295 individuals, following 1 year of ACT in Edmonton (12). Compared with the year prior to their enrolment in ACT, hospital separations, average length of stays when admitted, and emergency-room visits were reduced. Nonetheless, while service use reductions are an extremely important outcome in evaluating an ACT program, an individual’s level of functioning is also important. One might assume that if service use is reduced the group is functioning well enough not to need these services. The possibility exists, however, that these individuals do not change in functional status but that, with the intensive supports in the community, their reliance on traditional services is decreased. This paper examines this possibility by evaluating the long-term effects of ACT on the global functioning of individuals enrolled in an ACT program in Edmonton, Alberta.

Methods

Clients can be referred to the ACT program from the 4 general hospitals in Edmonton, from the provincial psychiatric hospital, from provincial mental health services, and from the offices of general practitioners. Individuals are eligible for registration if they are between the ages of 18 and 65 years, experience persistent and severe mental illness, and fulfill at least 3 of the following criteria: a history of multiple admissions to a psychiatric facility, difficulty functioning in the community, noncompliance with medication therapy, inability or unwillingness to receive follow-up services in an office setting, and a high risk for returning to hospital without assertive outreach. Once the referral has been accepted, the client is assigned a primary therapist who provides services tailored to individual client needs and makes most of the client contacts in a “natural” environment (that is, not in an office or clinic). The psychiatrist also maintains frequent direct contacts that include domicilary visits, crisis response, clinical supervision of treatment planning, and consultation.

On registration to the ACT program, clients are further interviewed by the assigned ACT psychiatrist for DSM-IV primary and comorbid diagnosis, as well as for complete

demographic data. The Global Assessment of Functioning (GAF) scale is recorded for each client at intake into the program and reviewed at intervals of 4 to 6 months The GAF is completed with input from all members of the community treatment team, including the psychiatrist, and recorded in the Comprehensive Client Review (CCR). Thus, the same treatment team completes the initial and follow-up GAFs for each client at the designated time periods. The CCR is completed every 6 months and placed in the client’s file. For the purpose of this study, GAFs were analyzed at baseline, 18 months, and 36 months after enrolment in the ACT program.

Although every effort is made to acquire GAFs on a regular basis, this does not always occur: clients may be in hospital or in jail or, due to their itinerant nature, the treatment team may have difficulty meeting with certain clients at the specific follow-up time. As a result, there was a discrepancy in sample size among groups, and examination of the data revealed that assumptions of normalcy and homogeneity were not met, precluding the use of analyses of variance (ANOVAs) as a statistical measure. For these reasons, Kruskal-Wallis 1-way analyses were used to detect general differences among groups, and Mann-Whitney follow-up was used to test for specific group comparisons. Additionally, Wilcoxon matched-pairs signed-ranks tests were used to detect within-group differences over time.

Results

Baseline and follow-up GAF scores spanning a period of 36 months were obtained for 411 patients whose initial assessment and enrolment in ACT was from 1994 to 1996 (which allowed capture of data from 1994 to 1999). Although 497 subjects were initially eligible, 52 (10.5%) did not meet the primary diagnosis we wished to capture (for example, primary substance abuse, or not otherwise specified [NOS] diagnosis other than for psychosis), and 34 (6.8%) were lost to follow-up. Mean age across all diagnostic groups was 40.1 years (range = 18 to 64 years), with approximately equal numbers of male (n = 204) and female (n = 207) patients.