Mental Health Services Research

, Volume 2, Issue 3, pp 155–164 | Cite as

Psychiatric Hospitalizations, Arrests, Emergency Room Visits, and Homelessness of Clients with Serious and Persistent Mental Illness: Findings from a Randomized Trial of Two ACT Programs vs. Usual Care

  • Gregory N. Clarke
  • Heidi A. Herinckx
  • Ronald F. Kinney
  • Robert I. Paulson
  • David L. Cutler
  • Karen Lewis
  • Evie Oxman


Objective: This investigation examined several adverse outcomes in clients with serious mental illness in a randomized trial of Assertive Community Treatment (ACT) versus usual care. Method: 163 subjects were randomized to one of two ACT experimental conditions (staffed by consumers or non-consumers) or usual community care. Conditions were compared on psychiatric hospitalization, emergency room visit, arrest, and homelessness, within the two-year study period. Demographic, program, and client variables were examined for significant associations with outcomes. Results: Significant differences were found between ACT and usual care in time to first arrest, but not hospitalization, homelessness or ER visits. Shorter time to first hospitalization was associated with male gender, diagnoses other than schizophrenia, high psychiatric symptomatology and lower provider case load. ER visits were associated with increased client symptomatology. Shorter times to homelessness were predicted by poorer therapeutic alliance between case manager and clients. Shorter time to first arrest was predicted by client minority status and enrollment in usual care. Conclusions: The paucity of significant main effects may have been due to a prolonged “start-up” phase of the ACT programs, poor ACT implementation, restricted availability of psychiatric hospital beds, or changes in usual care services delivered over the study period.

Assertive Community Treatment psychiatric hospitalizations arrests emergency room visits homelessness serious mental illness 


