Rio Hondo Forensics
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Contents
Introduction .................................................................................................................................................. 2
Contention 1: Inherency ............................................................................................................................... 3
1. All States are required to demonstrate comprehensive, effectively working plans for providing
services to people with disabilities because of the 1999 U.S. Supreme Court Case Olmstead v. L.C. ..... 3
2.
ACT not widely implemented............................................................................................................ 4
Contention 2: Harms ..................................................................................................................................... 5
1.
Institutions failing those with Mental Illness .................................................................................... 5
2.
Thousands of people with mental illnesses are being incarcerated................................................. 6
Contention 3: Plan ........................................................................................................................................ 7
Contention 4: Solvency ................................................................................................................................. 8
1.
ACT Works – reduces hospital use, increases housing stability and improves quality of life........... 8
2.
ACT reduced hospitalizations by 78% ............................................................................................... 9
3.
ACT is flexible to deliver the care that’s needed ............................................................................ 10
A/T Topicality .............................................................................................................................................. 11
___ Chronically Mentally Ill refers to persons with severe mental illness ............................................. 11
__ ACT serves the mentally ill ................................................................................................................. 12
___ ACT provides services to the mentally ill ......................................................................................... 13
A/T Medications .......................................................................................................................................... 14
___ ACT ensures all medications are appropriate .................................................................................. 14
A/T ACT not researched .............................................................................................................................. 15
___ ACT has been studied extensively .................................................................................................... 15
A/T ACT makes the situation worse ............................................................................................................ 16
___ Research has consistently found that ACT makes things better and patients appreciate the
services.................................................................................................................................................... 16
A/T Costs too much money......................................................................................................................... 17
___ ACT saves money ............................................................................................................................. 17
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Introduction
Current US policy for the provision of Mental Health Services to the Chronically Mentally Ill can do
better. Specifically, Assertive Community Treatment, or “ACT”, is a model that the US Federal
Government should mandate for all 50 states. As explained by the National Alliance on Mental
Illness in 2010:
[“Assertive Community Treatment (ACT)”,
http://www.nami.org/Template.cfm?Section=About_Treatments_and_Supports&template=/ContentMa
nagement/ContentDisplay.cfm&ContentID=8075, accessed 10/5/10]
ACT is a service-delivery model that provides comprehensive, locally based treatment to people
with serious and persistent mental illnesses. Unlike other community-based programs, ACT is not a
linkage or brokerage case-management program that connects individuals to mental health,
housing, or rehabilitation agencies or services. Rather, it provides highly individualized services
directly to consumers. ACT recipients receive the multidisciplinary, round-the-clock staffing of a
psychiatric unit, but within the comfort of their own home and community. To have the
competencies and skills to meet a client's multiple treatment, rehabilitation, and support needs,
ACT team members are trained in the areas of psychiatry, social work, nursing, substance abuse,
and vocational rehabilitation. The ACT team provides these necessary services 24 hours a day,
seven days a week, 365 days a year.
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Contention 1: Inherency
1. All States are required to demonstrate comprehensive, effectively
working plans for providing services to people with disabilities because
of the 1999 U.S. Supreme Court Case Olmstead v. L.C.
Edgar 2010
[“Where Does Assertive Community Treatment Fit into Your Mental Health System?”,Elizabeth Edgar is
the Director of the NAMI ACT Technical Assistance Center,
http://www.nami.org/Template.cfm?Section=actta_center&template=/ContentManagement/ContentDisplay.cfm&ContentID=33332, accessed 10/5/10]
Because of the Olmstead Decision, the federal government requires every state to plan for
community treatment for people with disabilities whose needs can be met outside an institution.
States must demonstrate to the federal government that they have "comprehensive, effectively
working plans" for providing services to people with disabilities in "less restrictive settings" and
that waiting lists for community services move at a "reasonable" pace. Every state department of
mental health is developing a plan to meet the requirements of the Olmstead Decision.
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2. ACT not widely implemented
National Alliance on Mental Illness 2010
[“Assertive Community Treatment (ACT)”,
http://www.nami.org/Template.cfm?Section=About_Treatments_and_Supports&template=/ContentMa
nagement/ContentDisplay.cfm&ContentID=8075, accessed 10/5/10]
Despite the documented treatment success of ACT, only a fraction of those with the greatest needs
have access to this uniquely effective program. Only six states (DE, ID, MI, RI, TX, WI) currently have
statewide ACT programs. Nineteen states have at least one or more ACT pilot programs in their
state. In the United States, adults with severe and persistent mental illnesses constitute one-half to
one percent of the adult population. It is estimated that 20 percent to 40 percent of this group could
be helped by the ACT model if it were available.
