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Background: There are recognised barriers to engagement with mainstream alcohol services for certain groups within populations. Alcohol assertive outreach is an approach that uses repeated, persistent and flexible methods to engage with patients with alcohol problems from these groups. There are few qualitative studies that explore how alcohol assertive outreach services are experienced by stakeholders. This study focuses on a unique service, The Primary Care Alcohol Nurse Outreach Service (PCANOS), that operated in Glasgow, Scotland and which involved Alcohol Nurses working closely with general practices. Methods: Twenty-three semi-structured qualitative interviews were used to explore staff and patient views and experiences of PCANOS. Interviews were conducted with 18 staff (nine general practice staff, five alcohol nurses, and four strategic staff) and seven patients from across six Deep End general practices. Results: Findings from this study suggest that PCANOS has the potential to engage patients who may have difficulties engaging with mainstream alcohol treatment services. Through PCANOS, the Alcohol Nurses, in collaboration with General Practitioners and other practice staff, were able to engage patients and deliver a flexible, person-centred care service that impacted positively on patients' drinking behaviour and general health and wellbeing. Conclusions: PCANOS was a unique alcohol assertive outreach service that had the potential to engage with people from the most deprived communities in Glasgow, who were not engaging with the mainstream services. Further research could examine the potential benefits of services like PCANOS, including patient outcomes, the economic impact on the wider healthcare system, and its transferability to other settings such as rural areas. [ABSTRACT FROM AUTHOR]

AbstractBackgroundAimsMethodsResultsConclusion\nPRISMA/PROSPEROAssertive outreach (AO) is a systematic approach to engage vulnerable patients with serious mental illness.This review aims to provide a comprehensive analysis of engagement strategies in relation to principles of the AO model to clarify effective components of AO, better understand engagement in an AO context, and consider encompassing change mechanisms.A systematic mixed-methods review was completed from 1806 to December 2022 (no pre-registration). Articles meeting the inclusion criteria were rated for methodological quality using the JBI scales and thematic synthesis using a meta-aggregative approach. Reporting was according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.Eighteen articles met the inclusion criteria. The literature was defined by three main themes: definition and perspectives of engagement; key principles of AO in relation to engagement; and additional principles and strategies enhancing engagement.Despite the heterogeneity in defining engagement, the relationship between AO professionals and patients emerged as crucial in the process of engagement. Subsequently, the four key principles of AO emerged as central to promoting engagement. Finally, we identified a number of additional principles that are considered crucial in the engagement process in AO. The review concludes with recommendations for future research and the implementation of AO in routine clinical care.The reporting of this review is conducted following the PRISMA guidance and not registered at PROSPERO because completed reviews cannot be registered. [ABSTRACT FROM AUTHOR]

Issue Addressed Methods Results Conclusions So What? In 2021, the Australian government implemented a population wide COVID‐19 vaccination program. People experiencing homelessness faced challenges accessing vaccines and many were not being reached. By reorienting vaccination services to include assertive outreach strategies, a Brisbane‐based non‐profit health care team successfully administered 2065 COVID‐19 vaccinations to homeless and precariously housed people. This study examines insights from stakeholders delivering the service and perspectives of clients who received a vaccine.Semi‐structured interviews with five stakeholders and a survey of 63 clients involved in the Micah Projects COVID‐19 vaccination program are reported. Client survey questions covered demographic characteristics, and motivations and hesitancies around vaccination. Stakeholder interviews were inductively analysed and quantitative survey data were exported into SPSS (IBM V27) and analysed using descriptive statistics.The Micah Projects team initiated 220 pop‐up vaccination clinics and worked closely with Aboriginal and Torres Strait Islander communities. Downsizing and mobilising the service engaged greater numbers of people sleeping rough and Aboriginal and Torres Strait Islander people. Clients' decisions to vaccinate were often spontaneous, driven by immediate availability and motivated by a desire to stay healthy and protect the community.Tailoring vaccination programs to include assertive outreach strategies effectively reduces barriers for people experiencing homelessness. Community embeddedness, trust, flexibility and cultural safety are critical elements for success.People experiencing homelessness are motivated to vaccinate. Reorientating health services to remove structural barriers and build the supportive environments needed to work through vaccine hesitancies are critical elements to ensure equitable access and promote health. [ABSTRACT FROM AUTHOR]

Purpose: This Multicenter Youth Flexible ACT Study examined the effect of Youth Flexible Assertive Community Treatment on symptomatic, social, and personal recovery outcomes of adolescents dealing with multifaceted psychiatric and social care needs who do not readily engage in regular office-based mental health services. Methods: Newly admitted clients (n = 199) aged 12–24 years from 16 Youth Flexible ACT teams participated in this observational prospective cohort study. Client and practitioner questionnaires were administered every 6 months, up to 18 months. Latent growth curve analyses were conducted to examine changes in symptomatic, social, and personal recovery outcomes throughout Flexible ACT. Results: Our analyses of client-reported outcomes showed a decrease in overall psychosocial difficulties, depressive symptoms, and subclinical psychosis symptoms. Moreover, outcomes showed improved social interaction with peers, quality of life, and feelings of empowerment and fewer contacts with the police/legal system. In addition, analyses of clinician-reported outcomes showed a decrease in problems related to family life, peer relationships, school/work attendance, emotional symptoms, and attentional problems. Problems related to personal finance, school and work status, substance misuse, disruptive and aggressive behavior, self-injury, and self-care and independence remained unchanged. Conclusion: Our results showed that clients participating in Youth Flexible ACT improved in symptomatic, social, and personal recovery outcomes over 18 months. With its integrated approach and personalized care, this service delivery model is promising for adolescents unable to engage successfully in regular (office based) mental health support services. [ABSTRACT FROM AUTHOR]

