Alcohol and Alcoholism Advance Access originally published online on April 24, 2008
Alcohol and Alcoholism 2008 43(4):451-455; doi:10.1093/alcalc/agn025
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Pilot Study of Assertive Community Treatment Methods to Engage Alcohol-Dependent Individuals
1 Division of Mental Health, Section of Addictive Behaviour, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK and
2 South West London and St George's Mental Health NHS Trust, Springfield University Hospital, 61 Glenburnie Road, London SW17 7DJ, UK
* Corresponding author: Professor Colin Drummond, National Addiction Centre, PO48, Division of Psychological Medicine and Psychiatry, Institute of Psychiatry, King's College London, 4 Windsor Walk, London SE5 8BB; E-mail: Colin.Drummond{at}iop.kcl.ac.uk
Received 10 December 2007; first review notified 18 January 2008; in revised form 17 March 2008; accepted 20 March 2008
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ABSTRACT |
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Aims: Assertive approaches to treatment, which are becoming established for individuals with severe and enduring mental illness, may also be beneficial for engaging alcohol-dependent individuals without severe psychiatric co-morbidity, but so far there has been little research on this. This pilot study looked at the feasibility and potential benefits of introducing assertive community methods into the treatment of alcohol-dependent individuals with a history of poor engagement. Methods: Non-randomized parallel cohort study comparing a Flexible Access Clinic employing assertive community treatment methods with the Usual Care Clinic. Participants were individuals re-referred to our service after they had previously disengaged from treatment. Results: Patients receiving assertive treatment attended assessment a mean of 14 days earlier than those receiving treatment as usual. Treatment at the Flexible Access Clinic was associated with significantly higher rates of completing assisted alcohol withdrawal (35% versus 26%) and entering an aftercare placement (23% versus 14%). Aftercare was entered significantly earlier in the Flexible Access Clinic group (93 days versus 125 days). Conclusions: These promising results point to the feasibility and potential efficacy of assertive community treatment methods for alcohol dependence, and the need for a randomized controlled trial of effectiveness and cost effectiveness.
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Introduction |
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Assertive community treatment (ACT) refers to a model of community service provision for people with severe mental illness (SMI) originally pioneered by the work of Stein and Test (1980
). While in most American studies this model was shown to be able to reduce the number and length of admissions (Burns et al., 2007; Marshall and Lockwood, 1998), in the UK no advantage over usual care has been found in relation to clinical or social outcomes (Killaspy et al., 2006). However, in the UK the approach did improve client engagement and satisfaction with services (Killaspy et al., 2006).
Like severe and enduring mental illness, alcohol dependence also often presents as a chronic relapsing disorder (Fillmore, 1988; McLellan, 2002; Vaillant, 2003) with high public health costs (Raistrick et al., 2006). More importantly, it includes a subgroup where engagement with treatment is problematic (Edwards et al., 1988) and for which elements of assertive management may be of benefit. In addition, for this subgroup it is possible that assertive management may also improve aspects of clinical outcome. In fact, while it has been suggested that in the UK usual care for SMI duplicates some of the key elements of ACT with this possibly contributing to the relative lack of effectiveness of the model in this country (see Killaspy et al., 2006; Burns et al., 2007), no such overlap is likely to occur for alcohol dependence, where treatment has historically emphasized personal choice and motivation more than assertive engagement.
The potential benefit of applying the principles of ACT to alcohol dependence is under-researched. The approach has been clearly described for SMI (Teague et al., 1998) and fidelity to the model can be measured using the Dartmouth Assertive Community Treatment Scale (Winter and Calsyn, 2000). Recent research has identified the following features as crucial elements of effective ACT: (i) rapid access to services, (ii) a small case load, (iii) a high ratio of community to office-based appointments, (iv) assertive engagement (e.g. with multiple attempts) and (v) a shared care approach, with care coordinators working within a multidisciplinary team that meets frequently (Burns et al., 2007; Wright et al., 2003). Some of these features have been already individually applied to the treatment of alcohol dependence and it has been found that they may improve aspects of outcome. For example, Gilbert (1988) used home visits as part of an aftercare package that increased the likelihood of treatment completion, and a recent randomized controlled trial found that a flexible (and extended) approach to aftercare increased the time to first drink and reduced the severity of relapses (Hilton et al., 2001; Stout et al., 1999). However, the potential benefits of elements of ACT in patients with alcohol dependence but without SMI remain unclear as are the specific aspects of the model that might apply to this disorder.
