Comparison of Assertive Community Treatment Programs in Urban Massachusetts and Rural North Carolina

Original Paper


In this pilot study, we compared teams in rural North Carolina (NC) and urban Massachusetts (MA) to examine the how sites vary the implementation of the Assertive Community Treatment (ACT) model to respond to state and local circumstances. We analysed and compared data on: client characteristics using the NC-TOPPS and a modified survey in MA; Regional Demographics and; Team Characteristics. Issues such as driving distances, lack of qualified clinical staff, scarcity of physicians, and more limited oversight created impediments to fidelity in rural NC, despite higher per patient funding. ACT is now national, but variability in implementation of the model remains.


Assertive community treatment (ACT) Mental health Rural Urban 



We would like to thank: Jill Sheridan; Wendy Webber; Gail Craddock and Marge Cawley at the National Development and Research Institutes in North Carolina; the Massachusetts Department of Mental Health; and the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services; and the team leaders from North Carolina who participated in the survey.


  1. American Community Survey. (2006). [cited 22 September 2007]; Available from:
  2. American Medical Association Physician-Related Data Resources. (2007). [cited 21 September 2007]; Available from:
  3. American Psychiatric Association. (2000). Task Force on DSM-IV. Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th ed.). Washington, DC: American Psychiatric Association.Google Scholar
  4. Atkinson, M., Zibin, S., & Chuang, H. (1997). Characterizing quality of life among patients with chronic mental illness: A critical examination of the self-report methodology. The American Journal of Psychiatry, 154(1), 99–105.PubMedGoogle Scholar
  5. Becker, R., Meisler, N., Stormer, G., et al. (1999). Employment outcomes for clients with severe mental illness in a PACT model replication. Psychiatric Services (Washington, DC), 50, 104–106.Google Scholar
  6. Blank, M. B., Fox, J. C., Hargrove, D. S., & Turner, J. T. (1995). Critical issues in reforming rural mental health service delivery. Community Mental Health Journal, 31(6), 511–524. doi: 10.1007/BF02189436.PubMedCrossRefGoogle Scholar
  7. Bond, G., Drake, R., Mueser, K., & Latimer, E. (2001). Assertive community treatment for people with severe mental illness: Critical ingredients and impact on patients. Disease Management & Health Outcomes, 9(3), 141–159. doi: 10.2165/00115677-200109030-00003.CrossRefGoogle Scholar
  8. Burns, T. (2000). Models of community treatments in schizophrenia: Do they travel? Acta Psychiatrica Scandinavica. 102(Suppl. 407), 11–14. doi: 10.1034/j.1600-0447.2000.00002.x.CrossRefGoogle Scholar
  9. Burns, B., & Santos, A. (1995). Assertive community treatment: An update of randomized trials. Psychiatric Services (Washington, DC), 46(7), 669–675.Google Scholar
  10. Ceilley, J. W., Cruz, M., & Denko, T. (2006). Active medical conditions among patients on an assertive community treatment team. Community Mental Health Journal, 42(2), 205–211. doi: 10.1007/s10597-005-9019-2.PubMedCrossRefGoogle Scholar
  11. Chandler, D., Meisel, J., Hu, T., McGowen, M., & Madison, K. (1996). Client outcomes in a three-year controlled study of an integrated service agency model. Psychiatric Services (Washington, DC), 47, 1337–1343.Google Scholar
  12. Craddock, S. G., Rounds-Bryant, J. L., Flynn, P. M., & Hubbard, R. L. (1997). Characteristics and pretreatment behaviors of clients entering drug abuse treatment: 1969–1993. The American Journal of Drug and Alcohol Abuse, 23(1), 43–59. doi: 10.3109/00952999709001686.PubMedCrossRefGoogle Scholar
  13. Cuddeback, G. S., Morrissey, J. P., & Cusack, K. J. (2008). How many forensic assertive community treatment teams do we need? Psychiatric Services (Washington, DC), 59(2), 205–208. doi: 10.1176/ Scholar
  14. Cuddeback, G. S., Morrissey, J. P., & Meyer, P. S. (2006). How many assertive community treatment teams do we need? Psychiatric Services (Washington, DC), 57(12), 1803–1806. doi: 10.1176/ Scholar
  15. Dixon, L., Friedman, N., & Lehman, A. (1993). Compliance of homeless mentally ill persons with assertive community treatment. Hospital & Community Psychiatry, 44(6), 581–583.Google Scholar