Early Intervention in Psychosis Services (EIP) offer a unique service model for people experiencing a first episode of psychosis. They are intensive case-management services which adopt an assertive outreach approach, employing flexible boundaries to meet clients in the community, and support them towards recovery and holistic goals. Current boundary theory is therefore not easily applied to this clinical context. This study aimed to explore how care-co-ordinators in EIP develop their understanding and practise around navigating boundaries. Participants were 13 EIP care co-ordinators. Semi-structured interviews with participants were conducted and analysed using grounded theory. A concentric model emerged, defining different layers of influence impacting care co-ordinators' navigation of boundaries. This included higher governing levels (e.g. professional codes of conduct), factors and challenges specific to EIP culture, client characteristics and individual care co-ordinator decision-making processes. A flexible, case-by-case approach was adopted in response to challenges. Findings suggest clinical implications for how care co-ordinators can jointly construct appropriate boundaries with clients and families, and discuss dilemmas using the team resource. This model can be used as a tool in clinical practice to aid clinicians' thinking and reflection around boundaries within EIP. [ABSTRACT FROM AUTHOR]

Objective: To examine if there is a relationship between introducing a Homeless Health Outreach Team (HHOT) and reduced acute Mental Health service usage. Methods: Electronic Medical Record (EMR) data were collected on a group of clients of the Tweed Byron HHOT 6 months before and after establishing the service. The data were evaluated for demographics, and differences in Emergency Department (ED) presentations, mental health admissions, length of stay and community mental health engagement. Results: The introduction of the team coincided with a significant reduction in ED presentations and an increase in community mental health engagement. There was an overall reduction in bed days but an increase in mean length of stay for those admitted post-intervention. Conclusions: The establishment of the HHOT coincided with reduced acute mental health service usage via ED and inpatient Mental Health Units (MHU). There is scope for expansion of such a service as well as exploration of costings analysis. A long-term focus on 'housing first' and outreach approaches to homeless service provision could improve individual and service provision outcomes. [ABSTRACT FROM AUTHOR]

Medications for opioid use disorder (MOUD) are the most effective treatment for OUD. Many patients struggle with adherence, but young adults face unique developmental barriers and experience higher relapse rates. The Youth Opioid Recovery Support (YORS) intervention is a developmentally informed behavioral approach to increase medication adherence through assertive outreach, family involvement, low-barrier access to extended-release MOUD, and contingency management. Early studies have shown promising results, and a randomized controlled trial is underway. Here we describe the implementation of YORS using case examples, offer guidance on adapting YORS to real-world clinical settings, and explore future directions for research and practice., Competing Interests: Disclosure Dr M. Fishman has been a consultant for Alkermes, Inc, Indivior, Nirsum Labs and Drug Delivery LLC. Dr M. Fishman has received research grant funding from Alkermes. Dr M. Fishman and Dr K. Wenzel have received research grant funding from NIH. Other authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Why you should read this article: • To refresh your knowledge of the characteristics of anorexia nervosa • To understand the factors that may affect the quality of life of women with severe and enduring anorexia • To learn about interventions that could benefit women with severe and enduring anorexia by enhancing their quality of life Background: Anorexia nervosa is a severe psychiatric disorder characterised by starvation and malnutrition. In severe and enduring anorexia nervosa, individuals may be unable to overcome persistent ruminations about their weight, food intake and body shape, so interventions may be required that focus on quality of life rather than on achieving full recovery. Aim: To identify which factors may affect the quality of life of women with severe and enduring anorexia. Method: Constructivist grounded theory was used and semi-structured interviews were conducted with eight women receiving inpatient care for severe and enduring anorexia in a severe eating disorder unit in the Netherlands. Data collection and analysis occurred simultaneously, and theoretical categories with associated properties emerged from this process. Findings: Four theoretical categories were identified: 'suffering, but not in silence'; 'one step forward, one step backwards'; 'connective tissue'; and 'best friend, best enemy'. The findings emphasised the need to recognise suffering as a continual affect experienced by people with severe and enduring anorexia, as well as the negative effects that the condition has on people's quality of life, largely due to its inextricable link with their identity. In addition, it was identified that severe and enduring anorexia can significantly affect an individual's family and friends, and that there is a need for eating disorder services to use an assertive outreach approach. Conclusion: The quality of life of people with severe and enduring anorexia could be enhanced by: education for nurses, patients and families; assertive outreach interventions; the use of therapy dogs; and a structured daily routine that includes social and family activities. [ABSTRACT FROM AUTHOR]

Young people in Out of Home Care (OoHC) have complex mental health and psychosocial needs due to a range of individual, systemic and intergenerational factors that may limit the effectiveness of usual clinic-based services. To address this, in 2017 an assertive-integrated service (AIS) model of care was adopted by the Child and Adolescent Mental Health Service (CAMHS) in South Western Sydney Local Health District (SWSLHD), Australia, through outreach to the young person in the community. This paper outlines the study protocol comparing AIS with clinic-based CAMHS usual care to meet the physical, mental health and wellbeing needs of young people in OoHC. Using routinely collected outcome data, the AIS model will be compared to clinic-based CAMHS treatment as usual care. Measures of overall functioning (e.g. Global Assessment Scale [CGAS]), psychological functioning (e.g. Strength and Difficulties Questionnaire [SDQ]), general health and social functioning (e.g. Health of the Nation Outcome Scales for Children and Adolescents [HoNOSCA]) and other relevant socio-demographic and clinical variables will be collected at intake and at 3-month intervals until discharge from the respective services. Semi-structured interviews will also be conducted with young people, their carers, and service providers, to examine qualitative themes about the suitability of service provision. It is expected that a better understanding of the key indicators of functioning for young people accessing AIS and clinic-based services will help inform what works for these young people so that they can receive targeted and tailored support from the start of service engagement. [ABSTRACT FROM AUTHOR]