The present study compared two clinics for the treatment of alcohol dependence differing in the degree of assertiveness with which they attempted to engage individuals with a history of repeatedly presenting to alcohol services. It is important to notice that this was not a trial of the full ACT model as used in SMI, but a pilot study to examine the feasibility and potential benefits of using assertive approaches to engage such individuals. It capitalized on the introduction of a clinic, within our service, specifically designed to assertively engage individuals who had previously disengaged from treatment. The clinic, established in November 1999, included some of the features of the ACT model, which was being developed in the mental health services at the same hospital around the same time. Compared to the usual care clinic, this new clinic included more flexible access arrangements, such as appointments in the community, a smaller case load, a more assertive engagement and a greater emphasis on regular multidisciplinary case discussion (Wright et al., 2003). Since the clinic was funded by one of the three London boroughs that form the catchment area of our service, as a control group we recruited patients re-referred from the other two boroughs, who received usual care. The outcome measures reflected the main focus of the study on early engagement, looking at aspects of treatments up to aftercare.
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Methods |
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The Community Alcohol Team based at Springfield University Hospital, a teaching hospital in southwest London, offers tertiary alcohol treatment services for adults in the London boroughs of Wandsworth, Merton and Sutton, with an adult population of
500,000 (with the combined population of Merton and Sutton being approximately equal in size to that of Wandsworth). Participants of this study were all alcohol-dependent individuals re-referred to the service after premature disengagement, between 1 November 1999 and 31 October 2000. Individuals re-referred from the borough of Wandsworth were allocated to the newly established Flexible Access Clinic; individuals re-referred from the other two London boroughs received the usual care provided by the Community Alcohol Team (Usual Care Clinic). For all the patients, the clinics included access to medically assisted withdrawal (in- or outpatient), community care assessment, referral to other specialist services as necessary (e.g. liver clinic, children and family social services, homeless persons unit), as well as psychological treatment, including motivational interviewing and group or individual relapse prevention interventions. The clinics accepted referrals from general practitioners, hospital services, community mental health teams, social services, non-statutory agencies and the criminal justice system. Prior to assisted withdrawal from alcohol, clients would ordinarily have agreed on a comprehensive aftercare plan, involving either residential rehabilitation or a day treatment programme.
Usual care clinic
The staff included 2 full-time specialist alcohol community psychiatric nurses (CPN) and the equivalent of 2.5 full-time social workers. Medical cover was provided by a consultant, an associate specialist and a junior doctor on a fixed session basis (overall equivalent to one full-time medical staff). This clinic accepted all new referrals, as well as re-referrals from the boroughs of Merton and Sutton and therefore each care coordinator had a relatively large caseload (25–30). Individuals allocated to this clinic were sent an opt-in letter, inviting them to telephone the clinic to request an appointment. If they telephoned the clinic, they were placed on a waiting list (the average waiting time was 1 month). Once they reached the top of the waiting list they were sent a letter offering them a fixed appointment. If they did not attend this appointment, they were sent another opt-in letter asking them to contact the clinic within 2 weeks; otherwise they would be discharged. If they did attend the appointment, they were assessed and their case was discussed at the weekly multidisciplinary meeting, where they could be referred to other members of the clinic for further assessment. They would then be sent letters offering fixed appointments to complete such assessment. Thus, in this clinic multidisciplinary case discussion took place once weekly or less, community-based assessments were not offered and there was relatively limited integration of health and social care staff work (since this was limited to the weekly multidisciplinary team meeting).