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Contention 2: Harms
1. Institutions failing those with Mental Illness
Harvard Mental Health Letter 2003
[“ Prisoners of mental illness.”, Jul2003, Vol. 20 Issue 1, p5-7, 3p]
Many of our institutions have failed these people. Mental hospitals have been emptied without
adequate provisions for care in the community. Involuntary psychiatric commitment has become
legally difficult, so we jail people who refuse treatment but are seen as a nuisance (usually) or a
danger (occasionally). Psychiatric facilities are sometimes reluctant to admit lawbreakers with
mental disorders. The public has an exaggerated fear of violence by the mentally ill. We do not
provide resources for offenders with mental disorders because of a belief that they will refuse help
or do not deserve it.
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2. Thousands of people with mental illnesses are being incarcerated
Harvard Mental Health Letter 2003
[“ Prisoners of mental illness.”, Jul2003, Vol. 20 Issue 1, p5-7, 3p]
For thousands of people with major mental illnesses -- schizophrenia, bipolar disorder, and major
depression -- state prisons and county jails have become the 21st-century equivalent of insane
asylums. The incarceration rate in the United States has quintupled in the last 20 years, while the
number of residents in state mental hospitals has declined from nearly 600,000 in the 1950s to
about 60,000 today. About 15% of prison and jail inmates have a major mental illness. Of those,
more than half abuse alcohol or drugs, and many also have post-traumatic stress disorder and other
anxiety disorders. According to the director of the National Center for Mental Health and Juvenile
Justice, 20% of the more than 100,000 adolescents in juvenile detention facilities have a serious
mental illness.
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Contention 3: Plan
The United States Federal Government will substantially reform the
provision of mental health services to the chronically mentally ill by
requiring that Assertive Community Treatment (or ACT) is a part of
every state's Olmstead plan. Funding and enforcement through
normal means.
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Contention 4: Solvency
1. ACT Works – reduces hospital use, increases housing stability and
improves quality of life
Bond, Drake, Mueser & Latimer 2001
[Gary R. Bond,1 Robert E. Drake,2 Kim T. Mueser2 and Eric Latimer3, 1 Indiana University-Purdue University
Indianapolis, Indianapolis, Indiana, USA, 2 Dartmouth Medical School, New Hampshire-Dartmouth Psychiatric Research
Center, Lebanon, New Hampshire, USA, 3 Douglas Hospital Research Centre, Montreal, Québec, Canada, “Assertive
Community Treatment for People with Severe Mental Illness Critical Ingredients and Impact on Patients”, : Disease
Management & Health Outcomes, March 1, 2001]
In agreement with most other reviews,[104] we conclude that ACT substantially reduces psychiatric
hospital use, increases housing stability and moderately improves symptoms and subjective quality
of life, but has little impact on social functioning. Also, as discussed in one review, ACT is highly
successful in engaging patients in treatment, increasing 1-year retention in mental health services
from 54% for patients receiving usual services to 84% for ACT patients.[124] Reviewers also
concluded that the more closely case management programs follow ACT principles, the better the
outcomes.[46,104]
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2. ACT reduced hospitalizations by 78%
Bond, Drake, Mueser & Latimer 2001
[Gary R. Bond,1 Robert E. Drake,2 Kim T. Mueser2 and Eric Latimer3, 1 Indiana University-Purdue University
Indianapolis, Indianapolis, Indiana, USA, 2 Dartmouth Medical School, New Hampshire-Dartmouth Psychiatric Research
Center, Lebanon, New Hampshire, USA, 3 Douglas Hospital Research Centre, Montreal, Québec, Canada, “Assertive
Community Treatment for People with Severe Mental Illness Critical Ingredients and Impact on Patients”, : Disease
Management & Health Outcomes, March 1, 2001]
All reviews agreed that the strongest finding in favour of ACT pertained to the reduction in hospital
use. One analysis of data from 34 study sites estimated that a higher-fidelity ACT program reduced
hospitalizations by 78% compared with standard aftercare (appointments at the outpatient clinic)
and by 58%compared with low intensity case management.[46]
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3. ACT is flexible to deliver the care that’s needed
Bond, Drake, Mueser & Latimer 2001
[Gary R. Bond,1 Robert E. Drake,2 Kim T. Mueser2 and Eric Latimer3, 1 Indiana University-Purdue University
Indianapolis, Indianapolis, Indiana, USA, 2 Dartmouth Medical School, New Hampshire-Dartmouth Psychiatric Research
Center, Lebanon, New Hampshire, USA, 3 Douglas Hospital Research Centre, Montreal, Québec, Canada, “Assertive
Community Treatment for People with Severe Mental Illness Critical Ingredients and Impact on Patients”, : Disease
Management & Health Outcomes, March 1, 2001]
ACT programs often fail to address other common problems,[143] such as trauma,[144] and medical
and dental care needs .According to Leonard Stein (personal communication, November 2000),
what makes ACT relatively unique is its flexibility as a vehicle to deliver cutting-edge treatment,
rehabilitation and case management services. What it delivers, and how and to whom it is provided,
may change with new discoveries.