A 'Zeitgeist' is defined as 'the defining spirit or mood of a particular period of history as shown by the ideas and beliefs of the time', and I am pleased to say I think this is what is currently happening with probation and mental health. For too long, mental health has been the poor relation in probation practice -- a situation that seems to be gradually changing. This paper draws from a series of research studies, undertaken locally, nationally and across Europe, to show that we are beginning to understand more and more about probation and the mental health of its clientèle. There are still serious gaps in our research knowledge, for example, about effective interventions, but the last decade has clarified the direction of travel that is required. The paper questions whether clients with mental health problems in probation require 'equivalence'. That is, the same services that other members of the general population can access, who live in the community. I argue that the complexity of clients' presentations does not equate to what is currently available in the community. Thus, new thinking is required, and much more research is needed to examine, for example, the role of assertive-outreach principles and models of service provision -- perhaps alongside a sub-group of specialist Probation Staff specifically trained in mental health. There is a long way to travel before we can say that all probation clients are receiving the mental health services they need. [ABSTRACT FROM AUTHOR]

Extended-release naltrexone (XR-NTX) is an important treatment option for individuals with opioid use disorder (OUD) and/or alcohol use disorder (AUD). However, problems with retention are a major barrier to its overall effectiveness, and interventions to improve adherence are underdeveloped. The purpose of this study was to pilot test the MAT-PLUS intervention, which combines assertive outreach and involvement of a treatment significant other (TSO) to improve adherence to XR-NTX. Adults (N = 41) seeking treatment for OUD and/or AUD with XR-NTX were recruited from an inpatient addiction treatment center and randomized to the MAT-PLUS intervention or treatment as usual (TAU) for 16-weeks. TSOs (N = 19) of individuals in the MAT-PLUS condition were also enrolled. The primary outcome was the number of XR-NTX doses received and relapse to regular heavy use (opioid or alcohol) was a secondary outcome. Participants in the MAT-PLUS group received 3.4 doses compared to 2.5 in TAU, which was significant after controlling for SUD diagnosis (p < 0.05). Rates of receipts of all prescribed doses were 61.1 % in MAT-PLUS compared to 30.4 % in TAU, giving an NNT of 3.3. Relapse rates and days of heavy use did not vary by treatment group. This study demonstrates preliminary efficacy of the MAT-PLUS intervention for XR-NTX adherence. This study was limited by its small sample size and future research should broaden the intervention to apply across medications for SUD in larger samples. Family support with an emphasis on medication adherence has strong potential for improving addiction treatment outcomes. • The MAT-PLUS intervention increased adherence to extended-release naltrexone. • The MAT-PLUS intervention did not have an effect on relapse or days of heavy use. • The MAT-PLUS intervention demonstrates preliminary feasibility and efficacy. [ABSTRACT FROM AUTHOR]

Abstract Background More knowledge about characteristics of children and adolescents who need intensive levels of psychiatric treatment is important to improve treatment approaches. These characteristics were investigated in those who need youth Assertive Community Treatment (youth-ACT). Method A cross-sectional study among children/adolescents and their parents treated in either a regular outpatient clinic or a youth-ACT setting in a specialized mental health treatment center in the Netherlands. Results Child, parent and family/social context factors were associated with treatment intensification from regular outpatient care to youth-ACT. The combination of the child, parent, and family/social context factors adds substantially to the predictive power of the model (Nagelkerke R2 increasing from 36 to 45% for the three domains separately, to 61% when all domains are combined). The strongest predictors are the severity of psychiatric disorders of the child, parental stress, and domestic violence. Conclusions Using a wide variety of variables that are potentially associated with treatment intensification from regular outpatient clinic to youth-ACT, we constructed a regression model illustrating a relatively strong relation between the predictor variables and the outcome (Nagelkerke R2 = 0.61), with three strong predictors, i.e. severity of psychiatric disorders of the child, parental stress, and domestic violence. This emphasizes the importance of a system-oriented approach with primary attention for problem solving and stress reduction within the system, in addition to the psychiatric treatment of the child, and possibly also the parents.

Background and Aims: Although medications for opioid use disorder (OUD), including extended‐release naltrexone (XR‐NTX), have demonstrated effectiveness, adherence is often low. We tested the preliminary efficacy of youth opioid recovery support (YORS), a multi‐component intervention designed to improve engagement and medication adherence for young adults with OUD. Design Single‐site randomized controlled trial with 24‐week follow‐up. Setting: Community substance use disorder treatment program in Baltimore, MD, USA. Participants: Young adults aged 18–26 years enrolled in inpatient/residential OUD treatment intending to pursue outpatient OUD treatment with XR‐NTX. Twenty‐one participants were randomized to YORS and 20 to treatment as usual (TAU). The analyzed sample was 65.8% male. Intervention and comparator: Components of YORS include: (1) home delivery of XR‐NTX; (2) family engagement; (3) assertive outreach; and (4) contingency management for receipt of XR‐NTX doses. The comparator was TAU, which consisted of a standard referral to outpatient care following an inpatient stay. Measurements Primary outcomes were number of XR‐NTX doses received over 24 weeks and relapse to opioid use (defined as ≥ 10 days of use within 28 days) at 24 weeks. Findings Participants in the YORS condition received more XR‐NTX doses [mean = 4.28; standard deviation (SD) = 2.3] compared with those in TAU (mean = 0.70; SD = 1.2), P < 0.01. Participants in the YORS group compared with TAU had lower rates of relapse (61 versus 95%; P < 0.01). Survival analyses revealed group differences on time to relapse with participants in TAU being more likely to relapse sooner compared with participants in the YORS condition [hazard ratio (HR) = 2.72, 95% confidence interval (CI) = 1.26–5.88, P < 0.01]. Conclusions: The youth opioid recovery support intervention for extended‐release naltrexone adherence and opioid relapse prevention among young adults with opioid use disorder appeared to improve treatment and relapse outcomes compared with standard treatment. [ABSTRACT FROM AUTHOR]