Flexible access clinic
This clinic operated two walk-in weekly slots each of 3 h, and the staff included two full-time alcohol treatment workers (CPN). Social work, clinical psychology and medical cover were provided on sessional basis by the staff of the Community Alcohol Team. This clinic only accepted re-referrals from the borough of Wandsworth and thus each care coordinator had a smaller caseload (15). Individuals allocated to this clinic were sent a letter on the receipt of referral, inviting them to attend any of the forthcoming clinic slots of the following month. They were telephoned to encourage attendance, and if they did not attend they were contacted to enquire about the reason for not attending and to offer them a further four assessment slots. Failure to attend the clinic would be discussed by the team and resulted in assessment at the patient's home or at the general practitioner's clinic. Multidisciplinary case discussion took place after each initial assessment, and again after further joint assessment with other members of the team, particularly social workers and psychiatrists. Thus, in this clinic multidisciplinary case discussion took place more often (on an ad hoc basis), offered community-based assessments whenever patients had failed to attend and included fuller integration of health and social care staff work (joint assessments and individuals from different disciplines immediately available on each assessment slot). The Flexible Access Clinic was therefore modelled on ACT in the sense that, compared to the Usual Care Clinic, (i) it specifically targeted patients with a history of disengagement; (ii) it maintained a small case load; (iii) it operated proactively and engaged assertively; (iv) it offered a flexible access including assessment and treatment in the community where required and (iv) it was run by a CPN care coordinator working within a multidisciplinary team that met frequently, typically after each assessment or review. Figure 1 illustrates some of the differences between the Flexible Access Clinic and the Usual Care Clinic.
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Data collection and statistical analysis
Data were collected on all clients re-referred to the Community Alcohol Team between November 1999 and October 2000. Information regarding the demographics and alcohol problem severity of participants was extracted from the intake assessment and included the Severity of Alcohol Questionnaire (SADQ; Stockwell et al., 1983
) and Alcohol Problem Questionnaire (APQ; Drummond, 1990; Williams and Drummond, 1994) scores. Outcome measures were (i) the time from receipt of referral to first appointment offer, (ii) the time from receipt of referral to attendance at initial assessment, (iii) the time from receipt of referral to aftercare placement, (iv) the percentage of referred individuals who completed assessment, (v) the percentage of referred individuals who completed assisted alcohol withdrawal and (vi) the percentage of referred individuals who entered a planned aftercare placement. Data were analysed using the SPSS 11.0 statistical package. Data for continuous variables were analysed using Student's t-test, while data for categorical variables were analysed using the Chi-square test. |
Results |
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Participants
Between November 1999 and October 2000, the Community Alcohol Team received a total of 411 re-referrals, including 188 alcohol-dependent individuals re-referred from Wandsworth, who were assessed at the Flexible Access Clinic, and 223 alcohol-dependent individuals from Merton and Sutton, who were offered appointments to attend the Usual Care Clinic. The baseline characteristics of these two groups are presented in Table 1. There were no statistically significant differences between the groups at baseline in terms of age, gender ratio or severity of alcohol problems as measured by the SADQ or APQ, suggesting that the two groups were reasonably well matched on these measures relevant to treatment outcome. However, the Usual Care Clinic group reported drinking a larger amount of alcohol per week than the group accessing the Flexible Access Clinic (Table 1).
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Access to treatment
In keeping with the aim of this clinic to provide rapid access, individuals referred to the Flexible Access Clinic were offered access to first assessment on average 5.2 ± 0.8 working days after referral, i.e. nearly 4 weeks earlier than those in the Usual Care Clinic (32.0 ± 0.7 days; t = 12.486, P < 0.01). These improvements in care delivery times were maintained throughout the treatment pathway leading up to the enrolment in aftercare, as clients in the Flexible Access Clinic were also assessed earlier (21.7 ± 1.5 versus 35.7 ± 1.6 days; t = 4.86, P < 0.01) and entered aftercare placement earlier (93.2 ± 3.2 versus 124.5 ± 3.9 days; t = 2.61, P < 0.02). Analysis of covariance showed that these effects remained significant when baseline alcohol consumption was included as a covariate. Other differences between care in the Flexible Access Clinic and in the Usual Care Clinic, besides rapid access to treatment, are illustrated in Fig. 1.
