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IMPLEMENTING SAMHSA EVIDENCE-BASED PRACTICE TOOLKITS
Assertive Community Treatment (ACT)
Brief description of the practice
Target group:
Persons with serious and persistent mental illness. Usually Assertive Community Treatment (ACT)
targets persons who are high utilizers of services, or jail recidivists, or homeless, or have dual disorders.
A rule of thumb is that it is offered to persons who have not responded well to usual services.
Practice components:
The Toolkit states: “The goal of Assertive Community Treatment is to help people stay out of the hospital
and to develop skills for living in the community, so that their mental illness is not the driving force in
their lives. Assertive Community Treatment offers services that are customized to the individual needs of
the consumer, delivered by a team of practitioners, and available 24 hours a day.”
The model is characterized by:1

Multidisciplinary staffing including full-time psychiatrist

Team approach with shared caseloads

Integrated services

Low client-staff ratios (from 10 to 1 to 15 to 1)

Maximum team size of 98 to100 clients2

More than 75% of contacts in the community

At least 2-4 contacts with clients per week3

Assertive outreach including delivering medications

Focus on symptom management and everyday problems in living

Ready access in times of crisis (24/7)

Time-unlimited services
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Individualized services, including: Individualized assessment and treatment planning; case
management; crisis intervention; individual supportive therapy; medication prescription and
monitoring and delivering; substance abuse services; work-related services; support for Activities
of Daily Living (ADL); social, interpersonal relationship, and leisure- time skill training;
education, support, and consultation to consumers’ families and other supports; coordination of
hospital admissions and discharges; other support services.4
Since there is often confusion about what is and is not ACT, it is important to delineate what ACT is not.5

Individual caseloads

Responsibilities outside ACT

Brokered services

Day treatment

Case management for persons in group homes

Traditional psychiatry role (i.e., med checks, occasional interactions with team members)

Traditional MH team (i.e., weekly meetings, limited backup, informal information sharing)
Extent of evidence for ACT
A.
Systematic Reviews
1.
ACT dates back to the mid-seventies, with at least 14 reviews having been done during that time.
A Cochrane Collaboration review, the most systematic and quantitative approach, was performed
in 1998. The most recent comprehensive review is by Bond, Drake, Mueser and Lattimer (2001)
and include 25 randomized controlled studies.
2.
Summary of review findings
a.
Bond, Drake, Mueser and Lattimer (2001) summarized the outcomes of 25 randomized
controlled studies as follows:6