SUMMARY: Homelessness has long been associated with high rates of psychosis, alcohol and substance misuse, and personality disorder. However, psychiatric services in the UK have only recently engaged actively with homeless people. This article provides some background information about homelessness and mental illness and describes the elements of inclusion health and some of the models of service for homeless people that have been established over the past 30 years. [ABSTRACT FROM AUTHOR]

Cognitive motivation theories contend that individuals have greater readiness for behavioral change during critical periods or life events, and a non-fatal overdose could represent such an event. The objective of this study was to examine if the use of a specialized mobile response team (assertive outreach) could help identify, engage, and retain people who have survived an overdose into a comprehensive treatment program. We developed an intervention, consisting of mobile outreach followed by medication and behavioral treatment, in Houston Texas between April and December 2018. Our primary outcome variables were the level of willingness to engage in treatment, and percent who retained in treatment after 30 and 90 day endpoints. We screened 103 individuals for eligibility, and 34 (33%) elected to engage in the treatment program, while two-thirds chose not to engage in treatment, primarily due to low readiness levels. The average age was 38.2 ± 12 years, 56% were male, 79% had no health insurance, and the majority (77%) reported being homeless or in temporary housing. There were 30 (88%) participants still active in the treatment program after 30 days, and 19 (56%) after 90 days. Given the high rates of relapse using conventional models, which wait for patients to present to treatment, our preliminary results suggest that assertive outreach could be a promising strategy to motivate people to enter and remain in long-term treatment. [ABSTRACT FROM AUTHOR]

Abstract Background During the past decades deinstitutionalisation policies have led to a transition from inpatient towards community mental health care. Many European countries implement Assertive Community Treatment (ACT) as an alternative for inpatient care for “difficult to reach” children and adolescents with severe mental illness. ACT is a well-organized low-threshold treatment modality; patients are actively approached in their own environment, and efforts are undertaken to strengthen the patient’s motivation for treatment. The assumption is that ACT may help to avoid psychiatric hospital admissions, enhance cost-effectiveness, stimulate social participation and support, and reduce stigma. ACT has been extensively investigated in adults with severe mental illness and various reviews support its effectiveness in this patient group. However, to date there is no review available regarding the effectiveness of youth-ACT. It is unknown whether youth-ACT is as effective as it is in adults. This review aims to assess the effects of youth-ACT on severity of psychiatric symptoms, general functioning, and psychiatric hospital admissions. Method A systematic literature search was conducted in PubMed, Cochrane Library, PsychINFO and CINAHL published up to March 2017. To assess methodological quality of the included studies, the Oxford Centre of Evidence-Based Medicine grading system was used. Results Thirteen studies were included in this review. There are indications that youth-ACT is effective in reducing severity of psychiatric symptoms, improving general functioning, and reducing duration and frequency of psychiatric hospital admissions. Conclusions The current literature on youth-ACT is limited but promising. There are indications that youth-ACT is effective in reducing severity of psychiatric symptoms, improving general functioning, and reducing duration and frequency of psychiatric hospital admissions. The effect of youth-ACT may be comparable with the effect of ACT in adults. Similar as in adult ACT, the studies on youth-ACT found effects that vary from small to large. Randomized experimental research designs are needed to further corroborate effectiveness.

Background: The future of assertive community treatment is uncertain, and studies have questioned whether it continues to provide a more effective treatment model for severely mentally ill patients in a modern mental health context. Studies conducted in new settings can contribute to the debate. Methods: This Danish study compares treatment from assertive community treatment with treatment by standard community mental health teams, using a non-blinded quasi-experimental multi-center trial. Outcomes included contact with mental health services, days of admission, days of involuntary admission, number of outpatient contacts, adherence to antipsychotic medication, social functioning, user satisfaction, and psychopathology. Results: A total of 366 patients receiving treatment from assertive community treatment (n = 213) or continuation of care from community mental health teams (n = 153) were included in the trial. Assertive community treatment was significantly better in sustaining contact with patients. At 2-year follow-up, 16 (8%) of patients receiving assertive community treatment versus 22(14%) receiving care from standard treatment had lost contact with treatment. Patients who received assertive community treatment had a larger reduction in inpatient service-use, increased adherence to antipsychotic medication, improved social functioning, and higher user satisfaction. No differences in days of involuntary admission and psychopathology were found. Conclusions: The results suggest that a high fidelity assertive community treatment may be a valuable tool to strengthen contact between severely mentally ill patients and the treatment staff and may contribute to improving outcomes in a modern Danish mental health context. [ABSTRACT FROM AUTHOR]

This article gives an overview of an innovative mental health worker role in an inpatient mental health rehabilitation team. It describes how the role was developed to offer care that is sustainable, integrated and attuned to service users' social, economic and domestic needs. It explains how the role was received and evaluated and promotes its adoption in other settings, arguing for the increased use of creative support worker roles as a response to the resource pressures facing today's mental healthcare services. [ABSTRACT FROM AUTHOR]

