service provision by service users and family caregivers but agreed that their involvement in service development, support roles, and provision of feedback was essential. [Three tables that provide more details about participants' responses are available as an online supplement to this letter at ps.psychiatryonline.org.]
The main limitation of this study was that participants did not share the same level of understanding about the original ACT model. In addition, they were typically serving persons with a wider range of mental health problems than those for whom ACT was originally intended. A focus on patients with more severe mental health problems—for example, by restricting future research on ACT among persons with intellectual disabilities to those who also have psychotic disorders—would better complement research on ACT among persons with mental illnesses.
We thus hope that the findings reported here are useful for generating further discussion about ACT for persons with intellectual disabilities. It remains difficult to adequately determine whether service users with intellectual disabilities and mental health problems might benefit from ACT because of ongoing problems with the definition and implementation of the model for this service user group as well the lack of specialist professionals working with people with intellectual disabilities and mental health problems who have close knowledge and experience of ACT. Hence studies such as this one will be similarly limited. In our opinion, therefore, it may be more fruitful at present to explore the effectiveness of broader models of specialist community-based services for people with intellectual disabilities and coexisting mental health problems.
Dr. Hemmings, Ms. Underwood, and Professor Bouras are affiliated with the Estia Centre, Institute of Psychiatry, King's College London.
The authors acknowledge the contributions of Stephen Higgins, M.Sc., Geraldine Holt, F.R.C.Psych., Dimitrios Paschos, M.R.C. Psych., Elias Tsakanikos, Ph.D., and Steve Wright, M.Sc.
The authors report no competing in interests.
Martin G, Costello H, Leese M, et al: An exploratory study of assertive community treatment for people with intellectual disability and psychiatric disorders: conceptual, clinical and service issues. Journal of Intellectual Disability Research 49:516—524, 2005
Oliver P, Piachaud J, Done J, et al: Difficulties in conducting a randomized controlled trial of health service interventions in intellectual disability: implications for evidence-based practice. Journal of Intellectual Disability Research 46:340—345, 2002
Stein LI, Test MA: An alternative model to mental hospital treatment: I. conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry 37:392—397, 1980
Teague GB, Bond GR, Drake RE: Program fidelity in assertive community treatment: development and use of a measure. American Journal of Orthopsychiatry 68:216—232, 1998