Retention in services: In 451 ACT clients, dropouts comprised 17% vs 49% in control
conditions (N=167).
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Outcomes other than retention in services:
Outcome
Psychiatric hospital use
Housing stability
Symptoms
Quality of life
Social adjustment
Jail/arrests
Substance use
Medication compliance
Vocational functioning
Patient satisfaction
Family satisfaction
Effectiveness of ACT compared with control conditions
ACT is better
No difference
Worse
N
N
N
%
%
%
17 (74%)
6 (26%)
0
8 (67%)
3 (25%)
1 (8%)
7 (44%)
9 (56%)
0
7 (58%)
5 (42%)
0
3 (23%)
10 (77%)
0
2 (20%)
7 (70%)
1 (10%)
2 (33%)
4 (67%)
0
2 (50%)
2 (50%)
0
3 (37%)
5 (63%)
0
7 (88%)
1 (12%)
0
2 (67%)
1 (33%)
0
The authors conclude: “ACT is one of the best-researched mental health treatment
models, with 25 randomized controlled trials evaluating its effectiveness. ACT
substantially reduces inpatient psychiatric hospital use, increases housing stability, and
moderately improves symptoms and subjective quality of life. In addition, ACT is highly
successful in engaging patients in treatment.”
b.
Cochrane Collaboration (Marshall, 1998).7
The Bond et al. review above did not differentiate studies by the control condition; the
Marshall review does. In summary:
ACT versus standard community care: All studies measuring retention in treatment
favored ACT. Most of the eight studies of hospitalization favored ACT; none favored
usual care. Small numbers of studies supported an ACT advantage around a) independent
living and not becoming homeless, b) employment, and c) patient satisfaction. Note that
the employment finding was based on only two studies, both of which involved ACT
teams supplemented by supported employment staff. Several other outcomes, such as
arrests and quality of life, show no advantage. ACT reduced hospital costs in all studies,
but overall cost-effectiveness advantages over usual care were not clear.
ACT versus case management: Other than ACT being favored for hospital days there was
insufficient data to permit robust comparisons.
Author’s conclusions: “ACT is a clinically effective approach to managing the care of
severely mentally ill people in the community. ACT, if correctly targeted on high users of
in-patient care, can substantially reduce the costs of hospital care whilst improving
outcome and patient satisfaction. Policy makers, clinicians, and consumers should
support the setting up of ACT teams.”
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B.
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Other issues regarding ACT that do not have an extensive data base
The Bond et al. (2001) article reviews literature on a number of other issues for which there is
only limited evidence: What percentage of a population needs ACT? Is ACT more effective than
intensive case management? How do clients, families and staff feel about ACT? Are there ethical
issues involved in the ACT model? What are the active ingredients of ACT?
C.
Advice of Consensus Panels:
The SAMHSA ACT Toolkit is a result of the consensus panel convened by Robert Wood
Johnson.8
The Schizophrenia Patient Outcomes Research Team (PORT) has issues a very influential set of
treatment guidelines for treating schizophrenia that include assertive community treatment. 9
The Expert Consensus Guideline Series for schizophrenia also endorses ACT.10
ACT is rated an effective practice in the American Psychological Association summary of
evidence-based interventions.11
The British National Institute for Clinical Excellence (NICE) guidelines endorse ACT.12
D.
Use with subpopulations or in other cultures
General applicability. Bond et al. (2001) summarize evidence that ACT is applicable to many
diagnoses, to persons of different ages, and cultural backgrounds.
“Evidence from both research and clinical practice suggests that ACT is very flexible across a
wide range of clients. Its effectiveness has been reported for clients from many different cultural
backgrounds. ACT is ideally suited for young adults as well as for older adults. Differences in
gender, education, and other such background characteristics have not been reported as factors
limiting the effectiveness of ACT. Moreover, as noted above, background characteristics do not
predict what types of clients are more satisfied with ACT services). ACT also appears to be
suitable for clients with a wide range of diagnoses. However, some observers have suggested that
clients diagnosed primarily with borderline personality or other personality disorders may not be
suitable candidates for an ACT team.”[Citations omitted]
Applicability to homeless persons with severe mental illness. A 2007 meta-analysis of 6
randomized control studies found that ACT programs reduced homelessness on average 37%
more than did usual case management and reduced symptoms 26% more; there was no significant
difference on hospitalization. Even larger effect sizes were found in four observational studies.12a
The effects of culture. While persons of many races and cultures have been served in ACT teams,
only minimal research has looked at culturally specific adaptations or the role of race and culture.
One large study matched Latino clients with Latino staff but found no advantage in outcomes.13
Another study found racial incongruence of staff to clients contributes to staff burn-out.14