Abstract: Substance use amongst people with schizophrenia is well‐established: up to 50% report using illicit substances. The occurrence of both conditions can also induce people to disengage from mental health services. The research question sought to understand, from the perspective of both service users and clinicians, cannabis use within the experience of people with schizophrenia. The transcripts of the seven participants and the two focus groups were analysed using interpretative phenomenological analysis. Service Users and Clinicians were recruited from Assertive outreach community‐based teams. seven male service users who described their ethnic identity as ‘black’, diagnosed with schizophrenia and a history of treatment disengagement and 12 clinicians who worked with this client group. The two component study involved semi‐structured interviews with the Service Users and two focus groups with the Clinicians. Service Users perceived cannabis use as a means by which they could ‘reestablish their identity’ that had been damaged and the social consequences of diagnosis. Clinicians similarly perceived drugs, cannabis in particular, as a significant part of the service users’ life. This study provides greater depth to understanding cannabis use within the experience of people with a diagnosis of schizophrenia. [ABSTRACT FROM AUTHOR]

Accessible summary: This study is a follow‐on study to a study into the experiences of disengagement from mental health services for men who described their ethnic identity as “black.” The aim of this study was to understand the same phenomenon from a clinician's perspective. What is known on the subject?: Literature highlights that people from ethnic minority backgrounds experience some difficulties engaging with mental health services; Disengagement from mental health services is a complex phenomenon that occurs for a variety of different reasons; Only one paper previously has investigated clinicians’ perspective on disengagement from mental health services; What the study adds to existing knowledge?: This study demonstrates that clinicians are aware that stigma and medication impact upon engagement with mental health services, which were also important components of the patients experience. A finding of the former study was that patients’ attitudes towards mental health services change over time, with patients engaging more as they get older, a finding was supported by wider literature. However, in this study, the participants were not certain that this was the case. What are the implications for practice?: The implications for practice from this study are that staff should persist with efforts to reduce the stigma surrounding mental health, carefully consider the significance and impact of medication and have an awareness of how patients’ attitudes towards mental illness and mental health services change and develop over time. Continued support for an AO approach to practice for people who find it difficult to engage with services, where a multidisciplinary “team” approach can focus on service user‐centred recovery goals and a positive space for collaboration. Abstract: Introduction: Engagement with services is often poor amongst people with severe mental health problems, yet key to improving clinical outcomes. Aims: This study explores the perception of clinicians on patients with severe mental health problems, in particular the experiences of black men, who disengage from mental health services. Method: Two focus groups consisting of a combined total of twelve, mainly white, experienced clinicians in the UK were recruited. Transcripts were analysed using interpretative phenomenological analysis. Results: Clinicians understood that patients’ awareness of stigma impacted upon engagement with mental health services. Clinicians were aware that medication negatively impacted on engagement. The passage of time was perceived as impacting upon engagement. Discussion: The perspectives of the clinicians in this study and the experiences of the patients in a former study converged. The participants had an understanding of the complexities that black men faced when engaging with mental health services. Implications for practice: This is the first study to highlight that AOT staff need to be aware of the key role that stigma plays in engagement in treatment, continue to focus on efforts to reduce the stigma surrounding mental health, consider the significance medication and be aware of how patients’ attitudes towards mental health services develop over time. [ABSTRACT FROM AUTHOR]

Early experience with relapse prevention medications in the treatment of opioid addiction in youth has been positive, but barriers to effectiveness and broader adoption have included problems with adherence and retention, and lack of evidence or consensus about implementation. In particular there is relatively little known about either the effectiveness of extended release naltrexone (XR-NTX) in youth, or optimal models of care for its delivery. The purpose of this study is to report on a pilot initiative to improve the effectiveness of XR-NTX by delivering doses at home with assertive outreach to patients enrolled in a community treatment outpatient program. This is a naturalistic case series based on retrospective chart abstractions of 14 young adults (mean age=20.5), who enrolled in the pilot program, and in particular, the 9 who received home-based doses of XR-NTX. They are compared to a historical group of patients (n=21) prior to the pilot, who were referred to receive standard clinic-based doses of XR-NTX. Home-based administration was viewed favorably by patients and families. Although the small sample size is not amenable to statistical analysis, patients in the home based group, compared to the historical clinic-based group, received a greater number of doses overall and over 16 weeks of treatment, had longer retention, and attended similar numbers of clinic-based counseling sessions. These preliminary findings suggest that home-based delivery of XR-NTX and assertive outreach are feasible and promising in this critical target population, may compare favorably to clinic-based treatment as usual, and should be explored further in more rigorous evaluations. [ABSTRACT FROM AUTHOR]

Background: During the past decades deinstitutionalisation policies have led to a transition from inpatient towards community mental health care. Many European countries implement Assertive Community Treatment (ACT) as an alternative for inpatient care for "difficult to reach" children and adolescents with severe mental illness. ACT is a well-organized low-threshold treatment modality; patients are actively approached in their own environment, and efforts are undertaken to strengthen the patient's motivation for treatment. The assumption is that ACT may help to avoid psychiatric hospital admissions, enhance cost-effectiveness, stimulate social participation and support, and reduce stigma. ACT has been extensively investigated in adults with severe mental illness and various reviews support its effectiveness in this patient group. However, to date there is no review available regarding the effectiveness of youth-ACT. It is unknown whether youth-ACT is as effective as it is in adults. This review aims to assess the effects of youth-ACT on severity of psychiatric symptoms, general functioning, and psychiatric hospital admissions. Method: A systematic literature search was conducted in PubMed, Cochrane Library, PsychINFO and CINAHL published up to March 2017. To assess methodological quality of the included studies, the Oxford Centre of Evidence-Based Medicine grading system was used. Results: Thirteen studies were included in this review. There are indications that youth-ACT is effective in reducing severity of psychiatric symptoms, improving general functioning, and reducing duration and frequency of psychiatric hospital admissions. Conclusions: The current literature on youth-ACT is limited but promising. There are indications that youth-ACT is effective in reducing severity of psychiatric symptoms, improving general functioning, and reducing duration and frequency of psychiatric hospital admissions. The effect of youth-ACT may be comparable with the effect of ACT in adults. Similar as in adult ACT, the studies on youth-ACT found effects that vary from small to large. Randomized experimental research designs are needed to further corroborate effectiveness. [ABSTRACT FROM AUTHOR]

