Assertive community treatment (ACT)versus casemanagement in treating homeless patients with severe mental illness; a randomized controlled trial.

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Homeless patients with severe mental illnesses have to deal with a broad spectrum of problems. Besides the housing problems they have poor physical and mental health, none or low financial income, difficulties in fulfilling social obligations, have relational handicaps, etc. This is more of importance as homeless psychiatric patients are typically avoidant in seeking help or accepting any help if offered. Assertive community treatment is a treatment model, developed in the United States in the seventies, that is characterised by a multidisciplinary teamapproach and a low caseload of patients per worker. Although research results are partially contradictive, the general opinion in research literature is that assertive community treament leads to less acute admissions in psychiatric hospital, shorter duration of the admissions and both a higher grade of satisfaction with the care by patients and workers, in comparison with treatment by casemanagement teams. The effect of ACT for homeless patient has hardly been studied. We hypothesize that ACT leads to more stabile housing conditions and more stabile treatment contacts than casemanagement.

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Workers from the Rehabteam of Mentrum Mental Health Organisation in Amsterdam, Netherlands, has in the past decade treated homeless patients via the casemanagement treatment model. The team is formed by specialised psychiatric nurses who were backed by a consulting psychiatrist for drugtreatment and (involuntary) admissions. In the last years workers felt that they lacked time and specific knowledge to consilidate the progression they made in treatment. For instance: when a patient was motivated for drugtreatment, at the same time the medical insurance was stopped, because the patient could not pay the bills, etc. Sitevisits to other teams in different cities and countries brougt the idea of assertive community treatment. In july 2005 a separate ACT-team was started within the Rehabteam. The ACT-team attracted a social worker, an experience worker, an office manager, etc. The remaining Rehabteam kept working via the casemanagementmodel. Only a portion of the homeless patients could be assigned for the ACT-team. A random sample of the homeless patients was assigned to the ACT-team. This made a comparison with the casemanagement team possible.




Intervention 1:

Assertive community treatment team; treatment during 24 months.




Intervention 2:

Casemanagement team; treatment during 24 months.

Data from the teamworkers/nurses will be collected at the start, after 12 months and after 24 months.