A recent study reports on a Toronto ACT team designed specifically to serve ethnic minorities,
particularly Asians and immigrants. In this program a variety of culture-specific adaptations have
been created and implemented, including ethnic and language matches of staff to clients and
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greater focus on the family. Hospital days were reduced 83% in one year.15
Finally, ACT results in European countries have been inconsistent, leading to speculation that
both treatment and research culture in the United States are different.16
Rural adaptations. There are a number of studies on the use of ACT in rural settings in South
Carolina and Indiana. In general adaptations have been necessary (and in some cases were
drastic), implementation was difficult and of less fidelity than in urban sites; positive outcomes
were modest in Indiana and robust in South Carolina. Counties considering ACT in rural areas
should read the articles cited here.17
E.
What outcomes can be expected?
The one clear outcome that favors ACT is reduction of hospital days. Lattimer summarized 34
studies and concluded hospital days were reduced 78% compared to usual care and 58%
compared to brokerage case management.
F.
Capsule Summary of Evidence: Effective, Efficacious, Promising, or Emerging, Not effective or
harmful
"Effective" compared to usual services with respect to decreasing hospital use, retention in
treatment, and patient satisfaction.
"Promising" compared to usual services with respect to housing stability and quality of life.
"Emerging" compared to case management and intensive case management.
"Promising" applies to research which has looked at supplementing the ACT model with
employment services, substance abuse services, family services or other specialized services and
to research indicating the ACT model can be adapted effectively to serve ethnic groups and
provide services in rural areas.
Information regarding implementation
A.
Information about the implementation process and its success
1.
Fidelity Scale
ACT was the original program for which a fidelity scale was conceived and developed. Since
then there have been three others. The Toolkit uses the fidelity scale developed by the New
Hampshire Psychiatric Institute researchers called the Dartmouth ACT Fidelity Scale (DACTS).
The origin and characteristics of all four scales are described in detail in the document prepared
by the Lewin Group for SAMHSA.19
The DACTS has been shown to discriminate ACT from ACT-like programs and to have good
inter-rater reliability. Also treatment drop-outs were 15% in high fidelity programs vs. 30% in
low fidelity programs; hospital admissions in a year averaged 2.87 in the high fidelity programs
and 5.69 in the low fidelity programs.20 Nonetheless, the one test of whether fidelity in 10 newlyimplemented ACT programs predicted reduction in hospital days was only marginally
successful.21
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The scale is helpful in planning implementation of ACT and in monitoring progress.22
2.
Fidelity of ACT programs
Although a great many programs have used the name “ACT,” surveys have shown many do not
accord with basic components of the model. Deci surveyed 303 ACT programs and found that
while 88 percent of programs included a psychiatrist and a nurse as a member of the team; only
55 percent of programs directly provided services to consumers, rather than brokering services to
other agencies; and only 45 percent of programs created teams that shared a common caseload.23
Similarly, Salyers found in 51 ACT teams that only 29% fully used a team approach, and only
45% had the requisite psychiatrist time available.24
In the national EBP trial, in which there was an attempt to systematize implementation, Gary
Bond reports that the 13 ACT programs reached high fidelity (a score of “4” on a scale of “5”)
within six months (see below).25
Fidelity of ACT
DACTS Mean
5
4.1
4.2
4.2
4.2
Baseline
6 mo.
12 mo.
18 mo.
24 mo.
(n = 13)
(n = 13)
(n = 13)
(n = 13)
(n = 13)
4
3
2.8
2
1
3.
Extent of implementation
Like Supported Employment, ACT has been widely implemented elsewhere but introduced rarely
in California counties. By 1996 there were 396 ACT teams in 34 states. Statewide
implementation has occurred primarily in smaller states (Wisconsin, Michigan, Rhode Island,
New Hampshire, Connecticut, South Carolina, Indiana) but has grown to include some large
states (New York, New Jersey, Texas, Florida, Illinois). By 2001 the Veteran’s Administration
has implemented over 50 ACT teams.
4.
Costs of implementation
Both the Cochrane and Bond et al. reviews cited above also reviewed cost studies and Bond et al.
reviewed cost-effectiveness studies.
Bond, Drake, Mueser, Lattimer (2001): Studies done in the mid-90s computed the cost of ACT
for one year for one person to be between $9,564 (New Hampshire) and $11,264 (Baltimore) in
2006 dollars. Usual services averaged about half that amount.26
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Most studies of costs have looked at the off-set provided by saving on inpatient care. Whether
savings will be arrived at depends in large part on which population is being served. Persons with
high inpatient utilization are likely to show a cost-offset when served in ACT. Lattimer calculated