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Initially developed in the United States, the Assertive Community Treatment (ACT) has expanded to Canada, Sweden and the UK and is being implemented in an increasing number of countries, amongst them Spain. While supported by solid scientific evidence, ACT has also being criticised for being too intrusive into the private lives of individuals with mental health problems. Recent literature suggests that a collaborative approach may be appropriate in order to resolve the ethical dilemmas posed by ACT as well as to promote social integration of people with serious mental illness. Such objectives require the active involvement within ACT teams of social workers, professionals who possess the specific skills needed to promote empathy and integration according to a bio-psychosocial approach to mental health.

Objective People living with HIV (PLHIV) who are homeless or at risk of homelessness experience significantly worse health outcomes than those in stable housing. They are more likely to be diagnosed late, use substances, engage in high-risk sexual activities and have difficulty adhering to treatments. This review identifies strategies described and evaluated in the international social science literature which can improve access to HIV-treatment and care for PLHIV who are homeless or at risk of homelessness, to inform policy and service development in Australia. Setting The principle research question addressed in this review is: * What strategies enhance the ability of PLHIV who are homeless to access health care services, in particular community nursing services? A literature review of social science research relating to the research question in the international and Australian contexts was conducted. Primary argument No literature was identified that addressed access to community nursing services for PLHIV experiencing homelessness in Australia, and very little internationally. Community-based nursing organisations are well-placed and experienced in engaging marginalised groups in health care. Specific interventions need not always be developed: rather, better use could be made of existing services that utilise assertive outreach models of care and co-location with other services. Conclusion HIV-specialist community nursing services could be better integrated with homelessness services to enhance access to care, link PLHIV into the health system and keep them engaged in care. The absence of research on engagement with HIV specialist community nursing services demands exploration. [ABSTRACT FROM AUTHOR]

OBJECTIVE: TO EVALUATE HOW ADDING ASSERTIVE OUTREACH PROGRAMS TO LONG-ACTING INJECTABLE ANTIPSYCHOTICS (LAAPS) INFLUENCES RELAPSE AND DURATION OF HOSPITALIZATION. METHODS: THE PUENTE PROJECT IS A BELGIAN PROGRAM INVOLVING LAAP TREATMENT; NURSE-LED CARE SUPERVISION; ONGOING PSYCHOEDUCATION; AND SYSTEMATIC ASSERTIVE OUTREACH TRIGGERED IF THERE IS NONADHERENCE TO LAAP ADMINISTRATION. RESULTS: DATA OF 117 MATCHED CASES OF PATIENTS RECEIVING TARGETED ASSERTIVE OUTREACH WITH LAAP THERAPY (PUENTE PROJECT GROUP) VS LAAP THERAPY ALONE WERE ANALYZED. RELAPSE RATE WAS LOWER IN PUENTE PROJECT PATIENTS (23% VS 37%; P=0.05) COMPARED WITH LAAP THERAPY ALONE. PUENTE PROJECT PATIENTS SPENT APPROXIMATELY HALF THE AMOUNT OF TIME IN HOSPITAL (18.6 DAYS/PATIENT/YEAR) COMPARED WITH CONTROL PATIENTS (38.9 DAYS/PATIENT/YEAR). PUENTE PROJECT PATIENTS REPRESENTED A SAVING OF €2,428.52/PATIENT/YEAR AT THE LEVEL OF THE NATIONAL HEALTH INSURANCE SYSTEM. CONCLUSIONS: ENROLLMENT IN THE PUENTE PROJECT RESULTED IN A SIGNIFICANT REDUCTION IN READMISSION RATES, LIKELY DERIVED FROM PUTATIVE IMPROVEMENT IN CONTINUITY OF CARE. THE PUENTE PROJECT WAS ALSO COST SAVING, SUGGESTING A COUNTRYWIDE ROLL-OUT WOULD RESULT IN SIGNIFICANT HEALTHCARE SAVINGS. [ABSTRACT FROM AUTHOR]

Background The majority of studies support modern assertive health service models. However, the evidence is limited for parts of continental Europe, as well as for the pharmacological adherence outcome parameter. Method We conducted a quasi-experimental controlled trial including adult patients with a schizophreniform disorder and a maximum of 60 points on the Global Assessment of Functioning Scale (GAF). Interventions ( n = 176) and controls (TAU, n = 142) were assessed every six-month within one year in 17 study practices in rural areas. Mental and functional state were rated using the Brief Psychiatric Rating Scale (BPRS) and the GAF. Functional limitations and pharmacological adherence were patient-rated using the WHO-Disability Assessment Schedule II (WHODAS–II) and the Medication Adherence Report Scale (MARS). We computed multilevel mixed models. Results The GAF and BPRS of both groups improved significantly, yet the increase in the intervention group was significantly higher. In contrast, patient-rated variables – WHODAS–II and MARS – neither showed a stable temporal improvement nor a difference between groups. Conclusion Our findings only partly support the investigated AO intervention, because of conflicting results between clinician- and patient-ratings. Accordingly, the benefits of AO need to be further evaluated. [ABSTRACT FROM AUTHOR]