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A/T Topicality
___ Chronically Mentally Ill refers to persons with severe mental illness
Kuntz 1995
[“PERSONS WITH SEVERE MENTAL ILLNESS:HOW DO THEY FIT INTO LONG-TERM CARE?” Crystal, Office
of the Assistant Secretary for Planning and Evaluation. U.S. Department of Health and Human Services,
May 1995 http://aspe.hhs.gov/daltcp/reports/mentalil.pdf]
In the field of mental health, the characteristics of diagnosis, disability, and duration have been used
to determine past and present estimates of people with SMI. In 1981 the term chronically
mentally ill was used and included those with a diagnosis for a major mental illness, severe
disability, and a duration of illness for at least one year (1.5% of the U.S. population ages 18+
qualified). Later the terminology changed and referred to the severely and persistently mentally ill,
including all mental illness diagnoses and all severe disabilities with a one year duration (estimates
ranged from 2.1-2.6% to 2.8 and 3.2% of the U.S. population ages 18+). The most recent definition
refers to persons with severe mental illness, which includes all diagnoses, substantial
disability, and no required duration (some estimates show this as encompassing 5-7% of the U.S.
population ages 18+).4 The definitions of SMI and the estimates of the population have changed in
attempts to encompass the heterogeneous group of persons with SMI. While the most recent
definition involves more people, it also captures those who have intermittent periods of serious
mental illness over a long period of time (CMHS, 1992).
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__ ACT serves the mentally ill
Bond, Drake, Mueser & Latimer 2001
[Gary R. Bond,1 Robert E. Drake,2 Kim T. Mueser2 and Eric Latimer3, 1 Indiana University-Purdue University
Indianapolis, Indianapolis, Indiana, USA, 2 Dartmouth Medical School, New Hampshire-Dartmouth Psychiatric Research
Center, Lebanon, New Hampshire, USA, 3 Douglas Hospital Research Centre, Montreal, Québec, Canada, “Assertive
Community Treatment for People with Severe Mental Illness Critical Ingredients and Impact on Patients”, : Disease
Management & Health Outcomes, March 1, 2001]
This article provides a detailed summary of the characteristics of the assertive community
treatment (ACT)model for people with severe mental illness. ACT is a comprehensive,
individualized approach to helping people with long term mental illness achieve optimal
integration into normal community life.