that in Quebec “break even” was at 50 days of inpatient utilization in the year.26 However, the
possibility for cost-offsets has decreased as strict controls on inpatient hospitalization have been
put in effect in many psychiatric hospitals.
Evidence for offsets in other areas (outpatient, housing) is either weak, inconsistent or shows
increased costs for ACT (moving homeless clients to stable housing, for example).
There have been only limited studies of cost-effectiveness.27 One showed the cost per day of
community tenure was no more expensive for ACT than standard case management. Another 5
year study found hospital savings to have been off-set by an increase in structured residential
costs. A third study found ACT and usual services incurred $242 and $415 respectively in direct
treatment costs per day of stable housing, an efficiency ratio of 0.58 favoring ACT. A final study
compared cost-effectiveness of an ACT based model that included substance abuse treatment
with an intensive case management model that included substance abuse treatment and found no
difference in cost-effectiveness.
Another recent body of literature reviewed by Bond has looked at the possibility of “stepping
down” clients to less intensive services after a period of time. Bond summarizes these studies by
saying: “Transferring ACT clients to less intensive case management services appears to be more
successful if the transfers are individualized and the “step-down” programs to which clients are
transferred are well designed, sharing many of the principles of organization in an ACT team, but
at a lesser intensity.
Cochrane (Marshall 1998): This review did not find any studies that showed total costs. Costs for
inpatient care were available in 5 studies (2 from California) as were costs for healthcare overall.
In all the studies ACT programs produced savings in inpatient costs.
B.
Assistance available for implementing ACT
1
Manual or other detailed description by developers.28 National standards for replicating
the original model developed in Madison; these are linked with “The PACT Model of
Community-Based Treatment for Persons with Severe and Persistent Mental Illnesses: A
Manual for PACT Start-Up.” Both can be ordered on the NAMI website.
A book on the model written by one of the originators is available Assertive Community
Treatment of Persons with Severe Mental Illness, By Leonard I. Stein and Alberto B.
Santos, W.W. Norton, New York, 1998
2.
Web resources.
Implementation resources from NAMI are available at
http://www.nami.org/Template.cfm?Section=ACT-TA_Center
The ACT Center of Indiana has many resources on its website:
www.psych.iupui.edu/ACTCenter/GettingStarted.htm
See also: The Assertive Community Treatment (ACT) Training Institute (located at the
University of Illinois at Chicago): www.psych.uic.edu/mhsrp/act.htm
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3.
The SAMHSA Toolkit. Like all the toolkits, this one contains descriptions of the practice
from a number of perspectives as well as other implementation resources. It is available
in Spanish.
4.
Other resources. The Lewin Group (see Endnote #2) describes other resources and is
particularly helpful in explaining differences between different standards and fidelity
scales.
Endnotes
1 Bond, G. R., Drake, R. E., Mueser, K. T., & Latimer, E. (2001). Assertive community treatment for people with
severe mental illness: Critical ingredients and impact on patients. Disease Management & Health Outcomes, 9, 141159.
2 Taken from: The Lewin Group (2000). "Assertive Community Treatment Literature Review." Retrieved
September 15, 2006, 2006, from
http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/community/tipsLiteraturereview/default.asp
3 Ibid.
4 Ibid.
5 This list is from a presentation by John McGrew. Also see: Salyers, M. P., Bond, G. R., Teague, G. B., Cox, J. F.,
Smith, M. E., Hicks, M. L., et al. (2003). Is it ACT yet? Real-world examples of evaluating the degree of
implementation for assertive community treatment. Journal of Behavioral Health Services and Research, 30(3), 304320.
6 Data from Bond et al (2001).
7 Marshall, M., & Lockwood, A. (2000). Assertive community treatment for people with severe mental disorders. Cochrane
Database Systematic Reviews(2), CD001089.
8 Members were Gary Bond, Deborah Becker, Morris Bell, Charles Rapp, Will Torrey and Earnest Quimby.
9 Lehman, A. F., Kreyenbuhl, J., Buchanan, R. W., Dickerson, F. B., Dixon, L. B., Goldberg, R., et al. (2004). The
Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophrenia
Bulletin, 30(2), 193-217.
10 McEvoy JP, Scheifler PL, Frances A. The Expert Consensus Guideline Series: Treatment of Schizophrenia 1999.
Journal of Clinical Psychiatry 1999;60 (Suppl 11).
11 Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: controversies
and evidence. Annual Review of Psychology, 52, 685-716.
12 Rowlands, P. (2004). The NICE schizophrenia guidelines: the challenge of implementation Advances in
Psychiatric Treatment, 10, 403-412.
12a. Coldwell, C. M., & Bender, W. S. (2007). The effectiveness of assertive community treatment for homeless
populations with severe mental illness: a meta-analysis. American Journal of Psychiatry, 164(3), 393-399.
13 Ortega, A. N., & Rosenheck, R. (2002). Hispanic client-case manager matching: differences in outcomes and
service use in a program for homeless persons with severe mental illness. Journal of Nervous and Mental Disease,