Effect of assertive methods on aspects of engagement
As shown in Table 2, the Flexible Access Clinic was more effective at engaging patients, compared to Usual Care Clinic. Although similar numbers completed the initial assessment, more individuals attending the Flexible Access Clinic were retained in treatment through assisted withdrawal and to placement in aftercare. Approximately one in four individuals from the Flexible Access Clinic, but only one in seven of those in the Usual Care Clinic, entered aftercare.
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Discussion |
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These results show that retention in treatment of alcohol-dependent individuals with history of treatment non-completion is more likely when the management includes elements of ACT, compared with standard care. Since this was not a randomized controlled trial, these differences may have arisen as a result of sampling bias. However, we found no significant difference between the groups in terms of demographics, history of contacts with general psychiatric services or severity of alcohol problems as measured by the SADQ or APQ. The only baseline difference between individuals attending the Flexible Access Clinic and those attending the Usual Care Clinic was that the former reported drinking fewer alcohol units per week. Sensitivity analysis showed that differences between the groups in time to assessment and time to aftercare persisted when baseline differences in alcohol consumption were taken into account.
It is unlikely that the differences in treatment retention between the groups were merely an effect of rapid access. There were similar uptake rates of assessment in the two groups, despite differences in waiting times of almost 4 weeks on average. Rather, it seems that introducing elements of an ACT approach improved treatment retention. This is in keeping with previous literature on waiting list studies, which showed no relationship between the time to first assessment on either treatment uptake or retention in drug or alcohol treatment (Best et al., 2002; Donmall et al., 2005). Thus, it appears that the assertive treatment approach of the new clinic, rather than simply the shorter waiting times, was associated with greater engagement in and completion of the treatment programme.
For this pilot study we decided to only collect data from case notes rather than conducting follow-up interviews. This choice presents the advantage that information about treatment retention could be obtained for all participants, without attrition. In addition, there were no exclusion criteria and thus the patient group included in the study is a representative sample of individuals re-referred to an alcohol service in London after disengaging prematurely. However, this methodology does not allow inferences to be made about any effects on outcome after treatment completion. While it seems fair to assume that longer retention in treatment is a prerequisite for treatment effectiveness, it remains unclear whether it is also associated with improved clinical outcome after leaving treatment. Thus, from this study we could not establish to what extent introducing elements of assertive treatment would translate into more favourable clinical outcome, and we suggest that a clinical trial is needed to investigate drinking outcome in the longer term. Our study supports the feasibility of introducing assertive treatment methods into the treatment of alcohol-dependent individuals with history of repeated referral to NHS services. Although these methods will be resource-intensive, given the high level of service use by this patient group and the effects on treatment retention, the extra costs might be offset by better clinical outcome with reduced healthcare and other costs.
Research on the natural history of alcohol dependence shows that about a third continue to drink heavily in the long term (10–20 years) in spite of conventional treatment, resulting in significant unplanned use of health care and placing a significant financial burden on medical, social and criminal justice services, as well as having high mortality rates. In order to meet the needs of alcohol-dependent individuals with prior treatment disengagement and a chronic course, treatment services in the UK have been encouraged to use intervention strategies designed to maintain changes in behaviour through extended, close, holistic clinical management (National Treatment Agency, 2006; Raistrick et al., 2006). However, there is limited evidence of the effectiveness of these approaches and a lack of agreement about the most effective model, particularly for the individuals with more severe alcohol problems (Moyer et al., 2002). Our study shows the feasibility and potential of ACT approaches for alcohol dependence in individuals with a history of disengagement and points to the need of a randomized controlled trial on the effectiveness and cost effectiveness of ACT in this group.
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ACKNOWLEDGEMENTS |
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This work was supported by Wandsworth Drug and Alcohol Action Team (DAAT) and Wandsworth Primary Care Trust, particularly Dr Richard Wiles, DAAT coordinator. It was conducted as a case note audit rather than a research study and therefore was not subject to research ethics committee approval.
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