  16. Drake, R., McHugo, G., & Noorsy, D. (1993). Treatment of alcoholism among schizophrenic outpatients: 4-year outcomes. The American Journal of Psychiatry, 150, 328–329.PubMedGoogle Scholar
  17. Dush, D., Ayres, S., Curtis, C., Worthington, G., Gabriel, R., & Chinnery, T. (2001). Reducing psychiatric hospital use of the rural poor through intensive transitional acute care. Psychiatric Rehabilitation Journal, 25, 28–34.PubMedGoogle Scholar
  18. Edwards, J., & McGorry, P. D. (2002). Implementing early intervention in psychosis: A guide to establishing early psychosis services. London: Martin Dunitz.Google Scholar
  19. Essock, S. M., Mueser, K. T., Drake, R. E., Covell, N. H., McHugo, G. J., Frisman, L. K., et al. (2006). Comparison of ACT and standard case management for delivering integrated treatment for co-occurring disorders. Psychiatric Services (Washington, DC), 57(2), 185–196. doi: 10.1176/ Scholar
  20. Fox, J., Blank, M., Berman, J., & Rovnyak, V. (1999). Mental disorders and help seeking in a rural impoverished population. International Journal of Psychiatry in Medicine, 29, 181–195. doi: 10.2190/Y4KA-8XYC-KQWH-DUXN.PubMedCrossRefGoogle Scholar
  21. Fraher, E., Swartz, M., & Gaul, K. (2006). The supply and distribution of psychiatrists in North Carolina: Pressing issues in the context of mental health reform. Chapel Hill, NC: Cecil G. Sheps Center for Health Services Research.Google Scholar
  22. Fuller, R. K., Lee, K. K., & Gordis, E. (1988). Validity of self-report in alcoholism research: Results of a veterans administration cooperative study. Alcoholism, Clinical and Experimental Research, 12(2), 201–205. doi: 10.1111/j.1530-0277.1988.tb00180.x.PubMedCrossRefGoogle Scholar
  23. Gold, P. B., Meisler, N., Santos, A. B., Carnemolla, M. A., Williams, O. H., & Keleher, J. (2006). Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness. Schizophrenia Bulletin, 32(2), 378–395. doi: 10.1093/schbul/sbi056.PubMedCrossRefGoogle Scholar
  24. Gwynn, R. C., McQuistion, H. L., McVeigh, K. H., Garg, R. K., Frieden, T. R., & Thorpe, L. E. (2008). Prevalence, diagnosis, and treatment of depression and generalized anxiety disorder in a diverse urban community. Psychiatric Services (Washington, DC), 59(6), 641–647. doi: 10.1176/ Scholar
  25. Hardre, P. L., & Reeve, J. (2003). A motivational model of rural students’ intentions to persist in, versus drop out of, high school. Journal of Educational Psychology, 95(2), 347–356. doi: 10.1037/0022-0663.95.2.347.CrossRefGoogle Scholar
  26. Hartley, D. (2004). Rural health disparities, population health, and rural culture. American Journal of Public Health, 94(10), 1675–1678. doi: 10.2105/AJPH.94.10.1675.PubMedCrossRefGoogle Scholar
  27. Hubbard, R. L. (1989). Drug abuse treatment: A national study of effectiveness. Chapel Hill: University of North Carolina Press.Google Scholar
  28. Hubbard, R. L., Rachal, J. V., Craddock, S. G., & Cavanaugh, E. R. (1984). Treatment outcome prospective study (TOPS): Client characteristics and behaviors before, during, and after treatment. NIDA Research Monograph, 51, 42–68.PubMedGoogle Scholar
  29. Human, J., & Wasem, C. (1991). Rural mental health in America. The American Psychologist, 46(3), 232–239. doi: 10.1037/0003-066X.46.3.232.PubMedCrossRefGoogle Scholar
  30. Kane, C., & Blank, M. (2004). NPACT: Enhancing programs of assertive community treatment for the seriously mentally ill. Community Mental Health Journal, 40, 549–559. doi: 10.1007/s10597-004-6128-2.PubMedCrossRefGoogle Scholar
  31. King, R. (2006). Intensive case management: A critical re-appraisal of the scientific evidence for effectiveness. Administration and Policy in Mental Health, 33(5), 529–535. doi: 10.1007/s10488-006-0051-5.PubMedCrossRefGoogle Scholar
  32. Latimer, E. (1999). Economic impacts of assertive community treatment: A review of the literature. Canadian Journal of Psychiatry, 44(5), 443–454.Google Scholar
  33. Lehman, A. F., Dixon, L. B., Kernan, E., DeForge, B. R., & Postrado, L. T. (1997). A randomized trial of assertive community treatment for homeless persons with severe mental illness. Archives of General Psychiatry, 54(11), 1038–1043.PubMedGoogle Scholar