190(5), 315-323.
14 Salyers, M. P., & Bond, G. R. (2001). An exploratory analysis of racial factors in staff burnout among assertive
community treatment workers. Community Ment Health J, 37(5), 393-404.
15 Yang, J., Law, S., Chow, W., Andermann, L., Steinberg, R., & Sadavoy, J. (2005). Best practices: assertive
community treatment for persons with severe and persistent mental illness in ethnic minority groups. Psychiatric
Services, 56(9), 1053-1055.
16 Burns, T., Fioritti, A., Holloway, F., Malm, U., & Rossler, W. (2001). Case management and assertive
community treatment in Europe. Psychiatric Services, 52(5), 631-636.
17 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), 153173; Santos, A. B., Deci, P. A., Lachance, K. R., Dias, J. K., Sloop, T. B., Hiers, T. G., et al. (January 1993).
Providing asertive community treatment for severely mentally ill patients in a rural area. Hospital and Community
Psychiatry, 44(1), 34-39; Fekete, D. M., Bond, G. R., McDonel, E. C., Salyers, M., Chen, A., & Miller, L. D.
(1998). Rural assertive community treatment: A field experiment. Psychiatric Rehabilitation Journal, 21(4), 371379.
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18 Latimer, E. A. (1999). Economic impacts of assertive community treatment: a review of the literature. Canadian
Journal of Psychiatry. Revue Canadienne de Psychiatrie, 44(5), 443-454.
19 The Lewin Group. (2000). Assertive Community Treatment Literature Review. Retrieved September 15, 2006,
2006, from
http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/community/tipsLiteraturereview/default.asp
Salyers, M. P., Bond, G. R., Teague, G. B., Cox, J. F., Smith, M. E., Hicks, M. L., et al. (2003). Is it ACT yet?
Real-world examples of evaluating the degree of implementation for assertive community treatment. Journal of
Behavioral Health Services and Research, 30(3), 304-320; and Winter, J. P., & Calsyn, R. J. (2000). The Dartmouth
Assertive Community Treatment Scale (DACTS). A generalizability study. Evaluation Review, 24(3), 319-338.
20 Bond, G. R., & Salyers, M. P. (2004). Prediction of outcome from the Dartmouth assertive community treatment
fidelity scale. CNS Spectator, 9(12), 937-942. The scale scores predicted about 25% of the variance in hospital days,
and this was marginally statistically significant. The scale correctly identified the 3 high performance sites, but
medium and low performance sites also were above average on the fidelity scale. Clearly, however, achieving high
fidelity was not a necessary and sufficient condition for achieving high performance.
22 Ibid. Note that scores on the earlier scale by McGrew retrospectively correlated with hospital days reductions in
18 ACT programs. McGrew, J. H., Bond, G. R., Dietzen, L., & Salyers, M. (1994). Measuring the fidelity of
implementation of a mental health program model. Journal of Consulting and Clinical Psycholgy, 62(4), 670-678.
23 Deci, P. A., Santos, A. B., Hiott, D. W., Schoenwald, S., & Dias, J. (1995). Dissemination of Assertive
Community Treatment Programs. Psychiatric Services, 46(7), 676-678.
24 Salyers, M. P., Bond, G. R., Teague, G. B., Cox, J. F., Smith, M. E., Hicks, M. L., et al. (2003). Is it ACT yet?
Real-world examples of evaluating the degree of implementation for assertive community treatment. Journal of
Behavioral Health Services Research, 30(3), 304-320. Table 2 contains a complete list of attainment of fidelity items
(compared to intensive case management).
25 Gary R. Bond, “Initial Findings from the National EBP Project in the USA,” presented at the EBP Symposium,
University of Tokyo, July 25, 2006.
26 Latimer, E. A. (1999). Economic impacts of assertive community treatment: a review of the literature. Canadian
Journal of Psychiatry. Revue Canadienne de Psychiatrie, 44(5), 443-454. In a more recent article, not reviewed by
Bond et al., Chandler found that after four years the costs of an ACT team were still considerably less than usual
care, but the population was clients in psychiatric skilled nursing facilities with average annual costs in baseline of
$78,000 annually.
27 Essock, S. M., Frisman, L. K., & Kontos, N. J. (1998). Cost-effectiveness of assertive community treatment
teams. Am J Orthopsychiatry, 68(2), 179-190; Borland, A., McRae, J., & Lycan, C. (April 1989). Outcomes of Five
Years of Continuous Intensive Case Managment. Hospital and Community Psychiatry, 40(4), 369-376; Lehman, A.
F., Dixon, L., Hoch, J. S., Deforge, B., Kernan, E., & Frank, R. (1999). Cost-effectiveness of assertive community
treatment for homeless persons with severe mental illness. British Journal of Psychiatry, 174, 346-352; Clark, R. E.,
Teague, G. B., Ricketts, S. K., Bush, P. W., Xie, H., McGuire, T. G., et al. (1998). Cost-effectiveness of assertive
community treatment versus standard case management for persons with co-occurring severe mental illness and
substance use disorders. Health Serv Res, 33(5 Pt 1), 1285-1308.
28 Drawn from Gary Bond, Assertive Treatment for People with Severe Mental Illness:
www.bhrm.org/guidelines/ACTguide.pdf Published by Behavioral Health Recovery Management.
The Lewin Group (2000). "Assertive Community Treatment Literature Review." Retrieved September 15, 2006,
2006, from
http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/community/tipsLiteraturereview/default.asp