Q. Where can I find data or research to support the need for community integration activities as part of services to improve the ability of mentally ill to function in society? For example, how can the person be successful at employment, have independent living, etc.?

A. If I understand your use of the term "community integration activities", it overlaps considerably with the term "assertive community treatment" (ACT). ACT emphasizes comprehensive, integrated programs that function 24 hours a day, and which aggressively support the patient in the community.

There are data showing that ACT programs lead to decreased length of re-admissions to hospital among schizophrenic patients, and to improved living conditions (see the American Psychiatric Association, Practice Guidelines for the Treatment of Patients with Schizophrenia, Am J Psychiatry 154(April suppl):1-63, 1997; and Tibbo et al, Can J Psychiatry 2001 Mar;46(2):144-8).

In the Tibbo et al study, Global Assessment of Functioning (GAF) scores were obtained for all patients at initial registration in the ACT program, and at subsequent 18- and 36-month time points while in ACT. At 18-month follow-up, significant improvements were seen in patients with delusional disorder (P < 0.05), dysthymia (P < 0.05), schizoaffective disorder (P < 0.05), and schizophrenia (P < 0.001). This was also seen at 36-month follow-up, with the addition of significant improvements in those with bipolar disorder (P < 0.05).

However, patients with major affective disorder or psychosis not otherwise specified (NOS) did not show significant improvements over time. GAF scores improved at 18- and 36-month follow-up from enrollment in the ACT program. Anttinen et al (1985) described an integrative stepwise rehabilitation model for schizophrenic patients, especially those hospitalized for long periods.

The model is based on the use of rehabilitation homes. The patient/client moves from one step to the next according to their particular needs. The steps for living are: small homes, supported lodgings, rented quarters and own apartments. Day clubs, therapeutic sheltered workshops, and vocational training are provided.

Although they don't present controlled data, the authors report that during 14 years of study, the majority of clients can be rehabilitated to live as fairly independent and responsible persons. Many other studies of ACT are reviewed by Marshall & Lockwood (Cochrane Database Syst Rev 2000;(2):CD001089).

August 2003

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