Best Practices: Assertive Community Treatment for Persons With Severe and Persistent Mental Illness in Ethnic Minority Groups

Assertive community treatment is a well-established model for providing intensive treatment and psychosocial rehabilitation services to people with severe and persistent mental illnesses (1). Use of this model has been shown to lead to significant reductions in psychiatric admissions and hospital stays and to improved housing stability, symptoms, and quality of life (2). Although assertive community treatment has been well studied in the general population in North America and parts of Europe, no studies have examined its effectiveness when used with specific populations of persons with serious mental illnesses, such as recent immigrants, refugees, and persons from ethnic minorities with cultural and language barriers.

Patients from ethnic minority groups who have serious and persistent mental illnesses represent one of the most difficult-to-serve populations. Their severe functional impairment is often compounded by stressors related to migration and acculturation, language difficulties, socioeconomic disadvantages, inadequate housing, lack of access to services, and discrimination. Furthermore, many patients may be alone in their new countries—members of their extended family or other supportive persons may not be available. Loss of this support network is critical because research has suggested that family and social support is associated with favorable outcomes in developing countries (3).

Even though patients from ethnic minority groups have many needs, studies have shown that these groups are underserved by the mainstream mental health system, as demonstrated by less access and lower quality of care (4,5). Language and cultural barriers are key reasons for the disparity.

Recognizing this challenge, the Mount Sinai Hospital, funded by the Ontario Ministry of Health, in partnership with Hong Fook Mental Health Association (a community agency), developed an assertive community treatment team with a mandate to serve persons from ethnic minority groups in central Toronto.

Research is needed to examine whether the assertive community treatment model can be adapted for patients from ethnic minority groups who have serious and persistent mental illnesses. In this column we report on the unique and innovative aspects of this ethnoculturally focused team and use data from a one-year outcome study to describe its effectiveness. We hope that this column will help to lay the "best practice" groundwork for assertive community treatment services for these patients.

The team

The design and operation of the assertive community treatment team are based on the original Program for Assertive Community Treatment (6) and closely follow the fundamental principles of assertive community treatment (1). A review of the team generated a score of 13 out of 14 points on the Index of Fidelity of Assertive Community Treatment (7). The team consists of ten full-time-equivalent staff; the clinician-client ratio ranges from 1:6 to 1:10.

Data from local surveys showed that the primary need for ethnoculturally focused services in this area was for East and Southeast Asians as well as for African, Caribbean, and aboriginal populations. The design of the supportive programming, community agency partnership, and staff composition reflected this focus. All staff are bilingual and share the cultural backgrounds of one of the key ethnominority groups identified in the surveys. Assignment of primary staff to patients is based on language, culture, gender, geographic location, patients' wishes, and clinical needs.

Aside from engaging in classic assertive community treatment practices, we focus on tailoring services to meet patients' unique cultural needs. We conduct an acculturation assessment as part the psychosocial evaluation for all patients and develop individual treatment plans accordingly. To engage patients, culturally sensitive and meaningful group activities are strongly incorporated into regular programming. For example, activities include a weekly Chinese noodle group, a baking group, and a yoga and exercise group. We pay particular attention and channel resources to creating liaisons between team members and families and to providing family psychoeducation in the patients' native tongue to support and promote family involvement in patients' care, which can be so easily disrupted by serious and persistent mental illnesses. For example, we have regular weekend psychoeducational multifamily groups that are based on William McFarlane's model (8).

We have developed expertise in assisting patients to deal with immigration issues, refugee claims, and social assistance matters. As part of our mission and team philosophy, all team meetings and special "clinical situation" discussions highlight specific cultural issues, such as culturally influenced stigma, a lack of trust of authority, compliance with medication, or use of alternative health practices. Different seasonal and festival celebrations from diverse cultures are incorporated into the timetable to enhance cultural understanding and promote mutual respect.

One-year outcome study

In the one-year outcome study, we included 66 patients who were consecutively admitted to the program between 1999 and 2003. To measure acculturation we used a locally developed survey that records and rates patients' ethnicity, language skills, acculturation levels, and attitudes toward mental illness. We tracked all data related to number and length of psychiatric hospitalizations before and after admission to the team.

We used the expanded 24-item version of the Brief Psychiatric Rating Scale (BPRS) (9) to assess general psychiatric symptoms and the 17-item Hamilton Depression Scale (HRSD) (10) for mood symptoms. Possible total scores on this version of the BPRS range from 24 to 168, with higher scores indicating more severe and persistent pathology and greater interference with functioning. Possible total scores on the HRSD range from 0 to 68, with higher scores indicating more severe symptoms. We surveyed patients' satisfaction by using the translated versions of Consumer Survey Scale from the Ontario Ministry of Health.