Purpose – Homeless populations are a politically contentious problem and researchers struggle to achieve a balanced approach. They place emphasis on sharply contrasting factors, such as; institutional structures, ideologies or individual dispositions and differences. Central questions remain unanswered, i.e., is homelessness an outcome of society’s failings related to housing shortages, or a personal choice, as in the status of “intentional homelessness?” The purpose of this paper is to set aside assumptions, to explore experiences of homelessness and psychosis. Design/methodology/approach – An existentially informed hermeneutic phenomenological analysis; exploring transcribed narratives from semi-structured interviews with three men. Findings – These participants started to wander as a spontaneous response to distressing life experiences. Without any plan they travelled to new locations living on the street. Being contained and treated against their will in the psychiatric system was another source of distress. They did not choose homelessness through a rational calculation of their best interests. They felt at odds with society, which did not protect them and failed to meet their needs. Research limitations/implications – In qualitative research, findings are not generalisable to other settings. Practical implications – Homeless services should be enhanced by psychological expertise along with more person-centred emphatic approaches; the authors of social policies should consider their philosophical assumptions. Social implications – Systemised mental healthcare does not solve complex problems; fails to meet needs. Originality/value – The analysis informs the design of further research, prompts practitioners to review their understandings and provides grounds for the rewriting of policies. [ABSTRACT FROM AUTHOR]

This article presents the findings of a 'street to home' study in Parramatta, Sydney. The study utilised a case study methodology to capture both the process of rehousing and the participants' evaluation of the interventions that supported them to access and maintain housing. Five of the men in the study were rehoused via a Housing First model, and three received traditional homeless services. The men participated in interviews pre- and post-housing over an eighteen-month period. This article discusses the outcomes for the men, including improvements in health and wellbeing, and workforce and social participation. The article also discusses the role of engagement, ongoing support and housing models in rehousing and maintaining tenancies. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the pattern of associations between changes in unmet needs and treatment motivation in elderly patients with severe mental illness. Methods: Observational longitudinal study in 70 patients treated by an assertive community treatment team for the elderly. Unmet needs and motivation for treatment were measured using the Camberwell assessment of needs for the elderly and the stages-of-change (SoC) scale, respectively, at baseline, after 9 and 18 months. SoC scores were dichotomized into two categories: motivated and unmotivated. Multinomial logistic regression analyses were conducted to determine whether changes in motivation were parallel to or preceded changes in unmet needs. Results: The number of patients who were not motivated for treatment decreased over time (at baseline 71.4 % was not motivated, at the second measurement 51.4 %, and at 18 months 31.4 % of the patients were not motivated for treatment). A decrease in unmet needs, both from 0-9 to 0-18 months was associated with remaining motivated or a change from unmotivated to becoming motivated during the same observational period (parallel associations). A decrease in unmet needs from 0 to 9 months was also associated with remaining motivated or a change from unmotivated to motivated during the 9-18 months follow-up (sequential associations). Conclusions: Our findings suggest that a decrease in unmet needs is associated with improvements in motivation for treatment. [ABSTRACT FROM AUTHOR]

Engagement is a determinant of how well a person will respond to professional input. This study investigates whether, in practice, routinely measured data predict initial client engagement with community mental health services. Engagement, problem severity, client characteristics, and duration before the first contact were measured at team entrance with clients (n = 529) of three community mental health teams. Regression analysis was used to predict engagement. Gender, age, referrer, having children, having a partner, and ethnicity showed a minor relationship with engagement. Higher problem severity measured by the team members with the Health of the Nation Outcome Scales, being referred for having psychiatric problems and/or causing severe and long-lasting trouble (as 'assessed' by the often non-professional referrer), and a longer duration between enrollment and the first conversation with a client, were indicative for a lower engagement. The final model explained 19.2 % of the variance in engagement. It can be concluded that initial client engagement with community mental health services can be predicted, in part, by routinely measured data. The findings can be used by community mental healthcare teams to create an awareness system. [ABSTRACT FROM AUTHOR]

Purpose: Lack of motivation for treatment makes a subgroup of patients with severe mental illness (SMI) difficult to engage in psychiatric treatment. Such difficult-to-engage patients may also be the most in need of treatment. We hypothesized that the level of psychosocial problems would be inversely related to motivation for treatment. Methods: Cross-sectional study in two independent samples. The first sample ( n = 294) included SMI patients who participated in a randomized controlled trial and were assessed using the Health of the Nation Outcome Scales (HoNOS) and self-rated and clinician-rated motivation-for-treatment scales. The second sample ( n = 1,170) included SMI patients who were treated in Assertive Outreach Teams and were routinely assessed with the HoNOS and a motivation-for-treatment scale. In both samples, patients also self-rated their quality of life. Results: In both samples, patients with HoNOS scores of 16 and higher had lower motivation scores on all motivation scales than patients with lower HoNOS scores, and also a lower quality of life. Conclusions: A motivation paradox seems inherent to this association between higher psychosocial problems levels, less motivation for treatment, and lower quality of life. Such a paradox has clinical relevance, as it may provide an ethical basis for outreach services which aim to engage marginally motivated SMI patients with severe psychosocial problems into mental health care. [ABSTRACT FROM AUTHOR]