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___ ACT provides services to the mentally ill
Bond, Drake, Mueser & Latimer 2001
[Gary R. Bond,1 Robert E. Drake,2 Kim T. Mueser2 and Eric Latimer3, 1 Indiana University-Purdue University
Indianapolis, Indianapolis, Indiana, USA, 2 Dartmouth Medical School, New Hampshire-Dartmouth Psychiatric Research
Center, Lebanon, New Hampshire, USA, 3 Douglas Hospital Research Centre, Montreal, Québec, Canada, “Assertive
Community Treatment for People with Severe Mental Illness Critical Ingredients and Impact on Patients”, : Disease
Management & Health Outcomes, March 1, 2001]
An ACT program consists of a multidisciplinary group of mental health professionals who work as a
team to provide intensive services to patients with SMI. Most ACT contacts occur in community
settings. ACT teams have a holistic approach to providing services, helping with medications,
housing, finances and anything else that is critical to an individual’s success in living
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A/T Medications
___ ACT ensures all medications are appropriate
Bond, Drake, Mueser & Latimer 2001
[Gary R. Bond,1 Robert E. Drake,2 Kim T. Mueser2 and Eric Latimer3, 1 Indiana University-Purdue University
Indianapolis, Indianapolis, Indiana, USA, 2 Dartmouth Medical School, New Hampshire-Dartmouth Psychiatric Research
Center, Lebanon, New Hampshire, USA, 3 Douglas Hospital Research Centre, Montreal, Québec, Canada, “Assertive
Community Treatment for People with Severe Mental Illness Critical Ingredients and Impact on Patients”, : Disease
Management & Health Outcomes, March 1, 2001]
A top priority for ACT teams is to ensure the effective use of medications, including accurate
assessments (diagnosis and targeting of symptoms), choice of medications (including the novel
antipsychotics), appropriate dosages and duration of therapy, and management of adverse effects,
in accordance with evidence-based practice guidelines.[32,33] A major role for ACT teams is the
delivery of medications.
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A/T ACT not researched
___ ACT has been studied extensively
Bond, Drake, Mueser & Latimer 2001
[Gary R. Bond,1 Robert E. Drake,2 Kim T. Mueser2 and Eric Latimer3, 1 Indiana University-Purdue University
Indianapolis, Indianapolis, Indiana, USA, 2 Dartmouth Medical School, New Hampshire-Dartmouth Psychiatric Research
Center, Lebanon, New Hampshire, USA, 3 Douglas Hospital Research Centre, Montreal, Québec, Canada, “Assertive
Community Treatment for People with Severe Mental Illness Critical Ingredients and Impact on Patients”, : Disease
Management & Health Outcomes, March 1, 2001]
ACT has been the most extensively researched of all case management models. Mueser et al.[109]
identified 32 randomized controlled trials of case management, of which 22 evaluated ACT and 5
evaluated ICM. ACT was the focus in 44 (59%) of 75 case management studies reviewed. Further,
unlike ACT, other case management approaches reported in the literature were typically
inadequately defined .Moreover, the most rigorous case management research has evaluated ACT
programs.
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A/T ACT makes the situation worse
___ Research has consistently found that ACT makes things better and patients
appreciate the services
Bond, Drake, Mueser & Latimer 2001
[Gary R. Bond,1 Robert E. Drake,2 Kim T. Mueser2 and Eric Latimer3, 1 Indiana University-Purdue University
Indianapolis, Indianapolis, Indiana, USA, 2 Dartmouth Medical School, New Hampshire-Dartmouth Psychiatric Research
Center, Lebanon, New Hampshire, USA, 3 Douglas Hospital Research Centre, Montreal, Québec, Canada, “Assertive
Community Treatment for People with Severe Mental Illness Critical Ingredients and Impact on Patients”, : Disease
Management & Health Outcomes, March 1, 2001]
The ACT literature has been very consistent in suggesting an absence of negative outcomes. As
shown in table II, only 2 isolated findings were reported showing worsening of patient outcomes
across the 11 outcome domains examined in 25 studies. Significantly, surveys suggest that patients
are generally satisfied with ACT services [34] to a greater extent than those receiving the usual
services.[109]
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A/T Costs too much money
___ ACT saves money
Bond, Drake, Mueser & Latimer 2001
[Gary R. Bond,1 Robert E. Drake,2 Kim T. Mueser2 and Eric Latimer3, 1 Indiana University-Purdue University
Indianapolis, Indianapolis, Indiana, USA, 2 Dartmouth Medical School, New Hampshire-Dartmouth Psychiatric Research
Center, Lebanon, New Hampshire, USA, 3 Douglas Hospital Research Centre, Montreal, Québec, Canada, “Assertive
Community Treatment for People with Severe Mental Illness Critical Ingredients and Impact on Patients”, : Disease
Management & Health Outcomes, March 1, 2001]
Based on the published evidence, the only reliable reduction in cost to counterbalance the cost of
ACT itself appears to be the reduction in hospital costs. However, this reduction is so significant
that almost all studies that have attempted to compare the costs of ACT with those of other
services have reported lower overall costs for ACT.[46] The comprehensiveness of the costs
measured and the methods used to measure costs vary greatly across studies.[46,139] However, it is
obvious that the greater the reduction in the number of hospital days patients average per year
prior to their admission into ACT, the greater the potential savings.