As shown in Table 1, a total of 23 patients (35 percent) had no family member available in Canada. Sixty-two patients (94 percent) had a severe illness, such as schizophrenia or schizoaffective disorder, with a mean±SD duration of 15±8.5 years. During the year before admission to assertive community treatment, none of the patients was employed.

Overall, our patients had a low level of acculturation. Fifty-three (80 percent) were immigrants from Asian countries, 21 (32 percent) were illiterate in English or French, 36 (55 percent) were not familiar with the mainstream culture; for example, they were unable to perform basic tasks such as setting up telephone or bank services or to maintain any social contact within the mainstream society.

A goal of the team is to match patients and primary workers on language and ethnic group. Two-thirds of patients who communicated in languages other than English were matched in both language and ethnicity with their primary workers.

Significant reductions in hospitalization rates were noted from the year before admission to assertive community treatment to the year afterward. Total number of hospitalized days for the sample declined by 5,874 days, from 7,095 days to 1,221 days—an 83 percent reduction. The mean number of hospital days declined from 108±113 days to 19±39 days (Z=-5.32, p<.001, Wilcoxon signed-rank test). The number of inpatient admissions declined from 106 to 43.

Data on severity of symptoms were available for 55 of the 66 patients. Significant improvements were noted at one-year follow-up as measured by the BPRS score. The mean score decreased from 57.27±20.23 to 45.44± 5.54—a mean change of -11.84 (t=4.56, df=54, p<.001, paired t test). The HRSD mean total score decreased from 12.13±7.2 to 8.62±5.5, a mean change of -3.51 (t=3.25, df=54, p<.01, paired t test).

Forty-five clients completed the consumer survey questionnaire (68 percent response rate). Overall, 91 percent of patients were very satisfied (24 percent) or satisfied (67 percent). Seven percent were dissatisfied, and 2 percent were very dissatisfied.

Conclusions

Patients from ethnic minority groups who have serious and persistent mental illnesses face many difficulties. Our one-year outcome evaluation shows that, as we hypothesized and observed, our patients had spent many days in the hospital before they were admitted to assertive community treatment. They experienced difficulty understanding and speaking the languages of the mainstream culture, had low levels of acculturation, and lacked family support. Despite these challenges, which complicated the already complex task of providing treatment to this patient population, our results demonstrate that an assertive community treatment team designed to specifically address this underserved population can be successful in enabling these individuals to live in the community and can reduce relapse rates and alleviate psychiatric symptoms. It is noteworthy that two-thirds of our clients had to use languages other than English to communicate with their primary workers, suggesting that bilingual and bicultural workers contribute enormously to effectively serving these individuals.

Reduction of hospitalization is central to the mission of assertive community treatment programs and is one of the essential determinants in the reduction of overall cost. On this front, it is encouraging to see that the results from this unique team design are at least as good as those reported in the literature, even though the management of this special population may be more complex (11).

In addition, consistent with findings from other assertive community treatment teams, symptoms were moderately improved, and the consumer satisfaction survey yielded generally favorable results.

Certain limitations of the evaluation deserve comment. First, our outcome variables were limited to a few areas and did not include such variables as employment, quality of life, life skills, and so forth. These outcomes should be assessed in the future. Second, the findings must be interpreted in light of the relatively small sample and the short one-year follow-up. Third, our study cannot be generalized to all client populations from ethnic minority groups. Fourth, we do not intend to suggest that ethnic matching alone is responsible for successful outcomes—it is only one of the many unique aspects of the services. Finally, this study was retrospective, with no control group.

Despite these limitations, our findings provide new information and outcome data on the effectiveness of ethno-specific assertive community treatment, suggesting that such an approach can be an emerging best practice in serving individuals from ethnic minority groups who have serious and persistent mental illnesses, a sector of the already marginalized population who are traditionally unable to obtain services because of linguistic and cultural barriers. The encouraging results may also act as an impetus for service development and planning in our multicultural society.

The authors are affiliated with the department of psychiatry at Mount Sinai Hospital in Toronto. For the hospital's assertive community treatment team, Dr. Yang is program evaluator, Dr. Law is clinical director, Ms. Chow is program manager, and Dr. Andermann is the psychiatrist. Ms. Steinberg is director of community health programs and Dr. Sadavoy is psychiatrist-in-chief. Send correspondence to Dr. Yang at 260 Spadina Avenue, Suite 204, Toronto, Ontario, Canada M5T 2E4 (e-mail, [email protected]). William M. Glazer, M.D., is editor of this column.

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