Background: Up to 30% of people with mental health problems drop out of contact with mental health services with negative implications for continuity of care. Services with an assertive outreach approach aim to sustain engagement. Aims: This study explored the perceptions and needs of people often described as 'hard to engage' in order to understand more about how services can best support them. Methods: This was a service user led qualitative study involving participants with serious mental health problems. Interviews were held with 33 people using assertive outreach or voluntary sector services and 15 people who had disengaged from services. Data were analysed for emergent themes. Results: Relationships with staff were central to maintaining engagement with services. Almost all participants wanted help for their problems, and preferred services that responded to their priorities and offered practical support with everyday living. Negative perceptions of inpatient care were common, and a focus on medication put many participants off mental health services. Many participants were not receiving support for the full range of their complex needs. Conclusions: Difficulties in sustaining engagement with mental health services does not necessarily mean that people do not want help. Participants were intolerant of service-determined priorities. [ABSTRACT FROM AUTHOR]

The evidence base for assertive outreach services in the UK is limited. Five established outcome measures were used in an attempt to capture the clinical complexities of an assertive outreach team caseload. The findings suggested that the Health of the Nation Outcome Scales: Learning Disabilities, risk scores and hospital data were appropriate outcome measures, whereas the service user questionnaire and Maslow Assessment of Needs Scale: Learning Disabilities required shortening to be acceptable to clients. Analysis indicated that the assertive outreach model is slightly more effective than a conventional service in meeting the needs of adults with learning disabilities and mental-health problems who find engagement with generic services challenging. [ABSTRACT FROM AUTHOR]

An assertive outreach team has developed and introduced a monitoring tool to improve identification of substance use in service users with serious mental health problems. The tool enables staff to record the extent of dependence, associated mental and physical health problems, social difficulties, risky behaviours and motivation for change. Feedback on the tool from staff and clients has been positive. Screening for substance use and its consequences should be part of routine practice and requires adequate training and updating for staff. [ABSTRACT FROM AUTHOR]

Résumé: On peut définir les programmes de soins intensifs à domicile comme des équipes mobiles de psychiatrie dispensant des soins alternatifs à l’hospitalisation. Ils font l’objet de nombreuses publications internationales. Développés depuis les années 1970 pour répondre aux problèmes posés par la désinstitutionnalisation, ces modèles peuvent être distingués en deux groupes. Le premier inclut Case Management et Assertive Community Treatment. Ce dernier, très étudié, est un programme intensif à domicile au long cours, s’adressant à des patients souffrant de pathologies psychiatriques sévères et invalidantes. Il consiste en une intervention médicosociale intensive, visant la restauration des habiletés sociales et de l’autonomie. Le second modèle est l’intervention de crise. Tout aussi intensif, ce programme consiste en une intervention à court terme à domicile, visant à éviter ou raccourcir l’hospitalisation lors d’une décompensation aiguë. En effet, il permet d’éviter 50 % des hospitalisations et d’intervenir auprès du patient et de son entourage. L’ACT, quant à lui, permet d’améliorer l’adhésion aux soins de patients en rupture de suivi et hauts utilisateurs de services. Mais son efficience, comparée à des modèles moins intensifs, est controversée. [ABSTRACT FROM AUTHOR]

Background Outcomes are reported for an assertive outreach team for adolescents that combines flexible service delivery (e.g. outreach) and broad-ranging interventions. Method A retrospective evaluation over a 2-year period from 30 June 2006 to 30 June 2008 examined rates of hospitalisation, engagement with education and scores on the Child Global Assessment Scale ( CGAS). Results The sample showed statistically significant decreases in hospitalisation rates (from 47% to 17%) and increases in engagement with education (full-time attendance from 23% to 56%). There was a mean increase of 7.4 points on the CGAS. Conclusion An intensive, flexible and broad-ranging approach can be applied to adolescents who display at-risk behaviours and/or have high risk factors for poor long-term outcome. [ABSTRACT FROM AUTHOR]

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The use of psychological approaches by community assertive outreach teams has generally meant a move away from traditional clinic-based therapy sessions with people who experience psychosis. Sharing the client's own environment -- their homes -- can reveal more about the nature and impact of their psychotic experiences, and working alongside the person in real-life situations can strengthen the therapeutic alliance. This article describes the risks and challenges of using this approach and emphasises the importance of team support in addressing them. [ABSTRACT FROM AUTHOR]

Objectives. Community psychiatry has mainly relied upon intermediate long term care services while there is a large gap between patient's needs and availability of acute care services. Taking this into consideration, the main aim of this paper is to review the evidence supporting the efficacy and feasibility of implementing the new models of care developed to fulfil the gap in the provision of community and hospital care for acute and severely ill patients. Finally the paper will propose a "care balanced approach" to integrate the key elements of the new alternatives of acute community and hospital care in the mental health system. Material and Method. A review of the current literature was used to identify the key components of acute care for psychiatric illness. For this purpose Medline (1966-2010), EMBASE (1980-2010), and PsycINFO (1985-2010) databases were reviewed using key terms relating to assertive outreach, home treatment/crisis resolution, psychiatric acute day care, deinstitutionalization, Mental Health Service Models. Results. Three main types of acute care have been identified: Acute Continuous Day Care (ACDC) -day hospitals -, Assertive Outreach Care (AOC) -Assertive Community and Assertive Outreach teams-, and Home Acute Care (HAC) -Crisis resolution, Home treatment teams-. The feasibility of these alternatives is supported by available evidence. Although these acute care alternatives may be complementary and could be combined for achieving a greater positive impact on the clinical and social recovery of the patients, there are usually implemented independently. Conclusions. An integrative acute care subsystem combining these three strategies in a balanced care system should be formally incorporated to the advanced community model in mental health care. [ABSTRACT FROM AUTHOR]