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  1. Bech, P., Larsen, J. K., & Anderson, J. (1988). The BPRS: psychometric developments. Psychopharmacology Bulletin, 24, 118-121.Google Scholar
  2. Bond, G. R., McGrew, J. H., & Fekete, D. M. (1995). Assertive outreach for frequent users of psychiatric hospitals: A metaanalysis. The Journal of Mental Health Administration, 22, 4-16.Google Scholar
  3. Burns, B. (1998). Links between research findings and the future of assertive community treatment: a commentary. American Journal of Orthopsychiatry, 68, 261-264.Google Scholar
  4. Burns, B. J., & Santos, A. B. (1995). Assertive community treatment: An update of randomized trials. Psychiatric Services, 46, 669-675.Google Scholar
  5. Chandler, D., Meisel, J., McGowen, M., Mintz, J., & Madison, K. (1996). Client outcomes in two model capitated integrated service agencies. Psychiatric Services, 47, 175-180.Google Scholar
  6. Drake, R. E. (1998). Brief history, current status, and future place of assertive community treatment. American Journal of Orthopsychiatry, 68, 172-175.Google Scholar
  7. Drake, R. E., McHugo, G. J., Clark, R. E., Teague, G. B., Xie, H., Miles, K., & Ackerson, T. H. (1998). Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: A clinical trial. American Journal of Orthopsychiatry, 68, 201-215.Google Scholar
  8. Drake, R. E., Mueser, K. T., & McHugo, G. J. (1996). Clinician rating scales: Alcohol Use Scale (AUS), Drug Use Scale (DUS), and Substance Abuse Treatment Scale (SATS). In L. I. Sederer, & B. Dickey (Eds.), Outcomes assessment in clinical practice (pp. 113-116). Baltimore: Williams and Wilkins.Google Scholar
  9. Drake, R. E., Osher, F. C., Noordsy, D. L., Hurlbut, S. C., Teague, G. B., & Beaudett, M. S. (1990). Diagnosis of alcohol use disorders in schizophrenia. Schizophrenia Bulletin, 16, 57-67.Google Scholar
  10. Drake, R. E., Osher, F. C., & Wallach, M. A. (1989). Alcohol use and abuse in schizophrenia: A prospective community study. Journal of Nervous and Mental Disease, 177, 408-414.Google Scholar
  11. Goldman, H. H., Gattozzi, A. A., & Taube, C. A. (1981). Defining and counting the chronically mentally ill. Hospital and Community Psychiatry, 32, 21-27.Google Scholar
  12. Herinckx, H., Kinney, R., Clarke, G. N., & Paulson, R. I. (1997). Assertive community treatment versus usual care in engaging and retaining clients with severe mental illness. Psychiatric Services, 48, 1297-1306.Google Scholar
  13. Horvath, A., & Greenberg, L. (1986). Development and validation of the working alliance inventory. Journal of Consulting and Clinical Psychology, 36, 223-233.Google Scholar
  14. Lamb, H. R. (1997). The new state mental hospitals in the community. Psychiatric Services, 48, 1307-1310.Google Scholar
  15. Luke, D. A., & Homan, S. M. (1998). Time and change: Using survival analysis in clinical assessment and treatment evaluation. Psychological Assessment, 10, 360-378.Google Scholar
  16. Lukoff, D., Liberman, R. P., & Nuechterlein, K. H. (1986). Symptom monitoring in the rehabilitation of schizophrenic patients. Schizophrenia Bulletin, 12, 578-602.Google Scholar
  17. Lukoff, D., Nuechterlein, K. H., & Ventura J. (1986). Manual for the Expanded Brief Psychiatric Rating Scale. Schizophrenia Bulletin, 12, 594-602.Google Scholar
  18. McGrew, J. H., Bond, G. R., Dietzen, L., McKasson, M., & Miller, L. D. (1995). A multisite study of client outcomes in assertive community treatment. Psychiatric Services, 46, 696-701.Google Scholar
  19. McHugo, G. J., Drake, R. E., Teague, G. B., & Xie, H. (1999). Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study. Psychiatric Services, 50, 818-824.Google Scholar
  20. McHugo, G. J., Hargreaves, W., Drake, R. E., Clark, R. E., Xie, H., Bond, G. R., & Burns, B. J. (1998). Methodological issues in assertive community treatment studies. American Journal of Orthopsychiatry, 68, 246-260.Google Scholar
  21. Morse, G. A., Calsyn, R. J., Allen, G., Tempelhoff, B., & Smith, R. (1992). Experimental comparison of the effects of three treatment programs for homeless mentally ill people. Hospital and Community Psychiatry, 43, 1005-1009.Google Scholar
  22. Mueser, K. T., Bond, G. R., Drake, R. E., & Resnick, S. G. (1998). Models of community care for severe mental illness: A review of research on case management. Schizophrenia Bulletin 24, 37-74.Google Scholar
  23. Nikkel, R. E., Smith, G., & Edwards, D. (1992). A consumeroriented case management project. Hospital and Community Psychiatry, 43, 577-579.Google Scholar
  24. Pandiani, J. A., Banks, S. M., & Schacht, L. M. (1998). Using incarceration rates to measure mental health program performance. The Journal of Behavioral Health Services & Research, 25, 300-311.Google Scholar
  25. Paulson, R., Clarke, G. N., Herinckx, H., Kinney, R., Cutler, D., & Lewis, K. (2000). A Randomized trial of consumer vs. Non-consumer-staffed assertive community treatment programs vs. Usual care for persons with major mental illness: Two year outcomes. Unpublished manuscript, Regional Research Institute, Portland State University, Oregon.Google Scholar
  26. Rosenheck, R., & Neale, M. (1998). Intersite variation in the impact of intensive psychiatric community care on hospital use. American Journal of Orthopsychiatry, 68, 191-200.Google Scholar
  27. Scott, J. E., & Dixon, L. B. (1995). Assertive community treatment and case management for schizophrenia. Schizophrenia Bulletin, 21, 657-668.Google Scholar
  28. Singer, J. D., & Willett, J. B. (1991). Modeling the days of our lives: Using survival analysis when designing and analyzing longitudinal studies of duration and the timing of events. Psychological Bulletin, 110, 268-290.Google Scholar
  29. Solomon, P., & Draine, J. (1995a). Issues in Serving the Forensic Client. Social Work, 40, 25-33.Google Scholar
  30. Solomon, P., & Draine, J. (1995b). The efficacy of a consumer case management team: 2-year outcomes of a randomized trial. The Journal of Mental Health Administration, 22, 135-146.Google Scholar
  31. SPSS Version 7.5. Chicago IL: SPSS Inc. 1997.Google Scholar
  32. Stylianos, S., & Goering, P. (1989). The working alliance inventory: Reliability and validity in the context of rehabilitation for clients with chronic psychiatric disorders. Paper presented at the annual meeting of the Society for Psychotherapy Research, Toronto, Canada.Google Scholar
  33. Teague, G., Bond, G. R., & Drake, R. E. (1998). Program fidelity in assertive community treatment: Development and use of ameasure. American Journal of Orthopsychiatry, 68, 216-232.Google Scholar
  34. Ventura, J., Green, M., & Shaner, A. (1993). Training and quality assurance on the BPRS: 'The drift busters.' International Journal of Methods in Psychiatric Research, 3, 221-224.Google Scholar

Copyright information

© Plenum Publishing Corporation 2000

Authors and Affiliations

  • Gregory N. Clarke
    • 1
  • Heidi A. Herinckx
    • 2
  • Ronald F. Kinney
  • Robert I. Paulson
    • 2
  • David L. Cutler
    • 2
  • Karen Lewis
    • 2
  • Evie Oxman
    • 2
  1. 1.Center for Health ResearchPortland
  2. 2.Regional Research InstitutePortland State UniversityPortland

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