  34. Macias, C., Rodican, C. F., Hargreaves, W. A., Jones, D. R., Barreira, P. J., & Wang, Q. (2006). Supported employment outcomes of a randomized controlled trial of ACT and clubhouse models. Psychiatric Services (Washington, DC), 57(10), 1406–1415. doi: 10.1176/ Scholar
  35. Marshall, M., & Lockwood, A. (2000). Assertive community treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews (Online: Update Software), (2), CD001089.Google Scholar
  36. McDonel, E. C., Bond, G. R., Salyers, M., Fekete, D., Chen, A., McGrew, J. H., et al. (1997). Implementing assertive community treatment programs in rural settings. Administration and Policy in Mental Health, 25(2), 153–173. doi: 10.1023/A:1022286921362.PubMedCrossRefGoogle Scholar
  37. McGrew, J. H., Pescosolido, B., & Wright, E. (2003). Case managers’ perspectives on critical ingredients of assertive community treatment and on its implementation. Psychiatric Services (Washington, DC), 54(3), 370–376. doi: 10.1176/ Scholar
  38. Mental Health: Culture, Race, Ethnicity. (2001). Supplement to mental health: Report of the surgeon general. Rockville, MD: US Department of Health and Human Services.Google Scholar
  39. Merwin, E., Hinton, I., Dembling, B., & Stern, S. (2003). Shortages of rural mental health professionals. Archives of Psychiatric Nursing, 17(1), 42–51. doi: 10.1053/apnu.2003.1.PubMedCrossRefGoogle Scholar
  40. Meyer, P. S., & Morrissey, J. P. (2007). A comparison of assertive community treatment and intensive case management for patients in rural areas. Psychiatric Services (Washington, DC), 58(1), 121–127.Google Scholar
  41. Mueser, K. T., Essock, S. M., Drake, R. E., Wolfe, R. S., & Frisman, L. (2001). Rural and urban differences in patients with a dual diagnosis. Schizophrenia Research, 48(1), 93–107. doi: 10.1016/S0920-9964(00)00065-7.PubMedCrossRefGoogle Scholar
  42. North Carolina Division of Mental Health. NC-Treatment Outcomes and Program Performance System (NC-TOPPS). (2008). [cited 2008]; Available from:
  43. Santos, A., Deci, P., Lachance, K., Dias, J., Sloop, T., Hiers, T., et al. (1993). Providing assertive community treatment for severely mentally ill patients in a rural area. Hospital & Community Psychiatry, 44, 34–39.Google Scholar
  44. Smith, R. P., Larkin, G. L., & Southwick, S. M. (2008). Trends in US emergency department visits for anxiety-related mental health conditions, 1992–2001. The Journal of Clinical Psychiatry, 69(2), 286–294.PubMedCrossRefGoogle Scholar
  45. Stein, L. I., & Test, M. A. (1980). Alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry, 37(4), 392–397.PubMedGoogle Scholar
  46. Sullivan, G., Jackson, C. A., & Spritzer, K. L. (1996). Characteristics and service use of seriously mentally ill persons living in rural areas. Psychiatric Services (Washington, DC), 47(1), 57–61.Google Scholar
  47. Teague, G. B., Bond, G. R., & Drake, R. E. (1998). Program fidelity in assertive community treatment: Development and use of a measure. The American Journal of Orthopsychiatry, 68(2), 216–232. doi: 10.1037/h0080331.PubMedCrossRefGoogle Scholar
  48. Twamley, E. W., Padin, D. S., Bayne, K. S., Narvaez, J. M., Williams, R. E., & Jeste, D. V. (2005). Work rehabilitation for middle-aged and older people with schizophrenia: A comparison of three approaches. The Journal of Nervous and Mental Disease, 193(9), 596–601. doi: 10.1097/01.nmd.0000177789.53840.e3.PubMedCrossRefGoogle Scholar
  49. US Bureau of Labor and Statistics. (2007). [cited 22 September 2007]; Available from:
  50. US Department of Justice. (2005). [cited 22 September 2007]; Available from:
  51. Weeks, W. B., Bott, D. M., Lamkin, R. P., & Wright, S. M. (2005). Veterans health administration and medicare outpatient health care utilization by older rural and urban New England veterans. The Journal of Rural Health, 21(2), 167–171. doi: 10.1111/j.1748-0361.2005.tb00077.x.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  1. 1.Queensland Center for Mental Health ResearchUniversity of QueenslandWacolAustralia
  2. 2.Division of Mental HealthPrincess Alexandra HospitalBrisbaneAustralia
  3. 3.Department of Health Policy and ManagementUniversity of North Carolina School of Public HealthChapel HillUSA

Personalised recommendations